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Biomedical subjects

Peter Rickenbacher

Publications and source records attributed to Peter Rickenbacher.

8 recordsLinked to original sources
PubMed2007

Unusual VDD-pacing.

The case of an 80-year-old woman who underwent permanent VDD-pacemaker implantation for recurrent syncope in the presence of second-degree type 2 AV-block is reported. During follow-up, low atrial sensing with AV-synchrony of only 58-73% was noted. Four years after the pacemaker implantation, the patient was hospitalized for non-cardiac reasons and the chest radiograph showed displacement of the atrial dipole into the right ventricular outflow tract (RVOT). It is hypothesized that AV-synchrony was maintained by left atrial sensing due to the anatomic proximity of the RVOT to the left atrial appendage.

Aged, 80 and over↗
PubMed2006

Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare-metal stents.

OBJECTIVES: We sought to define the incidence of late clinical events and late stent thrombosis in patients treated with drug-eluting (DES) versus bare-metal stents (BMS) after the discontinuation of clopidogrel as well as their timing and outcome. BACKGROUND: There is growing concern that delayed endothelialization after DES implantation may lead to late stent thrombosis and related myocardial infarction (MI) or death. However, event rates and outcomes after clopidogrel discontinuation versus BMS are unknown. METHODS: A consecutive series of 746 nonselected patients with 1,133 stented lesions surviving 6 months without major events were followed for 1 year after the discontinuation of clopidogrel. Patients were assigned randomly 2:1 to DES versus BMS in BASKET (Basel Stent Kosten Effektivitäts Trial). The primary focus of this observation was cardiac death/MI. RESULTS: Rates of 18-month cardiac death/MI were not different between DES and BMS patients. However, after the discontinuation of clopidogrel (between months 7 and 18), these events occurred in 4.9% after DES versus 1.3% after BMS implantation. Target vessel revascularization remained lower after DES, resulting in similar rates of all clinical events for this time period (DES 9.3%, BMS 7.9%). Documented late stent thrombosis and related death/target vessel MI were twice as frequent after DES versus BMS (2.6% vs. 1.3%). Thrombosis-related events occurred between 15 and 362 days after the discontinuation of clopidogrel, presenting as MI or death in 88%. CONCLUSIONS: After the discontinuation of clopidogrel, the benefit of DES in reducing target vessel revascularization is maintained but has to be balanced against an increase in late cardiac death or nonfatal MI, possibly related to late stent thrombosis.

Aged↗
PubMed2006

Management of elderly patients with congestive heart failure--design of the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF).

BACKGROUND: Little is known about the management of elderly patients with congestive heart failure (CHF) although they represent the majority of the CHF population. Therefore, the TIME-CHF study was set up (1) to evaluate the medical management of very old patients (> or = 75 years) with CHF compared with younger patients (60-74 years), (2) to compare an intensified with a standard treatment approach, and (3) to differentiate between systolic and diastolic dysfunction (ejection fraction < or = 45% vs > 45%). METHODS: In a prospective single-blinded multicenter trial, 824 symptomatic patients, CHF hospitalization within the last year and elevated NT-BNP, are randomized to an intensified versus a standard medical therapy. Treatment strategies follow the published guidelines with the aim to reduce symptoms to NYHA class < or = II (standard) or, additionally, NT-BNP levels below twice the upper limit of normal (intensified). The primary end points are 18-month hospitalization-free survival and quality of life. RESULTS: By the end of 2004, 297 patients have been included, 147 randomized to intensified and 150 to standard therapy. Mean age in the older age group was 82 +/- 4 years (n = 174) and 69 +/- 4 years in the younger group (n = 123), respectively. Ejection fraction was > 45% in 26% and 10%, respectively. Significant comorbidities were present in 93% of patients. CONCLUSION: TIME-CHF will be the first prospective randomized trial to comprehensively study the management of elderly patients with CHF. It will provide unique information comparing two treatment strategies in two age groups irrespective of ejection fraction regarding prognosis, quality of life, as well as resource utilization and costs.

Aged↗
PubMed2005

Long-term performance of a simple algorithm for early discharge after ruling out acute coronary syndrome: a prospective multicenter trial.

STUDY OBJECTIVES: To test the short- and long-term performance of a simple algorithm to detect or rule out acute coronary artery disease (CAD) in patients referred with acute chest pain (CP). DESIGN: Prospective, multicenter study with 30-day and 1-year follow-ups. SETTING: Emergency and coronary care units of two university hospitals and four affiliated teaching hospitals in a suburban region of northern Switzerland. PATIENTS: One hundred sixty-one consecutive patients referred with acute CP with a high CAD risk profile underwent exercise testing (ET) within 24 h if results of two troponin tests and ECG remained normal within 6 h. The patients were discharged if ET results were negative or underwent angiography if the results were positive. MEASUREMENTS AND RESULTS: The primary end point was survival free of death, myocardial infarction (MI), and acute coronary syndrome, as well as the correct diagnosis of CAD in need of revascularization. Failure of the algorithm included events not predicted and false-positive ET results. Symptom-limited ET was performed in 142 patients, and stress imaging was performed in 17 patients. Discharge within 24 h was possible in 76%. Angiography in 21 patients showed no CAD in 4 patients, whereas revascularization was necessary in 17 patients. During follow-up, three patients had an MI (one fatal) and two patients had unstable angina, for an event rate of 3.1%/yr. Overall sensitivity of the algorithm to detect CAD was 71%, whereby six of seven false-positive ET results were due to exercise-induced CP without ECG changes. More importantly, the negative predictive value was 96.4%, indicating that this simple algorithm failed to identify only 3.6% of patients at risk for future events. CONCLUSIONS: Discharge within 24 h after onset of acute CP in high-risk CAD patients is safe, irrespective of CAD history, if ECG findings remain unchanged and troponin test results are normal within 6 h, and if results of adequate ET are negative.

Acute Disease↗
PubMed2004

Cost-effectiveness of invasive versus medical management of elderly patients with chronic symptomatic coronary artery disease. Findings of the randomized trial of invasive versus medical therapy in elderly patients with chronic angina (TIME).

AIM: To compare benefits and costs of invasive versus medical management in elderly patients with chronic angina. METHODS AND RESULTS: In a predefined subgroup of 188 patients of the Trial of Invasive versus Medical therapy in Elderly patients with chronic angina (TIME), one-year benefits were assessed as freedom from major events and improvements in symptoms and quality of live. Costs were determined as one-year costs of resource utilisation. Invasive patients had higher 30-day, but lower months 2-12 hospital and intervention costs than medical patients, resulting in somewhat higher one-year costs for invasive management (p=0.08). However, billing data available for a subgroup of patients showed higher practitioner's charges in the medical patients (adjusted p=0.0015). Incremental costs to prevent one major event by invasive management averaged CHF 10100 (95% CI: -800 to 28300) or 6965, ranging from average CHF 5100 (euro 3515) to CHF 11600 (euro 8000) in a best, compared to a worst, case scenario. CONCLUSIONS: Early increased costs of revascularization in invasive patients were balanced after one year by increased practitioners' charges and symptom-driven late revascularizations in medical patients. Therefore, the invasive strategy with improved clinical effectiveness at only marginally higher costs as medical management was cost-effective. Costs should not be an argument against invasive management of elderly patients with chronic angina.

Aged↗
PubMed2003

Outcome of elderly patients with chronic symptomatic coronary artery disease with an invasive vs optimized medical treatment strategy: one-year results of the randomized TIME trial.

CONTEXT: The risk-benefit ratio of invasive vs medical management of elderly patients with symptomatic chronic coronary artery disease (CAD) is unclear. The Trial of Invasive versus Medical therapy in Elderly patients (TIME) recently showed early benefits in quality of life from invasive therapy in patients aged 75 years or older, although with a certain excess in mortality. OBJECTIVE: To assess the long-term value of invasive vs medical management of chronic CAD in elderly adults in terms of quality of life and prevention of major adverse cardiac events. DESIGN: One-year follow-up analysis of TIME, a prospective randomized trial with enrollment between February 1996 and November 2000. SETTING AND PARTICIPANTS: A total of 282 patients with Canadian Cardiac Society class 2 or higher angina despite treatment with 2 or more anti-anginal drugs who survived for the first 6 months after enrollment in TIME (mean age, 80 years [range, 75-91 years]; 42% women), enrolled at 14 centers in Switzerland. INTERVENTIONS: Participants were randomly assigned to undergo coronary angiography followed by revascularization (if feasible) (n = 140 surviving 6 months) or to receive optimized medical therapy (n = 142 surviving 6 months). MAIN OUTCOME MEASURES: Quality of life, assessed by standardized questionnaire; major adverse cardiac events (death, nonfatal myocardial infarction, or hospitalization for acute coronary syndrome) after 1 year. RESULTS: After 1 year, improvements in angina and quality of life persisted for both therapies compared with baseline, but the early difference favoring invasive therapy disappeared. Among invasive therapy patients, later hospitalization with revascularization was much less likely (10% vs 46%; hazard ratio [HR], 0.19; 95% confidence interval [CI], 0.11-0.32; P<.001). However, 1-year mortality (11.1% for invasive; 8.1% for medical; HR, 1.51; 95% CI, 0.72-3.16; P =.28) and death or nonfatal myocardial infarction rates (17.0% for invasive; 19.6% for medical; HR, 0.90; 95% CI, 0.53-1.53; P =.71) were not significantly different. Overall major adverse cardiac event rates were higher for medical patients after 6 months (49.3% vs 19.0% for invasive; P<.001), a difference which increased to 64.2% vs 25.5% after 12 months (P<.001). CONCLUSIONS: In contrast with differences in early results, 1-year outcomes in elderly patients with chronic angina are similar with regard to symptoms, quality of life, and death or nonfatal infarction with invasive vs optimized medical strategies based on this intention-to-treat analysis. The invasive approach carries an early intervention risk, while medical management poses an almost 50% chance of later hospitalization and revascularization.

Aged↗
PubMed1997

Age-Dependent Prevalence of Cardioembolic Sources Detected by TEE: Diagnostic and Therapeutic Implications.

To define the prevalence of cardioembolic sources found by transesophageal echocardiography (TEE) in different age groups of patients with and without cryptogenic systemic embolism, TEE risk factors for cardiogenic embolism were identified from 341 consecutive patients referred for TEE. One hundred and thirty-five had cryptogenic cerebral or systemic peripheral embolic events (CEE) and 206 other indications for TEE (CTR). Cardioembolic sources were found in 40% of CEE and in 29% of CTR (P < 0.02). Specifically, left atrial (LA) thrombi (P < 0.0001), atrial septal aneurysm with right-to-left shunt (P < 0.002), and atherosclerotic aortic plaques (P < 0.02) were more frequent. The prevalence of potential cardioembolic sources was significantly higher in patients >/= 70-years old than in younger patients (P < 0.03), specifically LA thrombi (P < 0.004) and atherosclerotic aortic plaques (P < 0.0001). In patients >/= 70-years old, potential cardioembolic sources were found in 63% and in 40% in CEE and CTR (P = 0.073), respectively. However, LA thrombi were more frequent in CEE (P < 0.003). Thus, potential cardioembolic sources observed by TEE are found more frequently in patients >/= 70-years old than in younger patients. LA thrombi were more frequent in CEE than in CTR patients >/= 70-years old. In patients >/= 70-years old with CEE who are eligible for an anticoagulant regimen, a search for potential cardioembolic sources by TEE should be considered.

Journal Article↗