Graham S. Hillis

Background—Severe renal dysfunction is associated with a worse outcome after coronary artery bypass graft surgery (CABG). Less is known about the effects of milder degrees of renal impairment, and previous studies have relied on levels of serum creatinine, an insensitive indicator of renal function. Recent studies have suggested that estimated glomerular filtration rate (eGFR) is a more discriminatory measure. However, data on the utility of eGFR in predicting outcome from CABG are limited.Methods and Results—We studied 2067 consecutive patients undergoing CABG. Demographic and clinical data were collected preoperatively, and patients were followed up a median of 2.3 years after surgery. Estimated GFR was calculated from the Modification of Diet in Renal Disease equation. The primary outcome was all-cause mortality. Mean±SD eGFR was 57.9±17.6 mL/min per 1.73 m²in the 158 patients who died during follow-up compared with 64.7±13.8 mL/min per 1.73 m²in survivors (hazard ratio [HR], 0.71 per 10 mL/min per 1.73 m²; 95% CI, 0.64 to 0.80;P2; 95% CI, 0.72 to 0.89;P2; 95% CI, 0.78 to 0.98;P=0.02).Conclusions—Estimated GFR is a powerful and independent predictor of mortality after CABG.

Introduction Transthoracic echocardiography is one of the most commonly performed cardiac investigations. It can provide comprehensive information about cardiac structure and function, helping to establish a diagnosis and guide therapy, and is no longer the preserve of the specialist cardiology department. Examinations are frequently requested by doctors in other branches of medicine; they need to know what questions an echocardiogram can, and cannot, answer. Echocardiography images are best viewed as moving pictures. These are shown on bmj.com, several with the motion of a full cardiac cycle. The website also contains brief explanations of the commonly used imaging modalities.

Background: Current guidelines recommend that patients with acute myocardial infarction should receive thrombolysis within 60 min of seeking professional help. Aim: To compare current rates of pre-hospital thrombolysis in Grampian with historical data, and assess the effect of pre-hospital thrombolysis on the proportion of patients achieving ‘call-to-needle’ times within national guidelines. Design: Prospective audit. Methods: Data were collected on all patients (n = 535) admitted to the coronary care unit and thrombolysed, either in hospital or in the community from July 2000 to June 2002, using standardized forms. Results: One hundred and thirty-three patients (25%) received pre-hospital thrombolysis and 402 (75%) received in-hospital thrombolysis. This compares with a 19% (195/1046) pre-hospital thrombolysis rate in the mid-1990s (p = 0.005). Median ‘call-to-needle’ times were 45 min for pre-hospital thrombolysis and 105 min for patients who received in-hospital thrombolysis (p < 0.001). Only 24% (96/396) of patients receiving in-hospital thrombolysis were treated within the recommended guideline, vs. 79% (88/111) of pre-hospital thrombolysis patients (p < 0.001). Discussion: Pre-hospital thrombolysis rates in Grampian are increasing. Administration of thrombolysis in the community greatly increases the proportion of patients achieving a ‘call-to-needle’ time of 60 min, with a median time saving of ∼1 h.