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Biomedical subjects

Charles W Hogue

Publications and source records attributed to Charles W Hogue.

17 recordsLinked to original sources
PubMed2006

C-reactive protein levels and atrial fibrillation after cardiac surgery in women.

BACKGROUND: The aim of this study was to evaluate whether risk for postoperative atrial fibrillation in women is related to preexisting inflammation as detected by plasma C-reactive protein (CRP) concentrations. We further sought to assess the importance of atrial fibrillation for outcome after cardiac surgery in women. METHODS: The CRP was measured before coronary artery bypass grafting and (or) valvular surgery using cardiopulmonary bypass in 141 women. Univariate and multivariate analyses were used to evaluate for differences in CRP levels between women with and without atrial fibrillation, and to assess for the importance of the arrhythmia and postoperative outcomes. RESULTS: Atrial fibrillation developed in 46 (33%) women. Neither CRP concentrations (median +/- standard error, 13.3 +/- 2.5 mg/L vs 11.7 +/- 1.4 mg/L, p = 0.847), nor the frequency of elevated levels (defined as > upper 95% confidence interval or >19.2 mg/L) (19% vs 21%, p = 0.807) differed between women with or without atrial fibrillation. Patient age and previous stroke, but not CRP levels, were independently associated with atrial fibrillation. Women with atrial fibrillation were more likely to have low cardiac output syndrome (p = 0.018), stroke (p = 0.031), longer duration of hospitalization in the intensive care unit (p = 0.012) and on the postoperative (p = 0.0008) ward, and they were more likely to require an extended care facility after surgery (p = 0.046). CONCLUSIONS: In contrast to findings from studies that have included mostly men, preoperative CRP concentrations are not associated with risk for atrial fibrillation after cardiac surgery for women. Postoperative atrial fibrillation in women is associated with increased risk for stroke, longer hospitalization, and extended care facility admission.

Aged↗
PubMed2006

Preexisting cognitive impairment in women before cardiac surgery and its relationship with C-reactive protein concentrations.

Preoperative cognitive state is seldom considered when investigating the effects of cardiac surgery on cognition. In this study we sought to determine the prevalence of cognitive impairment in women scheduled for cardiac surgery using nonhospitalized volunteers as a reference group and to examine the relationship between C-reactive protein levels and cognitive impairment. Psychometric testing was performed in 108 postmenopausal women scheduled for cardiac surgery and in 58 nonhospitalized control women. High sensitivity C-reactive protein levels were measured in the surgical patients. Preoperative cognitive impairment was defined as >2 sd lower scores on > or =2 tests compared with the controls. Cognitive impairment was present in 49 of 108 (45%) patients. C-reactive protein levels were higher for patients with compared with those without cognitive impairment (median, 8.1 mg/L versus 4.7 mg/L; P = 0.04). Based on multivariate logistic regression analysis, patient age, lower attained level of education, type 2 diabetes mellitus, and prior myocardial infarction identified risk for cognitive impairment (P < 0.05) but C-reactive protein levels did not (P = 0.09). In conclusion, cognitive impairment is prevalent in women before cardiac surgery. C-reactive protein levels are increased in women with this condition but the relationship between this inflammatory marker and preexisting cognitive impairment is likely secondary to the acute phase reactant serving as a marker for other predisposing conditions.

Aged↗
PubMed2006

Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices.

Neurologic complications after cardiac surgery are of growing importance for an aging surgical population. In this review, we provide a critical appraisal of the impact of current cardiopulmonary bypass (CPB) management strategies on neurologic complications. Other than the use of 20-40 microm arterial line filters and membrane oxygenators, newer modifications of the basic CPB apparatus or the use of specialized equipment or procedures (including hypothermia and "tight" glucose control) have unproven benefit on neurologic outcomes. Epiaortic ultrasound can be considered for ascending aorta manipulations to avoid atheroma, although available clinical trials assessing this maneuver are limited. Current approaches for managing flow, arterial blood pressure, and pH during CPB are supported by data from clinical investigations, but these studies included few elderly or high-risk patients and predated many other contemporary practices. Although there are promising data on the benefits of some drugs blocking excitatory amino acid signaling pathways and inflammation, there are currently no drugs that can be recommended for neuroprotection during CPB. Together, the reviewed data highlight the deficiencies of the current knowledge base that physicians are dependent on to guide patient care during CPB. Multicenter clinical trials assessing measures to reduce the frequency of neurologic complications are needed to develop evidence-based strategies to avoid increasing patient morbidity and mortality.

Brain Diseases↗
PubMed2005

Preoperative use of enoxaparin increases the risk of postoperative bleeding and re-exploration in cardiac surgery patients.

OBJECTIVE: The purpose of this study was to investigate if the preoperative use of new platelet inhibitors and low-molecular-weight heparins may contribute to bleeding after cardiac surgery. DESIGN: Retrospective data review. SETTING: University teaching hospital. PARTICIPANTS: One hundred eleven patients divided in 5 groups. INTERVENTIONS: Patients were grouped according to preoperative antithrombotic regimen: group 1, control, no agents (n=55); group 2, clopidogrel (n=9); group 3, enoxaparin (n=17); group 4, any GP IIb/IIIa inhibitor (n=14); and group 5, any drug combination (n=15). Data included cumulative mediastinal chest tube drainage, allogeneic blood transfusions, total blood donor exposures, and re-exploration. MEASUREMENTS AND MAIN RESULTS: Use of any drug (groups 2-5) resulted in greater total blood transfusions and donor exposure (p=0.0003) than control, especially red cells (p=0.002) and platelets (p=0.006). A greater percentage of patients on enoxaparin required mediastinal re-exploration for nonsurgical bleeding versus control (3/17 v 0/55, p=0.001). The use of enoxaparin was associated with significantly higher chest tube output after the first 24 hours postoperatively (p=0.048). CONCLUSION: Newer antithrombotic agents were associated with greater transfusion rates and total donor exposures. Enoxaparin use was associated with greater overall blood loss and with higher incidence of mediastinal re-exploration. The relative risk-benefit ratio of reduced periprocedure morbidity versus increased bleeding complications has yet to be determined.

Analysis of Variance↗
PubMed2005

Atrial fibrillation after cardiac surgery: an evidence-based approach to prevention.

A number of advances in surgical and anesthetic techniques have reduced the risk for patients undergoing cardiac surgery. However, postoperative atrial fibrillation remains common, with an incidence ranging between 25% and 40%. It is associated with an increased incidence of congestive heart failure, renal insufficiency, and stroke that prolongs hospitalization and increases rates of readmission after discharge. Consequently, there has been great interest in strategies to prevent this arrhythmia. When both safety and efficacy are considered, the available evidence to date suggests that only beta-blockers can be recommended for the prevention of atrial fibrillation after cardiac surgery. Other treatments might be considered on an individual basis after careful consideration of the patient's potential for side effects.

Anti-Arrhythmia Agents↗
PubMed2005

Pharmacologic prophylaxis: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.

New-onset atrial fibrillation (AF) occurs frequently in patients after cardiac surgery. The purpose of this study was to review the published trials and to provide clinical practice guidelines for pharmacologic prophylaxis against postoperative AF. Trials of pharmacologic prophylaxis against AF after heart surgery were identified by searching MEDLINE, the Cochrane Controlled Trials Register, and the bibliographies of published reports. Evidence grades and clinical recommendation scores were assigned to each prophylactic drug based on published evidence. Ninety-one trials were identified. The primary study design was a randomized, controlled trial of one drug vs placebo/usual care. Pharmacologic therapies that are reviewed include Vaughan-Williams class II agents (ie, beta-receptor antagonists) [29 trials; 2,901 patients], Vaughan-Williams class III agents (ie, sotalol and amiodarone) [18 trials; 2,978 patients], Vaughan-Williams class IV agents (ie, verapamil and diltiazem) [5 trials; 601 patients], and Vaughan-Williams class I agents (ie, quinidine and procainamide) [3 trials; 246 patients], as well as digitalis (10 trials; 1,401 patients), magnesium (14 trials; 1,853 patients), dexamethasone (1 trial; 216 patients), glucose-insulin-potassium (3 trials; 102 patients), insulin (1 trial; 501 patients), triiodothyronine (2 trials; 301 patients), and aniline (1 trial; 32 patients). A consistent finding in this review is that antiarrhythmic drugs with beta-adrenergic receptor-blocking effects (ie, class II beta-blockers, sotalol, and amiodarone) demonstrated successful prophylaxis. Furthermore, those therapies that did not inhibit beta-receptors generally failed to demonstrate a decreased incidence in postoperative AF. While sotalol and amiodarone have been shown in some studies to be effective, their safety and the incremental prophylactic advantage in comparison with beta-blockers has not been conclusively demonstrated. On the basis of evidence that has been reviewed and graded for quality, it is recommended that strong consideration should be given to the prophylactic administration of Vaughan-Williams class II beta-blocking drugs as a means of lowering the incidence of new-onset post-cardiac surgery AF.

Adrenergic beta-Antagonists↗
PubMed2005

Epidemiology, mechanisms, and risks: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.

Atrial fibrillation (AF) is one of the most frequent complications of cardiac surgery, affecting more than one third of patients. The mechanism of this arrhythmia is believed to be reentry. The electrophysiologic substrate may be preexisting or may develop due to heterogeneity of refractoriness after surgery. Multiple perioperative factors have been proposed to contribute to the latter, including operative trauma, inflammation, elevations in atrial pressure (including that due to left ventricular diastolic dysfunction), autonomic nervous system imbalance, metabolic and electrolyte imbalances, or myocardial ischemic damage incurred during the operation. Whether ectopic beats originating in the pulmonary veins explain at least some episodes of postoperative AF, as has been shown for nonsurgical patients with the arrhythmia, is of current interest as such sites could easily be isolated at the time of surgery. The development of postoperative AF is associated with a higher risk of operative morbidity, prolonged hospitalization, and increased hospital cost compared with that in patients remaining in sinus rhythm. Many factors have been identified as being associated with postoperative AF, but the most consistent variable across studies is increasing patient age. It is speculated that age-related pathologic changes in the atrium contribute to arrhythmia susceptibility. An important modifiable risk factor for postoperative AF is the failure to resume therapy with beta-adrenergic receptor blockers after surgery. The stratification of patients who are at higher risk for AF would focus preventative strategies on patients who are most likely to benefit from such therapy. Nonetheless, since postoperative AF often develops in patients with comorbidities who are predisposed to other complications and prolonged hospitalization, it is presently unclear whether the prevention of postoperative AF will result in improved patient outcomes, particularly shorter hospitalizations.

Age Factors↗
PubMed2004

Clinical prediction rule for atrial fibrillation after coronary artery bypass grafting.

OBJECTIVES: This study was designed to devise and validate a practical prediction rule for atrial fibrillation/atrial flutter (AF) after coronary artery bypass grafting (CABG) using easily available clinical and standard electrocardiographic (ECG) criteria. BACKGROUND: Reported prediction rules for postoperative AF have suffered from inconsistent results and controversy surrounding the added predictive value of a prolonged P-wave duration. METHODS: In 1,851 consecutive patients undergoing CABG with cardiopulmonary bypass, preoperative clinical characteristics and standard 12-lead ECG data were examined. Patients were continuously monitored for the occurrence of sustained postoperative AF while hospitalized. Multiple logistic regression was used to determine significant predictors of AF and to develop a prediction rule that was evaluated through jackknifing. RESULTS: Atrial fibrillation occurred in 508 of 1,553 patients (33%). Multivariate analysis showed that greater age (odds ratio [OR] 1.1 per year [95% confidence intervals (CI) 1.0 to 1.1], p < 0.0001), prior history of AF (OR 3.7 [95% CI 2.3 to 6.0], p < 0.0001), P-wave duration >110 ms (OR 1.3 [95% CI 1.1 to 1.7], p = 0.02), and postoperative low cardiac output (OR 3.0 [95% CI 1.7 to 5.2], p = 0.0001) were independently associated with AF risk. Using the prediction rule we defined three risk categories for AF: <60 points, 61 of 446 (14%); 60 to 79 points, 330 of 908 (36%); and >or=80 points, 117 of 199 (59%). The area under the receiver-operator characteristic curve for the model was 0.69. CONCLUSIONS: These data show that post-CABG AF can be predicted with moderate accuracy using easily available patient characteristics and may prove useful in prognostic and risk stratification of patients after CABG. The presence of intraatrial conduction delay on ECG contributed least to the prediction model.

Adrenergic beta-Antagonists↗
PubMed2004

Atrial fibrillation and cardiac surgery.

PURPOSE OF REVIEW: To discuss the pathophysiology, risk factors, and treatments for atrial fibrillation occurring after cardiac surgery. RECENT FINDINGS: Atrial fibrillation occurs frequently after cardiac surgery and it may lead to patient morbidity. Many variables have been suggested to be associated with this arrhythmia, but only advanced patient age can consistently identify risk for this complication. Immediate electrical cardioversion is indicated when the arrhythmia leads to hemodynamic instability or myocardial ischemia. Otherwise treatment is aimed at heart rate control, elective cardioversion with drugs or electrical means, and anticoagulation when the arrhythmia persists. Multiple investigations have evaluated methods for preventing postoperative atrial fibrillation, but only beta-adrenergic receptor blocking drugs have been consistently shown to be effective, and then not in all patients. Surgical treatments are increasingly being considered as a therapeutic means for ameliorating chronic atrial fibrillation. The use of these procedures has been simplified with the development of devices that can generate linear scars in the atrium and around the pulmonary vein orifices. These simplifications will allow for broader application of these techniques to patients undergoing other cardiac surgery (e.g. mitral valvular surgery). SUMMARY: Atrial fibrillation is one of the most common complications of cardiac surgery. There are three major aims for treating atrial fibrillation: conversion to sinus rhythm, heart rate control, and anticoagulation. Only beta-blockers can be recommended for prophylaxis against postoperative atrial fibrillation. Further refinements in surgical treatments for atrial fibrillation may allow for wider applications of this therapy with lower rates of complications.

Journal Article↗
PubMed2004

Atrial fibrillation after cardiac surgery: pathophysiology and treatment.

Atrial fibrillation (AF) occurs in 25% to 60% of patients after cardiac surgery. It is most consistently associated with advanced age and valvular heart operations. Despite improving knowledge of the pathophysiology of chronic AF, postoperative AF remains an obstinate clinical problem. It is associated with an increased risk of stroke, longer hospital stay, and higher hospital expenditure. Consequently, there has been great interest in strategies to prevent and treat this arrhythmia. Treatment for postoperative AF may require immediate electrical cardioversion for hemodynamically unstable patients. Heart rate control is useful in most patients, with anticoagulation considered after 48 hours. Antiarrhythmic therapy is often effective in restoring sinus rhythm but its use needs to be balanced against the patient's risk of proarrhythmic side effects such as torsade de pointes.

Anti-Arrhythmia Agents↗
PubMed2004

Vasopressin during spinal anesthesia in a patient with primary pulmonary hypertension treated with intravenous epoprostenol.

Primary pulmonary hypertension (PPH) is a progressive disease with frequent morbidity and mortality, including the risk of cardiac decompensation and death, during general anesthesia. Administration of IV epoprostenol (Flolan) improves symptoms and survival of patients with PPH and thus is an increasingly used long-term treatment for this condition. This therapy is associated with impaired platelet aggregation, which may complicate the perioperative management of patients with PPH. We present a case report of a patient with severe PPH receiving a continuous epoprostenol infusion undergoing skin grafting for a leg ulcer under spinal anesthesia. An IV infusion of vasopressin was given to prevent systemic hypotension resulting from sympathetic blockade while avoiding increases in pulmonary vascular resistance that may have resulted from catecholamine usage.

Anesthesia, Spinal↗
PubMed2003

Gender influence on cognitive function after cardiac operation.

BACKGROUND: Women are at higher risk than men for stroke after cardiac operation. The purpose of this study was to evaluate for gender influences on the more common postoperative neurologic complication, cognitive dysfunction. METHODS: A standard battery of neuropsychological tests was administered to 117 patients (79 men and 38 women) the day before and again 4 to 6 weeks after cardiac operation. The battery assessed a broad array of cognitive domains, including attention, memory, executive function, and psychomotor processing speed. Analysis was performed only on patients with data from both testing sessions. Data were analyzed to assess for a dichotomous definition of postoperative cognitive impairment and to evaluate for factors influencing test results for specific cognitive domains. RESULTS: The frequency of one standard deviation decline on two or more cognitive tests compared with preoperative results (women, 10.7 % versus men, 9.9 %; p = 0.527), no decline, or one standard deviation improvement on each test postoperatively was no different between genders. After adjusting for age, gender, preexisting medical conditions, level of attained education, preoperative cognitive tests results, type of operation, and duration of cardiopulmonary bypass, female gender was independently associated with poorer performance postoperatively on visuospatial tasks. Other variables significantly related to postoperative cognitive function varied among the specific cognitive domains. CONCLUSIONS: These data suggest that, although the frequency of cognitive dysfunction after cardiac operation is similar for women and men, women appear more likely to suffer injury to brain areas subserving visuospatial processing. Risk factors for postoperative cognitive impairment vary depending on cognitive domain, suggesting multiple etiologies for this form of perioperative neurologic injury.

Cardiac Surgical Procedures↗
PubMed2003

The importance of prior stroke for the adjusted risk of neurologic injury after cardiac surgery for women and men.

BACKGROUND: Women are at higher risk for stroke after cardiac surgery than men. Prior analysis of risk profiles for perioperative stroke that have mostly combined data from women and men may fail to identify gender-specific risks. The purpose of this study was to evaluate whether patient gender impacts adjusted risk for stroke after cardiac surgery. METHODS: Demographic and perioperative data were prospectively collected from 2,972 patients undergoing cardiac surgery. Carotid artery ultrasound examination was performed before surgery for patients aged 65 yr or older or when there was a history of transient ischemic attacks or prior stroke. Epiaortic ultrasound was performed at the time of surgery in all patients to assess for atherosclerosis of the ascending aorta. RESULTS: Strokes occurred after surgery in 30 women and 18 men (P < 0.0001). Based on multivariate logistic regression analysis, a history of a stroke was the strongest predictor of new stroke for both women and men. Low cardiac output syndrome, atherosclerosis of the ascending aorta, and diabetes mellitus were significantly associated with stroke for women but not for men. Analysis on the data from all patients using a gender-interaction term found that the risk for stroke associated with patient age, atherosclerosis of the aorta, diabetes, and duration of cardiopulmonary bypass was not affected by gender. The prior stroke-gender interaction, however, was significant (P = 0.017), suggesting that a prior cerebrovascular event was a more important predictor of stroke for men than women. CONCLUSIONS: These data show that prior stroke before surgery is strongly and independently associated with susceptibility for stroke after cardiac surgery, particularly for men. Other risk factors for perioperative stroke, though, do not appear to be influenced by patient gender.

Aged↗
PubMed2002

Autonomic nervous system responses during sedative infusions of dexmedetomidine.

BACKGROUND: The purpose of this study was to determine the effects of dexmedetomidine on systemic and cardiac autonomic reflex responses during rest and during thermal stress. METHODS: Volunteers received either placebo or low- or high-dose dexmedetomidine (target plasma concentrations 0.3 or 0.6 ng/ml, respectively) infusions in a prospectively randomized, double-blinded crossover study design. After 1 h, baroreflex sensitivity was assessed, and then core body temperature was raised to the sweating threshold and then lowered to the shivering threshold. Plasma catecholamines and blood pressure were measured, and cardiac autonomic responses were assessed by analysis of heart rate variability. RESULTS: Compared with placebo, plasma norepinephrine concentrations, blood pressure, heart rate, and some heart rate variability measures were lower after 1-h infusion of dexmedetomidine, but baroreflex responses did not differ significantly. Dexmedetomidine blunted the systemic and cardiac sympathetic effects of sweating observed during placebo infusion but had no effect on parasympathetic measures. Increases in blood pressure, and systemic catecholamines due to shivering were observed during placebo and dexmedetomidine, but these responses were less with dexmedetomidine. During shivering, dexmedetomidine infusion was associated with higher low-frequency and high-frequency heart rate variability power but lower heart rate compared with the sweating threshold and with the control period, suggesting nonreciprocal cardiac autonomic responses. CONCLUSIONS: Infusion of dexmedetomidine results in compensated reductions in systemic sympathetic tone without changes in baroreflex sensitivity. Dexmedetomidine blunts heart rate and the systemic sympathetic activation due to sweating, but it is less effective in blunting cardiac sympathetic responses to shivering. During dexmedetomidine infusion, cardiac sympathetic and parasympathetic tone may have nonreciprocal changes during shivering.

Adult↗