Objective: To evaluate the effects of the angiotensin converting enzyme inhibitor perindopril on six minute walking distance and quality of life in very old patients with left ventricular systolic dysfunction. Design: Prospective, double blind placebo controlled trial. Setting: Medicine for the elderly day hospital. Patients: 66 patients (average age 81) with left ventricular systolic dysfunction identified by echocardiography. Interventions: 10 weeks of treatment with titrated doses of perindopril or placebo. Main outcome measures: Six minute walking distance 10 weeks following treatment, quality of life measurements including the Minnesota living with heart failure questionnaire and the 36 item short form health survey. Results: In patients with left ventricular systolic dysfunction, six minute walking distance was significantly increased in the treatment group (37.1 m) compared with the placebo group (−0.3 m, p < 0.001). The medication was well tolerated and there were no significant adverse events. Conclusions: Six minute walking distance is improved considerably by treatment with perindopril in older patients with heart failure caused by left ventricular systolic dysfunction.
B-type natriuretic peptide may be a useful marker for cardiac disease in patients attending Day Hospital. Half of the patients assessed had cardiac disease detected. Both the electrocardiogram and B-type natriuretic peptide were sensitive in the detection of left ventricular systolic dysfunction but lacked specificity. B-type natriuretic peptide was superior to the electrocardiogram in the detection of valvular disease. If used to pre-screen cardiovascular disease in Day Hospital patients, B-type natriuretic peptide and the electrocardiogram could reduce the need for echocardiography in some patients before implementing evidence-based treatments. B-type natriuretic peptide increases progressively as the number of different cardiac abnormalities increases and this may explain why B-type natriuretic peptide is of such prognostic value in older patients.
Objective: Administration of unfractionated heparin to STEMI patients by the ambulance service is an established practice in Scotland, but the efficacy is unknown. We studied the effects of unfractionated heparin in STEMI patients treated by primary percutaneous coronary intervention, on infarct artery patency and mortality. Methods and Results: Consecutive patients (n = 1000) admitted to Ninewells Hospital, Dundee, from 2010 to 2014 for primary percutaneous coronary intervention were allocated to 2 groups: 437 (44%) prehospital heparin (PHH) administered by paramedics, and 563 (56%) in-hospital heparin. A trained medical student assessed coronary flow at presentation and collected the data. Mortality status was ascertained at 30 days and 5 years. Cox proportional hazards regression models were generated. The patient groups were similar, although PHH had shorter symptom onset-treatment time (187 vs. 251 minutes, P < 0.001) and less cardiogenic shock (3.9% vs. 8.0%, P = 0.008). Initial coronary flow was not different between the groups. Thirty day mortality in PHH was 2.5% versus 8.3%, P < 0.001. Independent predictors of 30-day mortality were age (odds ratio 1.07, 95% CI 1.04–1.09), cardiogenic shock (5.97, 3.33–10.69), radial access (0.53, 0.28–0.98), and PHH (0.33, 0.17–0.66). Five-year mortality in PHH was 13.0% versus 21.6%, P < 0.001. Significant predictors of long-term mortality were age (1.07, 1.06–1.09), cardiogenic shock (3.40, 2.23–5.17), and PHH (0.68, 0.49–0.96). Conclusions: PHH was associated with reduced short- and long-term mortality after adjusting for important potential confounders.
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