The role of cardiac rehabilitation in secondary prevention after coronary events.

Background Coronary risk factor control in Europe is suboptimal and there are large variations in the nature of cardiac rehabilitation (CR) programmes offered to coronary heart disease patients. We aim to explore characteristics and risk factor control in patients recruited from two neighbouring hospitals offering CR with different content. Methods In a cross-sectional study, 1127 Norwegian patients hospitalized with acute myocardial infarction and/or a revascularization procedure attended a clinical visit and completed a questionnaire at 2-36 months' follow-up. The hospital of Vestfold provides comprehensive CR, while the hospital of Drammen provides mainly exercise-based CR. Results At follow-up, patients in Vestfold performed more physical activity ( p = 0.02), were less obese ( p = 0.02) and reported better medication adherence ( p = 0.02) than patients in Drammen. The perceived need for information and follow-up was higher in Drammen than Vestfold ( p < 0.001). The CR participation rate in Vestfold was 75% compared with 18% in Drammen. CR participation in Vestfold was associated with higher prevalence of smoking cessation ( p = 0.001), lower low-density lipoprotein cholesterol ( p = 0.01) and better medication adherence ( p = 0.02) compared with non-CR, in adjusted analyses. No differences in diet, body weight, or blood pressure control were found between CR and non-CR. Conclusions Vestfold, with comprehensive CR, had a higher participation rate and more risk factors on target than Drammen. Participation in CR in Vestfold was associated with higher levels of smoking cessation and medication adherence, and lower low-density lipoprotein cholesterol, but overall risk factor control is still deficient, underlining the need for improved understanding of barriers to optimal risk factor control.

Medical and psychosocial factors and unfavourable low-density lipoprotein cholesterol control in coronary patients.

Objective Understanding the determinants of low-density lipoprotein cholesterol (LDL-C) control constitutes the basis of modelling interventions for optimal lipid control and prognosis. We aim to identify medical and psychosocial (study) factors associated with unfavourable LDL-C control in coronary patients. Methods A cross-sectional explorative study used logistic and linear regression analysis to investigate the association between study factors and LDL-C in 1095 patients, hospitalized with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records, a comprehensive self-report questionnaire, clinical examination and blood samples after 2-36 months follow-up. Results Fifty-seven per cent did not reach the LDL-C target of 1.8 mmol/l at follow-up. Low socioeconomic status and psychosocial factors were not associated with failure to reach the LDL-C target. Statin specific side-effects (odds ratio 3.23), low statin adherence (odds ratio 3.07), coronary artery by-pass graft operation as index treatment (odds ratio 1.95), ≥ 1 coronary event prior to the index event (odds ratio 1.81), female gender (odds ratio 1.80), moderate- or low-intensity statin therapy (odds ratio 1.62) and eating fish < 3 times/week (odds ratio 1.56) were statistically significantly associated with failure to reach the LDL-C target, in adjusted analyses. Only side-effects (standardized ß 0.180), low statin adherence ( ß 0.209) and moderate- or low-intensity statin therapy ( ß 0.228) were associated with LDL-C in continuous analyses. Conclusions Statin specific side-effects, low statin adherence and moderate- or low-intensity statin therapy were the major factors associated with unfavourable LDL-C control. Interventions to improve LDL-C should ensure adherence and prescription of sufficiently potent statins, and address side-effects appropriately.

The anesthesia in abdominal aortic surgery (ABSENT) study: a prospective, randomized, controlled trial comparing troponin T release with fentanyl-sevoflurane and propofol-remifentanil anesthesia in major vascular surgery.

BACKGROUND: On the basis of data indicating that volatile anesthetics induce cardioprotection in cardiac surgery, current guidelines recommend volatile anesthetics for maintenance of general anesthesia during noncardiac surgery in hemodynamic stable patients at risk for perioperative myocardial ischemia. The aim of the current study was to compare increased troponin T (TnT) values in patients receiving sevoflurane-based anesthesia or total intravenous anesthesia in elective abdominal aortic surgery. METHODS: A prospective, randomized, open, parallel-group trial comparing sevoflurane-based anesthesia (group S) and total intravenous anesthesia (group T) with regard to cardioprotection in 193 patients scheduled for elective abdominal aortic surgery. Increased TnT level on the first postoperative day was the primary endpoint. Secondary endpoints were postoperative complications, nonfatal coronary events and mortality. RESULTS: On the first postoperative day increased TnT values (>13 ng/l) were found in 43 (44%) patients in group S versus 41 (43%) in group T (P = 0.999), with no significant differences in TnT levels between the groups at any time point. Although underpowered, the authors found no differences in postoperative complications, nonfatal coronary events or mortality between the groups. CONCLUSIONS: In elective abdominal aortic surgery sevoflurane-based anesthesia did not reduce myocardial injury, evaluated by TnT release, compared with total intravenous anesthesia. These data indicate that potential cardioprotective effects of volatile anesthetics found in cardiac surgery are less obvious in major vascular surgery.