Cardioprotective Medications Research Articles

Comparison between type-2 and type-1 myocardial infarction: clinical features, treatment strategies and outcomes.

ObjectiveTo assess the differences in incidence, clinical features, current treatment strategies and outcome in patients with type-2 vs. type-1 acute myocardial infarction (AMI).MethodsWe included 824 consecutive patients with a diagnosis of type-1 or type-2 AMI. During index hospitalization, clinical features and treatment strategies were collected in detail. At 1-year follow-up, mortality, stroke, non-fatal myocardial infarction and major bleeding were recorded.ResultsType-1 AMI was present in 707 (86%) of the cases while 117 (14%) were classified as type-2. Patients with type-2 AMI were more frequently female and had higher co-morbidities such as diabetes, previous non-ST segment elevation acute coronary syndromes, impaired renal function, anaemia, atrial fibrillation and malignancy. However, preserved left ventricular ejection fraction and normal coronary arteries were more frequently seen, an invasive treatment was less common, and anti-platelet medications, statins and beta-blockers were less prescribed in patients with type-2 AMI. At 1-year follow-up, type-2 AMI was associated with a higher crude mortality risk (HR: 1.75, 95% CI: 1.14–2.68; P = 0.001), but this association did not remain significant after multivariable adjustment (P = 0.785). Furthermore, we did not find type-2 AMI to be associated with other clinical outcomes.ConclusionsIn this real-life population, compared with type-1, type-2 AMI were predominantly women and had more co-morbidities. Invasive treatment strategies and cardioprotective medications were less used in type-2, while the 1-year clinical outcomes were similar.

Serum Fatty Acids, Traditional Risk Factors, and Comorbidity as Related to Myocardial Injury in an Elderly Population with Acute Myocardial Infarction.

Background. Epidemiological and randomized clinical trials indicate that marine polyunsaturated n-3 fatty acids (n-3 PUFAs) may have cardioprotective effects. Aim. Evaluate the associations between serum fatty acid profile, traditional risk factors, the presence of cardiovascular diseases (CVD), and peak Troponin T (TnT) levels in elderly patients with an acute myocardial infarction (AMI). Materials and Methods. Patients (n = 299) consecutively included in the ongoing Omega-3 fatty acids in elderly patients with myocardial infarction (OMEMI) trial were investigated. Peak TnT was registered during the hospital stay. Serum fatty acid analysis was performed 2–8 weeks later. Results. No significant correlations between peak TnT levels and any of the n-3 PUFAs were observed. However, patients with a history of atrial fibrillation had significantly lower docosahexaenoic acid levels than patients without. Significantly lower peak TnT levels were observed in patients with a history of hyperlipidemia, angina, MI, atrial fibrillation, intermittent claudication, and previous revascularization (all p < 0.02). Conclusions. In an elderly population with AMI, no association between individual serum fatty acids and estimated myocardial infarct size could be demonstrated. However, a history of hyperlipidemia and the presence of CVD were associated with lower peak TnT levels, possibly because of treatment with cardioprotective medications.

Improving Cardiac Rehabilitation Nurse-led Clinics Boost Uptake of Cardioprotective Medications at 6 Months

Improving Cardiac Rehabilitation Nurse-led Clinics Boost Uptake of Cardioprotective Medications at 6 Months

Abstract 11776: The Questionable Clinical Impact of Routine Pre-operative Cardiology Consultation Prior to Vascular Surgical Procedures

Objective: No significant evidence basis exists for who and when a preoperative cardiac consultation should be obtained. We sought to define the variation in preoperative cardiology for patients requiring a vascular surgical procedure and determine whether this was associated with differences in perioperative myocardial infarction (poMI) or death. Methods: A 29 hospital statewide QI collaborative were queried for open aortic aneurysm repair, EVAR, and open vascular bypass procedures. Preprocedure documented cardiac consultation as well as stress testing was determined as part of the database. The primary outcome was poMI and death. Results: Among 5191 patients, 48% had a documented preoperative cardiac cardiology consultation, with the poMI rate of 2.1% and a 1.3% death rate. Across hospitals, preoperative cardiac consultation varied from &lt;10% to over 85%, and was not dependent on the procedural volume, academic versus community status , or hospital size. Cardiology consultation rates correlated with stress test usage (Pearson ρ = 0.6; p &lt; .001). Stratification of patients by the Revised Cardiac Risk Index (RCRI) categories showed consultation varied significantly by classification; RCRI=1; 38% had preoperative cardiology consult rate versus an RCRI =4; 66% had a cardiology consult. After stratification by RCRI, there was no association between cardiac consultation use and lower postoperative MI rate (Table) or death rate. Moreover, use of preoperative cardioprotective medications was not more common in those hospitals with high (&gt; 50%) cardiology consultation rates as compared to lower consultation hospitals. Discussion: Preoperative cardiology consultation for vascular surgical patients varies greatly between institutions. Cardiology consultation was not associated with better utilization of cardioprotective medications nor was it associated with a lower incidence of death or myocardial infarction. MI Frequency by Cardiac Consultation

Abstract 13555: Acute Efficacy of Sodium Zirconium Cyclosilicate (ZS-9) in Patients on Mineralocorticoid-Receptor Antagonists: Analysis From Two Phase 3 Studies

Introduction: Although mineralocorticoid-receptor antagonists (MRAs) are strongly recommended by guidelines for chronic management of patients with heart failure (HF), less than 1/3 of eligible patients receive these cardio-protective medications due to the risk of hyperkalemia (hyperK; potassium [K+] ≥5.1 mEq/L). Sodium zirconium cyclosilicate (ZS-9) is a highly selective K+ ion trap that binds K+ throughout the GI tract. We examined the effectiveness of ZS-9 in treating hyperK in patients receiving MRAs using pooled data from 2 recently completed Phase 3 clinical trials. Methods: Data were pooled from 2 Phase 3 trials of patients with hyperK: ZS003 (N=753) and HARMONIZE (N=258). In both trials, patients receiving MRAs at baseline, and treated with 10 g, three times daily (TID), ZS-9 for 48 hrs were selected. Per protocol, MRA doses remained stable for the duration of the study. We examined absolute change in K+ from baseline, proportion of patients who achieved normokalemia by 24 and 48 hrs, and time to K+ normalization. Results: Across studies, 19 patients were on MRAs (age 73y; 74% HF; 90% eGFR &lt;60; 74% diabetes mellitus). Mean baseline K+ was 5.7 mEq/L. ZS-9 significantly reduced K+ during 48 hrs after treatment initiation (Figure): by 0.3, 0.5, 0.5, 0.7 and 1.1 mEq/L at 1, 2, 4, 24 and 48 hrs, respectively (P&lt;0.005 for each time point vs. baseline). Normokalemia was achieved in 84% and 95% of patients by 24 and 48 hours, respectively. Median time to K+ normalization was 3.8 hrs. During the initial 48 hrs of treatment of the overall population treated with 10 g ZS-9, the adverse event rate was 9% compared to 11% among patients who received placebo. Conclusions: In patients with hyperK while on MRA therapy, ZS-9 rapidly lowered K+ to normal range, with 95% of patients achieving normokalemia by 48 hrs. If confirmed in future studies, these results suggest that ZS-9 may enable optimization of cardio-protective MRA therapy in HF patients with or at high risk for hyperK.

Cardiac Rehabilitation: Underrecognized/Underutilized.

Unfortunately, too many patients continue to rely on costly coronary revascularization procedures, cardioprotective medications, or both, as first-line strategies to stabilize the course of coronary heart disease. However, these palliative therapies do not address the foundational or most proximal risk factors for coronary disease, that is, unhealthy dietary habits, physical inactivity, and cigarette smoking. Because most acute myocardial infarctions evolve from mild-to-moderate coronary artery stenosis (<70% obstruction), rather than at the more severe obstructions that are commonly treated with coronary revascularization, these findings help explain the inability to demonstrate a reduction in acute cardiac events in most studies examining coronary artery bypass graft surgery and/or percutaneous coronary interventions. The delivery of comprehensive cardiovascular risk reduction, including exercise-based cardiac rehabilitation as an integral component, offers patients a bona fide treatment intervention to prevent recurrent cardiovascular events and the need for repeated revascularization procedures, while simultaneously providing referring physicians with ongoing surveillance data to potentially enhance their medical management.

Implementation of Cardiovascular Disease Prevention Guidelines in Clinical Practice-Can We Do Better?

Passive dissemination of guidelines in isolation is generally ineffective and results in only small changes in practice. The challenge is to motivate and support more physicians to routinely practice cardiovascular prevention. There is considerable potential to raise the standard of cardiovascular prevention through more effective lifestyle intervention, control of other risk factors and appropriate use of cardioprotective medication. A more comprehensive multidisciplinary and professional approach accessible to both patients with established disease as well as those who are at high risk of developing CVD and provided in each country by existing or adapted 'prevention centres' is needed. Cardiovascular prevention requires an integrated family-based approach, involving multidisciplinary teams of health care professionals, adapted to medical and cultural settings in each country in order to achieve better lifestyles, risk factor control and adherence with cardioprotective medications in our patients with coronary disease and to reduce their risk of recurrent cardiovascular events and improve quality of life and survival. Coronary intervention should always be followed by prevention.

DO STANDARD HEART FAILURE MEDICATIONS PREVENT FALL IN LVEF IN BREAST CANCER PATIENTS GIVEN TARGETED THERAPY?

Beta blockers and angiotensin modulators form the cornerstone of heart failure management in the general population. The benefit of these inexpensive agents is ill-defined in HER2-positive breast cancer patients with known cardiac-related comorbidities who are treated with trastuzumab, which is the gold standard targeted therapy in this patient population plus a known cause for reversible cardiotoxicity in many patients. We sought to determine if being on these cardiovascular medications up-front to exposure to targeted therapy prevents the decline in LVEF in patients with known cardiac-related comorbidities. Adhered to the PRISMA statement for pooled-analysis. Selection criteria: Clinical trials involving patient cohorts already on cardioprotective medications when treated with trastuzumab. Search strategy: PubMed, the Cochrane Library, Google Scholar, Web of Science, and Scopus databases from 1998 to 2013, plus www.asco.org and www.clinicaltrials.gov. Outcome measure: Decline in LVEF >10% of baseline per ECHO or MUGA while on beta blocker +/− angiotensin modulator (ACEi or ARB), plus trastuzumab. Statistical analysis: Dedicated pooled-analysis statistical software (BioStat Inc., NJ, USA). From 218 articles, 6 clinical trials (n = 329) were selected with extractable data. Patients on beta blocker +/− angiotensin modulator tended to be older and heavily pretreated with chemotherapy. Being on cardioprotective medications during trastuzumab therapy was beneficial for stability of LVEF in patients at above-average risk for cardiotoxicity [mean odds ratio (OR): 0.664, 95%CI 0.44 to 0.99; random effects model p = 0.05 versus fixed effect model p = 0.004]. Statistical analyses revealed robustness of our analysis for comorbidity index (p < 0.05). Evidence to support the up-front use of beta blockers as a cardioprotective strategy in breast cancer patients at highest risk for cardiotoxicity secondary to targeted therapy has yet to be fully investigated in a randomized clinical trial -- the results of the MANTICORE 101 clinical trial are pending. However, our hypothesis-generating analysis suggests that use of a beta blocker +/− angiotensin modulator while receiving targeted therapy blunts the decline in LVEF in breast cancer patients with known cardiac risk factors or comorbidities. Although our analysis only represents a statistical signal of possible clinical benefit, further investigation is warranted.

Medication burden in the first 5 years following diagnosis of type 2 diabetes: findings from the ADDITION-UK trial cohort

IntroductionIndividuals with screen-detected diabetes are likely to receive intensified pharmacotherapy to improve glycaemic control and general cardiometabolic health. Individuals are often asymptomatic, and little is known about the degree to...

Update on Peritoneal Dialysis: Core Curriculum 2016

Update on Peritoneal Dialysis: Core Curriculum 2016

Cardiovascular risk in relation to body mass index and use of evidence-based preventive medications in patients with or at risk of atherothrombosis.

Explore the relation between body mass index (BMI) and cardiovascular disease, and the influence of optimal medical therapy (OMT) on this relationship. Patients from the REACH cohort, an international, prospective cohort of patients with or at high risk of atherosclerosis with documentation of potential confounders, including treatments and risk factors, were followed up to 4 years (n = 54 285). Patients were categorized according to baseline BMI (ranging from underweight to Grade III obesity). Optimal medical therapy was defined as the use of the four cardioprotective medication classes (statins, ACE inhibitors/angiotensin II receptor blockers, β-blockers, and antiplatelet agents). The main outcomes were all-cause mortality, cardiovascular (CV) mortality, and CV events. In primary and secondary prevention, a reverse J-shaped curve best described the relationship between BMI categories and the incidence of the various outcomes. In secondary prevention, the highest adjusted risks were observed for underweight patients (1.97, P < 0.01, and 1.29, P = 0.03, for CV mortality and CV events) and the lowest HRs were observed, respectively, in Grade II and Grade III obese patients (0.73, P < 0.01 and 0.80, P < 0.01). The proportion of patients on OMT increased with BMI from 10.1 to 36% (P < 0.001). The apparent CV protection conferred by obesity persisted in patients receiving OMT. An obesity paradox was observed in both primary and secondary CV prevention patients. The intensity of use of evidence-based preventive medications does not account for the paradoxical CV protection associated with obesity. At extremes of BMI, further interventions beyond OMT may be needed to reduce CV risk.

Adherence to common cardiovascular medications in patients with schizophrenia vs. patients without psychiatric illness

The purpose of the study was to examine whether individuals with diagnoses of schizophrenia were differentially adherent to their statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) medications compared to individuals without psychiatric illness. Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of schizophrenia or schizoaffective disorder receiving two or more medication dispensings of a statin or an ACEI/ARB in 2011 (N=710) were identified and matched on age, sex and Medicare status to controls with no documented mental illness and two or more medication dispensings of a statin in 2011 (N=710). Medication adherence, and sociodemographic and clinical characteristics of the study population were assessed. Multivariable models indicated that having a schizophrenia diagnosis was associated with increased odds of statin medication adherence; the odds ratio suggested a small effect. After adjustment for medication regimen, schizophrenia no longer showed an association with statin adherence. Having a schizophrenia diagnosis was not associated with ACEI/ARB medication adherence. Compared to patients without any psychiatric illness, individuals with schizophrenia were marginally more likely to be adherent to their statin medications. Given that patterns of adherence to cardioprotective medications may be different from patterns of adherence to antipsychotic medications, improving adherence to the former may require unique intervention strategies.

Dimensional structure and correlates of posttraumatic stress symptoms following suspected acute coronary syndrome

BackgroundPosttraumatic stress disorder (PTSD) is a heterogeneous construct, and some have suggested that PTSD triggered by acute coronary syndrome (ACS) may differ from PTSD due to prototypical traumas. MethodsWe conducted the first examination of the latent structure of PTSD symptoms after suspected ACS in 399 adults in the REactions to Acute Care and Hospitalization (REACH) study, an observational cohort study of patients recruited from the emergency department during evaluation for ACS. Using confirmatory factor analysis, we compared the 4-factor dysphoria, 4-factor numbing, and 5-factor dysphoric arousal models of PTSD. ResultsAlthough all models fit well, the dysphoria model was selected as the best-fitting model. Further, there was measurement invariance of the dysphoria model by sex. PTSD dimensions evidenced differential associations with indicators of threat perception during ACS evaluation and adherence to cardioprotective medication. LimitationsOne limitation of this investigation is the use of self-report measures. In addition, only one-third of the sample was diagnosed with ACS at discharge; the remaining participants received diagnoses such as chest pain without a cardiac diagnosis, another symptom/disease process (e.g., hypertensive chronic kidney disease), or another cardiac disease. ConclusionsFindings suggest that suspected ACS-related PTSD symptoms are best-represented by a 4-factor structure distinguishing between specific (e.g., re-experiencing) and non-specific (dysphoria) symptoms of PTSD that has received support in the broader PTSD literature.

Determinants of adherence to evidence-based therapy after acute myocardial infarction

The extent to which drug adherence may be affected by patient characteristics remains unclear. This study investigated potential determinants of adherence to evidence-based cardioprotective medications in patients with acute myocardial infarction. Patient-based retrospective cohort study of 4655 elderly one-year survivors of acute myocardial infarction, members of a health organization in Israel, between 2005 and 2010. All patients filled at least one prescription for any key medication. Adherence was measured using the proportion-of-days-covered (PDC) metric and defined as PDC ≥ 80%. Nonadherence to aspirin, β-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers or statins approximated 50%, and 80% for combined therapy of all medications. In multivariable analyses, compared with nonadherents to all medications, adherers to at least one medication were more likely to be of Jewish origin (adjusted odds ratio (AOR), 2.11; 95% confidence interval (CI), 1.60-2.78), inhabitants of the central or northern districts, and attending a cardiologist at least once during the first year of follow-up (AOR, 1.26; 95% CI, 1.05-1.51). Increasing number of outpatient visits was associated with improved adherence and followed a significant dose-response gradient. Factors significantly associated with reduced adherence were presence of comorbid conditions, particularly chronic ischemic heart disease (AOR 0.69; 95% CI, 0.57-0.83) and readmissions (AOR, 0.65; 95% CI, 0.55-0.78). Results were consistent when evaluating adherence to each medication separately. Outpatient adherence to recommended therapy in patients with acute myocardial infarction is suboptimal and is related to health services utilization. Further research is needed to investigate patient subjective behavioral-related drivers for medication therapy discontinuation after myocardial infarction in the absence of a clinical reason.

Effect of adherence to evidence-based therapy after acute myocardial infarction on all-cause mortality.

Our aim is to estimate the effect of nonadherence to evidence-based cardioprotective medications on all-cause mortality in survivors of acute myocardial infarction (AMI). A patient-based retrospective cohort study of 1-year survivors of AMI, members of a health organization in Israel, between 2005 and 2010 was used. Adherence was measured using the proportion-of-days-covered metric and defined as a proportion of days covered ≥80%. In order to determine the independent impact of medication nonadherence on all-cause mortality, Cox proportional hazards models were constructed, adjusting for patient demographic and clinical characteristics. Of 4655 patients prescribed at least one medication, 864 died during an 8-year follow-up (median 4.5 years). Except for beta-blockers, medication nonadherence was significantly associated with increased adjusted all-cause mortality risk for aspirin [hazard ratio (HR), 1.28; 95% confidence interval (CI), 1.11-1.47], statins (HR, 1.36; 95%CI, 1.18-1.57), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers only among ischemic heart disease patients with documented heart failure (HR, 1.57; 95%CI, 1.16-2.14). Multidrug-combined therapy exerted incremental survival benefit in a dose-response gradient, exceeding that of single-component treatment. The highest risk of mortality was observed in patients adherent to none of the medications compared with adherents to all medications, with a 38% increase in risk of mortality (HR, 1.38; 95%CI, 1.06-1.80). Outpatient nonadherence to evidence-based cardioprotective medications in patients with AMI is common, and in the case of aspirin, statin or combined therapy is associated with a marked risk increase in all-cause mortality. Further research is needed to elucidate the role of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in patient subgroups.

Perspectives of patients on factors relating to adherence to post-acute coronary syndrome medical regimens.

PurposePoor adherence to cardioprotective medications after acute coronary syndrome (ACS) hospitalization is associated with increased risk of rehospitalization and mortality. Clinical trials of multifaceted interventions have improved medication adherence with varying results. Patients’ perspectives on interventions could help researchers interpret inconsistent outcomes. Identifying factors that patients believe would improve adherence might inform the design of future interventions and make them more parsimonious and sustainable. The objective of this study was to obtain patients’ perspectives on adherence to medical regimens after experiencing an ACS event and their participation in a medication adherence randomized control trial following their hospitalization.Patients and methodsSixty-four in-depth interviews were conducted with ACS patients who participated in an efficacious, multifaceted, medication adherence randomized control trial. Interview transcripts were analyzed using the constant comparative approach.ResultsParticipants described their post-ACS event experiences and how they affected their adherence behaviors. Patients reported that adherence decisions were facilitated by mutually respectful and collaborative provider–patient treatment planning. Frequent interactions with providers and medication refill reminder calls supported improved adherence. Additional facilitators included having social support, adherence routines, and positive attitudes toward an ACS event. The majority of patients expressed that being active participants in health care decision-making contributed to their health.ConclusionOur findings demonstrate that respectful collaborative communication can contribute to medication adherence after ACS hospitalization. These results suggest a potential role for training health-care providers, including pharmacists, social workers, registered nurses, etc, to elicit and acknowledge the patients’ views regarding medication treatment in order to improve adherence. Future research is needed with providers to understand how they elicit and acknowledge patients’ views, particularly in the face of nonadherence, and with patients to understand how to empower them to share their opinions with their providers.

Implantable cardioverter-defibrillators in patients with CKD: a propensity-matched mortality analysis.

Benefits of transvenous implantable cardioverter-defibrillators (ICDs) in prevention of sudden cardiac death among the general population are proven. However, the benefit of ICDs remains unclear in CKD. A propensity-matched analysis was conducted to examine the survival benefits of ICDs placed for primary prevention in those with CKD not on dialysis (eGFR<60 ml/min per 1.73 m(2)). The Cleveland Clinic CKD registry was utilized to identify individuals who had an echocardiogram at the institution (between 2001 and October 2011). A propensity score of the likelihood of receiving an ICD was developed with the following variables: demographics, comorbid conditions, use of cardioprotective medications, eGFR, left ventricular ejection fraction, and ventricular arrhythmia. One-to-one greedy matching was used with 0.1 caliper width to match patients with and without an ICD. A Cox proportional hazards model was used to examine survival of matched patients with and without an ICD. This study included 1053 ICD patients and 9435 potential controls. Of 1053 ICD patients (60%), 631 were matched to the control group. During a median follow-up of 2.9 years (25th and 75th percentiles, 1.5, 4.7), 578 patients died. After adjusting for covariates, the hazard of mortality among propensity-matched patients was 0.69 (95% confidence interval [95% CI], 0.59 to 0.82) for the ICD group compared with the non-ICD group. A significant interaction was found between ICDs and eGFR (P=0.04). Presence of an ICD was associated with a lower risk of death among those with eGFRs of 45-59 ml/min per 1.73 m(2) (hazard ratio [HR], 0.58; 95% CI, 0.44 to 0.77) and 30-44 ml/min per 1.73 m(2) (HR, 0.65; 95% CI, 0.50 to 0.85), but not among those with eGFRs<30 ml/min per 1.73 m(2) (HR, 0.98; 95% CI, 0.71 to 1.35). Transvenous ICDs placed for primary prevention are associated with a survival benefit in those with stage 3 CKD, but not in those with stage 4 CKD.

Sudden cardiac death in CKD patients.

The risk of sudden cardiac death (SCD) is high in chronic kidney disease patients, and it increases with the progression of kidney function deterioration. The most common causes of SDC are the following: ventricular tachycardia, ventricular tachyarrhythmia, tachycardia torsade de pointes, sustained ventricular fibrillation and bradyarrhythmia. Dialysis influences cardiovascular system and results in hemodynamic disturbances as well as electrolyte shifts altering myocardial electrophysiology. Studies suggest that this procedure exerts both detrimental (poor volume control can exacerbate hypertension and left ventricle hypertrophy) and beneficial effects (associated with fluid removal and subsequent decrease in left ventricle stretch). Dialysis-related vulnerability to serious arrhythmias is the result of sudden shifts in fluid status and electrolytes, particularly potassium, which alter the physiological milieu. Also Ca(2+) ions, in which concentration alters during dialysis, are of key importance in the contraction of vascular smooth muscle cells and cardiac myocytes, thus exerting significant effects on hemodynamics. Due to the fact that SCD occurs with similar frequency in peritoneal dialysis and in hemodialysis patients, it seems that end-stage renal disease factors are more important than the specific ones associated with dialysis type. The results of randomized trials suggested that hemodialysis patients may not derive the same benefit of cardiovascular disease therapy including beta-blockers, calcium channel blockers and angiotensin-converting enzyme inhibitors as the general population with normal kidney function. Noninvasive tests used to stratify SCD risk in HD patients have poor positive value, and thus, combining tests including HRV, baroreceptor sensitivity and effectiveness index as well as its function indices and heart rate turbulence should be implemented. There are only few large randomized placebo-controlled trials assessing the influence of cardioprotective medications or implantable cardioverter defibrillator (ICD) implantation in dialysis patients on life quality and survival, and their results are sometimes contradictory. The decision concerning treatment and/or ICD implantation in this group of patients should be made on the basis of careful assessment of individual risk factors. Moreover, due to the high hazard of cardiovascular mortality including SCD in dialysis patients, physicians should concentrate on the early selection of high-risk patients, monitoring them and introduction of preventive measures.

Acute myocardial infarction versus other cardiovascular events in community-acquired pneumonia.

The aim of the present study was to define the prevalence, characteristics, risk factors and impact on clinical outcomes of acute myocardial infarction (AMI) versus other cardiovascular events (CVEs) in patients with community-acquired pneumonia (CAP).This was an international, multicentre, observational, prospective study of CAP patients hospitalised in eight hospitals in Italy and Switzerland. Three groups were identified: those without CVEs, those with AMI and those with other CVEs.Among 905 patients, 21 (2.3%) patients experienced at least one AMI, while 107 (11.7%) patients experienced at least one other CVE. Patients with CAP and either AMI or other CVEs showed a higher severity of the disease than patients with CAP alone. Female sex, liver disease and the presence of severe sepsis were independent predictors for the occurrence of AMI, while female sex, age >65 years, neurological disease and the presence of pleural effusion predicted other CVEs. In-hospital mortality was significantly higher among those who experienced AMI in comparison to those experiencing other CVEs (43% versus 21%, p=0.039). The presence of AMI showed an adjusted odds ratio for in-hospital mortality of 3.57 (p=0.012) and for other CVEs of 2.63 (p=0.002).These findings on AMI versus other CVEs as complications of CAP may be important when planning interventional studies on cardioprotective medications.

Abstract P3-12-11: Cardiac toxicity in breast cancer patients: A single centre, retrospective review

Abstract Background: While advances in breast cancer treatment, including targeted therapies (e.g trastuzumab) have improved patient outcomes, such treatments may also be associated with both short and long term toxicity. In 2008, the Ottawa Hospital Cardiac Oncology Clinic (COC) was established with the goal of providing timely access and care to cancer patients experiencing cancer therapy-related cardiac toxicity. The purpose of this observational study is to review demographics, baseline characteristics, referral patterns and clinical outcomes of breast cancer patients referred to a dedicated COC. Methods: Breast cancer patients referred to the COC between October 2008 and December 2012 were reviewed. Data collected included: age, sex, date of diagnosis, date of referral to COC, stage of breast cancer at diagnosis and referral, cardiac history, medications, cancer therapy, treatment delays and completion rates, cardiac complications, cardiac test results and cardiology interventions. Descriptive statistical analysis was performed. Results: 263 breast cancer patients were assessed at the COC (median age = 57; range 23-87). The majority of patients (64%) had early stage (I-II) disease and 215 (81.4 %) of patients had at least one identifiable cardiac risk factor. The most common cardiac risk factors included: smoking (99/263, 37.6%), hypertension (87/263, 33.1%) and dyslipidemia (64/263, 24.3%). Reasons for referral to the COC included reduced left ventricular ejection fraction (LVEF) (137/263, 52.1%) followed by pre-treatment assessment (33/263, 12.5%) and cardiac arrhythmia (21/263, 8.0%). The majority of patients (243/263, 92.4%) received chemotherapy, 188 (77.4%) with first line anthracycline regimens, of those a minority 10/263 (3.8%) stopped chemotherapy for cardiac related toxicity, while 21/263 (8.0%) patients experienced cardiac related chemotherapy delays. The majority of patients 160/263 (60.8%) received first-line trastuzumab and of these, 66/160 (41.2%) suffered cardiac toxicity, 55/66 due to reduced LVEF. 23/160 (14.4%) discontinued therapy due to cardiac toxicity. 164/263 patients were on cardioprotective medications at time of COC referral. 100/263 referred patients had new cardiac medications initiated, most commonly ACE inhibitors (n=67), beta-blockers (n=54) and angiotensin receptor blockers (n =15). 15 patients (5.7%) had invasive testing/procedures, such as cardiac catheterization. After COC assessment/treatment, 117/263 (44.5%) of patients experienced full recovery of LVEF; 27/263 (10.3%) experienced partial recovery, 104/263 (39.5%) had no change, and 13/263 (4.9%) experienced continued decline. 39/263 (14.8%) patients were hospitalized for cardiac toxicity and 3/263 (1.1%) died of cardiac complications. Discussion: While the majority of breast cancer patients referred to a dedicated COC complete systemic therapy, there remains a significant population who require delay or discontinuation of treatment secondary to cardiac dysfunction. Tools to identify patients at higher risk of developing cardiac toxicity are urgently needed, so that appropriate monitoring and treatment can be initiated. Future studies will also determine the impact of this clinic on the delivery of cancer therapy and cardiac health, compared with non-COC referred patients. Citation Format: Moira Rushton, Freya Crawley, Jeffrey Sulpher, Susan Dent. Cardiac toxicity in breast cancer patients: A single centre, retrospective review [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-12-11.