Coronary revascularisation stents

For more than two decades, the most durable and effective option for revascularisation of the left coronary artery has been an internal mammary artery graft which, unlike vein grafts, is almost immune to the development of atherosclerosis. This strategy significantly reduces the risk of death, subsequent myocardial infarction, recurrent angina, and the need for repeat intervention.

However, because surgery has conventionally required a sternotomy incision and cardiopulmonary bypass, many cardiologists have favoured the less invasive option of percutaneous revascularisation with stents, unless this is contraindicated by certain anatomical or pathological complexities.

Two recent BMJ studies, one a systematic review and meta-analysis, the other a cost effectiveness analysis, report that internal mammary artery grafting using a less invasive surgical approach is clinically at least as effective and probably more cost effective than stenting over the medium to long term.

Compared with surgery, stenting resulted in an almost threefold increase in recurrent angina and an almost fourfold increase in the need for reintervention.

Several trials of stents versus surgery in patients with multivessel coronary artery disease have reported no survival benefit from surgery. However, the trials randomised less than 5% of all potentially eligible patients and included only low risk patients. In effect, therefore, these trials were biased against the prognostic benefit of surgery in most patients with multivessel disease. Several large registries show that most patients with multivessel disease survive significantly longer after coronary artery bypass grafting rather than stenting, and the benefit is even greater in patients with diabetes, who usually have more severe coronary artery disease.

A study of the cost effectiveness of medical treatment, stenting, and surgery concludes that both medical treatment and surgery (but not stents) are cost effective at a conventional National Health Service quality adjusted life year threshold of £30 000 and that the additional benefit of percutaneous coronary intervention over medical treatment is too small to justify its additional costs.

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Hand washing—again!

Despite the high profile given to hand washing in hospitals, there is still little robust evidence to show which are the best ways to improve hand hygiene.

Health care-associated infection is a major cause of illness and death, and effective hand hygiene is thought to be one of the best ways to prevent it. A  team of Cochrane Researchers therefore performed a systematic review to determine whether strategies to improve hand hygiene are effective.

Sadly they could only locate two trials that were worthy of consideration, and both were poorly controlled. The conclusion they could draw was that a single teaching session was unlikely to improve hand hygiene even in the short-term.

We desperately need some good research that will begin to show which interventions can bring about change in people's behaviour that will lead to increased hand hygiene," says Dinah Gould, Cochrane Review Author, who works at the School of Nursing and Midwifery at City University, London.
 

"In addition to preventing unnecessary spread of disease, good hand hygiene is highly desirable on aesthetic grounds alone, it forms an important indicator of the quality of health care and should continue to be promoted in all clinical settings," says Gould.

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Post operative thrombosis

New guidelines launched by the National Institute for Health and Clinical Excellence (NICE) are set to tackle the continuing problem of potentially life-threatening venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients who have undergone surgery. The guideline covers all patients admitted to hospital for an operation requiring an overnight stay.

Deep vein thrombosis (DVT) occurs in over 20% of surgical patients and over 40% of patients undergoing major orthopaedic surgery. Most of these thromboses are minor; the blood clot itself is not life threatening, and more often than not does not cause any symptoms. But if the blood clot comes loose it can travel in the blood stream to the lungs and cause a life threatening obstruction; a pulmonary embolism. Pulmonary embolism following lower limb DVT is the cause of death in 10% of patients who die in hospital, many of them after surgery. Even if a blood clot does not come loose, it can still cause long-term damage to the veins: for example, ‘post-phlebitic syndrome’ may develop after some years, causing chronic swelling and ulceration of the legs.

The degree of risk of embolism is dependent on factors inherent in the type of operation being carried out, as well as factors related to the individual patient – for example, whether they are overweight or have longstanding problems with their heart or lungs.

It is the combination of these factors that defines certain patients as being at ‘high risk’ of VTE. The guideline therefore recommends that all patients are assessed on admission to hospital to identify their individual risk of developing a VTE and that appropriate steps are taken to reduce any risk.

The guideline proposes a three step strategy for deciding the appropriate form of prevention. First, most people should be offered compression stockings to wear whilst in hospital, and for many the use of inflatable “boots” during the operation (to encourage blood flow in the legs) will also be beneficial.

Secondly, the guideline recommends that blood thinning medication, such as low molecular weight heparin or fondaparinux, should be given to all people having orthopaedic surgery and to other surgical patients who are at high risk of developing VTE. For people having surgery to mend a broken hip, this blood thinning medication should be continued for four weeks.

Thirdly, in some patients for whom it is feasible, the guideline recommends that regional anaesthesia (such as an “epidural” anaesthetic) instead of general anaesthesia would further reduce the risk of VTE, and should be considered.

Professor Colin Baigent, Clinical Epidemiologist and member of the GDG, said: "In many surgical patients the appropriate form of protection against blood clots is both compression stockings and heparin, but very often they are offered just one of these treatments. This guideline should ensure that both are considered routinely and thereby help avoid much unnecessary suffering caused by blood clots in the legs and pulmonary embolism.”

One of the reasons clots develop in the veins is that patients who have undergone surgery are often lying or sitting still for long periods of time. The guideline recommends that healthcare professionals encourage patients to get up and move around as soon as is possible and safe after surgery.

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