B-Type Natriuretic Peptide as a Predictor
The case for B-type natriuretic peptide (BNP) as a predictor of sudden death in patients with chronic heart failure gets a boost in a report in this week’s issue of Circulation (Circulation. 2002;105:2392–2397). In the article, Rudolf Berger, MD, and colleagues at the University of Vienna report on their prospective study of 452 patients with a left ventricular ejection fraction ≤35%.
At 3-year follow-up, 293 patients had survived without either heart transplantation or left ventricular assist device. Another 89 patients had died and 65 more had received a donated heart. Of those patients who had died, 44 (49%) had died of sudden death, 31 (35%) of pump failure, and 14 (16%) of other causes. The only independent variable that predicted sudden death was BNP, a finding that Alan Maisel, MD, of the Division of Cardiology at Veteran’s Affairs Medical Center in San Diego, Calif, noted had great promise as a prognosticator. “For the first time since the introduction of echocardiography some 20 years ago, a simple blood test appears to offer a significant advance,” he noted in his editorial in this issue of Circulation (Circulation. 2002;105:2328–2331). He noted that previous data had demonstrated the value of BNP as a prognostic device, but that its use had been held back because there was no simple test for the neurohormone. “In fact, present data, including the article in this issue of Circulation by Berger et al, suggest that BNP has finally cemented its role in these areas,” concluded Dr Maisel.
Bypass and Stenting Almost Equal in Unstable Angina
In an article in this week’s issue of Circulation (Circulation. 2002;105:2367–2372), P.J. de Feyter, MD, and colleagues from the University Hospital in Rotterdam, the Netherlands, demonstrate similar rates of mortality, myocardial infarction, and cerebrovascular events 1 year after patients with either stable angina or unstable angina and multivessel disease underwent revascularization by either stenting or coronary artery bypass grafting.
In their study, the researchers randomly assigned 755 stable angina patients with multivessel disease to coronary stenting or bypass surgery. Another 450 unstable angina patients with multivessel disease were randomized in a similar manner. However, stented patients in both groups underwent more revascularization at rates that were significantly higher.
New Liver Allocation System Called Fairer
A new set of rules delineating how cadaveric livers should be allocated has received positive reviews from members of the transplantation community, according to an article in the May 13, 2002, issue of American Medical News.
The change, announced by the United Network for Organ Sharing, scores potential transplant recipients on laboratory values for creatinine, bilirubin, and other factors that demonstrate the patients’ conditions, as well as the likelihood that the patients might die within 3 months without transplantation.
Under the new system, the Model for End-Stage Liver disease (MELD) and the Pediatric End-Stage Liver Disease (PELD) replaced 3 of 4 categories denoting transplantation status with a continuous scoring system. Only status 1—the most serious—remains the same, according to American Medical News.
“It’s fairer in concept, but it’s definitely a work in progress,” according to Saul Karpen, MD, PhD, Director of the Texas Children’s Liver Center in Houston and an Associate Professor of Pediatrics at Baylor College of Medicine.
Andrew Klein, MD, Director of the Johns Hopkins Comprehensive Transplant Center in Baltimore, Md, told American Medical News that the new system eliminates methods of “gaming” the system, such as when patients who were “quite healthy” ended up in intensive care units so that they could be placed higher on the priority list. Now, the location of the patient does not play a large role in determining the patient’s transplantation status.
According to some, however, the new plan is not perfect, because a dependence on lab values can penalize children as well as some adults. For example, in some children, laboratory values do not always reflect the extent of disease or risk of mortality, Dr Karpen told AM News.
Medical Students Sue Over Match System; AAMC Opposes
A class action suit filed in Washington, DC, on May 7, 2002, challenges the annual rite of Match Day on grounds of antitrust. The suit, which names 7 medical organizations, including the Association of American Medical Colleges (AAMC) and >1000 hospitals, claims that the Match Program is used to keep residents’ wages low and their hours long.
Most first-year residents earn <$40 000 per year and often work 100 hours a week, according to the suit. Under the National Resident Matching Program, matches are based on lists from hospitals and medical students. According to The New York Times, students and institutions have agreed to accept the match without negotiations about wages, hours, or any other terms of employment.
“The match basically controls where you are going to spend the first part of your professional life,” Paul Jung, MD, one of the plaintiffs in the suit, told The New York Times in its May 7, 2002, edition. Dr Jung is now a fellow at Johns Hopkins University.
The AAMC has said it will challenge the suit. AAMC President Jordan C. Cohen, MD, said in a released statement, “As one of the founding sponsors of the National Resident Matching Program (NRMP), the Association of American Medical Colleges knows that this program provides a valuable public service that helps maintain the high quality of physician training in the United States. By ensuring a smooth transition from medical school to residency, the NRMP is an important link in the continuum of medical education.”
Watching the Small Aneurysm
Patients who underwent elective repair of aneurysms smaller than 5.5 cm demonstrated no greater survival rate than did those whose lesions were carefully watched by ultrasonography or CT scan, according to researchers from a variety of Veterans Affairs Medical Centers around the nation in a report in the May 9, 2002, issue of The New England Journal of Medicine (N Engl J Med. 2002;346:1437–1444).
In this study, the researchers, led by Frank Lederle, MD, for the Aneurysm Detection and Management Veterans Affairs Cooperative (ADAM) Study Group, randomly assigned 569 patients with aneurysms between 4 and 5.4 cm in diameter to immediate repair and 567 similar patients to surveillance. None of the patients were considered to have a high surgical risk. By the end of the study, with follow-up ranging from 3.5 to 8 years, aneurysm repair had been performed in 92.6% of patients in the immediate surgery group and in 61.6% of patients in the surveillance group. There was no significant difference in the death rate between the 2 groups.
In an accompanying editorial (N Engl J Med. 2002;346:1484–1486), Robert W. Thompson, MD, of Washington University School of Medicine asked, “Do the results of the ADAM study mean that the threat of rupture of aneurysms has been previously overestimated and that no patient should undergo repair of an abdominal aortic aneurysm less than 5.5 cm in diameter? Unfortunately, the answer is not that simple.” He points out that surveillance in this trial was rigorous, with patients undergoing ultrasonography or CT scan every 6 months, and that 61% of patients in this group ultimately underwent repair. Although the results from ADAM are reassuring, he notes that “surveillance should therefore be viewed as only one of the management options to be considered for patients with small abdominal aortic aneurysms, and it should be recognized that some carefully selected patients will still benefit from early surgical treatment.”