Use Of Cardioprotective Drugs Research Articles

Carotid ultrasonography as a strategy to optimize cardiovascular risk management in type 1 diabetes: a cohort study.

Although cardiovascular disease (CVD) remains the leading cause of mortality in type 1 diabetes (T1D), the use of cardioprotective drugs is scarce. We aimed to evaluate the impact of carotid ultrasonography (US) on the improvement in cardiovascular risk factors (CVRFs) in T1D. T1D patients without CVD meeting criteria for lipid treatment according to guidelines (age ≥ 40years, nephropathy and/or ≥ 10years of diabetes duration with ≥ 1 additional CVRFs) were included. The carotid-US group (US-G) underwent a standardized US protocol and CVRF assessment; recommendations were made according to subclinical atherosclerosis status. The control group (CG) followed usual clinical practice. Changes in CVRFs, specially statin use and LDL cholesterol levels, at 1 year were analysed. A total of 318 patients were included (51.3% female, mean age of 49.1years and 25.5years of diabetes duration): 211 in the US-G and 107 in the CG. Participants in the US-G had a higher baseline LDL cholesterol than controls (114 vs. 102mg/dL; p < 0.001). Lipid-lowering treatment was modified in 38.9% in the US-G and 6.5% in the CG (p < 0.001). At 1year, the US-G was more frequently on statins, had lower LDL cholesterol and 27% had stopped smoking (p < 0.001 for all). Changes were more pronounced in those with plaques (p < 0.001). In multivariate analyses adjusted for age, sex and other CVRFs, belonging to the US-G was independently associated with the intensification of lipid-lowering treatment (OR 10.47 [4.06-27.01]). Propensity score-matching analysis yielded similar results (OR 20.09 [7.86-51.37]). Carotid-US is independently associated with an intensification of lipid-lowering therapy in a high-risk T1D population.

Longitudinal changes in cardiac function in Duchenne muscular dystrophy population as measured by magnetic resonance imaging

BackgroundThe lack of dystrophin in cardiomyocytes in Duchenne muscular dystrophy (DMD) is associated with progressive decline in cardiac function eventually leading to death by 20–40 years of age. The aim of this prospective study was to determine rate of progressive decline in left ventricular (LV) function in Duchenne muscular dystrophy (DMD) over 5 years.MethodsShort axis cine and grid tagged images of the LV were acquired in individuals with DMD (n = 59; age = 5.3–18.0 years) yearly, and healthy controls at baseline (n = 16, age = 6.0–18.3 years) on a 3 T MRI scanner. Grid-tagged images were analyzed for composite circumferential strain (ℇcc%) and ℇcc% in six mid LV segments. Cine images were analyzed for left ventricular ejection fraction (LVEF), LV mass (LVM), end-diastolic volume (EDV), end-systolic volume (ESV), LV atrioventricular plane displacement (LVAPD), and circumferential uniformity ratio estimate (CURE). LVM, EDV, and ESV were normalized to body surface area for a normalized index of LVM (LVMI), EDV (EDVI) and ESV (ESVI).ResultsAt baseline, LV ℇcc% was significantly worse in DMD compared to controls and five of the six mid LV segments demonstrated abnormal strain in DMD. Longitudinal measurements revealed that ℇcc% consistently declined in individuals with DMD with the inferior segments being more affected. LVEF progressively declined between 3 to 5 years post baseline visit. In a multivariate analysis, the use of cardioprotective drugs trended towards positively impacting cardiac measures while loss of ambulation and baseline age were associated with negative impact. Eight out of 17 cardiac parameters reached a minimal clinically important difference with a threshold of 1/3 standard deviation.ConclusionThe study shows a worsening of circumferential strain in dystrophic myocardium. The findings emphasize the significance of early and longitudinal assessment of cardiac function in DMD and identify early biomarkers of cardiac dysfunction to help design clinical trials to mitigate cardiac pathology. This study provides valuable non-invasive and non-contrast based natural history data of cardiac changes which can be used to design clinical trials or interpret the results of current trials aimed at mitigating the effects of decreased cardiac function in DMD.

Interventions for Preventing Cardiotoxicity in Breast Cancer Patients Receiving Trastuzumab: A Systemic Review and Bayesian Network Meta-Analysis.

Background: Trastuzumab is associated with the risk of cardiotoxicity. Here, we aim to explore interventions for preventing trastuzumab-related cardiotoxic effects in breast cancer patients.Methods: A systematic review was performed including trials of breast cancer patients with intervention to prevent cardiotoxicity of trastuzumab. Trials were searched through databases including PubMed, Embase, and Cochrane Library.Results: Eight RCTs were included. Five trials reported the outcomes of short-duration interventions, including 6-month and 9-week durations, and only 9-week treatment has a significant difference from the 12-month group (OR 0.38; 95% CI 0.18–0.83) using cardiotoxicity as the outcome. However, 6-month treatment turned out to yield less occurrence of trastuzumab discontinuation (OR 0.32; 95% CI 0.24–0.42). Three trials reported interventions of cardioprotective drugs, and there is no significant difference shown in any cardioprotective group compared with placebo (cardiotoxicity outcome: angiotensin-converting enzyme inhibitor: OR 0.48; 95% CI 0.057–2.3; angiotensin receptor blocker: OR 1.3; 95% CI 0.12–14; β-blocker: OR 0.48; 95% CI 0.057–2.3; trastuzumab interruption outcome: angiotensin-converting enzyme inhibitor: OR 0.45; 95% CI 0.12–1.3; angiotensin receptor blocker: OR 0.87; 95% CI 0.15–4.8; β-blocker: OR 0.41; 95% CI 0.11–1.2).Conclusion: Only the 9-week group has a significant difference from the 12-month group using cardiotoxicity as the outcome. And 6-month treatment turned out to yield less occurrence of trastuzumab discontinuation. The use of cardioprotective drugs failed to prevent trastuzumab-related cardiotoxic effects in breast cancer patients.

Chemotherapy induced cardio toxicity with doxorubicin and cyclophosphamide in breast cancer patient - A case report

Breast cancer is the most commonly occurring neoplasm in women, which can be curable as well as can reduce the recurrence of cancer, with the help of various multidisciplinary approaches and thereby decrease the morbidity as well as mortality. Chemotherapy is a well-defined therapeutic approach for breast cancer, but cardiotoxicity is the most potential side-effect associated with chemotherapeutic drugs. Doxorubicin, along with cyclophosphamide, produces serious cardiotoxicity due to potential drug interaction. It is a case of a 63-year-old female patient post-menopausal with k/c/o type 2 diabetic Mellitus on medication. Clinically and radiologically, she was diagnosed with carcinoma left breast (IMC grade III, TNBC, CT2N0Mx). She underwent breast-conserving surgery (BCS) or lumpectomy without reconstruction. The HPE report suggestive of infiltrating mammary carcinoma NST grade 3. She was currently on adjuvant chemotherapy IInd cycle. Post chemotherapy, she was admitted with complaints of chest discomfort and chest pain. Screening ECHO showed grade I diastolic dysfunction and also the cardiac enzymes and cardiac marker troponins I was found to be elevated. She had undergone CAG for risk stratification. She was thought to have chemotherapy-induced cardiotoxicity associated with atypical chest pain and was advised medical follow up. Doxorubicin and cyclophosphamide-induced cardiac dysfunction and associated adverse events can be prevented or minimized with dose modification, use of cardioprotective drugs, identifying patient-related risk factors and regular cardiac monitoring of the patient receiving chemotherapy with doxorubicin and cyclophosphamide in breast cancer treatment.

Suboptimal Use of Cardioprotective Drugs in Patients with a History of Cancer

Introduction: Success of modern cancer therapy leads to a decline in death rates for cancer patients. Cardiovascular disease (CVD) is now a leading cause of long-term morbidity and mortality among cancer survivors. There is increasing need to be more vigilant in the use of cardioprotective therapies for primary and secondary prevention of cardiovascular diseases in patients living with cancer. This study aims to examine the use of cardioprotective therapies in patients with or without previous history of cancer admitted to cardiology. Methods and Results: Patients (n = 333, mean age: 65 ± 13 yrs) who were admitted to cardiology unit at John Hunter Hospital for either acute or chronic CVD from July to November 2018. N = 76 (23%) of patients had a history of cancer (Hx Ca) as documented in case notes at the time of admission. There was no difference in the prevalence of cardiac ischaemia, hypertension, dyslipidaemia, diabetes, or heart failure, but significantly higher atrial fibrillation in patients with Hx Ca (26%) vs. those without (16%). There was under-use of cardiovascular medications in patients with Hx Ca vs those without: antiplatelets (53% vs. 73%, p < 0.01); β-blockers (61% vs 70%, p = 0.17), ACEi/ARB (50% vs 61%, p = 0.1), and statins (59% vs 78%, p < 0.01). On multivariate analysis, patients with Hx of Ca had significantly lower usage of statins adjusted for age, BMI, gender, and cardiovascular risk factors. Conclusions: Cardioprotective therapies appear to be under-utilised in patients with previous history of cancer with comparable CV risk factors. Strategies are required to increase cardioprotective pharmacotherapies in these patients.

Global Longitudinal Strain Accuracy for Cardiotoxicity Prediction in a Cohort of Breast Cancer Patients During Anthracycline and/or Trastuzumab Treatment.

BackgroundThe high cardiotoxicity morbidity and mortality rates associated with the antineoplastic therapy for breast cancer could be reduced with the early use of cardioprotective drugs. However, the low sensitivity of left ventricular ejection fraction limits its use in that preventive strategy. New parameters, such as global longitudinal strain, are being used in the early detection of contractile function changes.ObjectivesTo assess the incidence of cardiotoxicity in patients treated for breast cancer, the independent factors associated with that event, and the ability of strain to identify it early.MethodsProspective observational study of consecutive outpatients diagnosed with breast cancer, with no previous antineoplastic treatment and no ventricular dysfunction, who underwent anthracycline and/or trastuzumab therapy. The patients were quarterly evaluated on a 6- to 12-month follow-up by an observer blind to therapy. Cox regression was used to evaluate the association of cardiotoxicity with clinical, therapeutic and echocardiographic variables. A ROC curve was built to identify the strain cutoff point on the third month that could predict the ejection fraction reduction on the sixth month. For all tests, the statistical significance level adopted was p ≤ 0.05.ResultsOf 49 women (mean age, 49.7 ± 12.2 years), cardiotoxicity was identified in 5 (10%) on the third (n = 2) and sixth (n = 3) months of follow-up. Strain was independently associated with the event (p = 0.004; HR = 2.77; 95%CI: 1.39-5.54), with a cutoff point for absolute value of -16.6 (AUC = 0.95; 95%CI: 0.87-1.0) or a cutoff point for percentage reduction of 14% (AUC = 0.97; 95%CI: 0.9-1.0).ConclusionThe 14% reduction in strain (absolute value of -16.6) allowed the early identification of patients who could develop anthracycline and/or trastuzumab-induced cardiotoxicity.

Temporal trends in acute myocardial infarction presentation and association with use of cardioprotective drugs: a nationwide registry-based study.

The present study aimed to investigate temporal trends in myocardial infarction (MI) presentation with or without ST-segment elevation and the association with the use of cardioprotective drugs prior to admission. Using individual-level linkage of data from Danish nationwide registries, we identified all patients 30 years or older admitted with a first-time MI in the period 2003-2012, and their use of cardioprotective drugs 6 months prior to admission. We calculated incidence rates per 100 000 person-years (IRs) of ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI). We identified 22 247 patients admitted with STEMI and 50 403 with NSTEMI. IRs for NSTEMI decreased by 35% from 194 in 2003 to 126 in 2012, whereas IRs for STEMI peaked in 2007 and subsequently declined from 71 to 65. Preadmission use of cardioprotective drugs increased in both groups from 2003 to 2012. Patients admitted with STEMI had odds ratio (OR) 0.64 [95% confidence interval (CI) 0.61-0.67] for preadmission use of aspirin compared with patients admitted with NSTEMI. Corresponding ORs were 0.82 (CI 0.78-0.87) for statins, 0.87 (CI 0.82-0.91) for beta-blockers, 0.89 (CI 0.85-0.92) for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 0.52 (CI 0.44-0.61) for thienopyridines. Also, 30-day and 1-year mortality declined in patients both admitted with STEMI and NSTEMI. The IRs of MI declined between 2003 and 2012, primarily driven by a 35% reduction in IRs for NSTEMI whereas IRs for STEMI declined after 2007. Preadmission use of cardioprotective drugs increased markedly and was associated with lower ORs of presenting with STEMI than NSTEMI.

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology.

BackgroundIn order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines.MethodsA total of 6187 patients (18–80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012–2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys.ResultsA total of 2846 (46 %) patients had no diabetes, 1158 (19 %) newly diagnosed diabetes and 2183 (35 %) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60 %, respectively. A blood pressure target of <140/90 mmHg was achieved in 68, 61, 54 % and a LDL-cholesterol target of <1.8 mmol/L in 16, 18 and 28 %. Patients with newly diagnosed and previously known diabetes reached an HbA1c <7.0 % (53 mmol/mol) in 95 and 53 % and 11 % of those with previously known diabetes had an HbA1c >9.0 % (>75 mmol/mol). Of the patients with diabetes 69 % reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40 %) and only 27 % of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets.ConclusionsDespite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.

Prevalence and management of familial hypercholesterolaemia in coronary patients: An analysis of EUROASPIRE IV, a study of the European Society of Cardiology

BackgroundFamilial hypercholesterolaemia (FH) is a hereditary disorder predisposing to premature coronary heart disease (CHD) and is until now mainly diagnosed clinically on the basis of a classical phenotype. Its prevalence varies and is estimated around 1 in 200–500; in patients with established CHD the prevalence is less well documented. Methods and resultsIn EUROASPIRE IV data were collected in coronary patients from 24 European countries by means of a standardized interview, bioclinical examination and venous blood sampling. Potential FH was estimated using an adapted version of the Dutch Lipid Clinic Network Criteria.Among the 7044 patients eligible for analysis, the prevalence of potential FH was 8.3%; 7.5% in men and 11.1% in women. The prevalence was inversely related to age with a putative prevalence of 1:5 in those with CHD <50 yrs of age in both sexes. Even among women aged 70 the prevalence was 1:10. Irrespective of age and gender, prevalence differed substantially between European regions; potential FH patients were more likely to smoke, had higher triglycerides levels and their blood pressure was less well controlled. The use of cardioprotective drugs and the prevalences of diabetes, obesity and central obesity were similar. ConclusionsThe prevalence of potential FH in coronary patients is high; the results underscore the need to promote identification of FH in CHD patients and to improve their risk factor profile.

Age-dependent peculiarities of echocardiographic parameters of the heart in patients with nonalcoholic fatty liver disease

In present study echocardiographic features of the cardiovascular system in patients with nonalcoholic fatty liver disease (NAFLD) of different ages were examined. Structural and functional parameters of the heart change in nonalcoholic fatty liver patients with age: a progressive increase in the size of the left atrium, right ventricle, and decrease of ejection fraction. In young patients the formation of concentric remodeling and eccentric hypertrophy, in elderly patients – development of its concentric hypertrophy was observed. The above-mentioned requires timely use of cardio-protective drugs in the treatment of these patients.

Cardiovascular risk factors on the Framingham Risk Score among hypertensive patients attended by family health teams

The Framingham Risk Score (FRS) is used to stratify cardiovascular risk. This study sought to identify the prevalence of risk factors used in the FRS and the use of drugs that reduce cardiovascular risk among hypertensive patients attended by the Family Health Strategy (FHS). It is cross-sectional study, which evaluated a random sample of hypertensive patients in the FHS in northern Minas Gerais. Data were collected through interviews and from medical records. 505 hypertensive patients were evaluated in 9 municipalities of the region, with a predominance of women; 325 (64.4%), mean age of 66.4 years. In 90% of hypertensive patients there was at least one associated risk factor. The grouping of three or more factors occurred in 79 (15.7%) patients. Dyslipidemia was found in 188 (37.2%), diabetes in 101 (20%) and smoking in 36 (7.1%). The use of anti-hypertensive drugs was observed in 481 (95.2%) patients. The use of other cardioprotective drugs was higher among patients with 3 or more risk factors: 45.6% used antiplatelet and 27.8% used lipid-lowering drugs. The prevalence of risk factors from the FRS in the population studied was quite high and the use of cardioprotective drugs was seen to be restricted. Strategies to increase the use of FRS may improve the management of hypertension in the FHS.

Cardiotoxicity of Non Cardiovascular Drugs: A Mechanistic Point of View

Cardiotoxicity has evolved as an essential component of various adverse drug reactions and an important aspect in drug development and withdrawal. A triphasic interaction of the drug, its mechanism of action on the heart and various factors influencing toxicity is the basis of various cardiotoxicities. A comprehensive knowledge of the various mechanisms of cardiotoxicities and classes of drug causing it would promote appropriate drug selection, simultaneous use of cardioprotective drugs and work as a guideline for the development of new drugs and targeted therapies. A check in the drug causes of cardiotoxicities would definitely play a vital role in eliminating a significant fraction of the cardiovascular diseases and delay the rate and magnitude of the development of the impending cardiovascular disease epidemic. Birdem Med J 2013; 3(1): 35-43 DOI: http://dx.doi.org/10.3329/birdem.v3i1.17125

Obesity is associated with retinopathy and macrovascular disease in type 1 diabetes

Excessive body weight is increasingly seen in type 1 diabetes but its impact is debated. To address this uncertainty, we aimed to determine the association between excess body weight and the macro- and microvascular complications of type 1 diabetes. We identified 501 adults with type 1 diabetes attending an Australian hospital clinic and extracted their clinical and biochemical data from our patient management database. In both men and women, obesity (BMI > 30 kg/m(2)) was the predominant risk factor for retinopathy and cardiovascular disease despite similar HbA1c and increased use of cardioprotective drugs compared to non-obese patients. Obesity was associated with albuminuria in women, but not renal impairment or neuropathy in either sex. We conclude that obesity in type 1 diabetes may promote retinopathy and macrovascular disease. Future trials to determine the effect of weight loss on type 1 diabetes in obese people are needed.

Trends in Secondary Prevention of Coronary Heart Disease in Tunisia: Prevention of Recurrences of MI and Stroke

The survival benefits achieved by prescription of antiplatelet agents, B-adrenoreceptor antagonists (beta-blockers), angiotensin II receptor blockers (ARB), and lipid lowering agents in patients surviving the myocardial infarction (MI) have been well documented in large clinical trial. Despite well-established benefits, these pharmacological agents continue to be underutilized. The main objective of this study was to evaluate the progress of cardiovascular secondary prevention practices in Tunisia. The PREMISE (Prevention of Recurrence of Myocardial Infarction and Stroke) is a descriptive, cross-sectional study conducted in Tunisia in two phases (2002 and 2009). Seven hundred eighty two patients were recruited. The recruitment criteria were: previous MI, stable angina, unstable angina, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), stroke, transient ischemic attack (TIA) or carotid endarterectomy. This analysis is limited to coronary heart disease (CHD) patients. Five hundred hospital patients were interviewed and their medical records were reviewed: 250 in 2002 and 250 in 2009. Patients were included if they had confirmed diagnosis of MI, angina, CABG or PTCA, and if their first cardiovascular event had occurred more than one month but not later than 3 years ago. We compared the total of both patient groups, using the prevalence of Cardio-Vascular Risk Factors (CVRF) and the treatment prescribed at hospital discharge. The proportion of patients with reported hypertension, diabetes, hypercholesterolemia and current smoker patients had decreased. Concerning pharmacological prescriptions, a significant increase was observed in prescribing statins (38.9% vs. 70.3%) and ACE inhibitors (49.3% vs. 69.9%), non pharmacological prescriptions as healthy diet or tobacco cessation had opposite trends. Adherence to treatment did not change substantially. Although the use of cardioprotective drugs had increased in CHD patients, there are still gaps in secondary prevention in Tunisia. The recommended strategies of secondary prevention need to be applied more intensively in clinical practice.

Depression, anxiety, and risk factor control in patients after hospitalization for coronary heart disease: the EUROASPIRE III Study

To assess in coronary heart disease (CHD) patients: (1) differences in the prevalence of depression and anxiety between samples selected from 22 countries; (2) the association of depression and anxiety with age, education, diagnostic category, favourable behaviours, use of cardioprotective drugs, and reaching the secondary prevention treatment targets. Cross-sectional study. The study group consisted of 8580 patients from 22 European countries examined at least 6 months after hospitalization due to CHD. Depression and anxiety were assessed using Hospital Anxiety and Depression Scale (HADS). Prevalence of depression (HADS depression score ≥ 8) varied from 8.2% to 35.7% in men and from 10.3% to 62.5% in women. Prevalence of anxiety (HADS anxiety score ≥ 8) varied from 12.0% to 41.8% in men and from 21.5% to 63.7% in women. Older age, female sex, low education, and no history of invasive treatment were associated with more frequent depression and anxiety. Depression and anxiety were associated with less frequent modification of lifestyle. Depression was related with body mass index, waist circumference, fasting glucose, and more frequent self-reported diabetes but not with reaching the treatment targets for blood pressure and lipids. High prevalence of depression and anxiety in CHD patients, and relation with less frequent lifestyle modification, call to integrate methods of identification and minimizing unfavourable effects of depression and anxiety into the cardiac rehabilitation and prevention programmes.

Blood pressure stability in hemodialysis patients confers a survival advantage: results from a large retrospective cohort study

The association between changes in systolic and diastolic blood pressure, and the use of cardioprotective drugs on survival of incident hemodialysis patients, was examined in this retrospective cohort study. Pre-hemodialysis systolic and diastolic blood pressures were averaged over the first month of hemodialysis. Slopes, reflecting temporal changes, were computed by linear regression of systolic blood pressures and Cox regression was used for survival analyses. Patients were initially stratified into four cohorts (below 120, 120 to 150, 151 to 180, and above 180 mm Hg) and further subdivided into groups with stable (no more than a 1-mm Hg change per month), increasing (over 1-mm Hg per month), and decreasing (less than 1-mm Hg per month) slopes during the first year. Analyses were repeated for patients who were treated with cardioprotective drugs for 1 month or more in the second year. In 10,245 patients (59% prescribed cardioprotective drugs), both increases and decreases in all ranges of blood pressure were associated with worse outcomes, whereas stable blood pressure had a survival advantage at all levels of systolic and diastolic pressures. Use of cardioprotective drugs attenuated changes and improved survival. Validation and sensitivity analyses confirmed the primary findings. Therefore, previous temporal trends need to be considered in patient care, and the use of cardioprotective agents is associated with enhanced survival at all blood pressure levels.

Patients admitted to hospital with chest pain — Changes in a 20-year perspective

ObjectivesTo describe the differences in characteristics and outcome between two consecutive series of patients admitted to hospital with chest pain in a 20-year perspective. Particular emphasis is placed on changes in outcome in relation to the initial electrocardiogram (ECG). SubjectsIn the two periods, 1986–1987 and 2008, all patients with chest pain admitted to the study hospitals in Gothenburg, Sweden, were included. ResultsFive thousand and sixteen patients were registered in a period of 21months in 1986–1987 and 2287 patients were registered during 3months in 2008. In a comparison of the two time periods, the age of chest pain patients was not significantly different (mean age 60.1±17.8years in 1986–1987 and 59.8±19.1years in 2008, p=0.50). There was a lower prevalence of previous angina pectoris, congestive heart failure and current smoking in the second period, whereas a history of acute myocardial infarction, hypertension and diabetes mellitus had become more prevalent. The use of cardio-protective drugs increased and ECG changes indicating acute myocardial ischemia on admission to hospital decreased. Length of hospitalisation was reduced from a median of 5days to 3days (p<0.0001). A significant decrease in 30-day and 1-year mortality was found (3.8% in 1986–1987 vs 2.0% in 2008 and 9.9% vs 6.3% respectively, p<0.0001 for both comparisons). ConclusionsDuring a period of 20years, the characteristics and outcome of patients admitted to hospital with chest pain changed. The most important changes were a lower prevalence of ECG signs indicating acute myocardial ischemia on admission, shorter hospitalisation time and a lower 30-day and 1-year mortality.

Change in Mortality from Coronary Heart Disease and Stroke in Arkansas (1979 to 2007)

Coronary heart disease (CHD)- and stroke-related mortality rates have been greater in the Southern states than in the rest of the United States. Although a sustained decrease in mortality from CHD and stroke has occurred in the United States during the past 3 decades, it is not known whether a similar decrease occurred in the Southern states. We examined CHD- and stroke-related deaths from 1979 to 2007 in Arkansas and observed a marked and steady decrease in both death rates. A concurrent increase occurred in the prevalence of obesity, hypertension, and diabetes mellitus, with a decrease in physical inactivity and poverty during this period. However, we noted a significant decrease in the per capita cigarette sales in Arkansas that closely paralleled the decrease in CHD- and stroke-related deaths. In conclusion, although the extensive use of cardioprotective drugs, as well as coronary revascularization, might have contributed to the decrease, we have provided evidence to suggest that the decrease in cigarette smoking was a very important factor in the decrease in CHD- and stroke-related mortality.

Racial Disparities in Prescriptions for Cardioprotective Drugs and Cardiac Outcomes in Veterans Affairs Hospitals

Previous reports have suggested that blacks receive life-saving cardioprotective therapies less often than whites, probably because of a lower socioeconomic status, which leads to poor access to physicians. We questioned whether racial disparity existed in the Veterans Affairs Healthcare System. We examined the Veterans' Integrated Service Network (VISN 16) database with regard to the prescription rates for 4 cardiovascular agents-aspirin, beta blockers, statins, and angiotensin-converting enzyme inhibitors. The database, encompassing 474,565 patients (117,071 blacks and 357,494 whites), was analyzed. Cardioprotective drugs were prescribed significantly less often to black patients than compared to white patients (beta blockers 19.7% vs 24.8%, odds ratio [OR] 0.74, 95% confidence interval [CI] 0.72 to 0.75; statins 20.5% vs 30.2%, OR 0.54, 95% CI 0.52 to 0.55; and angiotensin-converting enzyme inhibitors 27.7% vs 30.0%, OR 0.94, 95% CI 0.92 to 0.96; all p <0.0001, after adjustment for all covariates used in the analysis). Nonetheless, the prescription rates for aspirin were greater among the black patients than among the white patients (OR 1.31, 95% CI 1.27 to 1.35, p <0.001) after adjustment. The black patients received coronary artery bypass grafting less often than did the white patients (0.4% vs 1.21%, OR 0.40% to 0.48%, 95% CI 1.34 to 1.42, p <0.001). After adjustment for the use of cardioprotective drugs and coronary artery bypass grafting, black patients still had greater odds of developing angina (OR 1.38, 95% CI 1.34 to 1.42, p <0.001) and acute myocardial infarction (OR 1.11, 95% CI 1.03 to 1.19, p <0.006) than did white patients in the Department of Veterans Affairs Veterans' Integrated Service Network 16 hospitals. In conclusion, the lower prescription rates of cardioprotective drugs and lower rates of coronary artery bypass grafting might be a partial basis for the high rates of cardiac morbidity among black patients.

The effectiveness of long-term rehabilitation in patients with cardiovascular diseases

Screening results of EuroAspire III study have revealed the failure of effective correction of cardiovascular risk factors in all 22 participating EU countries. How long should cardiac rehabilitation programs last to impact motivation for lifestyle change? To compare the impact of long-term (6 months) rehabilitation versus short-term (4 weeks) rehabilitation on the reduction of risk factors and cardiac events, as well as on the use of cardioprotective drugs. Study contingent of 150 patients, suffering from functional class III-IV (NYHA) chronic heart failure caused by ischemic and hypertensive cardiomyopathy, was subjected to complex rehabilitation: exercise training, dietary corrections, and smoking cessation. The patients were divided into two groups: long-term rehabilitation group (n=80) and short-term rehabilitation group (n=70). Blood pressure, body mass index, dietary habits, dyslipidemia, sedentary lifestyle, smoking, chronic fatigue, and use of cardioprotective drugs were evaluated in all patients at the onset of study, after 4 weeks, and 6 months. Cardiovascular events were estimated throughout the whole 6-month period. In the long-term rehabilitation group, there was a significant reduction (P<0.05) in systolic blood pressure (151+/-9.2 vs. 135+/-9.7 mm Hg), diastolic blood pressure (92.3+/-6.5 vs. 75.4+/-3.8 mm Hg,) body mass index (35.4+/-3.5 vs. 27.2+/-4.8 kg/m(2)), dyslipidemia (56.3 vs. 23.4%), sedentary lifestyle (31.3 vs. 4.7%), and smoking (10.0 vs. 0%). The impact of a short-term rehabilitation was not significant. Because of cardiac events, 13 patients (16.3%) in the long-term rehabilitation group and 26 (16.3%) in the short-term rehabilitation group failed to complete the 6-month study (P<0.05). The following change in drug use pattern was noted in the long-term rehabilitation group: nitrates, 74 vs. 65%; digitalis, 42 vs. 32%; antiarrhythmic agents, 15 vs. 10%; statins, 36 vs. 20% (P<0.05). During 6 months, in both groups, because of better physician monitoring, there was no decrease in the use of major cardioprotective drugs, such as antiaggregants, beta-blockers, and ACE inhibitors. Long-term (6 months) versus short-term (4 weeks) rehabilitation of cardiovascular patients significantly reduces manifestation of major cardiovascular risk factors, the rate of cardiac events, chronic fatigue and improves the use of cardioprotective drugs.