Effect of a Financial Education and Coaching Program for Low-Income, Single Mother Households on Child Health Outcomes.

The financial difficulties of parents have a negative impact on the health of their children. This problem is more pronounced in single mother families. There is limited research on low-income, single mothers and how interventions to help them address financial difficulties may also benefit their children. The purpose of this study was to evaluate the effect of a year-long financial education and coaching program on school absenteeism and health care utilization of children in employed, low-income, single mother households. This was a post hoc analysis of the Finances First study, a randomized controlled trial conducted in 2017-2020 examining the impact of a financial coaching and education program on economic stability and health outcomes in 345 low-income, single mothers. Either generalized estimating equations (GEEs) or generalized linear mixed models (GLMMs) were used to account for relationships between participants. For the continuous outcomes of child absenteeism, physician visits, emergency room visits, and hospitalization days, a linear mixed-effects model was used. The Finances First study demonstrated improvements in various financial strain measures. Compared to the control group, children of intervention group participants experienced 1 fewer day of school absence (p = 0.049) and 1 fewer physician visit (p = 0.032) per year, but no impact was seen on emergency room visits (p = 0.55) or hospitalizations (p = 0.92). Addressing social determinants of health in parents is necessary for improving child health outcomes.

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.

Improved Dosing and Administration of Rivaroxaban when Prescribed by a Cardiologist.

Rivaroxaban is a direct oral anticoagulant (DOAC) indicated to reduce risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF). A discrepancy exists between the recommended dosage and real-world use of DOACs, especially rivaroxaban, thus putting patients at risk of thromboembolic events. METHODS: This retrospective study assessed real-world prescribing and patient adherence to dietary requirements during use of rivaroxaban in 116 patients with AF. Associations between prescriber specialty and the correct dosing and administration were assessed using the Chi-Square test. RESULTS: Most rivaroxaban prescriptions were ordered by cardiologists (50.9%). Sixty-nine patients (59.5%) were taking the right dose at the correct time with an adequate meal. Of the 47 (40.5%) taking rivaroxaban incorrectly, 39 (33.6%) had not been administered an adequate meal and eight (6.9%) were not prescribed the correct dose. Compared with other prescribers, patients were most likely to be taking the correct dose and administration when prescribed by cardiologists (72.9% versus 45.6%; p=0.003). Patients were least likely to be taking the correct dose and administration when prescribed by primary care providers (44.4% versus 69.0%; p=0.009). This difference was driven by patients who did not take the treatment with an adequate meal. CONCLUSION: Inappropriate prescribing, administration and non-adherence to DOACs can have devastating consequences. This highlights the importance of formal systematic education of patients prescribed DOACs across the whole health system. Future studies are warranted to explore the impact of non-adherence to rivaroxaban dietary requirements on clinical outcomes.

Adherence to therapies for secondary prevention of cardiovascular disease: a focus on aspirin.

AIM: Suboptimal adherence to medications taken chronically for secondary prevention of cardiovascular disease (CVD, e.g., aspirin) continues to burden the healthcare system despite the well-established benefits of prevention. We conducted a literature search to examine patient adherence to medications for secondary prevention of CVD-as evaluated by prescription refill data, electronic medication monitors, pill counts, and physiologic markers-to better identify an unmet need for measures to improve patient adherence to these therapies. METHODS: English-language articles were obtained from the PubMed database using the following key words or combinations thereof "adherence," "compliance," "secondary prevention," and "cardiovascular disease." Publications that provided adherence data only for primary prevention, lacked data on medication adherence (e.g., focus on guideline adherence), emphasized quality-of-care outcomes, or focused on outcomes of acute interventions were excluded. RESULTS: Multiple patient-, disease-, and treatment-related factors may contribute to poor adherence to treatment regimens, and therefore, a multifactorial approach will likely be needed to improve compliance with prescribed treatments for CVD. Although no magic bullet exists to assure full adherence, adherence programs coupled with patient counseling and education (inclusive of over-the-counter therapies), along with treatments that are less complex or avoid bothersome adverse effects, are more likely to be associated with successful outcomes. CONCLUSION: Given the burden of CVD to the community and the healthcare system, nonadherence to CVD-preventative medications such as aspirin remains a substantial area of unmet need and represents a key opportunity for the development of quality-of-care enhancement programs to improve health outcomes in this patient population.

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.

The pharmacist role in predicting and improving medication adherence in heart failure patients.

BACKGROUND: Heart failure is one of the most common reasons for hospital admissions in patients aged 65 years and older, with an estimated 1 million hospitalizations annually. In 2010, health care expenditures for heart failure were estimated to be $32 billion. Nonadherence to medications and lifestyle contributes to hospital admissions in up to one-third of patients. Efforts to reduce readmissions are of critical importance. Pharmacist involvement in the management of heart failure patients has been shown to reduce heart failure hospitalizations, with trends towards a reduction in mortality. Literature is scarce on instruments that clinicians can use to identify patients at risk for medication nonadherence. OBJECTIVES: To (a) describe factors that predict medication adherence for patients with heart failure, (b) evaluate the impact and value of pharmacist interventions on adherence and outcomes, and (c) assess tools to predict medication nonadherence in heart failure patients. METHODS: From inception to September 2013, a search was conducted in the databases MEDLINE, PubMed, CINAHL, and The Cochrane Library to identify relevant studies for 3 separate searches, identifying predictors of medication adherence in heart failure patients, pharmacist involvement to impact medication adherence, and tools to predict medication nonadherence in this population. RESULTS: Many significant predictors of both medication adherence and nonadherence have been identified in heart failure patients. Studies evaluating the effect of pharmacist involvement in the management of heart failure demonstrated improvements in medication adherence that dissipated once the intervention was withdrawn. The Morisky Medication Adherence Scale and the Merck Adherence Estimator are simple and practical tools that may be useful for identifying nonadherence in heart failure patients. CONCLUSIONS: Clinicians should be cognizant of factors that may affect medication adherence in heart failure patients and be aware of instruments available to predict the risk for medication nonadherence. Pharmacist interventions should be part of a multidisciplinary system of care initiated at discharge that involve personal contact and are continued indefinitely in order to sustain these benefits.

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.

Impact of ranolazine on clinical outcomes and healthcare resource utilization in patients with refractory angina pectoris.

BACKGROUND: Ranolazine is a novel antianginal medication approved for the treatment of chronic angina. There are only limited data concerning the efficacy of ranolazine in reducing healthcare resource utilization in patients with refractory angina pectoris. OBJECTIVE: The primary objective of this analysis was to evaluate the efficacy and safety of ranolazine in refractory angina pectoris. In addition, the impact of ranolazine on healthcare resource utilization was assessed. METHODS: Consecutive patients with refractory angina pectoris treated with ranolazine at two cardiology practices in the state of Nebraska were included in this analysis. The Canadian Cardiovascular Society (CCS) angina class and frequency and type of healthcare resource consumption were determined during the 12 months prior to and the 12 months after initiation of ranolazine. RESULTS: A total of 150 pts (64 % men) with a mean age of 66 ± 12 years were included in this analysis. All patients had previously undergone coronary revascularization. Nitrates, ß-adrenoceptor antagonists (ß-blockers), and calcium antagonists (calcium channel blockers) were being used in 83, 97, and 75 % of patients, respectively. During ranolazine treatment, a significant improvement in CCS angina class was observed, with 23 patients improving by one class and no patient experiencing a deterioration in functional class (p = 0.025). A total of 53 side effects occurred in 28 (19 %) patients receiving ranolazine. Of those patients with side effects, four required dose reduction and seven required drug discontinuation. The frequency of clinic visits and emergency room visits was lower during ranolazine treatment, but the differences in frequency were not significant. The number of patients hospitalized and the number of hospitalizations were significantly lower during ranolazine therapy than in the pre-ranolazine study period (p = 0.002). CONCLUSION: Ranolazine improved the CCS angina class and reduced hospitalizations over a 12-month follow-up period in a group of patients with difficult-to-treat refractory angina pectoris.

Development of a Composite Lifestyle Index and Its Relationship to Quality of Life Improvement: The CLI Pilot Study.

An important component to optimal health is quality of life (QOL). Several healthy lifestyle behaviors have independently shown to improve QOL. The simultaneous implementation of multiple lifestyle behaviors is thought to be difficult, and the current literature lacks the assessment of multiple lifestyle behaviors simultaneously with respect to the effect on QOL. This current pilot study sought to develop a method to quantify multiple lifestyle behaviors into a single index value. This value was then measured with QOL for a possible correlation. The results showed that it is possible to convert multiple raw healthy lifestyle data points into a composite value and that an improvement in this value correlates to an improved QOL. After 12 months of participation in a cardiovascular risk reduction program, study participants (N = 35) demonstrated a 37.4% (P < 0.001) improvement in the composite lifestyle index (CLI). The improved CLI demonstrated a correlation with a statistically significant improvement in how participants rated their overall health in 12 months (r = 0.701, P < 0.001) as well as the number of self-reported unhealthy days per month in 12 months (r = -0.480, P = 0.004).

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.

New and emerging anticoagulant therapy for atrial fibrillation and acute coronary syndrome.

Abstract Thrombosis is an underlying cause of many cardiovascular disorders, and generation of thrombi in the arterial circulation can lead to unstable angina, myocardial infarction, or ischemic stroke. Antithrombotic therapy is widely used, with proven benefit to prevent ischemic stroke and thromboembolic events in patients with atrial fibrillation (AF) or to prevent further ischemic complications in patients with acute coronary syndrome (ACS). Traditional anticoagulants (including unfractionated heparin, low-molecular-weight heparin, and warfarin) and antiplatelet agents (including aspirin, clopidogrel, and prasugrel) are typically used for these indications. Limitations to their use include variable pharmacokinetic and pharmacodynamic profiles, inability to inhibit fibrin-bound thrombin, risk of heparin-induced thrombocytopenia, delayed onset of action, numerous drug interactions, need for substantial laboratory monitoring and dosage titrations, hyporesponsiveness or resistance, hypersensitivity, adverse events, and bleeding. To overcome some of the limitations of traditional agents, new antithrombotic agents under development are highly selective for specific coagulation factors blocking the synthesis of thrombin. Clinicians must have an understanding of the new anticoagulants to aid in the selection of appropriate therapies for patients. We describe the most relevant phases II and III clinical trials that evaluated several recent emerging anticoagulant drugs for use in patients with AF or ACS. The advantages of many new agents include predictable pharmaco-dynamic response and pharmacokinetic parameters, allowing for fixed oral dosing with no need for laboratory monitoring. For patients with AF, dabigatran is already approved for the prevention of stroke and systemic embolism, rivaroxaban appears to be an effective alternative to warfarin in high-risk patients, and apixaban may also be an effective alternative to aspirin in patients unable to take warfarin. Otamixaban shows promise as an intravenous alternative for patients with ACS in the acute care setting. Likewise, rivaroxaban, dabigatran, and darexaban with or without dual antiplatelet therapy may be beneficial for secondary prevention of ischemic events in patients with ACS.

Teaching heart failure treatment guidelines and assessing heart failure therapy.

OBJECTIVES: To determine the effectiveness of the heart failure screening form in teaching heart failure treatment guidelines and prompting students to evaluate patients' medications to initiate patient education and provider intervention. DESIGN: Between 2002 and 2009, 123 students used the heart failure screeing form during an elective cardiology advanced pharmacy practice experience (APPE). A subset of 41 students were also assessed for change in heart failure knowledge and confidence pre- and post-APPE. ASSESSMENT: A total of 1,114 heart failure patients were screened and assessed using the tool with a mean age of 71.9 ± 12.9 years. Of those, 535 (48%) patients met screening criteria and participated in heart failure education. From 2008 through 2009, there were 45 heart failure interventions with a 60% provider acceptance rate. Significant improvements were made in heart failure knowledge and in all areas of confidence at the end of the APPE for the 41 students assessed. DISCUSSION: The heart failure screening form is an effective tool to teach evidence-based medicine and to prompt students to initiate provider intervention and patient education. Its use is associated with significant increases in knowledge and confidence in heart failure medication therapy management in fourth-year pharmacy students.

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.

Randomized, double-blind, crossover comparison of amlodipine and valsartan in african-americans with hypertension using 24-hour ambulatory blood pressure monitoring.

STUDY OBJECTIVE: To compare the efficacy of amlodipine and valsartan in African-American patients with hypertension using ambulatory blood pressure monitoring (ABPM). DESIGN: Prospective, randomized, double-blind, crossover comparison study. SETTING: University-affiliated cardiac center clinic. PATIENTS: Twenty African-Americans (12 men, 8 women), with a history of uncomplicated hypertension (blood pressure > 140/90 mm Hg). INTERVENTION: Patients were randomized to receive amlodipine 5 or 10 mg/day or valsartan 80 or 160 mg/day for 8-10 weeks, depending on response. Dosages were titrated to achieve a blood pressure of 140/90 mm Hg or below. For patients whose blood pressures were not controlled, hydrochlorothiazide 12.5 mg/day was added to their regimens. Patients then underwent 24-hour ABPM. After an intervening washout period during which baseline blood pressure was reestablished, patients received the other treatment. MEASUREMENTS AND MAIN RESULTS: Mean +/- SD baseline blood pressure before the two ABPM periods were 155 +/- 12/100 +/- 8 mm Hg and 156 +/- 11/101 +/- 9 mm Hg, respectively. Fifteen (75%) patients achieved goal blood pressure with amlodipine and 14 (70%) with valsartan (p=0.62). Final daily dosages were as follows: amlodipine 5 mg in nine patients, 10 mg in five patients, and 10 mg plus hydrochlorothiazide in six patients; valsartan 80 mg in nine patients, 160 mg in four patients, and 160 mg plus hydrochlorothiazide in seven patients. Ambulatory blood pressure monitoring was not completed in three patients due to adverse effects: headache and dizziness (one patient each, amlodipine and valsartan) and hyperkalemia (one patient, valsartan). Four patients (20%) in each treatment group had drug-related adverse effects. Results of ABPM including averages for 24-hour, daytime, nighttime, first 4 hours, and last 8 hours, and trough:peak ratios were not significantly different between the amlodipine- and valsartan-based treatments. CONCLUSION: Based on both clinic blood pressure measurements and ABPM data, amlodipine and valsartan produced similar reductions in blood pressure in African-American patients with uncomplicated hypertension.

Low high-density lipoprotein cholesterol is associated with impaired endothelial function in Asian Indians.

This study was designed to assess the relationship between plasma lipid levels and endothelial function in Asian Indians without cardiovascular risk factors living in the United States. While traditional risk factors do not account for the increased incidence of coronary heart disease (CHD) in Asian Indians, low high-density lipoprotein (HDL) cholesterol, elevated triglycerides, elevated lipoprotein (a), and insulin resistance are consistently found in Asian Indians with CHD. Endothelial function was measured in 86 healthy Asian Indians (mean age 33 years) free of cardiac risk factors with LDL levels<160 mg/dL. Subjects were divided into two groups on the basis of HDL levels (low HDL<40 mg/dL and normal HDL-40 mg/dL). Endothelial function during reactive hyperemia was significantly impaired in Asian Indians in the low HDL group. After covariate adjustment, NTG-induced brachial vasodilation was not different between patients in the two HDL groups. These data indicate that low HDL is associated with endothelial dysfunction in this population.

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.

Fingernail clubbing and chromonychia associated with the use of angiotensin II receptor blockers.

Fingernail clubbing and discoloration frequently indicate serious pulmonary, cardiovascular, and gastrointestinal pathologies. A 76-year-old Caucasian man developed clubbing of the fingernails and discoloration of both the fingernails and toenails after 27 days of treatment with the angiotensin II receptor blocker (ARB) losartan 50 mg/day. Even though this therapy was switched to valsartan, the nail changes persisted for another 6 months. The patient's therapy then was changed to captopril, and the changes gradually subsided over 17 months. An extensive literature search revealed no reports of this effect in association with ARBs. However, one manufacturer had received spontaneous reports. Despite careful consideration of other possible causes of the patient's symptoms, the temporal association with the start and discontinuation of ARB therapy suggests a possible drug-related adverse event.

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.