(Circulation. 2002;105:e9067.)
© 2002 American Heart Association, Inc.
Cardiovascular News
Circulation Newswriter
High-Resolution Magnetic Resonance Angiography Differentiates Patent and Occluded Vein Grafts
High-resolution, navigator-gated, 3-dimensional magnetic resonance (MR) angiography not only provided good differentiation between patent and occluded vein grafts but also allowed experts to make a fairly good assessment of vein graft disease, according to a group led by Ernst E. van der Wall, MD, from the Leiden University Medical Center Departments of Cardiology, Radiology, and Medical Statistics and the Interuniversity Cardiology Institute of the Netherlands in Utrecht, in a report in this week’s issue of Circulation (Circulation. 2002;105:328–333).
In explaining their study, the authors noted that although coronary angiography is the gold standard for evaluating the status of vein grafts after coronary artery bypass graft (CABG) surgery, the procedure is invasive, requires x-ray exposure and (in some venues) hospitalization, and involves a slight risk of complications. All of these represent disadvantages to using the procedure to screen patients who have postoperative angina. Their study was an attempt to evaluate a noninvasive diagnostic alternative.
The small patient population included 38 patients with 56 vein grafts who were scheduled for coronary angiography because of postoperative angina. High-resolution MR angiography scans were performed on these patients as part of an MR cardiac function protocol in which adenosine stress testing was performed. Excluded from the study were patients with stents in the graft or near the distal graft anastomosis, unstable angina, a pacemaker, atrial fibrillation, claustrophobia, or the inability to lie flat. The MR angiography was performed before coronary angiography in 19 patients and after coronary angiography in the other 19. According to the authors, the study demonstrates that the MR angiographic technique has potential for regular use as a method of noninvasively screening patients who have angina after CABG.
Platelet Glycoprotein IIb/IIIa Inhibitor Effect Examined in 2 Studies
Two studies in this week’s issue of Circulation look at the effects of platelet glycoprotein (GP) IIb/IIIa inhibitors in patients with acute coronary syndromes (ACS) without persistent ST-segment elevation.
In a further examination of data from the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, researchers led by Marino Labinaz, MD, of the University of Ottawa Heart Institute in Ontario, Canada, found that there was no interaction between treatment with the platelet GP IIb/IIIa inhibitor eptifibatide (integrilin) and whether or not the patients with ACS and non–ST-segment elevation had had prior CABG. The report in this week’s issue of Circulation (Circulation. 2002;105:322–327) found that the ACS patients who had had CABG had a significantly worse prognosis than those with the same syndrome who had not undergone the surgery. In this study, however, the addition of the GP IIb/IIIa inhibitor had the same effect in patients who had had prior CABG as it did in patients who had not had prior CABG. Fifteen percent of patients with prior CABG who received eptifibatide either died or suffered a myocardial infarction within 30 days of treatment, compared with 16.5% of those who received placebo. In the patients who had never undergone CABG, the rates were 14.1% in the treated group compared with 15.5% in the untreated group.
The authors wrote that their study "is the first published report suggesting a similar beneficial treatment effect with GP IIb/IIIa inhibitors in ACS for patients with and without a history of prior CABG." However, they noted, the "beneficial effect" was not seen in patients after 30 days. They also admitted that although this was a large study, involving >1100 patients who had undergone CABG and >8300 who had not, it was still too small to yield conclusive statistical results. However, they said, statistically there appears to be no interaction between prior CABG and treatment with the GP IIb/IIIa inhibitor.
In the second study in this issue (Circulation. 2002;105:316–321), the investigators in the PARAGON B trial (Platelet IIb/IIIa Antagonism for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network), found that the addition of lamfiban, another platelet GP IIB/IIIa inhibitor, had no significant effect on clinical outcomes in patients with ACS with non–ST-segment elevation, even though adequate plasma concentrations of the drug were attained.
The study involved 4225 patients at 389 centers in 29 countries, who received a bolus and 
72-hour infusion of lamfiban or placebo (adjusted for renal function) along with aspirin and heparin. The primary end point of death, myocardial infarction, or severe, recurrent ischemia within 30 days was reached in 11.8% of treated patients and 12.8% of those on placebo.
Dim Prospects Seen for Patients’ Rights Legislation
Although patients’ rights bills passed the US House and Senate last year, The Los Angeles Times reported in its January 10, 2002, edition that the issue is likely to fall through the cracks because of a new focus on antiterrorism and the war abroad.
The House and Senate versions of the legislation differ in the extent of right-to-sue provisions, with the Senate bill allowing such lawsuits to take place in state courts, which are more hospitable to plaintiffs. The House bill would narrow the right to sue, restricting suits in state court only to noneconomic damages of up to $1.5 million in punitive damages.
The bills supposedly were headed to a conference committee in September, but the attacks of September 11, 2001, occurred, distracting the nation and legislatures from the healthcare issue. According to the Times, Harvard University health policy expert Robert Blendon called the bill a dead issue at the moment, even though it had reached the conference committee status. "When it’s all said and done, it is a casualty of September 11," he told the Times.
Leadership Void in FDA, NIH, and HRSA Delays Progress
The empty chairs at the top of the US Food and Drug Administration (FDA), the National Institutes of Health (NIH), and the Health Resources and Services Administration (HRSA) may postpone important decisions on vaccine development, cloning, new drugs, stem cell research, and even the abortion pill, said The Washington Post in its January 10, 2002, edition.
Even though the threat of bioterrorism and the puzzle of cloning and stem cell research have taken much of the Bush administration’s time, no appointments to fill the vacant positions have been forthcoming, the Post noted. "The bottom line is when the country is trying to mobilize for a huge new effort to fight bioterrorism, there aren’t any generals for the battle," Sen Ron Wyden (D-Ore) told the Post.
"I just don’t have the feeling it’s been a first priority for this administration," Paul Berg, PhD, a Nobel Laureate in chemistry and a researcher at Stanford University, told the Post. "Most people are suspicious there’s a litmus test to be passed. Certainly, the talk at NIH has been that somebody who is pro-choice, pro-stem cells and pro-cloning is persona non grata."
White House spokeswoman Anne Womack responded to the article by saying that the administration is looking for the best candidates and that the search has been made more difficult by the terrorist attacks.
Health Spending in 2000 Shows Greatest Acceleration in 12 Years
The acceleration in health spending is the greatest in 12 years and indicates that 9 years of stability in health spending as a percentage of the gross domestic product is at an end, said experts from the National Health Statistic Group office of the Actuary in the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration [HCFA]). The authors of the report, which appeared in the January/February 2002 issue of Health Affairs (Health Affairs. 2002;21:172–181), found a 6.9% increase in health spending in 2000 compared with that of 1999. In 1999, health spending increased 5.7%, they noted. However, they said much of the increase is the result of inflation that affects the entire economy.
The authors paint a bleak picture for the future of health care in the United States, predicting that the dwindling economy will make it difficult for private and public payers to finance the accelerating cost of health care. As more layoffs occur, more citizens will lose health benefits. Employed people will find that they are required to pay more for their health insurance, forcing some out of the plans altogether because they can no longer afford them. Some employers may opt out of the health insurance market altogether. "These national health spending estimates may well mark the end of an era of reasonably affordable health care cost growth," they wrote.
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