Use of Health Care System-Supplied Aspirin by Veterans With Postoperative Heart Attack or Unstable Angina.

Evidence-based guidelines for the use of aspirin in secondary prevention of cardiovascular disease events are well established. Despite this, the prevalence of aspirin use for secondary prevention is suboptimal. The study aimed to determine the prevalence of aspirin use for secondary prevention of cardiovascular disease events when it is dispensed as a prescription, as is performed in the Veterans Affairs (VA) managed care system. VA patients who had undergone major surgery and experienced a postoperative myocardial infarction (MI) or unstable angina between the years 2005 and 2009 were identified from administrative databases. VA pharmacy records were used to determine whether a prescription for aspirin was filled after the postoperative MI or unstable angina. Multivariable logistic regression models estimated odd ratios of filling aspirin prescriptions for the predictors of interest. Of the 321,131 men and women veterans who underwent major surgery, 7,700 experienced a postoperative MI or unstable angina. Among those 7,700, 47% filled an aspirin prescription. Only 59% of veterans with no co-pay filled an aspirin prescription. Aspirin fills were more common in younger veterans, Blacks, Hispanics, males, hypertensive veterans, mentally ill patients, those with no co-pay and those prescribed antiplatelets/anticoagulants in addition to aspirin postoperatively. These findings suggest that the impact of dispensing aspirin as a prescription may not be significant in increasing the appropriate use of aspirin for secondary prevention.

Single-stage repair of adult aortic coarctation and concomitant coronary artery disease: an unusual surgical approach through median sternotomy.

Surgical repair of postductal aortic coarctation associated with severe coronary artery disease is in most cases a difficult decision to make. As staged procedures are associated with a higher rate of morbidity and mortality, simultaneous operative management of both pathologies is desirable. We describe a case of a 51-year-old man who was referred to our department for surgical treatment of postductal aortic coarctation and concomitant coronary artery disease, which we managed with single-stage surgery through median sternotomy.

Mid-term outcomes of patients with PCI prior to CABG in comparison to patients with primary CABG.

The number of percutaneous coronary interventions (PCI) prior to coronary artery bypass grafting (CABG) increased drastically during the last decade. Patients are referred for CABG with more severe coronary pathology, which may influence postoperative outcome. Outcomes of 200 CABG patients, collected consecutively in an observational study, were compared (mean follow-up: 5 years). Group A (n = 100, mean age 63 years, 20 women) had prior PCI before CABG, and group B (n = 100, mean age 66, 20 women) underwent primary CABG. In group A, the mean number of administered stents was 2. Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 54 vs 34 (P = 0.007), distribution of CAD (P < 0.0001), unstable angina: 27 vs 5 (P < 0.0001). For intraoperative data, the total number of established bypasses was 2.43 +/- 1.08 vs 2.08 +/- 1.08 (P = 0.017), with the number of arterial bypass grafts being: 1.26 +/- 0.82 vs 1.07 +/- 0.54 (P = 0.006). Regarding the postoperative course, significant results could be demonstrated for: adrenaline dosage (0.83 vs 0.41 mg/h; [p is not significant (ns)]) administered in 67 group A vs 47 group B patients (P = 0.006), and noradrenaline dosage (0.82 vs 0.87 mg/h; ns) administered in 46 group A vs 63 group B patients (P = 0.023), CK/troponine I (P = 0.002; P < 0.001), postoperative resuscitation (6 vs 0; P = 0.029), intra aortic balloon pump 12 vs 1 (P = 0.003), and 30-day mortality (9% in group A vs 1% in group B; P = 0.018). Clopidogrel was administered in 35% of patients with prior PCI and in 19% of patients without prior PCI (P = 0.016). Patients with prior PCI presented for CABG with more severe CAD. Morbidity, mortality and reoperation rate during mid term were significantly higher in patients with prior PCI.

Impact of endoscopic versus open saphenous vein harvest techniques on outcomes after coronary artery bypass grafting.

BACKGROUND: Endoscopic saphenous vein harvest (EVH) decreases leg wound infections and improves cosmesis after coronary artery bypass grafting (CABG). Recent data, however, suggest that EVH may be associated with reduced graft patency rates. The objective of this study is to assess the effect of EVH on short-term and midterm outcomes after CABG. METHODS: Data were prospectively collected on all first-time isolated CABG and combined valve/CABG with saphenous vein graft between 1998 and 2007 at a single center. Patients having traditional "open" vein harvest (OVH) were compared with patients having EVH. Multivariate models were used to examine the risk-adjusted impact of EVH on postoperative leg infection, composite in-hospital adverse events, and individual and composite midterm adverse events. RESULTS: The study included 5,825 patients, of whom 2,004 (34.4%) had EVH. Patients having EVH were more likely to have ejection fraction less than 50% (32.0% versus 29.3%, p = 0.04), recent myocardial infarction (24.2% versus 18.3%, p < 0.0001), and left main disease (26.0% versus 22.1%, p = 0.0009). Median follow-up was 2.6 years. After risk adjustment, EVH was associated with reduced rates of leg infection (odds ratio 0.48, p = 0.003) but had no association with either in-hospital (odds ratio 0.93, p = 0.56) or midterm adverse outcomes (hazard ratio 0.93, p = 0.22). Endoscopic saphenous vein harvest was associated with reduced readmission to hospital for unstable angina (odds ratio 0.74, p = 0.01). CONCLUSIONS: Endoscopic saphenous vein harvest is associated with a lower rate of leg infection and is not an independent predictor of in-hospital or midterm adverse outcomes. Endoscopic saphenous vein harvest is a safe alternative to OVH for patients undergoing CABG with saphenous vein.

Long-term benefits of testosterone replacement therapy on angina threshold and atheroma in men.

INTRODUCTION: In short-term studies, testosterone replacement therapy has been shown to protect male subjects from exercise-induced ischaemia and modify cardiovascular risk factors such as insulin resistance, fat mass and lipid profiles. METHODS: This randomised parallel group controlled trial was designed to assess the treatment effect of testosterone therapy (Nebido) compared with placebo in terms of exercise-induced ischaemia, lipid profiles, carotid intima-media thickness (CIMT) and body composition during 12 months treatment in men with low testosterone levels and angina. RESULTS: A total of 15 men were recruited but 13 (n=13) reached adequate duration of follow-up; seven were treated with testosterone and six with placebo. Testosterone increased time to ischaemia (129+/-48 s versus 12+/-18, P=0.02) and haemoglobin (0.4+/-0.6 g/dl versus -0.03+/-0.5, P=0.04), and reduced body mass index (-0.3 kg/m(2) versus 1.3+/-1, P=0.04) and triglycerides (-0.36+/-0.4 mmol/l versus 0.3+/-1.2, P=0.05). The CIMT decreased in the testosterone group more than placebo, but full between group analyses suggested this was only a statistical trend (-0.5+/-0.1 vs -0.09+/-0.06, P=0.16). There were no significant effects on serum prostate specific antigen, total or high-density lipoprotein cholesterol; or on mood and symptom scores as assessed by Seattle Angina Score and EuroQol. CONCLUSION: The protective effect of testosterone on myocardial ischaemia is maintained throughout treatment without decrement. Previously noted potentially beneficial effects of testosterone on body composition were confirmed and there were no adverse effects.

Coronary spasm: a case of transient ST elevation and syncopal ventricular tachycardia without angina.

We report the case of a 60-year-old male with recurrent pre-syncope, referred with a provisional diagnosis of carotid sinus syndrome on the basis of a 4 s asystolic pause following carotid sinus massage. On repeat Holter monitoring there was ST-segment elevation followed by episodes of polymorphic ventricular tachycardia during a mild episode of pre-syncope. Coronary angiography showed mild right coronary artery irregularity without significant stenosis. An automatic cardioverter defibrillator was implanted and high dose combined vasodilator therapy was commenced. At follow-up 18 months after implantation, the device has recorded no episode of tachycardia and the patient reports no recurrence of symptoms.

Macrolide use and the risk of vascular disease in HIV-infected men in the Multicenter AIDS Cohort Study.

BACKGROUND: There has been increasing concern that HIV-infected individuals may be more at risk for cardiovascular events in the highly-active antiretroviral therapy (HAART) era. This study examined the risk of thromboembolic events in HIV-infected and non-infected individuals and the effect of macrolide prophylaxis on those outcomes. METHODS: A subcohort analysis was undertaken using data collected in the Multicenter AIDS Cohort Study to examine the relative risk of vascular events (myocardial infarction, unstable angina and ischaemic stroke). Cox proportional hazard model using age as the time scale with time varying cofactors obtained at each semi-annual visit were used to assess the independent effect of macrolide use. RESULTS: Controlling for other significant effects including race and smoking, HIV-infection was not independently associated with vascular events. Increased risk was observed among those who used HAART (relative hazard 1.09, 95% confidence intervals 1.00-1.19 in multivariate model), antihypertensive treatment (1.81 [1.26-2.60]), lipid-lowering medication (1.65 [1.12-2.42]), and antibiotics (1.72 [1.25-2.36]). The protective association of macrolide use for a vascular event in the HAART era was also significant (0.10 [0.01-0.75]). CONCLUSIONS: Traditional risk factors are important in the pathogenesis of vascular events in HIV-infected individuals. Macrolide antibiotics may have a protective effect in the HIV-infected individuals in the HAART era.

[Influence of percutaneous coronary intervention in non ST-elevation acute coronary syndromes on prescription of secondary prevention medications. Data from the S-Témoin Registry]. / Prevention secondaire après syndrome coronaire aigu sans sus-décalage de ST en fonction de l'utilisation de l'angioplastie coronaire: l'étude S-Témoin.

BACKGROUND: The interaction between the use of percutaneous coronary intervention (PCI) for non-ST-elevation acute coronary syndromes and the use of secondary prevention medications was analysed in the French S-Témoin Registry. METHODS: The population consisted of 2433 patients seen by their cardiologists at an outpatient clinic 2-12 months after non ST-elevation ACS; the survey was carried out from September 2004 to April 2005. RESULTS: Overall, patients undergoing PCI (75% of the population) had higher levels of prescription of recommended secondary prevention medications. Multivariate logistic regression analysis showed that the use and type of coronary intervention (drug eluting versus bare metal stents) was an independent correlate of the use of dual antiplatelet therapy. In addition, time from the acute episode was also a strong correlate of dual antiplatelet therapy. Statins were also more often used in patients with PCI. CONCLUSION: Patients not treated with PCI are less likely to receive appropriate secondary prevention medications after non ST-elevation acute coronary syndromes. Specific efforts should be directed towards these patients, in particular as regards the prescription of dual antiplatelet therapy.

Short-term prognosis of patients with acute coronary syndromes through the evaluation of physical activity status, the adoption of Mediterranean diet and smoking habits: the Greek Acute Coronary Syndromes (GREECS) study.

PURPOSE: Our aim was to evaluate whether healthy dietary habits, physical activity and non-smoking are associated with less severe acute coronary syndromes and better short-term prognosis. SUBJECTS AND METHODS: From October 2003 to September 2004, 2172 patients (1649 males), hospitalized for severe acute coronary syndromes in six major hospitals in Greece were included in the study. The severity of severe acute coronary syndromes was assessed through troponin-I and maximum creatinine kinase MB levels, while 30-day recurrent event rate (death or rehospitalization for cardiovascular disease, angioplasty or coronary artery bypass surgery) was used to evaluate the prognosis of the patients. A 'healthy index' that assessed adherence to the Mediterranean diet, moderate alcohol intake, physical activity and abstinence from smoking was developed (range 0-4). RESULTS: One unit increment in the healthy index was associated with -12.4+/-2.4 ng/ml decrease in troponin I levels (P=0.001) and -9.7+/-2.5 ng/ml decrease in maximum creatinine kinase MB levels (P=0.001). The in-hospital mortality rate was 3.2% in males and 5.7% in females (i.e. overall 82 deaths, P=0.009); during the first 30 days following hospitalization the event rate was 15.7% in males and 16.3% in females (P=0.001). Values of the healthy index above one (i.e. presence of two or more protective factors) seemed to be associated with 44-84% lower risk of having recurrent events (P<0.001), even after various adjustments were made. CONCLUSION: Among patients who had had severe acute coronary syndromes, a healthy lifestyle seemed to be associated with less severe cardiac events and lower risk of death or rehospitalization 30 days after the event.

[Knowledge and lifestyles of patients: a survey on patients admitted with acute coronary syndrome in the CCU of an Italian hospital]. / Le conoscenze e gli still di vita dei pazienti: indagine sui pazienti ricoverati per sindrome coronarica acuta nell'Unità Coronarica dell'Ospedale di Desio.

AIM AND METHODS: The lifestyles before hospital admission, knowledge on their illness and lifestyles after the acute coronary event were analysed with questionnaires, in three different samples of patients: a. all the patients admitted for acute coronary event from may 2003 to may 2005 to explore lifestyles before acute coronary event (416 patients) b. all the patients admitted from may 2003 to april 2004 (before the start of health information meetings organised by nurses), to explore the knowledge of the illness and its causes (132 patients) c. a sample of 83 patients followed in day hospital, to explore the lifestyles after the acute coronary event. RESULTS: Lifestyles before the event. Most patients have incorrect lifestyles: 50% eat cheese every day and never exercise for at least 30 minutes everyday. Even after the acute coronary event, some incorrect lifestyles are still present. Seventy-five percent of patients have incorrect or insufficient knowledge on illness and risk factors at discharge and only 50% is willing to increase the amount of fruit and vegetables in their diet. CONCLUSIONS: Although confirmed by other studies, these results are worrying and call for the systematic adoption of secondary prevention strategies with effective interventions aimed at increasing knowledge and modifying lifestyles.

[An health education program for patients admitted to CCU for an acute coronary event]. / Organizzazione di un incontro di educazione alla salute dedicato ai pazienti ricoverati per sindrome coronarica acuta: l'esperienza degli infermieri dell'ospedale di Desio.

UNLABELLED: In spite of the broad recognition of the importance of health education, time for structured one-to -one initiatives of health education during the hospital stay is limited. The organization of an health education meeting for patients admitted to CCU for an acute coronary event is described. METHODS: The planning and implementation of the initiative lasted two years and involved 7 nurses and one doctor. The organization required efforts related to the event itself (preparation of training aids, identification or contents and methods for delivery) but also organizative changes. Dietitians in fact had to be involved because the healthy diet recommended was different from the hospital diet. The assessment of the effectiveness of the health education was also planned: administration of a questionnaire to explore lifestyles and knowledge of the illness before and after the meeting; phone interviews after 3, 6 and 12 months from the meeting. RESULTS: Since may 2003, in the first 3 years 74 meetings have been organised, involving 507 patients and 329 relatives. Each meeting lasts 2 hours and contents delivered encompass the coronary event, risk factors and their modification, healthy lifestyles. Initial preliminary results on the impact of the meeting on lifestyle changes are promising. Initiatives are ongoing to include this activity among officially recognised nursing activities.

Pro-inflammatory cytokines may induce late preconditioning in unstable angina patients.

Late preconditioning can be induced by a wide variety of stimulus, including non-pharmacological and pharmacological. Thus, late preconditioning is a universal response of the heart to stress and it requires the simultaneous activation of multiple stress-responsive genes. Recently, compelling evidence has evolved that the up-regulation of pro-inflammatory cytokines plays an important role in induction of the late phase of ischemic preconditioning in rodent models. However, the role of cytokines in induction of late preconditioning in humans has not been explored. Patients with unstable coronary syndromes have a systemic inflammatory responses with increase of the pro-inflammatory cytokines, such as TNFalpha, IL-6. And some researchers find the patients undergoing CABG with unstable angina have a better cardioprotective effect caused by late preconditioning characterized by the activated NF-kappaB and synthesized effector proteins (HSP72 and eNOS). Therefore, we hypothesize that pro-inflammatory cytokines may induce late preconditioning in unstable angina patients directly or through remote preconditioning. It is difficult to test our hypotheses in vivo, but in vitro, human tissue culture with isolated atrial myocardium could be tested. If the hypotheses is true, the biological complication is immense. A new physiological function of pro-inflammatory cytokines is found, that is, inducing endogenous cytoprotection. From the clinical point of view, administering the appropriate pro-inflammatory cytokines will be beneficial to patients before cardiac surgery.

Cost effectiveness of a smoking cessation program in patients admitted for coronary heart disease.

BACKGROUND: Smoking cessation is probably the most important action to reduce mortality after a coronary event. Smoking cessation programs are not widely implemented in patients with coronary heart disease, however, possibly because they are thought not to be worth their costs. Our objectives were to estimate the cost effectiveness of a smoking cessation program, and to compare it with other treatment modalities in cardiovascular medicine. METHODS: A cost-effectiveness analysis was performed on the basis of a recently conducted randomized smoking cessation intervention trial in patients admitted for coronary heart disease. The cost per life year gained by the smoking cessation program was derived from the resources necessary to implement the program, the number needed to treat to get one additional quitter from the program, and the years of life gained if quitting smoking. The cost effectiveness was estimated in a low-risk group (i.e. patients with stable coronary heart disease) and a high-risk group (i.e. patients after myocardial infarction or unstable angina), using survival data from previously published investigations, and with life-time extrapolation of the survival curves by survival function modeling. RESULTS: In a lifetime perspective, the incremental cost per year of life gained by the smoking cessation program was euro 280 and euro 110 in the low and high-risk group, respectively (2000 prices). These costs compare favorably to other treatment modalities in patients with coronary heart disease, being approximately 1/25 the cost of both statins in the low-risk group and angiotensin-converting enzyme inhibitors in the high-risk group. In a sensitivity analysis, the costs remained low in a wide range of assumptions. CONCLUSIONS: A nurse-led smoking cessation program with several months of intervention is very cost-effective compared with other treatment modalities in patients with coronary heart disease.

Statin therapy is associated with improved cardiovascular outcomes and levels of inflammatory markers in patients with heart failure.

BACKGROUND: We wished to determine whether the addition of statins affect cardiovascular events and markers of inflammation in patients with heart failure. METHODS AND RESULTS: A total of 446 patients with heart failure and ejection fraction < or =35% were followed in a prospective, nonrandomized fashion and were classified according to treatment with a statin. We determined all-cause mortality, cardiovascular morbidity, and serum markers of inflammation over a 24-month period. Statin therapy in patients with heart failure was associated with decreased all-cause mortality at 2 years compared with those not on statin therapy (15% versus 33%, P < .005) as well as hospitalizations for heart failure (22% versus 38%, P = .001) and nonfatal myocardial infarction (11% versus 15%, P < .001). In addition, statin therapy was associated with a decrease in serum levels of C-reactive protein (1.12 +/- 0.13 versus 1.47 +/- 0.11 mg/dL, P = .001), interleukin-6 (13.3 +/- 0.8 versus 17.3 +/- 1.4 ng/dL, P = .001), and tumor necrosis factor-alpha receptor II (24.3 +/- 1.0 versus 34.5 +/- 3.0 ng/dL, P = .001). CONCLUSION: The use of statin therapy in this nonrandomized trial was associated with a significant reduction in all-cause mortality and cardiac morbidity. In addition, the improvement in levels of several serum inflammatory markers with statin therapy suggests in part possible mechanisms by which these agents may exert their benefits.

Myocardial protection in diabetics with left main stem disease: which is the best strategy?

AIM: Diabetes mellitus is a well known risk factor for extensive coronary disease. The optimal route for cardioplegia administration in patients with severe ischaemic heart disease undergone surgery, especially with left main stem disease (LMSD) is still under debate. Aim of the study is to compare 2 different strategies of myocardial protection in diabetics with LMSD. METHODS: Between January 2000 and June 2003 90 consecutive patients with type II diabetes mellitus and LMSD undergoing isolated myocardial revascularization were divided into 2 groups according to the route of cardioplegia delivery: antegrade in 45 patients (group A), antegrade followed by intermittent retrograde in 45 (group B). ECG, Troponin I, MB-CPK, MB-CPK mass were performed at 12, 24, 48, and 72 hours postoperatively. Echocardiography was performed preoperatively and before hospital discharge. RESULTS: Groups were homogeneous in preoperative and intraoperative variables, apart from higher incidence of unstable angina and longer cardiopulmonary bypass time in Group B and hypertension in Group A. Hospital deaths, in intensive care units (ITU) stay, perioperative acute myocardial infarction, intra-aortic balloon pump support, postoperative recovery of left ventricle ejection fraction and wall motion score index were similar in both groups. In hospital stay proved shorter in group B (p=0.002), whereas postoperative atrial fibrillation was higher in group A (p<0.001), as postoperative inotropic support (p=0.006). Troponin I proved significantly higher in group A from the 12 degrees to the 72 degrees postoperative hour (p<0.0001). CONCLUSIONS: Despite major in hospital end-points did not differ with strategy of cardioplegia administration, combined route of intermittent blood cardioplegia allows better biochemical and perioperative results in diabetics with LMSD.

Treatment with clarithromycin prior to coronary artery bypass graft surgery does not prevent subsequent cardiac events.

BACKGROUND: Recently, it has been suggested that Chlamydia pneumoniae possibly plays a possible role in the pathogenesis of atherosclerosis. We investigated whether treatment with clarithromycin prior to coronary artery bypass graft (CABG) surgery would prevent subsequent cardiovascular events and mortality. METHODS: Patients who were scheduled for CABG surgery were randomly assigned to receive either clarithromycin or placebo until the day of surgery in a double-blind trial. During the 2 years of follow-up, mortality and cardiovascular events were assessed. RESULTS: Follow-up at 2 years was achieved for 473 patients. The mean duration of treatment was 16 days. Patient characteristics at baseline were well balanced between the 2 treatment groups. Mortality was equal in the 2 groups: 10 (4.2%) of 238 patients in the clarithromycin group and 9 (3.8%) of 235 patients in the placebo group (relative risk, 1.10; 95% CI, 0.42-2.89; P=1.0). Also, there were no significant differences in the proportion of patients who experienced cardiovascular events during the follow-up period: 20 (8.4%) of 238 patients in the clarithromycin group and 19 (8.1%) of 235 patients in the placebo group (relative risk, 1.04; 95% CI, 0.55-1.98; P=1.0). The overall rate of such events was 58 (12.3%) of 473 patients. CONCLUSIONS: Treatment with clarithromycin in patients scheduled for CABG surgery did not reduce the subsequent occurrence of cardiovascular events or mortality during a 2-year follow-up period.

Clinical and biochemical results of the metalloproteinase inhibition with subantimicrobial doses of doxycycline to prevent acute coronary syndromes (MIDAS) pilot trial.

BACKGROUND: Vulnerable plaque demonstrates intense inflammation in which macrophages secrete matrix metalloproteinases (MMPs) that degrade the fibrous cap, ultimately leading to rupture, in situ thrombosis, and an associated clinical event. Thus, inhibition of MMP activity or more general suppression of vascular inflammation are attractive targets for interventions intended to reduce plaque rupture. We hypothesized that subantimicrobial doses of doxycycline (SDD) (20 mg twice daily) would benefit patients with coronary artery disease by reducing inflammation and MMP activity and thus possibly prevent coronary plaque rupture events. METHODS AND RESULTS: We conducted a prospective, randomized, double-blind, placebo-controlled pilot study of 6 months of SDD or placebo treatment to reduce inflammation and prevent plaque rupture events. A total of 50 patients were enrolled, of whom 24 were randomized to placebo and 26 to SDD. At 6 months, there was no difference in the composite endpoint of sudden death, fatal myocardial infarction (MI), non-fatal MI, or troponin-positive unstable angina in SDD compared with placebo-treated patients (8.4% versus 0%, P=0.491). Biochemical markers of inflammation were assessed in plasma at study entry and after 6 months of therapy in 30 patients. In SDD-treated patients, high-sensitivity C-reactive protein (CRP) was reduced by 46% from 4.8+/-0.6 microg/mL to 2.6+/-0.4 microg/mL (P=0.007), whereas CRP was not significantly reduced in placebo patients. Interleukin (IL)-6 decreased from 22.1+/-3.7 pg/mL at baseline to 14.7+/-1.8 pg/mL at 6 months in SDD-treated patients (P=0.025) but did not decrease significantly in placebo-treated patients. On zymography, pro-MMP-9 activity was reduced 50% by SDD therapy (P=0.011), whereas it was unchanged by placebo treatment. CONCLUSIONS: SDD appears to exert potentially beneficial effects on inflammation that could promote plaque stability. These findings should be investigated in a larger study.