All physicians increasingly will encounter patients who have implanted cardioverter-defibrillators (ICDs) for protection from ventricular arrhythmias. This advisory provides a concise summary relevant to the assessment and management of patients with ICDs, including those who present to primary care or emergency department physicians with symptoms suggesting arrhythmia or ICD malfunction and those who require cardiac or surgical procedures.

This article summarizes epidemiological studies of inflammation markers, particularly C-reactive protein, and cardiovascular disease as of early 2002. Gaps in the research and the public health practice implications are also discussed. Although considerable work has been published since this review was completed, the perspectives and issues presented are still useful in evaluating the use of inflammation markers for risk stratisfication and prevention.

Venous thromboembolism (VTE) is a common complication of surgical procedures. The risk for VTE in surgical patients is determined by the combination of individual predisposing factors and the specific type of surgery. Prophylaxis with mechanical and pharmacological methods has been shown to be effective and safe in most types of surgery and should be routinely implemented. For patients undergoing general, gynecologic, vascular, and major urologic surgery, low-dose unfractionated heparin or low-molecular-weight heparin (LMWH) are the options of choice. For low-risk urologic surgery, early postoperative mobilization of patients is the only intervention warranted. For higher-risk patients, including those undergoing elective hip or knee replacement and surgery for hip fracture, vitamin K antagonists, LMWH, or fondaparinux are recommended. For patients undergoing neurosurgery, graduated elastic stockings are effective and safe and may be combined with LMWH to further reduce the risk of VTE. The role of prophylaxis is less defined in patients undergoing elective spine surgery, as well as laparoscopic and arthroscopic surgery. A number of issues related to prophylaxis of VTE after surgery deserve further clarification, including the role of screening for asymptomatic deep vein thrombosis, the best timing for initiation of pharmacological prophylaxis, and the optimal duration of prophylaxis in high-risk patients.

Systematic cost-effectiveness analyses of regimens used for preventing venous thromboembolism (VTE) are becoming increasingly important for several reasons: the aging of the population, with an accompanying increase in admissions for orthopedic procedures or other surgery; expanded indications for thromboprophylaxis in nonsurgical patients; and the introduction of more expensive new agents that may increase safety and efficacy. At the same time, health care systems are under unprecedented pressure to contain the costs of care, particularly medications. Such economic analyses are made more difficult by the paucity of clinical trials comparing treatment regimens to one another rather than to placebo. Several methodological issues must be kept in mind when evaluating cost-effectiveness analyses of VTE prophylaxis. These include the perspective from which the analysis is performed (eg, the health care system as a whole versus a particular payer), limitations of trial data (eg, artificially short time horizons), and definition of outcomes (eg, flawed definition and grouping together of adverse effects or treatment failures). Quantifying costs across nations and health care systems is problematic as well. Another challenge is the extrapolation of efficacy data from highly monitored study patients to routine practice settings. Nevertheless, cost-effectiveness analyses of VTE treatments conducted in orthopedic surgery, trauma, general surgery, and acute medical settings can help define the relationships among expenditures, adverse outcomes, and patient benefit for particular therapeutic strategies in a variety of clinical situations.

Idiopathic venous thromboembolism (VTE), unassociated with surgery or trauma, is a chronic illness that warrants the implementation of strategies to prevent recurrence over a lifetime. Clinical trials show that the benefit associated with extended anticoagulation therapy < or =1 year in patients with idiopathic VTE is not maintained over the long term once treatment is discontinued. Controlled trials have established the efficacy of indefinite-duration anticoagulation, even if the therapy used is a novel agent that is not a coumarin derivative. The PREVENT, ELATE, and THRIVE III trials demonstrate that a strategy of long-term anticoagulation in patients with idiopathic VTE, including those with isolated calf deep vein thrombosis, is safe and effective. This successful strategy appears beneficial across all subgroups, regardless of the presence of an identified thrombophilic state. These include both young and old patients of both sexes, those with factor V Leiden or the prothrombin gene mutation, and those with first-time or recurrent VTE. Thus, the default strategy for idiopathic VTE should be universal anticoagulation unless contraindicated. Implementing this proven approach on a population basis would enable prevention of VTE recurrence with minimal individualization of treatment. Because lifelong therapy can exact a psychological and medical cost on the patient as well as the health care provider, future research should be directed to risk stratification of those most susceptible to recurrence. Avenues of investigation currently being evaluated include measurement of d-dimer levels, examination of residual venous thrombosis on ultrasound, and application of risk nomograms.

Given the increased number of patients hospitalized for acute medical illnesses and the associated risk of venous thromboembolism (VTE), the use of prophylaxis has become a public health matter. Thromboprophylaxis is not widely practiced in acutely ill medical patients, due in part to the heterogeneity of this group and the perceived difficulty in assessing those who would most benefit from treatment. Nevertheless, the results of recent well-conducted clinical trials support the evidence-based recommendations for more widespread systematic use of low-dose low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) in this population. Three large well-controlled studies (MEDENOX, PREVENT, and ARTEMIS) in acutely ill medical patients confirm previous findings that different at-risk patient populations show a consistent 50% reduction in VTE events with LMWH and fondaparinux. A meta-analysis in nearly 5000 patients in internal medicine comparing UFH and LMWH revealed a trend for reduction of deep vein thrombosis and pulmonary embolism with LMWH. Based on duration of use in clinical trials in acutely ill medical patients, prophylactic treatment with UFH and LMWH is recommended for 2 weeks.

Research published in Circulation has shown that cardiac mortality is highest during December and January. We investigated whether some of this spike could be ascribed to the Christmas/New Year's holidays rather than to climatic factors.

Outcome after cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002, a task force of the International Liaison Committee on Resuscitation (ILCOR) met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (ie, essential and desirable) data elements recommended by previous Utstein consensus conferences. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (registries) and research reports and that should be applicable to both adults and children. The revised and simplified template includes practical and succinct operational definitions. It is anticipated that the revised template will enable better and more accurate completion of all reports of cardiac arrest and resuscitation attempts. Problems with data definition, collection, linkage, confidentiality, management, and registry implementation are acknowledged and potential solutions offered. Uniform collection and tracking of registry data should enable better continuous quality improvement within every hospital, emergency medical services system, and community.