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Cardiology speCialMngmnt o cronc trl brlltonstrtg or prvnton o CVd

a n t u:

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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outdated bariatric surgical procedures

have been replaced by much improved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?

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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.

8/7/2019 IHE Sept09

13/28www.ihe-online.com & search 45104

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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.

8/7/2019 IHE Sept09

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(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



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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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

8/7/2019 IHE Sept09

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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.


8/7/2019 IHE Sept09

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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


Simone Lazzini, PhD,

Researcher, Department o Business

Administration E. Giannessi ,

Via C. Ridol 10,

Pisa 56124,Italy


Comments on this article?Feel free to post them at

www.ihe-online.com/comment/CCM

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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

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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

1988;116(2 Pt 1):385 92.

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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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

[email protected]

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!

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


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



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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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


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


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.

Weinmann

Hbu, gywww.ihe-online.com & search 45319


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

IHE Sept09

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