Jørgen Kanters
Assistant Professor
Lab. of Experimental Cardiology
Dept. of Medical Physiology
Panum Institute, bldg 6.5.22
University of Copenhagen
Phone: +45 40 58 50 80
Fax: +45 35 32 74 18
email: jkant…@mfi.ku.dk
Homepage: http://www.mfi.ku.dk/renal/jk/jk.html

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Venger’s Orchids wrote in message <345B6410.4…@vengers.com>…
>> Had mi in 85 some scarring caused mild episodes of multiple pvc’s, very
>> bothersome, but tests indicated non-life threatening. had some problems
>> with potassium that increased pvc’s. this  past week ended up going to
>> emergency room, very light headed pulse down to 40, from a normal resting
>> rate of 60. after a couple of hours at the ER, rate was back to normal,
>> potassium level tested at 3.5.
>> Same evening rate down to 40 again.
>> Went to see new cardiologist, decided to take me off Moduretic, next day
>> normal heart rate,? this is the second day, very few pvc’s. Dr. wants my
>> potassium level between 4 and 5. Comments Please.

>It sounds like you were dehydrating from the diuretic, which would cause
>a transient rise in your K+, hence the increased PVC’s. I don’t suppose
>the doc told you what your K+ level was? Depending on who you talk to,
>4.5 or 4.8 is the max normal K+ level. Anything between 3.5 and 5.0 is
>normally ok. -Rod-

>Venger’s Orchids

In article <01bce6d2$c495bf00$d290f5ce@utbpopki>, "Robert J Caron"

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<rjca…@fast.net> wrote:
> Had mi in 85 some scarring caused mild episodes of multiple pvc’s, very
> bothersome, but tests indicated non-life threatening. had some problems
> with potassium that increased pvc’s. this  past week ended up going to
> emergency room, very light headed pulse down to 40, from a normal resting
> rate of 60. after a couple of hours at the ER, rate was back to normal,
> potassium level tested at 3.5.
> Same evening rate down to 40 again.
> Went to see new cardiologist, decided to take me off Moduretic, next day
> normal heart rate,? this is the second day, very few pvc’s. Dr. wants my
> potassium level between 4 and 5. Comments Please.

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Jay Schonberger <jfsc…@hicom.net> wrote:

>Robert Coe wrote:

>> On Sun, 02 Nov 1997 00:59:23 -0800, Jay Schonberger <jfsc…@hicom.net> wrote:
>> : The October 1997 issue of the Harvard Heart Letter had an article reviewing
>> : the December 19, 1996 New England Journal of Medicine report on brain
>> : complications following CABG.  …
>> :
>> : The absolute level of 6.1 % for Type 1 plus Type II is appalling but the
>> : factor of 14 variation between institutions is more than appalling.
>> :
>> : That leads to the logical questions:
>> :
>> : 1. What is the cause of a 6.1 % brain damage rate?
>> :
>> : 2. What can be done to mitigate the problem?
>> :
>> : 3. How can one select a surgeon and/or anesthesiologist with a low
>> : complication rate?
>> :
>> : 4. How do you find the institutions with a low complication rate?

>> Questions 1 and 2 are outside my area of expertise.  Question 3 is almost a
>> subset of question 4: while there are exceptions, you’re statistically more
>> likely to find the best doctors at the best hospitals.

>> Question 4 is trickier.  Ideally, your cardiologist will be willing to tell
>> you.  (Mine did.)  If (s)he won’t, you can go find one who will.  If that’s
>> not feasible, you may be able to get the statistics from your state
>> government.  You may even be able to find them on the Web.

>> Sometimes you can tell a lot just by visiting the hospital and looking around.
>> The one that did my surgery has the best mortality statistics in the state for
>> bypass operations (they even tell you so in their brochure), and it wasn’t
>> hard to see why.  The building was was extremely clean and well kept, and the
>> staff, particularly the nurses, all seemed to know exactly what they were
>> doing.  And it’s good if the hospital specializes in coronary care, because
>> the coronary unit won’t have to compete for the attention of the
>> administration.
>> —
>>    ___            _                                             –  Bob
>>    /__) _   /    / ) _   _
>> (_/__) (_)_(_)  (___(_)_(/_____________________________________ b…@1776.COM
>> Robert K. Coe ** 14 Churchill St, Sudbury, MA 01776-2120 USA ** 978-443-3265

>  Robert,

>Thanks for the answer but I am not at all sure whether good mortality statistics
>and a professional atmosphere equates with low brain damage percentage.  In fact,
>a low mortality might equate with high brain damage since there are more sick
>survivors.

>There is a FACTOR of 14 difference between the best and the worst institution.
>That is 1400 % and very certainly statistically significant.  Why?   I am sure
>that some will claim that the bad performers handle sicker patients.  Maybe, but I
>would suggest that the medical profession to lift the secrecy and explain the
>differences.

>Jay

I hope you’re not holding your breath.

The Prof

>The article states that 3.1% had Type I complications and another 3 %
>had Type II complications.  Type I is death due to stroke, stroke,
>near-stroke or coma at the time of discharge.  Type II is abnormalities
>suggesting milder damage to the brain such as confusion, deterioration
>of intellect, agitation, disorientation, memory loss, etc.
>1. What is the cause of a 6.1 % brain damage rate?

Probably a varying combination of
  (a) patients with diffuse atherosclerotic disease, including
cerebrovascular disease, unable to tolerate the transient insults that
are unavoidable in major interventions like cardiopulmonary bypass and
bypass surgery; and
  (b) suboptimal surgical/anesthesiologic technique.

>2. What can be done to mitigate the problem?

Avoid low-volume surgeons and anesthesiologists.  Don’t have major
procedures unless you really need them.

>3. How can one select a surgeon and/or anesthesiologist with a low
>complication rate?

  There may be no good way to use data other than volume.  Historical
rates of bad outcomes are hard to interpret; they are usually
impossibly confounded by variations in the patient population.  New
York State starting publishing outcome statistics for its
institutions, and there were a few articles in the New England Journal
discussing these.  As I recall, the raw statistics turned out to be
almost meaningless, with the relative rankings of hospitals varying
wildly from year to year.  It may seem easy to decide how sick one
group of patients is,  compared to another, but it isn’t.

            Robert R. Fenichel, M.D.

(true email address is as above, but without initial NOTQUITE)

: > Sometimes you can tell a lot just by visiting the hospital and looking around.
: > The one that did my surgery has the best mortality statistics in the state for
: > bypass operations (they even tell you so in their brochure), and it wasn’t
: > hard to see why.  The building was was extremely clean and well kept, and the
: > staff, particularly the nurses, all seemed to know exactly what they were
: > doing.  And it’s good if the hospital specializes in coronary care, because
: > the coronary unit won’t have to compete for the attention of the
: > administration.
:
: Thanks for the answer but I am not at all sure whether good mortality statistics
: and a professional atmosphere equates with low brain damage percentage.  In fact,
: a low mortality might equate with high brain damage since there are more sick
: survivors.

Perhaps, but I think that’s unlikely.  I think it’s much more probable that a
low mortality rate correlates with a high skill level of the surgical team and
finicky attention to detail at all levels of the medical staff, leaving
nothing to chance.  That should result in a lower frequency of all types of
complication, including brain damage.

Let’s say that at an excellent hospital a patient who might have died is
saved, but suffers brain damage.  This should be offset by another patient who
might have suffered brain damage, but escapes with no serious complications.
—  
   ___            _                                             –  Bob
   /__) _   /    / ) _   _
(_/__) (_)_(_)  (___(_)_(/_____________________________________ b…@1776.COM
Robert K. Coe ** 14 Churchill St, Sudbury, MA 01776-2120 USA ** 978-443-3265

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Robert Coe wrote:
> On Wed, 05 Nov 1997 00:19:17 -0800, Jay Schonberger <jfsc…@hicom.net> wrote:
> : Robert Coe wrote:
> : > Sometimes you can tell a lot just by visiting the hospital and looking around.
> : > The one that did my surgery has the best mortality statistics in the state for
> : > bypass operations (they even tell you so in their brochure), and it wasn’t
> : > hard to see why.  The building was was extremely clean and well kept, and the
> : > staff, particularly the nurses, all seemed to know exactly what they were
> : > doing.  And it’s good if the hospital specializes in coronary care, because
> : > the coronary unit won’t have to compete for the attention of the
> : > administration.
> :
> : Thanks for the answer but I am not at all sure whether good mortality statistics
> : and a professional atmosphere equates with low brain damage percentage.  In fact,
> : a low mortality might equate with high brain damage since there are more sick
> : survivors.

> Perhaps, but I think that’s unlikely.  I think it’s much more probable that a
> low mortality rate correlates with a high skill level of the surgical team and
> finicky attention to detail at all levels of the medical staff, leaving
> nothing to chance.  That should result in a lower frequency of all types of
> complication, including brain damage.

> Let’s say that at an excellent hospital a patient who might have died is
> saved, but suffers brain damage.  This should be offset by another patient who
> might have suffered brain damage, but escapes with no serious complications.
> —
>    ___            _                                             –  Bob
>    /__) _   /    / ) _   _
> (_/__) (_)_(_)  (___(_)_(/_____________________________________ b…@1776.COM
> Robert K. Coe ** 14 Churchill St, Sudbury, MA 01776-2120 USA ** 978-443-3265

I agree with Bob. It would seem to be non-logical to try and find surgeon with worst
statistics for your surgery. Even given that some surgeons take on higher risk cases
with poorer results, it would seem that this is self limiting. If surgeon won’t take me
on then I have to go some with worse statistics!  My objective is not to provide
employment for surgeons with poor records, however altruistic their motives are, but to
find the best doctor who can help me. In this case statistics should be an improtant
consideration.

Long-term intellectual dysfunction following coronary artery
       bypass graft surgery: a six month follow-up study.
Author
       Shaw PJ; Bates D; Cartlidge NE; French JM; Heaviside D;
       Julian DG; Shaw DA
Address
       Department of Neurology, University of Newcastle upon
       Tyne.
Source
       Q J Med, 1987 Mar, 62:239, 259-68
Abstract
       As part of a prospective study of neurological and
       neuropsychological complications of coronary bypass
       surgery, 259 patients underwent psychometric assessment
       before operation and at seven days and six months after
       operation using a battery of 10 standard tests of intellectual
       function. This report describes the natural history of
       intellectual dysfunction soon after surgery and the incidence
       and functional impact of late neuropsychological impairment.
       The mean neuropsychological scores for the whole group
       remained unchanged or improved compared with levels
       before operation for the majority of the 10 tests. Analysis of
       the test scores for individuals showed that 147 of 259 (57 per
       cent) patients showed deterioration on at least one test score at
       six months. The degree of impairment was usually mild. One
       hundred and thirty of the 147 patients showed mild cognitive
       dysfunction (score deterioration on one or two tests) and only
       17 patients had moderate or severe impairment (score
       deterioration on three or more tests). Detectable
       neuropsychological deterioration at six months often did not
       matter to the patient in functional terms. Seventy-one per cent
       of these patients had no significant symptoms; 27 per cent had
       minor symptoms and only 2 per cent were seriously disabled.
       Of the patients unemployed at six months, in only one case
       was intellectual impairment the factor preventing return to
       work. A search for possible predisposing factors for
       long-term intellectual dysfunction was made using a
       multivariate analysis of 91 variables for each patient. Cardiac
       failure before surgery and global impairment of left
       ventricular function were the only factors showing significant
       correlation.

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np14015d0-Nilakhe wrote:

> Hi,

> I have to go through TST(I have costochondritis and sometimes it is very
> difficult to tell the source/location of the chest pain whether it is
> due to costochondritis-from the ribs or the heart). Otherwisw I feel
> fine and my resting EKG is also fine.
> Are there any side effects or risks in taking TST(I am allergic to
> radio-opaque dye) ?

> Are there any other tecniques/ways to differentiate costochondritis from
> the real chest(heart) pain ?

> If anybody has gone through the TST your feedback from your experience
> would be very much appreciated.

> Thanks in advance,

> cheers
> Shrikant

My wife had a TST the first week of Sep, this year.  I was with her
during the treadmill part which tired her, but otherwise, presented no
problems.  The X-Ray portion was a ‘piece of cake’.  Afterward, we ate
lunch, shopped for a while and returned to the hospital for the second
set of x-rays, another ‘piece of cake’.  She is not allergic to any of
the ingredients used with the iv that put the thalium in her system. [do
they use dyes?].  She has had costochondritis in the past, getting gold
shots for several years back in the 1970s.  So, we have sympathy for
your situation.  Hope this help!
—

     KOKO  [ Keep on keeping on ]     Hop

They do an echo before the exersice, and one right after the exersice. It
takes about 20 minutes and I am told is much cheaper and less invasive than
TST.

Sam

The radio-labelled thallium is not related to radio-opaque dyes so you
should not expect to get a allergic reaction with this form of testing.

> Are there any other tecniques/ways to differentiate costochondritis
> from
> the real chest(heart) pain ?

Relief of your chest pain symptoms with sublingual nitroglycerin might
distinguish heart symptoms from costochondritis symptoms.
—
For answers to similar sci.med/cardiology FAQs, see my webpages.
—
Andrew Chung
Homepage (with answers to sci.med FAQs) at:
http://userwww.service.emory.edu/~achung
Mirrored at:
http://www.emory.edu/WHSC/MED/HTN/~achung/