Predictors of Coronary Artery Disease Progression among High-risk Patients with Recurrent Symptoms.

BACKGROUND: Despite the availability of new potent medical therapies, the rate of progression of angiographic coronary artery disease (CAD) is not well described. The aim of this analysis is to describe the rate and predictors of progression of CAD among patients with recurrent symptoms. MATERIALS AND METHODS: We reviewed 259 patients (mean age 61 ± 11 years, 70% males) who underwent two coronary angiograms between 2008 and 2013. Progressive CAD was defined as obstructive CAD in a previously disease-free segment or new obstruction in a previously nonobstructive segment. Patients who had coronary artery bypass surgery between these two angiograms were excluded from the analysis. Multivariate logistic regression was used to determine the independent predictors of progression of CAD. RESULTS: The included cohort had a high prevalence of coronary risk factors; hypertension (71%), diabetes (69%), and dyslipidemia (75%). Despite adequate medical therapy, more than half of the patients (61%) had CAD progression. Using multivariate logistic regression, a drop in the left ventricular ejection fraction (LVEF) by more than 5% was the predictor of CAD progression (adjusted odds ratio 5.8, P = 0.042, 95% confidence interval 1.1-31.2). CONCLUSION: Among high-risk patients with recurrent symptoms, the short-term rate of progression of CAD is high. A drop in LVEF >5% is a predictor of CAD progression. Further studies are needed to determine the prognostic value of CAD progression in the era of potent medical therapy.

The Impact of Nurse-Led Clinics on the Mortality and Morbidity of Patients with Cardiovascular Diseases: A Systematic Review and Meta-analysis.

BACKGROUND: Nurse-led clinics (NLCs) have been developed in several health specialties in recent years. The aim of this analysis is to summarize and appraise the available evidence about the effectiveness of NLCs on the morbidity and mortality outcomes in patients with cardiovascular diseases (CVDs). METHODS: We searched Cochrane databases, MEDLINE, Web of Science, PubMed, EMBASE, Google Scholar, BIOSIS, and bibliography of secondary sources from inception through February 20, 2013. Studies were selected and data were extracted independently by 2 investigators. Eligible studies were randomized trials of NLCs of patients with CVD. Of 56 potentially relevant articles screened initially, 12 trials met the inclusion criteria. The outcomes of interest were all-cause mortality, cardiovascular mortality, nonfatal myocardial infarction, major adverse cardiac events, revascularization, lipids control, and adherence to antiplatelet medications. We performed random-effects meta-analysis to estimate summary risk ratios and quantified between-studies heterogeneity with the I2 statistic. RESULTS: The 12 trials allocated 4886 patients to NLCs and 4954 patients to usual care. The NLC patients had decreased all-cause mortality (odds ratio, 0.78; 95% confidence interval [CI], 0.65-0.95; P < .01) and myocardial infarction (odds ratio, 0.63; 95% CI, 0.39-1.00; P = .05) and had higher adherence to lipid-lowering medication (odds ratio, 1.57; 95% CI, 1.14-2.17; P = .006) compared with controls. They also had increased adherence to antiplatelet therapy compared with controls (odds ratio, 1.42; 95% CI, 1.01-1.98; P = .04). There was no statistically significant difference in the risk of cardiovascular death (odds ratio, 0.68; 95% CI, 0.40-1.15; P = .68), major adverse cardiac events (odds ratio, 0.79; 95% CI, 0.55-1.14; P = .21),or revascularization (odds ratio, 0.87; 95% CI, 0.66-1.16; P = .36) between NLC patients and controls. CONCLUSIONS: The available evidence suggests a favorable effect of NLCs on all-cause mortality, rate of major adverse cardiac events, and adherence to medications in patients with CVD.

Impact of a nurse-led heart failure program on all-cause mortality.

BACKGROUND: Nurse-led heart failure programs (HFPs) have been shown to reduce readmissions and improve medication adherence rates. However, their impact on survival is not well demonstrated. OBJECTIVE: The purpose of this study was to evaluate the impact of a nurse-led HFP on all-cause mortality. METHODS: This retrospective review included 413 consecutive patients who were admitted with heart failure exacerbations in 2008 and 2009. All patients were invited to attend a nurse-led HFP; 199 (48%) patients agreed and were compared with the 214 (52%) who chose usual care. Patients were followed for all-cause mortality, which was confirmed by the national death index. Independent predictors of outcomes were identified using multivariable Cox regression. RESULTS: Patients followed in the HFP were younger, more often men with lower ejection fraction, blood urea nitrogen, and systolic blood pressure. After a median follow-up of 15 months (range, 6-30 months), a total of 55 patients died: 14 in the HFP group (7%) compared with 41 patients (19%) in the usual care group. Participation in the HFP was independently associated with reduction in all-cause mortality (hazard ratio, 0.4; 95% confidence interval, 0.2-0.8; P = .008). CONCLUSIONS: Our nurse-led HFP was independently associated with improved survival among patients with decompensated heart failure. Further research is required to confirm this finding.