Circulation. 2007;115:1503
doi: 10.1161/CIRCULATIONAHA.107.182497
(Circulation. 2007;115:1503.)
© 2007 American Heart Association, Inc.
Issue Highlights
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BIPHASIC TRIAL: A RANDOMIZED COMPARISON OF FIXED LOWER VERSUS ESCALATING HIGHER ENERGY LEVELS FOR DEFIBRILLATION IN OUT-OF-HOSPITAL CARDIAC ARREST, by Stiell et al.
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Current resuscitation guidelines for cardiac arrest specify
360-J shocks with monophasic waveform external defibrillators
and 150- to 200-J shocks with biphasic waveform defibrillators.
Whether to increase shock strength with biphasic waveform defibrillators
when the initial shock fails is not clear. Stiell and colleagues
used automatic external defibrillators with recording capabilities
to conduct a randomized trial of biphasic waveform shocks fixed
at 150 J for initial and 2 subsequent shocks versus a 200 J
initial shock followed by escalating shock strengths of 300
J and 360 J in out-of-hospital cardiac arrest victims. First
shock conversion was similar with either energy, but escalating
shock strengths improved conversion to a stable rhythm after
a failed first shock with no evidence of additional myocardial
damage. Although the trial was not powered to assess long-term
outcome, the findings support increasing shock strength after
initial failed defibrillation and will inform future guidelines.
See p
1511.
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COMPARISON OF CLINICAL AND ADMINISTRATIVE DATA SOURCES FOR HOSPITAL CORONARY ARTERY BYPASS GRAFT SURGERY REPORT CARDS, by Shahian et al.
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Cardiac surgeons have consistently led the effort to collect,
analyze, and apply outcome data for the benefit of patients.
Cardiac surgery is also the paradigm for public performance
reporting. Public performance report cards and consumer demand
for reliable, transparent outcomes data must be based on the
highest quality, validated information that is rigorously analyzed
with appropriate statistical methodology. The gold standard
is a prospectively maintained, clinical database containing
core clinical variables. Using both standard logistic regression
and hierarchical models, the results of hospitals can be compared.
There has always been debate about the use of administrative
databases, designed for financial data, used as the dataset
for report cards. This study by Shahian et al compared hospital
cardiac surgery profiling based upon clinical data with profiling
derived from contemporaneous administrative data. An audited
and validated clinical registry has been available for all cardiac
procedures in Massachusetts since 2002. Results for fiscal year
2003 isolated coronary artery bypass grafting surgery based
upon these data were compared with those derived from a contemporaneous
state administrative database, the latter using the inclusion/exclusion
criteria and risk model of the Agency for Healthcare Research
and Quality. There was a 27.4% disparity in isolated coronary
artery bypass surgery volume, a 0.83% difference in observed
in-hospital mortality (2.05% versus 2.88%), and one hospital
determined to be an outlier only with the approach based on
administrative data. The discrepancies in volumes and risk adjusted
mortality were most notable for higher-volume programs. The
authors concluded cardiac surgery report cards using administrative
data are problematic compared with those derived from audited
and validated clinical data. Optimal statistical methodology
for risk-adjustment and provider profiling has been controversial,
however, and no statistical technique, regardless of its sophistication,
can compensate for flawed data. See p
1518.
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AMPLIFIED EXPRESSION PROFILING OF PLATELET TRANSCRIPTOME REVEALS CHANGES IN ARGININE METABOLIC PATHWAYS IN PATIENTS WITH SICKLE CELL DISEASE, by Raghavachari et al.
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Functional studies in platelets have shown an association of
sickle cell disease with an enhanced thrombotic state. In the
current issue of
Circulation, Raghavachari and colleagues examine
the platelet transcriptome from patients with sickle cell disease
and identify about 100 differentially expressed genes, most
notably, genes involved in arginine metabolism and redox homeostasis.
Further biochemical analyses confirmed the relevance of these
findings. As sickle cell disease is associated with reduced
nitric oxide and arginine bioavailability, these findings suggest
potential therapeutic and diagnostic targets for disease treatment
and identification. In addition, this is one of the first studies
utilizing the platelet transcriptome for disease characterization.
See p
1551.
Visit http://circ.ahajournals.org:
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Clinician Update
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Percutaneous Balloon Aortic Valvuloplasty Revisited: Time for
a Renaissance? See p
e334.
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Images in Cardiovascular Medicine
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Complementary Role of Multimodality Imaging in the Evaluation
of Intracardiac Lymphoma in an HIV-Infected Man. See p
e339.
Iatrogenic Aortic Coarctation. See p e342.
Fractional Flow Reserve as Evidence of Improvement in Flow After Subclavian Artery Stenting to Grafted Left Anterior Descending Artery. See p e344.
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Book Review
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Heart Failure: Molecules, Mechanisms and Therapeutic Targets.
See p
e347.
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Correspondence
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See p
e348.
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BIPHASIC Trial: A Randomized Comparison of Fixed Lower Versus Escalating Higher Energy Levels for Defibrillation in Out-of-Hospital Cardiac Arrest
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BIPHASIC TRIAL: A RANDOMIZED...
COMPARISON OF CLINICAL AND...