Suboptimal Secondary Prevention Research Articles

Risk Stratification in Patients with Ischemic Stroke and Residual Cardiovascular Risk with Current Secondary Prevention.

PurposeSuboptimal secondary prevention in patients with stroke causes a remaining cardiovascular risk desirable to reduce. We have validated a prognostic model for secondary preventive settings and estimated future cardiovascular risk and theoretical benefit of reaching guideline recommended risk factor targets.Patients and MethodsThe SMART-REACH (Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health) model for 10-year and lifetime risk of cardiovascular events was applied to 465 patients in the Norwegian Cognitive Impairment After Stroke (Nor-COAST) study, a multicenter observational study with two-year follow-up by linkage to national registries for cardiovascular disease and mortality. The residual risk when reaching recommended targets for blood pressure, low-density lipoprotein cholesterol, smoking cessation and antithrombotics was estimated.ResultsIn total, 11.2% had a new event. Calibration plots showed adequate agreement between estimated and observed 2-year prognosis (C-statistics 0.63, 95% confidence interval 0.55–0.71). Median estimated 10-year risk of recurrent cardiovascular events was 42% (Interquartile range (IQR) 32–54%) and could be reduced to 32% by optimal guideline-based therapy. The corresponding numbers for lifetime risk were 70% (IQR 63–76%) and 61%. We estimated an overall median gain of 1.4 (IQR 0.2–3.4) event-free life years if guideline targets were met.ConclusionSecondary prevention was suboptimal and residual risk remains elevated even after optimization according to current guidelines. Considerable interindividual variation in risk exists, with a corresponding variation in benefit from intensification of treatment. The SMART-REACH model can be used to identify patients with the largest benefit from more intensive treatment and follow-up.

Epidemiology and risk factors for stroke in young individuals: implications for prevention.

Summarize and examine the epidemiology, etiologies, risk factors, and treatment of stroke among young adults and highlight the importance of early recognition, treatment, and primordial prevention of risk factors that lead to stroke. Incidence of stroke, predominantly ischemic, among young adults has increased over the past two decades. This parallels an increase in traditional risk factors such as hypertension, diabetes, and use of tobacco, and use of illicit substances among young stroke patients. Compared to older patients, there is a much higher proportion of intracerebral and subarachnoid hemorrhage in young adults. The cause of ischemic stroke in young adults is also more diverse compared to older adults with 1/3rd classified as stroke of undetermined etiology due to inadequate effort or time spent on investigating these diverse and rare etiologies. Young premature Atherosclerotic Cardiovascular Disease patients have suboptimal secondary prevention care compared to older patients with lower use of antiplatelets and statin therapy and lower adherence to statins. Among young patients, time-critical diagnosis and management remain challenging, due to atypical stroke presentations, vast etiologies, statin hesitancy, and provider clinical inertia. Early recognition and aggressive risk profile modification along with primary and secondary prevention therapy optimization are imperative to reduce the burden of stroke among young adults and save potential disability-adjusted life years.

Prognostic significance of suboptimal secondary prevention pharmacotherapy after acute coronary syndromes.

Optimal secondary prevention pharmacotherapy is the cornerstone of post-acute coronary syndrome (ACS) management. The prognostic impact of not receiving five guideline-recommended therapies is poorly described. To ascertain the prognostic significance of suboptimal pharmacotherapy in ACS survivors. Consecutive patients with ACS from the Melbourne Interventional Group registry who were alive at 30 days following their index percutaneous coronary intervention were included. Patients were divided into three categories based on the number of secondary prevention medications prescribed. The optimal medical therapy (OMT), near-optimal medical therapy (NMT), suboptimal medical therapy (SMT) groups were prescribed 5, 4 and ≤ 3 medications, respectively. Primary endpoint was long-term mortality. Cox-proportional hazard modelling was undertaken to assess independent predictors of survival. Of the 9375 patients included, 5678 (60.6%) received OMT, 2903 (31.0%) received NMT and 794 (8.5%) received SMT. Patients receiving SMT were older, more likely to be female and had higher burden of comorbidities (renal impairment, congestive heart failure, diabetes, peripheral vascular disease; P < 0.01 for all). SMT was associated with higher long-term mortality at 3.9 ± 2.2 years when compared to NMT and OMT (16.8% vs 10.5% vs 8.2%, P < 0.001). Compared to OMT, SMT was an independent predictor of long-term mortality (hazard ratio, HR 1.62, 95% confidence interval, CI 1.30-2.02, P < 0.01) while NMT was associated with a clinically significant 14% mortality hazard (HR 1.14, 95% CI 0.97-1.34, P = 0.11). There is a graded long-term hazard associated with not receiving OMT after an ACS. Improvements in secondary prevention pharmacotherapy models of care are warranted to further decrease the long-term mortality.

Sex Differences in Causes of Death After Stroke: Evidence from a National, Prospective Registry

Background: We examined sex differences in cause of death and cause-specific excess mortality after stroke. Materials and Methods: First-ever strokes (2010–2013; 35 hospitals) participating in the Australian Stroke Clinical Registry were linked to national death registrations and other administrative datasets. One-year cause-specific mortality was categorized as stroke, ischemic heart disease, other cardiovascular disease (CVD; e.g., hypertension), cancer, and other. Specific hazard ratios (sHRs) of death for women compared to men were estimated using competing risk models, with adjustment for factors differing by sex (e.g., age and stroke severity). Age- and sex-specific mortality rates expected in the general population were derived from national data. Standardized mortality ratios (SMRs; observed/expected deaths) were estimated for cause-specific mortality by sex after age standardization. Results: Among 9,441 cases (46% women), women were 7 years older than men, had more severe strokes, and received similar patterns of suboptimal secondary prevention medications at discharge. Women had greater mortality associated with stroke (sHRunadjusted 1.65) and other CVD (sHRunadjusted 1.65), which was related to age and stroke severity rather than other factors. Compared to population norms, those surviving to 30 days had eight-fold increased mortality from stroke (primary/recurrent) events irrespective of sex (SMRage-standardised women 8.8; men 8.3). Excess mortality from other CVD was greater in women (SMRage-standardised 3.6 vs. men 2.8; p = 0.026). Conclusions: Cause-specific mortality after first-ever stroke differs by sex. The greater death rate attributed to stroke/other CVD in women was mostly explained by age and stroke severity. Greater implementation of secondary stroke prevention is relevant to both sexes.

Determinants of suboptimal long-term secondary prevention of acute myocardial infarction: the structural interview method and physical examinations

BackgroundSecondary prevention after an acute myocardial infarction (AMI) reduces morbidity and mortality, but suboptimal secondary prevention of cardiovascular disease is common. Therefore, the present study aimed to identify potential underlying factors for suboptimal secondary prevention 2 years after an AMI event.MethodsPatients aged 18–85 years at the time of their index AMI and hospitalized between July 2010 and December 2011, were identified retrospectively and consecutively from hospital discharge records. All patients who agreed to participate underwent a structured interview, physical examinations and laboratory analysis 2 years after their index AMI. The secondary preventive goals included are; blood pressure < 140/90 mmHg, LDL < 1.8 mmol/L, HbA1c < 48 mmol/mol, regular physical activity that causes sweating at least twice a week, non-smoking and BMI < 25 kg/m2. Multivariable and univariable logistic regression models were applied to identify independent predictors of different secondary prevention achievements.ResultsOf the 200 patients (mean age 63.3 ± 9.7 years) included in the study, 159 (80%) were men. No common determinants were found in patients who failed to achieve at least six secondary prevention guideline-directed goals. For individual secondary prevention goals, several determinants were defined. Patients born in Sweden were less likely to achieve optimal lipid control [odds ratio (OR) 0.28 (95% confidence interval, CI 0.12–0.63)]. Younger (≤ 65 years) [OR 0.24 (95% CI 0.07–0.74)] and unemployed patients [OR 0.23 (95% CI 0.06–0.82)] were less likely to be non-smokers. Patients with diabetes mellitus [OR 0.21 (95% CI 0.04–0.98)] or with a walking aid [OR 0.23 (95% CI 0.07–0.71)] were less likely to achieve an optimal body mass index (BMI < 25). Living alone was an independent predictor of achieving regular physical activity [OR 1.94 (95% CI 1.02–3.69)].ConclusionLong-term secondary prevention remained suboptimal 2 years after an AMI. Causes are likely multifactorial, with no single determinant for all six guideline-recommended preventive goals. Therefore a tailored comprehensive assessment should be requested and updated and treatment of risk factors should be applied.

Suboptimal Secondary Prevention Post Acute Coronary Syndromes: Insights from the SMART-REHAB Trial

Introduction: International guidelines clearly state optimal secondary prevention with targets for blood pressure, cholesterol and diabetes as well as optimal medical therapy and smoking cessation. It is uncertain how many of these targets are met post acute coronary syndromes (ACS). Methods: SMART-REHAB was a randomised controlled trial assessing the impact of a smartphone-based cardiac rehabilitation programme post ACS. Patients were recruited from 6 major tertiary hospitals in Victoria. We assessed the proportion of patients receiving optimal medical therapy (dual antiplatelet therapy, statin, beta-blocker, ACE inhibition) and those not achieving target BP (<130/80 mmHg), cholesterol (total cholesterol <4 mmol/L and LDL-C <1.8 mmol/L) or diabetic control (HbA1c < 7%) as well as those continuing to smoke at 8-week post ACS. Results: 168 patients were included (mean age 56 ± 10 years, 57% STEMI). At 8-weeks, the majority of patients were receiving aspirin (99%), a second anti-platelet agent (99%) and statin therapy (98%). The rate of beta-blocker (82%) and ACE/ARB (83%) use was lower. Suboptimal secondary prevention was evident, as seen below, but was not improved with smartphone technology.Tabled 1SmartphoneUsual Carep-valueTC >1.8mmol/L24%21%0.42LDL-C >1.8mmol/L38%45%0.42BP >130/80mmHg24%74%0.93HbA1C > 7%8%6%0.52Current Smokers15%15%0.76 Open table in a new tab Conclusion: A significant proportion of patients are not meeting secondary prevention targets, particularly for blood pressure, cholesterol and smoking, despite the use of smartphone technology. An updated approach with the use artificial intelligence and mhealth can be used to up-titrate medication to meet secondary prevention targets.

Gender Disparity in Secondary Prevention Medication and Outcomes Following Percutaneous Coronary Intervention for Acute Coronary Syndrome

Background: Women continue to receive suboptimal secondary prevention medications following acute coronary syndrome (ACS), however, impact on long-term outcomes are not well documented. Methods: We analysed data on medical management 30-days post percutaneous coronary intervention for ACS in 20,976 consecutive patients in the Melbourne Interventional Group registry (2005-2018). Optimal medical therapy (OMT) was defined as 5 guideline-recommended medications, near-optimal (NMT) as 4 medications, and sub-optimal (SMT) as ≤3 medications. Long-term mortality was determined by National-Death Index linkage. Results: 65% of patients were prescribed OMT, 27% NMT and 8% SMT. Mean age 64 ± 12 years; 24% (4,931) female. Women were older (68 ± 12 vs. 62 ± 12 years) and had more comorbidities (higher BMI, hypertension, dyslipidaemia, diabetes and renal failure) than males, all p ≤ 0.001. Women were less likely to receive OMT (61% vs. 66%) and more likely to receive SMT (10% vs. 8%) compared to men, p < 0.001. At 12-months (n = 17,224) women were more likely to have recurrent MI (6% vs. 5%, p = 0.001), major bleeding (2.3% vs. 0.9%, p = 0.001), stroke (1.5% vs. 0.8%, p < 0.001) and MACE (13% vs. 11%, p = 0.026). At mean 5.3 year follow up, women had higher mortality (20% vs. 13%, p < 0.001). Conclusion: Women are less likely to be prescribed optimal secondary prevention medications following ACS and have poorer 12-month outcomes and long-term survival.

Systematic underutilisation of secondary preventive drugs in patients with acute coronary syndrome and reduced renal function.

Aims The high risk of recurrent events in patients with reduced renal function following an acute coronary syndrome (ACS) may in part be due to suboptimal secondary prevention. We aimed to describe the association between renal dysfunction and the prescription, initiation and persistent use of secondary prevention during the first year after a first ACS. Methods We identified all patients admitted to any Swedish coronary care unit for a first ACS between 2005 and 2010 ( n = 77,432). In 75,129 patients, creatinine levels were available in order to obtain the estimated glomerular filtration rate (eGFR). Persistent use of prescribed drugs was determined for 1 year using the National Prescription Registry, with complete coverage of all prescribed and dispensed drugs in Sweden. Results After adjustment for relative and absolute contraindications, compared to patients with eGFR ≥ 60 mL/min/1.73 m2, patients with eGFR 30-59 had higher odds of not being prescribed acetylsalicylic acid (ASA; odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.47-1.67), statins (OR: 2.94, 95% CI: 2.86-3.13) or β-blockade (OR: 1.25, 95% CI: 1.18-1.32). Patients with eGFR 30-59 were more likely to discontinue treatment with ASA (hazard ratio [HR]: 1.59, 95% CI: 1.42-1.56), statins (HR: 1.35, 95% CI: 1.29-1.41), angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers (HR: 1.37, 95% CI: 1.31-1.43) or β-blockade (HR: 1.22, 95% CI: 1.18-1.27). Patients with eGFR < 30 showed a similar pattern in both prescription and discontinuation. Conclusion High-risk ACS patients with reduced renal function are less likely to be prescribed secondary prevention drugs at discharge, are less likely to initiate treatment when being prescribed these drugs, are less likely to be persistent in the use of these drugs and more often discontinue treatment.

Trajectories of Stroke Care in Ontario: Which Path to Best Care?

Few studies have tracked stroke survivors through transitions across the health system and identified the most common trajectories and quality of care received. The objectives of our study were to examine the trajectories that incident stroke patients experience and to quantify the extent to which their care adhered to the best practices for stroke care. A population-based cohort of first-ever stroke/transient ischemic attack (TIA) patients from the 2012/13 Ontario Stroke Audit was linked to administrative databases using an encrypted health card number to identify dominant trajectories (N=12,362). All trajectories began in the emergency department (ED) and were defined by the transitions that followed immediately after the ED. Quality indicators were calculated to quantify best practice adherence within trajectories. Six trajectories of stroke care were identified with significant variability in patient characteristics and quality of care received. Almost two-thirds (64.5%) required hospital admission. Trajectories that only involved the ED had the lowest rates of brain and carotid artery imaging (91.5 and 44.2%, respectively). Less than 20% of patients in trajectories involving hospital admissions received care on a stroke unit. The trajectory involving inpatient rehabilitation received suboptimal secondary prevention measures. There are six main trajectories stroke patients follow, and adherence to best practices varies by trajectory. Trajectories resulting in patients being transitioned to home care following ED management only are least likely and those including inpatient rehabilitation are most likely to receive stroke best practices. Increased time in facility-based care results in greater access to best practices. Stroke patients receiving only ED care require closer follow-up by stroke specialists.

O210 Risk factors for congestive heart failure in patients with chronic kidney disease: the CRIC study

R A L A B ST R A C T S hospital, ischaemic heart disease, valvular heart disease and chronic kidney disease were all significant predictors of increased HF readmissions. Conclusion: Aboriginal HF patients despite being younger have higher readmission rates and a shorter interval to first HF readmission compared with non-Aboriginal patients. Possible contributory factors include remoteness, a higher patient comorbidity burden, inferior multidisciplinary and coordinated before care after hospital discharge and suboptimal secondary prevention. Disclosure of Interest: None Declared

The impact of age and chronic kidney disease on secondary prevention post-primary percutaneous coronary intervention

Historical data suggest elderly patients and those with chronic kidney disease (CKD) receive suboptimal secondary prevention following myocardial infarction (MI). We evaluated the impact of age and CKD on secondary prevention following primary percutaneous coronary intervention (PPCI) in a contemporary unselected cohort. We studied 1169 consecutive patients from five UK centres receiving PPCI for ST elevation MI, with use of evidence-based secondary prevention at discharge assessed by age (<60, 60-75 and >75 years) and estimated glomerular filtration rate (eGFR). Follow-up prescribing practice was assessed in 567 patients. One-fifth of patients receiving PPCI were >75 years. This group received fewer secondary prevention drugs at discharge compared to younger patients (P < 0.01 for β-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARB) and statins). By 6 weeks post-PPCI, there was a small drop-off in evidence-based therapy; β-blocker and statin use in those >75 years fell from 90% to 86% and 96% to 93%, respectively. CKD (eGFR<60 ml/min/1.73 m(2)) was seen in 17.6%. Declining renal function was associated with age, female sex and lower use of ACE inhibitor/ARB. At discharge 83.5% of patients with eGFR<60 ml/min/1.73 m(2) were receiving ACE inhibitors/ARB, dropping to 77.5% at 6 weeks (compared with 95% and 92%, respectively, in patients with eGFR >60 ml/min/1.73 m(2)). The uptake of secondary prevention medication is high following PPCI in the UK, even in the elderly and in those with renal dysfunction. A focus on strategies to improve up-titration and continuation of drugs following discharge is required.

The Year 2011 in Interventional Cardiology

DOI: 10.5935/abc.20130238 Dear Editor, We are delighted to show Arquivos Brasileiros de Cardiologia readers a review of the most relevant studies on Interventional Cardiology published in Revista Espanola de Cardiologia in the last two years. In relation to national protocols of emergency transfer for primary percutaneous coronary intervention in ST elevation myocardial infarction patients, we have published two papers from northern Galicia and the Southern Metropolitan area of Barcelona. Of importance, the implementation of both programs resulted in an increase in the number of patients receiving primary angioplasty1,2. We have also published important studies regarding transcatheter aortic valve implantation, a hot topic in interventional cardiology. Lopez-Otero et al3 reported the experience of three Spanish hospitals with the use of the axillary approach in patients who have contraindication to the femoral approach. They showed that the axillary approach using the CoreValve® was safe and efficient for selected patients, with excellent results in terms of success implantation and in-hospital and 30-day mortality. Lopez-Otero et al4 also published the joint experience of four hospitals regarding safety and effectiveness of the treatment of degenerated aortic homograft in patients refused for surgery. They showed that transcatheter treatment of degenerated aortic homografts and aortic insufficiency was safe and effective. Hernandez-Antolin et al5 compared the results obtained in transfemoral implantation of an Edwards-SAPIEN or CoreValve® aortic valve prosthesis in patients with severe aortic stenosis and a high surgical risk. They showed that in-hospital mortality, the complication rate and medium-term outcomes were similar with the two devices. The only difference observed was a higher implantation success rate with the CoreValve®, although at the expense of a greater frequency of atrioventricular block. In the intracoronary imaging field, Jimenez-Quevedo et al6 investigated the clinical consequences and predictive factors of the change in the type of plaque as assessed by serial intracoronary ultrasound in type II diabetic patients with known coronary artery disease. They showed that qualitative changes in mild stenosis documented by intracoronary ultrasound in type II diabetics were associated with suboptimal secondary prevention. Also with intracoronary ultrasound, Medina et al7 studied plaque distribution in the coronary bifurcation and the prevalence of carina involvement. They showed plaque at the carina in one-third of the bifurcations. The incidence of plaque was higher in those bifurcations, with the minimal lumen area point distal to the carina, and was associated with a lower incidence of damage to the side branch ostium.

Assessment of Dynamic Coronary Plaque Changes and the Clinical Consequences in Type-II Diabetic Patients: a Serial Intracoronary Ultrasound Study

Introduction and objectives One of the aims of secondary prevention is to achieve plaque stabilization. This study sought to investigate the clinical consequences and predictive factors of the change in the type of plaque (CTP) as assessed by serial intracoronary ultrasound in type II diabetic patients with known coronary artery disease. Methods 237 segments (45 patients) from the DIABETES I, II, and III trials were included. Intracoronary ultrasound from motorized pullbacks (0.5 mm/s) after index procedure and at 9-month angiographic follow-up was performed in the same coronary segment. Nontreated mild lesions (angiographic stenosis < 25%) with ≥0.5 mm plaque thickening and ≥5 mm of length assessed by intracoronary ultrasound were included. As different types of plaques may be encountered throughout a given coronary lesion, each study lesion was divided into 3 segments for serial quantitative and qualitative analyses. Statistical adjustment by multiple lesion segments per patient (generalized estimating equations method) was performed. A CTP was defined as any qualitative change in plaque type at follow-up. At 1-year follow-up, major adverse cardiac events – death, myocardial infarction and target vessel revascularization) – were recorded. Results A CTP was observed in 48 lesions (20.2%) and occurred more frequently (52.1%) in mixed plaques. Independent predictors of CTP were glycated hemoglobin levels (odds ratio [OR] 1.2; 95% confidence interval [CI] 1.01-1.5; P = .04); glycoprotein IIb-IIIa inhibitors (OR 0.3; 95% CI 0.1-0.7; P = .004) and statin administration (OR 0.3; 95% CI 0.1-0.8; P = .02). At 1-year follow-up CTP was associated with an increase in major adverse cardiac events rate (CTP 20.8% vs non-CTP 13.8%, P = .008; hazard ratio = 1.9, 95% CI 1.3-1.9, P = .01). Conclusions Qualitative changes in mild stenosis documented by intracoronary ultrasound in type II diabetics are associated with suboptimal secondary prevention and may have clinical consequences.

Evaluación de los cambios dinámicos de las placas coronarias y sus consecuencias clínicas en pacientes con diabetes mellitus tipo 2: un estudio de ecografía intracoronaria seriada

Introduction and objectives One of the aims of secondary prevention is to achieve plaque stabilization. This study sought to investigate the clinical consequences and predictive factors of the change in the type of plaque (CTP) as assessed by serial intracoronary ultrasound in type II diabetic patients with known coronary artery disease. Methods 237 segments (45 patients) from the DIABETES I, II, and III trials were included. Intracoronary ultrasound from motorized pullbacks (0.5 mm/s) after index procedure and at 9-month angiographic follow-up was performed in the same coronary segment. Nontreated mild lesions (angiographic stenosis <25%) with ≥0.5 mm plaque thickening and ≥5 mm of length assessed by intracoronary ultrasound were included. As different types of plaques may be encountered throughout a given coronary lesion, each study lesion was divided into 3 segments for serial quantitative and qualitative analyses. Statistical adjustment by multiple lesion segments per patient (generalized estimating equations method) was performed. A CTP was defined as any qualitative change in plaque type at follow-up. At 1-year follow-up, major adverse cardiac events – death, myocardial infarction and target vessel revascularization) – were recorded. Results A CTP was observed in 48 lesions (20.2%) and occurred more frequently (52.1%) in mixed plaques. Independent predictors of CTP were glycated hemoglobin levels (odds ratio [OR] 1.2; 95% confidence interval [CI] 1.01-1.5; P = .04); glycoprotein IIb-IIIa inhibitors (OR 0.3; 95% CI 0.1-0.7; P = .004) and statin administration (OR 0.3; 95% CI 0.1-0.8; P = .02). At 1-year follow-up CTP was associated with an increase in major adverse cardiac events rate (CTP 20.8% vs non-CTP 13.8%, P = .008; hazard ratio = 1.9, 95% CI 1.3-1.9, P = .01). Conclusions Qualitative changes in mild stenosis documented by intracoronary ultrasound in type II diabetics are associated with suboptimal secondary prevention and may have clinical consequences. Full English text available from: www.revespcardiol.org

The paradox of excellent long-term survival and physical fitness after coronary artery bypass surgery despite suboptimal secondary prevention

To evaluate current lifestyle, secondary medical prevention and objective physical abilities in long-term survivors after coronary artery bypass grafting (CAGB). Data were collected by written questionnaires and telephone interviews in 476 (405 men, mean age 56 years) patients after a median follow-up of 16.6 yrs (95% CI 16.5–16.7 yrs post-CABG). Triple-vessel coronary heart disease (CHD) was present in 56%; combined arterial and venous revascularization was performed in 21% of patients and 83% received complete revascularization. All patients are today under continuous medical therapy (1–10 drugs, mean 3.8±0.08) and the majority of patients (49%) undergo daily administration of 3–4 drugs. Present cardiovascular risk profiles include overweight (52% with a BMI of >25 kg/m2), arterial hypertension (44%), hyperlipidemia (66%, of whom 22% are without lipid-lowering therapy) and diabetes (21%, of whom 27% are without glucose-lowering therapy). Seventy-three percent of patients are today in NYHA class I or II. Angina or dyspnea during stress affect 35% and 47% of patients, respectively. Mean ergometric stress testing level was 107±3 W and 43% of patients were found to perform at >100 W. Acute myocardial infarction re-occurred in 26% and ≥1 occluded graft was found in 24% of patients; the frequency of re-CABG was 21% after a mean of 11±0.4 yrs. Long-term survivors after CABG procedure show excellent clinical conditions and physical abilities despite suboptimal secondary prevention of CHD in medial therapy and lifestyle issues. The cause(s) of the fortunate outcome in this “highly responsive” group remain to be illuminated.

Comparison of Stage at Diagnosis of Melanoma Among Hispanic, Black, and White Patients in Miami-Dade County, Florida

To compare stage at diagnosis of melanoma between non-Hispanic white, non-Hispanic black, and Hispanic patients. Retrospective analysis. Melanoma cases reported to the Florida Cancer Data System, with known stage and race/ethnicity information, for residents of Miami-Dade County, Florida, from 1997 to 2002. Those diagnosed as having melanoma according to the Florida Cancer Data System. Stage of melanoma at diagnosis. Of the 1690 melanoma cases reported with both stage and race/ethnicity information, 1176 (70%) were among non-Hispanic white patients, 485 (29%) were among Hispanic patients of any race, and 29 (2%) were among non-Hispanic black patients. Late-stage (regional and distant) diagnosis was more common among Hispanic (26%) and non-Hispanic black patients (52%) compared with non-Hispanic white patients (16%) (P < .001). Advanced stage of melanoma diagnosis among Hispanic and black patients suggests suboptimal secondary prevention efforts in minority populations.

Secondary Prevention of Coronary Heart Disease in Primary Health Care

Significant increase in mortality from coronary heart disease (CHD) has been seen in Bosnia and Herzegovina in the past decade. Little is known about current secondary preventive practices and treatments among patients with CHD in primary health care. The aims of this study were to evaluate the components of secondary prevention for CHD and to detect possible gender differences. This trial included 70 patients, aged 40-70 years, with established CHD from Family Medicine Teaching Center Tuzla. We evaluated components of secondary prevention (serum total cholesterol and blood pressure levels, smoking habits, body mass index, using aspirin, ACE inhibitors and lipid lowering drugs) in all participants. Results showed that significantly more men than women had diagnosis of CHD. 26/70 (37.14%) patients had myocardial infarction, with significantly higher number of men than women, but more women had angina only. Mean systolic blood pressure was 148.09+/-20.22 and diastolic 91.62+/-10.17 mmHg; mean total cholesterol level was 6.23+/-1.33 mmol/l; mean BMI was 27.9+/-3.32 kg/m(2). Blood pressure was managed according to guidelines in 19 (27.14%), and lipid concentrations in 11 (15.71%) patients. 55/70 (78.71%) patients took aspirin, only 18/70 (25.71%) patients took lipid lowering therapy, and 20/23 (86.96%) patients with heart failure took ACE inhibitors. 16/70 (22.86%) patients were current smokers, only 19/70 (27.14%) patients had healthy body mass index, while 21/70 (30%) patients were obese. Results of this study show a suboptimal secondary prevention in primary health care, which indicate more effective public health messages and changes in the healthcare system that promotes preventive strategies.