AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation

Update in cardiology: Vascular risk and cardiac rehabilitation

Atherosclerotic cardiovascular disease remains the major cause of premature death in developed and developing countries. Nevertheless, surveys show that most patients still do not achieve the lifestyles, risk factor levels, and therapeutic targets recommended in primary and secondary prevention. The present update reflects the most recent novelties in risk classification and estimation of risk and documents the latest changes in fields such as smoking, diet and nutrition, physical activity, lipids, hypertension, diabetes, and cardiovascular rehabilitation, based on experimental trials and population-based observational studies.

How and when to decide on revascularization in stable ischemic heart disease

OPINION STATEMENT

Coronary artery disease is the leading cause of death and disability worldwide. While an invasive strategy of early revascularization reduces cardiovascular morbidity and mortality in patients with acute coronary syndromes, there is no convincing evidence that this strategy leads to an incremental survival advantage for patients with stable ischemic heart disease (SIHD) beyond that achieved by optimal medical therapy. Two landmark trials, COURAGE and BARI 2D, suggest that a strategy of aggressive medical therapy is a reasonable initial approach to such patients. However, there remain certain groups of patients, those with at least moderate ischemia on baseline stress testing, where there is still clinical equipoise. Major society guidelines favor revascularization based on observational data and trials of CABG conducted decades ago, yet data from modern randomized trials are lacking. Ongoing trials such as ISCHEMIA should provide clinicians with evidence to guide selection of the appropriate initial management strategy for patients with SIHD.

A self-regulation lifestyle program for post-cardiac rehabilitation patients has long-term effects on exercise adherence

As maintenance of lifestyle change and risk factor modification following completion of cardiac rehabilitation has been shown to be notoriously difficult, we developed a brief self-regulation lifestyle program for post-cardiac rehabilitation patients. Randomized-controlled trial. Following completion of cardiac rehabilitation 210 patients were randomized to receive either a lifestyle maintenance program (n = 112) or standard care (n = 98). The program was based on self-regulation principles and consisted of a motivational interview, 7 group sessions and home assignments. Risk factors and health behaviors were assessed at baseline (end of cardiac rehabilitation), and 6 and 15 months thereafter. ANCOVAs showed a significant effect of the lifestyle program on exercise behavior at 15-month follow-up. Mediation analysis demonstrated that the treatment effect on exercise behavior could be explained by self-regulation skills. Chi squared tests showed that patients in the intervention group had significantly fewer uncontrolled risk factors as compared to the control group. Finally, the lifestyle intervention program was associated with a 12 % reduction in self-reported cardiac hospital admission rates. This trial indicates that a relatively brief, theory-based lifestyle program is capable of inciting and maintaining improvements in exercise adherence. It is suggested that patients may need ongoing attention and guidance, for example in the form of (internet-based) booster sessions, as long-term consolidation of changes is arduous.

Does evidence support the American Heart Association's recommendation to screen patients for depression in cardiovascular care? An updated systematic review

Objectives

To systematically review evidence on depression screening in coronary heart disease (CHD) by assessing the (1) accuracy of screening tools; (2) effectiveness of treatment; and (3) effect of screening on depression outcomes.

Background

A 2008 American Heart Association (AHA) Science Advisory recommended routine depression screening in CHD.

Methods

CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases searched through December 2, 2011; manual journal searches; reference lists; citation tracking; trial registries. Included articles (1) compared a depression screening instrument to a depression diagnosis; (2) compared depression treatment to placebo or usual care in a randomized controlled trial (RCT); or (3) assessed the effect of screening on depression outcomes in a RCT.

Results

There were few examples of screening tools with good sensitivity and specificity using a priori-defined cutoffs in more than one patient sample among 15 screening accuracy studies. Depression treatment with antidepressants or psychotherapy generated modest symptom reductions among post-myocardial infarction (post-MI) and stable CHD patients (N = 6; effect size = 0.20–0.38), but antidepressants did not improve symptoms more than placebo in 2 heart failure (HF) trials. Depression treatment did not improve cardiac outcomes. No RCTs investigated the effects of screening on depression outcomes.

Conclusions

There is evidence that treatment of depression results in modest improvement in depressive symptoms in post-MI and stable CHD patients, although not in HF patients. There is still no evidence that routine screening for depression improves depression or cardiac outcomes. The AHA Science Advisory on depression screening should be revised to reflect this lack of evidence.

Behavioral mechanisms, elevated depressive symptoms, and the risk for myocardial infarction or death in individuals with coronary heart disease: the REGARDS (Reason for Geographic and Racial Differences in Stroke) study

OBJECTIVES

The aim of this study was to determine whether behavioral mechanisms explain the association between depressive symptoms and myocardial infarction (MI) or death in individuals with coronary heart disease (CHD).

BACKGROUND

Depressive symptoms are associated with increased morbidity and mortality in individuals with CHD, but it is unclear how much behavioral mechanisms contribute to this association.

METHODS

The study included 4,676 participants with a history of CHD. Elevated depressive symptoms were defined as scores ≥4 on the Center for Epidemiologic Studies Depression 4-item Scale. The primary outcome was definite/probable MI or death from any cause. Incremental proportional hazards models were constructed by adding demographic data, comorbidities, and medications and then 4 behavioral mechanisms (alcohol use, smoking, physical inactivity, and medication non-adherence).

RESULTS

At baseline, 638 (13.6%) participants had elevated depressive symptoms. Over a median 3.8 years of follow up, 125 of 638 (19.6%) participants with and 657 of 4,038 (16.3%) without elevated depressive symptoms had events. Higher risk of MI or death was observed for elevated depressive symptoms after adjusting for demographic data (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.15 to 1.72) but was no longer significant after adjusting for behavioral mechanisms (HR: 1.14, 95% CI: 0.93 to 1.40). The 4 behavioral mechanisms together significantly attenuated the risk for MI or death conveyed by elevated depressive symptoms (-36.9%, 95% CI: -18.9 to -119.1%), with smoking (-17.6%, 95% CI: -6.5% to -56.0%) and physical inactivity (-21.0%, 95% CI: -9.7% to -61.1%) having the biggest explanatory roles.

CONCLUSIONS

Our findings suggest potential roles for behavioral interventions targeting smoking and physical inactivity in patients with CHD and comorbid depression.

Validation of persuasive messages for the promotion of physical activity among people with coronary heart disease

OBJECTIVE

to validate the content of persuasive messages for promoting walking among patients with coronary heart disease (CHD). The messages were constructed to strengthen or change patients' attitudes to walking.

METHOD

the selection of persuasive arguments was based on behavioral beliefs (determinants of attitude) related to walking. The messages were constructed based in the Elaboration Likelihood Model and were submitted to content validation.

RESULTS

the data was analyzed with the content validity index and by the importance which the patients attributed to the messages' persuasive arguments. Positive behavioral beliefs (i.e. positive and negative reinforcement) and self-efficacy were the appeals which the patients considered important. The messages with validation evidence will be tested in an intervention study for the promotion of the practice of physical activity among patients with CHD.

Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study

BACKGROUND

Despite the evidence of benefit, cardiac rehabilitation (CR) remains highly underutilized. The present study examined the effect of two inpatient and one outpatient strategy on CR utilization: allied healthcare provider completion of referral (a policy that had been endorsed and approved by the cardiac program leadership in advance; PRE-APPROVED); CR intake appointment booked before hospital discharge (PRE-BOOKED); and early outpatient education provided at the CR program shortly after inpatient discharge (EARLY ED).In this prospective observational study, 2,635 stable cardiac inpatients from 11 Ontario hospitals completed a sociodemographic survey, and clinical data were extracted from charts. One year later, participants were a mailed survey that assessed CR use. Participating inpatient units and CR programs to which patients were referred were coded to reflect whether each of the strategies was used (yes/no). The effect of each strategy on participants' CR referral and enrollment was examined using generalized estimating equations.

RESULTS

A total of 1,809 participants completed the post-test survey. Adjusted analyses revealed that the implementation of one of the inpatient strategies was significantly related to greater referral and enrollment (PRE-APPROVED: OR = 1.96, 95%CI = 1.26 to 3.05, and OR = 2.91, 95%CI = 2.20 to 3.85, respectively). EARLY ED also resulted in significantly greater enrollment (OR = 4.85, 95%CI = 2.96 to 7.95).

CONCLUSIONS

These readily-implementable strategies could significantly increase access to and enrollment in CR for the cardiac population. The impact of these strategies on wait times warrants exploration.

Yoga for secondary prevention of coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the major cause of early morbidity and mortality in most developed countries. Secondary prevention aims to prevent repeat cardiac events and death in people with established CHD. Lifestyle modifications play an important role in secondary prevention. Yoga has been regarded as a kind of physical activity as well as stress management strategy. Growing evidence suggests the beneficial effects of yoga on various ailments.

OBJECTIVES

To determine the effectiveness of yoga for secondary prevention of mortality, morbidity, and health related quality of life of patients with CHD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2012, Issue 1), MEDLINE (1948 to January 2012), EMBASE (1980 to January 2012), ISI Web of Science for conference proceedings (1970 to January 2012), China Journal Net (CJN) (1994 to March 2012), WanFang Data (1990 to March 2012), and HKInChiP (from 1980). Ongoing studies were identified in the metaRegister of Controlled Trials (April 2012) and the World Health Organization (WHO) International Clinical Trials Registry Platform (April 2012). No language restrictions were applied.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) investigating the influence of yoga practice on CHD outcomes. We included studies that had at least a six months follow-up period. Men and women (aged 18 years and above) with a diagnosis of acute or chronic CHD were included. We included studies with one group practicing a type of yoga compared to the control group receiving either no intervention or interventions other than yoga.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies according to the pre-specified inclusion criteria. Disagreements were resolved by consensus or discussion with a third author.

MAIN RESULTS

We found no eligible RCTs that met the inclusion criteria of the review and thus we were unable to perform a meta-analysis.

AUTHORS' CONCLUSIONS

The effectiveness of yoga for secondary prevention in CHD remains uncertain. Large RCTs of high quality are needed.

Statin and aspirin therapy for the prevention of cardiovascular events in patients with type 2 diabetes mellitus

Patients with type 2 diabetes mellitus are at 2 to 4 times increased risk of cardiovascular events compared with those without diabetes, both among patients with multiple risk factors only and those with established atherothrombosis. In this review, we provide recommendations for the use of statins and aspirin for the prevention of cardiovascular events in high-risk patients with diabetes mellitus.

Atorvastatin with or without an antibody to PCSK9 in primary hypercholesterolemia

BACKGROUND

Serum proprotein convertase subtilisin/kexin 9 (PCSK9) binds to low-density lipoprotein (LDL) receptors, increasing the degradation of LDL receptors and reducing the rate at which LDL cholesterol is removed from the circulation. REGN727/SAR236553 (designated here as SAR236553), a fully human PCSK9 monoclonal antibody, increases the recycling of LDL receptors and reduces LDL cholesterol levels.

METHODS

We performed a phase 2, multicenter, double-blind, placebo-controlled trial involving 92 patients who had LDL cholesterol levels of 100 mg per deciliter (2.6 mmol per liter) or higher after treatment with 10 mg of atorvastatin for at least 7 weeks. Patients were randomly assigned to receive 8 weeks of treatment with 80 mg of atorvastatin daily plus SAR236553 once every 2 weeks, 10 mg of atorvastatin daily plus SAR236553 once every 2 weeks, or 80 mg of atorvastatin daily plus placebo once every 2 weeks and were followed for an additional 8 weeks after treatment.

RESULTS

The least-squares mean (±SE) percent reduction from baseline in LDL cholesterol was 73.2±3.5 with 80 mg of atorvastatin plus SAR236553, as compared with 17.3±3.5 with 80 mg of atorvastatin plus placebo (P<0.001) and 66.2±3.5 with 10 mg of atorvastatin plus SAR236553. All the patients who received SAR236553, as compared with 52% of those who received 80 mg of atorvastatin plus placebo, attained an LDL cholesterol level of less than 100 mg per deciliter, and at least 90% of the patients who received SAR236553, as compared with 17% who received 80 mg of atorvastatin plus placebo, attained LDL cholesterol levels of less than 70 mg per deciliter (1.8 mmol per liter).

CONCLUSIONS

In a randomized trial involving patients with primary hypercholesterolemia, adding SAR236553 to either 10 mg of atorvastatin or 80 mg of atorvastatin resulted in a significantly greater reduction in LDL cholesterol than that attained with 80 mg of atorvastatin alone. (Funded by Sanofi and Regeneron Pharmaceuticals; ClinicalTrials.gov number, NCT01288469.).

A qualitative analysis of coronary heart disease patient views of dietary adherence and web-based and mobile-based nutrition tools

PURPOSE

Dietary adherence can be challenging for patients with coronary heart disease (CHD), as they may require multiple dietary changes. Choosing appropriate food items may be difficult or take extensive amounts of time without the aid of technology. The objective of this project was to (1) examine the dietary challenges faced by patients with CHD, (2) examine methods of coping with dietary challenges, (3) explore the feasibility of a Web-based food decision support system, and (4) explore the feasibility of a mobile-based food decision support system.

METHODS

Food for the Heart (FFH), a Web site-based food decision support system, and Mobile Magic Lens (MML), a mobile-based system, were developed to aid in daily dietary choices. Three CHD patient focus groups were conducted and focused on CHD-associated dietary changes as well as the FFH and MML prototypes. A total of 20 CHD patients and 7 informal caregivers participated. Qualitative, content analysis was performed to find themes grounded in the responses.

RESULTS

Five predominant themes emerged: (1) decreasing carbohydrate intake and portion control are common dietary challenges, (2) clinician and social support makes dietary adherence easier, (3) FFH could make meal-planning and dietary adherence less complicated, (4) MML could save time and assist with healthy choices, and (5) additional features need to be added to make both tools more comprehensive.

CONCLUSION

Food for the Heart and MML may be tools that CHD patients would value in making food choices and adhering to dietary recommendations, especially if additional features are added to assist patients with changes.

The Use of Combination Lipid Therapy in a County Health System

Background:

With the paucity of clinical outcomes trials and guidelines to make compelling recommendations regarding the treatment of dyslipidemia beyond statin monotherapy, we present a descriptive analysis of the combination lipid-lowering therapies being used at a large county hospital system.

Objective:

To provide a descriptive evaluation of the comparative effectiveness and safety of various combination lipid therapies in conjunction with a statin.

Methods:

Patients of a county health system who received at least 3 months of combination lipid therapy in conjunction with a statin during a 1-year period were eligible for inclusion in this retrospective chart review. The main outcome was a descriptive analysis of the comparative effectiveness among combination lipid therapies, as evidenced by fasting lipid panels.

Results:

A total of 834 patients were included in the analysis. Approximately 88% were on 1 additional lipid-modifying agent beyond a statin; 2 or 3 additional medications were much less common. Fish oils and fibrates were the most common nonstatin agents used, comprising approximately 85% of the combination therapies. Approximately 17% of patients had all 4 lipids at goal. A majority of patients were at goal for low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol (non-HDL-C), and total cholesterol, but a large proportion were not at goal for HDL-C and triglycerides. No statistically significant differences were found among therapies for effectiveness related to lipid goals, medication adherence, or safety. The chart review did not find an appreciable number of adverse events. The overall adherence rate was subpar at 56% and varied modestly among treatments.

Conclusions:

This retrospective analysis found no significant differences in effectiveness, adherence, and safety among the combination lipid therapies used in a county health system. Further research is warranted to elucidate the recommended approach to using combination lipid therapies.

Antithrombotic strategies to reduce adverse clinical outcomes in patients with acute coronary syndrome

Acute coronary syndromes (ACSs), which include ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina, present a considerable burden to the health care system. Furthermore, many patients with a first ACS event will develop another event within 1 year. To prevent this, higher-risk patients with ACS are revascularized when possible after presentation and then prescribed ongoing treatments to prevent recurrent vascular events. These include agents that prevent platelet aggregation and subsequent coronary thrombosis. However, some patients will develop a recurrent event despite treatment with these drugs, prompting a search for additional strategies to augment the effectiveness of current therapies. One such approach is add-on therapy with oral anticoagulant drugs. These agents may act synergistically with antiplatelet agents in preventing thrombosis. In conclusion, new oral anticoagulants might represent an attractive therapeutic strategy if they do not result in unacceptable bleeding.

Six-minute walk test as a prognostic tool in stable coronary heart disease: data from the heart and soul study

BACKGROUND

The prognostic value of the 6-minute walk test (6MWT) in patients with stable coronary heart disease is unknown. We sought to determine whether the 6MWT predicted cardiovascular events in ambulatory patients with coronary heart disease.

METHODS

We measured 6MWT distance and treadmill exercise capacity in 556 outpatients with stable coronary heart disease from September 11, 2000, through December 20, 2002. Participants were followed up for a median of 8.0 years for cardiovascular events (heart failure, myocardial infarction, and death).

RESULTS

Cardiovascular events occurred in 218 of 556 participants (39.2%). Patients in the lowest quartile of 6MWT distance (87-419 m) had 4 times the rate of events as those in the highest quartile (544-837 m) (unadjusted hazard ratio, 4.29; 95% CI, 2.83-6.53; P < .001). Each SD decrease in 6MWT distance (104 m) was associated with a 55% higher rate of cardiovascular events (age-adjusted hazard ratio, 1.55; 95% CI, 1.35-1.78). After adjustment for traditional risk factors and cardiac disease severity measures (ejection fraction, inducible ischemia, diastolic dysfunction, amino-terminal portion of the prohormone of brain-type natriuretic peptide, and C-reactive protein), each SD decrease in 6MWT was associated with a 30% higher rate of cardiovascular events (hazard ratio, 1.30; 95% CI, 1.10-1.53). When added to traditional risk factors, the 6MWT resulted in category-free net reclassification improvement of 39% (95% CI, 19%-60%). The discriminative ability of the 6MWT was similar to that of treadmill exercise capacity for predicting cardiovascular events (C statistics both 0.72; P = .29).

CONCLUSIONS

Distance walked on the 6MWT predicted cardiovascular events in patients with stable coronary heart disease. The addition of a simple 6MWT to traditional risk factors improved risk prediction and was comparable with treadmill exercise capacity.

Dyslipidemia: Management Using Optimal Lipid-Lowering Therapy

Objective:

To evaluate current approaches and explore emerging research related to dyslipidemia management.

Data Sources:

MEDLINE (2004-April 2012) was searched for randomized controlled trials using the terms dyslipidemia and lipid-lowering therapy or statin (>1000 hits). Separate searches (MEDLINE, Google) identified meta-analyses (2010–2011), disease prevalence statistics, and current consensus guidelines (2004–July 2011). Additional references were identified from the publications reviewed.

Study Selection and Data Extraction:

English-language articles on large multi-center trials were evaluated.

Data Synthesis:

National Cholesterol Education Program Adult Treatment Panel III guidelines for the reduction of cardiovascular risk recommend the attainment of specific low-density lipoprotein cholesterol (LDL-C) and non–high-density lipoprotein cholesterol (non–HDL-C) target values, based on an individual's 10-year risk of coronary heart disease or global risk. For most patients unable to achieve recommended lipid level goals with therapeutic lifestyle changes, statins are the first option for treatment. Results of large, well-controlled clinical trials have demonstrated that statins are effective in primary and secondary prevention of cardiovascular disease in diverse populations, including patients with diabetes and the elderly, and that intensive statin therapy provides more effective lipid goal attainment and significantly greater risk reduction in patients with coronary artery disease. Stalin therapy is generally well tolerated but may increase the risk of myopathy. Statin use has been associated with increases in hepatic transaminases and an increased risk of diabetes, although the absolute risk of diabetes is low compared with the risk reduction benefit. Combination therapy including a statin may be appropriate for certain populations, but the risk reduction benefits of combination therapy remain unclear. Ezetimibe is an important treatment option for patients with hypercholesterolemia who do not tolerate intensive statin therapy. Although fibrates or niacin improves overall lipid profiles in patients with hypertriglyceridemia or dyslipidemia who are receiving statin therapy, their efficacy in reducing cardiovascular risk remains questionable and their use raises safety and tolerability concerns.

Conclusions:

Intensifying lifestyle changes and statin dose should be utilized first in patients not achieving their LDL-C and non-HDL-C goals.

The prevention and regression of atherosclerotic plaques: emerging treatments

Occlusive vascular diseases, such as sudden coronary syndromes, stroke, and peripheral arterial disease, are a huge burden on the health care systems of developed and developing countries. Tremendous advances have been made over the last few decades in the diagnosis and treatment of atherosclerotic diseases. Intravascular ultrasound has been able to provide detailed information of plaque anatomy and has been used in several studies to assess outcomes. The presence of atherosclerosis disrupts the normal protective mechanism provided by the endothelium and this mechanism has been implicated in the pathophysiology of coronary artery disease and stroke. Efforts are being put into the prevention of atherosclerosis, which has been shown to begin in childhood. This paper reviews the pathophysiology of atherosclerosis and discusses the current options available for the prevention and reversal of plaque formation.

Missed Opportunities

Background—

Patients with peripheral artery disease (PAD) are at high risk of cardiovascular events and benefit from aggressive secondary prevention; however, changes in the use of cardioprotective medications after incident diagnosis of PAD have not been well described.

Methods and Results—

We used Danish nationwide administrative registries (2000–2007) to identify 2 groups with incident PAD: PAD alone (n=34 160) and PAD with history of coronary artery disease (CAD) (n=9570). With the use of a comparator with incident CAD alone (n=154 183), we assessed temporal trends and comparative use of cardioprotective medications. Relative differences in medication use were examined by using multivariable logistic regression. Use of medications improved temporally among both groups: for PAD alone, any antiplatelet use increased from 29% to 59% from 2000 to 2007 ( P <0.0001), whereas statin use increased 6-fold (9%–56%; P <0.0001). However, use of these therapies by 18 months after incident diagnosis for both PAD groups remained modest and lower in comparison with CAD alone (any antiplatelet, 53% versus 66%; statins, 40% versus 52%; angiotensin-converting enzyme inhibitors, 20% versus 29%). Relative to CAD alone, patients with PAD alone were less likely to use any antiplatelet (adjusted odds ratio, 0.50; 95% confidence interval, 0.49–0.52), statins (adjusted odds ratio, 0.50; 95% confidence interval, 0.48–0.52), or angiotensin-converting enzyme inhibitors (adjusted odds ratio, 0.51; 95% confidence interval, 0.49–0.53) by 18 months.

Conclusions—

Despite improvement in the use of cardioprotective medications over time, patients with PAD alone remain less likely than those with CAD alone to use these agents.

Recent Trends in Adherence to Secondary Prevention Guidelines for Patients Undergoing Coronary Revascularization in Washington State: An Analysis of the Clinical Outcomes Assessment Program (COAP) Registry

BACKGROUND

Previous studies indicated that patients undergoing coronary artery bypass graft (CABG) surgery are less likely to receive guideline-based secondary prevention therapy than are those undergoing percutaneous coronary intervention (PCI) after an acute myocardial infarction. We aimed to evaluate whether these differences have persisted after the implementation of public reporting of hospital metrics.

METHODS AND RESULTS

The Clinical Outcomes Assessment Program (COAP) database was analyzed retrospectively to evaluate adherence to secondary prevention guidelines at discharge in patients who underwent coronary revascularization after an acute ST-elevation myocardial infarction in Washington State. From 2004 to 2007, 9260 patients received PCI and 692 underwent CABG for this indication. Measures evaluated included prescription of aspirin, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, or lipid-lowering medications; cardiac rehabilitation referral; and smoking-cessation counseling. Composite adherence was lower for CABG than for PCI patients during the period studied (79.6% versus 89.7%, P<0.01). Compared to patients who underwent CABG, patients who underwent PCI were more likely to receive each of the pharmacological therapies. There was no statistical difference in smoking-cessation counseling (91.7% versus 90.3%, P=0.63), and CABG patients were more likely to receive referral for cardiac rehabilitation (70.9% versus 48.3%, P<0.01). Adherence rates improved over time among both groups, with no significant difference in composite adherence in 2006 (85.6% versus 87.6%, P=0.36).

CONCLUSIONS

Rates of guideline-based secondary prevention adherence in patients with ST-elevation myocardial infarction who underwent CABG surgery have been improving steadily in Washington State. The improvement possibly is associated with the implementation of public reporting of quality measures.

Clinical value of drugs targeting inflammation for the management of coronary artery disease

Atherosclerosis and cardiovascular disease are the leading cause of death worldwide. Atherosclerosis is a complex inflammatory disease that results from lipid accumulation and oxidation in the arterial wall combined with an active inflammatory reaction involving transmigration of monocytes and other inflammatory cells from the blood stream into the vessel wall. Many therapeutic approaches have been tested to treat atherosclerosis and prevent its complications, with statins being the most efficient therapy by reducing the levels of atherogenic lipoproteins and preventing major cardiovascular events. However, the risk of atherothrombotic complications still remains high, causing millions of deaths around the world each year. Extensive research has shed light on the cascade of cellular and molecular events that lead from atherosclerotic plaque formation to its rupture and have highlighted promising new therapeutic targets, each being implicated at different stages of the atherosclerotic plaque formation and progression. In this review, we briefly discuss the potential of high-density lipoprotein-based therapies, given the anti-inflammatory properties of high-density lipoprotein. We then present different approaches that tackle inflammation, including inhibition of 5-lipoxygenase, blockade of P-selectin, use of a viral-derived serpin, and interleukin-1β inhibition. All these targets have shown encouraging results in clinical trials and support the idea that targeting inflammation could reduce cardiovascular complications in patients with coronary artery disease.

Modern management of acute myocardial infarction

Disruption of intracoronary plaque with thrombus formation provides the pathophysiologic foundation for acute coronary syndromes, which comprise ST-segment myocardial infarction, non-ST-segment myocardial infarction, and unstable angina. Management differs depending on whether ST-segment elevation is present, but the general principles of timely restoration of coronary blood flow and initiation of secondary prevention strategies are applicable to all patients. The purpose of this review is to discuss first the epidemiology, pathophysiology, and diagnosis of acute myocardial infarction. Risk stratification and therapy for patients with ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndromes are then reviewed along with diagnosis and management of the complications of myocardial infarction.

[Telemedicine during cardiac rehabilitation after acute myocardial infarction]

After acute myocardial infarction, cardiac rehabilitation should be an essential part of any therapy aimed at long-term success. Telemedical studies have mostly investigated ECG-monitored exercise training at home and internet-based counseling for lifestyle modification in selected patients. This approach cannot replace the holistic and multidisciplinary approach of cardiac rehabilitation. Telemedicine should be further evaluated, however, as it offers significant opportunities to facilitate access to rehabilitation for those patients who would otherwise not be able to attend for geographical, logistic or psychosocial reasons.

Use of Lipid-Lowering Medications and the Likelihood of Achieving Optimal LDL-Cholesterol Goals in Coronary Artery Disease Patients

Background. In clinical practice, most coronary artery disease patients are not achieving their recommend LDL-cholesterol goal of <70 mg/dL. Methods. We conducted a retrospective analysis of outpatient electronic health records and the most recent lipid profile, lipid-lowering medications and doses were collected. Results. We identified 9950 coronary artery disease patients. Only 37% on a statin alone achieved an LDL-cholesterol of <70 mg/dL, and most were on moderate-to-high-potency statins. The intensity of statin therapy did not improve LDL-cholesterol goal attainment. Among patients on combination therapy, 41% on statin plus ezetimibe and 46% on statin plus niacin achieved an LDL-cholesterol of <70 mg/dL (P = 0.01 and <0.0001 versus statin alone). If patients were switched to a high-potency statin LDL-cholesterol goal attainment of <70 mg/dL would increase to 46% and would increase up to 72% with combination therapy. Conclusions. Most coronary artery disease patients in clinical practice do not attain an LDL-cholesterol of <70 mg/dL, even among patients on high potency statins. The combination of statin plus either ezetimibe or niacin is the most effective regimen to achieve an LDL-cholesterol of <70 mg/dL, however, these drug combinations are used infrequently in clinical practice.

Secondary revascularization after CABG surgery

CABG surgery is an effective way to improve symptoms and prognosis in patients with advanced coronary atherosclerotic disease. Despite multiple improvements in surgical technique and patient treatment, graft failure after CABG surgery occurs in a time-dependent fashion, particularly in the second decade after the intervention, in a substantial number of patients because of atherosclerotic progression and saphenous-vein graft (SVG) disease. Until 2010, repeat revascularization by either percutaneous coronary intervention (PCI) or surgical techniques was performed in these high-risk patients in the absence of specific recommendations in clinical practice guidelines, and within a culture of inadequate communication between cardiac surgeons and interventional cardiologists. Indeed, some of the specific technologies developed to reduce procedural risk, such as embolic protection devices for SVG interventions, are largely underused. Additionally, the implementation of secondary prevention, which reduces the need for reintervention in these patients, is still suboptimal. In this Review, graft failure after CABG surgery is examined as a clinical problem from the perspective of holistic patient management. Issues such as the substrate and epidemiology of graft failure, the choice of revascularization modality, the specific problems inherent in repeat CABG surgery and PCI, and the importance of secondary prevention are discussed.

Pheidippides redux: reducing risk for acute cardiac events during marathon running

Prolonged strenuous exercise such as marathon running transiently increases the absolute and relative risk for sudden cardiac death. A 17-fold increase in the latter over resting baseline in previously sedentary middle-aged men is reduced due to cardioprotection from training in experienced marathon runners. Exertional rhabdomyolysis as a common occurrence during the race is accompanied by neutrophilia and elevated biomarkers of inflammation, including interleukin-6 and C-reactive protein. A hemostatic imbalance with prothrombotic effects includes in vivo platelet activation during the race. Suggesting a pathogenic role for these findings, plaque rupture due to atherothrombosis triggers acute exertional cardiac events, including sudden death, in low-risk runners as in high-risk patients such as those with diabetes mellitus. Strategies including prophylactic aspirin are considered to decrease the risk for acute cardiac events.

Delayed educational reminders for long-term medication adherence in ST-elevation myocardial infarction (DERLA-STEMI): protocol for a pragmatic, cluster-randomized controlled trial

Background

Despite evidence-based recommendations supporting long-term use of cardiac medications in patients post ST-elevation myocardial infarction, adherence is known to decline over time. Discontinuation of cardiac medications in such patients is associated with increased mortality.

Methods/design

This is a pragmatic, cluster-randomized controlled trial with blinded outcome assessment and embedded qualitative process evaluation. Patients from one health region in Ontario, Canada who undergo a coronary angiogram during their admission for ST-elevation myocardial infarction and who survive their initial hospitalization will be included. Allocation of eligible patients to intervention or usual care will take place within one week after the angiogram using a computer-generated random sequence. To avoid treatment contamination, patients treated by the same family physician will be allocated to the same study arm. The intervention consists of recurrent, personalized, paper-based educational messages and reminders sent via post on behalf of the interventional cardiologist to the patient, family physician, and pharmacist urging long-term adherence to secondary prevention medications. The primary outcome is the proportion of patients who report in a phone interview taking all relevant classes of cardiac medications at twelve months. Secondary outcomes to be measured at three and twelve months include proportions of patients who report: actively taking each cardiac medication class of interest (item-by-item); stopping medications due to side effects; taking one or two or three medication classes concurrently; a perfect Morisky Medication Adherence Score for cardiac medication compliance; and having a discussion with their family physician about long-term adherence to cardiac medications. Self-reported measures of adherence will be validated using administrative data for prescriptions filled.

Discussion

This intervention is designed to be easily generalizable. If effective, it could be implemented broadly. If it does not change medication utilization, the process evaluation will offer insights regarding how such an intervention could be optimized in future.

Trial registration

Clinicaltrials.gov NCT01325116