Knowledge, Perceptions, and Patterns of Fish Oil Use in Cardiac Patients.

BACKGROUND: Fish oils are the most widely used nonvitamin, nonmineral dietary supplements in the United States. They are not over-the-counter medications and are neither approved nor indicated for treating disease. Patient knowledge and patterns of fish oil use are not well defined. OBJECTIVE: To determine cardiac patients' knowledge and patterns of fish oil use. METHODS: One thousand consecutive patients admitted to an in-patient cardiology service (2015-2017) taking fish oil dietary supplements or prescription omega-3 fatty acids were asked to complete an anonymous questionnaire concerning product knowledge and use. RESULTS: A total of 711 (71%) patients completed the questionnaire. Primary reasons for use included general health (34%), heart health (28%), arthritis (9%), and lipid disorders (8%). Few patients (14%) were advised to take fish oil products by a health-care provider. Only 2.5% were taking prescription omega-3 fatty acids. Only 26% knew the active ingredient in their fish oil product. Supplements were purchased through a nonpharmacy retail seller by 81% of respondents. CONCLUSIONS: Most cardiac patients consuming fish oil dietary supplements do so without medical supervision and without knowledge of the active ingredients. As most patients obtain supplements outside of a pharmacy, opportunities to monitor and educate patients remain a major challenge.

Treatment of Depression in Patients with Concomitant Cardiac Disease.

Depressed patients are at increased risk of cardiovascular (CV) disease (CVD) and those with concomitant depression and CVD are at increased risk of death. The safety and efficacy of antidepressants in patients with CVD varies greatly between the agent used and type of disease. This review will summarize the CV adverse effect and drug interaction profile of antidepressants and discuss the use of antidepressants in CVD patients. We searched MEDLINE, PubMed, CINAHL, Web of Science, PsycINFO, and The Cochrane Library from inception to June 2014 to identify studies relevant to antidepressant use in patients with CVD. Primary references from the identified articles were also evaluated for inclusion. Descriptive analysis was performed for the included studies in this review. Orthostatic hypotension was more common with tricyclic antidepressants (TCAs), trazodone and monoamine oxidase inhibitors (MAOIs). Hypertension can be significant with serotonin norepinephrine reuptake inhibitors (SNRIs) and MAOIs. The potential for QT prolongation is present with TCAs, certain selective serotonin reuptake inhibitors (SSRIs), certain SNRIs and mirtazapine. Due to its low risk of drug-drug interactions, adverse effect profile and potential for beneficial antiplatelet activity, sertraline could be considered the choice antidepressant for patients with ischemic heart disease. SSRIs and potentially SNRIs are relatively safe and effective options for patients with heart failure. In patients at high risk for ventricular arrhythmias, bupropion has the overall lowest risk for QT prolongation. TCAs and MAOIs should be avoided in patients with concomitant CVD. In conclusion, due to the increased morbidity and mortality associated with comorbid CVD and depression, practitioners should readily assess and initiate management of depression in such patients. The choice of antidepressant should take into account the potential CV impact of the various agents balancing safety and efficacy.

Optimal aspirin dose in acute coronary syndromes: an emerging consensus.

Numerous clinical trials testing the efficacy of aspirin for the secondary prevention of cardiovascular disease have been published. We reviewed the literature pertaining to aspirin dose in acute coronary syndrome patients. Clinical trials assessing the comparative efficacy of different doses of aspirin are scarce. This complex antiplatelet therapy landscape makes it difficult to identify the best aspirin dose for optimizing efficacy and minimizing risk of adverse events, while complying with the various guidelines and recommendations. Despite this fact, current evidence suggests that aspirin doses of 75-100 mg/day may offer the optimal benefit:risk ratio in acute coronary syndrome patients.

Emerging antiplatelet therapy for coronary artery disease and acute coronary syndrome.

Antiplatelet therapy is used widely with proven benefit for the prevention of further ischemic cardiac complications in patients with known coronary artery disease (CAD) and a history of acute coronary syndrome (ACS). The limitations of conventional antiplatelet therapy with aspirin, clopidogrel, or prasugrel, as well as the fact that rates of recurrent ischemic events still remain high with use of these agents, underscore the need to investigate alternate agents that may further reduce event rates while limiting bleeding risk. The selection of antiplatelet therapy is further influenced by the following: ticagrelor was approved in July 2011 by the United States Food and Drug Administration (FDA), and clopidogrel is slated to become available as a generic productin 2012. We provide an overview of emerging agents for the treatment of CAD and ACS, including the reversible P2Y(12) antagonists ticagrelor, cangrelor, and elinogrel, and a new class of oral protease-activated receptor-1 (PAR-1) inhibitors, vorapaxar and atopaxar.The recently approved P2Y(12) antagonists prasugrel and ticagrelor demonstrate enhanced ability to prevent adverse cardiac outcomes. However, this comes at a cost of a potential increased risk of bleeding. New adverse effects have also emerged, including dyspnea for all of the reversible P2Y(12) antagonists (ticagrelor, cangrelor, and elinogrel) and ventricular pauses for ticagrelor. In addition, the newer P2Y(12) antagonists have a faster onset and offset. Two of these agents, cangrelor and elinogrel, are available as intravenous formulations, which may provide additional benefits in patients who undergo coronary artery bypass graft (CABG) surgery. Trials with the PAR-1 inhibitors have also shown trends toward reductions in cardiac events, but not without the possibility of increased bleeding. More than ever, as the arsenal of antiplatelet therapy expands, health care providers need to understand the pharmacologic and pharmacodynamic differences between conventional and emerging antiplatelet therapies for patients with ACS and CAD. Health care providers must also carefully assess patient-specific factors such as risk of thrombosis, concomitant disease states, age, drug adherence, and aspirin dose, and plan for those patients who will be undergoing CABG when selecting antiplatelet therapy in order to optimally balance bleeding and thrombosis risk.

Pharmacologic prophylaxis of postoperative atrial fibrillation in patients undergoing cardiac surgery: beyond beta-blockers.

Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery that increases patient morbidity, length of stay, and hospital costs. A substantial body of evidence exists evaluating various pharmacologic and nonpharmacologic methods to decrease the occurrence of POAF in an effort to decrease its burden on the health care system. Evidence-based guidelines support the use of beta-blockers as standard prophylaxis of POAF in patients undergoing cardiac surgery. Traditional prophylactic therapy for POAF targets the sympathetic nervous system, refractory period, and atrial conduction. However, associations between the development of POAF and the inflammatory process, oxidative stress, and atrial remodeling have prompted the investigation of novel therapies targeting these processes. To evaluate the role of pharmacologic strategies beyond beta-blockers in the prevention of POAF, we conducted a search of the PubMed database to identify studies published from 1950-February 2009. Emphasis was placed on how these therapies could be used in patients intolerant to beta-blockers or as additive therapy in high-risk patients. We found that sufficient evidence exists to recommend the use of amiodarone, sotalol, and possibly magnesium as monotherapy in patients unable to take beta-blockers or as add-on therapy for the prevention of POAF. Currently, available evidence does not support the use of propafenone, procainamide, digoxin, thiazolidinediones, triiodothyronine, or calcium channel blockers in the prevention of POAF. Preliminary evidence suggests that dofetilide, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), nonsteroidal antiinflammatory drugs, corticosteroids, omega-3 fatty acids, ascorbic acid, N-acetylcysteine, and sodium nitroprusside may be effective in preventing POAF. Additional large-scale, adequately powered clinical studies are needed to determine the benefit of these agents before they can be considered for routine use.

Amiodarone versus sotalol for the treatment of atrial fibrillation after open heart surgery: the Reduction in Postoperative Cardiovascular Arrhythmic Events (REDUCE) trial.

OBJECTIVES: This prospective, randomized, double-blind, placebo-controlled study compared the efficacy and safety of amiodarone and sotalol in the prevention of atrial fibrillation (AF) following open heart surgery. BACKGROUND: The incidence of supraventricular arrhythmias following open heart surgery ranges from 20% to 40%, with AF being the most common. Both amiodarone and sotalol have been shown to be effective in reducing postoperative arrhythmias, but no direct comparison of these agents has been conducted. METHODS: A total of 160 patients were randomized, of whom 134 underwent coronary artery bypass graft surgery (CABG) alone, 17 underwent CABG and concomitant aortic valve replacement surgery (AVR), 9 underwent AVR only, and 1 patient's surgery was canceled. Patients with signs or symptoms of congestive heart failure (CHF), ejection fraction < or =30%, estimated creatinine clearance <30 mL/min, or serum creatinine > or =2.5 mg/dL were excluded. Patients were randomized to receive either sotalol 80 mg 2 times per day (n = 76) or intravenous amiodarone 15 mg/kg over 24 hours followed by oral amiodarone 200 mg 3 times per day (n = 83). Study drug was started at the time of surgery and continued for 7 days or until discharge, whichever came first. RESULTS: AF occurred in 17% of patients randomized to amiodarone and 25% of the patients randomized to sotalol (P =.21). However, the duration of AF was significantly shorter in amiodarone-treated patients (169 +/- 224 min) compared to sotalol treated patients (487 +/- 505 min; P =.04). In a subgroup analysis, the incidence of AF in patients undergoing AVR or CABG with AVR was significantly less with amiodarone (1/15, 7%) compared to sotalol (9/11, 82%) (P <.001). Blood pressure was lower immediately after surgery with amiodarone but comparable to sotalol at 24 hours. Of the hemodynamic indices measured, only stroke volume was significantly lower in patients randomized to sotalol at 24 hours (P =.035). CONCLUSIONS: Amiodarone and sotalol share similar efficacy and safety in reducing postoperative AF. Hemodynamic effects were similar between both drugs at 24 hours, with the exception that stroke volume was lower in sotalol-treated patients. In patients undergoing more complex surgery, postoperative AF occurred more frequently with sotalol than with amiodarone.

Comparison of conservative and aggressive smoking cessation treatment strategies following coronary artery bypass graft surgery.

PURPOSE: Patients who continue to smoke following coronary artery bypass graft surgery (CABG) have substantially poorer outcomes than patients able to stop smoking after CABG. This study evaluated the effectiveness of two smoking cessation treatment strategies in patients undergoing CABG. METHODS: Two smoking cessation treatment strategies were compared in smokers who underwent CABG. In the conservative treatment strategy, smokers undergoing CABG were followed up prospectively at monthly intervals. Patients who started smoking again at any time in the year following CABG were asked to enroll in an 8-week smoking cessation program. In the aggressive treatment strategy, smokers undergoing CABG were asked to enroll in an 8-week smoking cessation program starting immediately after hospital discharge. The structure and makeup of the smoking cessation program used in the conservative and aggressive treatment strategies were identical. The primary study outcome was smoking status assessed by self-report and confirmed by expired carbon monoxide at 1.5 months, 3 months, 6 months, and 12 months after surgery. RESULTS: Nineteen patients were enrolled in the conservative treatment strategy, with 2 patients unavailable for follow-up prior to the first follow-up visit. Of the remaining 17 patients, 14 patients (82%) resumed smoking at an average of 10.3 weeks after CABG. Eleven of these 14 patients (79%) agreed to participate in the smoking cessation program. Based on evaluable patients, 10 of the 17 patients (59%) in the conservative strategy group were not smoking at the 12-month follow-up. Twenty patients were enrolled in the aggressive treatment strategy. All patients agreed to participate in the smoking cessation program. All patients were available for follow-up. At the 12-month follow-up, 17 of 29 patients (85%) in this treatment strategy were not smoking. Point prevalence and continuous abstinence cessation rates were significantly greater in the aggressive treatment strategy compared to the conservative treatment strategy at all follow-up intervals after CABG. CONCLUSION: Based on our findings in a small number of patients, an aggressive smoking cessation intervention is associated with a superior smoking cessation rate compared to a conservative treatment strategy in smokers undergoing CABG. A larger study will be needed to confirm that an early aggressive smoking cessation intervention should be provided to all smokers undergoing CABG.

Esmolol versus diltiazem in atrial fibrillation following coronary artery bypass graft surgery.

PURPOSE: Atrial fibrillation (AF) is the most common arrhythmic complication following coronary artery bypass graft surgery (CABG). The efficacy and safety of esmolol and diltiazem were compared in patients with post-CABG AF. METHODS: This study was a retrospective medical record review of consecutive patients with post-CABG AF > or =15 min in duration with a ventricular rate > or =110 b.p.m. who received either i.v. esmolol (n = 59) or i.v. diltiazem (n = 48) with or without concomitant digoxin therapy at a single university-affiliated teaching hospital. Treatment success was defined as either cardioversion to sinus rhythm or a reduction in the ventricular rate to < or =90 b.p.m. at 24 h after the start of therapy. Time to treatment success and the occurrence of adverse effects were considered secondary outcomes. RESULTS: A total of 107 patients with post-CABG AF were treated with i.v. esmolol (n = 59) or i.v. diltiazem (n = 48). The mean maximum dose of esmolol and diltiazem were 115 +/- 38 microg/kg/min and 11.2 +/- 3.5 mg/h, respectively. The average duration of the esmolol and diltiazem infusions were 19.3 +/- 8.5 h and 20.1 +/- 11.3 h, respectively. Based on the combined efficacy endpoint of cardioversion or ventricular rate control, esmolol was significantly more effective than diltiazem (90% vs 77%; p = 0.038). Time to treatment success was significantly better for esmolol than diltiazem at all time points (1, 2, 4, 6, 12, and 24 h post-treatment). The overall incidence of adverse effects was 44% with esmolol and 60% with diltiazem (p = 0.04). Rates of drug discontinuance for adverse effects were significantly less for esmolol (20%) compared with diltiazem (38%) (p = 0.04). CONCLUSIONS: Esmolol is significantly more effective than diltiazem in the management of post-CABG AF. More patients converted to sinus rhythm with esmolol as compared to diltiazem. Esmolol was associated with fewer adverse effects than diltiazem, including adverse effects leading to drug discontinuance. Due to study design limitations (retrospective data collection), an adequately powered randomised, controlled trial is needed to confirm these preliminary findings.