Primary and Secondary Prevention of CAD: A Review.

Coronary artery disease is the leading cause of death in both men and women, yet adequate control of risk factors can largely reduce the incidence and recurrence of cardiac events. In this review, we discuss various life style and pharmacological measures for both the primary and secondary prevention of coronary artery disease. With a clear understanding of management options, health care providers have an excellent opportunity to educate patients and ameliorate a significant burden of morbidity and mortality.

Effects of pressure variation and atrial fibrillation on CardioMEMS™ HF measured pulmonary artery diastolic pressure: comparison of device-averaged and visually inspected waveforms.

OBJECTIVE: Heart failure (HF) management guided by implantable hemodynamic monitoring reduces hospitalization rates. Hemodynamic data from the CardioMEMS™ HF system includes device-averaged pulmonary artery pressures (PAP) and heart rate. Agreement of device-averaged values compared to the standard method of visual inspection of pressure waveforms at end-expiration is unknown. We evaluated the agreement between device-averaged and visually inspected end-expiratory PAP. APPROACH: Twenty-one patients implanted with the CardioMEMS™ HF system were evaluated. Eight-hundred twenty-three PAP waveforms from the Merlin remote monitoring website were visually inspected and pulmonary artery systolic pressure (PASP) and pulmonary artery diastolic pressure (PADP) at end-expiration were recorded. Waveforms were evaluated for pressure variation (PV), defined as the difference between highest and lowest PASP measurement of ⩾20 mmHg. Bland-Altman analysis quantified differences between device-averaged and visually inspected waveforms. MAIN RESULTS: All patients were NYHA functional class III, mean age was 67 ± 15 years and 15 (71%) had AF. Bland-Altman analysis of all waveforms revealed a mean-difference in PADP of -1.4 mmHg, indicating that visually inspected values were higher than device-averaged values. For PV ⩾20 mmHg, this value increased to -2.8 mmHg. The mean-difference comparing waveforms from patients with or without AF was -1.3 and -1.6 mmHg, respectively. The 95% limits of agreement were >50% wider for waveforms from patients with versus without AF (10.3 versus 6.7 mmHg). SIGNIFICANCE: There is good agreement between device-averaged and visually inspected waveforms when pressure variation is <20 mmHg and for patients without atrial fibrillation.

Haemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomised controlled trial.

BACKGROUND: The administration of intravenous fluid remains the cornerstone treatment for the prevention of contrast-induced acute kidney injury. However, no well-defined protocols exist to guide fluid administration in this treatment. We aimed to establish the efficacy of a new fluid protocol to prevent contrast-induced acute kidney injury. METHODS: In this randomised, parallel-group, comparator-controlled, single-blind phase 3 trial, we assessed the efficacy of a new fluid protocol based on the left ventricular end-diastolic pressure for the prevention of contrast-induced acute kidney injury in patients undergoing cardiac catheterisation. The primary outcome was the occurrence of contrast-induced acute kidney injury, which was defined as a greater than 25% or greater than 0·5 mg/dL increase in serum creatinine concentration. Between Oct 10, 2010, and July 17, 2012, 396 patients aged 18 years or older undergoing cardiac catheterisation with an estimated glomerular filtration rate of 60 mL/min per 1·73 m(2) or less and one or more of several risk factors (diabetes mellitus, history of congestive heart failure, hypertension, or age older than 75 years) were randomly allocated in a 1:1 ratio to left ventricular end-diastolic pressure-guided volume expansion (n=196) or the control group (n=200) who received a standard fluid administration protocol. Four computer-generated concealed randomisation schedules, each with permuted block sizes of 4, were used for randomisation, and participants were allocated to the next sequential randomisation number by sealed opaque envelopes. Patients and laboratory personnel were masked to treatment assignment, but the physicians who did the procedures were not masked. Both groups received intravenous 0·9% sodium chloride at 3 mL/kg for 1 h before cardiac catheterisation. Analyses were by intention to treat. Adverse events were assessed at 30 days and 6 months and all such events were classified by staff who were masked to treatment assignment. This trial is registered with ClinicalTrials.gov, number NCT01218828. FINDINGS: Contrast-induced acute kidney injury occurred less frequently in patients in the left ventricular end-diastolic pressure-guided group (6·7% [12/178]) than in the control group (16·3% [28/172]; relative risk 0·41, 95% CI 0·22-0·79; p=0·005). Hydration treatment was terminated prematurely because of shortness of breath in three patients in each group. INTERPRETATION: Left ventricular end-diastolic pressure-guided fluid administration seems to be safe and effective in preventing contrast-induced acute kidney injury in patients undergoing cardiac catheterisation. FUNDING: Kaiser Permanente Southern California regional research committee grant.