Little randomized evidence is available to guide in-hospital therapy
for acute exacerbation of chronic heart failure (CHF). In this issue of THE
JOURNAL, 2 randomized trials evaluated treatments for this serious condition.
The Vasodilation in the Management of Acute Congestive Heart Failure (VMAC)
investigatorsArticle compared the efficacy and safety of intravenous nesiritide (a
recombinant human brain [B-type] natriuretic peptide), intravenous nitroglycerin,
and placebo added to standard therapy for patients with decompensated congestive
heart failure. At 3 hours after initiation of study drug, hemodynamic function
improved most in the nesiritide group, and improvement in self-reported symptoms
was greater in both active treatment groups compared with placebo. In the
second trial, Cuffe and colleaguesArticle report that among patients with acute exacerbation
of CHF for whom inotropic therapy was indicated but not required, the median
number of days of hospitalization for a cardiovascular cause within 60 days
following randomization was not significantly different in those who received
short-term intravenous milrinone plus standard care compared with those who
received placebo plus standard care, and episodes of sustained hypotension
and new atrial arrhythmias occurred significantly more frequently in the milrinone
group. In an editorial, Poole-WilsonArticle considers the mechanisms of action and
differences in short- and long-term outcomes of drugs used to treat acute
heart failure and discusses the importance of conducting clinical trials to
evaluate new therapies for heart failure.
Elevated blood pressure is associated with adverse clinical outcomes
in the general population, but in patients with end-stage renal disease (ESRD)
receiving maintenance hemodialysis, elevated blood pressure is associated
with improved survival. Elevated pulse pressure, however, has been associated
with poor clinical outcomes in studies of non-ESRD populations and in a small
study of patients with ESRD. In this large retrospective study of patients
with ESRD undergoing maintenance hemodialysis, Klassen and colleagues found
that after adjusting for systolic blood pressure, increasing pulse pressure
was directly associated with increased 1-year mortality.
To investigate whether anthrax vaccination has adverse reproductive
effects in women, Wiesen and Littell analyzed data in administrative and clinical
databases from a cohort of women aged 17 to 44 years in the US Army. Pregnancy
rates and birth rates after receiving at least 1 anthrax vaccination were
not significantly different from those among unvaccinated women.
Prenatal diagnosis of congenital anomalies and termination of affected
pregnancies have led to declines in the birth prevalence of congenital anomalies
and to decreases in infant deaths due to congenital anomalies. To determine
the effect of these changes on overall infant mortality, Liu and colleagues
conducted a population-based analysis of live births, stillbirths, and infant
deaths by birth cohort for 1991-1998 in Canada. Infant mortality rates decreased
in 1996 and 1997 in association with reductions in infant deaths from congenital
anomalies. These reductions in infant mortality were preceded by increases
in fetal deaths due to pregnancy termination at 20 to 23 weeks' gestation
in 1994 and by increased fetal deaths due to congenital anomalies at 20 to
21 weeks' gestation beginning in 1995.
Advances in laparoscopic general surgical procedures.
Critical care physicians are seeking new ways to address emerging pathogens,
septic shock, and bioweapons—threats to patients worldwide.
Kroenke discusses depression in the elderly, illustrated by the case
of Mr S, a 75-year-old man who experienced his first episode of depression
several years ago after coronary artery bypass graft surgery, followed by
an ablation procedure for persistent atrial fibrillation.
For your patients: Information about prenatal care.
This Week in JAMA. JAMA. 2002;287(12):1491. doi:10.1001/jama.2012.359