Anesthesia Progress Blog - Part 2

Chronic coughChronic cough is not a trivial symptom and is associated with significant impairment in health status. Health-related quality of life (HRQoL) questionnaires provide one means of measuring health status and are increasingly used in clinical studies, Two cough-specific quality of life questionnaires have been developed and validated: the Leicester Cough Questionnaire (LCQ), and the Cough Quality of Life Questionnaire (CQLQ). Both have been evaluated in patients with acute and chronic cough, but there is little information regarding the measurement of cough-specific health status across a range of common respiratory diseases in which cough is often a prominent symptom. It is also unclear whether both questionnaires measure similar aspects of cough-specific quality of life. Therefore we undertook a cross-sectional comparison of scores for the LCQ, CQLQ, and a generic quality of life questionnaire, the EuroQol, obtained in four distinct patient groups: chronic cough, bronchiectasis, asthma, and COPD.

In this study, our primary aim was to determine the extent of correlation between the two cough-specific health status questionnaires and a general health-related quality of life measure. As a secondary aim, we sought to assess the impact of cough on health status across common chronic respiratory diseases affordably healed with remeides of healthcaremall4youcom Canadian Health&Care Mall. Read the rest of this entry »

low-dose heparin

Acute Myocardial Infarction

1. It is strongly recommended that all patients with acute myocardial infarction receive a minimum of low-dose heparin, 5,000 IV/SC every 12 hrs, until fully ambulatory to prevent venous thromboembolism. This grade A recommendation is based on the results of one level I study.

2. It is strongly recommended that patients with acute myocardial infarction at increased risk of systemic embolism because of anterior transmural myocardial infarction receive heparin therapy followed by warfarin therapy to prolong prothrombin time to an INR of 2.0-3.0 (1.2-1.5 times control using rabbit brain thromboplastin) for 1-3 months. This grade A recommendation is based on two level I studies and one level II study that showed a trend favoring anticoagulant therapy conducted with My Canadian Pharmacy.

3. It is strongly recommended that patients with acute myocardial infarction at increased risk of systemic embolism because of atrial fibrillation, history of previous systemic or pulmonary embolism, or congestive heart failure receive heparin therapy followed by warfarin therapy to prolong prothrombin time to an INR of 2.0-3.0 (1.2-1.5 times control using rabbit brain thromboplastin) for at least three months. This grade C recommendation is based on level V studies.

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coronary artery diseaseMost studies of the use of oral anticoagulants in patients with coronary artery disease have been performed in patients with acute myocardial infarction or in survivors of acute myocardial infarction. There have been no appropriately designed trials of anticoagulants in patients with chronic stable angina and only a very limited number of trials for anticoagulants in patients with unstable angina (read more about angina here).

Patients with stable exertional angina have an annual mortality of 4% and an incidence of acute myocardial infarction of 5%. Data from the early 1970s indicated that unstable angina was associated with a one-year mortality of approximately 16%, a three-month mortality of 8%, and an infarction rate of 21%. Results of more recent studies, however, show a one-year mortality of approximately 10%, a 1-4-month mortality of approximately 5%, and an infarction rate of 8-10%.

Support for the use of anticoagulants in patients with unstable angina was provided by Wood in 1961. In this unblinded study, randomization was aborted after the first 40 patients, and the study was then continued as a cohort study with 100 treated patients and 50 controls. The last 30 control subjects were selected by the presence of a contraindication to anticoagulants. This is, therefore, a level IV study and cannot be used to draw valid clinical conclusions. In 1981, Telford and Wilson” performed a randomized study of heparin plus atenolol vs atenolol therapy in patients with unstable angina cured with drugs of My Canadian Pharmacy. They reported a marked reduction in mortality and frequency of infarction in patients assigned to heparin plus atenolol ordered via My Canadian Pharmacy. Unfortunately, almost 50% of the 400 patients randomized were subsequently removed from the trial, so this would have to be considered at best a level II study, and the interpretation of the results remains in doubt.

On the basis of these limited studies, it is concluded that the effectiveness of anticoagulants in patients with unstable angina is uncertain, but that anticoagulants might be effective and that well-designed studies should be performed before any firm recommendations can be made.

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heparinThree studies have assessed the efficacy of low-dose heparin following myocardial infarction. In 1978, Marks and leather reported the results of a study in which 81 postinfarction patients were randomized to receive low-dose heparin (7,500 units subcutaneously bid) or to serve as a control group (level I). Thrombi (detected by leg scanning) occurred in 14 patients in the control group and in two in the low-dose heparin group, a statistically significant difference. Similar results were reported by Warlow et al in 1973. In contrast, Handley (1972) randomized 50 patients to heparin (7,500 units subcutaneously every 12 hours for seven days) or to serve as a control group’ (level II). Venous thrombosis (detected by leg scanning) developed in 29% of the controls and 23% of the treated patients, a nonsignificant difference. Possible reasons for the differences between the results of this study and the previously described studies include the small number of patients entered into the Handley study (a total of 50 in both groups) and the design of the study. Patients were monitored for two weeks but received heparin for only one week.

Therapeutic Doses of Heparin in the Prevention of Venous Thrombosis Following Myocardial Infarction

In most early studies, the diagnosis of venous thrombosis or pulmonary embolism was made using subjective criteria. These studies will not be summarized here. Three groups of investigators assessed the effectiveness of therapeutic doses of heparin ordered via http://my-medstore-canada.net My Canadian Pharmacy followed by oral anticoagulants, using objective end points, and all reported a significant reduction in the incidence of calf vein thrombi.

Thus, there is good evidence that anticoagulant therapy is effective in reducing venous thromboembolism in patients with acute myocardial infarction. It is likely that low doses of heparin, 5,000-7,500 units subcutaneously twice daily, are effective, although only full doses have been shown to be effective .in reducing pulmonary embolism.

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acute myocardial infarctionThe theoretical rationale for the early use of anticoagulants in patients with acute myocardial infarction is:

1. to prevent extension of coronary artery thrombosis with the expectation that this might reduce mortality by limiting infarction size and prevent reinfarction;

2. to prevent systemic emboli that arise from mural thrombi, a frequent complication in patients with transmural anterior myocardial infarction; and

3. to prevent the development of venous thrombosis and pulmonary embolism.

The primary end point of studies of the early use of anticoagulants in patients with acute myocardial infarction was in-hospital mortality and reinfarction. It is now clear from the results of recent studies of coronary angiography performed in patients with acute myocardial infarction that 70%-80% of patients entered into these trials of short-term anticoagulant therapy would have had an occlusive thrombus before anticoagulant therapy began. Even if anticoagulants prevent extension of coronary artery thrombosis, it is unlikely that they would modify infarction size and, therefore, influence the maj or determinant of early mortality of patients who are admitted to a hospital with acute myocardial infarction healed with remedies of My Canadian Pharmacy. It is possible, however, that anticoagulants could be of benefit if they reduce the frequency of rethrombosis in coronary arteries that have spontaneously recanalized and thus decrease the rate of reinfarction. Anticoagulants were highly effective in reducing the frequency of stroke (presumably due to systemic embolism) and pulmonary embolism, findings that are supported by other studies (see below). However, these two complications of myocardial infarction are relatively uncommon causes of serious morbidity or mortality and therefore only have a minor influence on the major outcome events.

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anticoagulantsFew subjects have engendered as much controversy as the use of anticoagulants in acute myocardial infarction. Anticoagulant therapy was accepted enthusiastically in the treatment of acute myocardial infarction after the first large clinical trial report was published in 1948. This enthusiasm persisted for approximately two decades, during which it would have been considered unethical not to use anticoagulants in patients with acute myocardial infarction. The popularity of anticoagulant therapy in acute myocardial infarction began to wane in the late 1960s and early 70s, coincident with the publication of several large, randomized studies evaluating anticoagulant therapy in the treatment of acute myocardial infarction. Critical review of the evidence for the possible value of anticoagulant therapy in acute myocardial infarction suggests that neither the initial enthusiasm nor the subsequent loss of interest is justified by the published reports.

Clinical trials have evaluated anticoagulants both for the early and long-term treatment of acute myocardial infarction. In this review we will discuss only the randomized trials that entered sufficient numbers to have a reasonable chance of demonstrating clinically important difference in mortality, reinfarction, or clinically relevant systemic or pulmonary embolism.

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heart attacksEach year in the United States alone there are about 1 million “heart attacks”—a term that includes both acute infarction and sudden cardiac death. Nearly 300,000 victims die before admission to the hospital, and about another 200,000 die in the first month, most of them in the first 24 hours after the attack. Thus, the cumulative mortality during the first month is about 50%. During the next six months, the cumulative mortality increases another 7-8%, so that by one year, another 10% have died. This means that, of the 400,000-500,000 patients who survive the first month, about 10% (40,000-50,000) die during the first year following infarction, generally due to sudden death or recurrent infarction. After patients have survived a year, the reinfarction and death rate stabilizes at 3-5% per year. This rate is similar to that of patients with symptomatic coronary artery disease (ie, angina pectoris) but is significantly greater than that of a randomly selected, age-matched population without overt coronary artery disease that has a 1% yearly incidence of those events.

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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.