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Biomedical subjects

M W Rich

Publications and source records attributed to M W Rich.

At least 37 records · Page 2Linked to original sources
PubMed1999

The cost-effectiveness of losartan versus captopril in patients with symptomatic heart failure.

The Losartan Heart Failure ELITE Study recently found that in patients with symptomatic heart failure and a left ventricular ejection fraction of </=0.40, losartan compared to captopril improved survival with better tolerability. The objective of this study was to perform an economic evaluation of losartan versus captopril based on the results of the Losartan Heart Failure ELITE Study. The Losartan Heart Failure ELITE Study was a multinational, double-blind, randomized 48-week study comparing the safety and efficacy of losartan to captopril in angiotensin-converting enzyme-inhibitor-naive patients >/=65 years with symptomatic heart failure. Data on health care resource utilization were collected as part of the trial. We conducted a cost-effectiveness analysis to estimate the lifetime benefits of treatment and the associated costs. We observed no differences between treatments in the number of hospitalizations, hospital days, and emergency room visits per patient over the trial period. We estimated the total cost of losartan to be USD 54 (95% CI: USD -1,717, USD 1,755) less per patient than captopril over this time frame. We also estimated that over the projected remaining lifetime of the study population, losartan compared to captopril would increase survival by 0.20 years (undiscounted) at an average cost of USD 769 (discounted) more per patient. This cost increase translated into a cost-effectiveness ratio of USD 4,047 per year of life gained for losartan relative to captopril. In patients with symptomatic heart failure, losartan compared to captopril increased survival with better tolerability at a cost well within the range accepted as cost-effective.

Aged↗
PubMed1999

Management of chronic heart failure.

Although chronic heart failure remains a major source of morbidity and mortality, recent advances in treatment have resulted in substantial improvements in survival, quality of life and exercise capacity, while at the same time reducing hospitalizations and overall cost of care. An algorithm for CHF management based on currently available data is presented, with a focus on recent results from major clinical trials. The information should be used as a general guide, recognizing that revision will be necessary as additional studies are completed and new data become available.

Journal Article↗
PubMed1999

Porphyria cutanea tarda. Don't forget to look at the urine.

Diagnosis of porphyria cutanea tarda is usually fairly straightforward because of the characteristic clinical findings. Blisters and erosions develop acutely on sun-exposed skin, sometimes accompanied by hypertrichosis, abnormal pigmentation, and milia formation. Iron stores are usually elevated, and liver transaminases and blood glucose levels are often above normal as well. Gross examination of the urine can provide a valuable clue, since urine of porphyria cutanea tarda patients is red to brown in natural light and pink to red in fluorescent light. Biopsy of a bullous lesion is useful to rule out other diseases. Confirmation of porphyria cutanea tarda requires measurement of porphyrin levels in a 24-hour urine collection. Once the diagnosis is confirmed, it appears reasonable to screen all patients with porphyria cutanea tarda for hepatitis C and possibly B, but especially those less than 30 years old who have extremely high liver transaminase levels. Therapeutic measures for porphyria cutanea tarda include avoidance of exacerbating factors, especially ultraviolet light, ethanol, and certain medications. Phlebotomy or chloroquine therapy is reserved for patients in whom conservative measures fail.

Adult↗
PubMed1998

Physician management of patients with heart failure and normal versus decreased left ventricular systolic function. Council on Geriatric Cardiology.

A questionnaire was administered to a random sample of family practitioners, internists, cardiologists, and geriatricians to examine the current management of heart failure patients with preserved versus reduced left ventricular systolic function. In patients with preserved systolic function, electrocardiogram at rest, chest x-ray, echocardiography, digitalis, angiotensin-converting enzyme inhibitors, and restriction of dietary sodium and physical activity are used less often, whereas calcium channel blockers and beta blockers are given more often than to patients with reduced systolic function.

Female↗
PubMed1998

Temporal trends in pharmacotherapy for congestive heart failure at an academic medical center: 1990-1995.

The objectives of this study were to assess current practice patterns in pharmacotherapy for congestive heart failure at an academic medical center and to analyze temporal trends in management of congestive heart failure from 1990 to 1995. Records of all patients discharged from the hospital in 1990 or 1995 with a primary diagnosis of congestive heart failure who also underwent echocardiography were found by a search of the hospital's medical records database. All charts were reviewed, and relevant clinical data, including all discharge medications, were recorded. On the basis of echocardiograms, patients were classified as having preserved or impaired left ventricular systolic function (estimated ejection fraction > or =45% versus <45%). The use of digoxin, diuretics, angiotensin-converting enzyme (ACE) inhibitors, calcium and beta-blockers, nitrates, and hydralazine in 1990 and 1995 were compared in subgroups according to left ventricular function. A total of 297 patients were identified who fulfilled study criteria and for whom all pertinent data were available (1990, n = 109; 1995, n = 188). The median age was 74 years; 37.3% of the patients were men, and 45.1% were white. Among patients with impaired systolic function, the proportion receiving either an ACE inhibitor or the combination of nitrates and hydralazine increased from 80.9% in 1990 to 95.4% in 1995 (p = 0.009). In addition, among patients treated with an ACE inhibitor, the proportion receiving an optimal dose increased from 24.3% in 1990 to 61.5% in 1995 (p < 0.001). The use of beta-blockers also increased significantly during this time period (2.1% versus 15.7%; p = 0.031 ). Among patients with preserved ventricular function, the use of ACE inhibitors and beta-blockers increased from 1990 to 1995 (both p < 0.05). The use of other medications did not change for either subgroup. Current use of appropriate vasodilator therapy at an academic medical center is very high and is in accordance with published guidelines for the management of congestive heart failure. The use of vasodilators and beta-blockers has increased significantly since 1990 among patients with congestive heart failure with either impaired or preserved left ventricular contractility.

Academic Medical Centers↗
PubMed1998

Adherence to a prophylactic medication regimen in patients with symptomatic versus asymptomatic ischemic heart disease.

Although angina pectoris is the most common symptom of coronary artery disease, some patients do not experience angina during ischemic episodes. The effects of asymptomatic (silent) heart disease on patient self-management have rarely been studied. Studies of other patient populations with asymptomatic illnesses indicate that patients with silent myocardial ischemia might adhere less well to a prophylactic medication regimen than would those with symptomatic ischemia. Depression, a state associated with poor adherence to medical regimens is more common among patients with symptomatic ischemia. For prevention of thromboembolic events, 37 patients with documented ischemic heart disease who denied having anginal symptoms and 28 patients who reported almost daily symptoms were given a 3-week supply of low-dose aspirin packaged in an unobtrusive electronic adherence monitor. All other medications were provided in standard pill bottles. The symptomatic patients removed their prescribed aspirin on 62.4% of the days; the patients with silent ischemia took their medication on 77.3% of the days. Possible explanations for these results, their clinical implications, and directions for future research are discussed.

Aged↗
PubMed1998

Therapy for acute myocardial infarction in older persons.

OBJECTIVE: To review the early management of acute myocardial infarction (AMI) in older adults. METHODS: Recently published studies relevant to the early management of AMI were systematically reviewed. When possible, the impact of older age on complication rates and clinical outcomes was evaluated. RESULTS: In general, AMI therapies that are effective in younger patients are also effective in older patients. Conversely, older age is associated with an increased risk of complications from therapy, implying that careful patient selection is required to optimize outcomes while minimizing risks. The principal limitation of currently available data is that relatively few patients older than the age of 80 have been enrolled in prospective randomized clinical trials. CONCLUSIONS: Thrombolysis and primary angioplasty are effective in establishing reperfusion and improving clinical outcomes in older patients with AMI. In the absence of contraindications, aspirin and beta blockers should be considered standard therapy in AMI patients of all ages, whereas heparin, nitrates, and angiotensin converting enzyme inhibitors are indicated in selected subgroups. At the present time, calcium channel blockers, magnesium, and antiarrhythmic agents are not recommended for routine use in the AMI setting, and the role of glycoprotein IIb/IIIa inhibitors, low molecular weight heparin, and other newer agents await the results of ongoing clinical trials.

Age Factors↗
PubMed1998

Myocardial injury caused by an anaphylactic reaction to ampicillin/sulbactam in a patient with normal coronary arteries.

A 63-year-old woman presented with an exacerbation of her chronic obstructive pulmonary disease. While receiving an infusion of ampicillin/sulbactam, she developed anaphylaxis-induced myocardial injury. Subsequent coronary angiography revealed minimal atherosclerosis of her coronary arteries. The patient remained under continuous observation and cardiac monitoring throughout her reaction, thus providing unique insight into the pathophysiology of myocardial injury caused by anaphylaxis. The medical literature that pertains to this phenomenon is discussed.

Aged↗
PubMed1997

Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults.

OBJECTIVES: To review the epidemiology, pathophysiology, and etiology of congestive heart failure (CHF) in older adults. METHODS: Published reports relevant to the epidemiology, pathophysiology, and etiology of CHF were systematically reviewed. Studies involving older adults and more recent studies were emphasized. RESULTS: More than 75% of patients with CHF in the United States are older than 65 years of age, and CHF is the leading cause of hospitalization in older adults. CHF is also a major cause of chronic disability, and annual expenditures for CHF currently exceed $10 billion. In addition, both the incidence and prevalence of CHF are increasing, largely as a result of the aging of the population. Older adults are predisposed to developing CHF as a result of age-related changes in the cardiovascular system and the high prevalence of hypertension, coronary artery disease, and valvular heart disease in this age group. Although the fundamental pathophysiology of CHF is similar in younger and older patients, older individuals are more prone to develop CHF in the setting of preserved left ventricular systolic function. This syndrome, referred to as diastolic heart failure, accounts for up to 50% of all cases of CHF in adults more than 65 years of age. Coronary heart disease and hypertension are the most common etiologies of CHF in older adults, and they often coexist. Valvular heart disease, especially aortic stenosis and mitral regurgitation, are also common in older adults, whereas nonischemic dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy occur less frequently. CONCLUSIONS: Congestive heart failure is a major public health problem in the United States today as a result of its high and increasing prevalence in the older population as well as its substantial impact on healthcare costs and quality of life. There is an urgent need to develop more effective strategies for the prevention and treatment of CHF in older individuals.

Age Factors↗
PubMed1997

A case of eosinophilic pneumonia and vasculitis induced by diflunisal.

Drug-induced pneumonitis is an uncommon complication of nonsteroidal anti-inflammatory drug administration. Herein is the first reported case of pneumonitis resulting from diflunisal therapy. The patient demonstrated clinical and biopsy evidence of systemic vasculitis. She responded dramatically to administration of systemic glucocorticoids.

Adult↗