Use Of Cardiac Medications Research Articles

Patients' Use of Cardiac Medications After Coronary Revascularization

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) do not cure atherosclerosis; medical therapy (e.g., antiplatelet

Trends in the Medical Management of Patients With Heart Failure

BackgroundDespite the availability of effective therapies, heart failure (HF) remains a highly prevalent disease and the leading cause of hospitalizations in the U.S. Few data are available, however, describing changing trends in the use of various cardiac medications to treat patients with HF and factors associated with treatment. The objectives of this population-based study were to examine decade-long trends (1995 - 2004) in the use of several cardiac medications in patients hospitalized with acute decompensated heart failure (ADHF) and factors associated with evidence-based treatment.MethodsWe reviewed the medical records of 9,748 residents of the Worcester, MA, metropolitan area who were hospitalized with ADHF at all 11 central Massachusetts medical centers in 1995, 2000, 2002, and 2004.ResultsBetween 1995 and 2004, respectively, the prescription upon hospital discharge of beta-blockers (23%; 67%), angiotensin pathway inhibitors (47%; 55%), statins (5%; 43%), and aspirin (35%; 51%) increased markedly, while the use of digoxin (51%; 29%), nitrates (46%; 24%), and calcium channel blockers (33%; 22%) declined significantly; nearly all patients received diuretics. Patients in the earliest study year, those with a history of obstructive pulmonary disease or anemia, incident HF, non-specific symptoms, and women were less likely to receive beta blockers and angiotensin pathway inhibitors than respective comparison groups. In 2004, 82% of patients were discharged on at least one of these recommended agents; however, only 41% were discharged on medications from both recommended classes.ConclusionsOur data suggest that opportunities exist to further improve the use of HF therapeutics.

Serum carbohydrate antigen-125 is elevated in patients with chronic atrial fibrillation

ObjectiveTo determine whether CA-125 is elevated in medically stable patients with chronic atrial fibrillation (AF) compared with patients without AF and to examine whether levels of CA-125 are associated with demographic and clinical variables in a sample of patients under study. Methods55 patients with chronic AF and 58 control patients in sinus rhythm were included into the study. Patients with acute heart failure (HF), chronic inflammatory or neoplastic disease were excluded from the study. Circulating levels of CA-125 were assessed; all patients underwent clinical examination, assessment and medical records including demographic data, history of comorbid conditions, current use of cardiac medications, and the results of cardiac tests including electrocardiograms. ResultsThe mean age of the study sample was 53.2±6.5 years and 48% were men. Patients with sinus rhythm were significantly more likely to have lower heart rates, smaller dimensions of left atrium, and to be treated with aspirin. Coumadin, coumadin and digoxin were more often prescribed in patients with chronic AF. The CA-125 levels were significantly higher in patients with chronic AF than in patients in sinus rhythm (48.5±7.65 U/ml and 28.43±5.48 U/ml, P<0.005). An inverse relation was found between CA-125 levels and left ventricular ejection fraction (LVEF) (r=-0.48, P<0.001). CA-125 was significantly related to the left atrium (LA) diameter, left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD) and brain natriuretic peptide (BNP). There was no significant correlation between CA-125 and age. ConclusionIn subjects with chronic AF, CA-125 levels are increased; CA-125 was significantly related to the LA diameter, LVEDD, LVESD and BNP.

Influence of Aortic Valve Calcium on Outcome in Patients Undergoing Peripheral Vascular Surgery

Vascular surgery patients are at increased risk of adverse cardiovascular events because of silent coronary artery disease and an increased propensity for left ventricular dysfunction. The Revised Cardiac Risk Index is commonly used for preoperative risk stratification. Aortic valve calcium is associated with cardiovascular mortality in the general population. The present study evaluated the prognostic implications of aortic valve calcium on 30-day postoperative and long-term outcomes in vascular surgery patients. Echocardiographic aortic valve evaluation was completed in 1,172 vascular surgery patients. Aortic valve sclerosis was defined by the presence of thickening and/or calcium of ≥1 cusps of a tricuspid aortic valve not inducing stenosis (i.e., with a maximal velocity at continuous Doppler of <2.5 m/s). Stenosis was defined as a maximum velocity of >2.5 m/s. Troponin-T measurements and electrocardiograms were performed routinely after surgery. The study end points were the composite of postoperative cardiovascular events and long-term mortality. Aortic valve sclerosis was present in 416 patients (36%), and aortic valve stenosis was present in 30 patients (3%). After multivariate regression analyses adjusted for age, gender, Revised Cardiac Risk Index, hypertension, hypercholesterolemia, and medication use, aortic valve sclerosis was not associated with either the postoperative or long-term outcomes. In contrast, aortic valve stenosis was associated with a greater postoperative and long-term event rate (odds ratio 3.9, 95% confidence interval 1.7 to 8.7; and hazard ratio 2.1, 95% confidence interval 1.2 to 3.7, respectively). In conclusion, the present study has shown that aortic valve calcium is common in vascular surgery patients. Its presence is associated with negative postoperative and long-term outcomes.

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

BackgroundDespite evidence-based recommendations supporting long-term use of cardiac medications in patients post ST-elevation myocardial infarction, adherence is known to decline over time. Discontinuation of cardiac medications in such patients is associated with increased mortality.Methods/designThis is a pragmatic, cluster-randomized controlled trial with blinded outcome assessment and embedded qualitative process evaluation. Patients from one health region in Ontario, Canada who undergo a coronary angiogram during their admission for ST-elevation myocardial infarction and who survive their initial hospitalization will be included. Allocation of eligible patients to intervention or usual care will take place within one week after the angiogram using a computer-generated random sequence. To avoid treatment contamination, patients treated by the same family physician will be allocated to the same study arm. The intervention consists of recurrent, personalized, paper-based educational messages and reminders sent via post on behalf of the interventional cardiologist to the patient, family physician, and pharmacist urging long-term adherence to secondary prevention medications. The primary outcome is the proportion of patients who report in a phone interview taking all relevant classes of cardiac medications at twelve months. Secondary outcomes to be measured at three and twelve months include proportions of patients who report: actively taking each cardiac medication class of interest (item-by-item); stopping medications due to side effects; taking one or two or three medication classes concurrently; a perfect Morisky Medication Adherence Score for cardiac medication compliance; and having a discussion with their family physician about long-term adherence to cardiac medications. Self-reported measures of adherence will be validated using administrative data for prescriptions filled.DiscussionThis intervention is designed to be easily generalizable. If effective, it could be implemented broadly. If it does not change medication utilization, the process evaluation will offer insights regarding how such an intervention could be optimized in future.Trial registrationClinicaltrials.gov NCT01325116

A Comparison of Precipitants and Mortality When Acute Decompensated Heart Failure Occurs in the Community and Hospital Settings

We aimed to compare the precipitants of acute decompensated heart failure (ADHF) among patients admitted with diagnoses inclusive of ADHF (community patients) and patients admitted without ADHF but who developed it during their stay (hospital patients). This was a prospective, analytical, observational study undertaken in the Austin Hospital, a major metropolitan teaching hospital (September 2008-February 2010). Consecutive patients admitted to a general medicine unit, and diagnosed and treated for ADHF were enrolled. The unit medical staff completed a specifically designed data collection document. Three hundred and fifty-nine patients were enrolled (42.9% male, mean age 81.9 years). The community (n=312) and hospital (n=47) patient groups did not differ in age, gender, risk variables (living alone, cognitive impairment, multiple medications, compliance), cardiac failure medication use or cause of known heart failure (ischaemia, hypertension, valve dysfunction, 'other') (p>0.05). The ADHF precipitants comprised infection (39.8% patients), myocardial ischaemia (17.3%), tachyarrhythmia (16.2%), non-compliance with fluid and salt restriction (9.2%), non-compliance with medication (6.7%), renal failure (5.8%), medication reduction (5.0%), intravenous fluid complication (3.9%) and 'other' causes (13.9%). Significantly more hospital patients had their ADHF precipitated by intravenous fluid complications (25.5% versus 0.6%, p<0.001). Hospital patients also had a significantly greater death rate (25.5% versus 9.3%, p<0.01). Acute decompensated heart failure precipitated in hospital is a dangerous condition with a high mortality. While infection and myocardial ischaemia are the common precipitants, complications of intravenous fluid use, an iatrogenic condition, may be considerable and are potentially avoidable.

Kardiopulmonale Notfälle in Schwangerschaft und Postpartalperiode

The number of patients who develop cardiac problems during pregnancy are increasing and represent to date the major cause of maternal death in western countries. Pregnancy induces several changes which together increase the hemodynamic burden on the cardiovascular system and can also cause a prothrombotic state. Hence, latent or apparent cardiac disease can acutely decompensate during pregnancy. From a cardiovascular perspective, pregnancies are most often complicated by acute coronary syndromes, peripartum cardiomyopathy, arrhythmias, or pulmonary embolism. Due to potential fetal harm conventional diagnostic and therapeutic approaches are limited by the restricted use of radiogenic cardiac imaging and applicable medications. Therefore, knowledge about available therapeutic options is of greatest importance, since guideline recommendations have clearly been demonstrated to reduce morbidity and mortality in acute cardiac emergencies during pregnancy.

Adherence to Statin Therapy in Elderly Patients After Hospitalization for Coronary Revascularization

Low levels of statin adherence have been documented in patients with coronary artery disease (CAD), but whether coronary revascularization is associated with improved adherence rates has yet to be evaluated. We identified all Medicare beneficiaries enrolled in 2 statewide pharmacy assistance programs who were ≥65 years old, who had been hospitalized for CAD from 1995 through 2004, and who had been prescribed statin therapy within 90 days of discharge (n = 13,130). Statin adherence was measured based on the proportion of days covered with statin therapy after hospital discharge, and full adherence was defined as proportion of days covered ≥80%. Statin adherence was compared in patients with CAD treated with medical therapy (n = 3,714), percutaneous coronary intervention (n = 6,309), or coronary artery bypass graft surgery (n = 3,107). Statin adherence significantly increased over the period of the study from 70.5% to 75.4% (p <0.0001). After hospitalization for CAD, patients treated with percutaneous coronary intervention and coronary artery bypass graft surgery had full adherence rates of 70.6% and 70.2%, respectively. Full adherence rates were significantly lower for patients treated with coronary revascularization compared to patients treated with medical therapy (79.4%, p <0.0001). Independent predictors of higher statin adherence included treatment with medical therapy, later year of hospital admission, white race, previous statin use, and use of other cardiac medications after CAD hospitalization (p <0.01 for all comparisons). In conclusion, in patients receiving invasive coronary treatment, statin adherence remains suboptimal, despite strong evidence supporting their use. Given the health and economic consequences of nonadherence, these findings highlight the need for developing cost-effective strategies to improve medication adherence after coronary revascularization.

Pregnancy in women with corrected tetralogy of Fallot: Occurrence and predictors of adverse events

In women with corrected tetralogy of Fallot (ToF), pregnancy is associated with maternal cardiac, obstetric, and offspring complications. Our aim is to investigate the magnitude and determinants of pregnancy outcome in women with corrected ToF. In this retrospective international multicenter study using 2 congenital heart disease registries, 204 women with corrected ToF were identified. Within this group, 74 women had 157 pregnancies, including 30 miscarriages and 4 terminations of pregnancy. Detailed information on each completed pregnancy (n = 123) was obtained using medical records and supplementary interviews. Cardiovascular events occurred during 10 (8.1%) pregnancies, mainly (supra)ventricular arrhythmias. Obstetric and offspring events occurred in 73 (58.9%) and 42 (33.9%) pregnancies, respectively, including offspring mortality in 8 (6.4%). The most important predictor was use of cardiac medication before pregnancy (odds ratio for cardiac events 11.7, 95% CI 2.2-62.7; odds ratio for offspring events 8.4, 95% CI 1.4-48.6). In pregnancies with cardiovascular events, significantly more small-for-gestational-age children were born (P value < .01). Cardiovascular, obstetric, and offspring events occur frequently during pregnancies in women with ToF. Maternal use of cardiovascular medication is associated with pregnancy outcome, and maternal cardiovascular events during pregnancy are highly associated with offspring events.

Temporal trend of in-hospital major bleeding among patients with non ST-elevation acute coronary syndromes

Although randomized controlled trials support the use of intensive medical and invasive therapies for non-ST segment elevation acute coronary syndromes (NSTE-ACS), major bleeding is a serious treatment complication. We sought to determine the temporal trend of in-hospital major bleeding among patients with NSTE-ACS, in relation to the evolving management pattern. We identified 14111 NSTE-ACS patients enrolled in 4 successive, prospective, multicenter registries (ACS I, 1999-2001; ACS II, 2002-2003; GRACE, 2004-2007; and CANRACE, 2008) in Canada between 1999 and 2008. We collected data on patient characteristics, use of cardiac medications and procedures on standardized case report forms. In all registries, major bleeding was defined a priori as life threatening or fatal bleeding, bleeding requiring transfusion of ≥2 U of packed red cells, or resulting in an absolute decrease in hemoglobin of >30g/L. A total of 14111 patients had a final diagnosis of NSTE-ACS and were included in this study (3294 in the ACS-I registry, 1956 in the ACS-II registry, 7543 in GRACE, and 1318 in CANRACE). Over time, there was a substantial increase in the use of dual anti-platelet (aspirin and thienopyridine) therapy (P for trend <.001), and in rates of in-hospital cardiac catheterization and percutaneous coronary intervention (both Ps for trend <.001). Overall, major bleeding was relatively infrequent (1.7%). There was no significant increase in the unadjusted rates of major bleeding over time (P for trend = .19). In multivariable analysis adjusting for GRACE risk score and intensive treatment, enrolment period was not an independent predictor of bleeding (P for trend = .98). There was no interaction between the enrolment period and the use of intensive medical and invasive management. Despite more widespread use of dual anti-platelet therapies and invasive cardiac procedures in the management of NSTE-ACS, the rate of major bleeding remains relatively low and has not increased significantly over time. Our findings suggest that physicians selectively target treatment for their patients, and these evidence-based therapies can be safely administered to ACS patients in clinical practice.

Management and Outcomes of Renal Disease and Acute Myocardial Infarction

Background Contemporary trends in the management and outcomes of chronic kidney disease patients who develop an acute myocardial infarction have not been adequately described, particularly from the more generalizable perspective of a population-based investigation. Methods The study population consisted of 6219 residents of the Worcester, Massachusetts, metropolitan area who were hospitalized with acute myocardial infarction in 6 annual periods between 1995 and 2005. Patients were categorized as having preserved kidney function (n = 3154), mild to moderate chronic kidney disease (n = 2313), or severe chronic kidney disease (n = 752) at the time of hospital admission. Results Patients with chronic kidney disease were more likely to be older, to have a greater prevalence of comorbidities, and to experience significant in-hospital complications or die during hospitalization in comparison with patients with preserved kidney function. Although patients with chronic kidney disease were less likely to receive effective cardiac medications or undergo coronary interventional procedures than patients without kidney disease, we observed a marked increase in the use of effective cardiac medications and coronary interventional procedures in patients with chronic kidney disease during the period under study. In-hospital death rates declined over time among patients with chronic kidney disease, whereas these death rates remained unchanged among persons with normal kidney function. Conclusion The results of this study in residents of a large New England metropolitan area provide insights into changing trends in the treatment and impact of chronic kidney disease in patients hospitalized with acute myocardial infarction.

Discontinuation of Cholinesterase Inhibitor Treatment and Determinants thereof in the Netherlands

The cholinesterase inhibitors (ChEIs) rivastigmine and galantamine have been approved for the treatment of mild to moderate Alzheimer's disease in the Netherlands. Differences between ChEIs regarding persistence or the use of effective doses in daily clinical practice have been observed. However, most studies assessing ChEI discontinuation and associated determinants have been conducted in North America and there is a lack of knowledge about ChEI discontinuation and its determinants in daily clinical practice in Europe. To assess ChEI discontinuation in daily practice in the Netherlands and to seek its determinants, including suboptimal utilization. A retrospective cohort study was performed using data from the Dutch PHARMO Record Linkage System. Included patients were aged > or =50 years at first dispensing of a ChEI, had a first dispensing of a ChEI between 1998 and 2008, had a prior medication history of 12 months and had at least one subsequent dispensing of any kind of medication. The proportion of patients who discontinued ChEIs over 3 years was determined. Cox regression was used to assess determinants for early (< or =6 months) discontinuation and, separately, for late discontinuation during a subsequent 30-month follow-up among those persisting with treatment for >6 months. At 6 months, 30.8% of 3369 study patients had discontinued ChEIs, compared with 59.0% after 3 years. Thirty-five percent of patients taking rivastigmine reached the WHO-defined daily dose compared with 80% taking galantamine. At 6 months, compared with regular-dose rivastigmine, low-dose rivastigmine or low-dose galantamine was associated with an increased risk of early discontinuation, whereas regular-dose galantamine was associated with a decreased risk, as was concurrent use of cardiac medications, drugs for Parkinson's disease, propulsives, selective serotonin reuptake inhibitors and benzodiazepines. Associations of ChEI type/dose or co-medications with discontinuation among patients persisting for > 6 months differed somewhat from associations with discontinuation before 6 months. Fewer patients taking rivastigmine than those taking galantamine reached recommended doses. Furthermore, patients taking rivastigmine had an increased risk of early discontinuation compared with patients taking galantamine. Adverse effects leading to treatment intolerance and suboptimal utilization may have been contributing factors to these observed differences.

Age and sex differences, and changing trends, in the use of evidence-based therapies in acute coronary syndromes: perspectives from a multinational registry

A limited number of studies have examined the age and sex differences, and potentially changing trends, in cardiac medication and procedure use in patients hospitalized with an acute coronary syndrome (ACS). Using data from a large multinational study, we examined the age and sex differences, and changing trends (1999-2007) therein, in the hospital use of evidence-based therapies in patients hospitalized with an ACS using data from the Global Registry of Acute Coronary Events (n=50 096). After adjustment for several variables, in comparison with men below 65 years, patients in other age-sex strata had a significantly lower odds of receiving aspirin [odds ratios (ORs) for men 65-74, 75-84, and >or=85 years, women <65, 65-74, 75-84, and >or=85 years were 0.86, 0.84, 0.72, 0.80, 0.86, 0.68 and 0.46, respectively], angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ORs, 1.08, 1.01, 0,71, 0.83, 0.90, 0.89, and 0.63), beta blockers (ORs, 0.66, 0.52, 0.53, 0.67, 0.54, 0.53, and 0.52), statins (ORs, 0.72, 0.49, 0.29, 0.82, 0.68, 0.44, and 0.22), and undergoing coronary artery bypass graft surgery or a percutaneous coronary intervention (ORs, 0.79, 0.53, 0.21, 0.64, 0.57, 0.38, and 0.13) during their acute hospitalization. Age and sex differences in the receipt of these therapies remained relatively unchanged during the period under study. Although there were increasing trends in the use of evidence-based medications and cardiac procedures over time, important gaps in the utilization of effective cardiac treatment modalities persist in elderly patients and younger women.

Predictors of pregnancy complications in women with congenital heart disease

Data regarding pregnancy outcome in women with congenital heart disease (CHD) are limited. In 1802 women with CHD, 1302 completed pregnancies were observed. Independent predictors of cardiac, obstetric, and neonatal complications were calculated using logistic regression. The most prevalent cardiac complications during pregnancy were arrhythmias (4.7%) and heart failure (1.6%). Factors independently associated with maternal cardiac complications were the presence of cyanotic heart disease (corrected/uncorrected) (P < 0.0001), the use of cardiac medication before pregnancy (P < 0.0001), and left heart obstruction (P < 0.0001). New characteristics were mechanical valve replacement (P = 0.0014), and systemic (P = 0.04) or pulmonary atrioventricular valve regurgitation related with the underlying (moderately) complex CHD (P = 0.03). A new risk score for cardiac complications is proposed. The most prevalent obstetric complications were hypertensive complications (12.2%). No correlation of maternal characteristics with adverse obstetric outcome was found. The most prevalent neonatal complications were premature birth (12%), small for gestational age (14%), and mortality (4%). Cyanotic heart disease (corrected/uncorrected) (P = 0.0003), mechanical valve replacement (P = 0.03), maternal smoking (P = 0.007), multiple gestation (P = 0.0014), and the use of cardiac medication (P = 0.0009) correlated with adverse neonatal outcome. In our tertiary CHD cohort, cardiac, obstetric, and neonatal complications were frequently encountered, and (new) correlations of maternal baseline data with adverse outcome are reported. A new risk score for adverse cardiac complications is proposed, although prospective validation remains necessary.

Cardiac Arrest During Laparoscopic Roux-en-Y Gastric Bypass in a Bariatric Patient with Drug-Associated Long QT Syndrome

Obese patients often may demonstrate an acquired prolonged QTc interval due to alteration in cardiac physiology, electrolyte disturbances, and/or medication use. Intraoperatively, bariatric surgery may further contribute additional cardiac stressors to obese patients with long QT syndrome (LQTS). We present a case report of an obese woman with LQTS who underwent laparoscopic Roux-en-Y gastric bypass surgery and sustained an intraoperative cardiac arrest. We discuss identification, prevention, and treatment strategies for LQTS in the bariatric surgery patient.

Impact of Prophylactic β-Blocker Therapy to Prevent Stroke After Noncardiac Surgery

beta Blockers are widely used to improve the postoperative cardiac outcome in patients with coronary artery disease scheduled for noncardiac surgery. However, recently serious concerns regarding the safety of perioperative beta blockers have emerged. To assess the incidence, risk factors, and beta-blocker use associated with postoperative stroke in the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) trials, we evaluated all 3,884 patients of the DECREASE trials for postoperative stroke. All cardiac risk factors and medication use were assessed. The incidence of stroke within 30 days after surgery was recorded. The incidence of postoperative stroke in the DECREASE trials was 0.46% (18 of 3,884). For the beta-blocker users, the incidence was 0.5%. All the strokes had an ischemic origin. A history of stroke was associated with a greater incidence of postoperative stroke (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.2 to 11.6). Statins and anticoagulants were not associated with postoperative stroke (OR 0.85, 95% CI 0.3 to 2.4; and OR 1.27, 95% CI 0.4 to 4.6, respectively). No association with bisoprolol therapy was found (OR 1.16, 95% CI 0.4 to 3.4). In conclusion, with a low-dose bisoprolol regimen started > or =30 days before surgery, no association was observed between beta-blocker use and postoperative stroke.

Acute Coronary Syndrome in the Elderly

The spectrum of acute coronary syndrome (ACS) including unstable angina, non-ST-elevation myocardial infarction and ST-elevation myocardial infarction accounts for increasing numbers of deaths among persons age > or = 65 years in the US. This is important given demographic changes involving falling birth rates and increasing life expectancy. Elderly patients are likely to benefit the most from treatment of ACS, even though community practice still demonstrates less use of cardiac medications as an early-invasive approach among this population.

Use and cost of branded and generic drugs in patients with coronary heart disease--results from a prospective survey of 1008 patients in two London hospitals

Combination therapy with three classes of drug, antiplatelet, cholesterol and blood pressure lowering treatment markedly reduce the risk of recurrent cardiovascular events in patients with coronary heart disease (CHD). Within each class, generic and branded (patented) drugs are available which have similar efficacy but differ in cost. (i) To assess the extent to which preventive medical drugs are prescribed in patients with CHD and to examine the reasons for drug omissions and (ii) to assess the relative use of branded and generic drugs and the reasons for drug selection. The medication charts and hospital notes of consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at a large cardiothoracic centre were reviewed over a 3-month period. Interviews with patients, attending cardiologists and general practitioners were undertaken to establish why drugs were and were not prescribed. Among 1008 patients (755 who had PCI and 253 who had CABG) the use of aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), beta blockers and calcium channel blockers were, respectively, 97, 98, 81, 76 and 18%. The combination of any 4 classes of drug were used in 65% of patients. Almost all patients who did not receive aspirin or a statin had clinical contraindications and were on alternative drugs. In about 12% of patients without an ACE inhibitor (or ARB) and 7% of patients without a beta blocker, no reason to withhold such treatment was identified. Branded drugs were used in 52% of patients; the most commonly prescribed being atorvastatin in 33%. Clinical reasons for using branded rather than generic drugs were identified in 13% of cases. Our results show a high rate of use of secondary preventive cardiac medications in patients undergoing coronary revascularization procedures, but the use of ACE inhibitors or beta blockers is still overlooked in about 1 in 10 patients. Branded drugs are prescribed in about half of all patients undergoing PCI and CABG, but in almost 90% of cases, a generic equivalent could have been used to achieve similar risk reduction. If our results reflect wider practice, an estimated 11 million pounds a year would be saved by the National Health Service by switching to generic alternative drugs.

Effect of Race on the Clinical Outcomes in the Bypass Angioplasty Revascularization Investigation Trial

In observational studies, clinical outcomes for black patients with coronary disease have been worse than for white patients. There are few data from randomized trials comparing the outcomes of coronary revascularization between black patients and white patients. We analyzed data from the Bypass Angioplasty Revascularization Investigation randomized trial. At study entry, the 113 black patients had significantly higher rates of diabetes, hypertension, smoking, heart failure, and abnormal left ventricular function than the 1653 white patients. Black patients had significantly higher mortality than white patients (hazard ratio, 2.16; P<0.001), which remained significant after statistical adjustment for differences in baseline clinical characteristics (hazard ratio, 1.59; P=0.003). In a substudy of economic and quality of life outcomes, the 67 black patients had similar frequency of physician visits and use of evidence-based cardiac medications but significantly worse physical function scores than the 885 white patients. The effect of random assignment to either surgery or angioplasty on clinical outcomes was not significantly modified by race (interaction probability values >or=0.18). Clinical outcomes of black patients after coronary revascularization were worse than those of white patients in a clinical trial setting with similar treatment and access to care. The differences in outcome between black and white patients were not completely attributable to the greater levels of comorbidity among black patients at study entry.

Impaired heart rate recovery is associated with new-onset atrial fibrillation: a prospective cohort study

BackgroundAutonomic dysfunction appears to play a significant role in the development of atrial fibrillation (AF), and impaired heart rate recovery (HRR) during exercise treadmill testing (ETT) is a known marker for autonomic dysfunction. However, whether impaired HRR is associated with incident AF is unknown. We studied the association of impaired HRR with the development of incident AF, after controlling for demographic and clinical confounders.MethodsWe studied 8236 patients referred for ETT between 2001 and 2004, and without a prior history of AF. Patients were categorized by normal or impaired HRR on ETT. The primary outcome was the development of AF. Cox proportional hazards modeling was used to control for demographic and clinical characteristics. Secondary analyses exploring a continuous relationship between impaired HRR and AF, and exploring interactions between cardiac medication use, HRR, and AF were also conducted.ResultsAfter adjustment, patients with impaired HRR were more likely to develop AF than patients with normal HRR (HR 1.43, 95% confidence interval (CI) 1.06, 1.93). In addition, there was a linear trend between impaired HRR and AF (HR 1.05 for each decreasing BPM in HRR, 95% CI 0.99, 1.11). No interactions between cardiac medications, HRR, and AF were noted.ConclusionPatients with impaired HRR on ETT were more likely to develop new-onset AF, as compared to patients with normal HRR. These findings support the hypothesis that autonomic dysfunction mediates the development of AF, and suggest that interventions known to improve HRR, such as exercise training, may delay or prevent AF.