Post-myocardial Infarction Population Research Articles

I don't have to be terribly mobile do I?: a qualitative study on attitudes and beliefs about CR in heart failure

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): British Heart Foundation Background Factors affecting uptake of cardiac rehabilitation (CR) have been well researched in the post myocardial infarction population (1). However this is less well studied in people with chronic heart failure (CHF), who have poor engagement with this evidence based intervention (2). This qualitative study is part of a larger mixed methods study aimed at developing an intervention to improve uptake of CR by people with CHF. Purpose To investigate the influences of patient attitudes and beliefs on the uptake of CR in people with chronic heart failure. Methods An interpretive descriptive approach was taken (3). A purposive sample of participants from a tertiary hospital were recruited (at least 6 weeks post discharge from acute admission for heart failure) with representation according to gender, age and CR status. Semi-structured telephone interviews explored the reasons for accepting or rejecting an offer to participate in CR. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis (4). Analysis was validated by blinded collaborator coding and discussions in order to reach consensus of themes/ sub-themes. Results 15 participant interviews were analysed. 9 were male, ages ranged from 56 to 86 years, 8 had accepted referral to CR. Four themes were generated (Table 1 and 2) 1. Beliefs and expectations of CR: focused on participants’ understanding of what CR is and how it can benefit them. Subthemes included lack of knowledge of content or purpose of CR, focus on exercise component of the programme, uncertainty about tailoring to individual capability and needs, recognition of broader aspects of CR programme, alignment with perceived need to increase activity level/exercise. 2. Perception of health condition: focused on the relationship between participants approach to their health condition and how they perceived the need for regular exercise/activity. Subthemes include symptom burden, 'recovery' from CHF, 'chronicity' of condition, adapting to cope, no need for improving functional capacity. 3. Perception of self: focused on intrapersonal factors that impact the decision to take up CR. Subthemes include need for motivation to exercise, need to please others, social being, self-reliance and locus of control. 4. External factors: Subthemes included timing of offer, choice of CR format. Conclusions Study participants tended to view CR as a means of symptom management through exercise. They felt symptoms were influenced by medical management and passage of time (recovery) and those who had no improvement in symptoms had adapted their life to accommodate limitations to their functional ability (chronicity). CR was engaged in either to further improve symptoms or to make a change to the status quo. Considering both the point in the disease trajectory and the symptom burden of people with chronic heart failure may enable more targeted interventions to improve uptake of CR in this population.

The Stages of CS: Clinical and Translational Update.

Purpose of ReviewWith improvements in cardiovascular care, and routine percutaneous coronary intervention for ST elevation myocardial infarction, more patients are surviving following acute coronary syndromes. However, a minority of patients develop cardiogenic shock which results in approximately 50% 30-day mortality. There are various ways to classify cardiogenic shock, and much has been written about this topic in recent years. This review will examine recent developments and put them in context.Recent FindingsThe large randomized trials of cardiogenic shock treatments such as the IABP-SHOCK II trial used a clinical definition of shock including hypotension (systolic blood pressure of 90 mmHg or less, or requirement of vasopressors to maintain such a blood pressure), as well as hypoperfusion. However, while this defines a minimum standard to define cardiogenic shock, it does not distinguish between a patient on a single vasoconstrictor and one who is on multiple high dose infusions or one on extracorporeal membrane oxygenation. The Society for Cardiac Angiography and Intervention recently published an expert consensus statement defining stages of cardiogenic shock, from at risk to beginning, classic, deteriorating, and extremis cardiogenic shock stages. The simple framework has been validated rapidly in multiple populations including the intensive care unit, a post-myocardial infarction population, an out of hospital cardiac arrest population, and most recently in a multicenter shock collaborative,SummaryClassification is fundamental to understanding a disease state, and crafting solutions to improve outcomes. The last 20 years has witnessed an explosion of percutaneous mechanical circulatory support devices of increasing sophistication and capability, and yet there has been little progress in improving outcomes of cardiogenic shock. Hopefully, the next 20 years will see massive advances in understanding of the complexities of the various stages of cardiogenic shock. With such knowledge, it is likely that targeted treatments will be developed and the mortality of this disease will finally plummet.

Class 1C antiarrhythmic drugs in atrial fibrillation and coronary artery disease.

BackgroundClass 1C antiarrhythmic drugs (AADs) are effective first‐line agents for atrial fibrillation (AF) treatment. However, these agents commonly are avoided in patients with known coronary artery disease (CAD), due to known increased risk in the postmyocardial infarction population. Whether 1C AADs are safe in patients with CAD but without clinical ischemia or infarct is unknown. Reduced coronary flow capacity (CFC) on positron emission tomography (PET) reliably identifies myocardial regions supplied by vessels with CAD causing flow limitation.ObjectiveTo assess whether treatment with 1C AADs increases mortality in patients without known CAD but with CFC indicating significantly reduced coronary blood flow.MethodsIn this pilot study, we compared patients with AF and left ventricular ejection fraction ≥50% who were treated with 1C AADs to age‐matched AF patients without 1C AAD treatment. No patient had clinically evident CAD (ie, reversible perfusion defect, known ≥70% epicardial lesion, percutaneous coronary intervention, coronary artery bypass grafting, or myocardial infarction). All patients had PET‐based quantification of stress myocardial blood flow and CFC. Death was assessed by clinical follow‐up and social security death index search.ResultsA total of 78 patients with 1C AAD exposure were matched to 78 controls. Over a mean follow‐up of 2.0 years, the groups had similar survival (P = .54). Among patients with CFC indicating the presence of occult CAD (ie, reduced CFC involving ≥50% of myocardium), 1C‐treated patients had survival similar to (P = .44) those not treated with 1C agents.ConclusionsIn a limited population of AF patients with preserved left ventricle function and PET‐CFC indicating occult CAD, treatment with 1C AADs appears not to increase mortality. A larger study would be required to confidently assess the safety of these drugs in this context.

4952Level A evidence - for A-level patients only? Participants in clinical trials post myocardial infarction have higher socioeconomic status and better prognosis

Abstract Introduction Randomized clinical trials (RCT) produce the highest level of evidence and therefore form the basis for many guidelines. Their Achilles heel is external validity which is still poorly studied. Participants in clinical trials may partly be selected on unknown mechanisms in particular regarding socioeconomic status. To what extent participants in clinical trials after myocardial infarction (MI) are representative for the overall MI population is unknown. Purpose To investigate whether participants in clinical trials after myocardial infarction differ regarding socioeconomic status (SES), risk factor profile, prior and recurrent cardiovascular disease (CVD) events. Methods A total of 34,084 patients attending follow up after myocardial infarction between 2007 and 2014 were identified in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) out of which 3,037 had participated in a clinical trial. Information on disposable income, education level, marital status, prior CVD, risk factors and treatment were retrieved from national registers and patients were followed regarding recurrent CVD. Participants in clinical trials were compared to non-participants using logistic and Cox regression analyses. In a multivariable Cox-regression analysis adjustments were made for gender, age, inclusion-year, diabetes, LVEF, previous MI, previous stroke, prior cardiac surgery, ECG rhythm, eGFR, lipid levels, smoking status, use of ASA, use of ACE-I, use of beta-blockers, use of statins, level of education, disposable income and family status. Results Trial participants were more likely to be men (odds ratio (OR): 1.42; 95% CI: 1.29–1.55)), to be married (1.17; 1.09–1.27), to have a high income (1.58; 1.45–1.72), have a post-secondary education (>12 years) (1.33; 1.22–1.46) and less likely to be smokers (0.81; 0.72–0.90), have a reduced EF <30% (0.61; 0.46–0.80), history of previous stroke (0.79; 0.65–0.97) or MI (0.86; 0.77–0.97) compared to non-participants. The risk for recurrent CVD was lower among the participants compared to the non-participants (HR: 0.77; 95% CI: 0.67–0.88) and is illustrated in figure 1. In a fully adjusted model the lower risk remained after adjusting for age, gender, risk factors, prior disease including EF, evidence based treatments and SES (HR: 0.85; 95% CI: 0.74–0.97). Trial participation and recurrent CVD Conclusion Participants in clinical trials after MI constitute a highly selected group with higher SES, a more favourable risk profile and a better overall prognosis. The lower risk after full adjustments imply that additional selection bias exists. The external validity of post MI- trials in general can thus be questioned. To what extent results from clinical trials apply to the overall post MI population should be carefully scrutinized. Real world registry data are important. Acknowledgement/Funding Familjen Janne Elgqvists Stiftelse

OBSESSIVE COMPULSIVE PERSONALITY AND FATIGUE IN PATIENTS WITH ANXIETY AND MOOD DISORDERS

Introduction Prior analysis has demonstrated executive dysfunction as a cardinal feature of fatigue in a post myocardial infarction population [1]. Executive problems have also been demonstrated in a group of subjects with obsessive compulsive personality disorder (OCPD) [2]. Traits of OCPD are commonly associated with depression, which has fatigue as an intrinsic element; however, so far no study has investigated the possibility of a specific association between fatigue and OCPD. Aim To investigate whether measures of fatigue and OCPD were associated, in a sample of patients with anxiety and mood disorders (AMD) demonstrating high levels of fatigue. Material and Methods A cross-sectional study of patients with AMD attending a Stress Disorders Clinic. Socio-demographic and clinical information including diagnosis (as defined by The Mini International Neuropsychiatric Interview), medication use, body mass index, and history of smoking were collected. The severity of OCPD traits was evaluated using the observer-rated Compulsive Personality Assessment Scale (CPAS) [2]. The Multidimensional Fatigue Inventory (MFI-20) was used to assess general, physical and mental fatigue, reduced activity and motivation. The Beck Depression Inventory-II (BDI-II) and the Hamilton Depression Rating Scale (HAM-D) were employed to measure subjective and objective symptoms of depression, while the Hamilton Anxiety Rating Scale (HAM-A) measured anxiety symptoms. Two-tailed Student’s t-test or Fisher’s χ2 test were applied to compare socio-demographic, clinical, fatigue, anxiety and depression characteristics in AMD patients with and without OCPD. Binary logistic regression analyses were performed to test associations between OCPD and fatigue, while controlling for possible confounders. Results Sixty-seven patients participated, 49 (73.1 %) females with a mean age of 39±13. In this group, 14 (20.9%) patients had one mood disorder, 17 (25.4%) had one anxiety disorder, and the remaining 36 (53.7%) patients suffered simultaneously from AMD. Nine patients (13.4%) fulfilled operational criteria for OCPD. The OCPD group had higher subjective depression scores on the BDI-II relative to patients without OCPD (35.1±14.1 vs. 23.5±11.1; p = 0.007). However, scores on the HAM-D and HAM-A scales did not show any difference between groups (p’s > 0.05). Measures of physical and mental fatigue were higher among OCPD patients than non-OCPD (respectively, 81.9±22.8 vs. 62.5±25.8, p = 0.037; 88.9±13.5 vs. 65.7±27.6, p = 0.017). Controlling for potential confounders i.e. depression scores (BDI-II), age, gender, medication use and reduced motivation, the association between mental fatigue and OCPD remained significant and was associated with a 1.072-fold increase (95% confidence, 1.002 to 1.147, p = 0.045) in risk for OCPD. There was no longer a significant effect of physical fatigue on OCPD. Conclusions Mental fatigue in patients with AMD is associated with OCPD traits even when depression and reduced motivation symptoms are taken into account. Thus, mental fatigue might represent a previously under-explored marker of OCPD. Further investigation of mental fatigue in diverse groups of patients is needed to confirm this finding.

Predictors of subsequent myocardial infarction, stroke, and death in stable post-myocardial infarction patients: A nationwide cohort study

This study investigated the predictors of subsequent cardiovascular events in stable post-myocardial infarction patients in Taiwan. A total of 11,183 patients were recruited who had survived one year post-myocardial infarction without subsequent events of recurrent myocardial infarction or stroke from the Taiwan National Health Insurance Research Database. Their composite cardiovascular event rates were identified. The composite cardiovascular events rate in three year follow-up in the post-myocardial infarction population was 13.8%. Corresponding event rates were 5.8% recurrent myocardial infarction, 5.0% stroke, and 5.2% death. Independent factors associated with a higher risk of ischemic events or death included heart failure (hazard ratio (HR)=1.19), hypertension (HR=1.16), age (65-75 vs <65 years: HR=1.29; 75-85 vs <65 years: HR=1.50; >85 vs <65 years: HR=1.70), diabetes (HR=1.33), prior stroke (HR=1.24), chronic kidney disease (HR=1.4), atrial fibrillation (HR=1.27), and underutilization of guideline-based medication (HR=1.73). Composite risk for myocardial infarction, stroke and death increased progressively from 4.9% in patients with zero risk factor to 100.0% in patients with eight risk factors. For acute myocardial infarction patients surviving one year without subsequent events of recurrent myocardial infarction or stroke, the risk of cardiovascular events remained high. Eight predictors identified patients at increased risk for subsequent cardiovascular events within the next three years. These results suggest an unmet need, particularly in patients with additional risk factors.

Knowledge, attitude and practice on physical and psychosexual well being in a cohort of post MI patents in a Sri Lankan tertiary care cardiac center

Background The major challenges in survivors following myocardial infarction (MI) are to prevent the subsequent coronary events for the achievement of a better quality of physical and psycho-sexual wellbeing. Issues pertaining to resumption of sexual activity, quitting smoking and psycho-social wellbeing are addressed as an integral part of the cardiac rehabilitation programme. Objectives To explore the knowledge, attitude and practice pertaining to physical and psycho-sexual wellbeing among post MI patients and to identify the lapses in current practice with regard to patient management with the aim of designing a locally relevant cardiac rehabilitation programme. Methods Across-sectional observational study was conducted at Cardiology unit, Teaching Hospital Kandy in 2015 recruiting a cohort of post MI patients who attend to Cardiology outpatient clinic. A pre-tested interviewer administered questionnaire and relevant medical records were used to obtain information. Results Though the majority were aware about the advantages of physical exercise following MI, most were unaware about the exact time of commencement and the self-adjustment of their exercise programme. The prevalence of anxiety and depression, especially the borderline cases were higher in post MI population than in the normal population independent of other clinical and demographic parameters. The participants had commenced sexual activity following the MI, however majority had reduced the frequency than before. Information on commencement of sexual activity was minimally conveyed and only a handful of patients discussed openly about their sexual activity with the health care providers. With regard to Health related quality of life (HRQoL) assessment, women had lower values than men and diabetic patients scored poorly than non-diabetics, especially in emotional wellbeing and endurance level. Majority of male patients were engaged in smoking. The majority had received help to quit smoking and succeeded in it, however, a significant proportion still continued to smoke even after the coronary event. Conclusion This study highlights the areas that need to be improved in the post MI care, especially with regard to sexual education, post MI graded exercise, improving quality of life, assistance to quit smoking and identifying the at risk patients for psychological diseases.

Abstract 089: Can Medical Claims Accurately Assess Cardiovascular and Bleeding Events in an All-Aged Post-Myocardial Infarction Population? Insights Fom the TRANSLATE-ACS Study

Background: Pragmatic clinical trial designs have proposed the use of claims data to ascertain clinical events. However, little is known about the accuracy of medical claims diagnosis in identifying events. Methods: Administrative claims were obtained for all rehospitalizations occurring within 12 months of index acute myocardial infarction (MI) in those enrolled in the TRANSLATE-ACS study. Outcome events (recurrent myocardial infarction [MI], stroke, and hospitalized bleeding) were identified based on all diagnosis and procedure codes in these claims. These clinical events were also independently adjudicated by physicians based on medical record review. The cumulative 1-year incidences for each outcome were compared when identified by administrative claims vs. physician adjudication. Kappa statistics assessed the accuracy of claims-identified events using physician adjudication as the gold standard. Results: Among 12,351 MI patients, the cumulative 1-year incidence of events identified by administrative claims were 4.3% for MI, 0.9% for stroke, and 5.0% for bleeding. Incidence rates based on physician adjudication of medical records were 4.7% for MI, 0.9% for stroke, and 5.4% for bleeding. Agreement between claims-identified and physician-adjudicated events was modest for MI and stroke events: kappa=0.76 and 0.55, respectively. In contrast, agreement was poor between claims-identified and physician-adjudicated bleeding events: kappa=0.24 for any hospitalized bleeding event and 0.15 for GUSTO moderate-severe bleeding. Conclusion: Event rates at 1 year were lower for MI, stroke and bleeding when using administrative claims to identify events in comparison with physician adjudication. Administrative claims diagnoses are modestly accurate in identifying recurrent MI and stroke admissions but have limited accuracy in identifying bleeding events, which suggests that an alternative approach is needed to ensure good safety surveillance in cardiovascular studies.

Edetate Disodium-Based Treatment for Secondary Prevention in Post-Myocardial Infarction Patients.

An abundance of data, known for decades, is available linking metals, such as lead and cadmium, with cardiovascular disease. However, the idea that these toxic metals could be a modifiable risk factor for atherosclerosis did not become apparent clinically until the completion of the Trial to Assess Chelation Therapy in 2012. This pivotal study was the first double-blind, randomized, controlled trial of its kind to demonstrate a clear improvement in cardiovascular outcomes with edetate disodium therapy in a secondary prevention, post-myocardial infarction population. This effect size was most striking in diabetic patients, where the efficacy of edetate disodium was comparable, if not superior, to that of current guideline-based therapies. Given the economic burden of diabetes and cardiovascular disease, the potential impact of this therapy could be enormous if the results of this study are replicated.

Patient-provider communication, self-reported medication adherence, and race in a postmyocardial infarction population.

ObjectivesOur objectives were to: 1) describe patient-reported communication with their provider and explore differences in perceptions of racially diverse adherent versus nonadherent patients; and 2) examine whether the association between unanswered questions and patient-reported medication nonadherence varied as a function of patients’ race.MethodsWe conducted a cross-sectional analysis of baseline in-person survey data from a trial designed to improve postmyocardial infarction management of cardiovascular disease risk factors.ResultsOverall, 298 patients (74%) reported never leaving their doctor’s office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor’s office with unanswered questions. In multivariable logistic regression, although the simple effects of the interaction term were different for patients of nonminority race (odds ratio [OR]: 2.16; 95% confidence interval [CI]: 1.19–3.92) and those of minority race (OR: 1.19; 95% CI: 0.54–2.66), the overall interaction effect was not statistically significant (P=0.24).ConclusionThe quality of patient–provider communication is critical for cardiovascular disease medication adherence. In this study, however, having unanswered questions did not impact medication adherence differently as a function of patients’ race. Nevertheless, there were racial differences in medication adherence that may need to be addressed to ensure optimal adherence and health outcomes. Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills and to address potential differences in medication adherence in patients of diverse backgrounds.

Influence of Diabetes Mellitus on development of Heart Failure following anterior Myocardial Infarction

Summary Background: Diabetic patients are at an increased risk of developing heart failure after myocardial infarction, particularly when left ventricular function is severely impaired. We aimed to investigate the influence of dia- betes on the development of heart failure in a dynami- cally changing post-myocardial infarction population. Methods: In 272 patients enrolled in the Healing and Early Afterload Reducing Therapy (HEART) trial, left ventricular volumes, ejection fraction, and infarct segment length were assessed by echocardiography on day 1, day 14 and day 90. Echocardiographic measures, as well as clinical outcomes, were compared between diabetics and non-diabetics. Results: At presentation with myocardial infarc- tion, diabetics (n = 56, 21%) demonstrated higher Killip class than non-diabetics (n = 216, 79%) despite similar infarct size. Changes in left ventricular size and func- tion in the three months following infarction were sim- ilar in diabetics and non-diabetics. At one-year follow- up, diabetics demonstrated increased incidence o f heart failure (29% versus 14%, p = 0.014) and total car- diovascular events (39% versus 19%, p = 0.002). Conclusions: The coexistence of diabetes enhances the risk for developing heart failure after myocardial infarction even in patients with mild left ventricular dysfunction or preserved ejection fraction. This risk is independent of infarct size, ejection fraction, or subse- quent ventricular remodeling.

Association Between Perceived Life Chaos and Medication Adherence in a Postmyocardial Infarction Population

The benefits of medication adherence to control cardiovascular disease (CVD) are well defined, yet multiple studies have identified poor adherence. The influence of life chaos on medication adherence is unknown. Because this is a novel application of an instrument, our preliminary objective was to understand patient factors associated with chaos. The main objective was to evaluate the extent to which an instrument designed to measure life chaos is associated with CVD-medication nonadherence. Using baseline data from an ongoing randomized trial to improve postmyocardial infarction (MI) management, multivariable logistic regression identified the association between life chaos and CVD-medication nonadherence. Patients had hypertension and a myocardial infarction in the past 3 years (n=406). Nearly 43% reported CVD-medication nonadherence in the past month. In simple linear regression, the following were associated with higher life chaos: medication nonadherence (β=1.86; 95% confidence interval [CI], 0.96-2.76), female sex (β=1.22; 95% CI [0.22-2.24]), minority race (β=1.72; 95% CI [0.78-2.66]), having less than high school education (β=2.05; 95% CI [0.71-3.39]), low health literacy (β=2.06; 95% CI [0.86-3.26]), and inadequate financial status (β=1.93; 95% CI [0.87-3.00]). Being married (β=-2.09, 95% CI [-3.03 to -1.15]) was associated with lower life chaos. As chaos quartile increased, patients exhibited more nonadherence. In logistic regression, adjusting for sex, race, marital status, employment, education, health literacy, and financial status, a 1-unit life chaos increase was associated with a 7% increase (odds ratio, 1.07; 95% CI [1.02-1.12]) in odds of reporting medication nonadherence. Our results suggest that life chaos may be an important determinant of medication adherence. Life chaos screenings could identify those at risk for nonadherence. URL: http://www.clinicaltrials.gov. Unique identifier: NCT000901277.

Statins reduce new-onset atrial fibrillation in a first-time myocardial infarction population: a nationwide propensity score-matched study

To evaluate the effect of statins on reducing new-onset atrial fibrillation (AF) in a large real-world post-myocardial infarction (MI) population. Subsequently, to test if different statin doses, various types and compliance affected the incidence of new-onset AF post MI. All patients with first-time acute MI between 1997 and 2009 in Denmark and claimed prescriptions of statins after discharge were identified from the Danish nationwide administrative registers. Patients with a history of AF were excluded. Risk of new-onset AF according to statin use were analysed by multivariable time-dependent Cox regressions models adjusted for age, gender, year, concomitant medication, and comorbidity, and additionally in a propensity score-matched analysis. A total of 89,703 patients with average follow up of 5.0 ± 3.5 years were included in this study. In the 56,044 patients receiving statins, 5698 (10%) had new-onset AF vs. 5010 (15%) in the 33,659 patients serving as controls. The adjusted Cox regression analysis showed significant reduction in new-onset AF (HR 0.83, 95% CI 0.80-0.87, p < 0.001) in statin users. Adjustment for propensity score yielded nearly identical results (HR 0.82, 95% CI 0.78-0.85, p < 0.001). Furthermore, patients compliant to statin treatment had significant reduction in new-onset AF (HR 0.84, 95% CI 0.80-0.87, p < 0.001). Finally, simvastatin and atorvastatin were significantly more effective than pravastatin (both p < 0.01) in reducing new-onset AF. Statin therapy was significantly associated with less new-onset AF in a nationwide cohort of post-MI patients. Furthermore, statins showed a type-dependent effect in preventing new-onset AF. These results support the beneficial effect of statin therapy beyond lipid lowering in patients with MI and underline the importance of statin adherence and choice of statin type.

The pharmacokinetics and pharmacodynamics of valsartan in the post-myocardial infarction population

Introduction: The most common risk factors for heart failure are hypertension and myocardial infarction. Angiotensin receptor blockers (ARBs) attenuate the deleterious effects of angiotensin II. Valsartan is a once or twice daily ARB that is FDA-approved for hypertension, LV dysfunction post-myocardial infarction and congestive heart failure as both an adjunct in ACE-inhibitor tolerant, and alternative in ACE-I intolerant patients.Areas covered: This article presents a comprehensive review of the literature regarding the pharmacokinetics and pharmacodynamics of valsartan, with particular attention paid to the post-myocardial infarction population.Expert opinion: Valsartan is a safe, well-tolerated and readily titratable ARB. In addition to its vasodilatory effects there are pleotropic effects associated with the ARB such as modulation of a number of neurohormonal regulators, cytokines and small molecules. Given the clear evidence-based benefits above and beyond its hypertensive properties, it has the potential, if priced appropriately, to grow in its impact as a pharmacotherapeutic long after its patent expires.

A national survey of GP and nurse attitudes and beliefs towards depression after myocardial infarction

To investigate primary care practitioner's attitudes to depression after myocardial infarction. Depression after myocardial infarction affects almost half of all patients and has a considerable negative effect on recovery. Despite the increased prevalence of depression in this population, it is often not recognised or treated. Survey. A total of 813 (106 general practitioners and 707 nurses) practitioners responded. Our questionnaire developed for this project by the authors in collaboration with a group of ten cardiovascular nurse specialists contained 27 items that were summated into five subscales. Primary care practitioners underestimated the prevalence of depression in the post-myocardial infarction population. General acknowledgement of the negative impact that depression can have was reported by the majority of participants. Diagnosing depression was perceived as complex by both groups but significantly more so by nurses. General practitioners were significantly more positive about their understanding of the signs and symptoms of depression and in using depression-screening tools. We observed that training seems to have a significant effect on reported practice. Practitioners who reported that they had recent training in the management of depression were significantly more accurate in their estimate of how common depression was in this population. Depression may be underdiagnosed in this population because primary care practitioners, especially nurses, are not aware of how common the disorder is and lack competence in diagnosis. There is merit in developing and testing a brief training intervention to ensure competence in depression screening and treatment in post-myocardial infarction patients. Diagnosing depression in post-myocardial infarction patients is perceived by nurses as complex but training in the management of depression is seen as helping practice.

Relation Between Myocardial Infarct Size and Ventricular Tachyarrhythmia Among Patients With Preserved Left Ventricular Ejection Fraction Following Fibrinolytic Therapy for ST-Segment Elevation Myocardial Infarction

In the era of early reperfusion therapy for ST-segment elevation myocardial infarction, preserved left ventricular (LV) function is common. Despite preservation of LV ejection fraction (LVEF), there remains a spectrum of risk for adverse cardiovascular events, including ventricular tachycardia (VT) and ventricular fibrillation (VF). Larger infarct size has been independently associated with death, VT/VF, and heart failure in the post-myocardial infarction population. It was hypothesized that infarct size, as estimated by peak serum creatine kinase (CK)-MB concentration, would be associated with the incidence of VT/VF in patients with preserved LV function after ST-segment elevation myocardial infarctions. The Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis In Myocardial Infarction 28 (CLARITY-TIMI 28) study enrolled 3,491 patients with ST-segment elevation myocardial infarctions who underwent fibrinolytic therapy. The association between estimated infarct size (ratio of peak CK-MB to the upper limit of normal), the LVEF (measured using left ventriculography or echocardiography), and the incidence of VT/VF through 30 days was assessed. A total of 1,436 patients underwent assessments of LV function, of whom 1,133 had adequate CK-MB for analysis. The median LVEF in this group was 55% (interquartile range 45% to 65%), and most patients (n = 814 [87.1%]) had LVEF > or =40%. Among patients with LVEF > or =40%, the ratio of peak CK-MB to the upper limit of normal was significantly associated with the incidence of VT/VF through 30 days (2.2%, 3.7%, and 5.5% across tertiles, respectively, p = 0.041 for trend) and the incidence of the composite of cardiovascular death, heart failure, shock, and VT/VF through 30 days (3.7%, 6.0%, 8.5%, respectively, p = 0.018 for trend). In conclusion, in patients with ST-segment elevation myocardial infarction with preserved LV function after reperfusion therapy, larger infarct size, as estimated by peak serum CK-MB concentration, is significantly associated with VT/VF as well as other adverse clinical outcomes.

Fragmented Left Sided QRS in Absence of Bundle Branch Block: Sign of Left Ventricular Aneurysm

A left ventricular aneurysm (LVA) occurs between 3.5% and 9.4% of all cases of acute myocardial infarction. A fragmented left sided QRS (RSR; pattern or its variant RSr;, rSR;, or rSr;) without evidence of bundle branch block (QRS duration <or=120 ms) on the ECG may be associated with a significant myocardial scar, which is the characteristic of a LVA. We, therefore, postulate that fragmented QRS (RSR; pattern or its variant) in the left sided leads (I, aVL, V(3) to V(6)) may be a useful sign of LVA. ECGs of 110 consecutive patients with LVA documented by left ventricular angiography (30 degrees right anterior oblique view) was compared with 220 patients without LVA (110 patients with and 110 patients without coronary artery disease (CAD)), who were evaluated for CAD by symptoms and signs. The sensitivity of the fragmented QRS for identification of LVA was 50% (55 of 110 patients) and specificity was 94.6% (209 of 220). Within the study population, the positive predictive value of the fragmented QRS for LVA was 83.3% (55 of 66) and the negative predictive value was 79.2% (209 of 264). Based on the range of prevalence of LVA in postmyocardial infarction population (3.5-9.4%) and on observed sensitivity and specificity, the positive predictive value of fragmented QRS for LVA after infarction can be estimated at 29-53% and the negative predictive value can be estimated at 95-98%. The sensitivity of fragmented QRS in left precordial leads for LVA was only 50%, whereas the specificity was 94.5%. It has a relatively low to moderate positive predictive value and high negative predictive value.

Nebivolol: Novel β-blocker with Nitric oxide-induced Vasodilation

beta-blockers have been widely used for the treatment of hypertension, congestive heart failure and angina, as well as in the post-myocardial infarction population. Both beta(1) selective and nonselective agents are available. Nebivolol is a new highly beta(1 )selective antagonist with a nonadrenergic, nitric oxide potentiating vasodilatory property, which is unique among beta-blockers. In addition, nebviolol does not inhibit the increase in the heart rate response to exercise, which is unique among beta-blockers. Nebviolol has been tested successfully in double-blind, placebo-controlled trials in both hypertension and congestive heart failure.

A review of clinical trials assessing the efficacy and safety of newer antiarrhythmic drugs in atrial fibrillation.

Clinical trials assessing the efficacy of anti- arrhythmic drugs for terminating atrial fibrillation have demonstrated that rate control drugs have little to no added efficacy compared to placebo; however, spontaneous conversion of recent-onset atrial fibrillation is common. Antiarrhythmic drugs such as oral dofetilide, oral bolus-flecainide and propafenone and intravenous ibutilide all have a role in terminating atrial fibrillation. Active comparator trials have demonstrated that amiodarone is more efficacious in maintaining sinus rhythm than propafenone and sotalol. Multiple trials have demonstrated the safety of amiodarone, sotalol, dofetilide and azimilide in a post-myocardial infarction population and amiodarone and dofetilide in a congestive heart failure population. Newer antiarrhythmic agents, some with novel mechanisms of action, will add to the pharmacologic armamentarium in treating atrial fibrillation.

Safety concerns about digoxin after acute myocardial infarction

We examined clinical outcomes associated with non-randomised digoxin therapy in a postmyocardial infarction population with clinical heart failure (AIRE study). Our results raise concern about the safety of digoxin in this population.