cardiovascular-agents and Coronary-Disease

Changes in human body systems influence metabolism and may cause disease. The intestinal microbiota influence health and is itself influenced by factors including diet and drugs. Investigation of the relationship of the intestinal microbiota and chronic conditions like coronary heart disease (CHD) has been facilitated by advances in sequencing technology. Some studies have identified changes in the composition and the metabolism of intestinal microbiota in patients with CHD, including increases in phyla Bacteroidetes and Proteobacteria and decreases in phyla Firmicutes and Fusobacteria. The ratio of two metabolites of intestinal bacteria, trimethylamine and trimethylamine N-oxide, has been found to be related to CHD. This review summarizes recent research to provide ideas for further research on the relationships between intestinal microbiota and CHD and on the preventive measures for CHD.

Topics: Animals; Anti-Bacterial Agents; Bacteria; Cardiovascular Agents; Cardiovascular System; Coronary Disease; Dysbiosis; Gastrointestinal Microbiome; Host-Pathogen Interactions; Humans; Intestines; Prebiotics; Probiotics; Prognosis; Risk Factors

Elevated plasma concentrations of lipoprotein(a) (Lp(a)) are a causal risk factor for coronary heart disease (CHD) and calcific aortic valve stenosis (CAVS). Genetic, epidemiological and in vitro data provide strong evidence for a pathogenic role for Lp(a) in the progression of atherothrombotic disease. Despite these advancements and a race to develop new Lp(a) lowering therapies, there are still many unanswered and emerging questions about the metabolism and pathophysiology of Lp(a). New studies have drawn attention to Lp(a) as a contributor to novel pathogenic processes, yet the mechanisms underlying the contribution of Lp(a) to CVD remain enigmatic. New therapeutics show promise in lowering plasma Lp(a) levels, although the complete mechanisms of Lp(a) lowering are not fully understood. Specific agents targeted to apolipoprotein(a) (apo(a)), namely antisense oligonucleotide therapy, demonstrate potential to decrease Lp(a) to levels below the 30-50 mg/dL (75-150 nmol/L) CVD risk threshold. This therapeutic approach should aid in assessing the benefit of lowering Lp(a) in a clinical setting.

Topics: Aortic Valve; Aortic Valve Stenosis; Calcinosis; Cardiovascular Agents; Coronary Disease; Humans; Lipoprotein(a); Oligonucleotides, Antisense; Risk Factors; Translational Research, Biomedical

Non-adherence to medications for the secondary prevention of myocardial infarction (MI) is a major contributor to morbidity and mortality in these patients. This review describes recent advances in promoting adherence to therapies for coronary artery disease (CAD).. Two large randomized controlled trials to "incentivize" adherence were somewhat disappointing; neither financial incentives nor "peer pressure" successfully increased rates of adherence in the post-MI population. Patient education and provider engagement appear to be critical aspects of improving adherence to CAD therapies, where the provider is a physician, pharmacist, or nurse and follow-up is performed in person or by telephone. Fixed-dose combinations of CAD medications, formulated as a so-called "polypill," have shown some early efficacy in increasing adherence. Technological advances that automate monitoring and/or encouragement of adherence are promising but seem universally dependent on patient engagement. For example, medication reminders via text message perform better if patients are required to respond. Multifaceted interventions, in which these and other interventions are combined together, appear to be most effective. There are several available types of proven interventions through which providers, and the health system at large, can advance patient adherence to CAD therapies. No single intervention to promote adherence will be successful in all patients. Further study of multifaceted interventions and the interactions between different interventions will be important to advancing the field. The goal is a learning healthcare system in which a network of interventions responds and adapts to patients' needs over time.

Topics: Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Humans; Medication Adherence; Myocardial Infarction; Patient Education as Topic; Professional Role; Professional-Patient Relations; Randomized Controlled Trials as Topic; Reminder Systems; Secondary Prevention

Adherence to multiple cardiovascular (CV) medications is a cornerstone of coronary heart disease (CHD) management and prevention, but it is sub-optimal worldwide. This review aimed to examine whether interventions improve adherence to multiple CV medications in a CHD population.. This study was based on a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.. Randomised controlled trials were identified by searching multiple databases and reference lists. Studies were selected if they evaluated interventions aiming to improve adherence to multiple CV medications targeting a CHD population and if they provided an appropriate measure of adherence. Interventions were classified as complex or simple interventions. Odds ratios (ORs) were calculated and pooled for a meta-analysis. Risk of bias, heterogeneity and publication bias were also assessed.. Sixteen studies (10,706 patients) were included. The mean age was 62 years (standard deviation (SD) 3.6) and 72% were male. In a pooled analysis, the interventions significantly improved medication adherence (OR 1.52; 95% confidence interval (CI) 1.25-1.86; p < 0.001) and there were no significant differences based on intervention type (complex vs simple), components categories and adherence method. There was moderate heterogeneity (I(2) ( )= 61%) across the studies. After adjusting for publication bias, the effect size was attenuated but remained significant (OR 1.35; 95% CI 1.09-1.68).. Interventions to improve adherence to multiple CV medication in a CHD population significantly improved the odds of being adherent. Simple one-component interventions might be a promising way to improve medication adherence in a CHD population, as they would be easier to replicate in different settings and on a large scale.

Topics: Cardiovascular Agents; Coronary Disease; Humans; Medication Adherence; Randomized Controlled Trials as Topic

Recent trials reported that risk of atrial fibrillation (AF) is increased in patients using ivabradine compared with controls. We performed this meta-analysis to investigate the risk of AF association with ivabradine treatment on the basis of data obtained from randomized controlled trials (RCTs). We searched PubMed, EMBASE, Scopus, and the Cochrane Library for RCTs that comprised >100 patients. The incidence of AF was assessed. We obtained data from European Medicines Agency (EMA) scientific reports for the RCTs in which the incidence of AF was not reported. We used trial sequential analysis (TSA) to provide information on when we had reached firm evidence of new AF based on a 15% relative risk increase (RRI) in ivabradine treatment. Three RCTs and 1 EMA overall oral safety set (OOSS) pooled analysis (included 5 RCTs) were included in the meta-analysis (N = 40 437). The incidence of AF was 5.34% in patients using ivabradine and 4.56% in placebo. There was significantly higher incidence of AF (24% RRI) in the ivabradine group when compared with placebo before (RR: 1.24, 95% confidence interval: 1.08-1.42, P = 0.003, I 1980 = 53%) and after excluding OOSS (RR: 1.24, 95% confidence interval: 1.06-1.44, P = 0.008). In the TSA, the cumulative z-curve crossed both the traditional boundary (P = 0.05) and the trial sequential monitoring boundary, indicating firm evidence for ≥15% increase in ivabradine treatment when compared with placebo. Study results indicate that AF is more common in the ivabradine group (24% RRI) than in controls.

Topics: Aged; Atrial Fibrillation; Benzazepines; Cardiovascular Agents; Chi-Square Distribution; Coronary Disease; Female; Humans; Incidence; Ivabradine; Male; Middle Aged; Odds Ratio; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors

Cardiovascular disease (CVD) mortality in the UK is declining; however, CVD burden comes not only from deaths, but also from those living with the disease. This review uses national datasets with multiple years of data to present secular trends in mortality, morbidity, and treatment for all CVD and specific subtypes within the UK. We produced all-ages and premature age-standardised mortality rates by gender, standardised to the 2013 European Standard Population, using data from the national statistics agencies of the UK. We obtained data on hospital admissions from the National Health Service records, using the main diagnosis. Prevalence data come from the Quality and Outcome Framework and national surveys. Total CVD mortality declined by 68% between 1980 and 2013 in the UK. Similar decreases were seen for coronary heart disease and stroke. Coronary heart disease prevalence has remained constant at around 3% in England and 4% in Scotland, Wales, and Northern Ireland. Hospital admissions for all CVD increased by over 46 000 between 2010/2011 and 2013/2014, with more than 36 500 of these increased admissions for men. Hospital admission trends vary by country and CVD condition. CVD prescriptions and operations have increased over the last decade. CVD mortality has declined notably for both men and women while hospital admissions have increased. CVD prevalence shows little evidence of change. This review highlights that improvements in the burden of CVD have not occurred equally between the four constituent countries of the UK, or between men and women.

Topics: Adolescent; Adult; Age Distribution; Age of Onset; Aged; Cardiac Surgical Procedures; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Female; Health Status Disparities; Healthcare Disparities; Hospitalization; Humans; Male; Middle Aged; Practice Patterns, Physicians'; Prevalence; Risk Factors; Sex Distribution; Stroke; Time Factors; United Kingdom; Young Adult

HIV infection has progressed from an acute, terminal disease to a chronic illness with cardiovascular disease as the leading cause of death among persons living with HIV. As persons living with HIV infection continue to become older, traditional risk factors for atherosclerosis compounded by the pathophysiological effects of HIV infection and antiretroviral therapy markedly increase the risk for cardiovascular disease. Further, persons living with HIV are also at high risk for cardiomyopathy. Critical care nurses must recognize the risk factors for cardiovascular disease and the pathophysiology and complex treatment options in order to manage care of these patients and facilitate multidisciplinary collaboration. Two case studies are used to highlight the treatment options and nursing considerations associated with cardiovascular disease among persons living with HIV.

Topics: Anti-Retroviral Agents; Atrial Fibrillation; Cardiovascular Agents; Coronary Disease; Critical Care Nursing; Disease Management; Drug Therapy, Combination; Follow-Up Studies; HIV Infections; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Monitoring, Physiologic; Risk Assessment; Severity of Illness Index; Treatment Outcome

Restenosis after percutaneous coronary intervention (PCI) is a remained clinical problem which limits long-term success of PCI. Although there was recognition that probucol in treating restenosis after percutaneous transluminal coronary angioplasty, the efficacy of probucol on restenosis after stent-implantation is controversial. So this meta-analysis was conducted to investigate the association between probucol and late restenosis.. Articles were assessed by four trained investigators, with divergences resolved by consensus. PubMed, EMBASE, ScienceDirect and the Cochrane Central Register of clinical trials were searched for pertinent studies. Inclusion criteria were random allocated to treatment and a comparison of probucol-treated patients and control patients (not treated with lipid-lowering drug) undergoing PCI.. Fifteen studies with 859 subjects were analyzed. Major outcome, binary angiographic restenosis defined as >50% stenosis upon follow-up angiography, was significantly decreased with probucol treatment (RR = 0.59 [0.43, 0.80] among vessels, P = 0.0007; and RR = 0.52 [0.40, 0.68] among patients, P<0.00001). Probucol also increased the minimal luminal diameter (SMD = 0.45 [0.30, 0.61], P<0.00001) and decreased late loss upon follow-up after 6 months (SMD = -0.41 [-0.60, -0.22], P<0.0001). Moreover, there was a significantly lower incidence of major adverse cardiac events (MACE) in the probucol group than control group (RR = 0.69 [0.51, 0.93], P = 0.01).. Probucol is more than a lipid-lowering drug. It is also effective in reducing the risk of restenosis and incidence of MACE after PCI.

Topics: Anticholesteremic Agents; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Humans; Percutaneous Coronary Intervention; Probucol; Treatment Outcome

The paper gives data on the proven efficiency of myocardial cytoprotection with the pFOX inhibitors trimetazidine and meldonium for coronary heart disease. However, no algorithm has been defined for their differentiated use at different ischemic remodeling stages in these patients in terms of the mechanism of metabolic effects. Sequential use of meldonium and trimetazidine in different periods of acute and chronic myocardial ischemia may become one of the possible ways to increase the efficacy of the pFOX inhibitors.. Представлены данные о доказанной эффективности цитопротекции миокарда р-fox-ингибиторами триметазидином и мельдонием при ишемической болезни сердца. Однако не определен алгоритм их дифференцированного назначения на различных этапах формирования ишемического ремоделирования у пациентов этой категории с учетом механизма метаболического воздействия. Одним из возможных путей увеличения эффективности использования р-fox-ингибиторов может стать последовательное назначение мельдония и триметазидина в различные периоды острой и хронической ишемии миокарда.

Topics: Cardiotonic Agents; Cardiovascular Agents; Coronary Disease; Humans; Methylhydrazines; Trimetazidine

Topics: Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Electrocardiography; Humans; Microvascular Angina; Myocardial Infarction

Adiponectin is the most abundant peptide secreted by adipocytes, being a key component in the interrelationship between adiposity, insulin resistance and inflammation. Central obesity accompanied by insulin resistance is a key factor in the development of metabolic syndrome (MS) and future macrovascular complications. Moreover, the remarkable correlation between coronary artery disease (CAD) and alterations in glucose metabolism has raised the likelihood that atherosclerosis and type 2 diabetes mellitus (T2DM) may share a common biological background. We summarize here the current knowledge about the influence of adiponectin on insulin sensitivity and endothelial function, discussing its forthcoming prospects and potential role as a therapeutic target for MS, T2DM, and cardiovascular disease. Adiponectin is present in the circulation as a dimer, trimer or protein complex of high molecular weight hexamers, >400 kDa. AdipoR1 and AdipoR2 are its major receptors in vivo mediating the metabolic actions. Adiponectin stimulates phosphorylation and AMP (adenosin mono phosphate) kinase activation, exerting direct effects on vascular endothelium, diminishing the inflammatory response to mechanical injury and enhancing endothelium protection in cases of apolipoprotein E deficiency. Hypoadiponectinemia is consistently associated with obesity, MS, atherosclerosis, CAD, T2DM. Lifestyle correction helps to favorably modify plasma adiponectin levels. Low adiponectinemia in obese patients is raised via continued weight loss programs in both diabetic and nondiabetic individuals and is also accompanied by reductions in pro-inflammatory factors. Diet modifications, like intake of fish, omega-3 supplementation, adherence to a Mediterranean dietary pattern and coffee consumption also increase adiponectin levels. Antidiabetic and cardiovascular pharmacological agents, like glitazones, glimepiride, angiotensin converting enzyme inhibitors and angiotensin receptor blockers are also able to improve adiponectin concentration. Fibric acid derivatives, like bezafibrate and fenofibrate, have been reported to enhance adiponectin levels as well. T-cadherin, a membrane-associated adiponectin-binding protein lacking intracellular domain seems to be a main mediator of the antiatherogenic adiponectin actions. The finding of novel pharmacologic agents proficient to improve adiponectin plasma levels should be target of exhaustive research. Interesting future approaches could be the developmen

Topics: Adiponectin; Animals; Biomarkers; Cardiovascular Agents; Coronary Disease; Diabetes Mellitus, Type 2; Drug Delivery Systems; Humans; Hypoglycemic Agents; Metabolic Syndrome; Obesity; Signal Transduction

To determine the comparative effectiveness of exercise versus drug interventions on mortality outcomes.. Metaepidemiological study.. Meta-analyses of randomised controlled trials with mortality outcomes comparing the effectiveness of exercise and drug interventions with each other or with control (placebo or usual care).. Medline and Cochrane Database of Systematic Reviews, May 2013.. Mortality.. We combined study level death outcomes from exercise and drug trials using random effects network meta-analysis.. We included 16 (four exercise and 12 drug) meta-analyses. Incorporating an additional three recent exercise trials, our review collectively included 305 randomised controlled trials with 339,274 participants. Across all four conditions with evidence on the effectiveness of exercise on mortality outcomes (secondary prevention of coronary heart disease, rehabilitation of stroke, treatment of heart failure, prevention of diabetes), 14,716 participants were randomised to physical activity interventions in 57 trials. No statistically detectable differences were evident between exercise and drug interventions in the secondary prevention of coronary heart disease and prediabetes. Physical activity interventions were more effective than drug treatment among patients with stroke (odds ratios, exercise v anticoagulants 0.09, 95% credible intervals 0.01 to 0.70 and exercise v antiplatelets 0.10, 0.01 to 0.62). Diuretics were more effective than exercise in heart failure (exercise v diuretics 4.11, 1.17 to 24.76). Inconsistency between direct and indirect comparisons was not significant.. Although limited in quantity, existing randomised trial evidence on exercise interventions suggests that exercise and many drug interventions are often potentially similar in terms of their mortality benefits in the secondary prevention of coronary heart disease, rehabilitation after stroke, treatment of heart failure, and prevention of diabetes.

Topics: Anticoagulants; Cardiovascular Agents; Comparative Effectiveness Research; Confounding Factors, Epidemiologic; Coronary Disease; Diuretics; Exercise Therapy; Female; Heart Failure; Humans; Hypoglycemic Agents; Male; Mortality; Odds Ratio; Outcome Assessment, Health Care; Platelet Aggregation Inhibitors; Prediabetic State; Randomized Controlled Trials as Topic; Research Design; Stroke

Cardiovascular disease remains the commonest health problem in developed countries, and residual risk after implementing all current therapies is still high. The use of marine omega-3 fatty acids (DHA and EPA) has been recommended to reduce cardiovascular risk by multiple mechanisms.. To update the current evidence on the influence of omega-3 on the rate of cardiovascular events.. We used the MEDLINE and EMBASE databases to identify clinical trials and randomized controlled trials of omega-3 fatty acids (with quantified quantities) either in capsules or in dietary intake, compared to placebo or usual diet, equal to or longer than 6 months, and written in English. The primary outcome was a cardiovascular event of any kind and secondary outcomes were all-cause mortality, cardiac death and coronary events. We used RevMan 5·1 (Mantel-Haenszel method). Heterogeneity was assessed by the I2 and Chi2 tests. We included 21 of the 452 pre-selected studies.. We found an overall decrease of risk of suffering a cardiovascular event of any kind of 10 % (OR 0·90; [0·85-0·96], p = 0·001), a 9 % decrease of risk of cardiac death (OR 0·91; [0·83-0·99]; p = 0·03), a decrease of coronary events (fatal and non-fatal) of 18 % (OR 0·82; [0·75-0·90]; p < 1 × 10⁻⁴), and a trend to lower total mortality (5 % reduction of risk; OR 0·95; [0·89-1·02]; p = 0·15. Most of the studies analyzed included persons with high cardiovascular risk.. marine omega-3 fatty acids are effective in preventing cardiovascular events, cardiac death and coronary events, especially in persons with high cardiovascular risk.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Diet; Dietary Supplements; Docosahexaenoic Acids; Eicosapentaenoic Acid; Humans

The acute coronary syndrome is the most severe form of coronary artery disease. It is an immediate threat of life and the mortality rate can be high without proper therapy and patient management. Based on the first ECG, two different forms can be distinguished: acute coronary syndrome with and without ST elevation. Besides adequate medication, management of these patients is an essential part of treatment. In case of ST elevation, coronarography and percutaneous coronary intervention is needed in general, within 24 hours from the onset of symptoms. When ST elevation is not detected on the ECG, individual ischemic risk factors and predictable mortality of the patient may define the necessity and the date of the invasive examination. The Hungarian hemodynamic laboratory network covers almost the whole country and, therefore, practically each patient may receive a state-of-the-art therapy. Although indicators of cardiovascular diseases are still prominent, the mortality rate of myocardial Infarction is decreasing in Hungary due to the well-organized invasive care.

Topics: Acute Coronary Syndrome; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Diagnosis, Differential; Echocardiography; Electrocardiography; Heart Conduction System; Humans; Hungary; Magnetic Resonance Imaging; Percutaneous Coronary Intervention

There is increasing recognition that coronary microvascular dysfunction also plays an important role in coronary heart disease. Little is known about this aspect of coronary heart disease due to difficulties in studying the coronary microcirculation directly. The retina is a unique site where the microcirculation can be imaged directly, providing an opportunity to study in vivo the structure and pathology of the human circulation and the possibility of detecting changes in microvasculature relating to the development of cardiovascular disease. This review covers the recent progress in research linking retinal vascular signs to coronary heart disease, and finds accumulating evidence that retinal vascular signs may provide a window into the health of the coronary microvasculature. The most widely studied signs, arteriolar narrowing, and more recently, venular dilation, are likely associated with increased risk of coronary heart disease in women, independent of traditional risk factors. Attempts to improve coronary heart disease risk prediction by incorporating retinal vessel calibre size into risk prediction scores complementing traditional algorithms such as the Framingham risk scores have so far been disappointing. Research is ongoing into the predictive utility of other retinal vascular signs. Retinal photography provides long-lasting records that enable monitoring of longitudinal changes in these retinal signs and vascular health. Full English text available fromwww.revespcardiol.org.

Topics: Cardiovascular Agents; Coronary Disease; Heart Diseases; Humans; Microcirculation; Retinal Vessels; Risk Factors

Coronary artery disease is a leading cause of death in the United States. Angina is encountered frequently in clinical practice. Effective management of patients with coronary artery disease and stable angina should consist of therapy aimed at symptom control and reduction of adverse clinical outcomes. Therapeutic options for angina include antianginal drugs: nitrates, beta-blockers, calcium channel blockers, ranolazine, and myocardial revascularization. Recent trials have shown that although revascularization is slightly better in controlling symptoms, optimal medical therapy that includes aggressive risk factor modification is equally effective in reducing the risk of future coronary events and death. On the basis of the available data, it seems appropriate to prescribe optimal medical therapy in most patients with coronary artery disease and stable angina, and reserve myocardial revascularization for selected patients with disabling symptoms despite optimal medical therapy.

Topics: Acetanilides; Adrenergic beta-Antagonists; Angina Pectoris; Angiotensin-Converting Enzyme Inhibitors; Benzazepines; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Humans; Hypolipidemic Agents; Ivabradine; Myocardial Revascularization; Nitrates; Piperazines; Ranolazine; Treatment Outcome

Anginal chest pain is one of the most common complaints in the outpatient setting. While much of the focus has been on identifying obstructive atherosclerotic coronary artery disease (CAD) as the cause of anginal chest pain, it is clear that microvascular coronary dysfunction (MCD) can also cause anginal chest pain as a manifestation of ischemic heart disease, and carries an increased cardiovascular risk. Epicardial coronary vasospasm, aortic stenosis, left ventricular hypertrophy, congenital coronary anomalies, mitral valve prolapse, and abnormal cardiac nociception can also present as angina of cardiac origin. For nonacute coronary syndrome (ACS) stable chest pain, exercise treadmill testing (ETT) remains the primary tool for diagnosis of ischemia and cardiac risk stratification; however, in certain subsets of patients, such as women, ETT has a lower sensitivity and specificity for identifying obstructive CAD. When combined with an imaging modality, such as nuclear perfusion or echocardiography testing, the sensitivity and specificity of stress testing for detection of obstructive CAD improves significantly. Advancements in stress cardiac magnetic resonance imaging enables detection of perfusion abnormalities in a specific coronary artery territory, as well as subendocardial ischemia associated with MCD. Coronary computed tomography angiography enables visual assessment of obstructive CAD, albeit with a higher radiation dose. Invasive coronary angiography remains the gold standard for diagnosis and treatment of obstructive lesions that cause medically refractory stable angina. Furthermore, in patients with normal coronary angiograms, the addition of coronary reactivity testing can help diagnose endothelial-dependent and -independent microvascular dysfunction. Lifestyle modification and pharmacologic intervention remains the cornerstone of therapy to reduce morbidity and mortality in patients with stable angina. This review focuses on the pathophysiology, diagnosis, and treatment of stable, non-ACS anginal chest pain.

Topics: Age Factors; Angina Pectoris; Cardiovascular Agents; Chest Pain; Coronary Disease; Diagnosis, Differential; Diagnostic Imaging; Electrocardiography; Exercise Test; Female; Humans; Male; Myocardial Revascularization; Risk Factors; Sex Factors; Syndrome

Angina pectoris, the pain of myocardial ischemia, is the major initial and subsequent presentation of coronary disease in women. Angina in women is associated with more adverse morbidity, mortality, and quality-of-life outcomes than for men, despite women having less obstructive coronary artery disease and better left ventricular function. Women with chest pain and myocardial ischemia, in the absence of significant obstructive disease of the coronary arteries, have prominent morbidity and mortality outcomes; the postulated mechanism is microvascular disease. Women also have more non-chest pain manifestations of myocardial ischemia than men. These variables must be incorporated in assessments of optimal diagnostic and therapeutic strategies for myocardial ischemia in women.

Topics: Angina Pectoris; Cardiovascular Agents; Chest Pain; Coronary Disease; Coronary Vessels; Female; Humans; Myocardial Ischemia; Prognosis; Quality of Life; Risk Factors; United States

Coronary artery disease (CAD) in women is an important public health concern. However, the delayed onset of CAD in women and the apparent protective effect of estrogen are partly responsible for the misconception that CAD primarily affects men. Though women share the same traditional risk factors as men, they have some unique risk factors and differences in pathophysiology. Women are more likely to have atypical symptoms, contributing to the under-diagnosis of CAD. Fewer women than men receive pharmacological treatment for CAD on admission but more women receive anxiolytics, antidepressants, and narcotics. Disparities have been found in the administration and performance of both noninvasive testing and cardiac catheterization. The frequent absence of angiographic disease in symptomatic women often leads to searching for a noncardiac etiology for chest pain rather than the recognition of a higher incidence of nonocclusive CAD in women, a concept supported by imaging studies. Observational studies have pointed toward a beneficial effect of hormone replacement therapy (HRT) on CAD, but more recent randomized trials have disputed this and advocate against the use of HRT for CAD prevention. The role of HRT in CAD is still debated. Physicians have to be acutely aware of gender bias and gender-based differences in clinical presentation, accuracy of diagnostic tests, and clinical outcomes.

Topics: Cardiovascular Agents; Coronary Disease; Diagnostic Imaging; Electrocardiography; Estrogen Replacement Therapy; Female; Humans; Male; Prognosis; Risk Factors; Sex Characteristics; Sex Factors; Women's Health

Cerebrovascular disease is one of the leading causes of morbidity and mortality in developed countries. The identification of at-risk individuals is a high priority so that efficacious preventive measures can be implemented. Subjects with the highest risk of cerebrovascular diseases are those who already have had a stroke or a transient ischemic attack, and those with vascular disease in other territories, either in coronary or peripheral arteries. Other subjects at risk are those with cardiac disease, such as atrial fibrillation, those with hypertension, diabetes and smoking habit, as well as individuals with subclinical vascular disease. Although there is considerable evidence for the efficacy of preventive treatment in this population, the percentage of patients receiving optimum treatment is far from ideal. There is a need to implement strategies in the population directed towards increasing awareness of the need to establish healthy habits and adequate preventive pharmacological treatment that could reduce the incidence of this debilitating disease.

Topics: Arteriosclerosis; Cardiovascular Agents; Cerebrovascular Disorders; Coronary Disease; Evidence-Based Medicine; Health Knowledge, Attitudes, Practice; Humans; Patient Education as Topic; Patient Selection; Peripheral Vascular Diseases; Practice Guidelines as Topic; Recurrence; Registries; Risk Assessment; Risk Factors; Risk Reduction Behavior

This review concerns peculiarities of pharmacotherapy for patients with concomitant coronary heart disease and chronic obstructive pulmonary disease. It describes the main pharmacodynamic and pharmacokinetic properties of cholinolytics, beta-agonists, methylxanthines, corticosteroids, antibiotics, ACE inhibitors, calcium channel blockers, beta-blockers, nitrates, and anti-aggregants. These data are used to substantiate the application of these drugs to the treatment of overlapping pathologies with special reference to concomitant coronary heart disease and chronic obstructive pulmonary disease.

Topics: Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Humans; Pulmonary Disease, Chronic Obstructive; Respiratory System Agents

Coronary artery disease evolves, often unnoticed, over decades, often culminating in myocardial infarction. Metabolic and behavioural risk factors affect the development and progression of atherosclerotic lesions. The diagnosis may be arrived at clinically but typically involves confirmatory and prognostic laboratory tests and imaging studies. Treatment measures are aimed at controlling symptoms and preventing disease progression. In patients with clinically stable disease, treatment centres upon preventing disease progression using lifestyle modification, medical therapy and revascularisation for patients in whom medical treatment failure may be imminently fatal. In patients with acute coronary syndrome, urgent treatment is required in order to arrest lesion progression.

Topics: Adult; Angioplasty, Balloon, Coronary; Biomarkers; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Diagnostic Imaging; Exercise Test; Humans; Physical Examination

Regardless of the type of arterial reconstruction, luminal narrowing (stenosis or restenosis) develops in approximately one third of the vessels. In the past, the focus of research has been on the mechanisms of stenosis (intimal hyperplasia, pathologic remodeling) and pharmacologic approaches to prevention. An alternative approach is to induce intimal atrophy after luminal narrowing has developed, thus limiting treatment to only those patients that develop a problem. This approach to treat established disease by reducing wall mass through induction of cell death and extracellular matrix removal would be particularly useful for treating stenosis in synthetic bypass grafts or stented vessels, in which intimal hyperplasia is the primary mechanism of stenosis. This approach may be applicable as well to other vascular proliferative disorders, such as pulmonary hypertension and chronic transplant arteriopathy. Proof of principle has been shown in experiments with antibodies to platelet-derived growth factor (PDGF) receptors that cause neointimal regression in baboon polytetrafluoroethylene (PTFE) grafts and with angiotensin-converting enzyme inhibitors that induce medial atrophy in hypertensive arteries. Possible molecular targets could include PDGF receptors, A20, and BMP4. Further studies are needed to determine the utility of such a therapeutic approach to vascular disease.

Topics: Animals; Arterial Occlusive Diseases; Atrophy; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Blood Vessels; Cardiovascular Agents; Cell Death; Cell Proliferation; Constriction, Pathologic; Coronary Disease; Disease Models, Animal; Heart Transplantation; Humans; Hyperplasia; Hypertension; Hypertrophy; Recurrence; Remission Induction; Signal Transduction; Stents

The slow progression over decades of coronary atheroma is often compensated for by arterial remodeling and collateral circulation. Coronary artery disease is therefore often asymptomatic. Sudden rupture of unstable atheromatous plaque always leads to endocoronary thrombus formation. The magnitude and the time frame of this endovascular thrombotic process determine the severity of its clinical consequences: no symptoms, exercise angina, unstable angina, acute transmural myocardial infarction, or sudden death. Two amply validated treatments have the potential to decrease both the probability and the severity of plaque rupture: statins and platelet inhibitors, which are both indicated in all cases of coronary disease. The other therapeutic tools - anti-ischemic drugs, ACE inhibitors, angioplasty, and coronary bypass - are widely used in the management of coronary disease, but their indications should be tailored to each individual clinical situation.

Topics: Cardiovascular Agents; Coronary Disease; Coronary Thrombosis; Disease Progression; Humans; Inflammation; Myocardial Revascularization; Risk Factors; Rupture

Cardiovascular disease is one of the major causes of early morbidity and death in the developed world, and is becoming a serious public health concern in many developing countries. Over the last 30 years, in the USA and France, coronary angioplasty has become a standard treatment for stable angina, and this despite the recommendations of Learned Societies concerning the treatment of this condition. Today, 85 % of angioplasty procedures are performed on patients with stable angina. This study presents meta-analyses that compare medical treatment with angioplasty, and examine the impact of these strategies on more specific populations such as the elderly and post-myocardial infarction patients. To our minds, this synthesis seems to be of particular importance as the COURAGE study has rekindled the debate by showing that improvements in medical treatment and way of life reduced mortality and the recurrence of MI at five years, whereas there was no positive impact of an invasive strategy in any of the subgroups. Nevertheless, as a whole, studies on this subject underscore the value of angioplasty in the medium term for symptom relief in the case of ineffective medical treatment, notably during an acute coronary syndrome both in patients under medical treatment and in those who underwent invasive therapy at the initial phase.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Humans; Meta-Analysis as Topic; Myocardial Infarction; Practice Guidelines as Topic

Over the last 3 decades, our ability to mechanically dilate obstructive coronary arterial stenoses has fundamentally altered our approach to managing patients with coronary artery disease (CAD). The result has been a swing from an initial pharmacologic approach to anatomically driven revascularization. An accumulation of clinical evidence provides strong support for such intervention in acute coronary syndromes (ACS). In stable CAD, dilative therapy was believed to be superior based on the assumption that high-risk coronary anatomy or myocardial ischemia increases the risk of future death and myocardial infarction. However, there have been major advances in our understanding of the pathophysiology of ACS and the recognition of the significance of predisposing non-flow-limiting coronary stenoses prone to rupture, as well as increasing insight into plaque and patient vulnerability. This improved understanding of the disease has led to the more aggressive use of appropriately targeted pharmacologic agents and an evolution in what constitutes optimal medical therapy (OMT). Data from recent studies, such as the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, support the concept that in patients with stable CAD, OMT alone in this day and age compares favorably with a therapeutic strategy combining OMT with mechanical intervention. Thus, the treatment pendulum may be swinging back to the understanding that "best practice" today requires the judicious use of interventional and medical therapies in the appropriate patient population.

Topics: Acute Coronary Syndrome; Angina, Unstable; Angioplasty, Balloon, Coronary; Benchmarking; Cardiovascular Agents; Chronic Disease; Coronary Disease; Disease Progression; Endothelium, Vascular; Humans; Inflammation; Myocardial Revascularization; Oxidative Stress; Risk Factors; Xanthophylls

Diabetes mellitus (DM) is a worldwide epidemic. Its prevalence is rapidly increasing in both developing and developed countries. Coronary heart disease (CHD) is highly prevalent and is the major cause of morbidity and mortality in diabetic patients. The purpose of this review is to assess the clinical impact of recent advances in the epidemiology, prevention, and management of CHD in diabetic patients. A systematic review of publications in this area, referenced in MEDLINE in the past 5 years (2000 to 2005), was undertaken. Patients with CHD and prediabetic states should undergo lifestyle modifications aimed at preventing DM. Pharmacological prevention of DM is also promising but requires further study. In patients with CHD and DM, routine use of aspirin and an angiotensin-converting enzyme inhibitor (ACE-I)--unless contraindicated or not tolerated-and strict glycemic, blood pressure, and lipid control are strongly recommended. The targets for secondary prevention in these patients are relatively well defined, but the strategies to achieve them vary and must be individualized. Intense insulin therapy might be needed for glycemic control, and high-dose statin therapy might be needed for lipid control. For blood pressure control, ACE-Is and angiotensin receptor blockers are considered as first-line therapy. Noncompliance, particularly with lifestyle measures, and underprescription of evidence-based therapies remain important unsolved problems.

Topics: Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Coronary Disease; Diabetes Mellitus, Type 2; Dyslipidemias; Health Behavior; Humans; Hyperglycemia; Hypertension; Insulin Resistance; Life Style; Metabolic Syndrome; Treatment Refusal

(Drug-eluting stents substantially reduce the incidence of restenosis after percutaneous coronary interventions.) The cytostatic drugs however not only inhibit the proliferation of smooth muscle cell and neointima proliferation but also delay the endothelisation of the stent struts. It may result in persistent inflammatory reaction and also in stent thrombosis. The trials comparing the efficacy of drug-eluting and bare metal stents, and also that of the two drug-eluting stent brands are reviewed. The efficacy of the two brands of drug-eluting stents in prevention of restenosis is almost equal. Late stent thrombosis is more frequent after drug eluting, than after bare metal stents. This rare, but severe complication may develop if drug-eluting stents are used in off-label indications and anatomic situations. In order to avoid late stent thrombosis devices should be used as labelled, the platelet inhibitory treatment should be more efficacious and longlasting than these days. Thorough information about the importance of adherence to prescribed treatment should be delivered to the patients and to the medical community as well.

Topics: Cardiovascular Agents; Cell Proliferation; Coronary Disease; Coronary Restenosis; Coronary Thrombosis; Coronary Vessels; Humans; Stents; Time Factors

Nowadays the endothelium is considered a key determinant of vascular health. NO is the principal mediator of all endothelial protective effects, due to its antiinflammatory, antiproliferative, immunomodulatory and vasorelaxant properties. On the contrary, a growing body of evidence suggests that endothelial dysfunction is associated with cardiovascular events. Emerging data suggest that acute coronary syndromes (ACS) may involve a complex interplay between endothelial dysfunction, inflammation and thrombosis. Despite the success in reducing the mortality from acute cardiovascular events, the incidence of cardiovascular disease and its complication continues to increase. New insights into mechanisms of endothelial dysfunction, such as a better understanding of the regulation of vascular sources of oxygen radicals, may lead to novel therapeutic strategies with the potential to improve prognosis. The key pharmacological agents that improve clinical outcome in high-risk patients are statins, ACE-inhibitors or angiotensin receptor antagonists. Compelling scientific evidence suggests that these medications are effective in improving endothelial function. The present review focuses on the potential importance of benefits on endothelium of these medicaments in the management of acute coronary syndromes.

Topics: Adrenergic beta-Antagonists; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Animals; Cardiovascular Agents; Coronary Disease; Endothelin Receptor Antagonists; Endothelium, Vascular; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Nitric Oxide; Receptors, Endothelin

Coronary artery disease (CAD) is the most important cause of death in the industrialized world. After experimental myocardial infarction, numerous dilated vessels appear in the border zone between the infarct and noninfarct areas. Angiogenic therapy has been widely regarded as an attractive approach for both treating CAD and enhancing arterioprotective functions of the endothelium. In this report, we critically review the evidence supporting the regulation of angiogenesis and angiogenic factors by cardiovascular medications such as statins, cholesterol ester transfer protein inhibitor, angiotensin II type 1 receptor blocker, angiotensin-converting enzyme inhibitor and calcium channel blocker, etc. Furthermore, in patients with CAD, vascular growth (vasculogenesis), capillary network growth (angiogenesis) and collateral artery growth (arteriogenesis), may be important. Current evidence from clinical trials on these therapies suggests that the development of coronary collateral circulation is likely to be a viable therapeutic strategy for CAD, while adaptation to chronic coronary stenosis can proceed. Many studies have suggested that newly developed strategies which include the administration of angiogenic growth factors and the transplantation of bone marrow-derived angioblasts are beneficial for the ischemic heart. Our assessment of the evidence in this review leads us to conclude that the development of collateral circulation using conventional cardiovascular medications may also play a critical role and needs to be reconsidered in the treatment of patients with CAD.

Topics: Animals; Antihypertensive Agents; Calcium Channel Blockers; Cardiovascular Agents; Cholesterol Ester Transfer Proteins; Coronary Disease; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypolipidemic Agents; Neovascularization, Physiologic

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Coronary Restenosis; Drug Implants; Humans; Myocardial Infarction; Paclitaxel; Randomized Controlled Trials as Topic; Saphenous Vein; Sirolimus; Stents; Treatment Outcome

Omega-3 fatty acid therapy shows great promise in the secondary prevention of coronary artery disease. A meta-analysis of recent omega-3 trials shows reductions of coronary heart disease mortality of 36% (95% CI, 20%-50%; P<0.001) and total mortality of 17% (95% CI, 0%-32%; P=0.046). Some of the potential mechanisms for cardiovascular protection include a reduction in cardiac arrhythmias and plaque stabilization. Since the publication of the landmark GISSI-Prevenzione trial, there have been three major intermediate cardiovascular endpoint studies in patients with implantable cardioverter defibrillators (ICDs) and one large trial, the Japan EPA Lipid Interventional Study (JELIS) trial, which involved 18,645 Japanese patients in primary and secondary prevention. The three studies with ICD patients have been mixed, with favorable trends toward reduction in the incidence of ventricular arrhythmias in some but not all of the studies. Results of the recent JELIS trial in a Japanese population already consuming a high intake of omega-3 fatty acids showed a 19% risk reduction in major coronary events. Most of the reductions were in unstable angina and nonfatal coronary events, but not in sudden death and cardiovascular mortality. The totality of evidence suggests greater benefits with omega-3 fatty acids in secondary prevention than primary prevention and in populations consuming low amounts of omega-3 fatty acids.

Topics: Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Disease; Defibrillators, Implantable; Fatty Acids, Omega-3; Humans; Meta-Analysis as Topic; Randomized Controlled Trials as Topic

Topics: Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Nitroglycerin; Platelet Aggregation Inhibitors

Topics: Acute Disease; Cardiology; Cardiovascular Agents; Coronary Disease; Electrocardiography; Europe; Humans; Myocardial Revascularization; Periodicals as Topic; Practice Guidelines as Topic; Societies, Medical

Erectile dysfunction (ED) is a highly prevalent disorder associated with a significant burden of illness. The prevalence and incidence of ED are strongly age-related, affecting more than half of men >60 years. The first Princeton Consensus Conference (Princeton I) in 1999 developed guidelines for safe management of cardiac patients regarding sexual activity and the treatment of ED.. The second conference (Princeton II) was convened to update the recommendations based on the expanding knowledge base and new treatments available. This article reviews and expands on the Princeton II guidelines to address sexual dysfunction and cardiac risk.. A consensus panel of experts reviewed recent multinational studies in safety and drug interaction data for three phosphodiesterase type 5 (PDE5) inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease.. Erectile dysfunction is an early symptom or harbinger of cardiovascular disease, due to the common risk factors and pathophysiology mediated through endothelial dysfunction. Major comorbidities include diabetes, hypertension, hyperlipidemia and heart disease. Any asymptomatic man who presents with ED that does not have an obvious cause (e.g., trauma) should be screened for vascular disease and have blood glucose, lipids, and blood pressure measurements. Ideally, all patients at risk but asymptomatic for coronary disease should undergo an elective exercise electrocardiogram to facilitate risk stratification. Lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease, is literature-supported.. The recognition of ED as a warning sign of silent vascular disease has led to the concept that a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proven otherwise. Men with ED and other cardiovascular risk factors (e.g., obesity, sedentary lifestyle) should be counseled in lifestyle modification.

Topics: Adult; Aging; Cardiovascular Agents; Comorbidity; Consensus; Coronary Disease; Drug Interactions; Erectile Dysfunction; Hemodynamics; Humans; Impotence, Vasculogenic; Life Style; Male; Middle Aged; Patient Education as Topic; Phosphodiesterase Inhibitors; Practice Guidelines as Topic; Risk Factors; Vasodilator Agents

The treatment of patients with coronary artery disease continues to evolve. Recent, exciting data on the use of drug-eluting stents in diseased coronary vessels has generated immense enthusiasm within the interventional community leading to claims that "drug-eluting stents will put bypass surgeons out of business." However, despite promising short-term and midterm outcomes of this revolutionary new technology, valid concerns regarding long-term safety and efficacy of drug-eluting stents persist. This review article evaluates current status of drug-eluting stents with special emphasis on real and potential drawbacks of this emerging percutaneous coronary interventional modality and its impact on the practice of coronary artery bypass surgery.

Topics: Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Equipment Design; Humans; Multicenter Studies as Topic; Randomized Controlled Trials as Topic; Stents; Treatment Outcome

Angiographic no reflow is a recognized phenomenon during percutaneous coronary intervention (PCI). It usually follows successful lesion dilation and, by definition, it represents a reduction in epicardial coronary blood flow in the absence of identifiable dissection, obstruction or distal vessel cut off (indicative of distal embolisation). No reflow appears to be more commonly associated with PCI for acute myocardial infarction and PCI for saphenous vein graft occlusions. While the exact mechanism of no reflow is unknown, theoretical causes include local humoral and microembolic effects leading to microcirculatory dysfunction. As the process is multifactorial, various therapeutic strategies are required in different situations. The present day pharmacological management involves the use of vasodilators including nitrates, verapamil, papaverine, adenosine, nicardipine and sodium nitroprusside, but interestingly a vasoconstrictor like epinephrine may also have a role. Glycoprotein IIb/IIIa platelet receptors antagonist have shown a powerful de-thrombotic effect, and the intracoronary administration appears to be particularly promising. We review the pathogenesis of a reduced epicardial flow during PCI and focus on those drugs that have been studied for the treatment of no reflow. Although no double blind, randomized trial has been conducted to assess any of these agents, or to determine the appropriate dosage, we try to identify some useful conclusions from the published evidence.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Humans; Postoperative Complications

Five-year outcomes after coronary stenting are determined by restenosis of the original stented lesion during the first year and, later, by disease progression at non-stented segments, owing to either gradual progression of atherosclerosis or instability of vulnerable plaques. Drug-eluting stents have demonstrated potent anti-restenosis benefits in a variety of lesion types and high-risk patients, including complex long lesions and diabetic patients. It is likely that this benefit will translate into improved 5-year outcomes, with reduction in need for repeat revascularization in many patients and possibly reduced incidence of myocardial infarction and death, especially in diabetic patients, in whom the risk for occlusive restenosis and 5-year death and myocardial infarction rates are known to be higher after bare-metal stents. Future studies will determine the role of drug-eluting stents in preventing adverse outcomes owing to later disease progression. Such strategies and proposed clinical trials may include identification and prophylactic stenting of individual vulnerable plaques or coronary segments, and comparisons with coronary artery bypass surgery for complete revascularization success. While the outlook for benefit of drug-eluting stents in 5-year outcomes is hopeful, it is likely that a true improvement in these outcomes will be realized more from a judicious use of drug-eluting stents coupled with other proven aggressive secondary prevention therapies.

Topics: Angioplasty, Balloon, Coronary; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Clinical Trials as Topic; Coated Materials, Biocompatible; Coronary Disease; Coronary Restenosis; Diabetes Mellitus; Disease Progression; Humans; Stents; Treatment Outcome

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Biomarkers; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Defibrillators, Implantable; Diabetes Complications; Disease Progression; Female; Follow-Up Studies; Health Surveys; Heart Failure; Humans; Hypertension; Hypertrophy, Left Ventricular; Male; Mass Screening; Middle Aged; Multicenter Studies as Topic; Natriuretic Peptide, Brain; Pacemaker, Artificial; Practice Guidelines as Topic; Prevalence; Severity of Illness Index; Stroke Volume; Systole; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Remodeling

The First Hungarian Therapeutic Consensus Conference took place on 3rd Nov. 2003 with the participation of 9 medical societies. Over the past 2 years the results of new major studies have been published and the American ATP III has also updated its guidelines issued in 2004. Based on the above proposals, the Second Hungarian Therapeutic Consensus Conference held on 3rd Nov. 2005 partly confirmed its earlier suggestions, but made some changes as well. Within the high risk category the Conference optionally created a very high risk group from those patients who - in addition to their cardiovascular disease--have either diabetes or metabolic syndrome or acut coronaria syndrome or who are chain smokers. We have included - as a complement - into the asymptomatic high risk category such newly emerging risk factors, one of which already in itself means high risk: ankle/arm index < or = 0.9, GFR <60 ml/min, microalbuminuria (30-300 mg), preclinical atherosclerosis (plaque). Besides, 4 other risk factors were also categorised such as Lp/a (> or = 30 mg/dl), CRP (> or = 3mg/l), homocysteine (> or = 12 micromol), familiarity--atherogenic gene constellation, but only the presence of at least two of these verify high risk. In very high risk group the goals of 3.5 mmol/l and 1.8 mmol/l were determined as therapeutic option. The goal in obese patients--expressed earlier only in BMI--can now be equally determined by the abdominal circumference (94 cm for men, 80 cm for women respectively). ACE inhibitors were recommended earlier as a preventive therapy in case of dysfunction of the left ventricle, while at present they are suggested for all patients with cardiovascular disease. In the recent recommendations guidelines related to nutrition, smoking, exercise have also been included.

Topics: Abdominal Fat; Acute Disease; Albuminuria; Atherosclerosis; Body Mass Index; Cardiovascular Agents; Cardiovascular Diseases; Consensus Development Conferences as Topic; Coronary Disease; Diabetes Complications; Dyslipidemias; Exercise; Feeding Behavior; Female; Humans; Hungary; Hypertension; Life Style; Male; Metabolic Syndrome; Obesity; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Smoking Cessation; Societies, Medical; Therapeutics

The management of coronary artery disease should always include life style modification, control of cardiovascular risk factors and drugs with proven prognostic efficacy, i.e. antiplatelet drugs, statins, ss-blockers and, in most cases, ACE-inhibitors. Nitrates, sometimes also calcium antagonists, are used to control the symptoms of angina pectoris. Revascularisation by percutaneous treatment (stent implantation) or bypass surgery is indicated in patients with large areas of ischemia during stress testing or with high risk coronary anatomy during angiography, especially with reduced ventricular function, or when the angina cannot be adequately controlled by medicinal management. Single vessel and uncomplicated two vessel involvement are usually treated using a stent. Main stem stenosis, three vessel and severe two vessel involvement, particularly with reduced ventricular function, remain the domain of bypass surgery. Controlled studies show identical prognoses for patients with multiple vessel involvement for whom both treatment strategies are possible, although there is a higher reintervention rate for the stent patients. Coronary anatomy, ventricular function, as well as various patient-related factors have to be taken into account when deciding on the form of revascularisation therapy.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Evidence-Based Medicine; Humans; Myocardial Ischemia; Prognosis

The introduction of stents to clinical practice was the major breakthrough in the field of percutaneous coronary intervention. The introduction of stents was associated with two serious complications, the first was increase in subacute thrombosis within the first 30 days of stent implantation later controlled with the use of high pressure inflation and dual antiplatelet therapy, the second was the phenomenon of in-stent restenosis that was primarily caused by smooth muscle proliferation. While coronary stenting eliminates elastic recoil, it is unable to inhibit excessive neointimal formation. Stents were associated with an increase of neointimal formation compared to balloon angioplasty as a result of excessive injury to the vessel wall and the inflammatory process from interaction of metal with vessel wall. Local delivery of the potential agents for inhibition of neointimal formation to the site of the lesion was considered the desired approach. Several compounds have been tested for stent coating, primarily with the aim of the inhibition of SMC proliferation. Recently, new stents have emerged which are loaded with anti-inflammatory, anti-migratory, anti-proliferative or pro-healing drugs. In this review article the results of clinical studies investigating drug-eluting stents are discussed from pharmacological and clinical points of view, reviewing the current literature and the future prospective.

Topics: Animals; Anti-Inflammatory Agents, Non-Steroidal; Antineoplastic Agents; Biocompatible Materials; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Graft Occlusion, Vascular; Humans; Immunologic Factors; Polymers; Protease Inhibitors; Stents

Coronary artery bypass graft (CABG) procedures are among the most frequently performed surgical procedures in the United States. People with cardiovascular disease who also have diabetes have a greater risk of poor outcomes after CABG procedures than patients who do not have diabetes. This literature review examines current information regarding perioperative blood glucose (BG) control. It emphasizes BG control in adults during the hypothermic period of cardiopulmonary bypass. Hyperglycemia, not the diagnosis of diabetes, significantly increases the risk of adverse clinical outcomes, longer hospitalizations, and increased health care costs.

Topics: Adult; Blood Glucose; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Diabetes Complications; Diabetes Mellitus; Humans; Hyperglycemia; Hypothermia, Induced; Insulin; Perioperative Nursing; Risk Factors

Topics: Animals; Brachytherapy; Cardiovascular Agents; Coronary Disease; Humans; Stents

Epidemiology and prevention of coronary artery disease. The author summarizes the most important risk factors of atherosclerosis and epidemiological data of coronary heart disease. According to epidemiological data during the next 10-20 years cardiovascular diseases will be the leading cause of death all around the world. Smoking is the most important risk factor causing half of all avoidable death, half of these deaths caused by cardiovascular diseases. Three strategies of prevention are discussed: population strategies, high risk strategy and secondary prevention. All of these preventive strategies should be implemented to reach the goal. During the last years many drug studies were finished proving the effectiveness of aspirin, statins, ACE inhibitors and beta blockers as an effective tool of prevention.

Topics: Arteriosclerosis; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Humans; Hungary; Primary Prevention; Risk Factors; Smoking

Percutaneous coronary intervention (PCI) has been shown to improve symptoms compared with conservative medical treatment in patients with stable coronary artery disease (CAD); however, there is limited evidence on the effect of PCI on the risk of death, myocardial infarction, and subsequent revascularization. Therefore, we performed a meta-analysis of 11 randomized trials comparing PCI to conservative treatment in patients with stable CAD.. A total of 2950 patients were included in the meta-analysis (1476 received PCI, and 1474 received conservative treatment). There was no significant difference between the 2 treatment strategies with regard to mortality, cardiac death or myocardial infarction, nonfatal myocardial infarction, CABG, or PCI during follow-up. By random effects, the risk ratios (95% CIs) for the PCI versus conservative treatment arms were 0.94 (0.72 to 1.24), 1.17 (0.88 to 1.57), 1.28 (0.94 to 1.75), 1.03 (0.80 to 1.33), and 1.23 (0.80 to 1.90) for these 5 outcomes, respectively. A possible survival benefit was seen for PCI only in trials of patients who had a relatively recent myocardial infarction (risk ratio 0.40, 95% CI 0.17 to 0.95). Except for PCI during follow-up, there was no significant between-study heterogeneity for any outcome.. In patients with chronic stable CAD, in the absence of a recent myocardial infarction, PCI does not offer any benefit in terms of death, myocardial infarction, or the need for subsequent revascularization compared with conservative medical treatment.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Bayes Theorem; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Coronary Stenosis; Death; Female; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Odds Ratio; Randomized Controlled Trials as Topic; Risk Assessment; Treatment Outcome

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.

Topics: Age Distribution; Aged; Angina Pectoris; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Coronary Disease; Drug Interactions; Erectile Dysfunction; Humans; Incidence; Male; Middle Aged; Piperazines; Prognosis; Purines; Risk Assessment; Severity of Illness Index; Sildenafil Citrate; Sulfones; Survival Rate

To review the antihypertensive, cardiovascular and pleiotropic effects of angiotensin-receptor blockers (ARBs).. ARBs are the most recently approved class of antihypertensive agents. They selectively block the angiotensin II type 1 receptor, thus inhibiting most of the deleterious effects of angiotensin II. In addition to blood-pressure control, other benefits may be gained using ARBs. This is because the renin-angiotensin system plays a crucial role in circulatory homoeostasis, and in patients with atherosclerosis, diabetes or hypertension, angiotensin II contributes to the pathophysiology of disease. Evidence-based medicine includes well-controlled studies with mortality and morbidity endpoints in patients with a variety of conditions including hypertension, type 2 diabetes, stroke, renal disease, heart failure, left-ventricular hypertrophy and coronary heart diseases. In addition to these hard endpoints, it has been shown that treatment with ARBs prevents the development of type 2 diabetes, ameliorates coronary and peripheral vascular endothelial dysfunction and decreases plasma levels of several markers of vascular inflammation.. ARBs are first-line agents for the treatment of hypertension and cardiovascular diseases. Blocking the renin-angiotensin system with these agents has special advantages due to specific vascular and antiatherosclerotic effects, which contribute to a better cardiovascular and renal protection in patients at risk from or with cardiovascular disease.

Topics: Angiotensin II Type 1 Receptor Blockers; Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Cerebrovascular Disorders; Coronary Disease; Diabetes Mellitus, Type 2; Endothelium, Vascular; Heart Failure; Humans; Hypertension; Hypertrophy, Left Ventricular; Kidney Diseases

Intervention in coronary artery disease is an area of cardiology where novel drugs, in the form of drug-eluting stents (DES), are being used increasingly commonly. DES are used across the whole range of coronary intervention, from stable angina patients with single or multivessel disease, acute coronary syndromes and acute myocardial infarction (i.e. primary angioplasty). Most recently, they are being tested in a particularly challenging subset of patients, those experiencing symptoms due to restenosis within a previously stented area of vessel (in-stent restenosis, ISR). This article summarises the rationale for the use of DES, across all these areas, focussing specifically on the emerging results of trials and registries examining the effectiveness of DES in acute myocardial infarction (AMI) and ISR. Drug-eluting stents represent a significant shift in the use of locally-delivered drugs in interventional cardiology. On the basis of encouraging trial data, including in the specific areas of in-stent restenosis and myocardial infarction, their use is becoming extremely widespread in place of bare-metal (drug-free) stents. This change is happening despite their high costs, relatively short follow-up data and concerns of possible unwanted effects, because of the weight of evidence that they are superior in preventing restenosis in many patient groups. This reduction is highly significant in angiographic terms and, to a lesser degree, in the prevention of clinically important restenosis requiring revascularisation, but not clearly in terms of overall mortality.

Topics: Animals; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Coronary Restenosis; Drug Delivery Systems; Equipment Design; Humans; Stents

Cardiovascular diseases are the number one cause of death in Germany. In 2002 about 70,000 people died of acute myocardial infarction (AMI) and of these 37% died before arrival at hospital which underlines the relevance of adequate prehospital care. The generic term acute coronary syndrome (ACS) was introduced because a single pathomechanism accounts for the different forms and comprises unstable angina pectoris (iAP), non-ST-elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI) and sudden cardiac death (SCD). Characteristic features are retrosternal pain, vegetative symptoms and radiation of pain into the adjoining regions. Further differentiation can only be achieved by the 12-lead ECG, as cardiac-specific enzymes do not play a role in prehospital decisions. Prehospital delays should be avoided, history and physical examination should be brief but focused, vital parameters should be assessed and monitored. Basic treatment for ACS should comprise inhalative oxygen, nitrates, morphine, aspirin and beta-blockers. If STEMI is diagnosed, patients with symptoms <12 h should undergo fibrinolytic therapy unless there is primary percutaneous coronary intervention (PCI) available within 90 min or if contraindicated. Heparin should be given to patients with STEMI depending on the choice of fibrinolytic agent, it otherwise results in a higher risk of bleeding, but in patients with iAP or NSTEMI it reduces mortality. All patients must be accompanied by the emergency physician during transportation and should be brought to a hospital with primary PCI, especially those with complicated ACS. Treatment of complications depends largely on the type, persistence and severity.

Topics: Acute Disease; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Electrocardiography; Emergency Medical Services; Germany; Humans; Myocardial Infarction

Patients presenting with acute coronary syndromes without ST elevation on their electrocardiogram continue to contribute an important healthcare burden. Medical treatments to control symptoms include nitrates and beta-blockers. Morphine is a very effective analgesic although its use may be associated with adverse outcomes. Oral antiplatelet therapies including aspirin and clopidogrel form a cornerstone of prognostically modifying therapy. Similarly, the intravenous IIb/IIIa antagonists have emerged as having an important role in patients undergoing coronary intervention. Low molecular weight heparins are more convenient to use than unfractionated heparin and may be more effective. Care should be taken to avoid mixing the two antithrombins as this contributes to increased bleeding risk. Statins can impact on short-term outcomes when given during the acute admission; and this benefit is augmented if high doses are used.

Topics: Acute Disease; Cardiovascular Agents; Coronary Disease; Humans; Syndrome

Recent therapeutic advances in the treatment of acute ischemic heart disease have been proven by randomized clinical trials and approved by formal practice guidelines. This rigorous approach has led to a sizable reduction in mortality and morbidity across the spectrum of acute coronary syndromes (ACS). However, contemporary registries of non-ST-elevation ACS set up by the cardiological community in Italy, as well as in the rest of Europe and in America, have shown only limited compliance to the general indication of treating high-risk patients by an early invasive approach protected by the use of glycoprotein IIb/IIIa receptor blockers. This partial failure in the process of improving patient care may be attributed to several reasons, including the suspect that practice guidelines may be biased by conflict of interest, concern about the applicability of the results of clinical trials to the real world, unrealistic expectations about treatment effects and, finally, logistic and economic obstacles including the availability of cath-labs and the high cost of platelet receptor blockers. Although the practice guidelines may provide a cultural support for translating the results of clinical research into patient care, and national and local cardiological associations can help in increasing awareness of the real benefits of an early aggressive approach in high-risk patients, the health care managers should remove bureaucratic obstacles and reallocate resources from treatments of unproven benefit to those that have been clearly shown to reduce mortality and the risk of reinfarction in ACS patients.

Topics: Acute Disease; Cardiac Catheterization; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Evidence-Based Medicine; Guideline Adherence; Humans; Italy; Myocardial Revascularization; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Practice Guidelines as Topic; Practice Patterns, Physicians'; Randomized Controlled Trials as Topic; Recurrence; Registries; Risk Reduction Behavior

There are two types of acute coronary syndromes : those with or without ST-segment elevation. The former require urgent therapeutic measures to reopen the culprit artery (intravenous thrombolysis or primary percutaneous coronary intervention). For the latter, risk stratification is essential and is based upon clinical and biochemical markers. Among them, recent and repeated anginal attacks, ST-segment modifications on admission electrocardiogram, and increased markers of myonecrosis (particularly increased troponin levels) are strong predictors of untoward outcome. According to the risk profile, the initial management is based upon an invasive strategy with powerful antithrombotic medications and urgent angiography, or upon a non-invasive strategy using stress testing, preferably coupled with myocardial imaging techniques. In all instances, secondary prevention measures are determinant to try and stop the progression of the atherosclerotic disease.

Topics: Acute Disease; Adult; Aged; Biomarkers; Cardiovascular Agents; Case Management; Chest Pain; Coronary Angiography; Coronary Disease; Electrocardiography; Humans; Middle Aged; Myocardial Revascularization; Prognosis; Thrombolytic Therapy

Diabetic cardiomyopathy is characterized by a prominent interstitial fibrosis. Postulated etiologies include microangiopathy, autonomic neuropathy, and metabolic factors. A common root of these pathologies is hyperglycemia or hyperinsulinemia, both of which are prominent in type 2 diabetes mellitus, which has the highest incidence of cardiovascular morbidity and mortality. The relative importance of each factor is a matter of debate; it is likely that both of these factors in addition to the concomitant risk factors seen in diabetics (dyslipidemias, hypertension, obesity, coagulation abnormalities) contribute to the spectrum of myocardial disease in diabetes. A discussion of these contributive pathologies and the hyperglycemia and hyperinsulinemia that underlie them is the subject of this review. Treatment methodologies to control the development of such pathology also are discussed.

Topics: Albuminuria; Blood Coagulation Disorders; Cardiovascular Agents; Cause of Death; Coronary Disease; Diabetes Mellitus, Type 2; Female; Global Health; Heart Failure; Humans; Hyperinsulinism; Hyperlipidemias; Hypertension; Hypoglycemic Agents; Incidence; Insulin Resistance; Male; Obesity; Oxidative Stress; Prognosis; Risk Factors; Sex Characteristics; United States

Women who experience heart failure (HF) exhibit distinct differences from men. Because women are a minority in major HF trials and because diagnostic criteria have been variable in epidemiologic surveys, many questions remain unanswered. This article describes differences in sex hormone effects and responses to injury, pressure overload, and aging, which may account for differences observed in epidemiology, risk factors and causes, mechanisms for disease development, response to treatment, and outcomes. Hypertension,diastolic dysfunction, diabetes, obesity, and inactivity are more important factors in women, whereas ischemic heart disease and systolic dysfunction are more important factors in men. Women appear to benefit less from established treatments but have better survival. Future studies directed exclusively at women may be warranted to confirm or establish benefits of existing and future treatments.

Topics: Adult; Age Distribution; Aged; Cardiovascular Agents; Cause of Death; Clinical Trials as Topic; Coronary Disease; Death, Sudden, Cardiac; Epidemiologic Studies; Female; Gonadal Steroid Hormones; Heart Failure; Humans; Hypertension; Middle Aged; Patient Selection; Prognosis; Risk Factors; Sex Characteristics; Sex Distribution; Sex Factors; Survival Rate; Treatment Outcome; United States; Women's Health

Cardiovascular diseases represent a widespread heterogeneous group of conditions that have significant morbidity and mortality. The various diseases and their treatments can have an impact upon the periodontium and the delivery of periodontal care.. In this paper we consider three main topics and explore their relationship to the periodontist and the provision of periodontal treatment.. The areas reviewed include the effect of cardiovascular drugs on the periodontium and management of patients with periodontal diseases; the risk of infective endocarditis arising from periodontal procedures; the inter-relationship between periodontal disease and coronary artery disease.. Calcium-channel blockers and beta-adrenoceptor blockers cause gingival overgrowth and tooth demineralisation, respectively. Evidence suggests that stopping anticoagulant therapy prior to periodontal procedures is putting patients at a greater risk of thromboembolic disorders compared to the risk of prolonged bleeding. The relationship between dentistry and infective endocarditis remains a controversial issue. It would appear that spontaneous bacteraemia arising from a patient's oral hygiene practices is more likely to be the cause of endocarditis than one-off periodontal procedures. The efficacy of antibiotic prophylaxis is uncertain (and unlikely to be proven), and the risk of death from penicillin appears to be greater than the risk of death arising from infective endocarditis. Finally, the association between periodontal disease and coronary artery disease has been explored and there seem to be many issues with respect to data handling interpretation. Many putative mechanisms have been suggested; however, these only further highlight the need for intervention studies.

Topics: Bacteremia; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Endocarditis, Bacterial; Humans; Periodontal Diseases; Periodontium; Risk Factors

Topics: Animals; Cardiovascular Agents; Coronary Disease; Disease Models, Animal; Drug Evaluation, Preclinical; Female; Ligation; Mice; Models, Animal; Myocardial Infarction; Myocardial Reperfusion Injury; Rabbits; Rats; Rats, Wistar; Swine

Reviewing advances in cardiology and haematology together may appear at first sight to require some artificiality to make a satisfying fit. For two reasons, at least, this is not the case. Firstly, convergence in biology has become very clear over the past decade and this could not be better illustrated by the demonstration that the haemangioblast is the common progenitor of both haemapoietic stem cells and vascular endothelium. This opens the way to common (and differential) approaches to the manipulation of these cells, a field at present in its infancy. A second convergence is the common goal of understanding the processes resulting in haemostasis, thrombosis and vascular occlusion and the means for developing effective antithrombotics. This is exemplified by a number of agents either in use or in clinical trial as a result of haematological and cardiological collaboration. This collaboration is recognisable with the development, many years ago, of streptokinase and the use of aspirin in vascular disease and continues to this day with specific antiplatelet inhibitors and oral thrombin inhibitors as they become accepted into clinical use over the next few years. Here we review current advances in pharmacological treatments in cardiology and haematology, grouped primarily by disease process, focusing on novel and emerging therapies likely to be of importance in the future.

Topics: Angioplasty, Balloon, Coronary; Animals; Cardiovascular Agents; Coronary Disease; Heart Diseases; Hematologic Diseases; Hematologic Neoplasms; Humans; Myocardial Infarction; Stem Cell Transplantation; Thrombosis

Lots of changes has been made on the treatment of ischaemic heart disease (especially the acute ischaemic syndrome) during the last few years. Large scale, multicentre trials provided clinical evidences the novel therapeutical approach of acute coronary syndrome (ACS). In order to suit this great challenge and to treat the patients with ACS successfully, all efforts should be addressed to open the occluded coronary artery, and to restore coronary circulation as soon as possible. During this process the first mandatory step is to perform acute coronarography, in order to reveal the exact pathomorphology, and to make a plan for the optimal treatment. Patients with acute ischaemic syndrome should be transferred to the haemodynamic laboratory within 2-6 hours from the development of the first clinical symptoms, to perform a primary coronary intervention and/or pharmacological treatment when required. A well-established, local/regional system is suitable to organize different levels of medical treatment from the family medicine to the regional heart center, and enables to transfer patients to the appropriate place without delay, and gives an equal chance for every patient with acute ischaemic syndrome.

Topics: Acute Disease; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Heart Conduction System; Humans; Risk Assessment; Risk Factors

Our understanding of the pathophysiology of acute coronary syndromes (ACS), including acute ST elevation myocardial infarction, unstable angina and non-ST-segment elevation (NSTE) myocardial infarction, has evolved considerably over the years, with atherothrombosis playing a pivotal role. This review will discuss the recent advances/recommendations for drug therapy based on this enhanced understanding of the pathophysiology of thrombosis. More recently developed agents, such as low-molecular-weight heparins (LMWHs), glycoprotein (GP) IIb-IIIa inhibitors, direct thrombin inhibitors, Factor Xa inhibitors and thienopyridines, offer several potential advantages, either as an alternative to unfractionated heparin (i.e., LMWHs) or as an add-on therapy to aspirin and unfractionated heparin (or LMWHs; e.g., GP IIb-IIIa inhibitors, thienopyridines). The purpose of this review is to describe recent studies with novel antithrombotic agents (e.g., LMWHs, thienopyridines, GP IIb-IIIa inhibitors, bivalirudin) in patients with NSTE ACS, as well as to highlight recommendations for management of patients with NSTE ACS in the recently updated American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, including the appropriate use of antithrombotic therapies.

Topics: Acute Disease; Animals; Cardiovascular Agents; Coronary Disease; Factor Xa Inhibitors; Humans; Thrombin

We sought to evaluate international patterns of use and factors influencing use of evidence-based medications early after ACS.. Using a database of 15904 ACS patients enrolled in the SYMPHONY and 2nd SYMPHONY trials in 37 countries, we performed descriptive and logistic regression analyses. After controlling for other factors, region was significantly associated with the use of every class of evidence-based medication, most pronounced for intravenous unfractionated heparin (IV UFH), low-molecular-weight heparin (LMWH), angiotensin II converting enzyme inhibitors (ACEI) and discharge use of lipid-lowering agents. Latin America and Eastern Europe were among the highest users of early ACEI, yet the lowest users of discharge lipid-lowering therapy. Relative to the United States, all regions except Canada had greater use of LMWH and lower use of IV UFH. Compared with patients with acute myocardial infarction, those with unstable angina less often received aspirin, beta-blockers, ACEI, or IV UFH. Older age was associated with lower use of aspirin, beta-blockers, IV UFH, and lipid-lowering agents.. Use of evidence-based therapies for management of ACS patients is strongly associated with region. To improve patient outcomes, more research is needed to understand this variation, and to institute appropriate solutions.

Topics: Aged; Americas; Asia; Australasia; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Europe; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Practice Guidelines as Topic; Professional Practice; Prognosis; Regression Analysis; Residence Characteristics

Several factors are placing significant financial burdens on the health care system today. These include the growing older population, the obesity and type II diabetes epidemics, and the attendant increased prevalence of heart disease, which remains the leading cause of death in the United States. In response, cardiovascular medicine is undergoing sweeping change in the use of advanced technology and interventions. In addition, biomarkers, such as troponin, are emerging as critical predictors of responses to therapy, particularly for coronary stenting. Future trends in the treatment of acute coronary syndromes (ACS) will embrace the use of genomic solutions, such as gene expression profiling, to predict therapeutic outcomes. Careful consideration will need to be given to these innovative approaches to ensure they are cost effective.

Topics: Acute Disease; Biomarkers; Cardiology; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Genetic Therapy; Health Care Costs; Health Expenditures; Humans; Population Dynamics; Quality of Health Care; Stents; United States

This review analyzes important facets of contemporary percutaneous coronary interventions. The optimal strategy of acute myocardial infarction and shock is addressed, as is the role of angioplasty in multivessel coronary disease. Vascular Brachytherapy is essentially the sole available treatment modality for in-stent restenosis. The WRIST trials have provided the foundation for clinical experience and are discussed in detail. Finally, drug-eluting stents may become the next revolution in interventional cardiology and offer the hope of a "cure" for restenosis.

Topics: Angioplasty, Balloon; Animals; Brachytherapy; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Graft Occlusion, Vascular; Humans; Myocardial Infarction; Myocardial Revascularization; Shock, Cardiogenic; Stents

Topics: Aged; Animals; Cardiotonic Agents; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Female; Germany; Heart Failure; Humans; Male; Middle Aged; Practice Guidelines as Topic; Survival Rate

Topics: Algorithms; Cardiac Pacing, Artificial; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Cytokines; Defibrillators, Implantable; Enzyme Inhibitors; Exercise; Heart Failure; Humans; Matrix Metalloproteinase Inhibitors; Ventricular Dysfunction, Left

This chapter reviews the therapeutic armamentarium available for the treatment of cardiovascular disease during pregnancy. The management does not differ markedly from that of the non-pregnant population. Few drugs are absolutely contraindicated, although, for many, safety data are limited and caution is recommended. The potential risks to the fetus must be weighed against maternal benefit and the well-being of the pregnancy. Women of childbearing age requiring long-term medication should be offered pre-pregnancy counselling, and other non-pharmacological avenues, such as radio-frequency ablation for supraventricular arrhythmias, should be explored.

Topics: Anti-Arrhythmia Agents; Breast Feeding; Cardiovascular Agents; Coronary Disease; Female; Heart Failure; Humans; Pregnancy; Pregnancy Complications, Cardiovascular

During the past 25 years, the cardiovascular effects of marine omega-3 (omega-3) fatty acids have been the subject of increasing investigation. In the late 1970s, epidemiological studies revealed that Greenland Inuits had substantially reduced rates of acute myocardial infarction compared with Western control subjects. These observations generated more than 4,500 studies to explore this and other effects of omega-3 fatty acids on human metabolism and health. From epidemiology to cell culture and animal studies to randomized controlled trials, the cardioprotective effects of omega-3 fatty acids are becoming recognized. These fatty acids, when incorporated into the diet at levels of about 1 g/d, seem to be able to stabilize myocardial membranes electrically, resulting in reduced susceptibility to ventricular dysrhythmias, thereby reducing the risk of sudden death. The recent GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico)-Prevention study of 11,324 patients showed a 45% decrease in risk of sudden cardiac death and a 20% reduction in all-cause mortality in the group taking 850 mg/d of omega-3 fatty acids. These fatty acids have potent anti-inflammatory effects and may also be antiatherogenic. Higher doses of omega-3 fatty acids can lower elevated serum triglyceride levels; 3 to 5 g/ d can reduce triglyceride levels by 30% to 50%, minimizing the risk of both coronary heart disease and acute pancreatitis. This review summarizes the emerging evidence of the use of omega-3 fatty acids in the prevention of coronary heart disease.

Topics: alpha-Linolenic Acid; Cardiovascular Agents; Coronary Disease; Death, Sudden, Cardiac; Fatty Acids, Omega-3; Fish Oils; Greenland; Humans; Inuit; Myocardial Infarction; Randomized Controlled Trials as Topic

Diabetes mellitus as a disease of epidemiological impact leads to diabetic cardiopathy by modulation of myocardial, vascular and metabolic components. This includes the development of a coronary microangiopathy and a decrease of diastolic and systolic function of the left ventricle as well as the development of an autonomic diabetic neuropathy. Patients with diabetes show an increased mortality concerning cardiovascular events. They more often suffer from myocardial infarction as non-diabetics mostly with a more serious course. Moreover, the post-infarction course is affected with a worse prognosis as in non-diabetics. For diagnosis of cardial involvement in diabetes electrocardiographic and echocardiographic procedures are of use. Special tests of the autonomic function complete the diagnostic ensemble. An early therapy with ACE-inhibitors and beta blocking agents as well as a strong diabetes therapy, in particular with insulin, can influence the mortality favorably. Moreover, the diagnosis and therapy of additional cardiovascular risk factors (arterial hypertension, dyslipidemia) are very important, because these are correlated with a for diabetic patients markedly increased risk of mortality. The clinical relevance of the term diabetic cardiopathy is justified by the 6 factors: macroangiopathy, microangiopathy, disturbances of the myocardial metabolism, myocardial fibrosis, autonomic diabetic neuropathy and disturbances of the coagulability. Diagnostic and therapeutic goals are discussed.

Topics: Arteriosclerosis; Cardiovascular Agents; Coronary Disease; Diabetes Complications; Diabetes Mellitus; Diabetic Angiopathies; Diabetic Neuropathies; Diagnosis, Differential; Humans; Lipids; Myocardial Infarction; Risk Factors; Ventricular Dysfunction, Left

Diastolic dysfunction is the underlying problem in one third of patients with heart failure, but it is still not well understood. Carefully excluding other causes of heart failure and recognizing indicators of diastolic dysfunction on invasive and noninvasive tests are important in establishing the diagnosis and in guiding therapy. Left ventricular relaxation and stiffness and left atrial function are the most important factors acting together to maintain adequate cardiac output under normal filling pressure. Echocardiography is the most important tool for the diagnosis of diastolic heart dysfunction. It is portable, safe, and excludes other causes of heart failure, such as valvular disease. Diuretics can be used to reduce volume overload, but caution is advised, as aggressive diuresis decreases stroke volume more in diastolic dysfunction than in systolic dysfunction.

Topics: Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiac Output; Cardiomyopathies; Cardiovascular Agents; Coronary Disease; Diastole; Diuretics; Echocardiography; Electrocardiography; Heart Failure; Humans; Ventricular Dysfunction, Left

Management of acute coronary syndromes has been the focus of increased interest in recent years. This has come about with the recognition that the majority of patients who present to the hospital with chest pain have unstable angina or non-Q-wave myocardial infarction (MI). Further, sensitive biochemical markers of myocardial necrosis, such as troponin and creatine kinase, have improved early diagnosis. Markers of inflammation such as C-reactive protein (CRP), although not in wide clinical practice, may provide an early and important marker of prognosis. The current approach to management of acute coronary syndromes is careful risk stratification so as to select appropriate medical therapies and to guide the clinician to appropriate interventions such as angiography or percutaneous coronary intervention (PCI). Established therapies such as aspirin, heparin, intravenous nitrates, and, in selected patients, beta blockers or calcium antagonists, are being used concomitantly with, or are being supplanted by, newer therapies such as low-molecular-weight heparins and glycoprotein IIb/IIIa inhibitors. The role of hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) in patients with acute coronary syndromes is being investigated and shows promise.

Topics: Acute Disease; Adrenergic beta-Antagonists; Algorithms; Angina, Unstable; Biomarkers; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Heparin, Low-Molecular-Weight; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Myocardial Infarction; Nitroglycerin; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Randomized Controlled Trials as Topic; Risk; Risk Factors; Severity of Illness Index; Syndrome; Troponin I

The population of older individuals in the United States is growing rapidly. Because women generally live longer than men and make up the majority of this aging population, the elucidation of health issues related to older women is important. Cardiovascular disease is the leading cause of death and disability for women and claims the lives of more women than the next 14 causes combined. The majority of these deaths are due to atherosclerotic coronary heart disease, with nearly 250,000 women dying of myocardial infarction each year. There is evidence that women with suspected or established cardiovascular disease have not benefited fully from recent advances in the detection and management of coronary heart disease. Regardless of the mechanism and extent of the effect that sex differences have on approaches to cardiovascular disease, women appear to benefit from proven efficacious therapies, and the longer-term outcomes associated with these treatments are positive. The data regarding women and coronary heart disease are rapidly evolving and sometimes conflicting. The intent of this article is to summarize the most current understanding of coronary heart disease risks in women, highlighting the impact of prevention, and to discuss the latest novel findings that may become important in our armamentarium for prevention of coronary heart disease.

Topics: Adult; Age Factors; Aged; Cardiovascular Agents; Coronary Disease; Estrogen Replacement Therapy; Female; Humans; Life Style; Middle Aged; Risk Factors; United States; Women's Health

The coronary morbi-mortality is particularly high in type 2 diabetes, which represents the vast majority of all diabetes. Hyperglycemia is an independent vascular risk factor in the short and long-term. The relationship between the degree of hyperglycemia and vascular risk is linear with no threshold effect. The occurrence of a first coronary event is an occasion, though late, to review the management of all risk factors in diabetic patients. In these patients, intensive insulin therapy administered in the acute phase of infarction reduces cardiovascular mortality by 30% at 1 and 3 years. There are no specific studies of secondary prevention by optimal therapy of diabetes, but, in the UKPDS, the treatment of hyperglycemia with sulfonylurea or insulin only marginally reduced the number of cardiovascular events. On the other hand, treatment of obese patients with metformin significantly reduced the incidence of myocardial infarction and of mortality diabetes related. These results, though observed with the same level of glycemic control as in the other treatment groups, suggest a cardio-protective effect of metformin itself. These beneficial effects should be weighed up against the potential risk of lactic acidosis which still limits the widespread use of metformin in with coronary heart disease patients. Follow-up studies show that diabetic with coronary heart disease patients do not receive all effective therapeutic inventions in secondary prevention and that the treatment of hyperglycemia is often neglected. Close collaboration between cardiologists and diabetologists is necessary to improve the management of type 2 diabetes.

Topics: Acidosis, Lactic; Acute Disease; Adrenergic beta-Antagonists; Blood Glucose; Cardiovascular Agents; Case Management; Cohort Studies; Controlled Clinical Trials as Topic; Coronary Disease; Diabetes Complications; Diabetes Mellitus; Diabetes Mellitus, Type 2; Glyburide; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Incidence; Insulin; Metformin; Myocardial Infarction; Obesity; Prospective Studies; Randomized Controlled Trials as Topic; Risk; Sulfonylurea Compounds; Treatment Outcome

Coronary artery disease is a common, serious and insidious complication of diabetes. Myocardial ischaemia is often silent. All diabetics do not have the same coronary risk and, therefore, it is important to determine which investigations to perform and which patients. This strategy is justified because it allows identification of these cases which require a medical or an invasive (angioplasty, surgical revascularisation) approach, as these interventions may improve the prognosis. The first stage is clinical (investigation of cardiovascular risk factors). When more than two risk factors are found, further investigations are justified. Exercise stress testing provide reassuring diagnostic and prognostic data when maximal and negative. When sub-maximal, impossible or significantly ischaemic, a second investigation is useful. Holter ECG recording with analysis of ST variation lacks sensitivity and, above all, specificity. The diagnostic value of perfusion myocardial scintigraphy in the diabetic is not as good as that observed in the general population, but its prognostic value remains good. Ischaemia involving over 20% of the myocardium justifies therapeutic investigation. Stress echocardiography has been validated in the diagnosis and prognosis of coronary artery disease and its sensitivity and specificity are probably the same as those of scintigraphy. The authors conclude that the asymptomatic diabetic requires clinical and staged paraclinical investigation to assess prognosis and, depending on the results, the adoption of a beneficial therapeutic strategy.

Topics: Cardiovascular Agents; Coronary Angiography; Coronary Disease; Diabetes Complications; Diagnostic Techniques, Cardiovascular; Echocardiography; Electrocardiography, Ambulatory; Exercise Test; Humans; Myocardial Revascularization; Predictive Value of Tests; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Sestamibi

Drugs with the efficacy of modifying rheological properties of blood, blood vessels and their interactions are denoted by "hemorheologicals". Drugs of anti-hyperviscosemia, anti-coagulants, anti-platelet drugs, anti-thrombotics, vasodilators, endothelial cell protectors and anti-arthrosclerosis should be considered as hemorheologicals due to the actions in keeping blood fluidity and in maintaining normal vascular functions. The studies in hemorheology indicate that a tendency of hyperviscosity, hypercoagulation and being prone to thrombosis is prevalent in the elderly. Hemorheologicals are importance for and aging and life-threatening diseases. Blood stasis syndrome is a common pathological syndrome in the elderly. In traditional Chinese medicine, the treatment for the syndrome is by herbs which activates blood circulation to remove blood stasis. The herbs have the efficacy of improving hemorheological events. Therefore, the herbs are the source for developing hemorheologicals. Ligustrazine isolated from Chuangxiong is an example. It showed significant inhibition on shear induced platelet aggregation and on platelet intracellular calcium demonstrated by laser confocal microscope.

Topics: Aged; Animals; Anticoagulants; Blood Viscosity; Cardiovascular Agents; Coronary Disease; Drugs, Chinese Herbal; Fibrinolytic Agents; Hemodynamics; Hemorheology; Humans; Platelet Aggregation; Platelet Aggregation Inhibitors; Pyrazines; Rats; Rats, Wistar; Stroke; Thrombosis

This paper provides current information on the pharmacologic management of cardiovascular diseases. It also describes the drugs used to treat five common cardiovascular disorders--heart failure, coronary artery disease, atrial fibrillation, hypertension, and unstable angina--and lists their dental implications. This information can be used to monitor patients for potential adverse drug reactions and drug interactions and to provide an information base for medical consultation.

Topics: Angina, Unstable; Atrial Fibrillation; Cardiovascular Agents; Coronary Disease; Dental Care for Chronically Ill; Heart Failure; Humans; Hypertension

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Decision Making; Humans; Randomized Controlled Trials as Topic

Hypertension, a major risk factor for cardiovascular disease worldwide, remains inadequately diagnosed and treated, particularly in certain at-risk populations. Hypertension, often in association with other factors, increases the risk for the development of coronary artery disease (CAD). In turn, CAD increases the risk for related morbidity and mortality and presents treatment challenges. The chronobiology of many cardiovascular events offers a pathway for selecting optimal therapy for the hypertensive patient with CAD. Choosing a long-acting agent that achieves high plasma drug levels during critical hours may reduce the risk for cardiovascular morbidity and mortality.

Topics: Cardiovascular Agents; Chronotherapy; Circadian Rhythm; Coronary Disease; Hemodynamics; Humans; Hypertension; Risk Factors; Survival Rate

Biological functions and processes, including cardiovascular ones, exhibit significant circadian (24-hour) and other period rhythms. Ambulatory blood pressure assessment reveals marked circadian rhythms in blood pressure both in normotensive persons and hypertensive patients, whereas Holter monitoring substantiates day-night patterns in electrocardiographic events of patients with ischemic heart disease. The concept of homeostasis, that is, constancy of the milieu interne, which has dominated the teaching, research, and practice of medicine during the 20th century,is now being challenged by emerging concepts from the field of chronobiology-the science of biological rhythms. Epidemiologic studies document the heightened morning-time risk of angina, myocardial infarction, and stroke. Circadian rhythms in coronary tone and reactivity, plasma volume, blood pressure, heart rate, myocardial oxygen demand, blood coagulation, and neuroendocrine function plus day-night patterns in the nature and strength of environmental triggers all contribute to this morning vulnerability. Homeostatically devised pharmacotherapies, that is, medications formulated to ensure a near-constant drug concentration, may not be optimal to adequately control diseases that vary in risk and severity during the 24 hours. Moreover, circadian rhythms in the physiology of the gastrointestinal tract, vital organs, and body tissues may give rise to administration-time differences in the pharmacokinetics and effects of therapies. Thus the same medication consumed in the same dose under identical conditions in the evening and morning may not exhibit comparable pharmacokinetics and dynamics. New technology makes possible chronotherapy, that is, increase of the efficiency and safety of medications by proportioning their concentrations during the 24 hours in synchrony with biological rhythm determinants of disease. The chronotherapy of peptic ulcer disease achieved by the evening dosing of H 2-receptor antagonists and of asthma by the evening dosing of special drug delivery forms of theophylline and morning methylprednisolone administration has proven to be beneficial. Controlled-onset extended-release verapamil constitutes the first chronotherapy of essential hypertension and ischemic heart disease; once-a-day bedtime dosing results in a high drug concentration in the morning and afternoon and a reduced one overnight. Studies demonstrate effective 24-hour control of blood pressure, including the atte

Topics: Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Calcium Channel Blockers; Cardiovascular Agents; Chemistry, Pharmaceutical; Chronotherapy; Coronary Disease; Humans; Hypertension; Nitroglycerin; Vasodilator Agents

The clinical entities of unstable angina, non-Q wave myocardial infarction, and Q wave myocardial infarction share the same pathogenesis and, because of this, are linked under the heading of acute coronary syndromes. Prompt reperfusion in the early phase of acute ST segment elevation myocardial infarction, with thrombolysis or percutaneous transluminal coronary angioplasty, now has an established place in the treatment of this condition. However, thrombolysis has been disappointing and may be harmful in the treatment of unstable angina and non-Q wave myocardial infarction. While traditional therapy with morphine, oxygen, nitrates, aspirin, heparin, and beta blockers may be indicated in the treatment of all types of acute coronary syndromes, recent studies have led to advances in the treatment of unstable angina/non-Q wave myocardial infarction patients. In these patients, enoxaparin (a low molecular weight heparin) and the platelet glycoprotein IIb/IIIa receptor antagonists may be particularly effective.

Topics: Acute Disease; Cardiac Catheterization; Cardiovascular Agents; Coronary Disease; Heparin, Low-Molecular-Weight; Humans; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Syndrome; Thrombin

Important novel developments in the pharmacotherapy of cardiovascular diseases are briefly summarized. New results with lipid lowering statins in secondary prevention of atherosclerosis are mentionned. Atorvastatin, introduced recently, is compared to the other statins. The extended possibilities for inhibition of platelet-aggregation in coronary disease and after interventional coronary therapy with ticlopidine, clopidogrel and specific antagonists of platelet integrin IIb/IIIa receptors (abciximab, tirofibrane) as well as fibrinolysis with reteplase are covered. Among modern trends in pharmacotherapy of heart failure studies with angiotensin-II-receptor inhibition (losartane and related compounds) or betablockers (carvedilol) are worth mentioning.

Topics: Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Humans; Treatment Outcome

Topics: Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Coronary Disease; Humans; Oxidative Stress; Randomized Controlled Trials as Topic

The potential risk of drug-drug interactions is often overlooked during drug therapy selection. Multiple risk factors for drug-drug interactions exist in both the acute and chronic phases of acute coronary syndrome (ACS), including concomitant medications and underlying diseases. Some statins have been used for secondary prevention of coronary heart disease (CHD) in these patients and are not all equivalent in their susceptibility to drug-drug interactions. The lipophilic drugs lovastatin, simvastatin, atorvastatin, cerivastatin and fluvastatin are metabolized via the cytochrome P450 (CYP450) system in the liver and the gut, making them subject to potential interactions with concomitantly administered drugs that are competing for metabolism via this system. Clinically important interactions with simvastatin or lovastatin and drugs that inhibit the 3A4 isoenzyme (part of the CYP450 system) may result in myopathy and rhabdomyolysis, which can be fatal. However, pravastatin is water-soluble, it does not undergo metabolism via CYP450 to any significant extent (<1%), is excreted essentially unchanged and has not been shown to participate in any clinically relevant drug-drug interactions with CYP450 agents. When selecting drug therapy, knowledge of a drug's route of metabolism is important to predict and prevent life-threatening drug-drug interactions.

Topics: Anticholesteremic Agents; Cardiovascular Agents; Coronary Disease; Cytochrome P-450 Enzyme System; Drug Interactions; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors

Topics: Acute Disease; Angina, Unstable; Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Coronary Thrombosis; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Middle Aged; Myocardial Infarction; Syndrome

The coronary circulation is controlled by the central nervous system, circulating hormones and local vascular mechanisms. The importance of local regulatory mechanisms has only recently been recognized. The endothelium is in a strategical anatomical position within the blood vessel wall located between the circulating blood and vascular smooth muscle cells. It can respond to mechanical and hormonal signals from the blood; of particular importance is the fact that it is a source of mediators which can modulate the contractile state and proliferative responses of vascular smooth muscle cells, platelet function and coagulation as well as monocyte adhesion. Important relaxing factors are nitric oxide and prostacyclin and a putative hyperpolarizing factor. Nitric oxide also inhibits smooth muscle proliferation and, together with prostacyclin, platelet adhesion and aggregation. Bradykinin-induced nitric oxide production is regulated by angiotensin converting enzyme located on the endothelial cell membrane; indeed, the enzyme not only activates angiotensin I into angiotensin II, but also inactivates bradykinin. Endothelin-1 and thromboxane A2 and prostaglandin H2 are contracting factors produced by the endothelium. In contrast to thromboxane A2 and prostaglandin H2 which activate platelets, endothelin has no direct effects on these cells, but has proliferative properties in vascular smooth muscle. Under physiological conditions, the endothelium plays a protective role as it prevents adhesion of circulating blood cells, keeps the vasculature in a vasodilated state and inhibits vascular smooth muscle proliferation. In disease states, however, endothelial dysfunction contributes to enhanced vasoconstrictor responses, adhesion of platelets and monocytes and proliferation of vascular smooth muscle cells, events all known to occur in coronary artery disease. Nitrates substitute in part for deficient endogenous nitric oxide, while angiotensin converting enzyme inhibitors increase the bradykinin induced nitric oxide and prostacyclin production. The newly developed endothelin antagonists allow specific blocking of the effects of endothelin. Pharmacological correction of endothelial dysfunction may be important to treat coronary artery disease and its complications.

Topics: Acute Disease; Blood Platelets; Cardiovascular Agents; Coronary Disease; Endothelium, Vascular; Humans; Muscle, Smooth, Vascular; Myocardial Contraction; Nitric Oxide; Risk Factors; Syndrome

This review discusses the circadian phase dependency in the anti-anginal effects and in the pharmacokinetics of drugs used in the treatment of coronary heart diseased patients. beta-receptor blocking agents seem mainly to reduce ischaemic events during daytime hours and are of therapeutic value in the morning hours which are the hours of high cardiovascular risk. Calcium channel blockers seem to be less effective in reducing ischaemic event during the night and early morning. However, the galenic formulation and the type of calcium channel blocker may play an important role. Whereas the effects of the anti-ischaemic properties of oral nitrates are well established, their influence of the circadian organization of cardiovascular events needs to be clarified. Only limited data are available concerning the circadian phase dependency in the dose-response relationship of anti-anginal drugs. Such data would be valuable for a better understanding of the need of a time-specified drug treatment which is based on the circadian phase dependency of cardiovascular events such as coronary infarction and angina pectoris attacks.

Topics: Acute Disease; Adrenergic alpha-Antagonists; Calcium Channel Blockers; Cardiovascular Agents; Chronotherapy; Coronary Disease; Humans; Myocardial Ischemia; Nitrates; Syndrome

The growing size of trials on primary and secondary prevention of acute coronary syndromes characterised by very broad inclusion criteria may seem logical to 'trialists', who reason that the the broader the inclusion criteria, the easier it is to recruit large numbers of patients in a short period of time and the more widely applicable are the results of the study. However, large trials with very broad inclusion criteria raise two grounds for concern for physicians. The first is that the broader the inclusion criteria for enrollment in a trial in order to prove a statistically significant benefit, the greater the heterogeneity of the study population which is likely to include both susceptible and non-susceptible patients to the tested treatment. The second is that this method of assessment rapidly increases the number of treatments that produce a statistically-significant improvement in prognosis within the same broad group of patients. On the contrary, the identification of potential responders to a specific treatment can provide a personalised form of medical care suited to the needs of each individual patient with an optimal cost-benefit ratio. This approach, however, represents a major challenge as it can only be based on the identification of homogeneous subgroups of patients with common risk factors for the development of acute coronary syndromes or of their recurrence. This challenge can only be overcome by a strong commitment in funding studies on the multiple causes of acute coronary syndromes.

Topics: Acute Disease; Adult; Cardiovascular Agents; Coronary Disease; Cost-Benefit Analysis; Europe; Humans; Syndrome; United States

A rational approach to the treatment of chronic myocardial ischemia requires an appreciation of the pathophysiology of coronary artery disease and the treatment options available. Any factor that causes an imbalance between myocardial oxygen supply and demand can provoke ischemia. Myocardial oxygen requirements rise with increases in heart rate, contractility, or left ventricular wall stress. Myocardial oxygen supply is determined by coronary artery flow and myocardial oxygen extraction. Anti-anginal medications are the mainstay of anti-ischemic management and act to correct the balance between myocardial supply and demand by increasing coronary blood flow, reducing myocardial oxygen requirements, or both. These medications include nitrates (which act principally by venous vasodilation, but also probably by coronary dilation), beta-blockers (which act mainly by reducing heart rate and cardiac contractility), and calcium channel blockers (which act principally by arterial and coronary vasodilation). The choice of therapy and its effectiveness depend on the underlying cause of ischemia. The complimentary mechanisms of action of these drug classes suggest that their use in combination may result in a greater reduction in myocardial oxygen demand than that achieved with monotherapy. In addition, the pharmacological actions of some of these drugs may serve to offset the undesirable side effects associated with others, for example, the reflex tachycardia produced by some calcium channel blockers may be offset by beta-blocker therapy. Finally, aspirin and lipid-lowering drugs and the potential role for anti-oxidants must also be considered in combination therapy. Invasive techniques for myocardial ischemic management, such as coronary artery bypass and coronary angioplasty, improve myocardial oxygen supply by relieving or circumventing the atherosclerotic obstruction responsible for ischemia. Surgery is the preferred technique in patients with certain medical conditions, for example, those with triple-vessel disease, but is not recommended in patients with mild angina unless left main artery disease is present.

Topics: Animals; Cardiovascular Agents; Chronic Disease; Coronary Disease; Humans; Myocardial Ischemia

Patients with cardiovascular disease can derive significant benefit from the implementation of risk reduction therapies. Until recently, management of patients with coronary heart disease has centered on the use of angioplasty, bypass surgery and medical therapy for severe fixed obstructions. Several large randomized clinical trials now demonstrate the importance of medical risk reduction therapies in these patients. A consensus panel of the American Heart Association recommends that health care providers use a group of risk reduction therapies, which can significantly extend overall survival, improve quality of life, decrease the need for interventional procedures such as angioplasty and bypass grafting, and reduce the incidence of subsequent myocardial infarction. Since a minority of patients with cardiovascular disease now benefit from these strategies, changes in our health care delivery systems are recommended. Risk reduction case management by nursing staff can assist physicians and improve implementation of and patient adherence to these therapies. Programs are being discussed to develop support by third-party insurers for risk reduction therapies. Application of these therapies should be a routine part of care for patients with cardiovascular disease.

Topics: American Heart Association; Cardiovascular Agents; Case Management; Coronary Disease; Exercise; Humans; Hyperlipidemias; Hypertension; Myocardial Infarction; Nurses; Quality of Life; Randomized Controlled Trials as Topic; Risk; Risk Factors; Smoking; Smoking Cessation; Survival Rate; United States; Weight Loss

Topics: Adenosine; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Humans; Tomography, Emission-Computed; Tomography, Emission-Computed, Single-Photon; Vasodilator Agents

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Decision Trees; Diagnosis, Differential; Humans; Kidney Failure, Chronic; Risk Factors; Survival Analysis

Coronary heart disease (CHD) is the single most common cause of death in England and it has been estimated that about 26 per cent of all deaths each year are caused by CHD (Department of Health 1993). In light of this, it is important that all nurses understand the current investigations and treatment available for people with CHD.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Heart Transplantation; Humans; Mass Screening

Coronary artery disease is a major clinical problem in the elderly. This article discusses the medical management of stable and unstable angina pectoris. A review of the general measures and drug therapy used to treat these disorders, especially as they relate to the elderly patient are presented. In addition, new insights into the pathophysiologic mechanisms of chronic stable angina and unstable angina are reviewed.

Topics: Adrenergic beta-Antagonists; Aged; Angina Pectoris; Angina, Unstable; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Female; Humans; Male; Nitrates; Vasodilator Agents

The primary goals in treatment of unstable angina are to relieve pain and prevent or limit myocardial infarction or ischemia. Patients with distinct, rapid progression of their usual angina pattern should be admitted to a coronary care unit and given heparin and intravenous nitrates as well as aspirin. Cardioselective beta blockers should also be administered when there are no contraindications. Intravenous thrombolytic agents are indicated in patients with objective evidence of ischemia who fit criteria for this therapy. However, thrombolysis is not advocated for routine treatment of unstable angina. Percutaneous transluminal coronary angioplasty or coronary artery bypass grafting should be considered--depending on the location, age, and morphology of the culprit lesion and the degree of left ventricular dysfunction--in patients who have refractory or recurrent ischemia despite aggressive medical therapy. However, in general, high-technology interventions are not a substitute for long-term regimens, such as risk-factor and lifestyle modification, daily aspirin, and pharmacologic therapies aimed at maximizing cardiac function.

Topics: Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Humans

Topics: Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Diabetes Mellitus, Type 1; Female; Humans; Male; Myocardial Infarction; Prognosis

In the last few years, pharmacologic stress echocardiography is emerging as a promising diagnostic tool with a favorable cost/benefit ratio. Its main clinical applications include the assessment of coronary artery disease, the identification of viable myocardium, and risk stratification before major vascular surgery. However, cardiac (arrhythmic, ischemic, or hemodynamic) as well as noncardiac complications have been reported, so that a risk/benefit analysis is advisable in view of the extensive introduction of this technique in the clinical arena. The most popular pharmacologic agents employed for stress echocardiography are dipyridamole, dobutamine, and adenosine. A comparative analysis with exercise stress testing, the classical standard a reference of all ischemia-provoking tests, confirms that in terms of safety and tolerability pharmacologic stress echocardiography may be considered a good alternative in patients unable to exercise maximally. No appreciable difference among the safety profiles of the most common pharmacologic agents has been found, but a careful evaluation of the risk/benefit ratio is advisable for any stressor in the individual patient by considering the relative importance of the expected diagnostic contribution and the pharmacodynamic impact of the test. Finally, adequate training of the operator and monitoring of the patient during stress and recovery are essential for getting optimal safety conditions.

Topics: Adenosine; Cardiotonic Agents; Cardiovascular Agents; Coronary Disease; Dipyridamole; Dobutamine; Echocardiography; Exercise Test; Humans; Vasodilator Agents

Exercise echocardiography seems a relatively reliable diagnostic technique for evaluation of patients with coronary artery disease. The prognostic aspects of the stress echo have widely been documented with the use of various stressors (exercise, dipyridamole, dobutamine, pacing). Rapid atrial pacing echocardiography is highly specific and sensitive technique for the detection of the coronary disease, especially in patients who are unable to perform an active stress test. This technique minimizes the factors decreasing image quality during exercise (chest wall movements and hyperventilation). Exercise echocardiography is safe, relatively cheap, and can be done in every hospital.

Topics: Cardiac Pacing, Artificial; Cardiovascular Agents; Coronary Disease; Echocardiography; Electric Stimulation; Exercise Test; Humans; Prognosis; Sensitivity and Specificity

Angina pectoris and asymptomatic myocardial ischemia are part of the spectrum of coronary heart disease. Not the presence or absence of angina determines the future of the patient, but repeated ischemia and the progression of the coronaropathy. This progression is neither linear with time, nor is the moment of plaque rupture foreseeable. Silent myocardial infarctions increase with age and are very frequent in diabetics. In patients without neuropathy but with asymptomatic myocardial ischemia the central pain threshold is higher than in patients with angina pectoris. The best noninvasive test for the detection, localization and estimation of extension of myocardial ischemia, be it pain-free or symptomatic, is 201-thallium scintigraphy, combined with the exercise ECG. The fight against all amendable cardiovascular risk factors and pharmacotherapy are the first steps, if asymptomatic myocardial ischemia is suspected. Augmented dyspnea on effort and rhythm disturbances are indicators of advanced multivessel heart disease. Under these circumstances coronary angiography is indicated, and further treatment should follow the generally accepted rules such as for patients with angina pectoris.

Topics: Aging; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Diabetes Complications; Exercise Test; Humans; Myocardial Ischemia; Prognosis; Thallium Radioisotopes

The incidence and prevalence of congestive heart failure increase exponentially with advancing age. Congestive heart failure in the elderly is characterized by a multifactorial etiology, a high proportion of accompanying degenerative changes of the cardiovascular system and age-specific problems regarding diagnosis and treatment. The treatment strategy is the same as in younger patients, but the higher incidence of adverse effects and complications demands special awareness. The majority of decompensations leading to hospitalization are precipitated by insufficient compliance in life style change and drug intake.

Topics: Adult; Aged; Aging; Arrhythmias, Cardiac; Arteriosclerosis; Cardiomyopathies; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Hypertension; Incidence; Middle Aged; Prevalence

Topics: Aged; Aging; Cardiovascular Agents; Contraindications; Coronary Disease; Female; Humans; Male

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Hemodynamics; Humans; Myocardial Infarction; Myocardial Ischemia; Myocardial Revascularization; Postoperative Complications

To review clinical research pertaining to continuous ambulatory peritoneal dialysis (CAPD) and the heart.. A Medline computer search was employed to identify appropriate references from 1970 - 1994. Indexing terms were: continuous ambulatory peritoneal dialysis, hemodialysis, heart or cardiac, left ventricle, coronary artery disease, and survival. English and non-English language abstracts were scrutinized.. Forty-six studies were reviewed and utilized. Numerical data extracted are reported in this review as they were reported in the original article.. This review provides a broad-based survey of studies pertaining to CAPD and the heart. Most of the studies relate to CAPD and left ventricular structure or function. Little information exists concerning CAPD and coronary artery disease, valvular disease, pericardial disease, and cardiac arrhythmias. Studies pertaining to patient survival on CAPD identify coronary artery disease and congestive heart failure as major risk factors, but in-depth quantification of these cardiovascular disorders is lacking in the literature.. CAPD is capable of decreasing left ventricular (LV) volume and improving LV systolic function in patients with LV enlargement and those with LV systolic dysfunction. The effect of CAPD on left ventricular hypertrophy (LVH) and LV diastolic function is variable. CAPD produces symptomatic improvement in patients with refractory congestive heart failure, but its effect on survival in such patients is uncertain. Atherogenic lipid abnormalities occur in CAPD patients. The clinical significance of these abnormalities is uncertain. Coronary artery bypass surgery can be performed safely and effectively on CAPD patients. CAPD is not arrhythmogenic. Survival of CAPD patients is similar to that of hemodialysis patients except in elderly diabetics for whom it is slightly lower.

Topics: Arrhythmias, Cardiac; Cardiac Surgical Procedures; Cardiovascular Agents; Coronary Disease; Heart Diseases; Humans; Kidney Failure, Chronic; Peritoneal Dialysis, Continuous Ambulatory; Ventricular Function, Left

Heart failure is a major and increasing public health problem. Coronary artery disease has become the major etiology of heart failure. The differentiation of viable from nonviable myocardium in patients with coronary disease and impaired left ventricular systolic function is an issue of extreme importance to the clinician. Several diagnostic modalities including thallium imaging, dobutamine stress echocardiography, and positron emission tomography have gained considerable acceptance as useful tools in detecting myocardial viability. The management of heart failure with preserved left ventricular systolic function includes the use of beta blockers, calcium channel blockers, and nitrates. In patients with heart failure and impaired left ventricular systolic function, angiotensin converting enzyme inhibitors have become an integral part of the medical management. In patients whose angina is unresponsive to the addition of nitrates, a trial of bet blockers should be attempted and first generation calcium blockers should be avoided. Revascularization should always be sought, particularly when myocardial viability has been established.

Topics: Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Myocardial Revascularization; Ventricular Dysfunction, Left

The aim of our review is to summarize relevant data on the perioperative use of anti-ischaemic drugs in patients at risk for or with proven coronary heart disease.. The accessible medical literature according to current electronic information sources was explored.. One in every eight general anaesthetics is administered to a patient at risk for or with proven coronary heart disease. Of these patients, it is estimated that 20%-40% have perioperative myocardial ischaemia (PMI), the majority being non-symptomatic. This figure correlates with the occurrence of postoperative cardiac complications and myocardial infarction. The anaesthetist therefore has an important role to play in reducing the rate of perioperative cardiac sequelae. This can be achieved with good control of haemodynamic stability and the timely and appropriate use of antiischaemic drugs. Nitrocompounds (nitrates, molsidomine) serve as the gold standard in current angina pectoris treatment. Acting as coronary and systemic vasodilators, they effect an immediate reduction in preload and have been shown to be the drugs of first choice for intraoperative myocardial ischaemia. Beta-blockers reduce the rate of PMI to a greater extent than nitrates. They are also effective in myocardial ischaemia not accompanied by an increased heart rate. Single pre-operative administration of beta-blockers has also been shown to be beneficial in reducing the incidence of perioperative tachycardia, hypertension, and PMI. Consequently, such one-time medication can be considered for previously untreated high-risk patients presenting for surgery. The continuation of oral calcium channel blockers to the morning of surgery also reduces the rate of PMI and myocardial infarction in coronary-bypass patients, and combination with beta-blockers enhances this effect. Intra-operative diltiazem infusions are similarly advantageous in this patient group. In addition to nitrates, calcium antagonists are the drug of choice for coronary vasospasm. Drugs inhibiting platelet aggregation have a particular role in patients with coronary heart disease, however, they also cause increased perioperative bleeding. Consequently, it is recommended that these medications be discontinued 5-10 days prior to major surgery, with the exception of high-risk patients. Pilot studies using alpha 2-agonists have shown reduced anaesthetic requirements and a reduction in PMI. The perioperative relevance of these drugs is currently being investigated.. Beta-blockers, calcium channel blockers, nitrates, and possibly alpha 2-agonists lead to reduced rates of PMI and other cardiac complications in risk patients. Current anti-anginal medications, with the exception of anti-platelet agents, should be maintained to the day of surgery and continued as soon as possible thereafter. All of these drugs except anti-platelet agents may also be used intra-operatively, however, possible interactions with anaesthetic agents should be carefully considered.

Topics: Anesthesia, General; Cardiovascular Agents; Coronary Disease; Humans; Intraoperative Complications; Risk Factors

With rapidly progressing therapeutic methods in the cardiovascular medicine, scientific evaluations for newly developed cardiovascular drugs and therapies have become mandatory. We have launched five large scale multicenter cooperative studies, namely, Japan Multicenter Investigation for Cardiovascular Drugs/Therapies, J-MIC (I), (B), (M), (S), and (K). The aims of studies include to investigate: the best therapeutic approach in patients with acute myocardial infarction who underwent thrombolytic therapy with or without any adjunctive treatment (I), the long-term comparative study (3 years) of nifedipine (extended release tablet) with ACE inhibitor in patients with essential hypertension and ischemic heart disease (B), the long-term effect (3 years) of trapidil and/or ethyl icosapentate in patients with ischemic heart disease with or without arteriosclerotic obstructive disease in terms of progression or regression of atherosclerotic changes in coronary as well as peripheral arteries (M), the efficacy and safety of pravastatin to prevent post-PTCA restenosis (S), and regression of atherosclerotic lesion of coronary arteries in patients with familial hypercholesterolemia by LDL apheresis (K).

Topics: Cardiovascular Agents; Clinical Protocols; Coronary Artery Disease; Coronary Disease; Female; Heart Diseases; Humans; Hypertension; Japan; Male; Multicenter Studies as Topic

Topics: Adrenergic beta-Antagonists; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Humans; Nitrates; Platelet Aggregation Inhibitors; Primary Prevention

Topics: Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Coronary Disease; Heart Failure; Heart Transplantation; Hemodynamics; Humans; Myocardial Contraction; Myocardial Infarction; Prognosis; Ventricular Function, Left

Topics: Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Calcium Channel Blockers; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Fish Oils; Humans; Lovastatin; Methylprednisolone; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Recurrence

Exercise testing remains an important non-invasive diagnostic test modality in patients with coronary artery disease. In recent years considerable advances have been achieved in the test methodology and in interpretation. The following points are important for the test methodology: (1.) The optimal exercise time is 8-12 minutes. (2.) The stepwise increases in work load should be as small as possible (ideally, according to the ramp protocol). (3.) Whenever possible patients should be tested on a symptom-limited basis. Submaximal ergometry is only indicated in the 2-3 weeks after acute myocardial infarction. (4.) The value of the exercise test depends mainly on the double product achieved (maximal systolic blood pressure x maximal heart rate). The interpretation of the exercise test should consider the clinical and hemodynamic responses and ST-segment changes. ST-segment depressions are the most important diagnostic parameter. The ECG localization (most frequently lateral wall) does not necessarily correspond to the anatomic localization. Exercise capacity and blood pressure response are important prognostic variables.

Topics: Cardiovascular Agents; Coronary Disease; Electrocardiography; Exercise Test; Hemodynamics; Humans; Myocardial Infarction; Physical Endurance; Prognosis; Time Factors

Primary care physicians are often faced with follow-up care of patients who have had coronary artery bypass graft surgery. Familiarity with possible cardiac, pulmonary, neurologic, and infectious complications is important, and an open line of communication with the consulting cardiologist and the cardiac surgeon is essential. Modification of coronary risk factors is one of the greatest challenges after bypass surgery. The primary care physician plays the major role in directing and monitoring life-style changes that reduce the risk of progressive coronary atherosclerosis. Recurrent myocardial ischemia after bypass surgery should be evaluated fully and is often responsive to nonsurgical therapies, including percutaneous transluminal coronary angioplasty.

Topics: Activities of Daily Living; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Family Practice; Follow-Up Studies; Humans; Myocardial Ischemia; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Recurrence; Reoperation; Risk Factors; Time Factors

Topics: Adrenergic beta-Antagonists; Cardiovascular Agents; Coronary Disease; Drug Interactions; Hemodynamics; Humans; Physical Endurance; Physical Fitness

The incidence of ischemic cardiac events is highest in the early morning hours (symptomatic and asymptomatic cardiac ischemia, myocardial infarction, and sudden death). Quantitatively, however, most of them occur during the rest of the day; therefore, an ideal therapy should be established in the early morning hours and be efficient all day long. We recommend that nitrates should be taken as early as possible after a dose-is-free interval during the night. Patients taking beta-blockers do not show a circadian rhythm of the incidence of ischemic cardiac events. Compliance can be improved with the never long-acting agents. Therapy should be tailored individually for each patient. It is not yet known whether calcium blockers influence the circadian rhythm. The efficacy of the never preparations is comparable to the older ones. Aspirin can be taken at any time of the day because of its long duration of action.

Topics: Angina Pectoris; Anticoagulants; Calcium Channel Blockers; Cardiovascular Agents; Circadian Rhythm; Coronary Disease; Humans; Platelet Aggregation Inhibitors

Under certain circumstances the effect of insulin to promote glucose uptake in peripheral tissues is reduced because of a resistance to insulin action. This insulin resistance and the resulting hyperinsulinaemia are now recognised as common background factors that may be responsible for hypertension, hyperlipidaemia, decreased thrombolysis and also impaired glucose tolerance and diabetes. Hyperinsulinaemia has also been identified as an independent risk factor for coronary heart disease and promotes smooth muscle cell growth and plaque formation. A series of studies have now demonstrated that treatment with selective beta-blockers as well as thiazide diuretics impair insulin sensitivity by 15-30% and causes a compensatory increase in insulin concentrations. Furthermore, lipoprotein concentrations are affected in an unfavourable way. This is in contrast to the drugs belonging to ACE-inhibitors, calcium-channel blockers and alpha 1-blocker classes that are either neutral or may have the opposite effects in these respects.

Topics: Antihypertensive Agents; Cardiovascular Agents; Coronary Disease; Humans; Hyperinsulinism; Hypolipidemic Agents; Insulin Resistance

Percutaneous transluminal coronary angioplasty (PTCA) is now practised worldwide and offered to patients as a viable alternative to coronary artery bypass graft surgery or pharmacological therapy. However, despite its undoubted popularity, there is still a substantial amount of mystery surrounding this treatment modality. Firstly, we really don't know how it "works" or, why it "works" in some patients and not in others; secondly, we're not quite certain how to describe the impact of treatment with PTCA on the beneficiary insert; by the effect on the lesion itself as measured by coronary angiography, or by the effect on coronary blood flow, which is also measurable by various techniques, or by the effect on myocardial perfusion which can also be "objectively assessed", or indeed, by its impact on the well-being of the patient, which cannot actually be measured, but is the primary aim of the treatment as offered to the patient - since there is no evidence supporting a beneficial effect for PTCA on longevity (unlike CABG in certain patient subgroups). Thirdly, similar difficulties exist regarding the assessment of the long-term benefit of PTCA, which are further compounded by the variable response, over time, of the vessel wall to balloon dilatation, a process known as "restenosis", or the "Achilles heel". The main difficulties in this area are that: a) the pathology of the process is poorly understood, and much mystery and doubt still lingers, b) there is no universal agreement on how to define "restenosis", c) although angiography appears to be the best widely available descriptive technique, many investigators continue to use antiquated analysis methodology, the inaccuracy of which has been frequently and conclusively demonstrated. Fourthly, the introduction of new devices, instead of bringing answers or solutions, has further compounded the problem, by thus far failing to reduce restenosis, while increasing the armimentarium, and therefore, "the doctor's dilemma". In this treatise we present the pathological theory of restenosis and its clinical correlations, we identify the difficulties in its assessment, and propose our solution to this significant aspect of the problem. We provide an extensive summary of pharmacological attempts to prevent restenosis, a description of the new devices and their potential role, as well as a though for the future.

Topics: Angioplasty, Balloon, Coronary; Angioplasty, Laser; Cardiovascular Agents; Coronary Angiography; Coronary Circulation; Coronary Disease; Humans; Recurrence

Topics: Anesthetics; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Humans; Surgical Procedures, Operative

Topics: Cardiovascular Agents; Cholesterol, Dietary; Coronary Artery Bypass; Coronary Disease; Diet; Humans; Myocardial Revascularization

Treatment of patients with heart failure due to major ventricular systolic dysfunction should aim not only at symptomatic but also at prognostic improvement. If correction of the underlying problem is not possible, treatment should slow down the progression of cardiac failure and eliminate triggers for sudden cardiac death due to electromechanical dissociation or arrhythmias. In every patient with chronic congestive heart failure screening for myocardial ischemia and complete revascularization is mandatory, if possible. In patients with coronary artery disease and diminished systolic function, beta-blockade may improve prognosis by reducing ischemic events and sudden cardiac death. The incidence of life-threatening arrhythmias in patients with heart failure may be reduced by eliminating facilitating factors like electrolyte disturbances, altered autonomic tone and raised intracardiac pressure rather than by antiarrhythmic medical treatment itself. One of the most important prognostic aspects in treatment is the interference with the development of the cardiomyopathy of overload, uniformly observed in chronic congestive heart failure. Modification of mechanical and neuroendocrine stimuli may postpone myocardial hypertrophy and interstitial hyperplasia as a consequence of altered gene expression. Early treatment with ACE inhibitors and in certain patients with betablockers are the most promising strategies to delay the progression of the disease. In contrast, positive inotropic drugs, including digitalis and phosphodiesterase inhibitors, do not improve prognosis. Calcium antagonists should also be used with restriction, as Verapamil and Diltiazem, but also Nifedipine may adversely affect the outcome in congestive heart failure patients.

Topics: Arrhythmias, Cardiac; Cardiomyopathies; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Myocardial Revascularization; Prognosis

Topics: Adrenergic beta-Antagonists; Amiodarone; Angioplasty, Balloon, Coronary; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Humans; Myocardial Revascularization; Nitrites; Oxygen Inhalation Therapy

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Coronary Artery Bypass; Coronary Disease; Follow-Up Studies; Humans; Survival Rate

Chronopathology of cardiovascular disease is now well documented. Silent myocardial ischaemia involves the same pathophysiological changes as conventional ischaemia. Early morning peaks in angina and myocardial ischaemia call for adequate timing of medication. beta-blockers abolish the morning peak, and aspirin reduces morning infarctions. The effects of other antianginals on these phenomena are presently unknown.

Topics: Angina Pectoris; Blood Pressure; Cardiovascular Agents; Circadian Rhythm; Coronary Disease; Drug Administration Schedule; Heart Rate; Humans

In acute as well as in chronic ischemic heart disease, congestive heart failure indicates a poor prognosis. Treatment after acute myocardial infarction should differentiate between specific subsets. In cardiogenic shock due to extensive ischemic damage, acute revascularization by PTCA or CABG improves the otherwise poor outcome substantially. In congestive heart failure, pre- and afterload reduction by nitrates should be combined with dopamine if systolic blood pressure is below 100 mmHG or dobutamine if an inotropic substance is necessary despite systolic blood pressure greater than 100 mmHg. Amrinone is a potent alternative which combines positive inotropic and vasodilating properties. In chronic ischemic heart disease, congestive heart failure is a clearly defined indication for complete revascularization, if possible. As to drug treatment, progression of the disease characterized by a cardiomyopathy of overload as well as neurohormonal and peripheral maladaptation should be stopped in parallel with symptom relief. Therefore, ACE-Inhibitors are combined very early with diuretic treatment, and digitalis should be added in refractory patients.

Topics: Amrinone; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Digitalis Glycosides; Diuretics; Heart Failure; Humans; Myocardial Infarction; Shock, Cardiogenic; Vasodilator Agents

Topics: Cardiovascular Agents; Circadian Rhythm; Coronary Disease; Humans; Myocardial Infarction; Risk Factors; Sleep Stages

Topics: Cardiovascular Agents; Coronary Disease; Humans; Primary Prevention; Risk Factors

Results are presented of surgical treatment of ischemic heart disease at the Kiev Research Institute of Cardiovascular Surgery in 1988-1989; 424 patients were operated on including 73 undergoing aneurysmectomy and valve prosthesis. The lethality was 6.1% improvement was observed in 96.7%; 78.3% were completely free of angina attacks. The tactics of medical and surgical treatment of ischemic heart disease are discussed.

Topics: Angina Pectoris; Cardiac Care Facilities; Cardiovascular Agents; Coronary Disease; Humans; Myocardium; Oxygen Consumption; Ukraine

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Coronary Disease; Energy Metabolism; Humans; Myocardium

Coronary angioplasty is an accepted method of revascularization in selected patients with coronary artery disease. Immediately after a successful angioplasty, initial management concentrates on the detection and treatment of coronary artery spasm and acute vessel closure, should these complications occur. Once the patient is ambulatory, a formal assessment of the success of the procedure may be appropriate in some patients. Medical management is aimed at reducing the risk of coronary spasm and modifying those factors that may cause restenosis. During the next six months, coronary risk factor modification should be started while the patient is observed for symptoms that may suggest restenosis.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Coronary Vasospasm; Humans; Recurrence; Time Factors

Fifty years ago it was observed that a sudden restoration of antegrade flow in the ischemic myocardium can lead to a paradoxical deterioration of cardiac function. The implications of this observation were only fully understood during the last decade when, thanks to the improvement of angiographic methods and the development of thrombolytic agents, reperfusion could be demonstrated in humans. At present, it is generally accepted that reperfusion phenomena play an important role in ischemic heart disease and probably the reperfusion damage, which may occur as a consequence of thrombolytic therapy, reduces the finally observed effect of these agents. During the last few years, many agents have been studied for their potential to reduce reperfusion damage. Several groups of these agents and their mechanism of action are discussed in this report. Special attention is paid to the possible effects of angiotensin converting enzyme inhibitors in this situation, as this group of agents combine several interesting characteristics of other groups, among which are their effects on norepinephrine levels, prostaglandin synthesis, and free radicals.

Topics: Cardiomyopathies; Cardiovascular Agents; Coronary Disease; Humans; Myocardial Reperfusion Injury

Atherosclerotic coronary artery disease is an important problem in the elderly and is the leading cause of death. It is a diagnosis that is often difficult to make; signs and symptoms of angina pectoris and myocardial infarction can be atypical in the elderly patient for a variety of reasons. The chest radiograph, electrocardiogram, and echocardiogram can provide diagnostic clues as to the presence of coronary artery disease. Exercise testing is foremost among the noninvasive diagnostic modalities, but it has significant limitations particular to the elderly patient. These include a decreased ability to exercise in the elderly, difficulty in interpretation because of an abnormal resting electrocardiogram, and the nature of an imperfect test that provides a statement of probability rather than an unequivocal diagnosis. Cardiac catheterization can be performed with minimal risk in selected, particularly unstable patients, in whom a surgical alternative is contemplated. The elderly patient can benefit as much from coronary artery bypass graft surgery as younger counterparts, albeit with a modestly increased risk. The medical therapy of coronary artery disease, stable and unstable angina, and myocardial infarction is not substantially different in the older patient. Nitrates, beta blockers, and calcium antagonists provide relief of anginal symptoms. The older patient stands to derive the same benefits from CCU monitoring as does the younger patient. An increased awareness of adverse drug reactions is necessary, however, and as for patients of any age, the particular goals of therapy may differ substantially and require an individualized approach.

Topics: Aged; Angina, Unstable; Arrhythmias, Cardiac; Cardiac Catheterization; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Echocardiography; Exercise Test; Humans; Myocardial Infarction

Topics: Behavior; Cardiovascular Agents; Coronary Disease; Diet; Escape Reaction; Humans; Physical Exertion; Risk; Sex Factors; Stress, Physiological; Stress, Psychological; Type A Personality

An appreciation of the hemodynamic and biochemical changes induced by drugs is critical for a logical diagnostic interpretation of graded stress tests and the evaluation of the projected exercise prescription and exercise programs that a patient is asked to follow. Drug therapy is clearly not a contraindication to acute or chronic exercise as long as the potential benefits and complications of exercise and drug interaction are considered.

Topics: Angina Pectoris; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Hypertension; Physical Exertion

Topics: Acute Disease; Animals; Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Disease; Coronary Vessels; Diastole; Dinoprostone; Dogs; Heart Arrest, Induced; Humans; Infusions, Parenteral; Myocardial Infarction; Perfusion; Prostaglandins E; Streptokinase; Time Factors

Topics: Animals; Arachidonic Acids; Cardiovascular Agents; Coronary Disease; Free Radicals; Humans; Leukocytes; Lysosomes; Myocardial Infarction; Myocarditis; Necrosis; Oxygen Consumption; Phospholipids

The exercise test response and exercise capacity of patients with atherosclerotic coronary heart disease may be significantly altered by a number of commonly used cardiovascular drugs, alone or in combination, via complex interactions of hemodynamic and electrophysiologic changes. The clinician must assess the effects of pharmacotherapy when evaluating the results of exercise testing as well as when prescribing a rehabilitative exercise training regimen.

Topics: Adrenergic beta-Antagonists; Anti-Arrhythmia Agents; Antihypertensive Agents; Calcium Channel Blockers; Cardiovascular Agents; Catecholamines; Coronary Disease; Digitalis Glycosides; Electrocardiography; Exercise Test; Humans; Nitroglycerin; Physical Exertion; Vasodilator Agents

The strategy of primary prevention of coronary heart disease (CHD) needs reconsideration. Recent results of trials of reducing the risk of CHD in those at moderate risk have been inconclusive and disappointing. More may be expected from intervention in those at high risk, and a selective policy is advocated. But, in those at high risk, it is usually necessary to give drugs in order to reduce the risk from hypertension and hypercholesterolaemia. Many currently used and popular drugs have never been submitted to rigourous long-term testing of their safety, although it was only through formal clinical trials that the adverse effects of clofibrate and of thiazides were identified. More, not fewer, clinical trials are needed if we are to avoid new tragedies. A plea is made for the urgent establishment of drug data banks to permit accurate monitoring of changes in the incidence of commonly occurring diseases in relation to the increasing use of drugs for primary prevention of vascular diseases and for social convenience.

Topics: Adrenergic beta-Antagonists; Cardiovascular Agents; Cerebrovascular Disorders; Cholesterol; Clofibrate; Coronary Disease; Diuretics; Humans; Hypertension; Information Systems; Lipids; Risk; Thrombosis

Many cardiovascular drugs can significantly alter the exercise capacity of patients with symptomatic atherosclerotic coronary heart disease. The effects of specific pharmacological agents and of regiments of combined drug therapy on the results of exercise testing and in relation to exercise training warrant careful consideration.

Topics: Adrenergic beta-Antagonists; Antihypertensive Agents; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Digitalis Glycosides; Exercise Test; Exercise Therapy; Heart Rate; Humans; Myocardial Contraction; Nitrates; Vasodilator Agents

Topics: Adrenergic beta-Antagonists; Animals; Anti-Arrhythmia Agents; Anticoagulants; Antihypertensive Agents; Cardiotonic Agents; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Heart Rate; Myocardial Contraction

Topics: Angina Pectoris; Angina Pectoris, Variant; Cardiovascular Agents; Clinical Enzyme Tests; Coronary Angiography; Coronary Artery Bypass; Coronary Disease; Electrocardiography; Humans; Myocardial Infarction; Myocardial Revascularization; Prognosis

Topics: Animals; Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Death, Sudden; Denervation; Dogs; Heart; Humans; Stellate Ganglion; Sympathectomy; Sympathetic Nervous System; Ventricular Fibrillation

Topics: Anti-Arrhythmia Agents; Anticoagulants; Antihypertensive Agents; Cardiotonic Agents; Cardiovascular Agents; Central Nervous System Stimulants; Coronary Disease; Heart Failure; Hepatomegaly; Humans; Hypnotics and Sedatives; Oxygen Inhalation Therapy; Vasodilator Agents

Topics: Amyl Nitrite; Cardiovascular Agents; Coronary Disease; Digitalis Glycosides; Heart Diseases; Humans; Nitroglycerin; Pharmacology; Quinidine

Cardiorenal syndrome (CRS) is a group of disorders in which heart or kidney dysfunction worsens each other. This study aimed to explore the improvement effect of nicorandil on cardiorenal injury in patients with type I CRS. Patients with coronary heart disease complicated with type I CRS were enrolled. Based on the conventional treatment, the patients were prospectively randomized into a conventional treatment group and a nicorandil group, which was treated with 24 mg/d nicorandil intravenously for 1 week. Fasting peripheral venous blood serum and urine were collected before and at the end of treatment. An automatic biochemical analyzer and enzyme linked immunosorbent assay were used to detect B-type brain natriuretic peptide (BNP), serum creatinine (Scr) and cystatin C (Cys-C), renal injury index-kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), and interleukin-18 (IL-18) levels. The left ventricular ejection fraction was measured by echocardiography. All measurements were not significantly different between the nicorandil and conventional treatment groups before treatment (all P > 0.05), and BNP, Scr, Cys-C, NGAL, KIM-1, and IL-18 were decreased in the 2 groups at the end of treatment (all P < 0.05). Compared with the conventional treatment group, BNP, Scr, Cys-C, NGAL, KIM-1, and IL-18 were more significantly decreased in the nicorandil group (all P < 0.05) and left ventricular ejection fraction was more significantly increased (P < 0.05). Therefore, nicorandil could significantly improve the cardiac and renal function of patients with type I CRS. This may prove to be a new therapeutic tool for improving the prognosis and rehabilitation of type I CRS.

Topics: Aged; Aged, 80 and over; Biomarkers; Cardio-Renal Syndrome; Cardiovascular Agents; China; Coronary Disease; Creatinine; Cystatin C; Female; Functional Status; Hepatitis A Virus Cellular Receptor 1; Humans; Interleukin-18; Kidney; Lipocalin-2; Male; Middle Aged; Natriuretic Peptide, Brain; Nicorandil; Prospective Studies; Recovery of Function; Time Factors; Treatment Outcome; Ventricular Function, Left

To explore how patients with experience of acute coronary heart disease make sense of, and deal with, the fact of being prescribed cardiovascular preventive medication.. Qualitative interview study.. Swedish primary care.. Twenty-one participants with experience of being prescribed cardiovascular preventive medication, recruited from a randomised controlled study of problem-based learning for self-care for coronary heart disease.. The participants were interviewed individually 6-12 months after their hospitalisation for acute coronary disease. A narrative analysis was conducted of their accounts of being prescribed cardiovascular preventive medication.. Four themes shape the patients' experiences:. Unmet existential needs when being prescribed cardiovascular preventive medication seem to be a component of the burden of treatment. A continuous and trustful relationship with the prescribing doctor may facilitate the reconciliation of conflicting self-images, and support patients in their efforts to incorporate their medicines taking into daily life.

Topics: Cardiovascular Agents; Coronary Disease; Humans; Medication Adherence; Qualitative Research; Sweden

Mobile health-based individualized interventions have shown potential effects in managing cardiovascular risk factors. This study aims to assess whether or not mHealth based individualized interventions delivered by an Individualized Cardiovascular Application system for Risk Elimination (iCARE) could reduce the incidence of major cardiovascular events in individuals with coronary heart disease.. This study is a large-scale, multi-center, parallel-group, open-label, randomized controlled clinical trial. This study will be conducted from September 2019 to December 2025. A total of 2820 patients with coronary heart disease will be recruited from two clinical sites and equally randomized into three groups: the intervention group and two control groups. All participants will be informed of six-time points (at 1, 3, 6, 12, 24, and 36 months after discharge) for follow-up visits. Over a course of 36 months, patients who are randomized to the intervention arm will receive individualized interventions delivered by a fully functional iCARE that using various visualization methods such as comics, videos, pictures, text to provide individualized interventions in addition to standard care. Patients randomized to control group 1 will receive interventions delivered by a modified iCARE that only presented in text in addition to routine care. Control group 2 will only receive routine care. The primary outcome is the incidence of major cardiovascular events within 3 years of discharge. Main secondary outcomes include changes in health behaviors, medication adherence, and cardiovascular health score.. If the iCARE trial indeed demonstrates positive effects on patients with coronary heart disease, it will provide empirical evidence for supporting secondary preventive care in this population. Results will inform the design of future research focused on mHealth-based, theory-driven, intelligent, and individualized interventions for cardiovascular risk management.. Trial registered 24th December 2016 with the Chinese Clinical Trial Registry (ChiCTR-INR-16010242). URL: http://www.chictr.org.cn/showproj.aspx?proj=17398 .

Topics: Cardiovascular Agents; China; Coronary Disease; Health Knowledge, Attitudes, Practice; Healthy Lifestyle; Heart Disease Risk Factors; Humans; Medication Adherence; Patient Education as Topic; Randomized Controlled Trials as Topic; Recurrence; Risk Assessment; Risk Reduction Behavior; Secondary Prevention; Telemedicine; Time Factors; Treatment Outcome

Topics: Aged; Biomarkers; Cardiovascular Agents; Ceramides; Chromatography, Liquid; Coronary Disease; Female; Health Status Indicators; Humans; Male; Mass Spectrometry; Middle Aged; Phospholipids; Predictive Value of Tests; Risk Assessment; Risk Factors; Treatment Outcome

Secondary preventive therapies play a key role in the prevention of adverse events after coronary artery bypass grafting (CABG). However, adherence to secondary preventive drugs after CABG is often poor. With the increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve medication adherence. We aimed to evaluate the effectiveness and feasibility of using a smartphone-based application to improve medication adherence in patients after CABG.. The Measurement and Improvement Studies of Surgical coronary revascularizatION: medication adherence (MISSION-2) study is a multicenter randomized controlled trial that planned to enroll over 1000 patients who underwent isolated CABG at one of four large teaching hospitals in China; all enrolled participants had access to a smartphone and were able to operate at least three smartphone applications. The investigators randomly assigned the participants to one of two groups: (1) the intervention group with an advanced smartphone application for 6 months which was designed specifically for this trial and did not exist before. Participants could receive medication reminders and cardiac health education by the smartphone application or (2) the control group with usual care. The primary outcome was CABG secondary preventive medication adherence as measured by the translated Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) at 6 months after randomization. The secondary outcomes were mortality, major adverse cardiovascular and cerebrovascular events (MACCE), cardiovascular rehospitalization, self-reported secondary preventive medication use after 6 months of follow-up, blood pressure (BP), body mass index (BMI), and self-reported smoking status. All analyses were conducted using the intention-to-treat principle.. A total of 1000 patients (mean age, 57.28 [SD, 9.09] years; 85.5% male) with coronary heart disease after CABG were enrolled between September 2015 and September 2016 and were randomly assigned to the intervention (n = 501) or control group (n = 499). At 6 months, the proportion of low-adherence participants, categorized by MMAS-8 scores, was 11.8% in the intervention group and 11.7% in the control group (RR = 1.005, 95% CI 0.682 to 1.480, P = 1.000). Similar results were found in sensitivity analyses that considered participants who withdrew from the study, or were lost to follow-up as nonadherent. There were no significant differences in the secondary clinical outcome measures, and there were no significant differences in the primary outcome across the subgroups tested. In the intervention group, the proportion of participants who used and operated the application during the first month after CABG was 88.1%; however, the use rate decreased sharply from 42.5% in the second month to 9.2% by the end of the study (6 months).. A smartphone-based application supporting secondary prevention among patients after CABG did not lead to a greater adherence to secondary preventive medications. The limited room for improvement in medication adherence and the low participants' engagement with the smartphone applications might account for these non-significant outcomes.

Topics: Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Health Education; Humans; Male; Medication Adherence; Middle Aged; Outcome Assessment, Health Care; Postoperative Complications; Reminder Systems; Secondary Prevention; Smartphone; Software

Endothelial progenitor cells (EPCs) have been characterized as one of the key effectors of endothelial healing. The effect of Danhong injection (DHI), the most widely prescribed Chinese medicine for coronary heart disease (CHD), on EPCs mobilization remains unclear.. We aimed to assess the effect of DHI on EPCs mobilization to repair percutaneous coronary intervention (PCI) induced vascular injury, and to investigate the characteristics and potential mechanism of DHI on EPCs mobilization.. Forty-two patients with CHD underwent PCI and received stent implantation were enrolled in a Phase II clinical trials. All patients received routine western medical treatment after PCI, patients of DHI group received DHI in addition. The levels of CECs, cytokines (vWF, IL-6, CRP) and EPCs were analyzed at baseline, post-PCI and after treatment. To investigate the characteristics of DHI on EPCs mobilization, 12 healthy volunteers received intravenous infusion of DHI once and the other 12 received for 7 days. EPCs enumeration were done at a series of time points. At last we tested the effect of DHI and three chemical constituents of DHI (danshensu; lithospermic acid, LA; salvianolic acid D, SaD) on EPCs level and expression of Akt, eNOS and MMP-9 in bone marrow cells of myocardial infarction (MI) mice.. In the DHI group the angina symptoms were improved, the levels of cytokines and CECs were reduced; while EPCs population was increased after treatment. In the phase I clinical trials, EPCs counts reached a plateau phase in 9 h and maintained for more than 10 h after a single dose. After continuous administration, EPCs levels plateaued on the 3rd or 4th day, and maintain till 1 day after the withdrawal, then its levels gradually declined. DHI treatment induced a timely dependent mobilization of EPCs. DHI promoted EPCs mobilization via upregulating the expression of Akt, eNOS and MMP-9 in BM. LA and SaD have played a valuable role in EPCs mobilization.. These initial results demonstrated that DHI is effective in alleviating endothelial injury and promoting endothelial repair through enhancing EPCs mobilization and revealed the effect feature and possible mechanisms of DHI in mobilizing EPCs.

Topics: Aged; Animals; Cardiovascular Agents; Coronary Disease; Drugs, Chinese Herbal; Endothelial Progenitor Cells; Endothelium, Vascular; Female; Humans; Injections; Male; Matrix Metalloproteinase 9; Mice, Inbred C57BL; Middle Aged; Myocardial Infarction; Nitric Oxide Synthase Type III; Percutaneous Coronary Intervention; Proto-Oncogene Proteins c-akt; Vascular System Injuries

Chronic obstructive pulmonary disease (COPD) is associated with long-term all-cause death after percutaneous coronary intervention with bare-metal stents. Regarding other outcomes, previous studies have shown conflicting results and the impact of drug-eluting stent (DES) in this population is not well known. We analyzed 4,605 patients who underwent percutaneous coronary intervention with bare-metal stents (33.1%) or DES (66.9%) from the Basel Stent Kosten-Effektivitats Trial-Prospective Validation Examination trials I and II. COPD patients (n = 283, 6.1%), were older and had more frequently a smoking or cardiovascular event history. At 2-year follow-up, cumulative event rates for patients with versus without COPD were the following: major adverse cardiac events (MACE: composite of cardiac death, nonfatal myocardial infarction, and target vessel revascularization): 15.2% versus 8.1% (p <0.001); all-cause death: 11.7% versus 2.4% (p <0.001); cardiac death: 5.7% versus 1.2% (p <0.001); myocardial infarction: 3.5% versus 1.9% (p = 0.045); definite/probable/possible stent thrombosis: 2.5% versus 0.9% (p = 0.01); and major bleeding: 4.2% versus 2.1% (p = 0.014). After adjusting for confounders including smoking status, COPD remained an independent predictor for MACE (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.31 to 2.49), all-cause death (HR 3.62, 95% CI 2.41 to 5.45), cardiac death (HR 3.12, 95% CI 1.74 to 5.60), and stent thrombosis (HR 2.39, 95% CI 1.03 to 5.54). We did not find evidence of an interaction between COPD and DES implantation (p for interaction = 0.29) for MACE. In conclusion, COPD is associated with increased 2-year rates of all-cause death, cardiac death, and stent thrombosis after stent implantation. DES use appears to be beneficial also in patients with COPD.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Coronary Thrombosis; Drug-Eluting Stents; Female; Graft Occlusion, Vascular; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Prospective Studies; Pulmonary Disease, Chronic Obstructive; Risk Factors; Stents; Treatment Outcome

Cardiac rehabilitation (CR) is the standard of care for patients with coronary heart disease. Despite considerable epidemiological evidence that high stress is associated with worse health outcomes, stress management training (SMT) is not included routinely as a component of CR.. One hundred fifty-one outpatients with coronary heart disease who were 36 to 84 years of age were randomized to 12 weeks of comprehensive CR or comprehensive CR combined with SMT (CR+SMT), with assessments of stress and coronary heart disease biomarkers obtained before and after treatment. A matched sample of CR-eligible patients who did not receive CR made up the no-CR comparison group. All participants were followed up for up to 5.3 years (median, 3.2 years) for clinical events. Patients randomized to CR+SMT exhibited greater reductions in composite stress levels compared with those randomized to CR alone (P=0.022), an effect that was driven primarily by improvements in anxiety, distress, and perceived stress. Both CR groups achieved significant, and comparable, improvements in coronary heart disease biomarkers. Participants in the CR+SMT group exhibited lower rates of clinical events compared with those in the CR-alone group (18% versus 33%; hazard ratio=0.49; 95% confidence interval, 0.25-0.95; P=0.035), and both CR groups had lower event rates compared with the no-CR group (47%; hazard ratio=0.44; 95% confidence interval, 0.27-0.71; P<0.001).. CR enhanced by SMT produced significant reductions in stress and greater improvements in medical outcomes compared with standard CR. Our findings indicate that SMT may provide incremental benefit when combined with comprehensive CR and suggest that SMT should be incorporated routinely into CR.. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00981253.

Topics: Aged; Angina, Unstable; Baroreflex; C-Reactive Protein; Cardiovascular Agents; Cognitive Behavioral Therapy; Combined Modality Therapy; Coronary Disease; Counseling; Exercise Test; Female; Humans; Lipids; Male; Middle Aged; Myocardial Infarction; Proportional Hazards Models; Psychological Tests; Psychometrics; Psychotherapy, Group; Single-Blind Method; Social Support; Stress, Psychological; Stroke; Vascular Surgical Procedures

The study compared, by intravascular ultrasound (IVUS), acute gain (AG) at the site of the pre-procedural minimal lumen area (MLA) achieved by either the Absorb (Abbott Vascular, Santa Clara, California) scaffold or the Xience stent and identified the factors contributing to the acute performance of these devices.. It is warranted that the acute performance of Absorb matches that of metallic stents; however, concern exists about acute expansion and lumen gain with the use of Absorb.. Of a total of 501 patients (546 lesions) in the ABSORB II (ABSORB II Randomized Controlled Trial) randomized trial, 445 patients with 480 lesions were investigated by IVUS pre- and post-procedure. Comparison of MLA pre- and post-procedure was performed at the MLA site by matching pre- and post-procedural IVUS pullbacks.. Lower AG on IVUS (lowest tertile) occurred more frequently in the Absorb arm than in the Xience arm (3.46 mm(2) vs. 4.27 mm(2), respectively; p < 0.001; risk ratio: 3.04; 95% confidence interval: 1.94 to 4.76). The plaque morphology at the MLA cross-section was not independently associated with IVUS acute gain. The main difference in AG in MLD by angiography was observed at the time of device implantation (Xience vs. Absorb, Δ+1.50 mm vs. Δ+1.23 mm, respectively), whereas the gain from post-dilation was similar between the 2 arms (Δ+0.16 mm vs. Δ+0.16 mm) when patients underwent post-dilation, although expected balloon diameter was smaller in the Absorb arm than in the Xience arm (p = 0.003) during post-dilation.. At the site of the pre-procedural MLA, the increase of the lumen post-procedure was smaller in the Absorb-arm than in the Xience arm. To achieve equivalent AG to Xience, the implantation of Absorb may require more aggressive strategies at implantation, pre- and post-dilation than the technique used in the ABSORB II trial. (ABSORB II Randomized Controlled Trial [ABSORB II]; NCT01425281).

Topics: Absorbable Implants; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Vessels; Drug-Eluting Stents; Everolimus; Female; Humans; Logistic Models; Male; Metals; Middle Aged; Multivariate Analysis; Odds Ratio; Predictive Value of Tests; Prosthesis Design; Risk Factors; Stents; Time Factors; Treatment Outcome; Ultrasonography, Interventional

The aim of this study was to compare the long-term efficacy of everolimus-eluting stents (EES) and drug-eluting balloons (DEB) in patients with bare-metal stent in-stent restenosis (ISR).. The relative long-term clinical efficacy of current therapeutic modalities in patients with ISR remains unknown.. The 3-year clinical follow-up (pre-specified endpoint) of patients included in the RIBS V (Restenosis Intra-Stent of Bare-Metal Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent Implantation) randomized clinical trial was analyzed. All patients were followed yearly using a pre-defined structured questionnaire.. A total of 189 patients with bare-metal stent ISR were allocated to either EES (n = 94) or DEB (n = 95). Clinical follow-up at 1, 2, and 3 years was obtained in all patients (100%). Compared with patients treated with DEB, those treated with EES obtained better angiographic results, including larger minimal luminal diameter at follow-up (primary study endpoint; 2.36 ± 0.6 mm vs. 2.01 ± 0.6 mm; p < 0.001). At 3 years, the rates of cardiac death (2% vs. 1%), myocardial infarction (4% vs. 5%) and target vessel revascularization (9% vs. 5%) were similar in the DEB and EES arms. Importantly, however, at 3 years, the rate of target lesion revascularization was significantly lower in the EES arm (2% vs. 8%; p = 0.04; hazard ratio: 0.23; 95% confidence interval: 0.06 to 0.93). The need for "late" (>1 year) target vessel (3 [3.2%] vs. 3 [3.2%]; p = 0.95) and target lesion (1 [1%] vs. 2 [2.1%]; p = 0.54) revascularization was low and similar in the 2 arms. Rates of definite or probable stent thrombosis (1% vs. 0%) were also similar in the 2 arms.. The 3-year clinical follow-up of the RIBS V clinical trial confirms the sustained safety and efficacy of EES and DEB in patients treated for bare-metal stent ISR. In this setting, EES reduce the need for target lesion revascularization at very long-term follow-up. (RIBS V [Restenosis Intra-Stent of Bare Metal Stents: Paclitaxel-Eluting Balloon vs Everolimus-Eluting Stent] [RIBS V]; NCT01239953).

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiac Catheters; Cardiovascular Agents; Coated Materials, Biocompatible; Coronary Angiography; Coronary Disease; Coronary Restenosis; Drug-Eluting Stents; Everolimus; Female; Humans; Male; Metals; Middle Aged; Paclitaxel; Percutaneous Coronary Intervention; Prospective Studies; Prosthesis Design; Risk Factors; Spain; Stents; Surveys and Questionnaires; Time Factors; Treatment Outcome

To assess the differences in clinical outcome between complex patients treated with Resolute zotarolimus-eluting stents (ZES) versus Xience V everolimus-eluting stents (EES).. Nowadays, many complex patients with coronary disease are treated with percutaneous coronary interventions, using drug-eluting stents (DES).. We analyzed 2-year outcome data of 1,033 complex patients of the TWENTE trial, treated with second-generation Resolute ZES or Xience V EES. Complex patients had at least one of the following characteristics: renal insufficiency (creatinine ≥ 140 µmol/l); ejection fraction < 30%; acute myocardial infarction (MI) within previous 72 hrs; >1 lesion/vessel; >2 vessels treated; lesion length > 27 mm; bifurcation; saphenous vein graft lesion; arterial bypass graft lesion; in-stent restenosis; unprotected left main lesion; lesion with thrombus; or lesion with total occlusion. Target vessel failure (TVF), the primary composite endpoint of the trial, was defined as cardiac death, target vessel-related MI, or target vessel revascularization.. Among the 1,033 complex patients, 529 (51%) were treated with Resolute ZES and 504 (49%) with Xience V EES. Patient- and procedure-related characteristics were similar between DES groups. After 2-year follow-up, outcome was also similar between DES groups. TVF occurred in 12.1% of patients treated with Resolute ZES and 12.3% of patients treated with Xience V EES. In addition, DES groups did not differ significantly in cardiac death, MI, or target vessel revascularization-the individual components of TVF.. Complex patients treated with Resolute ZES and Xience V EES showed similar safety and efficacy during 2-year follow-up. © 2014 Wiley Periodicals, Inc.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Drug-Eluting Stents; Everolimus; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Netherlands; Percutaneous Coronary Intervention; Prosthesis Design; Risk Factors; Sirolimus; Time Factors; Treatment Outcome

Postoperative complications after cardiac surgery increase mortality. This study aimed to evaluate the efficacy of cardiopulmonary rehabilitation with adaptive servo-ventilation (ASV) in patients undergoing off-pump coronary artery bypass grafting (OPCAB).. A total of 66 patients undergoing OPCAB were enrolled and divided into 2 groups according to the use of ASV (ASV group, 30 patients; non-ASV group, 36 patients). During the perioperative period, all patients undertook cardiopulmonary rehabilitation. ASV was used from postoperative day (POD) 1 to POD5. Hemodynamics showed a different pattern in the 2 groups. Blood pressure (BP) on POD6 in the ASV group was significantly lower than that in the non-ASV group (systolic BP, 112.9±12.6 vs. 126.2±15.8 mmHg, P=0.0006; diastolic BP, 62.3±9.1 vs. 67.6±9.3 mmHg, P=0.0277). The incidence of postoperative atrial fibrillation (POAF) was lower in the ASV group than in the non-ASV group (10% vs. 33%, P=0.0377). The duration of oxygen inhalation in the ASV group was significantly shorter than that in the non-ASV group (5.1±2.2 vs. 7.6±6.0 days, P=0.0238). The duration of postoperative hospitalization was significantly shorter in the ASV group than in the non-ASV group (23.5±6.6 vs. 29.0±13.1 days, P=0.0392).. Cardiopulmonary rehabilitation with ASV after OPCAB reduces both POAF occurrence and the duration of hospitalization.

Topics: Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Breathing Exercises; Cardiovascular Agents; Combined Modality Therapy; Comorbidity; Coronary Artery Bypass, Off-Pump; Coronary Disease; Exercise Test; Exercise Therapy; Female; Hemodynamics; Humans; Incidence; Male; Middle Aged; Oxygen Inhalation Therapy; Positive-Pressure Respiration; Postoperative Care; Postoperative Complications; Pulmonary Ventilation; Respiration Disorders; Ultrasonography

This paper aims to study the effect of Shengjie Tongyu granules on the treatment of meteorological cardiovascular disease in clinical treatment. Tongxinluo capsule that is clinically recognized as the effective drug in treating coronary heart disease and angina and was adopted as positive control. The results showed that, angina score and TCM score of two groups were all significantly improved after the treatment (P<0.01), but there was no statistical significance in comparison between groups (P>0.05); total effective rate of angina in the treatment group (77.78%) was superior than the control group (62.52%) after the treatment; but the difference had no statistical significance (P>0.05); total effective rate of TCM syndrome in the treatment group (75%) was superior than the control group (58.62%), and the difference had statistical significance (P<0.05). All these findings suggested that, Shengjie Tongyu granules can effectively improve the clinical symptoms of patients with coronary heart disease and angina, with the curative effect similar to Tongxinluo capsule; meanwhile, it can increase HDL-C and improve abnormal lipid metabolism of angina patient. In the treatment process, there is no significant untoward effect, blood, routine urine test and hepatorenal function have no abnormality, which proves that this drug is safe.

Topics: Aged; Angina Pectoris; Biomarkers; Cardiovascular Agents; China; Cholesterol, HDL; Coronary Disease; Drugs, Chinese Herbal; Female; Humans; Male; Meteorological Concepts; Middle Aged; Treatment Outcome; Up-Regulation

There is a paucity of data on the use of optimal medical therapy (OMT) in patients with complex coronary artery disease undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting (CABG) and its long-term prognostic significance.. The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial is a multicenter, randomized, clinical trial of patients (n=1800) with complex coronary disease randomized to revascularization with percutaneous coronary intervention or CABG. Detailed drug history was collected for all patients at discharge and at the 1-month, 6-month, 1-year, 3-year, and 5-year follow-ups. OMT was defined as the combination of at least 1 antiplatelet drug, statin, β-blocker, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Five-year clinical outcomes were stratified by OMT and non-OMT. OMT was underused in patients treated with coronary revascularization, especially CABG. OMT was an independent predictor of survival. OMT was associated with a significant reduction in mortality (hazard ratio, 0.64; 95% confidence interval, 0.48-0.85; P=0.002) and composite end point of death/myocardial infarction/stroke (hazard ratio, 0.73; 95% confidence interval, 0.58-0.92; P=0.007) at the 5-year follow-up. The treatment effect with OMT (36% relative reduction in mortality over 5 years) was greater than the treatment effect of revascularization strategy (26% relative reduction in mortality with CABG versus percutaneous coronary intervention over 5 years). On stratified analysis, all the components of OMT were important for reducing adverse outcomes regardless of revascularization strategy.. The use of OMT remains low in patients with complex coronary disease requiring coronary intervention with percutaneous coronary intervention and even lower in patients treated with CABG. Lack of OMT is associated with adverse clinical outcomes. Targeted strategies to improve OMT use in postrevascularization patients are warranted.. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00114972.

Topics: Aged; Biomarkers; Cardiovascular Agents; Combined Modality Therapy; Comorbidity; Coronary Artery Bypass; Coronary Disease; Drug Utilization; Drug-Eluting Stents; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Infarction; Netherlands; Paclitaxel; Percutaneous Coronary Intervention; Prognosis; Proportional Hazards Models; Prospective Studies; Risk Factors; Stroke; Treatment Outcome

Acute exacerbation is a common cause of hospitalization in patients with chronic heart failure, and coronary heart disease is the most common cause. Shenfu injection, a Traditional Chinese Medicine injection, widely used in the adjuvant treatment of patients with acute exacerbation of chronic heart failure, shows some treatment effect in improving the symptoms and the quality of life, but it lacks the rigorous clinical evaluation of research reports. This paper describes the protocol for the clinical assessment of Shenfu injection loading in the treatment of patients with acute exacerbation of chronic heart failure.. This protocol adopts the design of a prospective, randomized, multicenter, blind imitation, placebo-controlled trial to assess the efficacy and safety of Shenfu injection loading in the treatment of patients with acute exacerbation of chronic heart failure due to coronary heart disease. The research will be carried out in 12 hospitals in China and is expected to enroll 160 inpatients with acute exacerbation of chronic heart failure due to coronary heart disease (yang and qi deficiency syndrome). On the basis of the conventional therapy of western medicine, patients will be randomized to either the treatment group (100 ml 5% glucose injection + 50 ml Shenfu injection) or the control group (150 ml 5% glucose injection) for 7 ± 1 days and follow-up for 28 ± 3 days. The primary outcomes are New York Heart Association cardiac function classification and Traditional Chinese Medicine syndromes. The secondary outcomes are left ventricular ejection fraction, brain natriuretic peptide level, Lee's heart failure score, 6-minute walking distance, and the incidence and readmission rate of cardiovascular events (including the emergency rate due to acute exacerbation of chronic heart failure).. This trial will assess the effect of loading Shenfu injection in the treatment of patients with acute exacerbation of chronic heart failure caused by coronary heart disease (yang-qi deficiency syndrome) on the symptoms and signs of heart failure, exercise tolerance, and other aspects, and observe its influence on the short-term prognosis with follow-up. The results of the study will provide clinical research evidence for application of Shenfu injection in the treatment.. This trial was registered on 26 December 2012 at the Chinese Clinical Trials Register (Identifier: ChiCTR-TRC-12002857 ).

Topics: Adult; Aged; Biomarkers; Cardiovascular Agents; China; Chronic Disease; Clinical Protocols; Coronary Disease; Disease Progression; Drugs, Chinese Herbal; Exercise Test; Exercise Tolerance; Female; Heart Failure; Humans; Injections; Male; Middle Aged; Natriuretic Peptide, Brain; Patient Readmission; Pilot Projects; Prospective Studies; Recovery of Function; Research Design; Stroke Volume; Time Factors; Treatment Outcome; Ventricular Function, Left; Walking

To investigate the clinical effectiveness of pioglitazone in the combination treatment of patients with asthma concurrent with coronary heart disease (CHD).. Fifty patients aged 40-75 years with asthma concurrent with CHD were examined. External respiratory function (ERF), electrocardiograms, blood pressure (BP), and anthropometric measurements were assessed in all the patients. Blood and urine laboratory values and high-sensitivity C-reactive protein (hs-CRP) concentrations were estimated; endothelial function was determined measuring endothelium-dependent and endothelium-independent vasodilation (EDVD and EIVD). The patients were randomized into a comparison group receiving only standard therapy and a study group taking pioglitazone as part of combination therapy for 3 months.. At the randomization stage prior to pioglitazone combination therapy, the patient groups did not statistically significantly differ in basic clinical and anamnestic data. Three-month standard therapy resulted in stabilization of ERF and endothelial function. During the treatment, there were increases in the frequency of asthma symptoms and the duration of angina attacks, however, there was a decline in hs-CRP levels (p<0.001). Incorporation of pioglitazone into the standard treatment regimen of patients with asthma concurrent with CHD improved clinical disease control, decreased the degree of bronchial obstruction and the frequency of angina pain and asthma attacks using nitroglycerin and salbutamol, lowered systolic and diastolic blood pressure, improved EDVD (increases in the maximum linear velocity of blood flow after a test for reactive hyperemia (RH), index of reactivity (IR), and A% brachial artery (BA) diameter) and EIVD (increases in IR and A% BA diameter), and reduced systemic inflammation from hs-CRP values (p<0.001) and hypercholesterolemia from total cholesterol levels (p<0.02).. The incorporation of pioglitazone in the combination therapy of patients with asthma concurrent with CHD improves the clinical course of the diseases and increases their control, reduces systemic inflammation, and improves endothelial functional activity.. Цель исследования. Изучить особенности клинической эффективности пиоглитазона в комплексной терапии больных, страдающих бронхиальной астмой (БА) в сочетании с ишемической болезнью сердца (ИБС). Материалы и методы. Обследовали 50 пациентов с БА в сочетании с ИБС в возрасте 40-75 лет. У всех оценивали функцию внешнего дыхания (ФВД), электрокардиограмму, артериальное давление (АД) и антропометрические показатели. Проводили оценку лабораторных показателей крови и мочи, определяли концентрацию высокочувствительного С-реактивного белка (вч-СРБ), функцию эндотелия с измерением зависимой и независимой от эндотелия вазодилатации (ЗЭВД и НЗЭВД). Пациентов рандомизировали на группу сравнения, которая получала только стандартную терапию, и основную группу, в которой в составе комплексной терапии больные получали пиоглитазон в течение 3 мес. Результаты. Группы пациентов на этапе рандомизации до включения в комплексную терапию пиоглитазона статистически значимо не различались по основным клиническим и анамнестическим данным. Стандартная 3-месячная терапия приводила к стабилизации показателей ФВД и функции эндотелия. В процессе лечения увеличились частота симптомов БА, длительность ангинозных приступов, однако отмечалось снижение уровня вч-СРБ (p<0,001). Включение пиоглитазона в стандартную терапию больных БА в сочетании с ИБС приводило к улучшению клинического контроля над заболеваниями, уменьшению степени обструкции бронхов, снижению частоты ангинозных болей и приступов БА с применением нитроглицерина и сальбутамола, систолического и диастолического АД, улучшению показателей ЗЭВД (увеличению показателей максимальной линейной скорости кровотока после пробы с реактивной гиперемией - РГ, индекса реактивности - ИР, Δ% диаметра плечевой артерии - ПА) и НЗЭВД (увеличению ИР и Δ% диаметра ПА), снижению уровня системного воспаления по показателю вч-СРБ (p<0,001) и гиперхолестеринемии по показателю общего холестерина (p<0,02). Заключение. Включение пиоглитазона в комплексную терапию пациентов с БА в сочетании с ИБС улучшает клиническое течение заболеваний и повышает контроль над их течением, снижает уровень системного воспаления и улучшает функциональную активность эндотелия.

Topics: Asthma; Cardiovascular Agents; Coronary Disease; Drug Monitoring; Drug Therapy, Combination; Endothelium, Vascular; Female; Heart Function Tests; Humans; Inflammation; Male; Middle Aged; Pioglitazone; Respiratory Function Tests; Thiazolidinediones; Treatment Outcome

Cardiac rehabilitation (CR) is a secondary prevention program that offers education and support to assist patients with coronary heart disease (CHD) make lifestyle changes. Despite the benefits of CR, attendance at centre-based sessions remains low. Mobile technology (mHealth) has potential to reach more patients by delivering CR directly to mobile phones, thus providing an alternative to centre-based CR. The aim of this trial is to evaluate if a mHealth comprehensive CR program can improve adherence to healthy lifestyle behaviours (for example, physically active, fruit and vegetable intake, not smoking, low alcohol consumption) over and above usual CR services in New Zealand adults diagnosed with CHD.. A two-arm, parallel, randomised controlled trial will be conducted at two Auckland hospitals in New Zealand. One hundred twenty participants will be randomised to receive a 24-week evidence- and theory-based personalised text message program and access to a supporting website in addition to usual CR care or usual CR care alone (control). The primary outcome is the proportion of participants adhering to healthy behaviours at 6 months, measured using a composite health behaviour score. Secondary outcomes include overall cardiovascular disease risk, body composition, illness perceptions, self-efficacy, hospital anxiety/depression and medication adherence.. This study is one of the first to examine an mHealth-delivered comprehensive CR program. Strengths of the trial include quality research design and in-depth description of the intervention to aid replication. If effective, the trial has potential to augment standard CR practices and to be used as a model for other disease prevention or self-management programs.. Australian New Zealand Clinical Trials Registry: ACTRN12613000901707.

Topics: Alcohol Drinking; Cardiovascular Agents; Cell Phone; Clinical Protocols; Coronary Disease; Diet; Exercise; Health Behavior; Health Knowledge, Attitudes, Practice; Humans; Life Style; Medication Adherence; New Zealand; Research Design; Risk Reduction Behavior; Self Care; Smoking Cessation; Text Messaging; Time Factors; Treatment Outcome

The practice of traditional Chinese medicine (TCM) has a profound history in many Asian countries. TCM syndrome is a set of characteristic physical signs and symptoms shared by a group of patients. Syndrome diagnosis and treatment assignment according to the identified TCM syndrome is a long-held practice of Chinese medicine. Owing to its distinctive way of interpreting illness and administering care, medical practitioners not well educated in TCM theories and practices are generally incapable of giving out prescriptions for Chinese patent drugs. Currently, the existence of a multitude of Chinese patent drugs marked with largely identical indications is further complicating this situation.. In this multicenter, randomized, controlled, double-blind, double-dummy clinical trial, in which we will use the comparative effectiveness research method, we will compare the efficacy of two commonly used Chinese patent medicines for angina patients diagnosed with qi deficiency and blood stasis syndrome. A total of 160 patients will be recruited and randomly assigned to receive either (1) QiShenYiQi dripping pills, Tongxinluo placebo and routine medication or (2) Tongxinluo capsules, QiShenYiQi placebo and routine medication. These treatment regimens will be carried out for 4 weeks, followed by a 10-day washout period and a 4-week crossover phase in which the treatments in the two patient groups will be exchanged. Patients will be allowed to choose symptoms that matter most to them and will be grouped accordingly. Patient-reported outcomes such as the Seattle Angina Questionnaire score and the 15-point Likert scale score will be measured and reported. The minimally clinical important difference will be calculated and used for efficacy assessment, and correspondence analysis will be performed to identify the best indications for each drug.. The goal of the study is to establish a methodology for the precise identification of the characteristic indications for which a Chinese patent drug is most effective. The findings of this study will inform the practicality of the proposed evaluation method.. Chinese clinical trials register Chi CTRTTRCC13003732.

Topics: Administration, Oral; Adult; Aged; Angina Pectoris; Capsules; Cardiovascular Agents; China; Clinical Protocols; Comparative Effectiveness Research; Coronary Disease; Cross-Over Studies; Double-Blind Method; Drugs, Chinese Herbal; Female; Humans; Male; Middle Aged; Research Design; Surveys and Questionnaires; Tablets; Time Factors; Treatment Outcome

There are no published randomized data on secondary prevention in humans about whether aspirin affects nitric oxide (NO) formation. In patients with chronic stable coronary disease, we tested whether aspirin at clinically relevant doses increases NO formation.. In a randomized, double-blind trial, 37 patients from 2 cardiology office practices were assigned to daily doses of 81, 162.5, 325, 650, or 1300 aspirin for 12 weeks. Primary prespecified outcome measures were changes in heme oxygenase (HO-1), a downstream target of NO formation, and asymmetrical dimethyl arginine (ADMA), a competitive inhibitor of NO synthase.. There were no significant differences for HO-1 or ADMA between any of the clinically relevant doses of aspirin tested, so all were combined. For HO-1, there was a significant increase (10.29 ± 2.44, P < .001) from baseline (15.37 ± 1.85) to week 12 (25.66 ± 1.57). The mean ratio (MR) of week 12 to baseline for HO-1 was significantly higher than 1.0 (1.67, confidence interval [CI] from 1.60 to 1.74, P < .001). For ADMA, there was a significant decrease (-0.24 ± 0.11, P < .001) from baseline (0.78 ± 0.08) to week 12 (0.54 ± 0.07). The MR of week 12 to baseline for ADMA was significantly lower than 1.0 (0.69, CI from 0.66 to 0.73, P < .001).. In patients with chronic stable coronary disease, all clinically relevant daily doses of aspirin tested, from 81 to 1300 mg, produce similar and statistically significant increases in HO-1 and decreases in ADMA. These are the first randomized data on secondary prevention patients. These data support the hypothesis that aspirin has additional beneficial effects mediated through NO formation. Further research, including direct randomized comparisons on atherosclerosis using noninvasive techniques as well as on occlusive vascular disease events, is necessary.

Topics: Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Arginine; Aspirin; Biomarkers; Cardiovascular Agents; Coronary Disease; Dose-Response Relationship, Drug; Double-Blind Method; Down-Regulation; Female; Heme Oxygenase-1; Humans; Male; Middle Aged; Nitric Oxide; Platelet Aggregation Inhibitors; Tablets, Enteric-Coated; Up-Regulation

There is limited contemporary data on achievement of risk factor goals for secondary prevention of cardiovascular (CV) disease from countries in many regions of the world. This report describes the global and regional prevalence of CV risk factors and use of preventive medications at baseline in participants in the ongoing STabilization of Atherosclerotic plaque By Initiation of darapLadIb TherapY (STABILITY) trial.. Detailed individual data on CV risk factors were obtained before randomization in 15,828 patients with chronic coronary heart disease (CHD) from 39 countries on five continents. Subjects had a history of myocardial infarction, prior coronary revascularization, or multi-vessel CHD without revascularization and at least one additional CV risk factor. The majority were taking a statin (97%), antiplatelet therapy (96%), beta-blocker (79%), or angiotensin converting enzyme inhibitor/angiotensin receptor blocker (77%). However, a large proportion of patients did not achieve guideline-recommended targets. For instance, in 29% low-density lipoprotein (LDL) cholesterol was >2.5 mmol/l and in 46% blood pressure was ≥140/90 mmHg or ≥130/80 mmHg in those with diabetes or renal impairment. The body mass index was >30 kg/m(2) in 36%, waist circumference ≥102 cm for men or ≥88 cm for women in 54%, and 18% were smoking. Regional differences in risk factor prevalence and target achievement were observed and were more marked for LDL cholesterol and obesity.. The prevalence of modifiable CV risk factors was generally high in the STABILITY population. Although, most patients were receiving evidence-based secondary preventive therapy many subjects from all regions did not reach recommended secondary prevention goals.

Topics: Aged; Benzaldehydes; Biomarkers; Blood Glucose; Blood Pressure; Cardiovascular Agents; Coronary Disease; Double-Blind Method; Female; Guideline Adherence; Humans; Hypolipidemic Agents; Lipids; Male; Middle Aged; Oximes; Phospholipase A2 Inhibitors; Practice Guidelines as Topic; Practice Patterns, Physicians'; Prevalence; Prospective Studies; Risk Factors; Secondary Prevention; Time Factors; Treatment Outcome

To investigate the effects of ivabradine in combination with perindopril on cerebral blood flow and endothelial functional activity.. Sixty-four patients with coronary heart disease (CHD) and arterial hypertension (AH) were examined. Group 1 (n = 38) patients took ivabradine in combination with perindopril and Group 2 (n = 26) received metoprolol. At baseline and 8 weeks after therapy, 24-hour blood pressure (BP) monitoring and electrocardiography were done, cerebral blood flow was estimated by Doppler ultrasound, reactive hyperemia and nitroglycerin tests were performed, and plasma nitrite levels were determined.. With a comparable decrease in BP and heart rate in the internal carotid artery basin in both groups over time, there was a fall in peak systolic blood flow velocity; Group 1 showed a reduction in pulsatility index (PI) and systolic/diastolic ratio (ISP). After 8 weeks, there was an increase in endothelium-independent vasodilation and baseline blood flow velocity in the brachial artery in Group 1 and a rise in endothelium-dependent vasodilation in Group 2; in both groups, reactive hyperemia were higher in the brachial artery basin. No changes in nitrite levels were recorded during therapy. There was an inverse correlation between PG and PI in Group 1 and between PG and ISP in Group 2.. By unidirectionally affecting the vasomotor function of the endothelium, ivabradine in combination with perindopril versus metoprolol has a more favorable effect on circulatory resistance and blood flow velocity in the brachiocephalic arteries of patients with CHD and AH.

Topics: Benzazepines; Blood Flow Velocity; Blood Pressure; Blood Pressure Monitoring, Ambulatory; Cardiovascular Agents; Cerebrovascular Circulation; Coronary Disease; Drug Combinations; Electrocardiography; Endothelium, Vascular; Female; Heart Rate; Humans; Hypertension; Ivabradine; Male; Metoprolol; Middle Aged; Perindopril; Research Design; Treatment Outcome; Ultrasonography, Doppler

We assessed the independent effects of beta blockers, calcium antagonists, lipid-lowering drugs, angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), anti-platelet drugs, vitamin K antagonists, percutaneous coronary intervention (PCI) and coronary artery by-pass grafting (CABG) on mortality and on the composite endpoint of death, myocardial infarction, stroke or heart failure in patients with stable angina pectoris. We estimated the effects of the interventions used at baseline by multivariate Cox regression and during follow-up by G-estimation in 7,665 patients followed for a mean of 5 years in the ACTION trial. Adjusted hazard ratios (95% confidence intervals) comparing all cause mortality among users during follow-up to non-users were 1.01 (0.91, 1.09) for beta blockade, 0.82 (0.75, 0.89) for ACEIs or ARBs, 0.93 (0.87, 0.98) for calcium antagonists, 0.54 (0.49, 0.62) for lipid-lowering drugs, 0.49 (0.42, 0.53) for anti-platelet drugs, 0.74 (0.69, 0.78) for PCI, and 0.91 (0.82, 0.98) for CABG. Effects on the composite endpoint were less marked. This observational study confirms that ACEIs or ARBs, lipid-lowering and anti-platelet drugs as used in the everyday management of stable angina have independent secondary preventive effects. Calcium antagonists, PCI and CABG also appear to improve outcome.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Cause of Death; Coronary Artery Bypass; Coronary Disease; Female; Humans; Hypolipidemic Agents; Male; Middle Aged; Proportional Hazards Models; Secondary Prevention; Treatment Outcome

The aim of this study was to evaluate a 3-week inpatient cardiac rehabilitation (Rehab) started early after the index event in patients with coronary heart disease and evidence-based secondary preventive medication.. All patients had acute coronary angiography, 679 were discharged from hospital receiving usual care (Hosp), 795 completed a comprehensive Rehab. Follow-up was 12 months.. Rehab patients were older (64 vs. 62 years; p < 0.001), had more multivessel disease (51 vs. 37%; p < 0.001), heart failure (64 vs. 40%, p < 0.001), ST-segment elevation myocardial infarction (59 vs. 52%, p = 0.014), and renal insufficiency (10 vs. 7%, p = 0.036). Gender, peripheral artery disease, diabetes, hypertension, and socioeconomic status were similar in groups. Rehab patients had more beta-blockers (88 vs. 75%, p < 0.001) and angiotensin-converting enzyme inhibitors (81 vs. 70%, p < 0.001), a lower low-density lipoprotein cholesterol (102 vs. 122 mg/dl, p < 0.001), and a higher proportion of non-smokers (44 vs. 39%, p = 0.024). Primary combined endpoint of mortality, myocardial infarction (MI), revascularization, and hospitalization occurred in 32.6% of Rehab patients and in 38.7% of Hosp patients [p = 0.014; absolute risk reduction 0.0615, relative risk reduction 16%, number needed to treat (NNT) 17]. Myocardial infarction (MI) (1.8 vs. 3.8%, p = 0.015; NNT 49) and hospitalization (31.8 vs. 38.0%, p = 0.013; NNT 17) were reduced. In multivariate analysis, primary endpoint was reduced significantly (OR 0.729; 95% CI 0.585-0.909; p = 0.005) giving a relative risk reduction of 27% in favour of Rehab.. Although Rehab patients were sicker at entry, their outcome was substantially improved within 12 months. With very low NNT, Rehab is highly effective and should be advised to all suitable patients with coronary heart disease.

Topics: Aged; Cardiology Service, Hospital; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Female; Follow-Up Studies; Germany; Humans; Inpatients; Logistic Models; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Odds Ratio; Patient Readmission; Prospective Studies; Risk Assessment; Risk Factors; Secondary Prevention; Time Factors; Treatment Outcome

We describe the rationale and design for the 'PercutAneous INTervention with biodegradable-polymer based paclitaxel-eluting or sirolimus-eluting versus bare stents for de novo coronary lesions - PAINT trial'.. To evaluate two novel formulations of paclitaxel-eluting stent and the sirolimus-eluting stent against a stent with the same metallic structure but without polymer coating or drug elution.. The PAINT is a multicenter 3-arm randomized trial, conducted in Brazilian tertiary institutions, which included 275 patients allocated for the InfinniumR paclitaxel-eluting stent, the SupralimusR sirolimus-eluting stent or the Milennium MatrixR bare metal stent in a 2:2:1 ratio. Patients had de novo coronary lesions in native vessels with a diameter between 2.5 and 3.5 mm, amenable for treatment with a single stent of 29 mm or less in length. The primary objective was to compare the in-stent late loss at 9 months of both paclitaxel- and sirolimus-eluting versus the late loss of control bare metal stents. Important secondary objectives included the comparison in outcomes between sirolimus and paclitaxel stents, as well as the analysis of the incidence of major adverse cardiac events.. The PAINT trial had a unique design that allowed for the evaluation of the safety and efficacy profiles of two novel drug-eluting stent formulations, with a biodegradable-polymer carrier and releasing paclitaxel or sirolimus, which were compared against a bare metal stent (primary objective). As the drug-eluting stents differed by the drug, but were identical otherwise, the trial also allowed the comparison of the anti-restenosis effects of sirolimus versus paclitaxel (secondary objective).

Topics: Absorbable Implants; Adolescent; Angioplasty, Balloon, Coronary; Brazil; Cardiovascular Agents; Coronary Disease; Coronary Restenosis; Coronary Thrombosis; Drug-Eluting Stents; Epidemiologic Methods; Humans; Paclitaxel; Polymers; Prosthesis Design; Sirolimus; Treatment Outcome; Young Adult

To evaluate the effect of Xinkeshu Tablet (XKS) on heart rate variability (HRV) in patients with coronary heart disease (CHD).. Sixty patients with their diagnosis of CHD confirmed by coronary angiography were randomized into two groups equally. Besides the conventional treatment for CHD, XKS and Metoprolol were given respectively to patients in the treated group and the control group for 8 weeks. Symptoms and 24 h dynamic ECG were observed before and after treatment.. Episode of angina pectoris decreased obviously in both groups after treatment, from 8.8 +/- 3.2 times per week (the same hereafter) to 4.4 +/- 2.1 in the treated group (P<0.05), and from 8.4 +/- 3.1 to 3.9 +/- 2.0 in the control group (P <0.05). HRV analysis showed that after treatment the average heart rate lowered from 85.44 +/- 2.89 beat/min to 77.32 +/- 2.17 beat/min in the treated group and from 83.80 +/- 4.30 beat/min to 76.70 +/- 2.93 beat/min in the control group (both P < 0.05), showing no significant difference in extent of lowering between groups (P > 0.05). The time-domain indexes elevated in both groups, showing no statistical difference between groups (P >0.05). As for the frequency-domain indexes, low frequency (LF), high frequency (HF) and total power raised, while LF/HF and very low frequency lowered in both groups, but the changes were more significant in the treated group (P <0.05).. XKS could improve HRV in patients of CHD and reduce the episode of angina pectoris in them.

Topics: Cardiovascular Agents; Coronary Disease; Depression, Chemical; Drugs, Chinese Herbal; Heart Rate; Humans

We assessed whether a novel programme to evaluate/communicate predicted coronary heart disease (CHD) risk could lower patients' predicted Framingham CHD risk vs. usual care.. The Risk Evaluation and Communication Health Outcomes and Utilization Trial was a prospective, controlled, cluster-randomised trial in nine European countries, among patients at moderate cardiovascular risk. Following baseline assessments, physicians in the intervention group calculated patients' predicted CHD risk and were instructed to advise patients according to a risk evaluation/communication programme. Usual care physicians did not calculate patients' risk and provided usual care only. The primary end-point was Framingham 10-year CHD risk at 6 months with intervention vs. usual care.. Of 1103 patients across 100 sites, 524 patients receiving intervention, and 461 receiving usual care, were analysed for efficacy. After 6 months, mean predicted risks were 12.5% with intervention, and 13.7% with usual care [odds ratio = 0.896; p = 0.001, adjusted for risk at baseline (17.2% intervention; 16.9% usual care) and other covariates]. The proportion of patients achieving both blood pressure and low-density lipoprotein cholesterol targets was significantly higher with intervention (25.4%) than usual care (14.1%; p < 0.001), and 29.3% of smokers in the intervention group quit smoking vs. 21.4% of those receiving usual care (p = 0.04).. A physician-implemented CHD risk evaluation/communication programme improved patients' modifiable risk factor profile, and lowered predicted CHD risk compared with usual care. By combining this strategy with more intensive treatment to reduce residual modifiable risk, we believe that substantial improvements in cardiovascular disease prevention could be achieved in clinical practice.

Topics: Cardiovascular Agents; Clinical Protocols; Cluster Analysis; Communication; Coronary Disease; Death, Sudden, Cardiac; Female; Humans; Male; Middle Aged; Myocardial Infarction; Prognosis; Prospective Studies; Risk Assessment; Risk Factors; Weight Loss

Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) is expressed abundantly in the necrotic core of coronary lesions, and products of its enzymatic activity may contribute to inflammation and cell death, rendering plaque vulnerable to rupture.. This study compared the effects of 12 months of treatment with darapladib (an oral Lp-PLA(2) inhibitor, 160 mg daily) or placebo on coronary atheroma deformability (intravascular ultrasound palpography) and plasma high-sensitivity C-reactive protein in 330 patients with angiographically documented coronary disease. Secondary end points included changes in necrotic core size (intravascular ultrasound radiofrequency), atheroma size (intravascular ultrasound gray scale), and blood biomarkers.. =0.37). In contrast, Lp-PLA(2) activity was inhibited by 59% with darapladib (P<0.001 versus placebo). After 12 months, there were no significant differences between groups in plaque deformability (P=0.22) or plasma high-sensitivity C-reactive protein (P=0.35). In the placebo-treated group, however, necrotic core volume increased significantly (4.5+/-17.9 mm(3); P=0.009), whereas darapladib halted this increase (-0.5+/-13.9 mm(3); P=0.71), resulting in a significant treatment difference of -5.2 mm(3) (P=0.012). These intraplaque compositional changes occurred without a significant treatment difference in total atheroma volume (P=0.95).. Despite adherence to a high level of standard-of-care treatment, the necrotic core continued to expand among patients receiving placebo. In contrast, Lp-PLA(2) inhibition with darapladib prevented necrotic core expansion, a key determinant of plaque vulnerability. These findings suggest that Lp-PLA(2) inhibition may represent a novel therapeutic approach.

Topics: 1-Alkyl-2-acetylglycerophosphocholine Esterase; Aged; Anti-Inflammatory Agents; Benzaldehydes; Cardiovascular Agents; Coronary Disease; Double-Blind Method; Enzyme Inhibitors; Female; Humans; Male; Middle Aged; Necrosis; Oximes; Treatment Outcome

The application of disease management algorithms by physician extenders has been shown to improve therapeutic adherence in selected populations. It is unknown whether this strategy would improve adherence to secondary prevention goals after acute coronary syndromes (ACSs) in a largely indigent county hospital setting.. Patients admitted for ACS were randomized at the time of discharge to usual follow-up care versus the same care with the addition of a physician extender visit. Physician extender visits were conducted according to a treatment algorithm based on contemporary practice guidelines. Groups were compared using the primary end point of achievement of low-density lipoprotein treatment goals at 3 months after discharge and achievement of additional evidence-based practice goals.. One hundred forty consecutive patients were randomized. A similar proportion of patients returned for study follow-up in both groups at 3 months (54 [79%]/68 in the usual care group vs 57 [79%]/72 in the intervention group; P = 0.97). Among those completing the 3-month visit, a low-density lipoprotein cholesterol level less than 100 mg/dL was achieved in 37 (69%) of the usual care patients compared with 35 (57%) of those in the intervention group (P = 0.43). There was no statistical difference in implementation of therapeutic lifestyle changes (smoking cessation, cardiac rehabilitation, or exercise) between groups. Prescription rates of evidence-based therapeutics at 3 months were similar in both groups.. The implementation of a post-ACS clinic run by a physician extender applying a disease management algorithm did not measurably improve adherence to evidence-based secondary prevention treatment goals. Despite initially high rates of evidence-based treatment at discharge, adherence with follow-up appointments and sustained implementation of evidence-based therapies remains a significant challenge in this high-risk cohort.

Topics: Acute Disease; Algorithms; Cardiovascular Agents; Coronary Care Units; Coronary Disease; Female; Follow-Up Studies; Guideline Adherence; Humans; Male; Middle Aged; Retrospective Studies; Syndrome; Treatment Outcome

The EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) trial has recently reported.. To assess the cost effectiveness of perindopril in stable coronary heart disease in the UK.. Clinical and resource use data were taken from the EUROPA trial. Costs included drugs and hospitalisations. Health-related quality of life values were taken from published sources. A cost-effectiveness analysis is presented as a function of the risk of a primary event (non-fatal myocardial infarction, cardiac arrest or cardiovascular death) in order to identify people for whom treatment offers greatest value for money.. The median incremental cost of perindopril for each quality-adjusted life year (QALY) gained across the heterogeneous population of EUROPA was estimated as 9700 pounds(interquartile range 6400-14,200 pounds). Overall, 88% of the EUROPA population had an estimated cost per QALY below 20,000 pounds and 97% below 30,000 pounds. For a threshold value of cost effectiveness of 30,000 pounds per QALY gained, treatment of people representing the 25th, 50th (median) and 75th centiles of the cost effectiveness distribution for perindopril has a probability of 0.999, 0.99 and 0.93 of being cost effective, respectively. Cost effectiveness was strongly related to higher risk of a primary event under standard care.. Whether the use of perindopril can be considered cost effective depends on the threshold value of cost effectiveness of healthcare systems. For the large majority of patients included in EUROPA, the incremental cost per QALY gained was lower than the apparent threshold used by the National Institute for Health and Clinical Excellence in the UK.

Topics: Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Cost-Benefit Analysis; Drug Costs; Europe; Female; Health Care Costs; Hospitalization; Humans; Length of Stay; Male; Middle Aged; Perindopril; Quality-Adjusted Life Years; Risk Assessment

Despite routine use of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI), no conclusive evidence exists that either modality is superior to medical therapy (MT) alone for treating multivessel coronary artery disease with stable angina and preserved ventricular function.. The primary end points were total mortality, Q-wave myocardial infarction, or refractory angina requiring revascularization. The study comprised 611 patients randomly assigned to undergo CABG (n=203), PCI (n=205), or MT (n=203). At the 5-year follow-up, the primary end points occurred in 21.2% of patients who underwent CABG compared with 32.7% treated with PCI and 36% receiving MT alone (P=0.0026). No statistical differences were observed in overall mortality among the 3 groups. In addition, 9.4% of MT and 11.2% of PCI patients underwent repeat revascularization procedures compared with 3.9% of CABG patients (P=0.021). Moreover, 15.3%, 11.2%, and 8.3% of patients experienced nonfatal myocardial infarction in the MT, PCI, and CABG groups, respectively (P<0.001). The pairwise treatment comparisons of the primary end points showed no difference between PCI and MT (relative risk, 0.93; 95% confidence interval, 0.67 to 1.30) and a significant protective effect of CABG compared with MT (relative risk, 0.53; 95% confidence interval, 0.36 to 0.77).. All 3 treatment regimens yielded comparable, relatively low rates of death. MT was associated with an incidence of long-term events and rate of additional revascularization similar to those for PCI. CABG was superior to MT in terms of the primary end points, reaching a significant 44% reduction in primary end points at the 5-year follow-up of patients with stable multivessel coronary artery disease.

Topics: Adrenergic beta-Antagonists; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Coronary Restenosis; Diet, Fat-Restricted; Disease-Free Survival; Drug Therapy, Combination; Electrocardiography; Endpoint Determination; Female; Follow-Up Studies; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Myocardial Infarction; Nitrates; Prognosis; Reoperation; Stents; Survival Analysis; Treatment Outcome

To describe a novel modification of the T-stenting technique and to report the bench test as well as the first clinical results obtained.. The best technique to treat bifurcated coronary lesions has not been defined.. This novel modification of the T-stenting technique is based, after stenting of the main vessel (MV) and kissing balloon, on the intentional minimal protrusion of the side-branch (SB) stent within the MV. Final kissing balloon is performed using the balloon kept uninflated into the MV before SB stenting. The technique was tested in vitro and applied in two independent series of patients undergoing elective drug-eluting stent implantation on one bifurcated lesion. Bifurcated lesions were classified according to the Medina classification. Patients' outcome up to 9 month was prospectively assessed.. The bench test showed perfect coverage of the bifurcation with minimal stent's struts overlap at the proximal part of SB ostium and a small, single layer stent struts, neo-carina not affecting the MV patency. Seventy-three complex patients (67% of Medina 1,1,1 lesions; 44% of unprotected distal left main lesions) were treated with sirolimus-, paclitaxel-, or zotarolimus-eluting stents using the TAP technique. Procedural success was achieved in all cases and the clinical outcome up to 9 month was characterized by a low rate of clinically-driven target vessel revascularization (6.8%).. The TAP-stenting is a modification of the T-stenting technique which allows full coverage of bifurcated lesions and facilitates final kissing balloon. The first clinical experience suggests that this technique may be practical, thus calling for further evaluations of the technique.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Disease; Female; Humans; Italy; Korea; Male; Middle Aged; Paclitaxel; Prospective Studies; Prosthesis Design; Radiography, Interventional; Severity of Illness Index; Sirolimus; Stents; Treatment Outcome; Ultrasonography, Interventional; Vascular Patency

Several studies have shown that treatment of coronary heart disease (CHD) does not meet the goals set in recommendations. The aim of this study was to investigate the adequacy of CHD drug treatment and secondary prevention measures, particularly with respect to age and gender biases, in a Finnish university hospital setting.. The participant pool consisted of patients in FINCAVAS (Finnish Cardiovascular Study), which is a cohort study recruiting consecutive patients performing a clinical exercise test at Tampere University Hospital, Tampere, Finland. 802 patients (581 men, 221 women) with a prior diagnosis of CHD recruited between October 2001 and December 2004 were included in the analysis.. Only roughly 12% of both men and women had an optimal risk factor profile. High blood pressure and hypercholesterolaemia were more common in women than in men, whereas smoking was more frequent among men. Men used ACE inhibitors (32.9% vs 20.4%, respectively), beta-adrenoceptor antagonists (80.8% vs 68.3%, respectively) and aspirin (acetylsalicylic acid) [69.7% vs 58.8%, respectively] more frequently than women, but the frequency of use of these medications was also not at the recommended levels in men. Risk factor control is poorer in older than younger age groups.. CHD patients, particularly women, who performed an exercise stress test in a university hospital are suboptimally treated.

Topics: Adrenergic beta-Antagonists; Adult; Age Factors; Aged; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Cohort Studies; Coronary Disease; Exercise Test; Female; Finland; Hospitals, University; Humans; Hypercholesterolemia; Hypertension; Male; Middle Aged; Practice Patterns, Physicians'; Risk Factors; Sex Factors; Smoking

To compare the effect of sirolimus-eluting stents to paclitaxel-eluting stents in complex and diffuse coronary lesions.. 138 consecutive patients with complex and diffuse coronary lesions were enrolled from April 2004 to August 2005; they were implanted with more than 25 mm long sirolimus-eluting stents or paclitaxel-eluting stents. Unsuccessful cases were excluded. All patients received medical treatment according to guideline. Aspirin 300 mg and clopidogrel 75 mg once daily were continually administered for 6 months after the procedure. The patients were followed up after 6 months.. The study population consisted of 138 patients, including 124 men and 14 women. There were 129 (87.8%) C ACC/AHA type lesions. The average reference vessel diameter was (2.91 +/- 0.43) mm. The average lesion length was (36.36 +/- 12.27) mm. The average stent length per lesion was (40.25 +/- 12.79) mm. There was no difference of patient and lesion baseline characteristics between the groups of sirolimus-eluting and paclitaxel-eluting stents. At the end of follow up, in-stent restenosis rate (5.9% vs 17.7%, P = 0.023) and in-segment restenosis rate (9.4% vs 21.0%, P = 0.048) in the group of sirolimus-eluting stents were less than that in the group of paclitaxel-eluting stents. The difference was also seen in in-stent late luminal loss [(0.26 +/- 0.46) mm vs (0.60 +/- 0.66) mm, P = 0.001)] and in-segment late lumens loss [(0.16 +/- 0.52) mm vs (0.45 +/- 0.65) mm, P = 0.003)]. There was no difference between the sirolimus-eluting stents group and paclitaxel-eluting stents group in the incidence of target lesion revascularization (7.1% vs 12.9%, P = 0.223).. In patients with complex and diffuse coronary lesions, the use of the sirolimus-eluting stent was associated with a decrease in the extent of late luminal loss, as compared with use of paclitaxel-eluting stents, suggesting that sirolimus-eluting stent might be more suitable to be used in small vessel.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Restenosis; Female; Follow-Up Studies; Humans; Male; Middle Aged; Paclitaxel; Sirolimus; Stents; Treatment Outcome

Little is known about the effect of revascularization in patients > or =75 years of age with symptomatic coronary artery disease (CAD) and diabetes mellitus (DM) for whom periprocedural risk and overall mortality are increased. Therefore, we examined the 301 patients of the Trial of Invasive versus Medical therapy in the Elderly with symptomatic CAD (TIME) with special regard to diabetic status. Patients were randomized to an invasive versus optimized medical strategy. The median follow-up was 4.1 years (range 0.1 to 6.9). Patients with DM (n = 69) had a greater incidence of hypertension (73% vs 58%, p = 0.03), > or =2 risk factors (93% vs 46%, p <0.01), previous heart failure (22% vs 12%, p = 0.04), and previous myocardial infarction (59% vs 43%, p = 0.02), and a lower left ventricular ejection fraction (48% vs 54%, p = 0.02) than did patients without DM. Mortality was greater in patients with DM than in those without DM (41% vs 25%, p = 0.01; adjusted hazard ratio 1.86, p = 0.01). Revascularization improved the overall survival rate from 61% (no revascularization) to 79% (p <0.01; adjusted hazard ratio 1.68, p = 0.03), an effect similarly observed in patients with and without DM. The event-free survival rate was 11% in nonrevascularized patients with DM compared with 40% in nonrevascularized patients without DM and 41% and 53% in revascularized patients with and without DM, respectively (p <0.01). Angina severity and antianginal drug use were similar for patients with and without DM, but those with DM performed worse in daily activities and physical functioning. In conclusion, elderly diabetic patients with chronic angina have a worse outcome than those with DM but benefit similarly from revascularization regarding symptom relief and long-term outcome. However, physical functioning related to daily activities is reduced in those with DM and may need special attention.

Topics: Age Factors; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Diabetes Mellitus; Female; Humans; Male; Myocardial Revascularization; Probability; Prognosis; Proportional Hazards Models; Quality of Life; Reference Values; Risk Assessment; Severity of Illness Index; Statistics, Nonparametric; Survival Analysis; Time Factors

To assess the efficacy of the Coronary Heart Disease (CHD) Capsules worked out by Prof. Deng --in improving quality of life of CHD patients of qi deficiency with phlegm and blood stasis syndrome.. According to the WHO's diagnosis criteria of CHD, a total of 93 stable angina patients were divided into 3 groups using the single blinded method. The groups were evenly distributed into CHD Capsule treated group (CHDC), isosorbide dinitrate control group (ID), and Compound Prescription Danshen Droplet Pills control group (CPDDP). Two courses of treatment lasting for 6 months were given. During the courses of treatment, the following parameters were observed: clinical symptoms of angina pectoris, ECG change, treadmill exercise test, 36 items in short form of health survey (SF-36) and Seattle Angina Questionnaire (SAQ) scale.. After 6 months of treatment, all the three groups showed good curative effect in angina pectoris, ECG and treadmill exercise test, differences between them had no statistical significance. The CHDC group showed a better result in nitro-glycerine stopping or alleviation rate and in improving symptoms than the other groups (P < 0.05). The general health, vitality, role-emotional, mental health and reported health transition in the CHDC group were significantly better than those in the control groups (P < 0.05). The scores in physiological functioning role, physiological function and pain alleviation were not different among the three groups.. Prof. DENG Tie-tao's CHDC is effective in treating CHD with qi deficiency, phlegm and blood stasis and also in improving the quality of life. CHDC is more suitable to be used in long-term treatment than isosorbide dinitrate. The SF-36 and SAQ can be used to appraise the curative effect of traditional Chinese medicine agents for CHD angina pectoris.

Topics: Aged; Angina Pectoris; Capsules; Cardiovascular Agents; Coronary Disease; Drugs, Chinese Herbal; Female; Humans; Isosorbide Dinitrate; Male; Medicine, Chinese Traditional; Middle Aged; Phytotherapy; Plant Preparations; Quality of Life; Salvia miltiorrhiza; Single-Blind Method; Treatment Outcome

Recent clinical trials have demonstrated that aggressive lipid lowering by statins could prevent recurrent events after acute coronary syndrome (ACS). We hypothesized that this efficacy was caused by a significant reduction in plaque volume by aggressive LDL cholesterol (LCL-C) lowering. The present study investigated the effect of early statin treatment on plaque volume of a nonculprit lesion by serial volumetric intravascular ultrasound in patients with ACS.. Seventy patients with ACS were enrolled. All patients underwent emergency coronary angiography and percutaneous coronary intervention (PCI). They were randomized to intensive lipid-lowering therapy (n=35; atorvastatin 20 mg/d) or control (n=35) groups after PCI. Volumetric intravascular ultrasound analyses were performed at baseline and 6-month follow-up for a non-PCI site in 48 patients (atorvastatin, n=24; control, n=24). LDL-C level was significantly decreased by 41.7% in the atorvastatin group compared with the control group, in which LDL-C was increased by 0.7% (P<0.0001). Plaque volume was significantly reduced in the atorvastatin group (13.1+/-12.8% decrease) compared with the control group (8.7+/-14.9% increase; P<0.0001). Percent change in plaque volume showed a significant positive correlation with follow-up LDL-C level (R=0.456, P=0.0011) and percent LDL-C reduction (R=0.612, P<0.0001), even in patients with baseline LDL-C <125 mg/dL.. Early aggressive lipid-lowering therapy by atorvastatin for 6 months significantly reduced the plaque volume in patients with ACS. Percent change in plaque volume showed a significant positive correlation with percent LDL-C reduction, even in patients with low baseline LDL-C.

Topics: Acute Disease; Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Atorvastatin; Cardiovascular Agents; Cholesterol, LDL; Cilostazol; Combined Modality Therapy; Coronary Angiography; Coronary Disease; Female; Follow-Up Studies; Heparin; Heptanoic Acids; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Platelet Aggregation Inhibitors; Prospective Studies; Pyrroles; Tetrazoles; Ticlopidine; Treatment Outcome; Ultrasonography, Interventional

The goal of this study was to investigate whether concomitant therapy with vasoactive medications alters the results of noninvasive assessment of endothelial function.. Ultrasound assessment of brachial artery flow-mediated dilation is emerging as a useful clinical tool. The current practice of withholding cardiac medications before ultrasound studies has unknown utility and would limit the clinical use of the methodology.. To determine whether a single dose of a vasoactive drug influences brachial reactivity, we examined flow-mediated dilation and nitroglycerin-mediated dilation in 73 healthy subjects (age 27 +/- 6 years). Studies were completed at baseline and 3 h after randomized treatment with a single oral dose of placebo, felodipine (5 mg), metoprolol (50 mg), or enalapril (10 mg). To determine if holding vasoactive therapy for 24 h before study yields different results than continuation of clinically prescribed medications, we examined vascular function in 72 patients (age 57 +/- 10 years) with coronary artery disease. Ultrasound studies were performed 24 h after the last dose and again 3 h after patients took their clinically prescribed medications.. In healthy subjects one dose of all three drugs lowered blood pressure, and metoprolol also lowered heart rate. However, there was no significant effect of treatment on brachial artery dilation. In patients with coronary artery disease on chronic treatment, taking prescribed medications reduced blood pressure and heart rate, but had no significant effect on brachial artery dilation.. Recent administration of commonly used nonnitrate vasoactive drugs has no significant effect on brachial reactivity. These findings suggest that current practice of withholding cardiac medications before testing endothelial function may not be necessary, making this methodology more practical for clinical use.

Topics: Adult; Analysis of Variance; Brachial Artery; Cardiovascular Agents; Coronary Disease; Double-Blind Method; Enalapril; Endothelium, Vascular; Felodipine; Female; Humans; Male; Metoprolol; Models, Cardiovascular; Reference Values; Reproducibility of Results; Vasodilation

The Circadian Anti-ischemia Program in Europe (CAPE II) compared the efficacy of amlodipine and diltiazem (Adizem XL) and the combination of amlodipine/atenolol and diltiazem (Adizem XL)/isosorbide 5-mononitrate on exercise and ambulatory myocardial ischemia during regular therapy and after omission of medication.. The optimal medical therapy for ischemia suppression and the impact of irregular dosing using agents with different pharmacologic properties has not been established in patients with coronary disease.. Patients with > or = 4 ischemic episodes or > or = 20 min of ST segment depression on 72-h electrocardiogram were randomized to amlodipine 10 mg once daily or diltiazem (Adizem XL) 300 mg once daily in a 14-week double-blind randomized multicountry study. In the second phase, atenolol 100 mg was added to amlodipine and isosorbide 5-mononitrate 100 mg to diltiazem (Adizem XL). Ambulatory monitoring (72 h) and exercise testing were repeated after both phases, on treatment and after a 24-h drug-free interval.. Both monotherapy with amlodipine and diltiazem (Adizem XL) were effective on symptoms and ambulatory and exercise ischemia. Combination therapy reduced ischemia further, with amlodipine/atenolol superior to diltiazem (Adizem XL)/isosorbide 5-mononitrate. Amlodipine/atenolol was significantly superior during the drug-free interval with maintenance of ischemia reduction.. Amlodipine, with its intrinsically long half-life alone or together with beta-blocker, is likely to produce superior ischemia reduction in clinical practice when patients frequently forget to take medication or dose irregularly.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Aged, 80 and over; Amlodipine; Atenolol; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Diltiazem; Double-Blind Method; Drug Administration Schedule; Drug Therapy, Combination; Electrocardiography; Exercise Test; Female; Humans; Isosorbide; Male; Middle Aged; Myocardial Ischemia

To examine whether the prophylactic antianginal agent perhexiline potentiates platelet responsiveness to nitric oxide (NO) in patients with stable angina pectoris (SAP) and acute coronary syndromes (ACS: unstable angina pectoris or non-Q-wave myocardial infarction).. Blood samples were obtained from patients before and after initiation of treatment with perhexiline. ADP-induced platelet aggregation and its inhibition by the NO donor sodium nitroprusside (SNP) were determined via impedance aggregometry in whole blood (WB) and platelet-rich plasma (PRP). Intraplatelet cGMP content was assayed by RIA, and superoxide (O(2)(-)) level by lucigenin-derived chemiluminescence. In patients with ACS not receiving perhexiline (n=12), platelet responsiveness to SNP did not vary significantly over the first 3 days post admission to hospital. Therapy with perhexiline for 3 days was associated with increases in SNP-induced inhibition of aggregation from 29+/-2% to 43+/-4% (n=50,P <0.001) in WB and from 20+/-5% to 42+/-7% (n=12, P<0.01) in PRP. Resolution of symptomatic ischaemia (n=39) was associated with significantly greater (P<0.01) increases than non-resolution (n=11). Similar increases in SNP responsiveness (P<0.001) occurred following institution of perhexiline therapy in patients with SAP (n=30), associated with a 85% decrease in anginal frequency. Treatment with perhexiline potentiated the cGMP-elevating effects of SNP in platelets (n=9,P =0.03). Although perhexiline did not alter whole blood O(2)(-) concentration ex vivo, it inhibited (P<0.01) O(2)(-) release from neutrophils in vitro.. Perhexiline potentiates platelet responsiveness to NO both in SAP and ACS patients; in the latter group this improvement was predictive of resolution of ischaemic symptoms. The predominant mechanism of perhexiline effect is an increase in platelet cGMP responsiveness. Perhexiline also may reduce the potential for NO clearance by neutrophil-derived O(2)(-).

Topics: Aged; Angina Pectoris; Blood Platelets; Cardiovascular Agents; Coronary Disease; Cyclic GMP; Female; Humans; Male; Neutrophils; Nitric Oxide; Nitric Oxide Donors; Nitroprusside; Perhexiline; Platelet Aggregation; Superoxides

A new variable termed the falloff constant (k(f)) was derived from the curve fitting of serial CK-MB measurements. k(f) represents the rate constant of maximal decline in serum CK-MB and is determined from the slope of the lognormal curve at the inflection point. Physiologically, kf's magnitude reflects the balance between CK-MB's rate of release from tissue and the rate of elimination. We examined k(f) in two myocardial infarction (MI) patient sets. The first set was homogeneous and taken from the TAMI 7 study (n = 147) and included 111 patients having TIMI 2-3 flow after thrombolytic therapy and 36 patients who initially had TIMI 0-1 flow. The TIMI 0-1 patients were opened to TIMI 3 by angioplasty within 3 h. The second set consisted of 196 patients enrolled in the IMPACT-AMI study that demonstrated the efficacy of the glycoprotein (GP) IIb/IIIa antagonist eptifibatide. This second set consisted of 93 patients in the GP IIb/IIIa treatment group and 103 in the placebo group. Log-normal curve-fitting parameters including peak maximum and curve area were also compared to k(f) in the GP IIb/IIIa versus placebo set. The Wilcoxon test showed no difference between the two groups of TAMI 7 patients (p = 0.22). However, there was a highly significant difference in kf between the GP IIb/IIIa treatment group versus the placebo group (p = 0.0014). Both k(f) and peak maximum from curve fitting showed significant differences between the GP IIb/IIIa treatment group and the placebo group; however, k(f) showed a substantially lower p-value (p = 0.0014 and p = 0.023, respectively). As expected, k(f) showed no difference between the TAMI 7 groups because this was a homogeneous patient set in that they all had TIMI 3 patency status within 3 h of treatment. However, in the patient set having very different treatments, GP IIb/IIIa versus placebo, there was a highly significant difference in the kf variable. These data suggest that differences in reperfusion are reflected by kf and that this variable may represent a valuable new nonmortality end point derived from curve fitting analysis.

Topics: Algorithms; Biomarkers; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Creatine Kinase; Creatine Kinase, MB Form; Data Interpretation, Statistical; Endpoint Determination; Humans; Isoenzymes; Models, Biological; Platelet Glycoprotein GPIIb-IIIa Complex; Prognosis; Treatment Outcome

The performance of the cardiovascular system depends on the interaction of the left ventricle and arterial system. An appropriate coupling of these two components is important to quantify the efficiency of myocardium, determined by Ea/Ees. The end-systolic elastance of the left ventricle (Ees) is an index of contractility which is independent of loading conditions, while the arterial end-systolic elastance (Ea) represents the properties of the arterial system. The aim of our study is to investigate the effects of a bolus of remifentanil (R) on myocardial efficiency.. In a period of 3 months we examined prospectively the effects of R in a group of 12 patients, ASA IV, 49-75 years old, submitted intraoperatively to cardiac anesthesia for revascularization of myocardium. After induction of anesthesia and before the beginning of surgery, a bolus of R (1 mg/kg/min) was administered and with the use of trans-esophageal echocardiography we determined both the left ventricle end-systolic volume and end-diastolic volume to assess, with different end-systolic arterial pressures, the ventricle elastance (Ees) and arterial elastance (Ea) before and after administration of R.. The present findings indicate that R decreases the ventricular elastance from 6.07 mmHg/ml/m2 to 4.8, with a less decrease of arterial elastance from 3.69 mmHg/ml/m2 to 3.07.. The results suggest that R preserves a good left ventricular-arterial coupling and mechanical efficiency, despite a little increase of coupling, probably because ventricular and arterial properties are so matched as to minimize the systolic work of the left ventricle.

Topics: Aged; Anesthetics, Intravenous; Aorta; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Bypass; Coronary Disease; Echocardiography, Transesophageal; Electric Impedance; Female; Heart Failure; Heart Rate; Hemorheology; Humans; Injections, Intravenous; Male; Middle Aged; Myocardial Contraction; Myocardial Infarction; Oxygen Consumption; Piperidines; Propofol; Prospective Studies; Remifentanil; Stroke Volume; Thiopental; Vascular Resistance; Vecuronium Bromide; Ventricular Function, Left

In patients with stable angina pectoris or silent myocardial ischemia, who had signs of ischemia in ECG during exercise, the Asymptomatic Cardiac Ischemia Pilot (ACIP) study compared 2 types of medication strategies (ischemia-guided and angina-guided) and a strategy of primary revascularization by PTCA or CABG. ACIP substantiated, after 2 years of observation, a clear advantage of the revascularization strategy compared to both drug strategies in terms of clinical effectiveness. This advantage is even more distinct in patients with very severe angiographic results.. This is a retrospective, incremental cost-effectiveness analysis from the perspective of the German third party payer (statutory sick funds) on the basis of the ACIP study.. The direct costs of the revascularization strategy after 2 years are about 2 to 3 times higher than those of the drug therapies. The incremental cost-effectiveness of the ischemia-guided strategy versus an angina-guided strategy is DM 2,600 per life-year saved. Furthermore, the cost-effectiveness of a revascularization strategy versus an angina guided therapy is DM 15,100 per life-year saved.. A primary revascularization strategy is cost-effective in patients with stable coronary artery disease with proven myocardial ischemia and positive angiographic signs.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Cost-Benefit Analysis; Disease Management; Female; Germany; Humans; Male; Middle Aged; Myocardial Ischemia; Myocardial Revascularization; Pilot Projects; Randomized Controlled Trials as Topic; Retrospective Studies; Single-Blind Method; Survival Analysis

The Women's Lifestyle Heart Trial was a small (N = 28) randomized controlled trial to evaluate the effects of a comprehensive lifestyle self-management program (very low-fat vegetarian diet, stress-management training, exercise, group support, and smoking cessation) on reduction of cardiovascular risk factors in postmenopausal women with coronary heart disease (CHD). Women assigned to the treatment condition (Prime Time) participated in a week-long retreat followed by twice-weekly 4-hour meetings. Endpoints were program adherence; changes in lipid profiles, body mass, blood pressure, hypolipidemic and antihypertensive medications; and quality of life. Risk factor and psychosocial evaluations were conducted at baseline and at 4, 12, and 24 months. Repeated measures analyses of covariance revealed that the dietary, stress management, and physical activity changes made by intervention women were dramatic and lasting. There were significantly greater improvements in the Prime Time condition compared to the usual care control group on body mass, angina symptoms, and quality of life, and a tendency for a greater reduction in blood pressure-lowering medications. Similar patterns were seen in lipids, blood pressure, and lipid-lowering medications, but did not reach significance. These results demonstrate that postmenopausal CHD women can make lasting lifestyle changes, and that these changes may reduce the need for cardiac medications and improve CHD risk factors and quality of life.

Topics: Aged; Blood Pressure; Body Weight; Cardiovascular Agents; Coronary Disease; Diet, Fat-Restricted; Exercise; Female; Humans; Life Style; Lipids; Middle Aged; Oregon; Postmenopause; Quality of Life; Risk Factors; Smoking Cessation; Social Support; Stress, Psychological; Survival Analysis; Treatment Outcome; Women's Health

The role of testosterone on the development of coronary artery disease in men is controversial. The evidence that men have a greater incidence of coronary artery disease than women of a similar age suggests a possible causal role of testosterone. Conversely, recent studies have shown that the hormone improves endothelium-dependent relaxation of coronary arteries in men. Accordingly, the aim of the present study was to evaluate the effect of acute administration of testosterone on exercise-induced myocardial ischemia in men.. After withdrawal of antianginal therapy, 14 men (mean age, 58+/-4 years) with coronary artery disease underwent 3 exercise tests according to the modified Bruce protocol on 3 different days (baseline and either testosterone or placebo given in a random order). The exercise tests were performed 30 minutes after administration of testosterone (2.5 mg IV in 5 minutes) or placebo. All patients showed at least 1-mm ST-segment depression during the baseline exercise test and after placebo, whereas only 10 patients had a positive exercise test after testosterone. Chest pain during exercise was reported by 12 patients during baseline and placebo exercise tests and by 8 patients after testosterone. Compared with placebo, testosterone increased time to 1-mm ST-segment depression (579+/-204 versus 471+/-210 seconds; P<0. 01) and total exercise time (631+/-180 versus 541+/-204 seconds; P<0. 01). Testosterone significantly increased heart rate at the onset of 1-mm ST-segment depression (135+/-12 versus 123+/-14 bpm; P<0.01) and at peak exercise (140+/-12 versus 132+/-12 bpm; P<0.01) and the rate-pressure product at the onset of 1-mm ST-segment depression (24 213+/-3750 versus 21 619+/-3542 mm Hgxbpm; P<0.05) and at peak exercise (26 746+/-3109 versus 22 527+/-5443 mm Hgxbpm; P<0.05).. Short-term administration of testosterone induces a beneficial effect on exercise-induced myocardial ischemia in men with coronary artery disease. This effect may be related to a direct coronary-relaxing effect.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Electrocardiography; Exercise Test; Humans; Injections, Intravenous; Male; Middle Aged; Myocardial Ischemia; Testosterone

The mechanisms leading to dobutamine-induced ischemia are not fully understood. In the present study, we investigated the effects of high-dose intravenous dobutamine on morphological and physiological indexes of coronary stenoses.. Twenty-two patients with normal left ventricular function and isolated coronary stenoses were studied. At catheterization, mean aortic pressure (P(a)), mean distal coronary pressure (P(d)), and P(d)/P(a) as an index of myocardial resistance were recorded at rest, after intracoronary adenosine, and during intravenous infusion of dobutamine (10 to 40 micrograms . kg(-1). min(-1)). Reference vessel diameter and minimal luminal diameter, as assessed by coronary angiography, did not change during dobutamine infusion compared with baseline (2.84+/-0.49 versus 2.77+/-0.41 mm and 1.35+/-0.38 versus 1. 27+/-0.31 mm, respectively; both P=NS). During peak dobutamine infusion, P(d) and P(d)/P(a) reached similar levels as during adenosine infusion (60+/-18 versus 59+/-18 mm Hg and 0.68+/-0.18 versus 0.68+/-0.17, respectively; all P=NS). In 9 patients, an additional bolus of intracoronary adenosine given at the peak dose of dobutamine failed to further decrease P(d)/P(a). Furthermore, in patients with dobutamine-induced wall motion abnormalities, the maximal decrease in P(d)/P(a) was similar during dobutamine and adenosine infusions.. High-dose intravenous infusion of dobutamine does not modify the dimensions of the epicardial coronary stenosis. However, much like the direct coronary vasodilator adenosine, dobutamine fully exhausts myocardial resistance regardless of the presence of mechanical dysfunction.

Topics: Adenosine; Cardiac Catheterization; Cardiovascular Agents; Coronary Disease; Dobutamine; Female; Hemodynamics; Humans; Male; Middle Aged; Pericardium; Radiography

Oxidized low-density lipoprotein is involved in the pathogenesis of atherosclerosis. In epidemiological studies antioxidants have been inversely related with coronary heart disease. Findings from controlled trials are inconclusive.. We studied the primary preventive effect of vitamin E (alpha tocopherol) and beta carotene supplementation on major coronary events in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study, a controlled trial undertaken primarily to examine the effects of these agents on cancer. A total of 27 271 Finnish male smokers aged 50 to 69 years with no history of myocardial infarction were randomly assigned to receive vitamin E (50 mg), beta carotene (20 mg), both agents, or placebo daily for 5 to 8 years (median, 6.1 years). The end point was the first major coronary event, either nonfatal myocardial infarction (surviving at least 28 days; n = 1204) or fatal coronary heart disease (n = 907).. The incidence of primary major coronary events decreased 4% (95% confidence interval, -12% to 4%) among recipients of vitamin E and increased 1% (95% confidence interval, -7% to 10%) among recipients of beta carotene compared with the respective nonrecipients. Neither agent affected the incidence of nonfatal myocardial infarction. Supplementation with vitamin E decreased the incidence of fatal coronary heart disease by 8% (95% confidence interval, -19% to 5%), but beta carotene had no effect on this end point.. Supplementation with a small dose of vitamin E has only marginal effect on the incidence of fatal coronary heart disease in male smokers with no history of myocardial infarction, but no influence on nonfatal myocardial infarction. Supplementation with beta carotene has no primary preventive effect on major coronary events.

Topics: Aged; beta Carotene; Cardiovascular Agents; Coronary Disease; Dietary Supplements; Female; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Risk; Treatment Outcome; Vitamin E

To compare clinical and functional status in patients who had similar 5-year survival after coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA).. Randomized trial of 1829 patients followed for an average 5.4 years.. Patients with multivessel coronary artery disease suitable for both CABG and PTCA and not previously revascularized.. Coronary artery bypass grafting or PTCA within 2 weeks after randomization.. Symptoms, exercise test results, medication use, and quality-of-life measures collected at 4 to 14 weeks, and at 1, 3, and 5 years after randomization.. Intention to treat.. Differences in angina-free rates between patients assigned to PTCA and CABG decreased from 73% vs 95% at 4 to 14 weeks (P<.001) to 79% vs 85% at 5 years (P=.007). Similar patterns were observed for exercise-induced angina and ischemia, except 5-year differences were not significant. At follow-up of 1 year and later, quality of life, return to work, modification of smoking and exercise behaviors, and cholesterol levels were similar for the 2 treatments. Compared with patients assigned to CABG, use of anti-ischemic medication was higher in patients assigned to PTCA, while smaller differences were observed for other medications. Among patients angina-free at 5 years, 52% of patients who had PTCA required revascularization after the initial procedure vs 6% of patients who had CABG.. The narrowing of treatment differences in angina and exercise-induced ischemia rates can be attributed to a return of symptoms among patients assigned to CABG and incremental surgical procedures among patients assigned to PTCA. Patients assigned to PTCA apparently were able to tolerate higher rates of residual ischemia as evidenced by comparable quality of life and 5-year survival.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Exercise Test; Female; Heart Function Tests; Humans; Male; Middle Aged; Myocardial Infarction; Outcome and Process Assessment, Health Care; Quality of Life; Risk Factors; Survival Rate; United States

Angiopeptin, a somatostatin analogue, inhibits intimal hyperplasia after (percutaneous transluminal coronary angioplasty) (PTCA) in several animal models. This pilot study sought to determine the effect of subcutaneous infusion of angiopeptin on clinical events and restenosis in patients undergoing successful PTCA. One hundred and twelve patients were randomized to receive continuous subcutaneous angiopeptin (750 micrograms/day) or placebo infusion from the day before PTCA and for the following four days in a double-blind study. Eighty patients had a successful PTCA, and 75 of these patients with 94 lesions underwent angiography 6 +/- 2 months after PTCA. All 112 patients underwent clinical follow-up at 12 months. The 12-month event rate (death, myocardial infarction, coronary artery bypass grafting and re-PTCA) was reduced from 34% to 25% (p = 0.30) by angiopeptin by intention to treat analysis. Restenosis (> or = 50% diameter stenosis) was significantly reduced in lesions treated with angiopeptin (12% vs 40%; p = 0.003). Late lumen loss was also significantly reduced after angiopeptin treatment (0.12 +/- 0.46 mm vs 0.52 +/- 0.64 mm; p = 0.003). In conclusion, continuous subcutaneous angiopeptin infusion for five days tended to decrease clinical events and restenosis after PTCA.

Topics: Adolescent; Adult; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Double-Blind Method; Female; Follow-Up Studies; Humans; Male; Middle Aged; Oligopeptides; Peptides, Cyclic; Recurrence; Somatostatin

The concept of "cardioprotection" based on ejection fraction was tested to see whether patients with coronary artery disease in whom medical treatment fails to be cardioprotective can be distinguished from those in whom it is safe to continue such treatment.. Ejection fraction is of fundamental prognostic importance. Its modification by anti-ischemic medication may allow assessment of cardioprotection from adverse outcome.. Exercise ejection fraction and the change in ejection fraction from rest to exercise were measured by radionuclide ventriculography with and without background medication in 102 mildly symptomatic patients with coronary artery disease suitable for revascularization but initially treated medically.. Over 20 months, 23 patients experienced an adverse event. With medication, exercise ejection fraction increased in patients with and without events. By contrast, the ejection fraction response to exercise improved significantly in the event-free group only; the group with events had a persistent decrease in ejection fraction. By Cox analysis, the ejection fraction response to exercise performed with medication made the most significant independent contribution to event-free survival. Comparison of areas under receiver operating characteristic curves suggested that this index is the most useful clinical measure of cardioprotection.. An exercise-induced decrease in ejection fraction despite anti-ischemic medication implies failure of cardioprotection and a greater short-term risk of adverse outcome and crossover to revascularization in patients initially treated medically. Conversely, a preserved left ventricular performance confers a satisfactory prognosis while continuing with that treatment. Thus, the effect of medication on the ejection fraction response to exercise--a reasonable estimate of its cardioprotective efficacy--may influence the choice of continuing with such treatment or performing early revascularization.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Disease; Drug Evaluation; Exercise Test; Female; Humans; Male; Middle Aged; Prognosis; Prospective Studies; Radionuclide Ventriculography; Regression Analysis; Stroke Volume

Angiopeptin, a somatostatin analogue, inhibits intimal hyperplasia after percutaneous transluminal coronary artery balloon angioplasty (PTCA) in several animal models. This pilot study sought to determine the effect of subcutaneous infusion of angiopeptin on clinical events and restenosis in patients undergoing successful PTCA. One hundred twelve patients were randomized to receive continuous subcutaneous angiopeptin (750 micrograms/day) or placebo infusion from the day before PTCA and for the following 4 days in a double-blind study. An additional subcutaneous injection of 375 micrograms of angiopeptin or saline was given immediately before PTCA. Eighty patients had a successful PTCA, and 75 of these patients with 94 lesions underwent angiography 6 +/- 2 months after PTCA. All 112 patients underwent a 12-month clinical follow-up examination. Age, sex, smoking, diabetes, hypertension, hyperlipidemia, and morphologic features of stenosis were similar in both groups. The hierarchical 12-month event rate (death, myocardial infarction, coronary artery bypass grafting, and repeated PTCA) was reduced from 34% to 25% (p = 0.30) by angiopeptin by intention-to-treat analysis. Restenosis (> or = 50% diameter stenosis) was significantly reduced in lesions treated with angiopeptin (12% vs 40%; p = 0.003). Late lumen loss also was significantly reduced after angiopeptin treatment (0.12 +/- 0.46 mm vs 0.52 +/- 0.64 mm; p = 0.003). In conclusion, continuous subcutaneous angiopeptin infusion for 5 days tended to decrease clinical events and restenosis after PTCA.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Double-Blind Method; Female; Follow-Up Studies; Humans; Incidence; Male; Middle Aged; Oligopeptides; Peptides, Cyclic; Placebos; Recurrence; Scandinavian and Nordic Countries; Somatostatin; Statistics as Topic; Time Factors; Treatment Outcome

Accelerated coronary artery disease (TxCAD) in the long term heart transplant patient remains the major limitation to long term survival, with approximately 50% of patients developing an angiographic event of TxCAD by five years post-transplant. This accelerated vasculopathic process is believed to be due to chronic immune injury to the endothelium with coronary intimal proliferation developing rapidly. Subsequent lipid deposition develops in these proliferated areas, leading to a diffuse progressive occlusive CAD which can be seen on serial coronary arteriography as a progressive luminal narrowing. Based on multiple annual studies demonstrating a protective effect of calcium blockers in diet- or injury-induced vascular disease in animals, the authors undertook a randomized trial of diltiazem versus no calcium blocker begun early after heart transplantation in 1986. Serial quantitative coronary arteriographic measurements have demonstrated no significant change in the diltiazem group versus a decrease in mean coronary lumen diameter, from 2.41 +/- 0.27 to 2.19 +/- 0.28 mm, in the no calcium blocker group. These differences persisted at two and three years of follow-up. Freedom from CAD based on qualitative angiographic data confirmed this protective effect of diltiazem. These observations are supported by other reported retrospective studies of calcium blockers post-heart transplantation and in non-TxCAD. Therefore, calcium blockers appear to prevent the early coronary intimal proliferation in response to chronic immune injury, as well as the later lipid deposition. The cardiac transplant patient may serve as a useful model for study of antiatherosclerotic agents in humans.

Topics: Arteriosclerosis; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Diltiazem; Female; Heart Transplantation; Humans; Male; Postoperative Complications; Time Factors

The aim of our review is to summarize relevant data on the perioperative use of anti-ischaemic drugs in patients at risk for or with proven coronary heart disease.. The accessible medical literature according to current electronic information sources was explored.. One in every eight general anaesthetics is administered to a patient at risk for or with proven coronary heart disease. Of these patients, it is estimated that 20%-40% have perioperative myocardial ischaemia (PMI), the majority being non-symptomatic. This figure correlates with the occurrence of postoperative cardiac complications and myocardial infarction. The anaesthetist therefore has an important role to play in reducing the rate of perioperative cardiac sequelae. This can be achieved with good control of haemodynamic stability and the timely and appropriate use of antiischaemic drugs. Nitrocompounds (nitrates, molsidomine) serve as the gold standard in current angina pectoris treatment. Acting as coronary and systemic vasodilators, they effect an immediate reduction in preload and have been shown to be the drugs of first choice for intraoperative myocardial ischaemia. Beta-blockers reduce the rate of PMI to a greater extent than nitrates. They are also effective in myocardial ischaemia not accompanied by an increased heart rate. Single pre-operative administration of beta-blockers has also been shown to be beneficial in reducing the incidence of perioperative tachycardia, hypertension, and PMI. Consequently, such one-time medication can be considered for previously untreated high-risk patients presenting for surgery. The continuation of oral calcium channel blockers to the morning of surgery also reduces the rate of PMI and myocardial infarction in coronary-bypass patients, and combination with beta-blockers enhances this effect. Intra-operative diltiazem infusions are similarly advantageous in this patient group. In addition to nitrates, calcium antagonists are the drug of choice for coronary vasospasm. Drugs inhibiting platelet aggregation have a particular role in patients with coronary heart disease, however, they also cause increased perioperative bleeding. Consequently, it is recommended that these medications be discontinued 5-10 days prior to major surgery, with the exception of high-risk patients. Pilot studies using alpha 2-agonists have shown reduced anaesthetic requirements and a reduction in PMI. The perioperative relevance of these drugs is currently being investigated.. Beta-blockers, calcium channel blockers, nitrates, and possibly alpha 2-agonists lead to reduced rates of PMI and other cardiac complications in risk patients. Current anti-anginal medications, with the exception of anti-platelet agents, should be maintained to the day of surgery and continued as soon as possible thereafter. All of these drugs except anti-platelet agents may also be used intra-operatively, however, possible interactions with anaesthetic agents should be carefully considered.

Topics: Anesthesia, General; Cardiovascular Agents; Coronary Disease; Humans; Intraoperative Complications; Risk Factors

Prostaglandins and prostacyclin are potent vasodilators with marked hemodynamic effects, i.e., both improve cardiac function and possibly cause myocardial ischemia. In order to assess the stable prostacyclin analogon taprostene (T) we first performed an open preliminary study with increasing T-doses (6.5-50 ng/kg/min) and, secondly a double-blind crossover study versus placebo to investigate its influence on ischemic ST-segment depression during exercise stress testing under continuous T-infusions of 25 ng/kg/min (in one case 12.5 ng/kg/min). Eleven of 12 normotensive male patients (age 40 to 60, mean 52.8 +/- 8.4 years) suffering from angiographically proven coronary heart disease and stable angina pectoris completed the study. T was well tolerated, even under increasing doses, and blood pressure and the ECG parameters did not change. The double-blind study revealed no variation in the extent of ischemic ST-segment depression when compared to placebo, and all other ECG parameters as well as the blood pressure remained unaffected. Thus, myocardial ischemia cannot be ruled out completely under T, but earlier clinical findings may be confirmed characterizing T as a marked cytoprotective agent and, to a less degree, as a potent vasodilator.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Dose-Response Relationship, Drug; Double-Blind Method; Electrocardiography; Epoprostenol; Exercise Test; Hemodynamics; Humans; Male; Middle Aged; Myocardial Ischemia

Altogether 359 paired bicycle ergometries coupled with administration of single doses of antianginal drugs were carried out in 62 men suffering from angina pectoris of effort, functional classes II and III. A study was made of the indicator characterizing the time that elapsed since the onset of a typical angina pectoris attack till the appearance of the signs of ischemia on the ECG. Administration of effective single doses of antianginal drugs raised the time elapsed since the pain onset till the appearance of the ST segment greater than or equal to 1.0 mm fall during the exercise. Administration of ineffective doses of nitrates, calcium antagonists and placebo entailed a decline of that indicator, a rise of the number of cases where the segment ST greater than or equal to 1.0 mm fall was recordable before the onset of painful sensations. Administration of propranolol in ineffective single doses failed to provoke a decrease of the time elapsed since the typical pain onset till the appearance of the ST segment greater than or equal to 1.0 mm fall. Intake of ineffective single doses of nitrates, calcium antagonists and placebo may deprive certain patients of early signalization and appearance of the ECG signs of myocardial ischemia.

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Disease; Dose-Response Relationship, Drug; Electrocardiography; Exercise Test; Humans; Male; Middle Aged; Physical Exertion; Placebos; Time Factors

The extent to which posture altered the haemodynamic response to slow calcium channel blocker nicardipine was evaluated in 22 male patients with angiographically confirmed coronary artery disease. Patients were randomly allocated to supine or upright posture and an otherwise identical protocol performed in each group. At rest, following a control saline period, four doses of the drug (log cumulative dosage: 1.25, 2.5, 5.0, and 10.0 mg) were administered by i.v. infusion over a total period of 40 min; haemodynamic indices were recorded during the 3-5 min following each 5 min infusion. The exercise effects of the drug, in each posture, were determined by comparison of a control predrug exercise with observations at the same workload following the maximal cumulative dose. Nicardipine reduced resting mean blood pressure (MBP) and systemic vascular resistance index (SVRI) in both postures, the decrease being more pronounced when upright (MBP, -12%, -18%; p less than 0.01: SVRI, -30%, -46%; p less than 0.01). The increases in cardiac index (CI) and stroke volume index (SVI) were higher when upright (29 and 54% vs. 10 and 27%; p less than 0.01). Pulmonary artery occluded pressure (PAOP) increased by 29% when upright, without change when supine. On exercise, the effects for HR, MBP, CI, SI, and SVRI responses were independent of posture; however, a qualitative difference was apparent for PAOP (-17% vs. +14%; p less than 0.05). Thus, although the actions of nicardipine were qualitatively similar, quantitative differences related to posture were confirmed. These differences appeared to relate to posture-related baseline haemodynamic differences between the groups but with similar postnicardipine absolute values.

Topics: Adult; Aged; Angina Pectoris; Blood Pressure; Cardiac Output; Cardiovascular Agents; Coronary Disease; Dose-Response Relationship, Drug; Exercise; Heart Rate; Hemodynamics; Humans; Male; Middle Aged; Nicardipine; Posture; Pulmonary Circulation; Vascular Resistance

Constriction of atherosclerotic coronary segments during exercise may further reduce coronary flow reserve in patients with coronary artery disease. This could influence the linear regression analysis of the heart rate-related changes in ST-segment depression (ST/HR slope) thereby limiting the accuracy of this method in identifying the severity of the disease. To test this hypothesis, the exercise related ST/HR slopes on placebo were compared with those obtained during coronary vasodilation induced by a prostacyclin analogue (iloprost 6 ng kg-1 min-1) in 42 anginal patients with documented coronary artery disease. In seven of these, the same protocol was repeated during right heart catheterization. The overall diagnostic accuracy of the ST/HR slope on iloprost was better than on placebo in patients with advanced coronary artery disease. This was due mainly to a consistent rightward shift of the ST/HR slope in patients with one- and two-vessel, but not three-vessel disease or left main stem disease. The reason for the greater effects of iloprost on ST/HR slopes in patients with a lesser degree of atherosclerosis remains unclear. However, coronary blood flow was higher during drug infusion, which suggests that iloprost may prevent the occurrence of dynamic coronary events able to reduce the maximum coronary flow reserve during exertion. This mechanism may be predominant in patients with minor coronary artery disease.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Coronary Artery Disease; Coronary Circulation; Coronary Disease; Electrocardiography; Epoprostenol; Exercise Test; Female; Heart Rate; Humans; Iloprost; Male; Middle Aged; Single-Blind Method

The effect of a chemically stable prostacyclin analogue (Iloprost) on platelet function was investigated in a controlled study in patients with angiographically confirmed stable angina pectoris after ischaemic exercise. In placebo experiments, ADP platelet aggregation was increased after exercise only when measured in whole blood and not in PRP. While plasma thromboxane B2 levels were unchanged, those of 6-keto PGF1 alpha were significantly although transiently increased after exercise. Iloprost displayed a potent antiaggregating activity in PRP and also reversed platelet hyperaggregation occurring in whole blood determinations after exercise. Plasma thromboxane B2 levels were significantly reduced but occasionally a rebound increase occurred 30 min. after end of the infusion. In contrast plasma level of 6-keto PGF1 alpha did not change after Iloprost and its recorded post-exercise increase was counteracted, thus suggesting a negative feed-back mechanism between Iloprost and natural prostacyclin. The data also suggest that degradation of the analogue is probably accomplished through pathways different from those of PGI2.

Topics: 6-Ketoprostaglandin F1 alpha; Aged; Angina Pectoris; Blood Platelets; Cardiovascular Agents; Coronary Disease; Epoprostenol; Humans; Iloprost; Male; Middle Aged; Physical Exertion; Platelet Aggregation; Platelet Function Tests; Random Allocation; Thromboxane B2

Topics: Adult; Aged; Blood Viscosity; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Double-Blind Method; Electrocardiography; Female; Humans; Male; Middle Aged; Phenanthrenes

Topics: Adult; Aged; Cardiovascular Agents; Coronary Disease; Double-Blind Method; Drugs, Chinese Herbal; Female; Heart; Humans; Male; Middle Aged; Plant Extracts

This study is aimed at investigating gender differences in the medical management of patients with coronary heart disease (CHD).. Analyses were based on the ESC EORP EUROASPIRE V (European Survey Of Cardiovascular Disease Prevention And Diabetes) survey. Consecutive patients between 18 and 80 years, hospitalized for a coronary event, were included in the study. Information on cardiovascular medication intake at hospital discharge and at follow-up (≥ 6 months to < 2 years after hospitalization) was collected.. Data was available for 8261 patients (25.8% women). Overall, no gender differences were observed in the prescription and use of cardioprotective medication like aspirin, beta-blockers, and ACE-I/ARBs (P > 0.01) at discharge and follow-up respectively. However, a statistically significant difference was found in the use of statins at follow-up, in disfavor of women (82.8% vs. 77.7%; P < 0.001). In contrast, at follow-up, women were more likely to use diuretics (31.5% vs. 39.5%; P < 0.001) and calcium channel blockers (21.2% vs. 28.8%; P < 0.001), whereas men were more likely to use anticoagulants (8.8% vs. 7.0%; P < 0.001). Overall, no gender differences were found in total daily dose intake (P > 0.01). Furthermore, women were less likely than men to have received a CABG (20.4% vs. 13.2%; P < 0.001) or PCI (82.1% vs. 74.9%; P < 0.001) at follow-up. No gender differences were observed in prescribed (P = 0.10) and attended (P = 0.63) cardiac rehabilitation programs.. The EUROASPIRE V results show only limited gender differences in the medical management of CHD patients. Current findings suggest growing awareness about risk in female CHD patients.

Topics: Cardiac Rehabilitation; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Europe; Female; Health Knowledge, Attitudes, Practice; Hospitalization; Humans; Middle Aged; Patient Care Management; Practice Patterns, Physicians'; Secondary Prevention; Sex Factors; Women's Health

Limited data were available on the current trends in optimal medical therapy (OMT) after PCI and its influence on clinical outcomes in China. We aimed to evaluate the utilization and impact of OMT on the main adverse cardiovascular and cerebrovascular events (MACCEs) in post-PCI patients and analyzed the factors predictive of OMT after discharge.. We collected data from 3812 individuals from 2016.10 to 2017.09 at TEDA International Cardiovascular Hospital. They were classified into an OMT group and a non-OMT group according to their OMT status, which was defined as the combination of dual antiplatelet therapy, statins, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers after PCI. Multivariable Cox regression models were developed to assess the association between OMT and MACCEs, defined as all-cause mortality, nonfatal myocardial infarction, stroke, and target vessel revascularization. A logistic regression model was established to analyze the factors predictive of OMT.. Our results revealed that the proportion of patients receiving OMT and its component drugs decreased over time. A total of 36.0% of patients were still adherent to OMT at the end of follow-up. Binary logistic regression analysis revealed that baseline OMT (P < 0.001, OR = 52.868) was the strongest predictor of OMT after PCI. The Cox hazard model suggested that smoking after PCI was associated with the 1-year risk of MACCE (P = 0.001, HR = 2.060, 95% CI 1.346-3.151), while OMT (P = 0.001, HR = 0.486, 95% CI 0.312-0.756) was an independent protective factor against postoperative MACCEs.. There was still a gap between OMT utilization after PCI and the recommendations in the evidence-based guidelines. Sociodemographic and clinical factors influence the application of OMT. The management of OMT and smoking cessation after PCI should be emphasized.

Topics: Aged; Cardiovascular Agents; China; Comorbidity; Coronary Disease; Drug Utilization; Female; Humans; Male; Medication Adherence; Middle Aged; Percutaneous Coronary Intervention; Practice Patterns, Physicians'; Prospective Studies; Risk Assessment; Risk Factors; Smoking; Smoking Cessation; Time Factors; Treatment Outcome

As advised by the European guidelines on cardiovascular prevention, medication intake is a major component of secondary prevention. The aim of this study is to provide an in-depth overview of the medication intake in stable European coronary heart disease (CHD) patients.. Analyses are based on the EUROASPIRE IV survey, including CHD patients (18 to 80 years) who were hospitalized for a coronary event. These patients were interviewed and examined 6 months to 3 years after their hospitalization. Information on cardiovascular medication intake is available for 7953 patients.. About 99.2% of patients were on any kind of cardiovascular medication and 67.6% of patients were taking at least 5 different cardiovascular drugs. Overall, even when patients are taking the recommended drug combination as advised by the European guidelines - accounting for their disease profile - a large proportion of patients is still not on blood pressure, LDL-C or HbA1c target. In addition, huge variations were seen in medication dose intake across countries. Comparing the dose intake to the defined daily dose (DDD as published by the WHO) indicated a substantial deviation from the DDDs for a large proportion of patients.. This study provides a unique overview of the cardiovascular medication intake in CHD patients. Overall, even when patients are taking the advised drug combination, a large proportion of patients is still not on risk factor target. Physicians should seek for a balance in medication intake and appropriate dose, accounting both for the benefits and risks of chronic drug intake.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Diabetes Mellitus; Drug Administration Schedule; Europe; Evidence-Based Medicine; Female; Hospitalization; Humans; Male; Middle Aged; Registries; Secondary Prevention; Surveys and Questionnaires

Adherence to medication regimens is essential for preventing and reducing adverse outcomes among patients with coronary artery disease (CAD). Greater understanding of the relation between negative illness perceptions, beliefs about cardiac rehabilitation (CR) and medication adherence may help inform future approaches to improving medication adherence and quality of life (QoL) outcomes. The aims of the study are: 1) to compare changes in illness perceptions, beliefs about CR, medication adherence and QoL on entry to a CR programme and 6 months later; 2) to examine associations between patients' illness perceptions and beliefs about CR at baseline and medication adherence and QoL at 6 months.. A longitudinal study of 40 patients with CAD recruited from one CR service in Scotland. Patients completed the Medication Adherence Report Scale, Brief Illness Perception Questionnaire, Beliefs about CR questionnaire and the Short-Form 12 Health Survey. Data were analysed using the Wilcoxon Signed Ranks test, Pearson Product Moment correlation and Bayesian multiple logistic regression.. Most patients were men (70%), aged 62.3 mean (SD 7.84) years. Small improvements in 'perceived suitability' of CR at baseline increased the odds of being fully adherent to medication by approximately 60% at 6 months. Being fully adherent at baseline increased the odds of staying so at 6 months by 13.5 times. 'Perceived necessity, concerns for exercise and practical barriers' were negatively associated with reductions in the probability of full medication adherence of 50, 10, and 50%. Small increases in concerns about exercise decreased the odds of better physical health at 6 months by about 50%; and increases in practical barriers decreased the odds of better physical health by about 60%. Patients perceived fewer consequences of their cardiac disease at 6 months.. Patients' beliefs on entry to a CR programme are especially important to medication adherence at 6 months. Negative beliefs about CR should be identified early in CR to counteract any negative effects on QoL. Interventions to improve medication adherence and QoL outcomes should focus on improving patients' negative beliefs about CR and increasing understanding of the role of medication adherence in preventing a future cardiac event.

Topics: Aged; Cardiac Rehabilitation; Cardiovascular Agents; Coronary Disease; Female; Health Knowledge, Attitudes, Practice; Humans; Illness Behavior; Longitudinal Studies; Male; Medication Adherence; Middle Aged; Quality of Life; Time Factors; Treatment Outcome

Topics: Aging; Cardiovascular Agents; Cardiovascular Surgical Procedures; Coronary Disease; Humans; Middle Aged

To quantify the implementation of the third Joint British Societies' Consensus Recommendations for the Prevention of Cardiovascular Disease (JBS3) after coronary event.. Using a cross-sectional survey design, patients were consecutively identified in 36 specialist and district general hospitals between 6 months and 2 years, after acute coronary syndrome or revascularisation procedure and invited to a research interview. Outcomes included JBS3 lifestyle, risk factor and therapeutic management goals. Data were collected using standardised methods and instruments by trained study nurses. Blood was analysed in a central laboratory and a glucose tolerance test was performed.. 3926 eligible patients were invited to participate and 1177 (23.3% women) were interviewed (30% response). 12.5% were from black and minority ethnic groups. 45% were persistent smokers, 36% obese, 52.9% centrally obese, 52% inactive; 30% had a blood pressure >140/90 mm Hg, 54% non-high-density lipoprotein ≥2.5 mmol/L and 44.3% had new dysglycaemia. Prescribing was highest for antiplatelets (94%) and statins (85%). 81% were advised to attend cardiac rehabilitation (86% <60 years vs 79% ≥60 years; 82% men vs 77% women; 93% coronary artery bypass grafting vs 59% unstable angina), 85% attended if advised; 69% attended overall. Attenders were significantly younger (p=0.03) and women were less likely to attend (p=0.03).. Patients with coronary heart disease (CHD) are not being adequately managed after event with preventive measures. They require a structured preventive cardiology programme addressing lifestyle, risk factor management and adherence to cardioprotective medications to achieve the standards set by the British Association for Cardiovascular Prevention and Rehabilitation and JBS3 guidelines.

Topics: Aged; Cardiac Rehabilitation; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Female; Guideline Adherence; Health Care Surveys; Healthcare Disparities; Humans; Male; Middle Aged; Practice Guidelines as Topic; Practice Patterns, Physicians'; Risk Reduction Behavior; Secondary Prevention; United Kingdom

To explore the mechanism of Shengmai Yin (SMY) for coronary heart disease (CHD) by systemic pharmacology and chemoinformatics.. Traditional Chinese Medicine Systems Pharmacology Database (TCMSP), traditional Chinese medicine integrative database (TCMID) and the traditional Chinese medicine (TCM) Database@Taiwan were used to screen and predict the bioactive components of SMY. Pharmmapper were utilized to predict the potential targets of SMY, the TCMSP was utilized to obtain the known targets of SMY. The Genecards and OMIM database were utilized to collect CHD genes. Cytoscape was then used for network construction and analysis, and DAVID was used for Gene Ontology (GO) and pathway enrichment analysis. After that, animal experiments were then performed to further validate the results of systemic pharmacology and chemoinformatics.. Three major networks were constructed: (1) CHD genes' protein-protein interaction (PPI) network; (2) SMY-CHD PPI network; (3) SMY known target-CHD PPI network. The other networks are minor networks generated by analyzing the three major networks. Experimental results showed that compared with the model group, the Shengmai injection (SMI) can reduce the myocardial injury score and the activities of serum aspartate aminoconvertase (AST), CK and lactate dehydrogenase (LDH) in rats (P<0.05), and reduce serum lipid peroxide (LPO) content and increase serum superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activities in myocardial infarction rats (P<0.05). SMI can also decrease the expression of MMP-9 mRNA and increase that of TIMP-1 mRNA (P<0.01).. SMY may regulate the signaling pathways (such as PPAR, FoxO, VEGF signaling), biological processes (such as angiogenesis, blood pressure formation, inflammatory response) and targets (such as AKT1, EGFR, MAPK1) so as to play a therapeutic role in CHD.

Topics: Animals; Cardiovascular Agents; Coronary Disease; Databases, Factual; Disease Models, Animal; Drug Combinations; Drugs, Chinese Herbal; Female; Gene Regulatory Networks; Humans; Male; Matrix Metalloproteinase 9; Myocardial Infarction; Myocytes, Cardiac; Protein Interaction Maps; Rats, Sprague-Dawley; Signal Transduction; Tissue Inhibitor of Metalloproteinase-1

Traditional Chinese medicine (TCM) has long been used in the clinical treatment of coronary heart disease (CHD). TCM is characterized by syndrome-based medication, which is, using different TCM formulae for different syndromes. However, the underlying mode of action remains unclear. In this work, we utilized network pharmacology and machine learning to explore the mechanism of eight classic TCM formulae in the treatment of different types of CHD. First, by integrating multiple databases, a total of 669 potential bioactive compounds and 581 targets of the eight formulae were screened. Then, the effectiveness of these formulae on CHD was evaluated using two network-based indicators. The results showed that each formula's targets were significantly correlated with CHD associated genes and overlapped with the targets of 9 classes of drugs for cardio vascular diseases (CVD) to some degree. Next, from 5 different levels, i.e., herb, symptom, compound, target, and pathway level, we systematically compared the eight formulae using network clustering and hierarchical clustering. We found that all the formulae could be grouped into five clusters and the clustering results were approximately consistent at different levels. All the formulae were involved in 7 pathways closely related to CHD and may exhibit the common effect of relieving angina. Formulae in the same group collectively regulated some unique pathways and suggest further specific indications. For example, the three formulae used for Qi stagnation and blood stasis, Qi deficiency and blood stasis, and Qi-Yin deficiency syndromes acted on two special pathways (TNF signaling pathway, NF-kappa B signaling pathway) and may exert anti-inflammatory and immune-enhancing effects; the two formulae for Yin deficiency of heart and kidney, and Yang deficiency of heart and kidney syndromes regulated two special pathways (PPAR signaling pathway, thyroid hormone signaling pathway) in endocrine system and could improve renal function. Subsequently, we designed a rank algorithm, which integrated network topology with biological function, to identify important targets of these formulae. The results were consistent with the multi-level clustering results. At last, our literature mining validated about 20 % putative targets, as well as clustering results and effects of the formulae by experimental evidences. This study explained the medication patterns and scientific significance of TCM formulae on different types of CHD from

Topics: Cardiovascular Agents; Cluster Analysis; Coronary Disease; Databases, Protein; Drugs, Chinese Herbal; Humans; Machine Learning; Medicine, Chinese Traditional; Protein Interaction Maps; Signal Transduction; Treatment Outcome

To determine whether sex differences exist in the management of patients with a history of coronary heart disease (CHD) in primary care.. General practice records of patients aged ≥18 years with a history of CHD in a large general practice dataset in Australia, MedicineInsight, were analysed. Sex-specific, age-standardised proportions of patients prescribed with recommended medications; assessed for cardiovascular risk factors; and achieved treatment targets according to the General Practice Management Plan were reported.. Records of 130 926 patients (47% women) from 438 sites were available from 2014 to 2018. Women were less likely to be prescribed with recommended medications (prescribed ≥3 medications: women 44%, men 61%; p<0.001). Younger patients, especially women aged <45 years, were substantially underprescribed (aged <45 years prescribed ≥3 medications: women 2%, men 8%; p<0.001). Lower proportions of women were assessed for cardiovascular risk factors (blood test for lipids: women 70%-76%, men 77%-81%; p<0.001). Body size was not commonly assessed (body mass index: women 59%, men 62%; p<0.001; waist: women 23%, men 25%; p<0.001). Higher proportions of women than men achieved targets for most risk factors (achieved ≥4 targets in patients assessed for all risk factors: women 82%, men 76%).. Gaps in preventative management including prescription of indicated medications and risk factor monitoring have been reported from the late 1990s and this large-scale general practice data analysis indicate they still persist. Moreover, the gap is larger in women compared to men. We need new ways to address these gaps and the sex inequity.

Topics: Adult; Age Factors; Aged; Anthropometry; Australia; Cardiovascular Agents; Coronary Disease; Drug Prescriptions; Female; General Practice; Humans; Lipids; Male; Middle Aged; Practice Guidelines as Topic; Practice Patterns, Physicians'; Primary Health Care; Risk Factors; Sex Factors; Sexism

The aim of this study was to analyze how the consumption of medication over time affects the survival rate in patients with a coronary event and whether there is a gender difference.. The study included 804 patients admitted to 4 hospitals with a coronary event during 2007. Monitoring after coronary event was carried out during 2007 and every 6 months in the subsequent 2 years (2008 and 2009) throughout the review of the clinical history of the patient. The main outcome was the analysis of mortality after the coronary event. Kaplan-Meier survival curves were plotted to calculate the time to death, comparing women versus men for 4 medication groups: aspirin, statins, β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs). A Cox regression model was used for the final mortality analysis.. During the follow-up time, 172 deaths were assessed. Each month of treatment with aspirin, statins, β-blockers, or ACEI/ARB was associated with a decrease in mortality between 13.0% and 0.5% (univariate analysis). The Kaplan-Meier method revealed a significant reduction in mortality after the coronary event for each month of treatment with aspirin (men), statins (men), and β-blockers (both men and women). No significant effect in survival was observed in either gender with ACEI/ARB treatment. The final multivariable model (Cox regression) showed that the taking of aspirin, statins, β-blockers, or ACEI/ARB is able to reduce mortality rates up to 7.0% (aspirin) throughout each month of treatment after a coronary event without any influence of gender.. Aspirin, statins, β-blockers, and ACEI/ARB revealed a protective character with each month of treatment throughout the follow-up period, in terms of risk reduction of death. Aspirin and statins showed the maximum benefit, followed by ACEI/ARB and β-blockers.

Topics: Aged; Aspirin; Cardiovascular Agents; Coronary Disease; Female; Follow-Up Studies; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Kaplan-Meier Estimate; Male; Retrospective Studies; Sex Factors; Survival Rate; Time Factors

Between the years 1993 and 2008, mortality rates from coronary heart disease (CHD) in the Slovak Republic have decreased by almost one quarter. However, this was a smaller decline than in neighbouring countries. The aim of this modelling study was therefore to quantify the contributions of risk factor changes and the use of evidence-based medical therapies to the CHD mortality decline between 1993 and 2008.. We identified, obtained and scrutinised the data required for the model. These data detailed trends in the major population cardiovascular risk factors (smoking, blood pressure, total cholesterol, diabetes prevalence, body mass index (BMI) and physical activity levels), and also the uptake of all standard CHD treatments. The main data sources were official statistics (National Health Information Centre and Statistical Office of the Slovak Republic) and national representative studies (AUDIT, SLOVAKS, SLOVASeZ, CINDI, EHES, EHIS). The previously validated IMPACT policy model was then used to combine and integrate these data with effect sizes from published meta-analyses quantifying the effectiveness of specific evidence-based treatments, and population-wide changes in cardiovascular risk factors. Results were expressed as deaths prevented or postponed (DPPs) attributable to risk factor changes or treatments. Uncertainties were explored using sensitivity analyses.. Between 1993 and 2008 age-adjusted CHD mortality rates in the Slovak Republic (SR) decreased by 23% in men and 26% in women aged 25-74 years. This represented some 1820 fewer CHD deaths in 2008 than expected if mortality rates had not fallen. The IMPACT model explained 91% of this mortality decline. Approximately 50% of the decline was attributable to changes in acute phase and secondary prevention treatments, particularly acute and chronic treatments for heart failure (≈12%), acute coronary syndrome treatments (≈9%) and secondary prevention following AMI and revascularisation (≈8%). Changes in CHD risk factors explained approximately 41% of the total mortality decrease, mainly reflecting reductions in total serum cholesterol. However, other risk factors demonstrated adverse trends and thus generated approximately 740 additional deaths.. Our analysis suggests that approximately half the CHD mortality fall recently observed in the SR may be attributable to the increased use of evidence-based treatments. However, the adverse trends observed in all the major cardiovascular risk factors (apart from total cholesterol) are deeply worrying. They highlight the need for more energetic population-wide prevention policies such as tobacco control, reducing salt and industrial trans fats content in processed food, clearer food labelling and regulated marketing of processed foods and sugary drinks.

Topics: Adult; Aged; Angioplasty; Cardiovascular Agents; Cardiovascular Diseases; Cholesterol; Coronary Artery Bypass; Coronary Disease; Diabetes Mellitus; Diet; Evidence-Based Medicine; Exercise; Female; Humans; Male; Meta-Analysis as Topic; Middle Aged; Models, Cardiovascular; Mortality; Overweight; Risk Factors; Slovakia; Smoking

Accumulating evidence has established that systemic inflammation is an important pathophysiologic factor of coronary heart disease (CHD). In this study, we investigated whether catechin exerts anti-inflammatory function in CHD rats. CHD model of rats was established by high-fat diet feeding and pituitrin injection. The successful building of CHD model was confirmed using blood liquid biochemical analyzer. Additionally, the effects of catechin on CHD parameters and several inflammatory signaling were investigated. The levels of total cholesterol, high-density lipoprotein, low-density lipoprotein cholesterin, triglyceride and blood glucose were all significantly elevated in CHD rats compared to them in control rats, suggesting the successful establishment of CHD model. Administration of catechin attenuated CHD by reversing the levels of creatine kinase, creatine kinase-MB, lactate dehydrogenase, cardiac troponin (cTnT), ventricular ejection fraction (LVEF) and systolic internal diameter (LVIDs). Additionally, several inflammatory biomarkers or cytokines such as C-reactive protein, lipoprotein-associated phospholipase A2 (Lp-PLA2), interleukin (IL)-6 and tumor necrosis factor-alpha (TNF-α) were inhibited by catechin. In contrast to nuclear factor-kappa beta (NF-κB), several proteins involved in inflammation such as farnesoid X receptor, signal transducers and activators of transcription (STAT)-3 and protein kinase B (PKB/Akt) were all activated by catechin. Catechin could be used as a promising treatment for CHD based on its role in suppressing inflammation and balancing STAT-3 signaling.

Topics: Animals; Anti-Inflammatory Agents; Biomarkers; Blood Glucose; Cardiovascular Agents; Catechin; Coronary Disease; Cytokines; Disease Models, Animal; Inflammation Mediators; Lipids; Myocytes, Cardiac; Rats, Wistar; Signal Transduction; Stroke Volume; Ventricular Function, Left

The objectives of this study are to assess the healing score (HS) and neointimal thickness of the Xinsorb scaffold, and explore the relationships between the implanted patterns, neointimal thickness, and HS. The Xinsorb bioresorbable sirolimus-eluting scaffold is the first domestically designed and fabricated bioresorbable scaffold in China. The 6-month follow-up found it to be safe and effective in the treatment of single de novo coronary lesions. The Xinsorb scaffolds were implanted in 30 patients with symptomatic ischemic coronary disease. A 6-month follow-up was performed in a subset of 19 patients; the HS and neointimal thickness were evaluated by optical coherence tomography. Struts were classified as ApposedCovered, ApposedUncovered, MalapposedCovered, MalapposedUncovered, jailing and presence of intraluminal masses. The implanted pressure, implanted duration, and post-expansion pressure were recorded during the operation. We evaluated the relationship between the HS or neointimal thickness and the implanted pressure, holding time, and post-expansion pressure. The device and procedure success rates were both 100%. No major adverse cardiac or scaffold-thrombus related events occurred. At 6 months, 12,295 struts were analyzed to determine the HS (6.23) and neointimal thickness (0.1021 ± 0.05718 mm) in the Xinsorb scaffolds. There was a strong negative relationship between the HS and the implantation duration (Pearson r = - 0.518, p = 0.023). A significant negative relationship also existed between the HS and post-dilatation (Pearson r = - 0.631, p = 0.004). The Xinsorb scaffold HS appears negative correlated with the implanted duration and post-dilatation. We will further evaluate the HS of randomized controlled trial of the Xissorb scaffold.

Topics: Absorbable Implants; Adult; Aged; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Vessels; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Neointima; Percutaneous Coronary Intervention; Prospective Studies; Severity of Illness Index; Sirolimus; Tissue Scaffolds; Tomography, Optical Coherence

Adherence to pharmacotherapeutic treatment guidelines in patients with heart failure (HF) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Our aim was to investigate prevalence and characteristics of HF in patients with coronary heart disease (CHD), and to assess the adherence to current HF guidelines in patients with HF stage C, thus identifying potential targets for the optimization of guideline implementation.. Patients from the German sample of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroAspire) IV survey with a hospitalization for CHD within the previous six to 36 months providing valid data on echocardiography as well as on signs and symptoms of HF were categorized into stages of HF: A, prevalence of risk factors for developing HF; B, asymptomatic but with structural heart disease; C, symptomatic HF. A Guideline Adherence Indicator (GAI-3) was calculated for patients with reduced (≤40%) left ventricular ejection fraction (HFrEF) as number of drugs taken per number of drugs indicated; beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists (MRA) were considered.. 509/536 patients entered analysis. HF stage A was prevalent in n = 20 (3.9%), stage B in n = 264 (51.9%), and stage C in n = 225 (44.2%) patients; 94/225 patients were diagnosed with HFrEF (42%). Stage C patients were older, had a longer duration of CHD, and a higher prevalence of arterial hypertension. Awareness of pre-diagnosed HF was low (19%). Overall GAI-3 of HFrEF patients was 96.4% with a trend towards lower GAI-3 in patients with lower LVEF due to less thorough MRA prescription.. In our sample of CHD patients, prevalence of HF stage C was high and a sizable subgroup suffered from HFrEF. Overall, pharmacotherapy was fairly well implemented in HFrEF patients, although somewhat worse in patients with more reduced ejection fraction. Two major targets were identified possibly suited to further improve the implementation of HF guidelines: 1) increase patients´ awareness of diagnosis and importance of HF; and 2) disseminate knowledge about the importance of appropriately implementing the use of mineralocorticoid receptor antagonists.. This is a cross-sectional analysis of a non-interventional study. Therefore, it was not registered as an interventional trial.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Echocardiography, Doppler; Female; Germany; Guideline Adherence; Health Care Surveys; Health Knowledge, Attitudes, Practice; Heart Failure; Humans; Male; Medication Adherence; Middle Aged; Mineralocorticoid Receptor Antagonists; Patient Education as Topic; Practice Guidelines as Topic; Practice Patterns, Physicians'; Prevalence; Process Assessment, Health Care; Risk Factors; Time Factors; Treatment Outcome

Patients with angina and coronary microvascular dysfunction, without evidence of structural or epicardial coronary disease (Type I CMVD) remain without evidence based treatment options. Previous work has demonstrated that ranolazine can improve angina frequency and stability among patients with Type 1 CMVD; however, the mechanism remains unclear. Therefore, the objective of this pilot project was to assess the impact of ranolazine on Type I CMVD as measured using an invasive tool to measure global resistance (index of microcirculatory resistance (IMR)).. Patients with Type 1 CMVD diagnosed using IMR were enrolled and treated with ranolazine 1000mg BID. Coronary angiography and IMR were performed at baseline and on treatment after four weeks. The primary outcome measure was change in IMR pre- and post-treatment. Secondary outcome measures, improvement in angina and activity level, were assessed using the Seattle Angina Questionnaire (SAQ), Duke Activity Status Index (DASI) and Metabolic equivalent for Task (MET) scores.. A total of 7 patient were enrolled and completed the study. Mean age was 57.6±7.5, 43% were female and 43% were Hispanic. Mean baseline IMR was 37.25±16.27 which decreased to 19.48±5.69 (p=0.02; (-48% Δ) after treatment with ranolazine. Four of the five SAQ domains improved on treatment with significant improvement in physical limitation (p=0.001), angina frequency (p=0.04), angina stability (p=0.05) and disease perception (p=0.001). Non-significant improvements in activity were also seen in both the DASI and MET scores.. Among patients with Type 1 CMVD, our pilot data suggest favorable changes in IMR, anginal symptoms and activity status with ranolazine treatment. These findings support further evaluation of the effects of ranolazine on microcirculatory function and angina symptoms in a larger cohort of patients with Type 1 CMVD.

Topics: Aged; Angina, Stable; Cardiovascular Agents; Coronary Disease; Female; Humans; Male; Microcirculation; Middle Aged; Pilot Projects; Ranolazine; Treatment Outcome

The EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) cross-sectional surveys describe time trends in lifestyle and risk factor control among coronary patients between 1999 and 2013 in Belgium, Czech Republic, Finland, France, Ireland, the Netherlands, Poland, Slovenia, and the United Kingdom as part of the EuroObservational Research Programme under the auspices of European Society of Cardiology.. This study sought to describe time trends in lifestyle, risk factor control, and the use of evidence-based medication in coronary patients across Europe.. The EUROASPIRE II (1999 to 2000), III (2006 to 2007), and IV (2012 to 13) surveys were conducted in the same geographical areas and selected hospitals in each country. Consecutive patients (≤70 years) after coronary artery bypass graft, percutaneous coronary intervention, or an acute coronary syndrome identified from hospital records were interviewed and examined ≥6 months later with standardized methods.. Of 12,775 identified coronary patients, 8,456 (66.2%) were interviewed. Proportion of current smokers was similar across the 3 surveys. Prevalence of obesity increased by 7%. The prevalence of raised blood pressure (≥140/90 mm Hg or ≥140/80 mm Hg with diabetes) dropped by 8% from EUROASPIRE III to IV, and therapeutic control of blood pressure improved with 55% of patients below target in IV. The prevalence of low-density lipoprotein cholesterol ≥2.5 mmol/l decreased by 44%. In EUROASPIRE IV, 75% were above the target low-density lipoprotein cholesterol <1.8 mmol/l. The prevalence of self-reported diabetes increased by 9%. The use of evidence-based medications increased between the EUROASPIRE II and III surveys, but did not change between the III and IV surveys.. Lifestyle habits have deteriorated over time with increases in obesity, central obesity, and diabetes and stagnating rates of persistent smoking. Although blood pressure and lipid management improved, they are still not optimally controlled and the use of evidence-based medications appears to have stalled apart from the increased use of high-intensity statins. These results underline the importance of offering coronary patients access to modern preventive cardiology programs.

Topics: Adolescent; Adult; Aged; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Europe; Female; Follow-Up Studies; Forecasting; Humans; Life Style; Male; Middle Aged; Population Surveillance; Prevalence; Primary Prevention; Risk Assessment; Risk Factors; Young Adult

Topics: Cardiovascular Agents; Coronary Disease; Humans; Myocardial Infarction; Prognosis

To determine whether the Joint European Societies guidelines on cardiovascular prevention are being followed in everyday clinical practice of secondary prevention and to describe the lifestyle, risk factor and therapeutic management of coronary patients across Europe.. EUROASPIRE IV was a cross-sectional study undertaken at 78 centres from 24 European countries. Patients <80 years with coronary disease who had coronary artery bypass graft, percutaneous coronary intervention or an acute coronary syndrome were identified from hospital records and interviewed and examined ≥ 6 months later. A total of 16,426 medical records were reviewed and 7998 patients (24.4% females) interviewed. At interview, 16.0% of patients smoked cigarettes, and 48.6% of those smoking at the time of the event were persistent smokers. Little or no physical activity was reported by 59.9%; 37.6% were obese (BMI ≥ 30 kg/m(2)) and 58.2% centrally obese (waist circumference ≥ 102 cm in men or ≥88 cm in women); 42.7% had blood pressure ≥ 140/90 mmHg (≥140/80 in people with diabetes); 80.5% had low-density lipoprotein cholesterol ≥ 1.8 mmol/l and 26.8% reported having diabetes. Cardioprotective medication was: anti-platelets 93.8%; beta-blockers 82.6%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75.1%; and statins 85.7%. Of the patients 50.7% were advised to participate in a cardiac rehabilitation programme and 81.3% of those advised attended at least one-half of the sessions.. A large majority of coronary patients do not achieve the guideline standards for secondary prevention with high prevalences of persistent smoking, unhealthy diets, physical inactivity and consequently most patients are overweight or obese with a high prevalence of diabetes. Risk factor control is inadequate despite high reported use of medications and there are large variations in secondary prevention practice between centres. Less than one-half of the coronary patients access cardiac prevention and rehabilitation programmes. All coronary and vascular patients require a modern preventive cardiology programme, appropriately adapted to medical and cultural settings in each country, to achieve healthier lifestyles, better risk factor control and adherence with cardioprotective medications.

Topics: Adolescent; Adult; Aged; Cardiology; Cardiovascular Agents; Comorbidity; Coronary Disease; Cross-Sectional Studies; Diet; Europe; Exercise; Female; Guideline Adherence; Health Care Surveys; Humans; Male; Middle Aged; Practice Guidelines as Topic; Practice Patterns, Physicians'; Prevalence; Prospective Studies; Risk Assessment; Risk Factors; Risk Reduction Behavior; Secondary Prevention; Sedentary Behavior; Smoking; Smoking Cessation; Societies, Medical; Time Factors; Treatment Outcome; Young Adult

The primary objective of this study was to evaluate the impact of polypharmacy on primary and secondary adherence to evidence-based medication (EBM) and to measure factors associated with non-adherence among patients who underwent percutaneous coronary intervention (PCI).. We conducted a retrospective analysis for patients who underwent PCI at a tertiary cardiac care hospital in Qatar. Patients who had polypharmacy (defined as ≥6 medications) were compared with those who had no polypharmacy at hospital discharge in terms of primary and secondary adherence to dual antiplatelet therapy (DAPT), beta-blockers (BB), angiotensin converting enzyme inhibitors (ACEIs) and statins.. A total of 557 patients (mean age: 53±10 years; 85%; males) who underwent PCI were included. The majority of patients (84.6%) received ≥6 medications (polypharmacy group) while only 15.4% patients received ≥5 medications (nonpolypharmacy group). The two groups were comparable in term of gender, nationality, socioeconomic status and medical insurance. The non-polypharmacy patients had significantly higher adherence to first refill of DAPT compared with patients in the polypharmacy group (100 vs. 76.9%; p=0.001). Similarly, the non-polypharmacy patients were significantly more adherent to secondary preventive medications (BB, ACEI and statins) than the polypharmacy group.. In patients who underwent PCI, polypharmacy at discharge could play a negative role in the adherence to the first refill of EBM. Further studies should investigate other parameters that contribute to long term non-adherence.

Topics: Adrenergic beta-Antagonists; Adult; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Coronary Disease; Drug Prescriptions; Evidence-Based Medicine; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Medication Adherence; Middle Aged; Patient Discharge; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Polypharmacy; Qatar; Retrospective Studies; Tertiary Care Centers; Time Factors

The internal mammary artery (IMA) is the preferred conduit for bypassing the left anterior descending (LAD) artery in patients undergoing coronary artery bypass grafting. Systematic evaluation of the frequency and predictors of IMA failure and long-term outcomes is lacking.. The Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial participants who underwent IMA-LAD revascularization and had 12- to 18-month angiographic follow-up (n=1539) were included. Logistic regression with fast false selection rate methods was used to identify characteristics associated with IMA failure (≥75% stenosis). The relationship between IMA failure and long-term outcomes, including death, myocardial infarction, and repeat revascularization, was assessed with Cox regression. IMA failure occurred in 132 participants (8.6%). Predictors of IMA graft failure were LAD stenosis <75% (odds ratio, 1.76; 95% confidence interval, 1.19-2.59), additional bypass graft to diagonal branch (odds ratio, 1.92; 95% confidence interval, 1.33-2.76), and not having diabetes mellitus (odds ratio, 1.82; 95% confidence interval, 1.20-2.78). LAD stenosis and additional diagonal graft remained predictive of IMA failure in an alternative model that included angiographic failure or death before angiography as the outcome. IMA failure was associated with a significantly higher incidence of subsequent acute (<14 days of angiography) clinical events, mostly as a result of a higher rate of repeat revascularization.. IMA failure was common and associated with higher rates of repeat revascularization, and patients with intermediate LAD stenosis or with an additional bypass graft to the diagonal branch had increased risk for IMA failure. These findings raise concerns about competitive flow and the benefit of coronary artery bypass grafting in intermediate LAD stenosis without functional evidence of ischemia.. URL: http:/www.clinicaltrials.gov. Unique identifier: NCT00042081.

Topics: Aged; Cardiac Catheterization; Cardiovascular Agents; Combined Modality Therapy; Comorbidity; Coronary Angiography; Coronary Disease; Coronary Restenosis; Diabetes Complications; Double-Blind Method; Female; Graft Occlusion, Vascular; Humans; Internal Mammary-Coronary Artery Anastomosis; Kaplan-Meier Estimate; Male; Middle Aged; Multicenter Studies as Topic; Myocardial Infarction; Postoperative Complications; Proportional Hazards Models; Randomized Controlled Trials as Topic; Reoperation; Treatment Failure

Does the use of post-menopausal vaginal estradiol (VE) affect the mortality risk for coronary heart disease (CHD) and stroke.. The use of VE reduces the risk for cardiovascular mortality.. A growing number of women use VE for post-menopausal genitourinary symptoms. Although this therapy is intended to have only local effects, estrogen is absorbed into the blood circulation and thus VE use may also have systemic effects.. We studied a nationwide cohort in Finland 1994-2009 during which post-menopausal women (n = 195 756) initiated the use of VE (age [mean ± SD] 65.7 ± 10.9 years). Follow-up data gathered 1.4 million women-years and we assessed the mortality risk due to CHD (n= 9656) or stroke (n = 4294).. The mortality risk in VE users was compared with that in the age-matched background population (standardized mortality ratio; [SMR]; 95% confidence interval) and related to various durations of exposure to VE (1 to ≤3, >3 to ≤5, >5 to ≤10 and >10 years).. The use of VE was accompanied by decreases in the risk for CHD and stroke death. The risk reduction for CHD death was highest for >3 to ≤5 years exposure (SMR 0.64; 0.57-0.70) and for stroke for >5 to ≤10 years exposure (SMR 0.64; 0.57-0.72). The risk reductions for both CHD and stroke mortality were detected in all age groups with the highest risk reduction being in women aged 50-59 years (SMR 0.43; 0.19-0.88 and SMR 0.21; 0.06-0.58, respectively).. Our series lack a placebo arm and thus, may harbor a healthy woman bias. Moreover, data on clinical variables such as weight, smoking, blood pressure and family background were unobtainable for this study. Women using both VE and systemic hormone therapy (HT) were included in the comparator background population. This should not cause any significant error because the proportion of women using VE or other HT was modest (<10% in age-matched population) and because the use of systemic HT also reduces death risks in the same population. Our data cannot be directly applied for local regimens containing conjugated equine estrogens, because they are absorbed differently and may show effects that differ from those of estradiol.. In 1000 women using VE for up to 10 years, a maximum of 24 fewer CHD deaths and 18 fewer stroke deaths is likely to occur.. This work was supported by unrestricted grants from the Päivikki and Sakari Sohlberg Foundation, the Emil Aaltonen Foundation, the Finnish Medical Foundation, Finska Läkaresällskapet, the Orion Farmos Research Foundation, the Paavo Nurmi Foundation and a special governmental grant for health sciences research. The funding sources had no role in the study design, data handling or manuscript preparation. EPID Research is a company that performs financially supported studies for several pharmaceutical companies. Dr Korhonen, Dr Hoti and MSc Vattulainen, employed by Epid Research, report financial activities from several other pharmaceutical companies outside the submitted work. Dr Mikkola has been a speaker and/or received consulting fees from Mylan and Novo Nordisk. Dr Tuomikoski has been a speaker and/or received consulting fees from Orion and Mylan. The remaining authors report no conflict of interest.

Topics: Aged; Cardiovascular Agents; Cohort Studies; Coronary Disease; Delayed-Action Preparations; Drug Prescriptions; Estradiol; Estrogens; Female; Female Urogenital Diseases; Finland; Follow-Up Studies; Humans; Middle Aged; Postmenopause; Registries; Risk Factors; Stroke; Vaginal Creams, Foams, and Jellies

Regarding the effectiveness of disease management programs (DMPs) in Germany, several studies have been published on the DMP for type 2 diabetes. This pilot study provides methodological insights into evaluating the DMP for coronary heart disease (CHD), which currently includes 1.7 million participants, and reveals trends in healthcare outcomes for mortality, guideline adherent prescribing and costs. Major methodological challenges that need to be considered for the development of an appropriate matching method for this indication have been identified. The results show positive trends in favor of the DMP regarding mortality, costs and medication according to guidelines. A matching design is applicable to the CHD indication; the knowledge gained regarding the quality of care can be used for a targeted development of the program.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Disease; Cost-Benefit Analysis; Costs and Cost Analysis; Delivery of Health Care, Integrated; Disability Evaluation; Disease Management; Female; Germany; Guideline Adherence; Humans; Length of Stay; Male; Matched-Pair Analysis; Middle Aged; National Health Programs; Pilot Projects; Propensity Score; Treatment Outcome

Topics: Aspirin; Atorvastatin; Capsules; Cardiovascular Agents; Coronary Disease; Drug Combinations; Humans; Ramipril; Secondary Prevention

Sexual activity is a central component of intimate relationships, but sexual function may be impaired by coronary heart disease (CHD). There have been few representative population-based comparisons of sexual behaviour and concerns in people with and without CHD. We therefore investigated these issues in a large nationally representative sample of older people.. We analysed cross-sectional data from 2979 men and 3711 women aged 50 and older from the English Longitudinal Study of Ageing. Sexual behaviour and concerns were assessed by validated self-completion questionnaire and analyses were weighted for non-response. Covariates included age, partnerships status and comorbidities.. There were 376 men and 279 women with CHD. Men with CHD were less likely to be sexually active (68.7% vs 80.0%, adjusted OR 0.62, 95% CI 0.47 to 0.81), thought less about sex (74.7% vs 81.9%, OR 0.72, CI 0.54 to 0.95), and reported more erectile difficulties (47.4% vs 38.1%, OR 1.46, CI 1.10 to 1.93) than men without CHD. Effects were more pronounced among those diagnosed within the past 4 years. Women diagnosed <4 years ago were also less likely to be sexually active (35.4% vs 55.6%, OR 0.44, CI 0.23 to 0.84). There were few differences in concerns about sexual activity. Cardiovascular medication showed weak associations with erectile dysfunction.. There is an association between CHD and sexual activity, particularly among men, but the impact of CHD is limited. More effective advice after diagnosis might reverse the reduction in sexual activity, leading to improved quality of life.

Topics: Age Factors; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; England; Erectile Dysfunction; Female; Humans; Logistic Models; Male; Middle Aged; Odds Ratio; Penile Erection; Quality of Life; Risk Factors; Sex Factors; Sexual Behavior; Surveys and Questionnaires; Time Factors

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Benzazepines; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Drug Combinations; Humans; Ivabradine; Metoprolol; Recurrence

The study sought to investigate the relationship between post-procedural asymmetry, expansion, and eccentricity indices of metallic everolimus-eluting stent (EES) and bioresorbable vascular scaffold (BVS) and their respective impact on clinical events at 1-year follow-up.. Mechanical properties of a fully BVS are inherently different from those of permanent metallic stent.. The ABSORB II (A bioresorbable everolimus-eluting scaffold versus a metallic everolimus-eluting stent for ischaemic heart disease caused by de-novo native coronary artery lesions) trial compared the BVS and metallic EES in the treatment of a de novo coronary artery stenosis. Protocol-mandated intravascular ultrasound imaging was performed pre- and post-procedure in 470 patients (162 metallic EES and 308 BVS). Asymmetry index (AI) was calculated per lesion as: (1 - minimum scaffold/stent diameter/maximum scaffold/stent diameter). Expansion index and optimal scaffold/stent expansion followed the definition of the MUSIC (Multicenter Ultrasound Stenting in Coronaries) study. Eccentricity index (EI) was calculated as the ratio of minimum and maximum scaffold/stent diameter per cross section. The incidence of device-oriented composite endpoint (DoCE) was collected.. Post-procedure, the metallic EES group was more symmetric and concentric than the BVS group. Only 8.0% of the BVS arm and 20.0% of the metallic EES arm achieved optimal scaffold/stent expansion (p < 0.001). At 1 year, there was no difference in the DoCE between both devices (BVS 5.2% vs. EES 3.1%; p = 0.29). Post-procedural devices asymmetry and eccentricity were related to higher event rates while there was no relevance to the expansion status. Subsequent multivariate analysis identified that post-procedural AI >0.30 is an independent predictor of DoCE (hazard ratio: 3.43; 95% confidence interval: 1.08 to 10.92; p = 0.037).. BVS implantation is more frequently associated with post-procedural asymmetric and eccentric morphology compared to metallic EES. Post-procedural devices asymmetry were independently associated with DoCE following percutaneous coronary intervention. However, this approach should be viewed as hypothesis generating due to low event rates. (ABSORB II Randomized Controlled Trial [ABSORB II]; NCT01425281).

Topics: Absorbable Implants; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chi-Square Distribution; Coronary Angiography; Coronary Disease; Coronary Vessels; Drug-Eluting Stents; Everolimus; Female; Humans; Least-Squares Analysis; Male; Metals; Middle Aged; Multivariate Analysis; Proportional Hazards Models; Prospective Studies; Prosthesis Design; Risk Factors; Single-Blind Method; Stents; Time Factors; Treatment Outcome; Ultrasonography, Interventional

The aim of this pilot study was to evaluate if ranolazine (R) could improve insulin resistance (IR) in obese/overweight non-diabetic patients with coronary heart disease (CHD).. The study enrolled 40 patients with already diagnosed CHD, previous revascularization, residual ischemia at ergometric test and IR. Mean age was 62.4±9years, M/F=31/9. Patients were randomly assigned to one of the two following groups: group 1 (20 patients) started R at dose of 500mg/bid; group 2 (20 patients) increased the dose of beta/blockers or calcium-channel blockers without introducing R. IR was defined as having HOMA-IR>2.5. At baseline and after 12weeks, all subjects performed an ergometric test and 12h fasting blood sample collection for determining glucose and insulin levels.. At 12weeks follow-up visit HOMA-IR significantly decreased in group 1 (from 3.1±1.7 to 2.3±0.9; p=0.02) while it remained unchanged in group 2 (from 3.0±1.4 to 2.8±1.2; p=0.14) (between groups p=0.009). At 12weeks follow-up visit patients of both groups obtained a significant increase of ischemic threshold at ergometric test, compared to baseline, (group 1 from 308.4±45s to 423.9±57s, p=0.0004); (group 1 from 315.7±63s to 441.2±51s, p=0.0001); without between groups difference (p=0.25).. Our data suggest that starting R, instead of increasing the dose of beta-blockers/calcium-channel blockers, could be a preferable choice in obese/overweight CHD subjects with residual ischemia after revascularization.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Disease; Diabetes Mellitus, Type 2; Exercise Test; Female; Follow-Up Studies; Humans; Insulin Resistance; Male; Middle Aged; Obesity; Pilot Projects; Ranolazine

Topics: Angina Pectoris; Benzazepines; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Dose-Response Relationship, Drug; Drug Combinations; Humans; Ivabradine; Metoprolol; Physical Fitness

This study sought to report on clinical outcomes beyond 1 year of the BVS Expand registry.. Multiple studies have proven feasibility and safety of the Absorb bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, California). However, data on medium- to long-term outcomes are limited and available only for simpler lesions.. This is an investigator-initiated, prospective, single-center, single-arm study evaluating performance of the BVS in a lesion subset representative of daily clinical practice, including calcified lesions, total occlusions, long lesions, and small vessels. Inclusion criteria were patients presenting with non-ST-segment elevation myocardial infarction, stable/unstable angina, or silent ischemia caused by a de novo stenotic lesion in a native previously untreated coronary artery. Procedural and medium- to long-term clinical outcomes were assessed. Primary endpoint was major adverse cardiac events, defined as a composite of cardiac death, myocardial infarction, and target lesion revascularization.. From September 2012 to January 2015, 249 patients with 335 lesions were enrolled. Mean number of scaffolds per patient was 1.79 ± 1.15. Invasive imaging was used in 39%. In 38.1% there were American College of Cardiology/American Heart Association classification type B2/C lesions. Mean lesion length was 22.16 ± 13.79 mm. Post-procedural acute lumen gain was 1.39 ± 0.59 mm. Median follow-up period was 622 (interquartile range: 376 to 734) days. Using Kaplan-Meier methods, the MACE rate at 18 months was 6.8%. Rates of cardiac mortality, myocardial infarction, and target lesion revascularization at 18 months were 1.8%, 5.2%, and 4.0%, respectively. Definite scaffold thrombosis rate was 1.9%.. In our study, BVS implantation in a complex patient and lesion subset was associated with an acceptable rate of adverse events in the longer term, whereas no cases of early thrombosis were observed.

Topics: Absorbable Implants; Aged; Angina, Stable; Angina, Unstable; Cardiovascular Agents; Coated Materials, Biocompatible; Coronary Disease; Coronary Thrombosis; Everolimus; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Netherlands; Non-ST Elevated Myocardial Infarction; Percutaneous Coronary Intervention; Prospective Studies; Prosthesis Design; Recurrence; Registries; Risk Factors; Time Factors; Treatment Outcome

To the best of the authors' knowledge, very few publications are available which report on the prognostic significance of the culprit vessel in patients with ST elevation myocardial infarction treated with successful primary percutaneous coronary intervention.. The aim of the authors was to obtain data on the significance of the culprit vessel in patients with ST elevation myocardial infarction treated successfully by primary percutaneous coronary intervention.. The authors performed a retrospective study in 10,763 patients with ST elevation myocardial infarction who underwent successful primary percutaneous coronary intervention. The culprit vessels were the left main artery, left anterior descendent artery, left circumflex artery, and right coronary artery. The authors constructed univariate survival curves for different culprit vessels and also performed multivariate modelling of time-to-death, controlling for age, sex, and comorbidities.. The majority of the culprit lesions were found in the left anterior descendent artery (44.3%), the right coronary artery (40.9%), and the left circumflex artery (13.7%). The culprit vessel was overall a highly significant (p<0.0001) factor of survival, with right coronary artery exhibiting a highly significantly better prognosis (hazard ratio 0.69, 95% CI 0.61-0.79, p<0.0001) and left main artery exhibiting a significantly worse prognosis (hazard ratio 1.56, 95% CI 1.04-2.35, p = 0.0321) than the reference vessel (left anterior descendent artery).. These data demonstrate that the culprit vessel has independent prognostic significance. Orv. Hetil., 2016, 157(32), 1282-1288.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Vessels; Female; Heart Conduction System; Humans; Male; Middle Aged; Myocardial Infarction; Patient Discharge; Percutaneous Coronary Intervention; Predictive Value of Tests; Prognosis; Retrospective Studies; Secondary Prevention

to analyze clinical and economical effectiveness of meldonium as component of integrated program of cardio-rehabilitation in patients with ischemic heart disease (IHD) in the early period after percutaneous coronary intervention (PCI) with incomplete revascularization.. A program of controlled physical training (CPT) was carried out in patients with stable IHD and positive post PCI exercise test (n=48, age less or equal 65 years) starting 8-10 days after PCI. CRT program consisted of 2 phases - inhospital (exercise on treadmill with max heart rate [HR] 80% of that achieved in initial test, 10 times during 2 weeks) and home (exercise on treadmill with max HR 60% of HR achieved in initial test, 3 times a week for 2 months). Before initiation of CRT patients were distributed into 2 groups: CRT without (n=23; 56.7+/-7.1 years) and with (n=25; 54.6+/-6.8 years) administration of meldonium (1000 mg/day intravenously). Control group (n=24; 50+/-8.4 years) consisted of patients who were under outpatient observation, received similar drug therapy, but were not subjected to CRT. After completion of CRT (in 2.5 months) all patients underwent clinical-instrumental examination with determination of exercise tolerance.. Exercise duration and metabolic equivalent (MET) increased by 43.9, 36.6, 4.1% and 42.1, 34.8, 3.4% in CRT+ meldonium, CRT only, and control groups, respectively.. In patients with documented ischemia after PCI inclusion of meldonium in the scheme of rehabilitation was associated with improved physical performance and optimal cost-effectiviness.

Topics: Cardiovascular Agents; Coronary Disease; Exercise Test; Exercise Tolerance; Female; Humans; Male; Methylhydrazines; Middle Aged; Myocardial Ischemia; Percutaneous Coronary Intervention; Treatment Outcome

Fist-line drugs in ischemic heart disease are -adrenoblockers. However there are cases when comorbidities limit possibilities of their use. In metabolic syndrome some representatives of this class unfavorably affect insulin sensitivity, carbohydrate and lipid metabolism. Alternative is to use ivabradine - selective inhibitor of If receptors with negative chronotropic activity. Ivabradine is metabolically neutral, has no negative inotropic effect, no influence on atrioventricular conduction and arterial pressure.

Topics: Benzazepines; Cardiovascular Agents; Coronary Disease; Heart Rate; Humans; Ivabradine; Metabolic Syndrome

Meta-analysis has been used extensively for evaluation of efficacy and safety of medical interventions. Its advantages and utilities are well known. However, recent studies have raised questions about the accuracy of the commonly used moment-based meta-analytic methods in general and for rare binary outcomes in particular. The issue is further complicated for studies with heterogeneous effect sizes. Likelihood-based mixed-effects modeling provides an alternative to moment-based methods such as inverse-variance weighted fixed- and random-effects estimators. In this article, we compare and contrast different mixed-effect modeling strategies in the context of meta-analysis. Their performance in estimation and testing of overall effect and heterogeneity are evaluated when combining results from studies with a binary outcome. Models that allow heterogeneity in both baseline rate and treatment effect across studies have low type I and type II error rates, and their estimates are the least biased among the models considered.

Topics: Biomedical Research; Cardiovascular Agents; Chi-Square Distribution; Computer Simulation; Coronary Disease; Data Interpretation, Statistical; Diabetes Mellitus, Type 2; Diabetes, Gestational; Female; Humans; Likelihood Functions; Logistic Models; Meta-Analysis as Topic; Numerical Analysis, Computer-Assisted; Odds Ratio; Percutaneous Coronary Intervention; Pregnancy; Research Design; Risk Assessment; Risk Factors; Treatment Outcome

The purpose of this study was to determine the association of socioeconomic factors on use of cardioprotective medicines in known coronary heart disease (CHD) or stroke in South Asia.. We enrolled 33,423 subjects aged 35-70 years (women 56%, rural 53%, low education 51%, low household wealth 25%) in 150 communities in India, Pakistan and Bangladesh during 2003-2009. Information regarding socioeconomic status, disease conditions and treatments was recorded. We studied influence of rural location, educational status and household wealth on use of drug therapies. Odds ratios (ORs) and 95% confidence intervals were calculated.. CHD was reported in 683 (2.0%), stroke 316 (0.9%), and CHD/stroke in 970 (2.9%). Median duration since diagnosis was four years. Participants with CHD/stroke were older with greater prevalence of smoking, overweight, hypertension and diabetes (p < 0.01). In patients with CHD, stroke and CHD/stroke, respectively, use (%) of antiplatelets was 11.6, 3.8 and 9.3, beta-blockers 11.9, 7.0 and 10.4, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers 6.4, 1.9 and 5.3 and statins 4.8, 0.6 and 3.5. In CHD/stroke patients any one of these drugs was used in 18.1%, any two in 7.2%, any three in 2.8% and none in 81.5%. Details of drug dose were not available. Use of drugs was significantly lower in rural low education and low wealth index participants (all p < 0.01). Low wealth index participants had the lowest use of these therapies with no attenuation after multiple adjustments.. The use of secondary preventive drug therapies in patients with known CHD or stroke in South Asia is low with over 80% receiving none of the effective drug treatments. Low household wealth is the most important determinant.

Topics: Adult; Aged; Bangladesh; Cardiovascular Agents; Comorbidity; Coronary Disease; Developing Countries; Drug Costs; Educational Status; Female; Humans; Income; India; Linear Models; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Pakistan; Poverty; Prospective Studies; Residence Characteristics; Risk Factors; Rural Health Services; Secondary Prevention; Socioeconomic Factors; Stroke; Treatment Outcome; Urban Health Services

The implementation of the latest medical innovations can vary widely within the same geographic area. This study aimed to describe the current status of recent innovations in the field of coronary interventional cardiology in 4 regions of Northern Italy.. From April to May 2014, 4 regional delegations of the Italian Society of Invasive Cardiology (SICI-GISE) have promoted a multicenter survey. By means of a web-based methodology, a focused questionnaire was administered to head physicians of 97 cath-labs in 4 Italian regions within the "GISE TOLOVE" area (Lombardy, Veneto, Tuscany, Emilia-Romagna).. Pharmacological and technological innovations in coronary interventional cardiology appear to be widely used in the area covered by this survey, with uniformity in application and availability of therapeutic devices and drugs within the 4 regions involved. The main limiting factors to the adoption of new technologies and drugs were economic factors or lack of scientific evidence for some specific devices or drugs.. This survey showed widespread and consistent application of the main latest innovations in coronary interventional cardiology across 4 Italian regions of Northern Italy.

Topics: Angioplasty, Balloon; Cardiac Catheterization; Cardiovascular Agents; Catchment Area, Health; Combined Modality Therapy; Coronary Disease; Delivery of Health Care; Diagnostic Techniques, Cardiovascular; Diffusion of Innovation; Drug Utilization; Drug-Eluting Stents; Health Care Surveys; Humans; Inventions; Italy; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Stents; Surveys and Questionnaires

Studies evaluating long-term (≥5 years) outcome of percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) in patients with unprotected left main coronary artery disease (ULMCAD) are still limited, despite concerns for late adverse events after drug-eluting stents implantation.. We identified 1,004 patients with ULMCAD (PCI: n=364, CABG: n=640) among 15,939 patients with first coronary revascularization enrolled in the CREDO-Kyoto PCI/CABG registry cohort-2. The primary outcome measure in the current analysis was a composite of death, myocardial infarction, and stroke (death/MI/stroke). The cumulative 5-year incidence of and the adjusted risk for death/MI/stroke were significantly higher in the PCI group than in the CABG group (34.5% vs. 24.1%, log-rank P<0.001, adjusted hazard ratio (HR): 1.48 [95% confidence interval (CI): 1.07-2.05, P=0.02]). The adjusted risks for all-cause death was not significantly different between the 2 groups. Regarding the stratified analysis by the SYNTAX score, the adjusted risk for death/MI/stroke was not significantly different between the 2 groups in patients with low (<23) or intermediate (23-33) SYNTAX score, whereas it was significantly higher in the PCI group than in the CABG group in patients with high (≤33) SYNTAX score.. CABG as compared with PCI was associated with better long-term outcome in patients with ULMCAD, especially those with high anatomical complexity.

Topics: Cardiovascular Agents; Cause of Death; Combined Modality Therapy; Comorbidity; Coronary Artery Bypass; Coronary Disease; Death, Sudden, Cardiac; Follow-Up Studies; Humans; Japan; Kaplan-Meier Estimate; Mortality; Myocardial Infarction; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Proportional Hazards Models; Registries; Risk; Severity of Illness Index; Stents; Stroke; Treatment Outcome

Topics: Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Humans; Male; Percutaneous Coronary Intervention

Although non-adherence to medications is associated with increased cardiovascular risks, very little information is focused on the relationship between knowledge and medication adherence among patients with coronary heart disease (CHD).. The purposes were to assess the relationship between medication adherence and medication- or disease-related knowledge in patients with CHD, and to investigate whether educating patients would alter their medication adherence behaviour.. This study was carried out at the outpatient clinic of a public university teaching hospital in China.The primary outcome was the ability of patients to follow medication instructions, which was assessed by the Morisky Medication Adherence Scale (MMSA-8). The Medication- or Disease-Related Knowledge Test (MDRKT) was used to assess patients'medication-related knowledge. We also explored patients'preferences for receiving education about medications and whether it is necessary for pharmacists to provide education.. Among the 159 patients who completed the survey, approximately 38.4% were considered non-adherent (MMAS-8 score <6). Medication- or disease-related knowledge and concerns about adverse drug events were significantly associated with non-adherence. The MDRKT revealed that most participants had very little knowledge about their drug treatment. Specifically, 22 participants said that pharmacists were their primary source of information. Subsequently, 95.0% of participants expressed an interest in activities related to medication education.. Knowledgeable patients with CHD are more likely to adhere to medication instructions. Many patients have difficulty acquiring medication information; thus, patients need increased access to education about their medication. Pharmacist services may be required to provide such information.

Topics: Cardiovascular Agents; China; Coronary Disease; Female; Follow-Up Studies; Humans; Male; Medication Adherence; Middle Aged; Patient Education as Topic; Surveys and Questionnaires

Topics: Aspirin; Atorvastatin; Cardiovascular Agents; Coronary Disease; Drug Combinations; Humans; Medication Adherence; Ramipril

We sought to evaluate the prognosis of different treatment strategies on patients with multivessel coronary disease and high SYNTAX score. 171 patients with multivessel coronary disease and SYNTAX score ε33, who underwent coronary angiography between July 2009 and July 2010 at our hospital were retrospectively selected and divided into incomplete and complete revascularization intervention groups (IR), a coronary artery bypass surgery group (CABG), a conservative drug therapy group according to treatment strategies chosen and agreed by the patients. These patients were followed up for 19.44 ± 5.73 months by telephone or outpatient service. We found the medical treatment group has a lower overall survival than the IR, CR group, and CABG group (P log-rank values are 0.03, 0.03, and 0.02, respectively). The medical treatment group also has a lower survival than the IR group, CR group, and CABG group in cerebral stroke and recurrent myocardial infarction (MI) (P log-rank values are 0.004, 0.03, and 0.001, respectively) and MACE events (P log-rank values are 0.003, 0.001 and P < 0.001, respectively). The medical treatment group and IR group have lower survival in recurrent angina pectoris than the CR group and CABG group (P log-rank values are 0.02, 0.02 and 0.03, 0.008, respectively). There are no significant differences between the CR group and the CABG group in number of deaths, strokes and recurrent MIs, MACE events, angina pectoris (P log-rank values are 0.69, 0.53, and 0.86, respectively). The IR group shows a lower survival than the CR group and CABG group only in angina pectoris (P log-rank values are 0.03 and 0.008, respectively). For the patients with a high SYNTAX score, medical treatment is still inferior to revascularization therapy (interventional therapy or coronary artery bypass surgery). It appears that the CABG is not obviously superior to the coronary intervention therapy. Complete revascularization and coronary artery bypass grafting treatments simply have better survival in angina pectoris compared to the incomplete revascularization. Therefore, individual treatment strategies are recommended and more trials are required to study these effects.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Humans; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Stroke; Survival Analysis

Coronary angiography holds a central role in the diagnosis of coronary heart disease. We studied temporal trends in referral patterns 2000-09.. We identified 156 496 first-time coronary angiographies in 2000-09 in nationwide registries. Trends were analyzed in 2-year intervals. Numbers of acute (5943-10 707) and elective (17 294-25 550) procedures increased between 2000-01 and 2008-09. Mean age increased from 61.8 to 63.9 years (P < 0.001) and the proportion of females increased from 33 to 37% (P < 0.001). An increase in the number of patients with prior chronic heart failure (2866 vs. 3197), cerebrovascular disease (1790 vs. 2906), diabetes (2527 vs. 4593), and arrhythmias (2985 vs. 4733) was observed. The proportion of acute patients examined the same day as hospitalized increased from 56.6 to 83.1%. Odds ratios (95% confidence interval) for treatment with statins [3.42(3.27;3.57)], RAS-inhibitors [1.85(1.77;1.93)], and acetylsalicylic acid [1.43(1.37;1.49)] at the time of coronary angiography increased towards 2008-09. Elective patients received medical treatment more often than acute patients (P < 0.001).. During a 10-year period, there was an increase in the mean age of patients and the proportion of female patients, and a 56% increase in number of coronary angiographies performed. The use of prophylactic cardiovascular drugs among these high-risk patients increased during our study period.

Topics: Adult; Aged; Cardiovascular Agents; Cerebrovascular Disorders; Comorbidity; Coronary Angiography; Coronary Disease; Denmark; Follow-Up Studies; Forecasting; Heart Failure; Humans; Middle Aged; Population Surveillance; Retrospective Studies

The JAK2 V617F mutation is not only found in the majority of patients with myeloproliferative neoplasms (MPN), including essential thrombocythemia (ET), but also has been reported in individuals without overt MPN. A close relation of the JAK2 V617F mutation to atherothrombotic events has been described, at least in patients with MPN. The prevalence of the JAK2 V617F mutation and its clinical impact in coronary patients is unknown. To address this issue, DNA samples from 1,589 subjects undergoing coronary angiography with up to 11 years of follow up were genotyped using allele-specific real-time PCR assays. Prevalence of the JAK2 V617F mutation was 1.32% (n = 21) in coronary patients. Two JAK2 V617F positive patients showed baseline platelet counts indicative for ET and a third patient developed ET during follow up, finally resulting in a percentage of 0.188% of ET cases. This corresponds to an up to fivefold accumulation of ET cases in coronary patients compared with the general population. Our study showed no impact of the JAK2 V617F mutation on future atherothrombotic events or overall survival (HR = 1.04 [0.33-3.27]; P = 0.949 and HR = 0.35 [0.05-2.46]; P = 0.288, respectively). Therefore, our data suggest that JAK2 V617F positive coronary patients are not at increased risk for future atherothrombotic complications. Routine mutation screening in coronary patients is, therefore, not warranted. However, number of ET cases appears to be accumulated in coronary patients. For this reason, we recommend JAK2 V617F testing only in coronary patients showing abnormal blood cell counts for further clarification.

Topics: Aged; Aged, 80 and over; Alleles; Amino Acid Substitution; Cardiovascular Agents; Case-Control Studies; Coronary Angiography; Coronary Artery Disease; Coronary Disease; Female; Gene Dosage; Gene Frequency; Genetic Predisposition to Disease; Genetic Testing; Genotype; Humans; Janus Kinase 2; Male; Middle Aged; Mutation, Missense; Platelet Count; Point Mutation; Polycythemia Vera; Prevalence; Prognosis; Prospective Studies; Real-Time Polymerase Chain Reaction; Risk; Thrombocythemia, Essential; Unnecessary Procedures

Topics: Cardiovascular Agents; Coronary Disease; Exercise Therapy; Female; Heart Failure; Humans; Hypoglycemic Agents; Male; Prediabetic State; Stroke

Non-adherence to medication is common among coronary heart disease patients. Non-adherence to medication may be either intentional or unintentional. In this analysis we provide estimates of intentional and unintentional non-adherence in the year following an acute coronary syndrome (ACS).. In this descriptive prospective observational study of patients with confirmed ACS medication adherence measures were derived from responses to the Medication Adherence Report Scale at approximately 2 weeks (n=223), 6 months (n=139) and 12 months (n=136) following discharge from acute treatment for ACS.. Total medication non-adherence was 20%, 54% and 53% at each of these time points respectively. The corresponding figures for intentional non-adherence were 8%, 15% and 15% and 15%, 52% and 53% for unintentional non-adherence. There were significant increases in the levels of medication non-adherence between the immediate discharge period (2 weeks) and 6 months that appeared to stabilize between 6 and 12 months after acute treatment for ACS.. Unintentional non-adherence to medications may be the primary form of non-adherence in the year following ACS. Interventions delivered early in the post-discharge period may prevent the relatively high levels of non-adherence that appear to become established by 6 months following an ACS.

Topics: Acute Coronary Syndrome; Adult; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Female; Humans; Intention; Male; Medication Adherence; Middle Aged; Patient Discharge; Prospective Studies

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Comorbidity; Coronary Angiography; Coronary Circulation; Coronary Disease; Diagnostic Imaging; Diagnostic Techniques, Cardiovascular; Disease Management; European Union; Female; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Physical Exertion; Practice Guidelines as Topic; Prognosis; Risk Factors; Unnecessary Procedures

Limited data are available regarding specific differences among countries in demographic and clinical characteristics and treatment of patients with stable coronary artery disease.. CLARIFY is an international, prospective and longitudinal registry including more than 33 000 patients with stable coronary artery disease enrolled in 45 countries worldwide. Data were used to compare the characteristics of patients enrolled in Italy with those enrolled in Europe and in the rest of the world.. Baseline data were available for 33 283 patients, 2112 of whom from Italy and 12 614 from the remaining western European countries. Italian patients were found to be older, more frequently smoker, hypertensive and with sedentary habits. In addition, they presented more frequently a history of myocardial infarction, carotid arterial disease and chronic obstructive pulmonary disease. In addition, when compared with patients of both European and international cohorts, more Italian patients had undergone coronary angiography and angioplasty. As far as treatment was concerned, a greater number of Italian patients were taking ivabradine, angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, nitrates, thienopyridines, while those taking beta-blockers, calcium antagonists and other antianginal medications were fewer.. Among ambulatory patients with stable coronary artery disease, there are important geographic differences in terms of risk factors, clinical characteristics, surgical and pharmacological treatment.

Topics: Age Distribution; Aged; Ambulatory Care; Cardiovascular Agents; Comorbidity; Coronary Disease; Disease Management; Europe; Female; Geography, Medical; Global Health; Hemodynamics; Humans; Italy; Life Style; Male; Middle Aged; Myocardial Revascularization; Percutaneous Coronary Intervention; Prospective Studies; Registries; Risk Factors; Socioeconomic Factors

We aimed to identify factors easily collected at admission in patients with transient ischemic attack (TIA) that were associated with early recurrence, so as to guide clinicians' decision-making about hospitalization in routine practice. From September 2011 to January 2013, all TIA patients who were referred to the University Hospital of Dijon, France, were identified. Vascular risk factors and clinical information were collected. The etiology of the TIA was defined according to the results of complementary examinations performed at admission as follows: large artery atherosclerosis (LAA-TIA) TIA, TIA due to atrial fibrillation (AF-TIA), other causes, and undetermined TIA. Logistic regression analyses were performed to identify factors associated with any recurrence at 48 hours (stroke or TIA). Among the 312 TIA patients, the etiology was LAA-TIA in 33 patients (10.6%), AF-TIA in 57 (18.3%), other causes in 23 (7.3%), and undetermined in 199 (63.8%). Early recurrence rates were 12.1% in patients with LAA-TIA, 5.3% in patients with AF-TIA, 4.3% in patients with another cause of TIA, and 1.0% in patients with undetermined TIA. In multivariable analysis, the LAA etiology was independently associated with early recurrence (odds ratio [OR]: 12.03; 95% confidence interval [CI]: 1.84-78.48, p=0.009). A non-significant trend was also observed for AF-TIA (OR: 3.82; 95% CI: 0.40-36.62, p=0.25) and other causes (OR: 3.73; 95% CI: 0.30-46.26, p=0.31). A simple initial assessment of TIA patients in the emergency room would be helpful in targeting those with a high risk of early recurrence and who therefore need to be hospitalized.

Topics: Aged; Aged, 80 and over; Atherosclerosis; Atrial Fibrillation; Cardiovascular Agents; Coronary Disease; Diabetes Mellitus; Diagnostic Imaging; Emergencies; Female; France; Humans; Hypercholesterolemia; Hypertension; Ischemic Attack, Transient; Length of Stay; Male; Middle Aged; Patient Admission; Recurrence; Risk Factors; Smoking

Despite evidence-based interventions, coronary heart disease (CHD) remains a leading cause of global mortality. As therapies advance, patient non-adherence to established treatments is well recognized. Non-adherence is a powerful confounder of evidence-based practice and can affect daily patient management, resulting in inappropriate therapeutic escalation with greater costs and potential for harm. Moreover, it increases risk for adverse cardiac events, including mortality. Yet, non-adherence is complex, remains difficult to define, and provider ability to identify its presence accurately remains limited. Improved screening tools are needed to detect at-risk patients, enabling appropriate targeting of interventions. Given the rapidly expanding global population with CHD and emerging clinical and cost-benefits of adherence, addressing non-adherence to prescribed therapies is a top priority.

Topics: Cardiovascular Agents; Coronary Disease; Global Health; Humans; Medication Adherence; Patient Education as Topic; Patient Satisfaction; Risk Factors; Treatment Outcome

Topics: Alcohol Drinking; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Diabetes Complications; Drug Combinations; Dyslipidemias; Female; History, 20th Century; History, 21st Century; Humans; Hypertension; Medication Adherence; Menopause; Metabolic Syndrome; Obesity; Risk Factors; Sedentary Behavior; Smoking; Women's Health

Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina.. This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of β-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina.. Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.

Topics: Adrenergic beta-Antagonists; Age Factors; Aged; Angina Pectoris; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Delivery of Health Care; Female; Health Care Surveys; Healthcare Disparities; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Myocardial Infarction; Outcome and Process Assessment, Health Care; Platelet Aggregation Inhibitors; Practice Patterns, Physicians'; Primary Health Care; Secondary Care; Secondary Prevention; Sex Factors; Socioeconomic Factors; State Medicine; Treatment Outcome; United Kingdom

Persons with known coronary heart disease (CHD) are at a greater risk of subsequent events. The current guidelines for secondary prevention have focused on lifestyle modifications, risk factor control, and drug therapy. However, current data lack information on the United States population and its adherence to these guidelines. Using data from the National Health and Nutrition Examination Survey from 2007 to 2010, we identified those with CHD and assessed the adequacy of their adherence to the current guidelines for secondary prevention. Of 759 subjects with CHD (weighted to 12.7 million), the use of recommended therapies was 55%, 45%, and 62% for β blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and lipid-lowering agents, respectively (24% for all), with adherence lower in women than in men and in blacks and Hispanics than in whites. The nonsmoking status and control of blood pressure, low-density lipoprotein cholesterol, and, for those with diabetes, glycated hemoglobin was 73%, 67%, 59%, 60%, respectively (14% for all). Also, 17%, 70%, and 7% were at the recommended levels for physical activity, alcohol consumption, and sodium intake, respectively. Moreover, only 20% and 29% were at the recommended body mass index and waist circumference targets, respectively. Those with metabolic syndrome and diabetes were more likely to have ≥2 risk factors uncontrolled, despite being more likely to be receiving recommended therapies. A significant gap still exists between the secondary prevention guidelines and their adherence and control of CHD risk factors among United States adults. In conclusion, greater efforts are needed to ensure adherence to all aspects of secondary prevention guidelines to optimize the prognosis in subjects with CHD.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Body Mass Index; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Female; Follow-Up Studies; Guideline Adherence; Humans; Life Style; Male; Middle Aged; Morbidity; Nutrition Surveys; Patient Compliance; Retrospective Studies; Risk Factors; United States; Young Adult

To demonstrate the utilization of a clinical improvement program in stable coronary artery disease patients to increase the evidence-proven treatment utilization, and to describe the ongoing clinical practice and lifestyle change counseling.. Cross-sectional study followed by a longitudinal component in which the tools utilization to improve clinical practice was assessed by means of additional cross-sectional data collection. 710 consecutive patients were included (Phase 1). After tools implementation, within 6 months period, 705 patients were included (Phase 2) for comparative analysis. Randomly, 318 patients from Phase 1 were selected, 6-12 months after the first evaluation (Phase 3).. Phase 1 to Phase 2: there were improvement on smoking cessation (P=0.019), dyslipidemia (P<0.001), hypertension and physical activity (P<0.001). There was significant difference on angiotensin converting enzyme inhibitors - ACEI (67.2% vs. 56.8%, P<0.001); angiotensin II receptor blockers - ARB II (25.4% vs. 32.9%, P=0.002) and beta-blocker (88.7% vs. 91.9%, P=0.047). Phase 1 to Phase 3: there was both weight (P=0.044), and blood pressure reduction (P<0.001). There was statistical significant difference on ACEI (64.8% vs. 61.6%, P=0.011) and ARB II (27.0% vs. 31.3%, P=0.035).. There was no significant change on the evidence-based pharmacological treatment utilization between pre and post-intervention phases; there was significant improvement concerning smoking and physical activity in phase 2; substantial improvement on blood pressure levels in both comparisons (Phase 1 to 2 and Phase 1 to 3). The inclusion of a case-manager for the process management was crucial for program efficacy. Comprehensive programs for clinical practice should be pursued for longer follow-up period.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Dyslipidemias; Female; Guideline Adherence; Humans; Hypertension; Life Style; Male; Middle Aged; Reproducibility of Results; Risk Factors; Secondary Prevention; Smoking Cessation; Time Factors; Treatment Outcome

Cholesteryl ester transfer protein (CETP) converts high density lipoprotein cholesterol to low density lipoproteins. It is a promising target for treatment of coronary heart disease. Two dimensional quantitative structure activity relationship (2D-QSAR), hologram QSAR (HQSAR) studies and comparative molecular field analysis (CoMFA) as well as comparative molecular similarity analysis (CoMSIA) were performed on 104 CETP inhibitors. The statistical qualities of generated models were justified by internal and external validation, i.e., q(2) and R(2)pred respectively. The best 2D-QSAR model was obtained with q(2) and R(2)pred values of 0.794 and 0.796 respectively. The 2D-QSAR study suggests that unsaturation, branching and van der Waals volumes may play important roles. The HQSAR model showed q(2) and R(2)pred values of 0.628 and 0.550 respectively. Similarly, CoMFA model showed q(2) and R(2)pred values of 0.707 and 0.755 respectively whereas CoMSIA model was obtained with q(2) and R(2)pred values of 0.696 and 0.703 respectively. CoMFA and CoMSIA studies indicate that steric factors are important at substituted phenoxy and tetrafluoroethoxy groups whereas electropositive factors play important role at difluoromethyl group. The results of 3D-QSAR studies validate those of 2D-QSAR and HQSAR studies as well as the earlier observed SAR data. Current work may help to develop better CETP inhibitors.

Topics: Algorithms; Cardiovascular Agents; Cholesterol Ester Transfer Proteins; Cluster Analysis; Coronary Disease; Drug Discovery; Humans; Least-Squares Analysis; Linear Models; Models, Molecular; Propanols; Quantitative Structure-Activity Relationship

Evidence on recent time trends in age-gender differences in cardiovascular drug use is scarce. We studied time trends in age-gender-specific cardiovascular drug use for primary prevention, secondary prevention, and in-hospital treatment of coronary heart disease.. The PHARMO database was used for record linkage of drug dispensing, hospitalization, and population data to identify drug use between 1998 and 2010 in 1 203 290 persons ≥25 years eligible for primary prevention, 84 621 persons hospitalized for an acute coronary syndrome (ACS), and 15 651 persons eligible for secondary prevention. The use of cardiovascular drugs increased over time in all three settings. In primary prevention, the proportion of women that used lipid-lowering drugs was lower than men between 2003 and 2010 (5.7 vs. 7.3% in 2010). The higher proportion of women that used blood pressure-lowering drugs for primary prevention, compared with men, attenuated over time (15.1 vs. 13.8% in 2010). During hospital admission for an ACS, the proportion of women that used cardiovascular drugs was lower than men. In secondary prevention (36 months after hospital discharge), drug use was lowest in young women. The proportion receiving lipid-lowering drugs declined after the age of 75 in all three settings. This age difference attenuated over time.. Age differences in drug use tended to attenuate over time, whereas gender differences persisted. Areas potentially for improvement are in the hospital treatment of ACS in young women, in secondary prevention among young women and the elderly, and in the continuity of drug use in secondary prevention.

Topics: Adult; Age Distribution; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Female; Follow-Up Studies; Healthcare Disparities; Hospitalization; Humans; Male; Middle Aged; Netherlands; Primary Prevention; Secondary Prevention; Sex Distribution

Under observation were 40 hypertensive patients with coronary heart disease, gout and obesity I and II degree. Patients with hypertension in combination with coronary heart disease, gout and obesity, syndrome of early vascular aging is shown by increased stiffness of arteries, increased peak systolic flow velocity, pulse blood presure, the thickness of the intima-media complex, higher level endotelinemia and reduced endothelial vasodilation. Obtained evidence that losartan in complex combination with basic therapy and metamaks in complex combination with basic therapy positively affect the elastic properties of blood vessels and slow the progression of early vascular aging syndrome.

Topics: Antihypertensive Agents; Blood Flow Velocity; Blood Pressure; Cardiovascular Agents; Carotid Arteries; Coronary Disease; Elasticity; Endothelium, Vascular; Female; Gout; Humans; Hypertension; Losartan; Male; Methylhydrazines; Middle Aged; Obesity; Severity of Illness Index; Tunica Intima; Tunica Media; Vascular Stiffness

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.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anxiety; Cardiovascular Agents; Chi-Square Distribution; Coronary Disease; Cross-Sectional Studies; Depression; Educational Status; Europe; Female; Health Behavior; Health Knowledge, Attitudes, Practice; Hospitalization; Humans; Male; Middle Aged; Prevalence; Prognosis; Risk Assessment; Risk Factors; Risk Reduction Behavior; Secondary Prevention; Sex Factors; Time Factors; Young Adult

To quantify how much of the coronary heart disease (CHD) mortality decline in Northern Ireland between 1987 and 2007 could be attributed to medical and surgical treatments and how much to changes in population cardiovascular risk factors.. The IMPACT mortality model was used to integrate data on uptake and effectiveness of cardiological treatments and risk factor trends in the Northern Ireland population between 1987 and 2007. The main data sources were official population and mortality statistics, hospital administration systems, primary care datasets, published trials and meta-analyses, clinical audits, and national surveys. Between 1987 and 2007, CHD mortality rates in Northern Ireland decreased by 52% in men and 60% in women aged 25-84 years. This resulted in 3180 fewer deaths in 2007 than expected if 1987 mortality rates had persisted. Approximately 35% of this decrease was attributed to increased uptake of treatments in individuals and 60% to population risk factor reductions (principally blood pressure, total cholesterol, and smoking); however, these reductions were partially offset by adverse trends in diabetes, physical inactivity, and obesity.. Approximately 60% of the substantial CHD mortality decline in Northern Ireland between 1987 and 2007 was attributable to major cardiovascular risk factor changes and approximately 35% was attributable to treatments. However, adverse trends in diabetes, obesity, and physical inactivity are of major concern.

Topics: Adult; Aged; Aged, 80 and over; Cardiac Surgical Procedures; Cardiovascular Agents; Comorbidity; Coronary Disease; Diabetes Mellitus; Diet; Exercise; Female; Humans; Hypercholesterolemia; Hypertension; Male; Middle Aged; Models, Statistical; Northern Ireland; Obesity; Preventive Health Services; Prognosis; Risk Assessment; Risk Factors; Risk Reduction Behavior; Sedentary Behavior; Smoking Cessation; Time Factors

To describe lifestyle and risk-factor management in patients attending cardiac rehabilitation programmes (CRPs) compared to those who do not.. A cross-sectional survey.. The EUROASPIRE III survey was conducted in 76 centres in 22 European countries. Consecutive patients having had a coronary event or revascularization before the age of 80 were identified and interviewed at least 6 months after hospital admission.. 13,935 medical records were reviewed and 8845 patients interviewed (participation rate 73%); 44.8% of patients reported being advised to attend a CRP and of these 81.4% did so (36.5% of all patients). There were wide variations between countries and diagnostic categories, ranging from 15.9% in the Ischaemia group to 68.1% in the CABG group. Characteristics associated with participation in a CRP included younger age, male sex, higher educational level and CABG as a recruiting index event, while smokers were less likely to attend a CRP. Patients who attended a CRP had a significantly lower prevalence of smoking, better control of total and LDL-cholesterol and higher use of beta-blockers, ACE inhibitors/ARBs and lipid-lowering drugs.. CRPs in Europe are underused, with poor referral and low participation rate and wide variations between countries. Despite this heterogeneity, the control of smoking and cholesterol and the use of cardioprotective medication is better in those who attend a CPR. There is an urgent need for comprehensive, multidisciplinary rehabilitation programmes to integrate professional lifestyle interventions with effective risk-factor management, appropriately adapted to the medical, cultural and economic settings of a country.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Europe; Female; Health Care Surveys; Humans; Hypolipidemic Agents; Male; Middle Aged; Patient Compliance; Practice Patterns, Physicians'; Referral and Consultation; Risk Factors; Risk Reduction Behavior; Smoking Cessation; Time Factors; Treatment Outcome

Numerous studies have documented suboptimal adherence to guideline recommendations in secondary prevention of coronary heart disease (CHD(SP)). Clinical practice guidelines (CPGs) are continuously developed to define appropriate patient care, aiming to reduce risk of morbidity and death. The Medication Assessment Tool for CHD(SP) (MAT-CHD(SP)) was developed to assess adherence to CPGs concerning medication therapy and follow-up of patients with CHD(SP). The aim of this study was to explore whether the MAT-CHD(SP) could be applied retrospectively to assess guideline adherence and therapy goal achievement in secondary prevention of CHD.. We collected data from electronic medical records of all patients who underwent percutaneous coronary intervention with stent implantation from January to March 2008 (n = 300) and applied the MAT-CHD(SP). We measured time for data collection and MAT application and tested reproducibility by calculating Cohen's kappa (κ) value for inter and intraobserver agreement.. A total of 247 MAT applications were analyzed, showing overall applicability of 66 % of the 4,446 MAT-CHD(SP) criteria and a high reproducibility of MAT-CHD(SP) application (κ values 0.93 and 0.95 for intra- and interobserver agreement, respectively). Mean time for data collection and MAT-CHD(SP) application was 11 min. Adherence to criteria concerning prescription was high (>75 %), but achievement of therapy goals for cholesterol and blood pressure was low (<50 %). Documentation of lifestyle advice achieved intermediate (50-75 %) or low adherence, as did therapy amendments in patients in whom therapy goals were unachieved at hospital admission.. The MAT-CHD(SP) offers a means to identify both adherence and nonadherence to CPGs concerning CHD(SP) is applicable in retrospective assessment of CHD(SP), and identifies potentials for improved patient care.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Disease; Drug Prescriptions; Electronic Health Records; Female; Guideline Adherence; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Practice Guidelines as Topic; Practice Patterns, Physicians'; Quality Indicators, Health Care; Retrospective Studies; Risk Reduction Behavior; Secondary Prevention; Stents; Time Factors; Treatment Outcome

Evidence for cardioprotective effects of lycopene is inconsistent. Studies of circulating lycopene generally report inverse associations with CVD risk, but studies based on lycopene intake do not. The failure of dietary studies to support the findings based on biomarkers may be due in part to misclassification of lycopene intakes. To address this potential misclassification, we used repeated measures of intake obtained over 10 years to characterise the relationship between lycopene intake and the incidence of CVD (n 314), CHD (n 171) and stroke (n 99) in the Framingham Offspring Study. Hazard ratios (HR) for incident outcomes were derived from Cox proportional hazards regression models using logarithmically transformed lycopene intake adjusted for CVD risk factors and correlates of lycopene intake. HR were interpreted as the increased risk for a 2·7-fold difference in lycopene intake, a difference approximately equal to its interquartile range. Using an average of three intake measures with a 9-year follow-up, lycopene intake was inversely associated with CVD incidence (HR 0·83, 95% CI 0·70, 0·98). Using an average of two intake measures and 11 years of follow-up, lycopene intake was inversely associated with CHD incidence (HR 0·74, 95% CI 0·58, 0·94). Lycopene intake was unrelated to stroke incidence. The present study of lycopene intake and CVD provides supporting evidence for an inverse association between lycopene and CVD risk; however, additional research is needed to determine whether lycopene or other components of tomatoes, the major dietary source of lycopene, are responsible for the observed association.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Carotenoids; Coronary Disease; Diet; Energy Intake; Female; Humans; Incidence; Lycopene; Male; Middle Aged; Phytotherapy; Plant Extracts; Proportional Hazards Models; Solanum lycopersicum; Stroke

Global coronary heart disease (CHD) risk assessment is recommended to guide primary preventive pharmacotherapy. However, little is known about physicians' understanding and use of global CHD risk assessment. Our objective was to examine US physicians' awareness, use, and attitudes regarding global CHD risk assessment in clinical practice, and how these vary by provider specialty.. Using a web-based survey of US family physicians, general internists, and cardiologists, we examined awareness of tools available to calculate CHD risk, method and use of CHD risk assessment, attitudes towards CHD risk assessment, and frequency of using CHD risk assessment to guide recommendations of aspirin, lipid-lowering and blood pressure (BP) lowering therapies for primary prevention. Characteristics of physicians indicating they use CHD risk assessments were compared in unadjusted and adjusted analyses.. A total of 952 physicians completed the questionnaire, with 92% reporting awareness of tools available to calculate CHD global risk. Among those aware of such tools, over 80% agreed that CHD risk calculation is useful, improves patient care, and leads to better decisions about recommending preventive therapies. However, only 41% use CHD risk assessment in practice. The most commonly reported barrier to CHD risk assessment is that it is too time consuming. Among respondents who calculate global CHD risk, 69% indicated they use it to guide lipid lowering therapy recommendations; 54% use it to guide aspirin therapy recommendations; and 48% use it to guide BP lowering therapy. Only 40% of respondents who use global CHD risk routinely tell patients their risk. Use of a personal digital assistant or smart phone was associated with reported use of CHD risk assessment (adjusted OR 1.58; 95% CI 1.17-2.12).. Reported awareness of tools to calculate global CHD risk appears high, but the majority of physicians in this sample do not use CHD risk assessments in practice. A minority of physicians in this sample use global CHD risk to guide prescription decisions or to motivate patients. Educational interventions and system improvements to improve physicians' effective use of global CHD risk assessment should be developed and tested.

Topics: Cardiology; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Family Practice; Female; Guideline Adherence; Health Knowledge, Attitudes, Practice; Health Surveys; Humans; Internal Medicine; Internet; Male; Practice Patterns, Physicians'; Primary Prevention; Risk Assessment

The Second Medicine, Angioplasty, or Surgery Study (MASS II) included patients with multivessel coronary artery disease and normal systolic ventricular function. Patients underwent coronary artery bypass graft surgery (CABG, n=203), percutaneous coronary intervention (PCI, n=205), or medical treatment alone (MT, n=203). This investigation compares the economic outcome at 5-year follow-up of the 3 therapeutic strategies.. We analyzed cumulative costs during a 5-year follow-up period. To analyze the cost-effectiveness, adjustment was made on the cumulative costs for average event-free time and angina-free proportion. Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years and 2.07 quality-adjusted life-years; PCI presented 3.59 and 2.77 quality-adjusted life-years; and CABG demonstrated 4.4 and 2.81 quality-adjusted life-years. The event-free costs were $9071.00 for MT; $19,967.00 for PCI; and $18,263.00 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P<0.01) and versus CABG (P<0.01) and CABG versus PCI (P=0.01). The event-free plus angina-free costs were $16,553.00, $25,831.00, and $24,614.00, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P=0.04), and versus CABG (P<0.001); there was no difference between CABG and PCI (P>0.05).. In the long-term economic analysis, for the prevention of a composite primary end point, MT was more cost effective than CABG, and CABG was more cost-effective than PCI.. www.controlled-trials.com.. ISRCTN66068876.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Cost-Benefit Analysis; Diagnostic Techniques, Cardiovascular; Disease-Free Survival; Female; Follow-Up Studies; Health Resources; Hospitalization; Humans; Male; Middle Aged; Multicenter Studies as Topic; Office Visits; Postoperative Complications; Prospective Studies; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Treatment Outcome

Conflicting evidence exists on sex-based outcomes after coronary stenting.. Data on 426 996 patients ≥65 years old (42.3% women) from the National Cardiovascular Data Registry CathPCI Registry (2004-2008) were linked to Medicare inpatient claims to compare in-hospital outcomes by sex and long-term outcomes by sex and stent type. In-hospital complications were more frequent in women than in men: death (3869 [2.2%] versus 3737 [1.6%]; adjusted odds ratio, 1.41; 95% confidence interval [CI], 1.33-1.49), myocardial infarction (2365 [1.3%] versus 2858 [1.2%]; odds ratio, 1.19; 95% CI, 1.11-1.27), bleeding (7860 [4.4%] versus 5627 [2.3%]; odds ratio, 1.86; 95% CI, 1.79-1.93), and vascular complications (2381 [1.3%] versus 1648 [0.7%]; odds ratio, 1.85; 95% CI, 1.73-1.99). At 20.4 months, women had a lower adjusted risk of death (hazard ratio [HR], 0.92; 95% CI, 0.90-0.94) but similar rates of myocardial infarction, revascularization, and bleeding. Relative to bare metal stent use, drug-eluting stent use was associated with similar improved long-term outcomes in both sexes: death (women: adjusted HR, 0.78; 95% CI, 0.76-0.81; men: HR, 0.77; 95% CI, 0.74-0.79), myocardial infarction (women: HR, 0.79; 95% CI, 0.74-0.84; men: HR, 0.81; 95% CI, 0.77-0.85), and revascularization (women: HR, 0.93; 95% CI, 0.90-0.97; men: HR, 0.91; 95% CI, 0.88-0.94). There was no interaction between sex and stent type for long-term outcomes.. In contemporary coronary stenting, women have a slightly higher procedural risk than men but have better long-term survival. In both sexes, use of a drug-eluting stent is associated with lower long-term likelihood for death, myocardial infarction, and revascularization.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Bypass; Coronary Disease; Drug-Eluting Stents; Female; Follow-Up Studies; Humans; Inpatients; Kaplan-Meier Estimate; Male; Medicaid; Medicare; Odds Ratio; Postoperative Complications; Proportional Hazards Models; Registries; Risk; Sex Factors; Stents; Treatment Outcome; United States

Heartwatch is a secondary prevention programme of coronary heart disease (CHD) in primary care in Ireland. The aim was to further examine the effect of the Heartwatch programme on cardiovascular risk factors and treatments of patients with a follow-up of 3.5 years.. Prospective cohort study of 12,358 patients with established CHD (myocardial infarction, percutaneous cardiac intervention, coronary artery bypass graft) recruited by participating general practitioners; patients invited to attend on a quarterly basis, with continuing care implemented according to defined clinical protocols.. Changes in risk factors and treatments at 1, 2, 3 and 3.5-year follow-up from baseline were made using paired t-test for continuous and McNemar's test for categorical data.. Important changes in systolic and diastolic blood pressure, total and low-density lipoprotein cholesterol and smoking status were observed at 1, 2, 3 and 3.5 years (P < 0.0001) with significant increase in proportions of patients within the target. However, changes in body mass index were small, with no significant improvement in waist circumference. There was a significant increase in prescription of secondary preventive medications and good patient compliance. Males were more likely to be within the target for systolic blood pressure, total cholesterol, waist circumference and exercise level at 3.5 years, but less likely for body mass index.. Studies of cardiac rehabilitation without any follow-up programmes show that over time patients revert in part to previous lifestyle habits; this primary care-delivered programme has shown sustained improvements in major risk factors, particularly smoking, blood pressure and cholesterol, and treatments for CHD. Weight management presents a greater challenge.

Topics: Aged; Biomarkers; Blood Glucose; Blood Pressure; Body Mass Index; Cardiovascular Agents; Cholesterol; Cholesterol, LDL; Coronary Disease; Drug Prescriptions; Female; Follow-Up Studies; Health Knowledge, Attitudes, Practice; Humans; Ireland; Logistic Models; Male; Middle Aged; Odds Ratio; Patient Compliance; Patient Education as Topic; Practice Patterns, Physicians'; Primary Health Care; Program Evaluation; Risk Assessment; Risk Factors; Risk Reduction Behavior; Secondary Prevention; Sex Factors; Smoking; Smoking Cessation; Smoking Prevention; Time Factors; Treatment Outcome; Waist Circumference

The achievement of the therapeutic objectives in patients with ischemic heart disease and metabolic syndrome is unknown. This study has aimed to evaluate whether the prevalence of risk factors, the prescription rate of evidence-based cardiovascular therapies and the attainment of therapeutic goals differ in coronary patients with and without the metabolic syndrome (MS).. A multicenter, cross-sectional study carried out with the participation of 7,600 patients with stable coronary heart disease (mean age 65.3 years, 82% males, 37.7% with MS) attended in primary care. Data on drug prescription and goal attainment were extracted from clinical records. MS was defined according to the National Cholesterol Education Program (NCEP) criteria.. Patients with MS had a higher prevalence of cardiovascular risk factors and cardiovascular disease. They also had a higher prescription rate of blood-pressure lowering drugs, statins and antidiabetic agents, without differences in the rate of use of antithrombotics and beta-blockers. After adjusting for cardiovascular risk factors and co-morbidity, only fibrates and angiotensin II receptor blockers were used more frequently in MS patients. A lower percentage of subjects with MS achieved therapeutic goals of LDL cholesterol (23.4% vs 27.7%, P<.001), blood pressure (29.1% vs 52.2%, P<.001) and, in diabetics, of glycated hemoglobin (54.7% vs 75.9%, P<.001).. Patients with stable coronary disease and MS do not reach therapeutic objectives as frequently as those without MS, in spite of receiving a higher amount of cardiovascular drugs.

Topics: Aged; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Cross-Sectional Studies; Female; Humans; Male; Metabolic Syndrome; Prevalence; Risk Factors

To evaluate whether good statin adherence is associated with a reduced incidence of major coronary events (MCEs) among diabetic patients with and without coronary heart disease (CHD).. Using data derived by linkage of nationwide health databases in Finland, we conducted a nested case-control analysis of 3513 cases with an MCE, a composite of acute myocardial infarction and/or coronary revascularization, and 20,090 matched controls identified from a cohort of 60,677 statin initiators with diabetes. Cases and controls were matched according to gender, time of cohort entry and duration of follow-up and further classified to two risk groups according to the presence of CHD at statin initiation. The incidence of MCEs was compared between patients with good statin adherence (the proportion of days covered ≥80%) and patients with poor statin adherence (<80%). Odds ratios (OR) for MCEs were estimated by conditional logistic regression adjusting for several covariables.. Good statin adherence was associated with a reduced incidence of MCEs in those with prior CHD [OR 0.84 (95% CI 0.74-0.95)] and in those without it [OR 0.86 (95% CI 0.78-0.95)]. The association persisted among those followed up for 5 years or longer [OR 0.77 (95% CI 0.58-1.02) and OR 0.79 (95% CI 0.66-0.94) respectively]. In sensitivity analyses, a reduced MCE incidence was observed also in those without any documented cardiovascular disease (CVD) at statin initiation [OR 0.87 (95% CI 0.78-0.96) overall and OR 0.80 (95% CI 0.66-0.97) for those followed up 5 years or longer].. In patients with diabetes, good adherence to statins predicts reduced incidence of MCEs irrespective of the presence of CHD at statin initiation.

Topics: Aged; Cardiovascular Agents; Case-Control Studies; Coronary Disease; Diabetic Angiopathies; Drug Administration Schedule; Female; Finland; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Medication Adherence; Middle Aged; Myocardial Infarction; Myocardial Revascularization

Between 1986 and 2002, coronary heart disease (CHD) mortality in Sweden fell by more than 50%. Approximately one-third (4800 fewer deaths) of this decline in age-adjusted CHD mortality could be attributed to treatments in patients with CHD and primary prevention medications. High treatment levels were achieved in some cases, but in others, only 50-80% of eligible patients received appropriate therapy. We therefore examined to what extent increasing the use of specific treatments in eligible patients might have reduced CHD mortality rates in Sweden.. We used the previously validated IMPACT CHD model to combine data on CHD patient numbers, medical and surgical uptake levels and treatment effectiveness. We estimated the number of deaths prevented or postponed for 2002 (baseline scenario) and for an alternative scenario (if at least 60% of eligible patients were treated).. If treatments were increased to consistently cover at least 60% of eligible patients, approximately 8900 deaths could have been postponed or prevented, representing a potential gain of approximately 4100 fewer deaths than actually occurred in 2002. Approximately 45% of the 4100 gain would have come from primary prevention with statins, 23% from acute coronary syndrome treatments, 15% from secondary prevention therapies and 15% from treatments for heart failure.. Increasing the proportion of eligible patients with CHD who receive evidence-based treatment could have resulted in approximately 4100 fewer deaths in 2002, almost doubling the actual mortality reduction. These findings further emphasize the importance of aggressively identifying and treating patients with CHD and high-risk individuals.

Topics: Adult; Age Distribution; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Disease; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Myocardial Revascularization; Sex Distribution; Sweden

The SYNergy between percutaneous intervention with TAXus drug eluting stents and cardiac surgery (SYNTAX) Score is a tool for risk stratification of patients according to the complexity of coronary lesions developed during the SYNTAX trial. We examined the influence of the SYNTAX Score on the incidence of major adverse cardiac and cerebrovascular events.. All patients with de novo left main or 3-vessel disease undergoing coronary artery bypass grafting from January 2005 to December 2008 at our institution (Hospital Clínico San Carlos, Madrid, Spain) were retrospectively assessed, and their SYNTAX Score was calculated. The influence of the SYNTAX Score on postprocedural and follow-up mortality and combined major adverse cardiac and cerebrovascular events (including death, myocardial infarction, cerebrovascular accident, and repeat revascularization) was identified by multivariate analysis. Balancing score analysis was performed to eliminate the effect of potential confounders.. A total of 716 patients were enrolled. Mean SYNTAX Score was 34.5 (standard deviation, 6.7; range, 11.5-76). Three groups of patients were identified according to the score terciles: low (≤33), intermediate (33-37), and high (>37). These terciles scores differed greatly from those reported by the SYNTAX trial investigators. The multivariate analysis identified that the SYNTAX Score was associated with follow-up mortality (hazard ratio = 1.046, P = .015) and combined early and follow-up major adverse cardiac and cerebrovascular events (odds ratio = 1.079, P < .001; and hazard ratio = 1.034, P = .026, respectively). Balancing score-adjusted analyses demonstrated that the SYNTAX Score was independently associated with early and late major adverse cardiac and cerebrovascular events (odds ratio = 1.65, P < .001; and hazard ratio = 1.034, P = .027, respectively).. SYNTAX Score was remarkably high among patients undergoing surgical off-pump myocardial revascularization at our institution. In this subset of patients, a higher SYNTAX Score was associated with a higher incidence of in-hospital and follow-up major adverse cardiac and cerebrovascular events after coronary artery bypass grafting, but not with early or late mortality.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass, Off-Pump; Coronary Disease; Drug-Eluting Stents; Female; Health Status Indicators; Humans; Male; Middle Aged; Multivariate Analysis; Paclitaxel; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors

Information relating the outcome of percutaneous coronary intervention to diabetes mellitus or hypertension is limited. The study objective was to describe the outcome in patients undergoing percutaneous coronary intervention in relation to diabetes and hypertension.. Data were extracted from 5 national registers: the Swedish Coronary Angiography and Angioplasty Register (all percutaneous coronary interventions), the Prescribed Drug Registry (all prescribed pharmaceuticals purchased in Swedish pharmacies), the Swedish Hospital Discharge Register (data on myocardial infarction, revascularization, stroke, and congestive heart failure from in-hospital and specialist health care), and the National Population Register and Cause of Death Register (data on death). We included all "first percutaneous coronary interventions" between January 1, 2006, and December 31, 2008 (n=44,268; followed an average of 1.9 [± 0.9] years).. Mortality was 6.4% and highest in patients with diabetes plus hypertension. Hypertension per se did not increase mortality or the risk for repeat intervention, but carried a 10% increased risk for subsequent myocardial infarction, increasing to a 4-fold increase when combined with diabetes. Stroke occurred in 2%; the importance of hypertension was evident in nondiabetic patients, but even stronger in diabetic patients. Congestive heart failure caused hospital admission in 8%, with a negative influence from hypertension with and without diabetes.. After percutaneous coronary intervention and with modern pharmacotherapy, diabetes had a negative effect on the outcome, especially when combined with hypertension. Hypertension per se was not associated with increased mortality but with an increased risk for myocardial infarction, stroke, and congestive heart failure, probably related to widespread coronary artery disease. Improved diabetes care might improve the prognosis.

Topics: Adult; Aged; Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Cardiovascular Diseases; Confounding Factors, Epidemiologic; Coronary Disease; Coronary Restenosis; Diabetes Complications; Diabetes Mellitus, Type 2; Female; Follow-Up Studies; Heart Failure; Humans; Hypertension; Hypoglycemic Agents; Male; Middle Aged; Myocardial Infarction; Prognosis; Registries; Retreatment; Stroke; Sweden; Treatment Outcome

Self-reported angina symptoms are collected in epidemiological surveys. We aimed at validating the angina symptoms assessed by the Rose Questionnaire against registry data on coronary heart disease. A further aim was to examine the sex paradox in angina implying that women report more symptoms, whereas men have more coronary events.. Angina symptoms of 6601 employees of the City of Helsinki were examined using the postal questionnaire survey data combined with coronary heart disease registries.. The self-reported angina was classified as no symptoms, atypical pain, exertional chest pain, and stable angina symptoms. Reimbursed medications and hospital admissions were available from registries 10 years before the survey. Binomial regression analysis was used.. Stable angina symptoms were associated with hospital admissions and reimbursed medications [prevalence ratio (PR), 6.75; 95% confidence interval (CI), 4.56-9.99]. In addition, exertional chest pain (PR, 5.31; 95% CI, 3.45-8.18) was associated with coronary events. All events were more prevalent among men than women (PR, 2.36; 95% CI, 1.72-3.25).. The Rose Questionnaire remains a valid tool to distinguish healthy people from those with coronary heart disease. However, a notable part of those reporting symptoms have no confirmation of coronary heart disease in the registries. The female excess of symptoms and male excess of events may reflect inequality or delay in access to treatment, problems in identification and diagnosis, or more complex issues related to self-reported angina symptoms.

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Drug Costs; Female; Finland; Humans; Insurance, Health, Reimbursement; Male; Middle Aged; Odds Ratio; Patient Admission; Prevalence; Registries; Regression Analysis; Reproducibility of Results; ROC Curve; Self Report; Sex Distribution; Sex Factors; Surveys and Questionnaires; Time Factors

Buyang Huanwu Decoction (BYHWD), a traditional Chinese medicine (TCM) formula, has been recognized as a clinical treatment for coronary heart disease (CHD) with qi deficiency and blood stasis syndrome. The effects of BYHWD on hemorheological disorders and energy metabolism in CHD with qi deficiency and blood stasis syndrome are still unclear.. To investigate whether the ameliorative effects of BYHWD on CHD rats with qi deficiency and blood stasis syndrome are associated with the regulation of hemorheological disorders and energy metabolism.. The rats were lavaged with 25.68, 12.84 and 6.42 g/kg BYHWD (g weight of mixed crude drugs/kg body weight), respectively, once a day for 21 days. The body weight, exhaustive swimming time and tongue characters were observed and recorded. The whole blood viscosity and plasma viscosity were determined by hematology analyzer. The level of fibrinogen (Fbg) in plasma was determined by using Fbg assay kit. The platelet aggregation induced by adenosine diphosphatase was measured by semi-automatic whole blood platelet analyzer. The level of blood glucose (BG) was determined by LifeScan. The activity of Na(+)-K(+)-ATPase in heart tissues was detected by spectrophotometer.. BYHWD improved the exterior signs of qi deficiency and blood stasis syndrome in rats with CHD, including the body weight, exhaustive swimming time and tongue quality. The whole blood viscosity in rats treated with 25.68 g/kg BYHWD decreased at the shear rate of 10s(-1) (P<0.05) and the plasma viscosity decreased in rats treated with 25.68 and 12.84 g/kg BYHWD (P<0.05). The plasma Fbg level and the platelet aggregation decreased in rats treated with 25.68 g/kg BYHWD (P<0.01). The results also revealed that the BG level decreased and the Na(+)-K(+)-ATPase activity in heart tissues increased in rats treated with 25.68 and 12.84 g/kg BYHWD (P<0.01).. The results suggest that the ameliorative effects of BYHWD on CHD rats with qi deficiency and blood stasis syndrome are mediated by the improvement of hemorheological disorders and energy metabolism.

Topics: Animals; Biomarkers; Blood Glucose; Blood Viscosity; Body Weight; Cardiovascular Agents; Coronary Disease; Disease Models, Animal; Dose-Response Relationship, Drug; Drugs, Chinese Herbal; Energy Metabolism; Female; Fibrinogen; Hemorheology; Male; Myocardium; Physical Endurance; Platelet Aggregation; Qi; Rats; Rats, Sprague-Dawley; Sodium-Potassium-Exchanging ATPase; Swimming; Time Factors; Tongue

Topics: Body Weight; Cardiovascular Agents; Coronary Disease; Diet, Reducing; Humans; Randomized Controlled Trials as Topic; Religion; Risk Factors; Sedentary Behavior; Television

Topics: Antihypertensive Agents; Cardiovascular Agents; Coronary Disease; Developed Countries; Developing Countries; Female; Humans; Male; Secondary Prevention; Stroke

Although most cardiovascular disease occurs in low-income and middle-income countries, little is known about the use of effective secondary prevention medications in these communities. We aimed to assess use of proven effective secondary preventive drugs (antiplatelet drugs, β blockers, angiotensin-converting-enzyme [ACE] inhibitors or angiotensin-receptor blockers [ARBs], and statins) in individuals with a history of coronary heart disease or stroke.. In the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged 35-70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven effective secondary preventive drugs and blood-pressure-lowering drugs with standardised questionnaires, which were completed by telephone interviews, household visits, or on patient's presentation to clinics. We report estimates of drug use at national, community, and individual levels.. We enrolled 153,996 adults from 628 urban and rural communities in countries with incomes classified as high (three countries), upper-middle (seven), lower-middle (three), or low (four) between January, 2003, and December, 2009. 5650 participants had a self-reported coronary heart disease event (median 5·0 years previously [IQR 2·0-10·0]) and 2292 had stroke (4·0 years previously [2·0-8·0]). Overall, few individuals with cardiovascular disease took antiplatelet drugs (25·3%), β blockers (17·4%), ACE inhibitors or ARBs (19·5%), or statins (14·6%). Use was highest in high-income countries (antiplatelet drugs 62·0%, β blockers 40·0%, ACE inhibitors or ARBs 49·8%, and statins 66·5%), lowest in low-income countries (8·8%, 9·7%, 5·2%, and 3·3%, respectively), and decreased in line with reduction of country economic status (p(trend)<0·0001 for every drug type). Fewest patients received no drugs in high-income countries (11·2%), compared with 45·1% in upper middle-income countries, 69·3% in lower middle-income countries, and 80·2% in low-income countries. Drug use was higher in urban than rural areas (antiplatelet drugs 28·7% urban vs 21·3% rural, β blockers 23·5%vs 15·6%, ACE inhibitors or ARBs 22·8%vs 15·5%, and statins 19·9%vs 11·6%; all p<0·0001), with greatest variation in poorest countries (p(interaction)<0·0001 for urban vs rural differences by country economic status). Country-level factors (eg, economic status) affected rates of drug use more than did individual-level factors (eg, age, sex, education, smoking status, body-mass index, and hypertension and diabetes statuses).. Because use of secondary prevention medications is low worldwide-especially in low-income countries and rural areas-systematic approaches are needed to improve the long-term use of basic, inexpensive, and effective drugs.. Full funding sources listed at end of paper (see Acknowledgments).

Topics: Adrenergic beta-Antagonists; Adult; Aged; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Data Collection; Developed Countries; Developing Countries; Drug Utilization; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Platelet Aggregation Inhibitors; Rural Population; Secondary Prevention; Stroke; Urban Population

Apolipoprotein A-I (apoA-I) exerts many potentially anti-atherogenic properties and is therefore attractive for prevention and therapy of coronary heart disease. Since induction of apoA-I production by small molecules has turned out as difficult, application of exogenous apoA-I is pursued as an alternative therapeutic option. To counteract fast renal filtration of apoA-I, a trimeric high-molecular weight variant of apoA-I (TripA) was produced by recombinant technology. We compared TripA and apoA-I for important properties in reverse cholesterol transport. Reconstituted high-density lipoproteins (rHDL) containing TripA or apoA-I together with palmitoyl-2-oleyl-phosphatidylcholine (POPC) differed slightly by size. Compared to apoA-I, TripA activated lecithin:cholesterol acyltransferase (LCAT) with similar maximal velocity but concentration leading to half maximal velocity was slightly reduced (K(m)=2.1±0.3μg/mL vs. 0.59±0.06μg/mL). Both in the lipid-free form and as part of rHDL, TripA elicited cholesterol efflux from THP1-derived macrophages with similar kinetic parameters and response to liver-X-receptor activation as apoA-I. Lipid-free TripA is bound and transported by aortic endothelial cells through mechanisms which are competed by apoA-I and TripA and inhibited by knock-down of ATP-binding cassette transporter (ABC) A1. Pre-formed TripA/POPC particles were bound and transported by endothelial cells through mechanisms which are competed by excess native HDL as well as reconstituted HDL containing either apoA-I or TripA and which involve ABCG1 and scavenger receptor B1 (SR-BI). In conclusion, apoA-I and TripA show similar in vitro properties which are important for reverse cholesterol transport. These findings are important for further development of TripA as an anti-atherosclerotic drug.

Topics: Animals; Aorta; Apolipoprotein A-I; Atherosclerosis; ATP-Binding Cassette Transporters; Cardiovascular Agents; Cattle; Coronary Disease; Endothelial Cells; Gene Silencing; Humans; Kinetics; Lipoproteins, HDL; Phosphatidylcholine-Sterol O-Acyltransferase; Phosphatidylcholines; Protein Binding; Protein Transport; Recombinant Proteins; RNA, Small Interfering

We examined the potential of oral administration of nicorandil for protecting against cardiac death in hemodialysis patients without obstructive coronary artery disease.. This study was based on a cohort study of 155 hemodialysis patients with angiographic absence of obstructive coronary lesions, with analysis performed in 100 propensity-matched patients (54 men and 46 women, 64 ± 10 years), including 50 who received oral administration of nicorandil (15 mg/day, nicorandil group) and 50 who did not (control). The efficacy of nicorandil in preventing cardiac death was investigated.. Over a mean follow-up period of 5.3 ± 1.9 years, we observed 25 cardiac deaths among 100 propensity-matched patients, including 6 due to acute myocardial infarction, 11 due to heart failure, and 8 due to sudden cardiac death. The incidence of cardiac death was lower (p < 0.001) in the nicorandil group (4/50, 8%) than in the control (21/50, 42%). On multivariate Cox hazard analysis, cardiac death was inversely associated with oral nicorandil (hazard ratio, 0.123; p = 0.0002). On Kaplan-Meier analysis, cardiac death-free survival rates at 5 years were higher in the nicorandil group than in the control group (91.4 vs. 66.4%).. Oral nicorandil may inhibit cardiac death of hemodialysis patients without obstructive coronary artery disease.

Topics: Administration, Oral; Aged; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Death, Sudden, Cardiac; Drug Evaluation; Female; Follow-Up Studies; Heart Failure; Humans; Insulin Resistance; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Middle Aged; Myocardial Infarction; Nicorandil; Proportional Hazards Models; Renal Dialysis; Retrospective Studies; Tomography, Emission-Computed, Single-Photon

To examine the extent to which the decrease in coronary heart disease mortality rates in Spain between 1988 and 2005 could be explained by changes in cardiovascular risk factors and by the use of medical and surgical treatments.. We used the previously validated IMPACT model to examine the contributions of exposure factors (risk factors and treatments) to the main outcome, changes in the mortality rates of death from coronary heart disease, among adults 35 to 74 years of age. Main data sources included official mortality statistics, results of longitudinal studies, national surveys, randomized controlled trials, and meta-analyses. The difference between observed and expected coronary heart disease deaths in 2005 was then partitioned between treatments and risk factors.. From 1988 to 2005, the age-adjusted coronary heart disease mortality rates fell by almost 40%, resulting in 8530 fewer coronary heart disease deaths in 2005. Approximately 47% of the fall in deaths was attributed to treatments. The major treatment contributions came from initial therapy for acute coronary syndromes (11%), secondary prevention (10%), and heart failure (9%). About 50% of the fall in mortality was attributed to changes in risk factors. The largest mortality benefit came from changes in total cholesterol (about 31% of the mortality fall) and in systolic blood pressure (about 15%). However, some substantial gender differences were observed in risk factor trends with an increase in diabetes and obesity in men and an increase in smoking in young women. These generated additional deaths.. Approximately half of the coronary heart disease mortality fall in Spain was attributable to reductions in major risk factors, and half to evidence-based therapies. These results increase understanding of past trends and will help to inform planning for future prevention and treatment strategies in low-risk populations.

Topics: Adult; Aged; Cardiac Surgical Procedures; Cardiovascular Agents; Coronary Disease; Female; Heart Failure; Humans; Male; Middle Aged; Models, Statistical; Risk Factors; Secondary Prevention; Spain

Topics: Cardiovascular Agents; Coronary Disease; Developed Countries; Developing Countries; Humans; Residence Characteristics; Stroke

Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care.. A cross-sectional study of quality of care measures extracted from electronic medical records and EBM knowledge assessed via a validated questionnaire.. One region of the largest Health Maintenance Organization in Israel.. Seventy-four physicians and their 8334 diabetic patients, 7092 coronary heart disease patients and 17 132 hypertensive patients.. Outcome measures were four diabetes quality of care indicators (LDL tests, microalbumin tests, hemoglobin A1C tests, eye examination referrals), and two drug prescription indicators (statin prescription for coronary heart disease patients, and thiazide prescription for hypertensive patients). Independent variables were total EBM knowledge and its components: critical appraisal and information retrieval.. Total EBM knowledge was independently and significantly associated with LDL testing (b = 0.13; P = 0.036), microalbumin testing (b = 0.33; P = 0.001), hemoglobin A1C testing (b = 0.17; P = 0.036), eye examination referrals (b = 0.16; P = 0.021) and statin prescriptions (b = 0.18; P = 0.025). Critical appraisal was independently associated with microalbumin tests (b = 0.46; P = 0.002) and eye examination referrals (b = 0.20; P = 0.048). Information retrieval was only independently associated with hemoglobin A1C testing (b = 0.43; P = 0.004). Thiazide prescription was not associated with EBM knowledge scores.. Physicians' higher total EBM knowledge primarily correlates with better quality of care; however, correlations were modest and explained only a small portion in the variance of clinical performance. Results indicate that there might be a need to focus on teaching all the components of EBM rather than EBM microskills.

Topics: Adult; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Diabetes Mellitus; Drug Utilization; Evidence-Based Medicine; Female; Health Knowledge, Attitudes, Practice; Humans; Hypertension; Israel; Male; Middle Aged; Physicians, Family; Practice Patterns, Physicians'; Quality Indicators, Health Care; Quality of Health Care

Previous studies have suggested that patients with coronary artery disease (CAD) in rural areas may have worse outcomes due to limited availability of specialists, fewer resources, and less institutional funding. Data were collected from hospitals participating in the Get With the Guidelines-Coronary Artery Disease Program (GWTG-CAD) from January 2000 to December 2008. In-hospital outcomes and quality of care were stratified by care at rural versus urban hospitals. Multivariate logistic regression analysis was used to determine the association of rural locale with in-hospital mortality, length of stay, and compliance with the GWTG-CAD performance measurements including (1) early aspirin use, (2) smoking cessation counseling and discharge prescriptions of (3) aspirin, (4) angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers for left ventricular systolic dysfunction, (5) beta-blockers, and (6) lipid-lowering therapy and a composite of all 6 measurements. Data were collected from 22,096 patients at 71 rural centers and 329,938 patients at 477 urban centers. Unadjusted rates of compliance with performance measurements were lower in rural (range 82.4% to 90.5%) compared to urban (range 81.3% to 95.0%) hospitals including the composite (74.7% vs 80.6%, p <0.0001). In multivariate analysis, rural status was not independently associated with lower compliance with any of the performance measurements. Unadjusted mortality rates were higher in rural versus urban hospitals (5.7% vs 4.4%, p <0.0001), but this was not significant in multivariate analysis (odds ratio 1.05, 95% confidence interval 0.87 to 1.26). In conclusion, within the GWTG-CAD quality improvement initiative, patients with CAD treated at rural hospitals receive similar quality of care and have similar outcomes as those at urban centers.

Topics: Aged; Cardiovascular Agents; Cohort Studies; Coronary Disease; Female; Guideline Adherence; Hospital Mortality; Hospitals, Rural; Hospitals, Urban; Humans; Length of Stay; Male; Myocardial Revascularization; Practice Guidelines as Topic; Quality of Health Care; United States

Despite evidence of effective combination drug therapy for secondary prevention of coronary heart disease (CHD), older adults with this condition remain undertreated.. To describe time trends (1992-2003) in the adoption of combination cardiac drug therapies (beta-blockers [beta-adrenoceptor antagonists], ACE inhibitors or angiotensin II type 1 receptor antagonists [angiotensin receptor blockers; ARBs], and lipid-lowering agents) among older adults in the US with CHD and to identify factors associated with not using combination therapy.. The study took the form of a cross-sectional time-series. The study population consisted of a nationally representative sample of adults aged >or=65 years with CHD (unweighted n = 6331; weighted n = 20.1 million) included in the 1992-2003 Medicare Current Beneficiary Survey. The outcome measure was low-intensity cardiac pharmacotherapy (no drug or single drug therapy with beta-blockers, ACE inhibitors/ARBs or lipid-lowering agents) compared with combination therapy (>or=2 cardiac drugs) for secondary CHD prevention.. The use of combination drug therapy in older adults with CHD increased 9-fold during the study period (from 6% in 1992 to 54% in 2003). Adjusted analyses demonstrate that suboptimal drug therapy was independently associated with advanced age (relative risk [RR] 1.18; 95% CI 1.14, 1.23) for patients aged >or=85 years versus patients aged 65-74 years, and with being non-Hispanic Black (RR 1.05; 95% CI 1.01, 1.10) or Hispanic (RR 1.13; 95% CI 1.06, 1.21) versus being non-Hispanic White.. Combination drug therapy use for secondary CHD prevention increased in older US adults over the last decade, but improvements were not uniform. The oldest-old, non-Hispanic Blacks and Hispanics experienced slower adoption of optimal medical therapy to improve their long-term prognosis for CHD.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Drug Prescriptions; Drug Therapy, Combination; Ethnicity; Humans; Medicare; Practice Patterns, Physicians'; Sex Factors; United States

Cigarette smoking, raised blood pressure, unfavourable lipid concentrations, diabetes and - more indirectly - obesity, are responsible for most coronary heart disease events in developed and developing countries.. The objective of our study was to compare prevalence, treatment and control of cardiovascular risk factors in two samples of men with stable coronary heart disease, recruited in France and Spain.. Standardized measurements of body mass index, systolic and diastolic blood pressures, plasma lipids, glycaemia, and smoking were collected and drug use was registered. Cross-sectional comparisons were made between French and Spanish samples.. Data from 982 individuals were analysed (420 French and 562 Spanish men). Current smoking was more frequent in Spain (p<0.001), whereas hypertension and uncontrolled blood pressure were more frequent in France (p<0.001). Mean concentrations of low-density lipoprotein cholesterol and triglycerides were significantly higher in France (p<0.001). No significant differences were observed regarding obesity, high-density lipoprotein cholesterol and diabetes. More than 97% of participants presented with at least one of the following conditions: hypertension, dyslipidaemia, diabetes, obesity or smoking. Antiplatelet agents, calcium inhibitors, diuretics and hypoglycaemic drugs were used more frequently in France, whereas angiotensin-converting enzyme inhibitors and lipid-lowering treatments were used more frequently in Spain.. Prevalence of cardiovascular risk factors is high among French and Spanish patients with stable coronary heart disease, with differences between countries regarding the distribution of the various risk factors. A great proportion of patients do not reach the recommended levels for risk factor control.

Topics: Aged; Cardiovascular Agents; Cardiovascular Diseases; Chi-Square Distribution; Coronary Disease; Cross-Sectional Studies; Diabetes Mellitus; Dyslipidemias; France; Health Status Disparities; Healthcare Disparities; Humans; Hypertension; Male; Middle Aged; Obesity; Prevalence; Registries; Risk Assessment; Risk Factors; Smoking; Spain; Time Factors

Guidelines for cardiovascular risk factor control in people with coronary heart disease (CHD) focus on compliance with beta-adrenoceptor antagonists (beta-blockers), angiotensin receptor blockade (ACE inhibitors/angiotensin II receptor antagonists [angiotensin receptor blockers; ARBs]) [ACE/ARBs], and lipid-lowering agents, with goals for BP of <140/90 mmHg and low-density lipoprotein cholesterol (LDL-C) levels of <2.6 mmol/L (100 mg/dL). Most data derive from registries of hospitalized patients or are from clinical trials. Little data exist on goal attainment and adherence with therapy among CHD survivors of major US ethnic groups in the real-world setting.. We assessed levels of cardiovascular risk factor control and adherence with recommended therapies among US CHD survivors.. We identified 364 US adults (representing 12.8 million in the US with CHD) aged 18 years and over in the National Health and Nutrition Examination Survey 2005-6 with known CHD. We calculated proportions of patients who were receiving recommended treatments, and who achieved goal targets for BP, LDL-C levels, glycosylated hemoglobin (HbA(1c)), and nonsmoking status, and differences between actual and goal levels ('distance to goal'), stratified by sex and ethnicity.. Overall, 58%, 38%, and 60% of CHD survivors were receiving beta-adrenoceptor antagonists, ACE/ARBs, and lipid-lowering medications, respectively (22% received all three). However, treatment rates for beta-adrenoceptor antagonists and lipid-lowering agents were lower (p < 0.05 to p < 0.01) in Hispanics (36% and 27%, respectively) and non-Hispanic Blacks (47% and 42%, respectively) than in non-Hispanic Whites. Moreover, lipid-lowering treatment rates were lower in females (50%) than in males (67%) [p < 0.01]. Overall, 78% were nonsmokers while 68% achieved goal levels for BP, 57% for LDL-C levels, and, if diabetic, 67% for HbA(1c). Only 12% met all four goals. Non-Hispanic Whites had the lowest SBP and DBP as well as HbA(1c) (p < 0.05 to p < 0.01 across ethnicity). In those who did not achieve goal levels, distance to goal averaged 1.0 mmol/L (37.0 mg/dL) for LDL-C levels, 15.6 mmHg for SBP, and 1.3% for HbA(1c).. Despite clear treatment guidelines, we show that many US adults with CHD, especially Hispanics and non-Hispanic Blacks, are neither receiving recommended treatments nor adequately treated in terms of BP, LDL-C levels, and HbA(1c). Greater efforts by healthcare systems to disseminate and implement guidelines are needed.

Topics: Aged; Black or African American; Blood Pressure; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Female; Health Care Surveys; Hispanic or Latino; Humans; Hypolipidemic Agents; Male; Medication Adherence; Middle Aged; Practice Guidelines as Topic; Risk Factors; Sex Factors; United States; White People

Local polyclinic therapists' long experience in timely identifying, treating and rehabilitating patients with coronary heart disease (CHD) is analyzed. A local therapist's attention is given to diferent course types--the clinical manifestations of CHD. The principles of continuity in the work of a therapist and a hospital: possibilities of extrahospital treatment are denoted; indications for hospitalization are specified. Rehabilitative measures include psychotherapy sessions in addition to drug, dietary, and exercise therapies. Continuity in the work of a therapeutic unit and a sociomedical expert commission contributes to the elaboration of clearer criteria for determining the degree of working capacity loss.

Topics: Ambulatory Care; Cardiovascular Agents; Coronary Disease; Delivery of Health Care; Early Diagnosis; Exercise Therapy; Humans; Outcome Assessment, Health Care; Physicians, Family; Psychotherapy; Russia; Time Factors

To examine patients' use of medication management strategies (e.g., reminders, pill boxes), and to determine how their use influences the relationship between patient characteristics and medication adherence.. Retrospective and cross-sectional study of 434 patients with coronary heart disease, examining both refill adherence and self-reported adherence.. The most common strategy for managing refills was seeing a near empty pill bottle (89.9%), and for managing daily medications, it was associating medications with daily events (80.4%). Age<65 (OR = 1.7), as well as marginal (OR = 2.0) or inadequate health literacy (OR = 1.9), was independently associated with low refill adherence. Patients <65 also had lower self-reported adherence (OR = 1.8). Adjustment for use of medication management strategies did not substantially change these relationships. Reliance on reminders from friends or family to take medications, or waiting to refill a medicine only when the bottle was near empty, each were associated with 3-fold greater odds of non-adherence.. Age <65 and marginal or inadequate health literacy were independently associated with medication non-adherence. Use of medication management strategies did not explain these relationships.. The strategies which patients report using to assist with managing medication refills and daily medication use may be ineffective.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Drug Prescriptions; Educational Status; Female; Health Literacy; Humans; Male; Medication Adherence; Middle Aged; Physician-Patient Relations; Reminder Systems; Retrospective Studies; Self Administration; Socioeconomic Factors; Urban Population

To compare gender-related lifestyle changes and risk factor management after hospitalisation for a coronary event or revascularisation intervention in Europe.. The EUROASPIRE III survey was carried out in 22 European countries in 2006-2007. Consecutive patients having had a coronary event or revascularisation before the age of 80 were identified. A total of 8966 patients (25.3% women) were interviewed and underwent clinical and biochemical tests at least 6 months after hospital admission. Trends in cardiovascular risk management were assessed on the basis of the 1994-1995, 1999-2000 and 2006-2007 EUROASPIRE surveys.. Female survey participants were generally older and had a lower educational level than male participants (p<0.0001). The prevalences of obesity (p<0.0001), high blood pressure (BP) (p=0.001), elevated low-density lipoprotein (LDL)-cholesterol (p<0.0001) and diabetes (p<0.0001) were significantly higher in women than in men, whereas current smoking (p<0.0001) was significantly more common in men. The use of antihypertensive and antidiabetic drugs (but not that of other drugs) was more common in women than in men. However, BP (p<0.0001), LDL-cholesterol (p<0.0001) and HbA1c (p<0.0001) targets were less often achieved in women than in men. Between 1994 and 2007, cholesterol control improved less in women than in men (interaction: p=0.009), whereas trends in BP control (p=0.32) and glycaemia (p=0.36) were similar for both genders.. The EUROASPIRE III results show that despite similarities in medication exposure, women are less likely than men to achieve BP, LDL-cholesterol and HbA1c targets after a coronary event. This gap did not appear to narrow between 1994 and 2007.

Topics: Adolescent; Adult; Age Factors; Aged; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Diabetes Complications; Educational Status; Europe; Female; Health Care Surveys; Humans; Hypercholesterolemia; Hypertension; Life Style; Male; Middle Aged; Obesity; Risk Factors; Sex Factors; Smoking Cessation; Young Adult

Patients with coronary heart disease often engage in unhealthy lifestyle behaviours. We explored patients' and general practitioners' (GPs') perceptions about the effectiveness of healthy behaviours and medications for the prevention of further cardiovascular disease. This exploratory study used semi-structured interviews with eight Sydney GPs and 13 of their patients with coronary heart disease. Patients perceived medications to be more effective than healthy behaviours in improving specific aspects of cardiovascular health, such as angina symptoms, cholesterol and blood pressure, whilst GPs perceived that medications were more effective in patients they considered at highest cardiovascular risk, patients with uncontrolled risk factors, or where adherence to healthy behaviours was poor. Among patients we found a negative perception of the effort required to adhere to healthy behaviours and possible underestimation of their future cardiovascular risk. Patients valued support from peers and family. This study opens up avenues for investigation in further research, including whether patient adherence to healthy behaviours may be enhanced by the exploration oftheir perceptions about behaviour effectiveness, barriers and cardiovascular risk and by GP facilitation of practical supports.

Topics: Aged; Attitude of Health Personnel; Cardiovascular Agents; Coronary Disease; Female; General Practitioners; Health Behavior; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; New South Wales; Qualitative Research; Risk Factors

Drug-eluting stents become increasingly popular for the treatment of coronary artery disease. Consequently, side effects including hypersensitivity reactions have to be anticipated.. Here we report on a patient with an anaphylactic reaction 2 weeks after implantation of a polymer-based paclitaxel-eluting stent (Taxus, Boston Scientific). The patient presented with disseminated wheals, pruritus, bronchial asthma and acute synovitis. The reaction was successfully treated with initial intravenous injection followed by oral antihistamine treatment for 1 month until all stent-bound paclitaxel was assumed to be eluted. Thereafter no further anaphylactic reaction occurred.. This sequence of events points towards a causal relation of the stent implantation and hypersensitivity reaction with a central role of paclitaxel. The increasing use of this type of stent should therefore be carefully monitored for such adverse reactions.

Topics: Aged; Anaphylaxis; Anti-Allergic Agents; Cardiovascular Agents; Coronary Disease; Coronary Restenosis; Drug Hypersensitivity; Drug-Eluting Stents; Histamine H1 Antagonists; Humans; Male; Paclitaxel; Treatment Outcome

The aim of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events III (EUROASPIRE III) survey was to determine whether the Joint European Societies' guidelines on cardiovascular prevention are being followed in everyday clinical practice and to describe the lifestyle, risk factor and therapeutic management in patients with coronary heart disease (CHD) in Europe.. The EUROASPIRE III survey was carried out in 2006-2007 in 76 centres from selected geographical areas in 22 countries in Europe. Consecutive patients, with a clinical diagnosis of CHD, were identified retrospectively and then followed up, interviewed and examined at least 6 months after their coronary event.. Thirteen thousand nine hundred and thirty-five medical records (27% women) were reviewed and 8966 patients were interviewed. At interview, 17% of patients smoked cigarettes, 35% were obese and 53% centrally obese, 56% had a blood pressure >or=140/90 mmHg (>or=130/80 in people with diabetes mellitus), 51% had a serum total cholesterol >or=4.5 mmol/l and 25% reported a history of diabetes of whom 10% had a fasting plasma glucose less than 6.1 mmol/l and 35% a glycated haemoglobin A1c less than 6.5%. The use of cardioprotective medication was: antiplatelets 91%; beta-blockers 80%; angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers 71%; calcium channel blockers 25% and statins 78%.. The EUROASPIRE III survey shows that large proportions of coronary patients do not achieve the lifestyle, risk factor and therapeutic targets for cardiovascular disease prevention. Wide variations in risk factor prevalences and the use of cardioprotective drug therapies exist between countries. There is still considerable potential throughout Europe to raise standards of preventive care in order to reduce the risk of recurrent disease and death in patients with CHD.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Europe; Female; Guideline Adherence; Health Care Surveys; Healthcare Disparities; Humans; Life Style; Male; Middle Aged; Practice Guidelines as Topic; Practice Patterns, Physicians'; Quality of Health Care; Retrospective Studies; Risk Factors; Risk Reduction Behavior; Secondary Prevention; Treatment Outcome

High-sensitivity C-reactive protein (hsCRP) levels can predict cardiovascular events among apparently healthy individuals and patients with coronary artery disease (CAD). However, hsCRP levels vary among ethnic populations. We previously reported hsCRP levels in Japanese to be much lower than in Western populations. We investigated the prognostic value of hsCRP levels in Japanese patients with stable CAD. The hsCRP levels were measured in 373 Japanese patients who underwent elective coronary angiography and thereafter decided to receive only medical treatment. Patients were followed up for 2.9+/-1.5 years for major cardiovascular events (death, myocardial infarction, unstable angina, stroke, aortic disease, peripheral arterial disease, or heart failure). The median hsCRP level was 0.70 mg/l. During the follow-up, cardiovascular events occurred in 53 (14%) of the 373 patients. Compared with 320 patients without events, 53 with events had higher hsCRP levels (median 1.06 vs. 0.67 mg/l, P<0.05). To clarify the association between hsCRP levels and cardiovascular events, the 373 study patients were divided into tertiles according to hsCRP levels: lower (<0.4 mg/l), middle (0.4-1.2mg/l), and higher (>1.2mg/l). The Kaplan-Meier analysis demonstrated a significant difference in the event-free survival rate between higher vs. middle or lower tertiles (P<0.05). In multivariate Cox regression analysis, the hsCRP level of >1.0mg/l was an independent predictor for cardiovascular events (hazard ratio, 2.0; 95%CI, 1.1-3.4; P<0.05). Thus, in Japanese patients with stable CAD who received only medical treatment, higher hsCRP levels, even >1.0mg/l, were found to be associated with a significantly increased risk for further cardiovascular events.

Topics: Aged; Asian People; Biomarkers; C-Reactive Protein; Cardiovascular Agents; Cohort Studies; Coronary Angiography; Coronary Disease; Disease Progression; Disease-Free Survival; Female; Humans; Inflammation; Inflammation Mediators; Japan; Kaplan-Meier Estimate; Male; Middle Aged; Predictive Value of Tests; Proportional Hazards Models; Risk Assessment; Time Factors; Treatment Outcome; Up-Regulation

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial confirmed that percutaneous coronary intervention is no better than optimal medical therapy for the prevention of major adverse cardiac events in patients with stable angina. The impact of these findings on clinical practice remains unknown.. Clinicians may more frequently opt for medical rather than procedural therapy of stable angina in response to the COURAGE trial.. Clinical information was collected from patients with stable angina referred to our hospital for cardiac catheterization between January 1, 2007 and June 18, 2007 (n = 332). Catheterization referral volume and the use of medications and coronary revascularization were compared before and after the release of the COURAGE trial.. There was a significant increase in anti-ischemia medication use prior to catheterization referral following the COURAGE trial (mean = 1.31 [SD 0.83] medications pre-COURAGE, mean = 1.54 [SD 0.84] medications post-COURAGE, P = 0.012). Among 217 patients with coronary disease on catheterization, treatment with medication rather than percutaneous or surgical revascularization increased after COURAGE (11.1% pre-COURAGE vs 23.0% post-COURAGE, P = 0.03). There was also a significant decrease in referral volume following the COURAGE trial (3.12 referrals/day pre-COURAGE vs 2.51 referrals/day post-COURAGE, P = 0.034).. The COURAGE trial immediately impacted the management of stable angina. Catheterization referral volume decreased, medication use increased, and the use of medical therapy rather than revascularization increased among patients with coronary disease.

Topics: Academic Medical Centers; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Drug Utilization; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Patient Selection; Practice Patterns, Physicians'; Referral and Consultation; Retrospective Studies; Time Factors; Treatment Outcome

Topics: Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Dyslipidemias; Europe; Guidelines as Topic; Humans; Life Style; Risk Factors

Topics: Angina Pectoris; Animals; Blood Flow Velocity; Cardiovascular Agents; Chest Pain; Coronary Circulation; Coronary Disease; Diagnosis, Differential; Humans; Mibefradil; Quality of Life; Randomized Controlled Trials as Topic; Rest; Vasodilator Agents

Slow coronary flow is an angiographic phenomenon characterized by delayed opacification of vessels in the absence of any evidence of obstructive epicardial coronary disease. In this article, we present serious clinical manifestations of extremely slow coronary flow in two hypertensive patients with preserved ejection fraction in echocardiographical examination: a 57 year-old woman with acute coronary syndrome and temporary ST elevation; and a 65 year-old man with atrial tachycardia which was leading to sudden arrest of circulation. The woman was admitted to hospital due to recurrent syncope and chest pain. Because of severe bradycardia, an AAI pacemaker was implanted. Coronary angiography without evident obstructive lesion revealed extremely slow flow of dye through arteries. The man was admitted to hospital because of heart palpitations (paroxysmal atrial tachycardia, PAT) followed by chest pain. During hospitalization, a sudden arrest of circulation in the course of supraventricular tachycardia of 220/min with atrioventricular conduction of 1:1 occurred. Coronary arteriography did not show any occlusions in the coronary arteries, although extremely slow dye flow was seen. Electrophysiological examination revealed arrhythmia of the left atrial (PAT) (tricuspid valve anulus mapping) without induced ventricular arrhythmia. Because of symptomatic bradyarrhythmia, a VVI heart pacemaker was implanted. Over a 12-month observation, his heart rate remained under control, and the patient did not complain of chest pains or heart palpitations.

Topics: Acute Coronary Syndrome; Aged; Angina Pectoris; Blood Flow Velocity; Bradycardia; Cardiac Pacing, Artificial; Cardiovascular Agents; Combined Modality Therapy; Coronary Angiography; Coronary Circulation; Coronary Disease; Drug Therapy, Combination; Electrocardiography; Female; Heart Rate; Humans; Male; Middle Aged; Syncope; Tachycardia, Paroxysmal; Tachycardia, Supraventricular; Treatment Outcome

Topics: Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Family Practice; Germany; Humans; Life Style; Myocardial Revascularization; Physician's Role; Survival Rate; Treatment Outcome

After novel findings from genomewide association studies that sequence variation on chromosome 9p21.3 is a genetic factor for coronary heart disease, we investigated whether this locus influenced the clinical and angiographic outcomes after implantation of drug-eluting stents in coronary arteries.. Recently, genomewide association studies have identified a locus on chromosome 9 (approximately 100 kb in band p21.3) as the strongest genetic factor for coronary heart disease.. We studied the rs7865618, rs1537378, rs1333040, and rs1333049 polymorphisms located on chromosome 9p21.3 in a cohort of 2,028 patients who were treated with percutaneous coronary intervention and implantation of sirolimus- or paclitaxel-eluting stents. Records of 3-year adverse clinical outcomes were obtained from all stented patients. Follow-up angiography at 6 to 8 months after stenting was performed in 1,683 patients (83%).. The polymorphisms were not significantly related with clinical outcomes at 3 years, including death (p >or= 0.18), myocardial infarction (p >or= 0.19), repeat revascularization (p >or= 0.08), and the composite end point of adverse events (death, myocardial infarction, repeat revascularization) (p >or= 0.34). No association of the polymorphisms was found with angiographic measures at follow-up, including minimal lumen diameter (p >or= 0.51), diameter stenosis (p >or= 0.31), late lumen loss (p >or= 0.05), and binary restenosis (p >or= 0.31).. Specific polymorphisms in the chromosome 9p21.3 region that were shown to be associated with coronary heart disease in genomewide analyses were not related to the clinical and angiographic outcomes after the placement of drug-eluting stents in coronary arteries.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chromosomes, Human, Pair 9; Coronary Angiography; Coronary Disease; Coronary Restenosis; Drug-Eluting Stents; Female; Gene Frequency; Genetic Predisposition to Disease; Humans; Logistic Models; Male; Middle Aged; Myocardial Infarction; Paclitaxel; Phenotype; Polymorphism, Single Nucleotide; Proportional Hazards Models; Risk Assessment; Risk Factors; Sirolimus; Thrombosis; Time Factors; Treatment Outcome

Cardiovascular diseases are responsible for disability, quality of life impairment and mortality in the elderly. Although it is efficient, cardiovascular prevention is underused in old individuals. Coronary heart disease can be prevented by antihypertensive agents in old subjects with hypertension, and by statins and antiplatelet agents in high risk subjects. In addition, betablockers and angiotensin converting enzyme inhibitors prevent cardiovascular events in patients with coronary heart disease. Heart failure can also be prevented in the elderly. The treatment of hypertension results in a two-fold decrease in heart failure incidence, even in subjects >80 years. Influenza vaccine reduces the risk of hospital admission for heart failure in old subjects, even in those with no history of cardiac or respiratory diseases. Lifestyle modifications should be encouraged in old individuals, especially smoking cessation, physical activity and mediteranean type diet, because their effects on cardiovascular health seem as positive in the elderly as in younger adults.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Life Style; Risk Factors

Women have a higher morbidity and mortality than men after an acute coronary event. We analyzed the prescription rates of evidence-based pharmacological therapies for patients with stable coronary heart disease and whether there were any differences with respect to gender.. This cross-sectional study evaluated 8817 patients, 26.3% women, receiving attention from 1799 family doctors in primary care centers (PCC) throughout Spain, and who had had a coronary event requiring hospitalization in the previous 6 months to 10 years.. Mean age was 65.4 years and a mean time-lapse since hospitalization of 37.4 months. In the overall population, prescription medications were: antiplatelet drugs in 80.5% of patients, 79% statins, 66% blockers of the angiotensin-renin system (BARS) and 47% beta-blockers. Males received less cardiovascular disease medications than females (4.3+/-1.5 versus 4.6+/-1.6, respectively; p<0.001), but when adjusted for risk factors the significance was lost (p=0.231). Following adjustment for risk factors and for co-morbidities, the use of diuretics was significantly higher in women while beta-blockers and statins were higher in men. The triple combination of antithrombotics, beta-blockers and statins was used in 41.4% (43.8% males versus 34.6% females; p<0.001) while 24.3% used this triple combination plus a BARS; without significant difference between the genders.. An important percentage of patients with stable coronary disease, particularly women, attended-to in primary care do not receive medications that have been shown to decrease the morbido-mortality of cardiovascular disease.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Evidence-Based Medicine; Female; Follow-Up Studies; Humans; Male; Middle Aged; Sex Characteristics

Cardiac rehabilitation (CR) has a pivotal role in the management of patients with coronary heart disease. We aimed to describe temporal trends and centre variances of patient characteristics, drug prescriptions, and risk-factor management of in-patients in inpatient CR in Germany.. Data on 117 983 inpatients in CR, obtained from two large-scale registries (Transparency Registry to Objectify Guideline-Oriented Risk-Factor Management and Registry of Guidelines) were pooled resulting in a database of six yearly cross-sectional samples, repeated over centres. For each response variable, a three-level mixed model (patients within years within centres) shifted to the data. Statistical tests were performed on average time trends over groups, average group levels over years, and on parallelism of trends within groups.. Compared with patients in CR in 2000, patients in CR in 2005 were significantly older and had a higher BMI. They, however, also showed improved control over blood pressure, lipids, and glucose at the beginning of rehabilitation; their use of angiotensin-converting enzyme inhibitors and beta-blockers had increased; whereas their use of statin and acetylsalicylic acid remained relatively stable. At discharge, no changes were noted for blood pressure and glucose--at a high target-level attainment of more than 80%. Lipid values, however, tended to improve over time, with an increase in target-level attainment from 45 to 55%. Large centre effects were noted for age, total cholesterol at entry, and exercise capacity at entry and discharge. In general, sex differences were limited.. Compared with previous findings, general management of risk factors before initiation of CR, as well as control over lipid, hypertension, and glucose levels at discharge from CR, have improved over time: this is probably due to more intensive drug treatment.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Female; Germany; Hospitalization; Humans; Hypolipidemic Agents; Male; Middle Aged; Registries; Rehabilitation Centers; Risk Factors; Treatment Outcome

Topics: Anti-Inflammatory Agents; Biomarkers; C-Reactive Protein; Cardiovascular Agents; Coronary Disease; Humans; Incidence; Inflammation; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Time Factors; Up-Regulation

Topics: Angioplasty, Balloon, Coronary; Anticholesteremic Agents; Azetidines; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Coronary Stenosis; Death, Sudden, Cardiac; Ezetimibe; Humans; Kaplan-Meier Estimate; Life Style; Multicenter Studies as Topic; Myocardial Infarction; Outcome and Process Assessment, Health Care; Randomized Controlled Trials as Topic; Simvastatin

Some studies show coronary heart disease (CHD) to be a risk factor for cognitive function while others report no association between the two. We examined the effect of CHD history and duration on cognition in a middle-aged population.. Data come from the Whitehall II study of 10,308 participants (33% women), aged 35-55 years at baseline (Phase 1; 1985-88). CHD events were assessed up to Phase 7 (2002-04) when 5837 participants (28.4% women) undertook six cognitive tests: reasoning, vocabulary, phonemic and semantic fluency, memory and the mini-mental-state-examination (MMSE); standardized to T-scores (mean = 50, standard deviation = 10). Analysis of covariance was used first to model the association between CHD history and cognition and then to examine the effect of time since first CHD event (in the last 5 years, 5-10 years ago, >10 years ago). Among men, in analyses adjusted for age, education, marital status and medication for cardiovascular disease, CHD history was associated with lower T-scores on reasoning [-1.16; 95% confidence interval (CI) = -2.07, -0.25], vocabulary (-2.11; 95% CI = -3.01, -1.21), and the MMSE (-1.45; 95% CI = -2.42, -0.49). In women, these effects were also evident for phonemic and semantic fluency. Among men, the trend within CHD cases suggested progressively lower scores on reasoning, vocabulary and semantic fluency among those with longer duration of CHD.. Our findings go some way towards suggesting an association between CHD history and cognitive performance in middle-aged adults.

Topics: Adult; Age Factors; Analysis of Variance; Cardiovascular Agents; Cognition Disorders; Coronary Disease; Educational Status; Female; Humans; Male; Marital Status; Middle Aged; Risk Factors

Topics: 1-Alkyl-2-acetylglycerophosphocholine Esterase; Anti-Inflammatory Agents; Benzaldehydes; Cardiovascular Agents; Coronary Disease; Enzyme Inhibitors; Humans; Oximes

Secondary prevention in patients with coronary heart disease includes treatment with platelet inhibitors, beta-blockers, ACE inhibitors or AT (1)-blockers, and statins. Initiation of therapy generally does not require a slow gradual dose increase. In treatment naive patients with acute coronary syndromes, administration of a loading dose of aspirin and/or clopidogrel is recommended. To reduce flushing, nicotinic acid should be initiated at low stepwise increasing dosages. beta-blocker therapy should not be stopped acutely in coronary heart disease patients. If beta-blocker therapy has to be terminated, blood pressure should be monitored closely and, if necessary controlled with other medication. Termination of statin therapy in the acute phase after strokes or acute coronary syndromes is associated with increased cardiovascular events and should therefore be avoided.

Topics: Adrenergic beta-Antagonists; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Anticholesteremic Agents; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Therapy, Combination; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypercholesterolemia; Platelet Aggregation Inhibitors; Substance Withdrawal Syndrome

Heartwatch, a secondary prevention programme in primary care was initiated in 2003, based on the second European Joint Task Force recommendations for secondary prevention of coronary heart disease (CHD). The aim was to examine the effect of the first 2 years of the Heartwatch programme on cardiovascular risk factors and treatments.. Prospective cohort study of patients with established CHD enrolled into the Heartwatch programme.. Four hundred and seventy (20%) general practitioners nationwide participated in the programme, recruiting 11,542 patients with established CHD (earlier myocardial infarction, coronary intervention or coronary artery bypass surgery). Clinical data were electronically transferred by each general practitioner to a central database. Comparison of changes in risk factors and treatments at 1-year and 2-year follow-up from baseline were made using paired t-test for continuous and McNemar's test for categorical data.. Statistically significant changes in systolic blood pressure, diastolic blood pressure, total and low-density lipoprotien cholesterol and smoking status at 1 and 2 years (P <0.0001) were observed. Little or no improvements were shown for exercise, BMI or waist circumference. Increases in the prescribing of statins, angiotensin-converting enzyme inhibitors and beta-blockers over the course of the study were observed.. The Heartwatch programme has demonstrated significant improvements in the main risk factors and treatments for CHD. More effective interventions are required to reduce BMI, waist circumference and physical inactivity in this population. The increases in treatment uptake are approaching the optimal levels in this population.

Topics: Adrenergic beta-Antagonists; Aged; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Cardiovascular Agents; Coronary Disease; Databases as Topic; Diabetes Complications; Dyslipidemias; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypertension; Hypoglycemic Agents; Ireland; Male; Medical Records Systems, Computerized; Middle Aged; Obesity; Primary Health Care; Program Evaluation; Prospective Studies; Risk Factors; Secondary Prevention; Smoking; Smoking Cessation; Smoking Prevention; Time Factors; Treatment Outcome

Ranolazine is a piperazine derivative believed to reduce anginal symptoms by preventing ischemia-mediated sodium and calcium overload in myocardial cells through inhibition of the late sodium current (late INa). Three small studies demonstrated the antianginal efficacy of ranolazine alone and in combination with betablockers or calcium channel blockers on conventional end points such as total exercise duration and time to ischemia/angina on a treadmill; however, questions of safety related to QT prolongation, efficacy in women and potential utility in higher risk populations remained. Metabolic Efficiency with Ranolazine for Less Ischemia in Non-ST Elevation Acute Coronary Syndromes-Thrombolysis in Myocardial Infarction (MERLIN-TIMI) 36 was a large randomized, double-blind, placebo-controlled trial, which evaluated the efficacy and safety of ranolazine initiated acutely and continued as chronic therapy following a non-ST-segment elevation acute coronary syndrome event. A total of 6560 patients were randomized 1:1 to ranolazine or placebo; the primary efficacy end point of the trial was a composite of cardiovascular death, myocardial infarction or recurrent ischemia. The key safety end points were death from any cause and symptomatic documented arrhythmia. Although statistically significant differences between the ranolazine and placebo groups were not reached in the primary efficacy analysis or in the major secondary outcome end point analyses (cardiovascular death, myocardial infarction or severe recurrent ischemia), the individual component of recurrent ischemia was significantly reduced by ranolazine, and ranolazine was demonstrated to be safe.

Topics: Acetanilides; Acute Coronary Syndrome; Acute Disease; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Double-Blind Method; Drug Therapy, Combination; Enzyme Inhibitors; Female; Humans; Male; Middle Aged; Myocardial Infarction; Piperazines; Quality of Life; Randomized Controlled Trials as Topic; Ranolazine; Recurrence; Sex Factors; Thrombolytic Therapy

The following comment provides another perspective on the COURAGE Trial. A prior Editorial on this subject was by Franklin (Franklin BA. Lessons learned from the COURAGE Trial: generalizability, limitations, and implications. Prev Cardiol. 2007;10(3):117-120.).-Ezra A. Amsterdam, MD, Editor in Chief.

Topics: Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Humans; Randomized Controlled Trials as Topic

Topics: Cardiovascular Agents; Coronary Disease; Hospitalization; Humans; India; Registries; Risk Factors; Smoking; Smoking Prevention

The first results of a big Russian multicenter study " RELIF - Regular treatment and prevention - the key of improvement of the situation with cardiovascular diseases in Russia " are presented. The study examines the accordance of arterial hypertension (AH) and coronary heart disease (CHD) treatment recommended by physicians to contemporary standards. Patients adherence to physicians recommendations is also studied. 512 general practitioners and 2517 patients with AH and CHD from 20 cities of Russia were included. In the present article the current situation with medical treatment of AH, isolated or in comorbidity with CHD is presented.

Topics: Cardiovascular Agents; Coronary Disease; Follow-Up Studies; Humans; Hypertension; Morbidity; Patient Compliance; Prognosis; Retrospective Studies; Russia

Predictors of cardiac events and restenosis after sirolimus-eluting stent (SES) implantation in small coronary arteries were evaluated.. Although SES implantation has markedly reduced the risk of restenosis, small vessel disease remains a major cause of SES failure.. We prospectively investigated the factors predictive of cardiac events and restenosis in 1,092 consecutive patients who received SES implantation for 1,269 lesions in small coronary arteries (< or = 2.8 mm). Follow-up angiography at 6 months was performed in 751 patients with 889 lesions (follow-up rate 70.3%).. Restenosis (diameter stenosis > or = 50%) was angiographically documented in 65 patients with 77 lesions (8.7%): 55 focal (71.4%), 8 diffuse (10.4%), 2 diffuse proliferative (2.6%), and 12 total (15.6%). Lesion length, stent length, reference artery size, and in-stent restenotic lesions were univariate predictors of restenosis. By multivariate analysis, lesion length (OR 1.04; 95% CI 1.02-1.05; P < 0.001) and in-stent restenotic lesions (OR 3.38; 95% CI 1.80-6.35; P < 0.001) were significant independent predictors of restenosis. During follow-up (23.2 +/- 7.9 months), there were 17 deaths (5 cardiac and 12 noncardiac), 5 nonfatal Q-wave myocardial infarctions, and 42 target lesion revascularizations. The cumulative probability of survival without major adverse cardiac events (MACE) was (96.6 +/- 0.6)% at 1 year and (95.1 +/- 0.7)% at 2 years. In multivariate analysis, lesion length (HR 1.04; 95% CI 1.01-1.07; P = 0.004) and in-stent restenotic lesions (HR 3.29; 95% CI 1.58-6.86; P = 0.001) were independently related to MACE.. SES implantation in small coronary arteries is safe and effective, with lesion length having a major impact on restenosis and MACE.

Topics: Adult; Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Restenosis; Coronary Stenosis; Coronary Vessels; Female; Follow-Up Studies; Humans; Male; Middle Aged; Odds Ratio; Predictive Value of Tests; Prospective Studies; Risk Assessment; Risk Factors; Sirolimus; Stents; Time Factors; Treatment Outcome

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Coronary Artery Bypass; Coronary Disease; Endpoint Determination; Follow-Up Studies; Humans; Myocardial Infarction; Prognosis; Research Design; Sample Size; Stents; Treatment Outcome

Until recently, for many people dying from a myocardial infarction was an inevitable fate. Myocardial infarction mortality rates have decreased drastically. At the same time, stents have clearly secured coronary angioplasties, removing the problems linked to coronary dissections such as abrupt closure or emergency coronary bypass. The iatrogenic risks have increased on account of the use of sophisticated techniques, powerful medications or the treatment of older patients. On the one hand, the media have informed people about the tremendous improvements in cardiology, however, on the other hand they have also given them over-optimistic expectations leading to an increase in the number of physicians sued. Now, physicians have to master ever more complex parameters such as new examination techniques prescriptions and interpretation (CT-scanner, MRI) and new medications. In order to prevent lawsuits, physicians should educate and inform their patients. To increase their chances in case of a lawsuit, physicians should improve the traceability of the treatment prescribed and information given to patients, but also make patients assume their responsibilities when they are reluctant to follow medical advices or treatments.

Topics: Age Factors; Cardiovascular Agents; Coronary Disease; Humans; Iatrogenic Disease; Informed Consent; Liability, Legal; Medical Errors; Medical Laboratory Science; Myocardial Infarction; Patient Education as Topic; Patient Participation; Risk Factors

Topics: Aged; Cardiomyopathy, Dilated; Cardiovascular Agents; Chronic Disease; Coronary Disease; Disease Progression; Drug Therapy, Combination; Dyspnea; Fatal Outcome; Heart Failure; Humans; Leukemia, Lymphoid; Male; Myocardial Stunning; Pleural Effusion

Since the introduction of drug-eluting stents (DESs), patterns of revascularization strategies for patients with non-ST-segment elevation acute coronary syndromes have not been assessed. We studied 82,924 patients from the CRUSADE Initiative who presented with non-ST-segment elevation acute coronary syndromes and underwent coronary angiography at 365 United States hospitals that had capabilities for surgical (coronary artery bypass grafting [CABG]) and percutaneous (percutaneous coronary intervention [PCI]) revascularization from January 2002 to June 2005. Temporal trends in the use of PCI, CABG, and medical management without revascularization were analyzed with respect to the introduction of DESs. In total, 73,577 patients (89%) had >50% stenosis in > or =1 coronary artery, and there was a significant increase in the use of PCI (vs CABG or medical management without revascularization) during the study period (38.3% vs 52.5%). By quarter 2 of 2005, 80% of patients who underwent PCI received a DES. In total, 18,462 of 25,068 patients (73.6%) with 3-vessel disease (3VD) underwent revascularization and use of CABG decreased for these patients (48.9% to 39.9%, p <0.001), whereas use of PCI increased (51.1% to 60.1%, p <0.001). Factors significantly associated with use of PCI for patients with 3VD who underwent any revascularization included previous PCI, previous CABG, cardiology inpatient care, care at an academic hospital, renal insufficiency, and previous congestive heart failure. In conclusion, coinciding with the introduction of DESs, there has been a significant increase in the use of PCI and, in those patients with 3VD, a decrease in the use of CABG with a shift toward increasing use of PCI. Long-term implications of this shift remain uncertain, especially in patients with 3VD.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Databases, Factual; Female; Humans; Male; Middle Aged; Patient Selection; Retrospective Studies; Risk Factors; Stents; Syndrome; United States

Topics: Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Coronary Restenosis; Drug Delivery Systems; Humans; Prosthesis Design; Stents

To compare the postprocedural and long-term clinical outcomes of two groups of patients, all presenting with chronic saphenous vein graft (SVG) occlusion, who underwent either SVG or native vessel reopening.. Chronic total occlusions (CTO) treatment in patients who underwent previous surgical revascularization is a dilemma and the choice of performing native vessel or SVG recanalization is not always easy.. Between July 2002 and October 2004, a total of 260 patients were successfully treated for a CTO. Of them, we selected all patients (n = 24) who had previous bypass surgery with graft occlusion. Of this final group, 13 patients underwent a percutaneous graft recanalization while 11 underwent native vessel reopening.. Primary end points were in-hospital and 3-year rates of death, myocardial infarction, target lesion revascularization, and target vessel revascularization. No events occurred in either group during the in-hospital period. Cumulative 3-year event-free survival in the native vessel and SVG group was 81.8% and 83.9% respectively (P = NS). One death and one TVR occurred in each group.. In selected cases, SVG reopening instead of the native vessel is feasible. In such a high-risk population, drug-eluting stent implantation in both SVG and native CTO lesions is associated with good long-term outcomes.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Coronary Artery Bypass; Coronary Disease; Feasibility Studies; Female; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Male; Middle Aged; Myocardial Infarction; Prosthesis Design; Retrospective Studies; Saphenous Vein; Stents; Time Factors; Treatment Outcome

The purpose of this study was to determine whether hemodynamic and pharmacologic factors can influence the extent and severity of myocardial necrosis produced by coronary occlusion. In 48 dogs, 10 to 14 epicardial leads were recorded on the anterior surface of the left ventricle in the distribution and vicinity of the site of occlusion of a branch of the left anterior descending coronary artery. The average S-T segment elevation for each animal was determined at 5-min intervals after occlusion. This elevation was used as an index of the presence and severity of myocardial ischemic injury. Isoproterenol, ouabain, glucagon, bretylium, and tachycardia given prior to a repeated occlusion each increased the severity and extent of ischemic injury, while propranolol decreased it. Elevation of arterial pressure with methoxamine reduced the occlusion-induced S-T segment elevation, and lowering of the mean arterial pressure by hemorrhage had the opposite effect. In 19 additional experiments, propranolol, isoproterenol, and alterations in arterial pressure produced similar alterations in S-T segment elevation when these interventions were applied as long as 3 hr after ligation. Myocardial creatine phosphokinase (CPK) activity determined 24 hr after coronary artery ligation correlated well with S-T segment elevation at the same sites recorded 15 min after ligation. Moreover, isoproterenol increased and propranolol decreased the area of depression of myocardial CPK activity. We conclude that the hemodynamic status and neurohumoral background at the time of coronary occlusion and for at least 3 hr thereafter can alter the extent and severity of myocardial ischemic injury and myocardial necrosis.

Topics: Anesthesiology; Animals; Atorvastatin; Blood Pressure; Cardiovascular Agents; Coronary Disease; Dogs; Heart Diseases; Heart Rate; Heptanoic Acids; History, 20th Century; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Myocardial Ischemia; Myocardial Revascularization; Necrosis; Oxygen; Pyrroles

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Humans; Life Style; Myocardial Infarction; Randomized Controlled Trials as Topic

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Cost-Benefit Analysis; Humans; Patient Selection; Practice Guidelines as Topic; Stents; Treatment Outcome

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiac Catheterization; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Coronary Stenosis; Cost-Benefit Analysis; Humans; Myocardial Infarction; Quality-Adjusted Life Years; Stents

The dramatic development of modern medicine on patho physiology, diagnosis and therapeutic technique of coronary heart disease (CHD) has brought great challenge to the position of traditional Chinese medicine (TCM) and integrative Chinese and Western medicine (ICWM) in preventing and treating cardiovascular diseases. Although great progress has been achieved recently in this field, many difficulties and problems still remain unresolved. Countermeasures and prospects were put forward in this article.

Topics: Cardiovascular Agents; Coronary Disease; Diagnosis, Differential; Drug Therapy, Combination; Drugs, Chinese Herbal; Humans; Medicine, Chinese Traditional; Phytotherapy

Combination therapy to reduce risk factors is effective in preventing recurrent cardiovascular disease events in patients with coronary heart disease (CHD), but medications need to be continued indefinitely to maximize the benefits.. To evaluate the extent of long-term continuation with cardiovascular drug therapy and its expected impact on the prevention of CHD.. We studied 242 patients with CHD who underwent percutaneous coronary intervention following an acute coronary syndrome over a 6 month period in 2004. We prospectively examined the extent to which specific drugs and drug combinations were continued over time by reviewing medication use at the time of hospital discharge and after 2 years. The results were used to estimate the expected loss in preventive efficacy due to discontinuation of therapy.. The changes over a 2 year period in the proportions of patients taking each drug class were as follows: 15% reduction for aspirin (95% CI, -21 to -9), 10% reduction for statins (95% CI, -16 to -5), 19% reduction for angiotensin-converting enzyme inhibitors (95% CI, -26 to -12), 12% reduction for beta-blockers (95% CI, -18 to -6), 0% increase for calcium-channel blockers (95% CI, -5 to 6), 2% increase for thiazides (95% CI, -2 to 6), and 12% increase for angiotensin-II receptor blockers (95% CI, 6 to 18). The combination of aspirin, statin, and at least 2 blood pressure lowering drugs was prescribed to 81% of patients, three-quarters of whom remained on this combination after 2 years. The overall expected preventive effect on CHD of the combined medication taken during hospitalization and after 2 years was 80% and 74%, respectively.. In patients with CHD, long-term continuation of combination cardiovascular drug therapy is considerably greater than generally perceived.

Topics: Cardiovascular Agents; Coronary Disease; Female; Humans; Male; Middle Aged; Patient Discharge; Prospective Studies; Retrospective Studies; Time

Topics: Cardiology; Cardiovascular Agents; Coronary Disease; Cost-Benefit Analysis; Germany; Health Policy; Humans; Risk Factors

Chronic heart failure (CHF) in patients with diabetes mellitus (DM) is a condition that is frequent and has a poor prognosis. Diabetes mellitus is an independent risk factor for CHF and vice versa. CHF is found in 10-15% of the patients with DM compared to 3% in individuals without DM. Apart from CHD and hypertension, hyperglycaemia and insulin resistance are directly linked to the development of diastolic dysfunction and to CHF. According to the stepwise diagnostic procedure recommended by the ESC in its guidelines from 2005, if heart failure is suspected, the disease should first be diagnosed by ECG, X-ray, or testing for natriuretic peptide and followed by echocardiography when test results are abnormal. Treatment of CHF in patients with diabetes mellitus is the same as that for nondiabetic patients and includes the use of ACEIs, ARBSs (as an alternative to or in combination with ACEIs), BBs, diuretics (in particular loop diuretics), aldosterone inhibitors and digitalis. Most importantly, meticulous glucose control is a must in patients with diabetes mellitus and CHF to improve prognosis. Contraindications for antidiabetic drugs such as glitazones for CHF-NYHA classes I-IV and metformin for NYHA classes III-IV need to be considered in patients with CHF and diabetes mellitus.

Topics: Cardiomyopathies; Cardiovascular Agents; Coronary Disease; Diabetes Complications; Diabetic Angiopathies; Heart Failure; Humans; Hypoglycemic Agents; Prognosis; Risk Factors

North Kirklees, an urban area in the East of England, known to have a 6.8 percent incidence of Coronary Heart Disease (CHD), embarked on a nurse-led CHD primary prevention service in order to improve residents' health. This paper seeks to investigate this serice.. Keen to utilise the principles of performance management, the team applied the European Foundation for Quality Management (EFQM) Excellence Model RADAR logic believing that it would strengthen their "results orientation". This paper investigates the results.. Using RADAR, the team identified baseline data for CHD health indicators. The teams were then equipped to set targets for continuous improvement, thereby increasing their potential to progress local residents' health. The case-study findings enable others to adopt a similar approach in their pursuit of excellence.. The CHD Primary Prevention team focused only on performance results in the first instance and did not look at other EFQM Excellence Model results areas.. The paper describes an original case study into how nurses applied RADAR, which gives insight into the team's experiences during their 18-month journey.

Topics: Cardiovascular Agents; Coronary Disease; Health Behavior; Humans; Nurses; Patient Satisfaction; Primary Health Care; Primary Prevention; Program Development; Program Evaluation; Quality Assurance, Health Care; Risk Factors

This study was conducted to reevaluate the significance of angiographic late loss and to assess the agreement between new proposed neointimal volumetric measurements derived from quantitative coronary angiography (QCA) and standard intravascular ultrasound (IVUS)-based parameters. Neointimal volumetric measurements may better estimate the magnitude of neointimal growth after stenting than late loss. In 56 in-stent segments (27, everolimus; 29, bare metal) in the SPIRIT FIRST study, we compared QCA measures with the corresponding IVUS parameters. Two IVUS-late loss models were derived from minimal luminal diameter (MLD) using either a circular model or a so-called projected MLD. QCA-neointimal volume was calculated as follows: stent volume (mean area of the stented segment x stent length) at post procedure - lumen volume (mean area of the stented segment x stent length) at follow-up (the stent length either from nominal stent length or the length measured by QCA). Videodensitometric neointimal volume was also evaluated. Each of the three neointimal volume and percentage volume obstruction by QCA showed significant correlation with the corresponding IVUS parameters (r = 0.557-0.594, P < 0.0001), albeit with a broad range of limits of agreement. Late loss and volumetric measurements by QCA had a broader range of standard deviation than those by IVUS. QCA-volumetric measurements successfully confirmed the efficacy of everolimus-eluting stents over bare metal stents (P < 0.05). Our proposed QCA volumetric measurements may be a practical surrogate for IVUS measurements and a discriminant methodological approach for assessment of treatment effects of drug-eluting stents.

Topics: Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Restenosis; Drug Delivery Systems; Everolimus; Female; Humans; Linear Models; Male; Randomized Controlled Trials as Topic; Sirolimus; Stents; Tunica Intima; Ultrasonography, Interventional

Topics: Academies and Institutes; Cardiology; Cardiovascular Agents; Coronary Disease; Germany; Humans; Legislation, Medical; Stents

The DETECT study was performed to obtain representative data about the frequency, distribution, and treatment of patients with coronary artery disease (CAD) in the primary care setting in Germany.. The DETECT study was a cross-sectional clinical- epidemiological survey of a nationally representative sample of 3795 primary care offices and 55,518 patients. Overall, 12.4% of patients were diagnosed with CAD. Stable angina pectoris and myocardial infarction were the most frequent (4.2%) subgroups, followed by status post (s/p) percutaneous coronary interventions (PCI, 3.0%) and s/p coronary bypass surgery (2.2%). Patients with CAD were prescribed AT1 receptor antagonists (in 19.4% of cases), beta blockers (57.2%), ACE inhibitors (49.9%), antiplatelet agents (52.7%), statins (43.0%), and long-term nitrates (24.5%). When comparing all CAD patients with social health care insurance to those who had private insurance, private patients had significantly higher rates of revascularisation procedures and use of preventive medications.. Great potential remains for improving secondary prevention in primary care in Germany to reduce the risk of further coronary or vascular events, especially in patients with social health care insurance.

Topics: Adolescent; Adult; Aged; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Female; Follow-Up Studies; Germany; Humans; Male; Middle Aged; Myocardial Revascularization; Outcome Assessment, Health Care; Physicians, Family; Prevalence; Prospective Studies

This study sought to analyze the cost of percutaneous coronary interventions with use of sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) in patients at high risk of restenosis.. Recent studies have shown different clinical efficacy with these drug-eluting stents. Whether this difference extends on cost estimates between the 2 stents is not known.. We included 450 patients with diabetes mellitus and in-stent restenosis from 2 randomized studies comparing SES with PES. Assigned costs for the economic evaluation were the initial hospitalization and all subsequent cardiac-related inpatient/outpatient health resources during 9 to 12 months of clinical follow-up. The economic evaluation was performed from the health insurance system's perspective.. There were no differences between the 2 study groups regarding mortality (p = 0.78) and myocardial infarction rates (p = 0.76). Target lesion revascularization was performed in 16 patients (7.1%) in the SES group and in 34 patients (15.1%) in the PES group (p = 0.01). Initial hospital costs were not significantly different between the 2 stents (p = 0.53). The follow-up costs were, however, different: 2,684 +/- 2,072 euros per patient treated with SES and 4,527 +/- 6,466 euros per patient treated with PES (p < 0.001). Total costs also differed at the end of the follow-up: 8,924 +/- 3,077 euros per patient treated with SES and 10,903 +/- 7,205 euros per patient treated with PES (p < 0.001).. In patients at high risk of restenosis, use of SES is associated with lower costs compared with PES. The cost savings are mainly due to the reduced need of repeat revascularization procedures with SES.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Coronary Restenosis; Cost Savings; Costs and Cost Analysis; Diabetic Angiopathies; Female; Germany; Health Services; Hospital Costs; Hospitalization; Humans; Male; Middle Aged; Paclitaxel; Randomized Controlled Trials as Topic; Sirolimus

This study sought to compare aggregate medical care costs for patients undergoing percutaneous coronary intervention with paclitaxel-eluting stents (PES) and bare-metal stents (BMS) and to formally evaluate the incremental cost effectiveness of PES for patients undergoing single-vessel percutaneous coronary intervention.. Although the cost effectiveness of SES has been studied in both clinical trials and decision-analytic models, few data exist on the cost effectiveness of alternative drug-eluting stent (DES) designs. In addition, no clinical trials have specifically examined the cost effectiveness of DES among patients managed without mandatory angiographic follow-up.. We performed a prospective economic evaluation among 1,314 patients undergoing percutaneous coronary revascularization randomized to either PES (N = 662) or BMS (N = 652) in the TAXUS-IV trial. Clinical outcomes, resource use, and costs (from a societal perspective) were assessed prospectively for all patients over a 1-year follow-up period. Cost effectiveness was defined as the incremental cost per target vessel revascularization (TVR) event avoided and was analyzed separately among cohorts assigned to mandatory angiographic follow-up (n = 732) or clinical follow-up alone (n = 582).. The PES reduced TVR by 12.2 events per 100 patients treated, resulting in a 1-year cost difference of 572 dollars per patient with incremental cost-effectiveness ratios of 4,678 dollars per TVR avoided and 47,798 dollars/quality-adjusted life year (QALY) gained. Among patients assigned to clinical follow-up alone, the net 1-year cost difference was 97 dollars per patient with cost-effectiveness ratios of 760 dollars per TVR event avoided and $5,105/QALY gained.. In the TAXUS-IV trial, treatment with PES led to substantial reductions in the need for repeat revascularization while increasing 1-year costs only modestly. The cost-effectiveness ratio for PES in the study population compares reasonably with that for other treatments that reduce coronary restenosis, including alternative drug-eluting stent platforms.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Cost-Benefit Analysis; Double-Blind Method; Female; Health Care Costs; Health Services; Humans; Male; Middle Aged; Paclitaxel; Prospective Studies; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Retreatment; Stents; Treatment Outcome; United States

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Cost Savings; Cost Sharing; Cost-Benefit Analysis; Economics, Hospital; Health Care Costs; Humans; Medicare; Paclitaxel; Stents; United States

To determine patterns and outcomes of drug-eluting stents (DES) use in clinical practice.. DES are technology associated with superior outcomes. The initial limited availability and high cost of DES had the potential to influence their use.. Data from the American College of Cardiology-National Cardiovascular Data Registry were examined to describe the patterns of DES use in 408,033 percutaneous coronary intervention (PCI) procedures at 383 sites. Predictors of DES use were determined, and inhospital outcomes were examined.. From April 2003 through December 2004, the proportion of procedures using DES increased from 19.7% to 78.2%. DES use increased across all patient groups and hospital types, but adoption was slower among older patients and those without health insurance. DES use varied among hospitals such that use was lower at rural and low-volume hospitals. Multivariable regression demonstrated a progressive decrease in the odds of DES use as age increased. White race, female sex, presence of insurance, diabetes mellitus, PCI of de novo lesion, PCI at a high volume center, and PCI at a suburban hospital were significant predictors of DES use. The availability of a second DES product did not influence the adoption patterns. Inhospital outcomes with DES were excellent.. Access to DES was influenced by demographic, socioeconomic, and hospital characteristics. Further study is needed to determine if the availability of another DES platform or increased overall availability of DES impacts favorably on PCI practice patterns.

Topics: Adult; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Coronary Restenosis; Coronary Stenosis; Drug Delivery Systems; Female; Hospital Mortality; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Outcome Assessment, Health Care; Registries; Stents; Survival Analysis

Topics: Cardiovascular Agents; Cause of Death; Coronary Disease; Humans; Peripheral Vascular Diseases

Diabetic patients have a higher rate of recurrent cardiovascular events and death than nondiabetic individuals. Although partially attributable to lower use of evidence-based preventive therapies, studies are lacking on the prescription rate during the stable phase of the disease.. Between June 1 and October 19, 2004, we obtained, from 1799 primary care centers throughout Spain, data on 8817 subjects (mean age 65.4 years, 73.7% male, 32.7% with diabetes) who had had a coronary event requiring hospitalization in the previous 6 months to 10 years.. After adjustment for confounding variables, the diabetic patients received more frequent treatment with angiotensin-renin system blockers (73.5% vs 61%, P < .001), calcium channel blockers (29.8% vs 21.9%, P < .001), nitrates (58% vs 47.5%, P < .001), digoxin (6.6% vs 3.9%, P < .001), and diuretics (46.2% vs 32.2%, P < .001), but it is similar with respect to lipid-lowering drugs (81.1% vs 80.3%), antiplatelet drugs (80.2% vs 80.2%), or beta-blockers (45.4% vs 47.7%). The percentage of diabetic subjects attaining objectives for smoking habit, low-density lipoprotein cholesterol, blood pressure, and glycated hemoglobin were 90.7%, 29%, 38.2%, and 49.7%, respectively. Only 7% had optimum control of all their risk factors. The parameters most closely related to optimum treatment and risk-factor control were the specialist follow-up and the attending physician's awareness of appropriate treatment objectives.. A significant percentage of diabetic patients with stable coronary disease receive evidence-based preventive medications in primary care. However, the percentage achieving adequate control of their risk factors is low and is related to the level of physician awareness of appropriate therapeutic targets.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Diabetic Angiopathies; Drug Prescriptions; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Primary Health Care; Risk Factors; Treatment Outcome

Topics: Cardiovascular Agents; Coronary Disease; Developing Countries; Drug Costs; Humans; India

There is a limited amount of literature examining the burden and cost of illness of acute coronary syndrome (ACS) in the managed care population. The goal of this study was to estimate the total cost of health care utilization (health plan plus patient) in the 12-month period following newly onset ACS. The demographic and health characteristics of these patients are compared with the similar data from 2 large clinical trials: CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) and PROVE IT-TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy--Thrombolysis in Myocardial Infarction 22).. A retrospective claims analysis was conducted for the 2-year period from July 1, 1999, through June 30, 2001. ACS was defined as an emergency room visit or hospitalization with a primary International Classification of Diseases, 9th Edition/Revision (ICD-9) diagnosis of 410.xx (acute myocardial infarction) or 411.1x (intermediate coronary syndrome). Patients were required to be free of any ACS claim in the previous 6 months. Patients without 6 months of prior continuous enrollment or those patients younger than 18 years were excluded. Patients were followed up to 12 months to identify total medical and pharmacy costs, revascularization procedures, and medication use.. A total of 13,731 patients met the inclusion criteria, yielding 133,814 months of follow-up (mean: 9.75 months per patient) and representing approximately 0.4% of the managed care members in the database during the study period. The mean age was 54 years and 68% were male. The total direct cost incurred by the health plan and patients was dollar 309 million (dollar 2,312 per patient-month of follow-up); 72% of total costs were attributable to hospitalizations. The majority of costs were medical (dollar 286 million, 93%), and dollar 23 million (7%) were pharmacy costs. Fifty-one percent of patients had a revascularization procedure, which was typically performed during the index hospitalization (median time to revascularization was 0 days). Coronary artery stent implantation was the most common revascularization procedure (68%). During follow-up, 490 patients (3.6%) had a detectable death, 58% of patients received a beta-blocker, 60% received one or more cholesterol-lowering medications, and 36% of patients received clopidogrel therapy. Aspirin therapy was not measured.. These managed-care patients with newly onset ACS incurred substantial costs in the 12 months following initial presentation. Revascularization was a common therapeutic intervention for these patients. There appear to be opportunities to improve medication therapy after an acute ACS event. There were some demographic and health characteristics that were different in these commercially insured patients from those in 2 large clinical trials.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Disease; Cost of Illness; Female; Health Services; Humans; Male; Managed Care Programs; Middle Aged; Myocardial Revascularization; Retrospective Studies

Topics: Amlodipine; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Blood Pressure; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Echocardiography; Enalapril; Humans; Middle Aged; Patient Selection; Randomized Controlled Trials as Topic; Risk Factors; Vasodilator Agents

Topics: Adrenergic beta-Antagonists; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Cause of Death; Combined Modality Therapy; Comorbidity; Coronary Disease; Drug Interactions; Exercise; Heart Failure; Hospital Mortality; Humans; Metabolic Clearance Rate; Practice Guidelines as Topic; Risk Factors; Stents

Topics: Arrhythmias, Cardiac; Cardiac Surgical Procedures; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Myocardial Infarction

Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes.. Patients were stratified by CKD stage using creatinine clearance (CrCl, ml/min) estimated by the modified MDRD equation using baseline core laboratory creatinine measures. Serum creatinine > or =1.5 mg/dl was an exclusion criterion for the SYMPHONY trials. Baseline characteristics and outcomes across CKD categories were compared and Cox proportional hazards regression was used to assess the relationship of renal insufficiency with clinical outcomes after adjusting for previously identified outcome predictors. Interactions between the use of specific medications and calculated CrCl were tested in the final Cox proportional hazards model predicting time to mortality.. Of 13 707 patients analysed, 6840 had CKD stage I (CrCl > or =90 ml/min), 5909 stage II (CrCl 60-89 ml/min), 955 stage III (CrCl 30-59 ml/min) and three stage IV (CrCl <30 ml/min). Patients with more advanced CKD (III) were older, more often female, non-smokers and more likely to have co-morbid diseases including diabetes mellitus, hypertension and congestive heart failure. Cardiovascular medications were used less frequently in patients with CKD. Unadjusted survival was poorer in patients with CKD stages > or =II. In adjusted analyses, for those with CrCl < or =91, each 10 ml/min increase in CrCl was associated with a significantly decreased risk of mortality (hazards ratio 0.897, 95% confidence interval 0.815-0.986) (P = 0.024). The interaction between use of angiotensin-converting enzyme (ACE) inhibitors and CrCl was significantly associated with outcomes; the benefit of drug therapy was greater among patients with CKD.. CKD is an independent predictor of risk among ACS patients, and is associated with less frequent use of proven medical therapies. More aggressive use of conventional cardiovascular therapies in patients with CKD and ACS may be warranted.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Creatinine; Female; Humans; Kidney; Kidney Failure, Chronic; Male; Middle Aged; Proportional Hazards Models; Treatment Outcome

Topics: Cardiovascular Agents; Chronic Disease; Clinical Trials as Topic; Coronary Disease; Double-Blind Method; Humans

The choice of optimal therapy in a patient with borderline coronary lesion is difficult. The long-term outcome of conservatively treated patients has not yet been well defined.. To analyse long-term outcome in patients with a borderline lesion in a single coronary artery who were selected for conservative treatment.. The study group consisted of 65 patients (mean age 59.4+/-7.4 years, 48 males) with (1) stable angina (CCS class I/II), (2) isolated single borderline coronary lesion (40-70% stenosis demonstrated by quantitative coronary angiography) and (3) no demonstrable ischaemia during non-invasive tests. Patients with heart failure, left ventricular ejection fraction <50% or acute coronary syndrome within 6 months preceding the study were not included. All patients were prescribed statins, angiotensin converting enzyme inhibitors and aspirin. Follow-up end-points included cardiac death, new myocardial infarction (MI) with or without ST segment elevation and revascularisation of the target coronary artery.. The follow-up duration was 18.4+/-8.5 months (range 12-33, median 18 months). Forty nine (75%) patients remained free from angina during daily activity. Coronary events occurred in 16 (25%) patients, including three (5%) serious complications -- sudden death, new MI with ST elevation and new MI without ST elevation. The remaining 13 (20%) patients underwent percutaneous revascularisation of the target coronary artery. Coronary angiography was repeated in 16 (25%) patients. When the patients were divided into two groups according to the follow-up results (with or without coronary event), no differences in the clinical characteristics, lesion localisation and length or degree of stenosis were noted.. (1) Conservatively treated patients with stable angina and borderline coronary stenosis have a high rate of coronary events, especially revascularisation, during a long-term follow-up. (2) Clinical parameters and quantitative coronary angiography do not identify those patients with borderline coronary lesions who are at increased risk of future coronary events.

Topics: Angina Pectoris; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Stenosis; Death, Sudden, Cardiac; Female; Heart Conduction System; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Time Factors; Treatment Outcome

The authors describe a case of a 74-year-old man with advanced coronary heart disease in whom pulmonary hemorrhagic complications during therapy with ticlopidine and subsequently with clopidogrel and amiodarone were observed. Fever and massive hemoptysis following five days of ticlopidine treatment, before elective coronary angiography, were noticed. Transient interstitial X-ray changes of the right lung were visible. Three months later a new episode on the third day of clopidogrel administration was manifested. He was after PCI, performed because of ACS complicated with ventricular fibrillation. Two days following clopidogrel discontinuation hemoptysis remitted but after ten days occurred again (this time with bilateral X-ray changes). Amiodarone, given after VF, was stopped. Spectacular improvement with steroid treatment was observed. Indobufen (reversible COX- 1 inhibitor) as an antiplatelet therapy was availed. The authors discuss therapeutic dilemma concerning the patient with coexisting different diseases.

Topics: Aged; Amiodarone; Cardiovascular Agents; Clopidogrel; Coronary Disease; Drug Interactions; Drug Therapy, Combination; Hemoptysis; Humans; Male; Platelet Aggregation Inhibitors; Pyridines; Recurrence; Ticlopidine

To ascertain, whether, conventional risk factors and readiness of coronary patients to modify their behaviour and to comply with recommended medication were associated with education in patients with established coronary heart disease.. EUROASPIRE II was a cross sectional survey undertaken in 1999-2000 in 15 European countries to ascertain how effectively recommendations on coronary preventions are being followed in clinical practice. Consecutive patients, men and women

Topics: Adult; Aged; Blood Glucose; Blood Pressure; Body Mass Index; Cardiovascular Agents; Cholesterol, HDL; Coronary Disease; Cross-Sectional Studies; Drug Utilization; Educational Status; Europe; Female; Health Behavior; Health Surveys; Humans; Hypolipidemic Agents; Male; Middle Aged; Odds Ratio; Patient Compliance; Risk Factors; Sex Factors

The cardioprotective effects of (2S,3R,4S)-N'-benzyl- N"-cyano-N-(3,4-dihydro-2-dimethoxymethyl-3-hydro- xy-2-methyl-6-nitro-2H-benzopyran-4-yl)-guanidine (KR-31372) were evaluated against ischemic/reperfusion injury in isolated rat hearts in vitro and in anesthetized rats and dogs in vivo. In isolated perfused rat hearts subjected to a 30-min global ischemia/30-min reperfusion, KR-31372 (1-10 microM) significantly improved severe contracture (end-diastolic pressure and time to contracture), markedly reduced reperfusion lactate dehydrogenase release, and enhanced the recovery of reperfusion contractile function (left ventricular developed pressure and double product) in a concentration-dependent manner compared with the vehicle-treated group. In anesthetized rats subjected to a 45-min coronary occlusion and a 90-min reperfusion, intravenous KR-31372 dose-dependently reduced infarct size from 58.6% to 48.5, 48.1 and 39.6% at 0.3, 1.0 and 3.0 mg/kg, respectively (p < 0.05). In anesthetized beagle dogs that underwent a 1.5-hour occlusion followed by a 5-hour reperfusion, KR-31372 (2 mg/kg, i.v.) markedly reduced infarct size from 57.0% in controls to 28.0% (p < 0.05). The cardioprotective effects of KR-31372 on contractile function in globally ischemic rat hearts and on reperfusion injury in anesthetized rats were significantly reversed by pretreatment with selective adenosine triphosphate-sensitive potassium (K(ATP)) channel blockers, sodium 5-hydroxydecanoate and glibenclamide. Taken together, these results indicate that KR-31372 possesses potent cardioprotective effects in rats and dogs and its effects may be mediated by activation of mitochondrial K(ATP) channels.

Topics: Animals; Benzopyrans; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Dogs; Dose-Response Relationship, Drug; Glyburide; Guanidines; Heart Rate; Hypoglycemic Agents; In Vitro Techniques; L-Lactate Dehydrogenase; Male; Myocardial Reperfusion Injury; Rats; Rats, Sprague-Dawley; Ventricular Dysfunction, Left

Topics: Atrial Fibrillation; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Drug Industry; Genetic Therapy; Humans; Nitric Oxide Donors; Transcription Factors

Topics: Angioplasty, Balloon; Angioplasty, Balloon, Coronary; Cardiac Catheterization; Cardiac Surgical Procedures; Cardiology; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Humans; Multicenter Studies as Topic; Radiology, Interventional; Randomized Controlled Trials as Topic; Stents; Vascular Surgical Procedures

Despite the epidemiological importance of coronary artery disease, cardiovascular events are rare from the individual viewpoint. There is considerable uncertainty when to start medical treatment. A given risk factor modification results in a relative risk reduction independent of the global risk. Therefore the global risk determines the absolute benefit of a preventive measure. The global risk can be estimated using different scoring systems. Using the global risk and the expected relative risk reduction, the Number Needed to Treat (NNT) to avoid one event or cardiac death can be calculated. The NNT is a measure for the usefulness of a preventive intervention. A NNT of < 200 appears acceptable for primary prevention. This can be achieved with pharmacological preventive strategies if the global risk of 10 years is > or = 20%. As age is one of the most important risk predictors the need for treatment at comparable risk factor constellations is age dependent. Risk stratification with estimation of the NNT is therefore important for the decision to treat or not to treat.

Topics: Adult; Aged; Cardiovascular Agents; Cholesterol, HDL; Cholesterol, LDL; Coronary Disease; Cross-Sectional Studies; Death, Sudden, Cardiac; Diabetes Complications; Diabetes Mellitus; Female; Germany; Humans; Hypercholesterolemia; Hypertension; Male; Mass Screening; Middle Aged; Risk Assessment; Triglycerides

Sudden cardiac death is mainly caused by arrhythmic events, triggered by ischemia. About half of the affected persons had no previous diagnosis of coronary heart disease, thus rendering them practically unreachable for specific preventive measures. This fact makes it necessary to optimize reanimation conditions. The establishment of international reanimation standards (ILCOR) has stimulated an intensified scientific evaluation of therapeutic options. While the use of vasopressin, adrenaline and reanimation by bystanders is being evaluated at the moment, amiodarone has not fulfilled the expectation of reducing mortality. Secondary prevention of sudden cardiac death after cardiac events is based on betablockers, ACE inhibitors and antilipemic therapy. Guidelines on prevention of sudden cardiac death also recommend aldosterone blockade and n-3-fatty acids. Persons at highest risk gain most from the use of ICDs, yet it has not been shown that their use immediately after myocardial infarction reduces mortality.

Topics: Arrhythmias, Cardiac; Cardiopulmonary Resuscitation; Cardiovascular Agents; Cause of Death; Coronary Disease; Death, Sudden, Cardiac; Humans; International Cooperation; Practice Guidelines as Topic; Risk Assessment; Secondary Prevention; Survival Analysis

Perhexiline is a prophylactic anti-anginal agent that ameliorates the metabolic basis for myocardial ischaemia and is increasingly used in the management of acute coronary syndromes. No intravenous preparation is available and usual oral loading regimens require 2-3 days to achieve therapeutic drug levels. Two patients presenting to hospital with single-dose over-dosage of perhexiline (6500 mg and 1000 mg, respectively) provided a basis for examining the safety of large single dosage of perhexiline and associated time-course of drug levels. Neither patient had previously taken perhexiline. Peak plasma perhexiline concentrations occurred within 12 h of ingestion and were 2.58 and 0.50 mg/L, respectively (therapeutic range 0.15-0.60 mg/L). The first patient developed transient nausea and vomiting; the second patient had no adverse effects. Subsequently, a series of 10 patients with acute coronary syndromes received an 800-mg loading dose. Peak concentrations occurred within 12 h postdose; the mean levels achieved were 0.40 +/- 0.16 mg/L (standard error of the mean). No serious adverse effects were seen. Two patients reported transient nausea or vomiting within 24 h of the loading dose. The utility of this rapid loading regimen for incremental suppression of myocardial ischaemia remains to be assessed.

Topics: Adult; Cardiovascular Agents; Coronary Disease; Drug Administration Schedule; Drug Overdose; Female; Humans; Male; Middle Aged; Perhexiline; Self Medication

Topics: Adolescent; Adult; Cardiovascular Agents; Child; Coronary Disease; Health Behavior; Health Education; Humans; Life Style; Risk Factors

Coronary heart disease (CHD) mortality is rising in many developing countries. We examined how much of the increase in CHD mortality in Beijing, China, between 1984 and 1999 could be attributed to changes in major cardiovascular risk factors and assessed the impact of medical and surgical treatments.. A validated, cell-based mortality model synthesized data on (1) patient numbers, (2) uptake of specific medical and surgical treatments, (3) treatment effectiveness, and (4) population trends in major cardiovascular risk factors (smoking, total cholesterol, blood pressure, obesity, and diabetes). Main data sources were the WHO MONICA and Sino-MONICA studies, the Chinese Multi-provincial Cohort Study, routine hospital statistics, and published meta-analyses. Age-adjusted CHD mortality rates increased by approximately 50% in men and 27% in women (1608 more deaths in 1999 than expected by application of 1984 rates). Most of this increase ( approximately 77%, or 1397 additional deaths) was attributable to substantial rises in total cholesterol levels (more than 1 mmol/L), plus increases in diabetes and obesity. Blood pressure decreased slightly, whereas smoking prevalence increased in men but decreased substantially in women. In 1999, medical and surgical treatments in patients together prevented or postponed approximately 642 deaths, mainly from initial treatments for acute myocardial infarction ( approximately 41%), hypertension (24%), angina (15%), secondary prevention (11%), and heart failure (10%). Multiway sensitivity analyses did not greatly influence the results.. Much of the dramatic CHD mortality increases in Beijing can be explained by rises in total cholesterol, reflecting an increasingly "Western" diet. Without cardiological treatments, increases would have been even greater.

Topics: Adult; Aged; Antihypertensive Agents; Aspirin; Cardiovascular Agents; China; Coronary Disease; Developing Countries; Diabetes Mellitus; Diet; Drug Utilization; Female; Humans; Hypercholesterolemia; Hypertension; Male; Middle Aged; Models, Cardiovascular; Mortality; Obesity; Risk Factors; Smoking

Topics: Cardiovascular Agents; Clinical Trials as Topic; Coronary Artery Disease; Coronary Disease; Humans

Adherence to established guidelines for patients discharged from the hospital after acute coronary syndrome is known to be suboptimal. The aim of this study was to assess the efficacy of a program for physicians centered on the treatment of acute coronary syndrome.. 39 hospitals participated.. a set of measures was developed by consensus for the creation and distribution of educational materials.. Proportion of patients in whom ejection fraction and residual ischemia were evaluated, treatment at discharge, and health and dietary recommendations to patients (smoking, diet, exercise, etc.) referred to all patients in whom these measures or treatments should have been used ("ideal patients"). Changes were assessed with four cross-sectional surveys.. A total of 1157, 1162, 1149 and 1158 patients were included. There were no relevant differences between these groups in baseline characteristics. In general, there was improvement in all variables between the first and the last survey. The proportion of patients who were weighed and measured increased (from 33.5% to 53.4%; P<.0001), as did the proportion of those in whom cholesterol was measured early (42.6 to 53.7%; P=.006). The proportion in whom residual ischemia was not measured despite indications for this test decreased (18.2% to 10.8%; P=.013), and the proportion increased for appropriate treatment with statins on discharge (68.6% to 81.4%; P<.0001), advice to quit smoking (60.1% to 72.2%; P<.0001) and advice to exercise (58.3% to 67.4%; P=.003).. The educational intervention seems to have had a positive effect on improving the appropriateness of procedures and treatments for patients discharged after acute coronary syndrome.

Topics: Aged; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Cross-Sectional Studies; Education, Medical; Female; Guideline Adherence; Humans; Male; Middle Aged; Patient Discharge; Physicians; Program Evaluation; Risk Factors

When managing the risk factors of coronary heart diseases, therapies using drugs play an important role. This present study analyses self-reported data on current drug usage of men and women with coronary heart disease. The data were collected as a part of a wider drug utilisation survey which in turn is a module of the German National Health Interview and Examination Survey 1998 (Bundes-Gesundheitssurvey 1998). This survey was compiled by conducting a standardised computer-assisted medical interview with a representative sample of the German population between the ages of 18 and 79 years. Of the 7099 participants, 209 of the women and 252 of the men affirmed having had a medically diagnosed coronary heart disease (CHD) such as angina pectoris and/ or myocardial infarction. Slightly more men (87.3%) were using drugs to treat CHDs than the women (86.1%). They (the men) also used more drugs on average (men 3.3, women 3.0). These differences however were not statistically significant. Clear and statistically significant differences were present in the usage of salicylic acid (men 54.4%, women 45.6%), HMG CoA reductase inhibitors (men 26%, women 15.3%) and cardiac glycosides (men 14%, women 25.8%). The higher usage prevalence rate of salicylic acid found in the men still remained after taking their age, social status and the region (east vs west) into account. The differences in the usage of specific drugs in the treatment of CHDs in men and women indicate a difference in prescription behaviour in the ambulatory medical care. Whether and to which extent gender-specific differences still remain today has to be decided by using current epidemiological data representative of the population.

Topics: Adolescent; Adult; Age Distribution; Aged; Angiotensin-Converting Enzyme Inhibitors; Cardiac Glycosides; Cardiovascular Agents; Coronary Disease; Drug Prescriptions; Drug Utilization; Drug Utilization Review; Female; Germany; Health Surveys; Humans; Male; Middle Aged; Population Surveillance; Prevalence; Risk Assessment; Risk Factors; Salicylic Acid; Sex Distribution; Socioeconomic Factors

Prescribing is the most common therapeutic intervention in primary care, and there is substantial variation in prescribing practice across England. We investigate broad patterns of prescribing across Health Authorities in England, concentrating on ethnically diverse populations.. Initially we examined the association between a number of prescribing indicators from the Prescribing Support Unit Prescribing Toolkit and 'Needs Profiles'. We then considered whether the observed patterns of prescribing were appropriate, that is, could be largely explained by variations in the prevalence of a medical condition for which the corresponding group of drugs would be prescribed.. The volume and cost of prescribing was generally lower in more ethnically diverse Health Authority populations when compared with more elderly or deprived populations. There was a significant negative association between ethnic composition and net-ingredient-cost per patient of cardiovascular drugs, but this disappeared upon adjusting for mortality from coronary heart disease.. The volume and cost of prescribing was generally lower in more ethnically diverse Health Authority populations relative to other high-need population profiles. Further work on this subject matter is merited, particularly if individual level data is available.

Topics: Age Factors; Cardiovascular Agents; Coronary Disease; Databases, Factual; Drug Utilization; England; Ethnicity; Health Services Accessibility; Humans; Practice Patterns, Physicians'; Sex Factors

Topics: Academic Medical Centers; Aged; American Heart Association; Cardiac Care Facilities; Cardiovascular Agents; Coronary Disease; Female; Guideline Adherence; Humans; Male; Patient Compliance; Pharmaceutical Services; Pharmacists; Pilot Projects; Practice Guidelines as Topic; Program Evaluation; Societies, Medical; Telemetry

Although reciprocal ST segment depression (RSTD) in patients with acute inferior myocardial infarction is a common electrocardiogram finding, its significance is not yet established. In this prospective study, the relationship between RSTD and the extent of coronary artery disease (CAD) was investigated.. One hundred eighty-eight patients with acute inferior myocardial infarction who received thrombolytic therapy were enrolled in this study. The magnitude and location of ST segment depression in noninfarcted leads and the maximum ST segment elevation (STEmax) in inferior leads were measured. All patients were divided into two main groups according to the presence of RSTD and five subgroups according to the location of RSTD, the maximum RSTD and the STEmax. The coronary angiography was performed in all patients 28 +/- 4 days after acute myocardial infarction.. There were no significant differences in the proportion of coronary disease risk factors in patients with, versus those without, RSTD (P=0.6). Multivessel CAD was present in 63 of the 108 (58%) patients with RSTD and in 32 of the 80 (40%) patients with no RSTD (P=0.02). According to the location of reciprocal changes, multivessel disease was present in significantly more patients with anterior RSTD concomitant with or without lateral ST segment depression (P=0.01 and P=0.03, respectively); the proportion of single vessel disease was greater in patients with only lateral RSTD (P=0.02). In addition, the presence of anterior RSTD to a greater magnitude than the STEmax in inferior myocardial infarction increases the likelihood of multivessel disease (P=0.006).. The presence of RSTD during an acute inferior myocardial infarction correlates with the presence of multivessel CAD and may not be only an electrical phenomenon.

Topics: Analysis of Variance; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Electrocardiography; Female; Humans; Male; Middle Aged; Myocardial Infarction; Prospective Studies; Risk Factors; Stroke Volume; Thrombolytic Therapy; Ventricular Function, Left

Effects of altiazem PP-180 ("Berlin Chemie", Germany; "Menarini Group". Italy) and dilren-300 ("Sanofi", France) on clinical symptoms and circadian hemodynamic chronostructure were studied in 22 patients with coronary heart disease (CHD) with stable angina pectoris of functional class II-III. Tetrapolar chest rheography (TCR), echocardiography (Echo-CG), ECG, arterial pressure measurement (APM) by N. S. Korotkov were used for examination. TCR, ECG and APM were made 6 times a day: at 10.00, 14.00, 18.00, 22.00, 02.00 and 06.00. The drugs were given in a single daily dose at 08.00 for 10 days. The information was processed statistically and by F. Halberg's cluster analysis. The results showed that altiazem PP and dilren had an antianginal activity which is stronger in dilren administration. The drugs produced moderate hypotensive and vasodilating effects. Altiazem PP raised mean daily level of stroke and minute volumes and their indices. Dilren raised ejection fraction and reduced the double product. Dilren normalized chronostructure of hemodynamic circadian rhythms.

Topics: Adult; Aged; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Chronotherapy; Circadian Rhythm; Cluster Analysis; Coronary Disease; Diltiazem; Female; Hemodynamics; Humans; Male; Middle Aged; Stroke Volume; Time Factors; Vasodilator Agents

The relationship between the amount of inducible ischemia present on stress myocardial perfusion single photon emission computed tomography (myocardial perfusion stress [MPS]) and the presence of a short-term survival benefit with early revascularization versus medical therapy is not clearly defined.. A total of 10 627 consecutive patients who underwent exercise or adenosine MPS and had no prior myocardial infarction or revascularization were followed up (90.6% complete; mean: 1.9+/-0.6 years). Cardiac death occurred in 146 patients (1.4%). Treatment received within 60 days after MPS defined subgroups undergoing revascularization (671 patients, 2.8% mortality) or medical therapy (MT) (9956 patients, 1.3% mortality; P=0.0004). To adjust for nonrandomization of treatment, a propensity score was developed using logistic regression to model the decision to refer to revascularization. This model (chi2=1822, c index=0.94, P<10-7) identified inducible ischemia and anginal symptoms as the most powerful predictors (83%, 6% of overall chi2) and was incorporated into survival models. On the basis of the Cox proportional hazards model predicting cardiac death (chi2=539, P<0.0001), patients undergoing MT demonstrated a survival advantage over patients undergoing revascularization in the setting of no or mild ischemia, whereas patients undergoing revascularization had an increasing survival benefit over patients undergoing MT when moderate to severe ischemia was present. Furthermore, increasing survival benefit for revascularization over MT was noted in higher risk patients (elderly, adenosine stress, and women, especially those with diabetes).. Revascularization compared with MT had greater survival benefit (absolute and relative) in patients with moderate to large amounts of inducible ischemia. These findings have significant consequences for future approaches to post-single photon emission computed tomography patient management if confirmed by prospective evaluations.

Topics: Adenosine; Aged; Cardiovascular Agents; Coronary Disease; Exercise Test; Female; Follow-Up Studies; Humans; Male; Middle Aged; Models, Statistical; Multivariate Analysis; Myocardial Revascularization; Prognosis; Proportional Hazards Models; Survival Analysis; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Tomography, Emission-Computed, Single-Photon

Topics: Adenosine; Cardiotonic Agents; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Dipyridamole; Dobutamine; Echocardiography; Exercise Test; Family Practice; Female; Humans; Male; Middle Aged; Radionuclide Imaging; Referral and Consultation; Risk Factors; United States; Vasodilator Agents

The role of systemic hypertension in acute coronary syndrome (ACS) has not been well studied. We studied consecutive subjects admitted to the University of Michigan Health System (Ann Arbor, Michigan) with symptoms of ACS. Data were collected using a standardized form. This observational study is currently ongoing; we collected data from May 1999 to December 2000 for 979 subjects, 890 of whom also had 6-month follow-up data. Hypertensives represented 64.4% (n = 630) of the total population. In general, hypertensive patients were older than normotensives (66.3 vs 59.9 years, p <0.0001), more often women (38.7% vs 26.9%, p = 0.0002), and had more comorbidities, such as previous myocardial infarction (47.9% vs 33.8%, p <0.0001), congestive heart failure (25.7% vs 12.0%, p <0.0001), and diabetes (36.9% vs 17.8%, p <0.0001). At admission, hypertensives had higher systolic blood pressure. Hypertensives had fewer electrocardiographic abnormalities indicating ischemic changes (67.9% vs 76.3%, p = 0.01) and had fewer incident of acute myocardial infarction (AMI) (70.7% vs 76.1%, p = 0.07) than normotensives. There was consistency over different levels of admission systolic blood pressure. Hypertensives received more oral cardiovascular drugs, and had undergone more invasive procedures. The lower rate of AMI in hypertensives seemed to be related to the higher frequency of a history of percutaneous coronary intervention and coronary artery bypass grafting. However, at 6-month follow-up, age- and gender-adjusted odds ratios for adverse events were equivalent in hypertensives and normotensives, suggesting no continuing differential treatment benefit for hypertensives in the months after the initial ACS episode.

Topics: Acute Disease; Age Distribution; Aged; Biomarkers; Cardiovascular Agents; Comorbidity; Coronary Disease; Creatine Kinase; Electrocardiography; Female; Follow-Up Studies; Humans; Hypertension; Male; Michigan; Middle Aged; Myocardial Infarction; Odds Ratio; Reference Values; Regression Analysis; Sex Distribution; Syndrome; Troponin I

Previous studies have examined medication use among patients with coronary artery disease who have suffered an acute myocardial infarction (MI). However, little is known about medication use among patients with coronary artery disease who undergo percutaneous coronary intervention (PCI).. To examine the patterns of use of medical therapy among patients who undergo PCI; and to examine the determinants of medical therapy in these patients.. The Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) registry is a prospective multicentre study examining the use of functional testing after PCI. The medication use was examined among 787 patients who were enrolled in the ROSETTA registry at 13 clinical centres in five countries.. Most patients were men (mean age 61+/-11 years, 76% male) who underwent single vessel PCI (85%) with stent implantation (58%). At admission, discharge and six months, rates of acetylsalicylic acid use were 77%, 96% and 93%, respectively (discharge versus six months, P<0.0001). Rates of use of other oral antiplatelet agents were 11%, 59% and 2% (P=0.02). For individual anti-ischemic medications, rates of use were as follows: beta-blockers 49%, 58% and 59% (P<0.0001); calcium antagonists 34%, 43% and 42% (P<0.0001); and nitrates 42%, 56% and 43% (P<0.0001). Rates of use of combination anti-ischemic medications were as follows: triple therapy 7%, 9% and 9% (P<0.0001); double therapy 34%, 47% and 38% (P<0.0001); monotherapy 36%, 36% and 41% (P<0.0001); and no anti-ischemic therapy 23%, 8% and 12% (P<0.0001). Rates of use of angiotensin-converting enzyme inhibitors were 25%, 33% and 32% (P<0.0001), and rates of use of lipid lowering agents were 41%, 52% and 61% (P<0.0001).. Trials and guidelines statements have favourably affected the rates of use of acetylsalicylic acid and other antiplatelet agents after PCI. However, in spite of patients undergoing a successful revascularization procedure, physicians do not reduce the use of anti-ischemic medical therapy.

Topics: Adrenergic beta-Antagonists; Aftercare; Aged; Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Drug Utilization; Exercise Test; Female; Follow-Up Studies; Humans; Hypolipidemic Agents; Male; Middle Aged; Myocardial Ischemia; Nitrates; Platelet Aggregation Inhibitors; Prospective Studies; Registries

There is a marked underutilization of antiplatelet drugs, beta blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and lipid-lowering drugs, and an overutilization of calcium channel blockers in elderly patients with coronary artery disease (CAD).. An ongoing educational program is being given by Dr. Wilbert Aronow on the appropriate utilization of cardiovascular drugs in patients with CAD during hospitalization and at hospital discharge. In a prospective study, charts of 200 unselected patients hospitalized for CAD at least 6 months after the onset of the educational program were analyzed by a medical resident to investigate the appropriate utilization of cardiovascular drugs. The 200 patients included 115 men and 85 women, mean age 70 years, with documented CAD. Of the 200 patients, 127 (64%) had the diagnosis of prior CAD. The use of cardiovascular medications in these 127 patients prior to hospitalization served as a control group.. After the educational program, aspirin, clopidogrel, or warfarin was given to 93% of patients compared with 67% in the control group; beta blockers were given to 81% of patients compared with 56% in the control group; ACE inhibitors or ARBs were given to 70% of patients compared with 42% in the control group. Lipid-lowering drugs if dyslipidemia were given to 88% of patients compared with 52% in the control group; calcium channel blockers were given to 18% of patients compared with 24% in the control group.. In patients with CAD, the educational program increased the use of antiplatelet drugs by 26%, beta blockers by 25%, ACE inhibitors or ARBs by 28%, and lipid-lowering drugs by 36%, and decreased the use of calcium channel blockers by 6%.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Drug Prescriptions; Female; Hospitalization; Humans; Hypolipidemic Agents; Male; Middle Aged; Patient Discharge; Patient Education as Topic; Platelet Aggregation Inhibitors

Relevant national societies attribute special importance to the secondary prevention of coronary patients. This is well formulated in their recommendations (9, 11). Actual clinical practice was studied in 1995-1996 by the EUROASPIRE I study. Its Hungarian data were published in 1999 (8). The scope of EUROASPIRE II in 1999-2000 was to study changes occurred in these 5 years. In this paper the authors intend to answer the question whether the clinical practice of secondary prevention of coronary patients showed any changes at the turn of the millennium. Participating centres, the criteria of patient selection and the applied methods were identical in the two studies. Hospital data of 516 patients below the age of 70 were analysed. There was no difference between the two studies neither in the distribution according to gender and age, nor in the number of death. Documentation of the relevant data in the hospital records improved substantially: blood pressure was registered in every patient chart, lipid values in 91%. Information on smoking however is still missing in 1/3 of the patients, while on weight and height in half of them. The response rate at the follow up investigation on was 75%. The prevalence of obesity increased by 60%, that of smoking by 13% since the first investigation 5 years ago. This rate of increase is the largest among the 9 participating centres. The prevalence of hypertension decreased by 24.5% and the proportion of hypertensive patients receiving treatment increased by 7%. In spite of these blood pressure values over 140/90 mmHg were found in 37% of the patients. The mean triglyceride value increased by 53% and the prevalence of severe hypercholesterolaemia by 43%. Lipid lowering drugs are given to 51% of the patients in contrast to 22% 5 years earlier. In spite of this cholesterol values above 5.5 mmol/l were found in 42%. In respect of prophylactic drugs the proportion of patients receiving beta blockers increased from 58 to 84%.. The evaluation of complex risk of patients and their long-term care is still deficient. Drug treatment improved quantitatively but not qualitatively. This and the lack of lifestyle-improving medical efforts is reflected by the increase of the proportion of obese and smoking patients and the persistently high prevalence of hypercholesterolaemia and hypertension.

Topics: Age Distribution; Aged; Angioplasty, Balloon, Coronary; Blood Pressure; Cardiovascular Agents; Clinical Trials as Topic; Coronary Artery Bypass; Coronary Disease; Female; Humans; Hungary; Hypercholesterolemia; Hypertension; Incidence; Life Style; Lipids; Male; Middle Aged; Myocardial Infarction; Obesity; Retrospective Studies; Risk Factors; Sex Distribution; Smoking

Topics: Cardiovascular Agents; Coronary Disease; Diltiazem; Exercise Test; Heart Rate; Humans; Male; Middle Aged; Radionuclide Imaging

Topics: Acute Disease; Angina, Unstable; Angioplasty, Balloon, Coronary; Atrial Fibrillation; Cardiology; Cardiovascular Agents; Clinical Trials as Topic; Congresses as Topic; Coronary Artery Bypass; Coronary Disease; Echocardiography; Europe; Heart Failure; Humans; Myocardial Infarction; Stents; Syndrome; Thrombolytic Therapy

The measures of secondary prevention in patients undergoing coronary bypass graft surgery (CABG) remains largely undetermined in Turkey.. We designed a multicentre cross-sectional study to estimate the prevalence of cardiovascular risk factors in patients after CABG and to evaluate the association of demographic-socio-economic factors with secondary prevention in these patients.. A total of 622 patients who underwent CABG between 1 January 1999 and 15 January 2000 at four centres in Adana, Turkey; 273 (ages 35-77, 208 men) were interviewed and examined 1.0-2.2 years after the procedure.. Of 273 patients interviewed, 81.5% were overweight, 65.5% had unhealthy food choices for a lipid-lowering diet, 56.0% were physically inactive, 28.8% were obese and 17.6% were current smokers. Hypercholesterolaemia, elevated blood pressure and fasting blood glucose were found in 65.6, 34.1 and 19.8%, respectively. Of diabetic patients, 63.8% had elevated fasting blood glucose. The use of angiotensin-converting enzyme inhibitors, beta-blockers and statins was low. Women had a higher rate of obesity and physical inactivity; smoking was less prevalent in females. More women were taking antihypertensive and lipid-lowering drugs than men. Logistic regression analysis revealed an association between hypercholesterolaemia and low educational level.. Turkish patients have a high prevalence of modifiable risk factors related to unhealthy lifestyle and ineffective prophylactic drug use 1 year or more after CABG. Low educational level has a significant influence in this situation.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Cross-Sectional Studies; Epidemiologic Factors; Female; Health Behavior; Humans; Male; Middle Aged; Prevalence; Risk Factors; Secondary Prevention; Socioeconomic Factors; Turkey; Urban Population

A prospective study was performed in 177 patients, mean age 78+/-6 years, hospitalized with acute coronary syndromes. Obstructive coronary artery disease was documented by coronary angiography in 154 of 177 patients (87%). Coronary revascularization was performed in 96 of 177 patients (54%). Five of 177 patients (3%) died during hospitalization. Compared to use before hospitalization, at hospital discharge the use of aspirin increased from 43% to 84% (p<0.001), the use of clopidogrel increased from 21% to 54% (p<0.001), the use of beta blockers increased from 38% to 76% (p<0.001), the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers increased from 42% to 70% (p<0.001), the use of long-acting nitrates increased from 15% to 31% (p<0.001), and the use of calcium channel blockers decreased from 28% to 23% (p=NS). Dyslipidemia was present in 62% of the 177 patients. The use of statins increased from 34% before hospitalization to 63% at hospital discharge (p<0.001).

Topics: Acute Disease; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Calcium Channel Blockers; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Drug Utilization; Female; Hospitalization; Humans; Male; Myocardial Revascularization; Patient Discharge; Probability; Prognosis; Prospective Studies; Severity of Illness Index; Survival Rate

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Humans; Randomized Controlled Trials as Topic; Survival Rate; Treatment Outcome

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Disease; Humans; Quality of Life; Risk; Survival Rate

Topics: Cardiovascular Agents; Coronary Disease; Humans; Outcome and Process Assessment, Health Care

To evaluate the implementation of secondary prevention and treatment of coronary heart disease (CHD) in general practice in Iceland.. Two health care centers adjacent to Reykjavik with a total of 25766 inhabitants.. All patients (533) with CHD living in the study area were sent an invitation letter and a request for informed consent. Those who chose to participate answered a questionnaire about CHD risk factors and their current treatment, and their medical records were reviewed. The patients were divided into four groups on the basis of their history: I. Coronary artery bypass surgery (CABG), II. Percutaneous transluminal coronary angioplasty (PTCA), III. Myocardial infarction (MI), IV. Angina pectoris (AP). If a patient fulfilled the criteria for more than one diagnostic group the CABG group had the highest priority followed by PTCA, MI and finally AP.. Blood pressure, smoking habits, BMI, exercise profile, cholesterol levels and drug therapy.. Of 533 patients with CHD, 402 (75%) participated in the study, 15% were managed exclusively by their family physician and 23% by both cardiologists and family physicians. Obesity was relatively common, with nearly 60% being overweight (BMI > 25). Average cholesterol in the total group was 6.2 mmol/L (95% CI 6.07 to 6.34). Blood pressure had been recorded in 92% of the patients, and mean systolic and diastolic blood pressures were 143 and 82 mmHg, respectively. While 15% were current smokers, 56% were ex-smokers. A total of 113 patients (28%) were being treated with cholesterol-lowering drug therapy at the time of the study. Respective treatment ratios in the four subgroups were 47% in group I, 42% in II, 25% in III and 13% in group IV. Aspirin was taken by 284 patients (71%), beta blockers by 52% and calcium channel blockers by 36%. More than twice as many women than men were treated with nitrates, 57% versus 27%.. The results indicate that there are numerous possibilities for improvements in secondary prevention and medical management of coronary heart disease in Iceland. Particular emphasis should be placed on smoking cessation, life-style modification with exercise and diet recommendations to lower BMI and lipid-lowering therapy.

Topics: Angioplasty, Balloon, Coronary; Anticholesteremic Agents; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Bypass; Coronary Disease; Drug Utilization; Exercise; Family Practice; Female; Health Care Surveys; Humans; Hypertension; Iceland; Male; Needs Assessment; Obesity; Practice Patterns, Physicians'; Primary Health Care; Primary Prevention; Risk Factors; Smoking

Topics: Cardiology; Cardiovascular Agents; Coronary Disease; Humans; Louisiana; Netherlands; Research

Ischaemic heart disease is a leading cause of death in the world. It has clinically defined phases as: Asymptomatic, stable angina, progressive angina and unstable angina. It is important to differentiate patients of angina into those with stable and unstable angina--risk stratification and management differ in the two groups. Risk stratification of patients with stable angina using clinical parameters helps in development of clearer indication of referral for exercise testing and cardiac catheterisation. Chronic stable angina patients with history of documented myocardial infarction of Q waves on ECG should have measurement of left ventricular systolic function (ie, ejection fraction) as it is important for choosing the appropriate medical or surgical therapy. Symptomatic patients with suspected or known coronary artery disease should usually undergo exercise testing to assess the risk of future cardiac events. The treatment of stable angina has two purposes: To prevent myocardial infarction and death and therapy directed towards preventing death. Pharmacotherapy consists of: Aspirin, lipid lowering agents, beta-blockers, nitrates, short acting dihydropyridine calcium antagonists, etc. For surgery, there are two well established approaches of revascularisation. One is coronary artery by-pass grafting and the other is percutaneous transluminal coronary angioplasty. Studies comparing different treatment modalities are elaborated in this article. In conclusion, it can be said that patients having severe symptoms affecting quality of life despite optimal medical therapy should be referred for revascularisation surgery.

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Disease; Electrocardiography; Exercise Test; Humans; India; Myocardial Infarction; Myocardial Revascularization; Recurrence; Risk Factors; Survival Rate

Cost-sharing in US prescription drug coverage plans for elderly persons varies widely. Evaluation of prescription drug use among elderly persons by type of health insurance could provide useful information for designing a Medicare drug program.. To determine use of effective cardiovascular drugs among elderly persons with coronary heart disease (CHD) by type of health insurance.. Cross-sectional evaluation of 1908 community-dwelling adults, aged 66 years or older, with a history of CHD or myocardial infarction from the 1997 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries.. Use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), beta-blockers, and nitrates, and out-of-pocket expenditures for prescription drugs, stratified by type of health insurance: Medicare without drug coverage (Medicare only or self-purchased supplemental insurance) or with drug coverage (Medicaid, other public program, Medigap, health maintenance organization, or employer-sponsored plan).. Statin use ranged from 4.1% in Medicare patients with no drug coverage to 27.4% in patients with employer-sponsored drug coverage (P<.001). Less variation between these 2 types occurred for beta-blockers (20.7% vs 36.1%; P =.003) and nitrates (20.4% vs 38.0%; P =.005). In multivariate analyses, statin use remained significantly lower for patients with Medicare only (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.49) and beta-blocker use was lower for Medicaid patients (OR, 0.55; 95% CI, 0.34-0.88) vs those with employer-sponsored coverage. Nitrate use occurred less frequently in persons lacking drug coverage (patients with Medicare only, P =.049; patients with supplemental insurance without drug coverage, P =.03). Patients with Medicare only spent a much larger fraction of income on prescription drugs compared with those with employer-sponsored drug coverage (7.9% vs 1.7%; adjusted P<.001).. Elderly Medicare beneficiaries with CHD who lack drug coverage have disproportionately large drug expenditures and lower use rates of statins, a class of relatively expensive drugs that improve survival.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Cost Sharing; Cross-Sectional Studies; Humans; Insurance, Medigap; Insurance, Pharmaceutical Services; Logistic Models; Medicare Part B; Multivariate Analysis; United States

Elderly individuals constitute an increasing proportion of coronary patients, and up-to-date information is needed of their treatments in the community.. A random sample of 75-, 80-, 85-, 90- and 95-year-old residents (n = 3,921) of Helsinki, Finland, was studied during 1998-1999. They were sent a postal questionnaire with questions about health, diseases and current drug use.. The response rate of home-dwelling elderly persons was 78% (n = 2,511). Of men and women, 75.8% and 79.8%, respectively, had some regular medication (P< 0.05 between genders). Of home-dwelling individuals with coronary heart disease (CHD, n = 717, 28.6%), 61.0% of women and 68.3% of men used aspirin, 58.4% and 52.9% nitrates, 54.7% and 52.4% beta-blockers, 20.0% and 13.7% (angiontensin-converting enzyme) ACE inhibitors and 25.1% and 21.1% calcium-channel blockers. Only 14.3% and 19.4% were on cholesterol-lowering drugs. The difference in ACE inhibitor, diuretic and digoxin use was statistically significant (P < 0.05) between genders (women used more).. Cardiovascular drug use is very common among the oldest age cohorts, but assuming that knowledge from younger individuals applies, there is a suboptimal use of several evidence-based treatments, especially lipid-lowering drugs, aspirin and beta-blockers in elderly coronary patients.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Cohort Studies; Coronary Disease; Cross-Sectional Studies; Drug Monitoring; Evidence-Based Medicine; Female; Finland; Humans; Male; Population Surveillance; Surveys and Questionnaires

Coronary artery disease (CAD) alters the vasomotor response to a variety of pharmacological agents. We tested the hypothesis that CAD also has an impact on the coronary vasomotor response to radiologic contrast media.. We performed quantitative coronary angiography in 42 patients without angiographic evidence of CAD and 38 patients with CAD in the left coronary artery. Angiographically smooth coronary segments (n=235) were analyzed for changes on luminal diameters and coronary venous oxygen saturation in response to 3 media: the nonionic dimer iodixanol, the nonionic monomer iopromide, and the ionic agent ioxaglate. In subjects without CAD, we assessed the effects of intracoronary administration of the nitric oxide synthase inhibitor N(G)-monomethyl-L-arginine and of the cyclooxygenase inhibitor indomethacin on such changes. Iodixanol induced coronary vasodilation in subjects without CAD (8.8+/-8.6%, P<0.001). Patients with CAD exhibited no significant diameter changes in segments >/=20 mm apart from a stenosis (4.7+/-9.4%, P=NS) and significant constriction in segments <20 mm from a stenosis (-3.8+/-4.6%, P<0. 05). Similar results were obtained with iopromide, but no changes were found with ioxaglate. All contrast media induced transient (<35 seconds) increases in coronary venous oxygen saturation in all subjects. Indomethacin, but not N(G)-monomethyl-L-arginine, blunted the vasodilating effect of iodixanol and iopromide (by 80% and 76%, respectively; P<0.001).. Nonionic contrast media induce a vasodilatory response in normal vessels not by a mechanism involving increased flow or endothelial nitric oxide synthesis, but rather by depending on preserved vascular cyclooxygenase activity. CAD changes normal epicardial vasodilatory response into vasoconstriction.

Topics: Aged; Cardiovascular Agents; Contrast Media; Coronary Angiography; Coronary Circulation; Coronary Disease; Coronary Vessels; Extravasation of Diagnostic and Therapeutic Materials; Female; Humans; Indomethacin; Male; Middle Aged; omega-N-Methylarginine; Oxygen; Time Factors; Triiodobenzoic Acids; Vasomotor System

The revolution in coronary care in the mid-1980s to mid-1990s corresponded with monitoring of coronary heart disease (CHD) in 31 populations of the WHO MONICA Project. We studied the impact of this revolution on coronary endpoints.. Case fatality, coronary-event rates, and CHD mortality were monitored in men and women aged 35-64 years in two separate 3-4-year periods. In each period, we recorded percentage use of eight treatments: coronary-artery reperfusion before, thrombolytics during, and beta-blockers, antiplatelet drugs, and angiotensin-converting-enzyme (ACE) inhibitors before and during non-fatal myocardial infarction. Values were averaged to produce treatment scores. We correlated changes across populations, and regressed changes in coronary endpoints on changes in treatment scores.. Treatment changes correlated positively with each other but inversely with change in coronary endpoints. By regression, for the common average treatment change of 20, case fatality fell by 19% (95% CI 12-26) in men and 16% (5-27) in women; coronary-event rates fell by 25% (16-35) and 23% (7-39); and CHD mortality rates fell by 42% (31-53) and 34% (17-50). The regression model explained an estimated 61% and 41% of variance for men and women in trends for case fatality, 52% and 30% for coronary-event rates, and 72% and 56% for CHD mortality.. Changes in coronary care and secondary prevention were strongly linked with declining coronary endpoints. Scores and benefits followed a geographical east-to-west gradient. The apparent effects of the treatment might be exaggerated by other changes in economically successful populations, so their specificity needs further assessment.

Topics: Adult; Cardiovascular Agents; Coronary Disease; Female; Humans; Male; Middle Aged; Multicenter Studies as Topic; Registries; Regression Analysis; Sex Distribution; World Health Organization

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Coronary Vessels; Female; Humans; Male; Randomized Controlled Trials as Topic; Reproducibility of Results; Treatment Outcome

We have previously shown that superoxide anion (O2-) stimulates the release of vasoconstrictor prostanoids and induces a prolonged rise in coronary perfusion pressure (CPP) that persists even after removal of O2-. In this study, we tested the hypothesis that the increased CPP is mediated by activation of TxA2/ PGH2 (TP) receptors and protein kinase C (PKC)-dependent mechanisms. In Langendorff perfused rat hearts, O2- was applied for 15 min and then washed out over a period of 20 min. Application of O2- increased the release of vasoconstrictive (TxA2 and PGF2alpha) and decreased vasodilating (PGI2 and PGE2) prostanoids. Although indomethacin (10 microM), a cyclooxygenase inhibitor, attenuated the rise in CPP during O2- perfusion, the increase was not completely blocked. OKY 046Na (10 microM), a thromboxane synthase inhibitor, had no effect on O2--induced increases in CPP, whereas ONO 3708 (10 microM), a TP receptor antagonist, suppressed this effect. PKC activity was also elevated by more than 50% by O2- perfusion. CPP typically increased throughout the O2- wash-out. This post-O2- vasoconstriction was not inhibited by indomethacin, nitroglycerin or nitrendipine. In contrast, ONO 3708 (10 microM) and two PKC inhibitors, staurosporine (10 nM) and calphostin C (100 nM), completely blocked the rise in CPP, and even elicited vasodilation. PDBu enhanced the post-O2- vasoconstriction. We conclude that O2--induced coronary vasoconstriction is initially mediated by TP receptors, but activation of PKC sustains the response.

Topics: 15-Hydroxy-11 alpha,9 alpha-(epoxymethano)prosta-5,13-dienoic Acid; Animals; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Dinoprost; Enzyme Inhibitors; In Vitro Techniques; Indomethacin; Male; Methacrylates; Naphthalenes; Perfusion; Prostaglandins; Protein Kinase C; Rats; Rats, Sprague-Dawley; Receptors, Prostaglandin; Receptors, Thromboxane; Receptors, Thromboxane A2, Prostaglandin H2; Staurosporine; Superoxides; Thromboxane A2; Thromboxane-A Synthase; Vasoconstrictor Agents

The aim of the study was to verify the prognostic implications of viability detection using baseline-nitrate sestamibi imaging in patients with left ventricular (LV) dysfunction due to chronic coronary artery disease (CAD) submitted to different therapeutic strategies.. The prognostic meaning of preserved viability in these patients is still debated. Sestamibi is increasingly used for myocardial perfusion scintigraphy and is being accepted also as viability tracer, but no data are available about the relationship between viability in sestamibi imaging, subsequent treatment, and patient's outcome.. Follow-up data were collected in 105 CAD patients with LV dysfunction who had undergone baseline-nitrate sestamibi perfusion imaging for viability assessment and had been later treated medically (group 1), or submitted to revascularization, which was either complete (group 2A) or incomplete (group 2B).. Eighteen hard events (cardiac death or nonfatal myocardial infarction) were registered during the follow-up. A significantly worse event-free survival curve was observed in the patients of group 1 (p < 0.0002) and group 2B (p < 0.03) compared to those of group 2A. Using a Cox proportional hazard model, the most powerful prognostic predictors of events were the number of nonrevascularized asynergic segments with viability in sestamibi imaging (p < 0.003, risk ratio [RR] = 1.4), and the severity of CAD (p < 0.02, RR = 1.28).. Viability detection in sestamibi imaging has important prognostic implications in CAD patients with LV dysfunction. Patients with preserved viability kept on medical therapy or submitted to incomplete revascularization represent high-risk groups.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Coronary Disease; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Revascularization; Nitrates; Prognosis; Radiopharmaceuticals; Technetium Tc 99m Sestamibi; Tissue Survival; Tomography, Emission-Computed, Single-Photon; Ventricular Dysfunction, Left

Topics: Acute Disease; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Humans; Syndrome

Based upon the positive results of a large epidemiological study and the negative results of an interventional clinical trial recently published in the New England Journal of Medicine, we will briefly discuss the impact of estrogen replacement therapy on the protection against coronary heart disease in postmenopausal women.

Topics: Adult; Aged; Cardiovascular Agents; Cholesterol, HDL; Cholesterol, LDL; Clinical Trials as Topic; Coronary Disease; Dietary Fats; Epidemiologic Studies; Estrogen Replacement Therapy; Estrogens, Conjugated (USP); Fatty Acids; Female; Humans; Middle Aged; Placebos; Postmenopause; Protective Agents; Smoking

Despite the deleterious and sometimes catastrophic consequences of proximal left anterior descending (LAD) artery occlusion, there is a paucity of data to guide the treatment of patients with such disease. Our aim was to describe outcomes with medical therapy, angioplasty, or left internal mammary artery (LIMA) bypass grafting in patients with 1-vessel, proximal LAD disease. We retrospectively analyzed prospectively collected data from 1,188 patients first presenting only with proximal LAD disease at 1 center over 9 years. We assessed the rates of death, acute myocardial infarction, and repeat intervention by initial treatment over a median 5.7 years of follow-up. Patients undergoing angioplasty or LIMA bypass were more often men and had progressive or unstable angina; those receiving medical therapy had a lower median ejection fraction. Both revascularization procedures offered slightly better adjusted survival versus medicine (hazard ratio for angioplasty, 0.82; 95% confidence interval, 0.60 to 1.11; hazard ratio for bypass, 0.74; 95% confidence interval, 0.44 to 1.23). Bypass, but not angioplasty, was associated with significantly fewer composite end point events (death, infarction, or reintervention, p <0.0001), and angioplasty was associated with a higher composite event rate than bypass or medical therapy (p <0.0001 and p = 0.0003, respectively). The initial advantages of bypass and medicine over angioplasty diminished over time; angioplasty became more advantageous than medicine after 1 year (p = 0.05) and not significantly different from bypass. Treatment of 1-vessel, proximal LAD disease with medicine, angioplasty, or UMA bypass resulted in comparable adjusted survival. However, LIMA bypass alone reduced the long-term incidence of infarctions and repeat procedures.

Topics: Aged; Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiac Output, Low; Cardiovascular Agents; Cohort Studies; Confidence Intervals; Coronary Disease; Disease Progression; Female; Follow-Up Studies; Humans; Incidence; Internal Mammary-Coronary Artery Anastomosis; Male; Middle Aged; Myocardial Infarction; Odds Ratio; Proportional Hazards Models; Prospective Studies; Reoperation; Retreatment; Retrospective Studies; Sex Factors; Stroke Volume; Survival Rate; Treatment Outcome

Percutaneous coronary revascularization frequently relieves angina in patients with ischemic heart disease and may obviate the need for antianginal medications.. To examine the use of antianginal medications after successful percutaneous coronary revascularization.. Retrospective cohort study of the Mayo Clinic PTCA [percutaneous transluminal coronary angioplasty] Registry.. Tertiary care center.. 3831 patients who underwent successful percutaneous coronary revascularization from September 1979 through August 1997 and had not had myocardial infarction within the year before the intervention.. Use of antianginal medications (beta-adrenergic blockers, nitrates, and calcium-channel blockers) before the intervention, at hospital discharge, and 6 months after the intervention.. 99% of patients reported improvement in their symptoms at hospital discharge. At 6 months, 87% of patients were free of myocardial infarction, coronary bypass surgery, or additional percutaneous intervention. Compared with 66% of patients before the index intervention, only 12% of patients had severe angina at 6 months and 69% were completely free of angina. Nonetheless, at 6 months, 39% of patients were receiving beta-adrenergic blockers (preprocedure proportion, 43%; P < 0.001), 36% were receiving nitrates (preprocedure proportion, 41%; P < 0.001), and 57% were receiving calcium-channel blockers (preprocedure proportion, 50%; P < 0.001). These trends persisted for patients without hypertension and those who had complete revascularization.. Successful percutaneous coronary revascularization did not substantially supplant the use of antianginal medications, which were commonly used despite the marked improvement in anginal status. This may reflect reluctance to alter therapy once symptoms of angina subside. Guidelines on continued medical therapy after percutaneous coronary revascularization are needed.

Topics: Adrenergic beta-Antagonists; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Female; Follow-Up Studies; Humans; Male; Middle Aged; Nitrates; Postoperative Period; Retrospective Studies

This study examined the prognostic value of single-photon emission computed tomography in angiographically high-risk patients with left main and/or 3-vessel coronary artery disease who were treated medically. Multivariable Cox survival analysis revealed the single-photon emission computed tomography score (based on size of perfusion abnormality, multivessel abnormality, left ventricular dilation, and lung uptake) as the only independent predictor of outcome.

Topics: Adenosine; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Electrocardiography; Exercise Test; Female; Follow-Up Studies; Humans; Injections, Intravenous; Male; Middle Aged; Observer Variation; Retrospective Studies; Thallium Radioisotopes; Tomography, Emission-Computed, Single-Photon; Treatment Outcome; Vasodilator Agents

To describe variations by age, sex, symptom severity and hospital region in the use of various medications amongst patients with stable angina pectoris who are candidates for coronary revascularization.. Patients (n = 2030) with chronic stable angina pectoris participating in a national survey evaluating the appropriateness of the use of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG).. As part of a national study of the appropriateness of coronary revascularization, data were prospectively collected on patients referred for consideration of coronary revascularization to seven of the eight public Swedish heart centres that performed approximately 92% of all bypass operations in Sweden in 1994.. Amongst all patients 76% were treated with beta blockers, 41% with calcium antagonists and 71% with long-acting nitrates and 70% were treated with at least two of these three drugs. Eighty-two per cent of the patients used aspirin and 14% lipid-lowering drugs. According to logistic regression analysis, with medication as the dependent variable and independent variables of age, sex, angina functional class, findings at exercise test, history of various diseases and region in Sweden where the investigation took place, the most consistent factor explaining the use of various medications was found to be geographical region. A previous history of acute myocardial infarction (AMI) was also associated with the use of all drugs and age was associated with all with the exception of beta blockers. Sex was not an independent factor explaining the use of any of the drugs.. In a national survey including patients with stable angina pectoris who are potential candidates for coronary revascularization, the most important predictor for the use of various medications was the geographical region in which the investigation took place.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Humans; Hypolipidemic Agents; Male; Middle Aged; Prospective Studies; Severity of Illness Index; Sex Factors; Sweden

Little information is available on the long-term evolution of left ventricular function of medically treated patients with coronary artery disease and gross limitation of coronary flow reserve. The aim of this study was to assess the long-term evolution of effort tolerance and left ventricular function and their relation to the control of ischemic events in patients with coronary artery disease and prolonged inducible exercise-induced myocardial dysfunction who either declined or were ineligible for cardiac revascularization.

Topics: Aged; Amlodipine; Anti-Arrhythmia Agents; Atenolol; Cardiovascular Agents; Coronary Disease; Data Interpretation, Statistical; Diastole; Diltiazem; Drug Therapy, Combination; Echocardiography; Electrocardiography, Ambulatory; Exercise Test; Follow-Up Studies; Humans; Middle Aged; Nifedipine; Nitrates; Stroke Volume; Systole; Time Factors; Vasodilator Agents; Ventricular Function, Left

Topics: Abciximab; Alanine; Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Antibodies, Monoclonal; Aspirin; Benzamidines; Biphenyl Compounds; Cardiology; Cardiovascular Agents; Clinical Trials as Topic; Clopidogrel; Combined Modality Therapy; Coronary Disease; Dalteparin; Defibrillators, Implantable; Double-Blind Method; Enalapril; Endothelial Growth Factors; Fatty Acids, Omega-3; Guanidines; Heart Failure; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Immunoglobulin Fab Fragments; Laser Therapy; Lymphokines; Metoprolol; Multicenter Studies as Topic; Myocardial Revascularization; Platelet Aggregation Inhibitors; Pyrrolidines; Randomized Controlled Trials as Topic; Simvastatin; Sodium-Hydrogen Exchangers; Stents; Sulfones; Thrombolytic Therapy; Ticlopidine; Tissue Plasminogen Activator; Vascular Endothelial Growth Factor A; Vascular Endothelial Growth Factors; Vitamin E

The CD40 ligand (CD40L) on activated T cells and platelets may be activating matrix metalloproteinases, inducing procoagulant activity, and be involved in the pathogenesis of acute coronary syndromes by promoting plaque rupture in atheroma.. To study the role of CD40L-CD40 interaction in coronary disease, we analyzed levels of soluble (s) and membrane-bound CD40L in the peripheral blood from 29 patients with stable angina, 26 with unstable angina, and 19 controls. Our main findings follow. (1) Patients with unstable angina had significantly raised serum levels of sCD40L when compared with patients with stable angina and controls. (2) Platelets could release large amounts of sCD40L when stimulated ex vivo with the thrombin receptor-agonist peptide SFLLRN in both patients and controls. (3) Platelets in patients with unstable angina were characterized ex vivo by decreased intracellular levels and decreased SFLLRN-stimulated release of sCD40L, which may possibly represent a higher percentage of degranulated platelets in these patients. (4) T cells in patients with unstable angina had enhanced surface expression of CD40L and increased release of sCD40L on anti-CD3/anti-CD28 stimulation in vitro when compared with patients with stable angina and controls. (5) Recombinant CD40L and serum from patients with unstable angina who had high sCD40L levels induced enhanced release of monocyte chemoattractant peptide-1 from mononuclear cells, a CC-chemokine involved in the pathogenesis of atherosclerosis.. This first demonstration of enhanced levels of soluble and membrane-bound forms of CD40L in angina patients, with particularly high levels in patients with unstable angina, suggests that CD40L-CD40 interaction may play a pathogenic role in both the long-term atherosclerotic process and in the triggering and propagation of acute coronary syndromes.

Topics: Acute Disease; Aged; Angina Pectoris; Angina, Unstable; Blood Platelets; Cardiovascular Agents; CD4-Positive T-Lymphocytes; CD40 Antigens; CD40 Ligand; CD8-Positive T-Lymphocytes; Cell Membrane; Chemokine CCL2; Cholesterol; Coronary Disease; Cytoplasmic Granules; Female; Humans; Male; Membrane Glycoproteins; Metalloendopeptidases; Middle Aged; Peptide Fragments; Platelet Activation; Rupture, Spontaneous; Smoking; Solubility; Syndrome; Triglycerides; Vasculitis

Therapeutic options in acute coronary syndrome (unstable angina pectoris/non-Q-wave myocardial infarction), as also in acute Q-wave infarction, include conservative medical and mechanical-interventional measures. Early hospitalization for surveillance and induction of treatment is always necessary. Administration of oxygen, analgesia, sedation and treatment with nitrates, beta blockers or calcium antagonists, acetylsalicylic acid (ASA) and heparin are the basic measures. As alternatives to ASA, the new ADP antagonists, ticlopidine, clopidogrel, and as an alternative to heparin, hirudin or low-molecular-weight heparins can be used. If this does not result in rapid clinical stabilisation (here, transient ST-T changes in the ECG and the detection of troponine I or T represent major risk indicators) the new glycoprotein-IIb/IIIa receptor antagonists may be employed as highly potent platelet aggregation inhibitors. In addition, the patients should then undergo coronary angiography prior to interventional treatment of the underlying coronary stenosis.

Topics: Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Humans; Myocardial Infarction; Survival Rate; Treatment Outcome

Cardiovascular stress testing remains the mainstay of provocative evaluation for patients with known or suspected coronary artery disease. Stress echocardiography has become a valuable means of cardiovascular stress testing. It plays a crucial role in the initial detection of coronary disease, in determining prognosis, and in therapeutic decision making. The purpose of this document is to outline the recommended methodology for stress echocardiography with respect to personnel and equipment as well as the clinical use of this recently developed technique. Specific limitations will also be discussed.

Topics: Cardiovascular Agents; Contraindications; Coronary Disease; Echocardiography; Exercise Test; Humans

We evaluated ambulatory prescriptions by general practitioners for outpatients with cardiovascular (CV) disease referred to the cardiology outpatient clinic of the Frankfurt University Hospital in order to prove adherence to generally acknowledged therapy standards for treating CV disease.. Appropriateness of current CV medication was assessed according to the following criteria: aspirin or anticoagulants obligatory after myocardial infarction (MI), unless contraindicated; beta-blockers should be prescribed after MI, unless contraindicated or not tolerated; ACE inhibitors should be given in left ventricular dysfunction (LVD) after MI, unless contraindicated; and hypertension should be adequately controlled. 346 patients (28-94 years) received a median of 3 CV drug prescriptions (range 0-7). 240 patients had CAD, 142 patients previous MI, 121 patients had LVD (59 after MI), 143 patients were hypertensive. Aspirin was used appropriately in 80% of all MI patients, 13% received oral anticoagulants due to atrial fibrillation. However, 7% received no antithrombotic therapy. ACE inhibitors were administered in 65% of the MI patients with LVD. beta-blockers were used in 25% of the MI-patients. In the remaining patients, beta-blockers were contraindicated, not tolerated, and/or verapamil had been prescribed. However, in 14% of the patients beta-blockers were withheld without evident reason or alternative drug. In 41% of the hypertensive patients, blood pressure was not sufficiently controlled.. A considerable number of ambulatory prescriptions for CV drugs are not in accordance with current therapeutic guidelines. The role of a cardiology outpatient clinic to detect the misuse or underuse of CV drugs is emphasised.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Disease; Drug Prescriptions; Drug Utilization; Germany; Humans; Hypertension; Middle Aged; Myocardial Infarction; Outpatient Clinics, Hospital; Prospective Studies

Topics: Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Fibrinolytic Agents; Humans; Risk Factors; Treatment Outcome

The impact of coronary heart disease (CHD) on elderly patients' functional abilities is of growing interest because of the increasing number of people that survive the disease. The aim of our study was, firstly, to describe functional abilities among elderly CHD patients and, secondly, to analyze the relationships between physical disability and the severity of chest pain or dyspnea. The third aim was to assess whether there is an independent association between physical disability and CHD. The study was carried out at the health center of the municipality of Lieto, southwestern Finland. From a population of 1196 community-dwelling persons aged > or = 64 years, 89 men and 73 women with CHD (angina pectoris and/or a past myocardial infarction) were selected along with 178 male and 146 female sex- and age-matched controls without CHD. Physical functioning was assessed by means of interviewer-based questionnaires, compared between patients and controls and described in relation to the severity of chest pain and dyspnea among patients. The associations between dependence or difficulties in mobility, ADL (activities of daily living) and IADL (instrumental activities of daily living) and CHD, age, smoking, comorbidities, drug therapy and clinical characteristics were assessed by logistic regression analyses. On items representing mobility and managing in IADL, patients reported more difficulties or dependence than controls. Among female patients, more severe chest pain was associated with poor managing in IADL and tended to be associated with poor mobility. More severe dyspnea was associated with poor mobility among both male and female patients, and with poor managing in IADL among male patients. Logistic regression analyses failed to show that CHD was associated independently with physical disability among the elderly. However, physical disability was associated with the use of cardiovascular drugs in the models among both genders, which probably indirectly indicated an association between physical disability and CHD. Several confounding factors, such as higher age, depression, cancer and the use of psychotropic drugs, contributed to the decline in functional abilities even among persons with CHD. In conclusion, elderly CHD patients have greater limitations in their functional ability than matched controls, which may depend on the severity of the disease. Especially male patients' limitations in physical abilities may be influenced by the fact that men with C

Topics: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Cardiovascular Agents; Case-Control Studies; Chest Pain; Coronary Disease; Disability Evaluation; Dyspnea; Female; Humans; Logistic Models; Male; Middle Aged; Smoking

There is a continuous increase in the number of percutaneous transluminal coronary angioplasty procedures performed per year per population in most industrialised countries. This analysis searches for trends in treatment decisions after diagnostic coronary angiography.. The degree of coronary artery disease and the therapeutic strategy were determined retrospectively in consecutive patients undergoing coronary angiography at a Swiss university hospital during three different time periods in the past 11 years (n = 750 in 1994, n = 500 in 1990, and n = 545 in 1983). The indication for coronary angioplasty rose from 45% in 1983 to 78% in 1990 and 87% in 1994 in patients with one-vessel disease, from 25% to 38% and 71% in patients with two-vessel disease, and from 10% to 24% and 29% in patients with three-vessel disease. In contrast, the use of conservative therapy declined with time, independent of the severity of coronary artery disease. Indications for coronary artery bypass grafting decreased in patients with two-vessel disease, but did not change in patients with three-vessel disease over the 11 year period.. The use of coronary angioplasty, bypass surgery, and conservative therapy changed drastically over the past decade, with an increasing use of angioplasty and a multivessel disease, and of bypass surgery in two-vessel disease. The expansion of coronary angioplasty is mainly related to increased use in patients previously treated conservatively.

Topics: Adult; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Disease; Female; Hospitals, University; Humans; Male; Middle Aged; Retrospective Studies; Switzerland

In-stent restenosis results primarily from neointimal hyperplasia. This study evaluated the efficacy and the optimal mode of administration of angiopeptin, a somatostatin analogue with antiproliferative activity, in a porcine coronary in-stent restenosis model.. Forty pigs were randomly assigned to one of four groups (n = 10 per group): (1) controls receiving saline infusion at the site of stent implantation via a local delivery catheter, (2) local treatment group receiving one-time treatment (200 (micrograms angiopeptin) at the site of stent placement, (3) systemic treatment group receiving continuous angiopeptin over a 1-week period via a subcutaneous osmotic pump (200 micrograms/kg total dose) and (4) combined local and systemic treatment group. Then, one oversized Palmaz-Schatz stent (mean ratio of stent to artery diameters, 1.3:1) was implanted in the left anterior descending coronary artery. The degree of neointimal reaction was evaluated 4 weeks later by angiography (maximal percent diameter stenosis), intravascular ultrasound (total in-stent neointimal volume), and histology (maximal area stenosis). Systemic treatment produced the least neointimal hyperplasia and significantly reduced in-stent restenosis compared with the control group by all end points, despite similar degrees of injury. Angiography showed 25 +/- 17% versus 50 +/- 17% diameter stenosis in the systemic angiopeptin group versus the control group (P < .0001), intravascular ultrasound revealed 23 +/- 10 versus 58 +/- 27 mm3 neointimal volume in the systemic angiopeptin versus control group (P = .0002), and histology showed 41 +/- 16% versus 69 +/- 18% area stenosis (P = .0016) in the systemic angiopeptin versus control group. Plasma angiopeptin levels revealed rapid clearance (within 6 hours) after local therapy, whereas the levels persisted for up to 2 weeks in the systemic group.. This study shows that continuous subcutaneous treatment with angiopeptin after stent implantation significantly reduces in-stent restenosis by inhibiting neointimal hyperplasia.

Topics: Animals; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Hyperplasia; Injections, Subcutaneous; Oligopeptides; Peptides, Cyclic; Recurrence; Somatostatin; Stents; Swine; Tunica Intima; Ultrasonography, Interventional

Topics: Animals; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Heart; Humans

In-stent restenosis results primarily from neointimal hyperplasia. In a previous study we showed that continuous subcutaneous Angiopeptin infusion for 1 week significantly reduces neointimal hyperplasia in a porcine coronary overstretch in-stent restenosis model. The present study evaluated the relative efficacy of immediate-release and sustained-release Angiopeptin in the same model.. Thirty pigs (n = 10 in each group) were randomly assigned to three groups: controls receiving no Angiopeptin (Group 1); a sustained-release treatment group receiving one time intramuscular administration of 20 mg of Angiopeptin (Group 2); and a systemic treatment group receiving continuous Angiopeptin over a 1-week period via a subcutaneous osmotic pump (200 micrograms/kg total dose) (Group 3). One oversized Palmaz-Schatz stent (mean stent/artery = 1.25) was subsequently implanted in the left anterior descending coronary artery. The degree of neointimal reaction was evaluated 4 weeks later by angiography (maximal per cent diameter stenosis) and histology (maximal neointimal area corrected for injury score).. A trend towards a reduction in diameter stenosis was observed by angiography, despite a similar degree of injury (25 +/- 17% in Group 1, 13 +/- 8% in Group 2, and 14 +/- 9% in Group 3; P = 0.072 by ANOVA). Histology demonstrated that both Angiopeptin treatment strategies significantly reduced in-stent neointimal area compared with the control group (1.65 +/- 0.97 mm2 in Group 1 versus 0.93 +/- 0.41 mm2 in Group 2 versus 0.85 +/- 0.28 mm2 in Group 3; P = 0.016 by ANOVA). Measurement of plasma Angiopeptin levels revealed comparable levels in both treatment groups, which persisted for up to 2 weeks.. This study shows that single-dose intramuscular administration of sustained-release Angiopeptin reduces in-stent restenosis as effectively as the prolonged systemic treatment requiring a subcutaneous pump. Thus, a practical, effective, pharmacologic therapy for preventing in-stent restenosis may be available and should be evaluated in patients.

Topics: Animals; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Vessels; Hyperplasia; Injections, Intramuscular; Oligopeptides; Peptides, Cyclic; Radioimmunoassay; Random Allocation; Somatostatin; Stents; Swine; Tunica Intima

To investigate the prevalence of and indications for digoxin use and the prevalence of beta blocker and calcium channel blocker use in older patients with previous myocardial infarction or coronary artery disease (CAD), and the prevalence of use of diuretics, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers in older patients with hypertension in an academic hospital-based geriatrics practice.. A retrospective analysis of charts from 528 unselected older patients, seen from June 1995 through July 1996 at an academic hospital-based geriatrics practice, was performed to investigate the prevalence of digoxin use and indications for digoxin use, the prevalence of beta blocker and calcium channel blocker use in older patients with previous myocardial infarction or coronary artery disease (CAD), and the prevalence of use of diuretics, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers in older patients with hypertension.. An academic hospital-based, primary care geriatrics practice staffed by fellows in a geriatrics training program and full-time faculty geriatricians.. A total of 416 women and 112 men, mean age 81 +/- 8 years (range 58 to 101), were included in the study.. Ninety-two of the 528 patients (17%) were taking digoxin. Recorded indications for digoxin were atrial fibrillation with or without congestive heart failure (CHF) in 39% of patients, CHF with sinus rhythm and abnormal left ventricular ejection fraction (LVEF) in 18% of patients, a clinical assessment of CHF with sinus rhythm and no recorded measurement of LVEF in 20% of patients, paroxysmal atrial fibrillation in 14% of patients, and coronary artery disease (CAD) in 9% of patients. Of 121 patients with previous myocardial infarction, 23 (19%) were prescribed beta blockers, and 54 (45%) were taking calcium channel blockers. Of 173 patients with CAD, 41 (24%) were treated with beta blockers, and 79 (46%) were taking calcium channel blockers. LVEF was not recorded in the charts of 90 of 121 patients (74%) with prior myocardial infarction and of 125 of 173 patients (72%) with CAD. Of 480 older patients with hypertension, 154 (37%) were treated with diuretics, 55 (13%) were treated with beta blockers, 160 (38%) were treated with ACE inhibitors, and 197 (47%) were treated with calcium channel blockers.. In 528 older patients seen in an academic hospital-based geriatrics practice, the prevalence of digoxin use was 19%. Appropriate indications for digoxin were documented clearly in the charts of 53 of 92 patients (57%). Calcium channel blockers were used more often than beta blockers in patients with previous myocardial infarction or CAD. Calcium channel blockers were the most frequently used antihypertensive drugs.

Topics: Academic Medical Centers; Adrenergic beta-Antagonists; Age Factors; Aged; Aged, 80 and over; Ambulatory Care Facilities; Angiotensin-Converting Enzyme Inhibitors; Arrhythmias, Cardiac; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Digoxin; Diuretics; Drug Utilization; Female; Geriatrics; Heart Failure; Humans; Hypertension; Male; Middle Aged; Myocardial Infarction; Retrospective Studies

The present study was performed to compare coronary flow reserve by transesophageal Doppler echocardiography and intracoronary Doppler flow wire measurements in patients with LAD disease.. 17 patients with various degree of LAD stenosis were studied. Intracoronary LAD Doppler measurements were performed at baseline and after intracoronary injection of 18 micrograms adenosine. Transesophageal coronary sinus and LAD Doppler measurements were performed at baseline and after intravenous dipyridamole (0.6 mg/kg/5 min). Coronary flow reserve was calculated as the ratio of hyperemic to baseline average peak velocities.. Coronary flow reserve was 2.44 +/- 0.62 and 2.19 +/- 0.76 for proximal and distal intracoronary measurements and was 2.25 +/- 0.64 and 1.74 +/- 0.63 for transesophageal LAD- and coronary sinus measurements. Proximal intracoronary flow reserve significantly correlated with transesophageal coronary sinus (r = 0.73, p < or = 0.001) and LAD (r = 0.70, p < or = 0.005) measurements, whereas distal intracoronary flow reserve only correlated with transesophageal coronary sinus flow reserve (r = 0.56, p < or = 0.02). Receiver operating characteristic curve analysis demonstrated similar diagnostic accuracy of all applied techniques for detection of a significant LAD stenosis.. Coronary flow reserve by both transesophageal techniques correlated with intracoronary Doppler flow wire measurements, however considerable discrepancies may occur in the individual patient.

Topics: Adenosine; Cardiovascular Agents; Coronary Angiography; Coronary Circulation; Coronary Disease; Dipyridamole; Echocardiography, Doppler; Echocardiography, Transesophageal; Female; Humans; Male; Middle Aged; Sensitivity and Specificity; Ultrasonography, Interventional; Vasodilator Agents

The perioperative risk in patients undergoing coronary artery bypass grafting (CABG) might be influenced by premedication procedures. This study was undertaken to evaluate present premedication regimens in CABG patients in Germany.. Using a detailed written questionnaire, each of the 58 German centres of cardioanaesthesia were asked to complete it.. 37 (64%) of all questionnaires were returned and analysed. All centres used orally administered drugs for premedication in the evening before the operation. Flunitrazepam is the most often administered drug (54%), followed by dipotassium clorazepat (8%), and diazepam (8%). Premedication in the morning on the day of surgery is performed orally in 29 centres (78%), of which 18 centres (49%) prefer flunitrazepam and 6 centres (16%) midazolam as first choice. In contrast, 7 centres (19%) used intramuscularly administered regimens. 5 centres (14%) combined intramuscularly opioids with sedatives for that indication. If anaesthesia was induced late in the morning or in the afternoon, respectively, 11 centres (30%) administered additional benzodiazepines early in the morning. 68% of all centres maintained the administration of chronic treatment with ss-blockers until the morning of the operating day. Chronic treatment with nitrates is continued in 65%, treatment with calcium-channel blockers in 62%. Angiotensin converting enzyme inhibitors are continued in 30%, alpha 2-agonists in 27%, other antihypertensive drugs in 19%, and inotropic glycosids in 11%. 31 of 37 centres (84%) discontinued the administration of acetylsalicylic acid 5 or more days prior to surgery, but 68% tolerate individual exceptions from this principle.. The results of our survey indicate that most of the German cardioanaesthesia centres use oral premedication regimens in patients undergoing coronary revascularisation. Anti-anginal medications, with the exception of anti-platelet agents, were continued until the day of surgery in most of the centres.

Topics: Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Utilization; Germany; Humans; Hypnotics and Sedatives; Preanesthetic Medication; Risk Factors

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Decision Making; Humans

When improvement in prognosis of patients with coronary artery disease is the goal, the physician must be knowledgeable about the patient-related factors and the fact that therapies influence prognosis in such patients. Further, the clinician must be very specific in choice of therapeutic agents directed toward improvement of prognosis, and this process must include prescriptions of appropriate formulation and dosage.

Topics: Cardiovascular Agents; Coronary Disease; Humans; Prognosis

Smoking prevalence had been steadily decreasing in the United States until 1993 when the rate stabilized. In 1993 there were 46 million adult smokers, which represented 25% of adults aged 18 years and older. Between 1983 and 1993, smoking prevalence among white men declined from 34% to 27% and from 41% to 32% in black men. Smoking prevalence among women declined from 30% to 27%. Currently, smoking prevalence is still higher for men than women, 28% and 23% respectively. More than 70% of adults began their daily habit of smoking by the age of 18 years. The frequency of this habit is highest among Native Americans/Native Alaskans (39%) compared with that of other ethnic groups. It is interesting that smoking prevalence is highest among men who are high-school dropouts (42%). Our role as healthcare providers is clear. We must protect our patients and society from the consequences of smoking. But healthcare professionals must first lead by example. Although the frequency of smokers is decreasing in this segment of society, it was still 18% for RNs and 27% for licensed practical nurses in 1991. Among physicians, the frequency of smokers has decreased from 19% in 1976 to 3% in 1991. With respect to effects on human health and the costs of tobacco use, our direction, responsibility, and duty to our patients and society are very clear.

Topics: Adult; Cardiovascular Agents; Coronary Disease; Female; Humans; Male; Middle Aged; Smoking

Topics: Aged; Blood Pressure; Cardiovascular Agents; Coronary Disease; Diltiazem; Electrocardiography; Heart Rate; Humans; Metoprolol; Middle Aged; Nitroglycerin; Plethysmography; Signal Processing, Computer-Assisted

We hypothesized that microvascular reserve is a better indicator of the extent of viable myocardium postinfarction than contractile reserve, especially in the presence of a residual stenosis of the infarct-related artery.. Fifteen dogs with various infarct sizes were studied after reperfusion. Contractile reserve, studied by use of dobutamine echocardiography, and microvascular reserve, studied by use of myocardial contrast echocardiography, were measured both before and after creation of a stenosis. In the absence of a stenosis, the relation between infarct size, expressed as percent of risk area, and wall thickening improved with increasing doses of dobutamine (r = .41, .71, and .90 for 5, 10, and 15 micrograms.kg-1.min-1, respectively; P < .01 for dobutamine 15 micrograms.kg-1.min-1). In the presence of a stenosis, however, the relation was poor for all doses of dobutamine (r = .22, .57, and .32 for 5, 10, and 15 micrograms.kg-1.min-1, respectively; P < .01 for 15 micrograms.kg-1.min-1 dobutamine in the absence of a stenosis). There was a fair correlation between infarct size and perfusion defect size on myocardial contrast echocardiography after reperfusion (r = .82), with the defect size underestimating infarct size by approximately 20%. This relationship improved (P < .01) during infusions of both adenosine (r = .99) and dobutamine (r = .94) in the absence of a stenosis. The correlations between infarct size and perfusion defect on myocardial contrast echocardiography also remained good in the presence of a stenosis (r = .95 and .81 for adenosine and dobutamine, respectively; P = NS compared with stenosis).. Microvascular reserve is superior to contractile reserve for definition of the spatial topography of necrosis and hence the extent of viable myocardium within the infarct bed after reperfusion, particularly when a residual stenosis is present in the infarct-related artery.

Topics: Adenosine; Animals; Cardiotonic Agents; Cardiovascular Agents; Contrast Media; Coronary Circulation; Coronary Disease; Dobutamine; Dogs; Echocardiography; Microcirculation; Myocardial Contraction; Myocardial Ischemia; Myocardial Reperfusion; Salvage Therapy

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Drug Evaluation; Humans; Myocardial Ischemia

Topics: Actuarial Analysis; Adult; Cardiovascular Agents; Cholesterol; Coronary Disease; Creatinine; Diltiazem; Female; Follow-Up Studies; Graft Rejection; Heart Transplantation; Humans; Male; Middle Aged; Prevalence; Survival Rate; Tissue Donors

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Humans; Oligopeptides; Peptides, Cyclic; Somatostatin

Topics: Adrenergic beta-Antagonists; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Humans; Intraoperative Complications; Myocardial Ischemia; Postoperative Complications

Topics: Aortic Valve Stenosis; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Digitalis Glycosides; Drug Therapy, Combination; Humans; Hypertension

Causes of decompensation of treated chronic congestive heart failure in patients referred for emergency hospitalization were examined prospectively. 111 consecutive patients (76 +/- 11 years) were interviewed and their records examined on admission. The diagnosed underlying diseases were coronary artery disease (80%), hypertensive heart disease (40%), valvular heart disease (11%), and idiopathic dilated (7%) and alcoholic (5%) cardiomyopathy. The grounds for decompensation of chronic congestive heart failure were: insufficient compliance 47% (n = 52, irregular or not intake of medication [25%], salt [9%] or fluid [7%] excess, stopping medication because of side effects [6%]), uncontrolled hypertension (27%), insufficient diuretic therapy in spite of progressive symptoms (23%), treatment with negative inotropic drugs (21%), acute rhythm disturbances (14%), acute myocardial infarction or unstable angina pectoris (14%), infections (6%). 80% of the patients were treated with diuretics, 34% with digoxin, 31% with ACE-inhibitors. Insufficient basic knowledge about the disease (regular weighing, diet, behavior if symptoms worsen) was found in 78% of patients, complete lack of knowledge concerning the prescribed drugs in 29%. Only 44% were regularly followed by their physicians, 53% had either no regular follow-ups or they were set at too long intervals.. In the majority of patients, one or more avoidable causes leading to decompensation of chronic congestive heart failure can be identified. The main potential for intervention aiming at a reduction of the hospitalization frequency lies in improving patient compliance and state of the art medication by the primary care physician. Equally unsatisfactory is the low frequency of follow-up checks to reassess and renew drug therapy.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Diet; Drug Prescriptions; Female; Heart Failure; Hospitalization; Humans; Hypertension; Male; Middle Aged; Patient Compliance; Patient Education as Topic; Prospective Studies; Sick Role

This article discusses exercise testing in valvular heart disease, hypertension, and the evaluation of patients for surgery. It also provides information on the effects of drugs on the exercise test and the clinical significance of block patterns and arrhythmias encountered during exercise.

Topics: Arrhythmias, Cardiac; Cardiac Rehabilitation; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Disability Evaluation; Electrocardiography; Exercise Test; Heart Valve Diseases; Hemodynamics; Humans; Prognosis

Topics: Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Humans; Myocardial Infarction; Survival Rate

In choosing drugs for treatment of ischemic heart disease or hypertension one has--next to effects on angina or blood pressure--to consider possible influences on long term course. A simple dosing-scheme with a low number of tablets as well as a thorough information of the patient about the prescribed medication are equally important for the therapeutic success.

Topics: Adrenergic beta-Antagonists; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Drug Tolerance; Humans; Hypertension

Topics: Cardiomyopathies; Cardiovascular Agents; Coronary Disease; Humans

A comparison of cardiovascular drug sales and cardiovascular mortality was made between two Swedish counties (Värmland and Malmöhus) and between two rural municipalities in those counties (Torsby in Värmland and Hörby in Malmöhus). Cardiovascular drug sales (defined daily doses (DDD) per 1,000 inhabitants per day) during 1986-87 were 25% higher in Värmland than in Malmöhus county, and the age-standardized mortality of coronary heart disease (CHD) was 36% (men) and 54% (women) higher. In Torsby, age-standardized CHD mortality (1986-87) was 71% (both sexes) higher than in Hörby, and the sales of cardiovascular drugs (1978-87) were 58% higher. Statistically, every third inhabitant of Torsby took one DDD of a cardiovascular drug every day, as compared to every fifth inhabitant in Hörby. In Torsby there was a 6% higher serum cholesterol, 71% lower tap water hardness, 33% lower income, a lower educational level, a three-fold higher unemployment rate, and a different ethnic background (20% eastern Finnish ancestry), all factors assumed to promote a high CHD rate. All of these factors may contribute to the higher CHD mortality, which was in turn reflected in higher sales of cardiovascular drugs.

Topics: Adult; Aged; Blood Pressure; Cardiovascular Agents; Cholesterol; Coronary Disease; Drug Utilization; Ethnicity; Female; Humans; Male; Middle Aged; Population Density; Risk Factors; Socioeconomic Factors; Sweden

Topics: Adult; Aged; Blood Flow Velocity; Cardiovascular Agents; Carotid Arteries; Coronary Disease; Hemodynamics; Humans; Hypertension; Lung Diseases, Obstructive; Male; Middle Aged; Pacemaker, Artificial; Pulse

The effects of N-]4-(2-(2-[4-(methanesulphonamide)phenoxy]-N- methylethylamino)ethyl)phenyl]methanesulphonamide, free base (UK-68,798) (30 and 100 micrograms/kg i.v.), a class III antiarrhythmic with potassium channel blocking activity, on regional ventricular function during exercise-induced ischemia in conscious dogs were compared to those of 1,3,4,5-tetrahydro-7,8-dimethoxy-3-[3-(]2-ad3,4- dimethoxyphenyl]ethyl)methylamino)propyl]-2H-3-benzazepin-2-one, hydrochloride (UL-FS 49) (500 micrograms/kg, i.v.), a specific bradycardic agent. Studies were performed in chronically instrumented dogs trained to run on a motor-driven treadmill. After stenosis of the left anterior descending coronary artery, dogs were submitted to a submaximal exercise. UK-68,798 did not change the resting heart rate, but reduced exercise heart rate by 6.5 and 13.5% at 30 and 100 micrograms/kg, respectively (P less than .05). In a normal area, both doses of UK-68,798 slightly increased regional function. In an ischemic area, the lower dose of UK-68,798 (30 micrograms/kg) was without effect. At the higher dose (100 micrograms/kg), the ischemic dysfunction was worsened, because the percent systolic shortening was reduced from 22.6 +/- 2.6% in the control exercise to 11.1 +/- 5.6% in the presence of UK-68,798 (P less than .05). UL-FS 49 (500 micrograms/kg) reduced heart rate before and during exercise. At rest, UL-FS 49 slightly increased systolic shortening in normal and ischemic areas. In the ischemic area, UL-FS 49 reversed the exercise-induced dysfunction. Before and during exercise, UL-FS 49 (500 micrograms/kg) prolonged diastolic time significantly more than UK-68,798 (100 micrograms/kg; P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Animals; Anti-Arrhythmia Agents; Benzazepines; Cardiovascular Agents; Coronary Disease; Dogs; Electrocardiography; Female; Heart; Heart Rate; Male; Myocardial Contraction; Phenethylamines; Physical Conditioning, Animal; Potassium Channels; Sulfonamides

The effects of UL-FS 49, a specific bradycardic agent, on systemic hemodynamics, regional myocardial function (sonomicrometry, percentage of segment shortening), and regional coronary blood flow (radioactive microspheres) were studied in open-chest, anesthetized dogs with severe left circumflex coronary artery (LCX) stenosis. UL-FS 49 was administered as two sequential bolus injections of 0.25 mg/kg. Heart rate decreased from 149 +/- 13 beats/min to 102 +/- 6 and 77 +/- 4 beats/min after 0.25 and 0.5 mg/kg cumulative doses of UL-FS 49, respectively. The reduction in heart rate was not associated with any significant change in left ventricular pressure or mean arterial pressure, left ventricular dp/dt, or coronary vascular resistance. Similarly no hemodynamic changes occurred with atrial pacing to the initial heart rate. Application of an LCX stenosis of sufficient severity to produce a 50% reduction in mean LCX blood flow (44 +/- 4 to 22 +/- 2 ml/min) resulted in a significant reduction in the percentage of segment shortening in the ischemic zone (9.8 +/- 1.6% to 6.5 +/- 1.1%). The percentage of segment shortening in the ischemic zone progressively improved to 8.4 +/- 1.2% and 9.4 +/- 0.5% after 0.25 and 0.5 mg/kg UL-FS 49, respectively. Subepicardial perfusion in the ischemic zone was decreased and subendocardial perfusion was increased after administration of UL-FS 49. Consequently the ischemic zone endocardial/epicardial ratio increased from 0.43 +/- 0.08 to 1.12 +/- 0.22 and 1.48 +/- 0.32 with low and high doses of UL-FS 49.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Animals; Benzazepines; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Depression, Chemical; Dogs; Female; Heart Rate; Hemodynamics; Male; Myocardial Contraction; Myocardium; Oxygen Consumption

Free radicals may cause part of the irreversible injury which occurs during myocardial infarction and reperfusion. In the present study MDL 73404, an alpha-tocopherol analogue which is a free radical scavenger has been evaluated for its effects on infarct size in an anaesthetised rat model of coronary artery ligation (60 min) and reperfusion (30 min). Intravenous infusion of the compound began 10 min before occlusion until the end of reperfusion. MDL 73404 (0.3-3 mg/kg per h) reduced infarct size, although not in a dose-related manner. Infusion of MDL 73404 (3 mg/kg per h) commencing 30 min before reperfusion until the end of reperfusion also induced a significant reduction in infarct size. In the isolated rat heart (Langendorff technique) subjected to 30 min no-flow global ischaemia, pretreatment with MDL 73404 (0.03 and 0.1 mM) in the perfusion buffer and during 30 min of reperfusion resulted in a significant increase in the maximal pressure development (+dP/dt max) and relaxation (-dP/dt max), left ventricular systolic pressure and heart rate during reperfusion, whereas left ventricular diastolic pressure was significantly reduced. In contrast, only one control heart out of five exhibited signs of recovery. Replacement, for 2 min, with a cardioplegic solution before the 30 min period of ischemia resulted in an increased heart rate and contractility during reperfusion compared to hearts that did not receive the cardioplegic solution. The presence of MDL 73404 (0.03 and 0.1 mM) in the perfusion fluid induced an additional increase in left ventricular systolic pressure to the pre-ischaemic levels. MDL 73404 may have potential for cardioprotective use in acute reperfusion of the myocardium following ischaemia.

Topics: Animals; Cardioplegic Solutions; Cardiovascular Agents; Coronary Disease; Free Radical Scavengers; In Vitro Techniques; Male; Myocardial Infarction; Myocardial Reperfusion Injury; Rats; Rats, Inbred Strains; Vitamin E

Topics: Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Humans; Myocardial Infarction; Thrombolytic Therapy

The effects of low dose human superoxide dismutase and low dose taprostene, a stable analogue of prostacyclin, were investigated separately and together in a model of myocardial ischemia (1.5 h) with reperfusion (4.5 h) in open chest, anesthetized cats. Taprostene (60 ng/kg per min), human superoxide dismutase (0.25 mg/kg per h), both agents together, or their vehicle, were infused intravenously in cats starting 0.5 h after occlusion of the left anterior descending coronary artery. Neither low dose taprostene nor low dose human superoxide dismutase exerted any endothelial or myocardial protection in this model. However, the two agents together showed a significant endothelial and myocardial protection in cats with myocardial ischemia and reperfusion. Compared with cats that were untreated or received only taprostene or human superoxide dismutase, cats receiving both agents exhibited a lower plasma creatine kinase activity at every time point observed after reperfusion, a reduced area of cardiac necrosis (7 +/- 2% vs. 21 +/- 5% area at risk, p less than 0.001), lower myeloperoxidase activity in the ischemic region (p less than 0.01) and a significant preservation of vasorelaxant responses of left anterior descending coronary rings to endothelium-dependent vasodilators, acetylcholine (p less than 0.001) and A-23187 (p less than 0.001). Taprostene appears to act additively with human superoxide dismutase to inhibit neutrophil adherence and activation and to inactivate superoxide radicals, and thus reduce cellular injury 4.5 h after reperfusion of the ischemic heart. Use of this agent may allow low doses of superoxide dismutase to be used more effectively in early myocardial ischemia.

Topics: Animals; Cardiovascular Agents; Cats; Coronary Disease; Drug Evaluation, Preclinical; Drug Synergism; Drug Therapy, Combination; Epoprostenol; Humans; Male; Myocardial Reperfusion Injury; Myocardium; Prostaglandins, Synthetic; Superoxide Dismutase

The authors present a system of computer control in drug therapy of cardiac patients aimed at preventing complications and adverse interactions of simultaneously administered drugs. The system includes data on the 196 most frequently used cardiac drugs and 433 other drugs showing clinically important interactions with cardiac drugs.

Topics: Algorithms; Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Drug Therapy, Computer-Assisted; Humans; Risk Factors; Software

To find a noninvasive method for estimating left ventricular end-systolic pressure, 40 patients were studied during cardiac catheterization. Arterial pressure was taken directly from the ascending aorta. Carotid pulse tracing and measurement of blood pressure by cuff sphygmomanometry were taken simultaneously. The tracings were calibrated and left ventricular end-systolic pressure was estimated directly and indirectly. Simple linear regression analysis gave the equations: (1) left ventricular end-systolic pressure direct = 0.56 left ventricular end-systolic pressure indirect + 43.8 (r = 0.61, P = 0.00004), and (2) left ventricular end-systolic pressure direct = 0.39 systolic arterial pressure indirect + 48.8 (r = 0.62, P = 0.00002). To test the accuracy of the technique the study was continued in 40 patients. Left ventricular end-systolic pressure was also estimated by the 2 equations. Left ventricular end-systolic pressure direct was correlated with left ventricular end-systolic pressure estimated by the 2 equations and there was no statistical difference. This noninvasive technique is a bedside method for clinical measurement of left ventricular end-systolic pressure.

Topics: Aged; Blood Pressure; Blood Pressure Determination; Cardiac Catheterization; Cardiovascular Agents; Carotid Arteries; Coronary Disease; Electrocardiography; Evaluation Studies as Topic; Female; Humans; Male; Middle Aged; Monitoring, Physiologic; Pulse; Stroke Volume; Systole; Vascular Resistance

Cordialin, the agent extracted from the heart, is known to inhibit hyperoxidation of succinic acid, increasing NADH oxidation speed in suspension of cardiomyocytes in hypoxia. Cordialin presence in oxygenated cells' suspension oxidating succinate, doesn't change oxygen consumption speed. The results received may be a theoretical basis for cordialin utilization in therapy of myocardial diseases, associated with hypoxia and ischemia. Cordialin utilization may be recommended for the treatment of acute myocardial infarction and for prolongation of time-period for thrombolytic therapy, treatment of IMD, angina and other pathological states, in which oxygen transport disturbance to myocardium cells occurs.

Topics: Animals; Cardiovascular Agents; Coronary Disease; Heart; In Vitro Techniques; Intercellular Signaling Peptides and Proteins; Myocardial Infarction; Myocardium; NAD; Oxygen Consumption; Peptides; Rats; Succinates

In patients with coronary artery disease, the reduction of heart rate (HR) by beta-blockers can further impair myocardial function by reducing the contractility and coronary perfusion. This is possibly not the case for "specific bradycardic agents" like alinidine (ALI). The effect of ALI on ischemic myocardium, therefore, was studied in anesthetized open-chest dogs measuring left ventricular end-diastolic pressure (LVedP), dP/dt, aortic pressure (AoP) by catheter tip manometers, coronary blood flow (Q) electromagnetically, end-diastolic length (edL) and systolic shortening (sdL in %edL) of ischemic (RISC) and non-ischemic (NISC) wall segments by sonomicrometry. Group A (n = 11): Left coronary artery constriction to reduce Q (-53%) and poststenotic sdL (-54%), then i.v. injection of ALI (0.25 + 0.25 + 0.5 + 1.0 mg/kg), thereafter atrial pacing at HR before ALI. Group B (n = 9): Installation of an aorto-coronary bypass, pump-perfused at 50% of free flow, infusion of ALI into the bypass. The results showed that ALI iv dose-dependently reduced HR from 135/min to 90/min, LVedP rose from 8.6 to 10.0 mmHg and NISC-edL from 14.1 to 14.6 mm indicating increased ventricular filling. Non-ischemic systolic shortening did not change. Ischemic systolic shortening was improved from 9.2% to 17.5%, which was not due to an increase in RISC-edL (14.8 versus 14.7 mm), enhanced RISC-Q (13 versus 12 ml/min), reduced AoP (86 versus 84 mmHg) or change in inotropy (dP/dtmax: 2290 versus 2240 mmhg/s), but the increase in RISC-sdl correlated closely (r greater than 0.85) to the reduction in HR (oxygen-demand).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Animals; Anti-Arrhythmia Agents; Cardiovascular Agents; Clonidine; Coronary Circulation; Coronary Disease; Dogs; Female; Heart; Heart Rate; Hemodynamics; Male

Topics: Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Disease; Electrocardiography; Heart Failure; Hemodynamics; Humans; Long-Term Care

Diastolic dysfunction is characterized by an abnormal function of one or both ventricles which is manifested by an increased resistance to diastolic filling. The pathophysiology of diastolic dysfunction includes relaxation disturbances, abnormal diastolic filing and/or abnormal passive elastic properties. In 1/5 to 1/3 of all patients with congestive heart failure, diastolic dysfunction is found to be the sole cause of heart failure. The etiology is most commonly severe myocardial hypertrophy and less often coronary artery disease. The prognosis in patients with isolated diastolic dysfunction is good; the annual mortality rate is 8% and 5-year survival approximately 70%. Therapy is based on a reduction of circulating blood volume to reduce diastolic filling pressure and improvement of relaxation and diastolic filling by the administration of calcium antagonists.

Topics: Cardiomegaly; Cardiovascular Agents; Coronary Disease; Diastole; Heart Failure; Humans; Prognosis; Ventricular Function

The cardioprotective effects of fructose-1,6-diphosphate (FDP) were investigated in infarcted rats and in conscious rabbits with myocardial ischemia. The influence of FDP on metabolic acidosis was studied in isolated hypoxic rat hearts. It was shown that FDP did not change the threshold of the initiation of ischemia in conscious rabbits, but decreased necrotic zone in infarcted rat hearts. After administration of FDP the myocardial contractility was prolonged significantly as compared with control under conditions of severe metabolic acidosis. However, FDP was not effective in hypoxic hearts with compensated metabolic acidosis. It was considered, that FDP influenced only ischemic myocytes with the changes in sarcolemmal permeability.

Topics: Acidosis; Animals; Cardiovascular Agents; Coronary Disease; Disease Models, Animal; Drug Evaluation, Preclinical; Fructosediphosphates; Male; Myocardial Infarction; Rabbits; Rats; Time Factors

Topics: Aged; Aged, 80 and over; Aging; Cardiovascular Agents; Cardiovascular Diseases; Cardiovascular Physiological Phenomena; Cardiovascular System; Coronary Disease; Female; Humans; Syncope

We tested the benzazepine, SQ 31,486 for its ability to selectively block the voltage-dependent calcium channel and to protect the ischemic myocardium. SQ 31,486 was found to be a selective calcium antagonist in vascular tissue with an IC50 value of 1.5 microM in KCl-contracted rabbit aorta. SQ 31,486 decreased contractile function and increased coronary flow in nonischemic isolated rat hearts in a concentration-dependent manner. SQ 31,486 also significantly reduced postischemic lactate dehydrogenase (LDH) release and end-diastolic pressure (EDP) compared to vehicle. Reperfusion double product [heart rate (HR) x left ventricular developed pressure (LVDP)] was also significantly improved by SQ 31,486. Diltiazem was a less potent anti-ischemic agent and was significantly more cardiodepressant relative to its anti-ischemic efficacy than was SQ 31,486. Thus, SQ 31,486 should have a larger therapeutic index. In a model of pacing-induced myocardial ischemia in anesthetized, open chest dogs, SQ 31,486 reduced pacing-induced ST-segment elevation approximately 50% at 10, 40, and 70 min after drug administration. This protective effect occurred despite a lack of effect of SQ 31,486 on ischemic regional blood flow and peripheral hemodynamic status.

Topics: Animals; Benzazepines; Blood Pressure; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Diltiazem; Dogs; Electric Stimulation; Electrocardiography; Female; Hemodynamics; In Vitro Techniques; Lysergic Acid Diethylamide; Male; Muscle, Smooth, Vascular; Myocardial Contraction; Rabbits; Rats

The detailed antiischemic pharmacology of the potassium channel activator cromakalim was determined in isolated globally ischemic rat hearts and a canine model of coronary occlusion and reperfusion. Cromakalim significantly improved reperfusion function in rat hearts starting at a concentration of 1 microM; this effect peaked at 7 microM. No cardiodepressant effects were observed in nonischemic tissue with cromakalim until a concentration of 100 microM was achieved, and this effect was reversed by glyburide. The antiischemic effect of 7 microM cromakalim was also completely reversed by glyburide and the novel ATP-sensitive potassium channel blocker sodium 5-hydroxydecanoate (5-HD). Glyburide did not reverse the antiischemic effects of 1 microM diltiazem. Cromakalim not only improved reperfusion contractile function in rat hearts, but improved the functional reserve and efficiency of O2 utilization. In anesthetized dogs, intracoronary cromakalim (0.1 micrograms/kg/min given throughout ischemia and reperfusion) significantly reduced infarct size in hearts subjected to 90-min coronary occlusion and 5-h reperfusion. Along with this reduced infarct size, the frequency of ectopic beats and the proportion of animals fibrillating during reperfusion were significantly reduced by cromakalim. In isolated globally ischemic and reperfused rat hearts, cromakalim was significantly profibrillatory. Thus, cromakalim is significantly cardioprotective, and may have the propensity for profibrillatory activity, although this is not true under all conditions.

Topics: Anesthesia; Animals; Anti-Arrhythmia Agents; Benzopyrans; Blood Pressure; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Cromakalim; Decanoic Acids; Diltiazem; Dogs; Female; Glyburide; Heart; Heart Rate; Hydroxy Acids; In Vitro Techniques; L-Lactate Dehydrogenase; Male; Myocardial Infarction; Myocardial Reperfusion; Myocardium; Oxygen Consumption; Potassium Channels; Pyrroles; Rats; Rats, Inbred Strains

Over 30 per cent of coronary patients die of cardiac failure excluding the acute phase of myocardial infarction. With the exception of preexisting hypertension, there is no compensatory hypertrophy in ischemic heart disease. However, hypertrophy is a costly adaptation in terms of myocardial oxygen demand and, therefore, coronary flow. Fibrous zones are unresponsive to inotropic drugs and so the treatment of cardiac failure due to ischemic heart disease consists in limiting or preventing episodes of ischemia. Each mechanism of ischemia has an appropriate treatment: the preload is reduced by trinitrin and its derivatives and by molsidomine; the after-load by calcium antagonists and angiotensin converting enzyme inhibitors; tachycardia and hypercontractile states by betablockers. The risk of arrhythmia, aggravated by many inotropic therapies, constitutes the major danger to ischemic heart failure; amiodarone, betablockers and preventive nitrate therapy are the most effective and least dangerous antiarrhythmics. Revascularisation is effective for permanently ischemic segments or for ischemia on effort but does not improve large plaques of fibrosis which sometimes require surgical ablation or plastic procedures. But these measures are incomplete if all aspects of the disease are not taken in consideration: loss of excessive body weight, exercise rehabilitation by modern techniques, limitation of bed rest at the ultimate stage of the disease allowing patients with ischemic cardiac failure a better quality of life without aggravating the prognosis.

Topics: Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Myocardial Revascularization; Physical Exertion

The study evaluates and compares among the three French MONICA centres the access to emergency care, and the treatment administered to 1444 patients aged 25-64 years hospitalized for an acute coronary event. It was carried out in 1985 in Bas-Rhin (BR) on 596 subjects, in 1986 in Haute-Garonne (HG) on 450 subjects, and from October 1986 to July 1987 in the Urban Community of Lille (UCL) on 395 subjects. The time before receiving initial medical care could be analysed only in BR and HG: it is shorter in HG (p less than 0.001). Patients with a history of coronary disease are inclined to consult more quickly than patients with a first event (p less than 0.001). According to the three centres, 68.5 to 72.5% of the patients consult first a private practitioner, while 9 to 10.5% contact first a mobile team (mobile emergency care unit), and 6 to 15% go directly to hospital. Patients with a previous history tend more to call a mobile team directly, or to go to hospital directly than patients without a history (p less than 0.001). The analysis of the treatment was made only on patients classified in MONICA diagnostic category 1: the therapeutic schemes are similar in the three centres, although differences are noted in the frequency of prescription. The use of new medications and procedures seems to be best established in HG and in UCL than in BR, with the reservation that the three studies were not conducted at the same time.

Topics: Adult; Angioplasty, Balloon; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Emergency Medical Services; Female; France; Hospitalization; Humans; Longitudinal Studies; Male; Middle Aged; Myocardial Infarction; Time Factors

The platelets from 74 patients with acute myocardial infarction or with unstable angina showed decreased prostaglandin E1/I2 receptor activity when compared with that of 56 normal volunteers by using [3H]prostaglandin E1 as a probe. In normals, Scatchard analyses showed the presence of one high-affinity-low-capacity (Kd1 = 9.0 +/- 1.2 nM [mean +/- SD]; n1 = 120 +/- 30 sites/cell) and one low-affinity-high-capacity (Kd2 = 1.1 +/- 0.5 microM; n2 = 1,460 +/- 250 sites/cell) prostaglandin E1/I2 receptor population in platelets. In contrast (p less than 0.01), platelets from patients showed decreased ligand binding (n1 = 40 +/- 20 sites/cell; n2 = 800 +/- 210 sites/cell) with little change in the affinity of the receptors (Kd1 = 7.50 +/- 1.6 nM; Kd2 = 0.68 +/- 0.24 microM). On the other hand, the platelets from the patients with dilated cardiomyopathy (n = 7) who were hospitalized for acute chest pain but had normal coronary arteries did not show any impairment of the receptor activity. The plasma prostacyclin level of the patients with acute ischemic heart disease was similar to that of normal volunteers; this finding indicated that the defective receptor function was not related to the prostaglandin receptors occupancy in vivo. The impaired receptor activity was temporary in nature. The follow-up studies showed that the prostaglandin receptor activity of the patients' platelets improved to "normal" levels within 2-8 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Acute Disease; Adult; Angina, Unstable; Blood Platelets; Cardiomyopathies; Cardiovascular Agents; Coronary Disease; Cyclic AMP; Epoprostenol; Female; Humans; Male; Middle Aged; Prostaglandins E; Receptors, Epoprostenol; Receptors, Prostaglandin; Receptors, Prostaglandin E; Reference Values

Topics: Cardiovascular Agents; Coronary Disease; Diabetes Complications; Electrocardiography, Ambulatory; Humans

Structural modification of the calcium-antagonist verapamil (1) by replacement of the lipophilic alpha-isopropylacetonitrile moiety by various heterocyclic ring systems has led to a new class of cardiovascular compounds which are characterized by a specific bradycardic activity. These agents reduce heart rate without binding to classical calcium channels or beta-adrenoceptors, interacting instead specifically with structures at the sino atrial node. Therefore they have also been termed sinus node inhibitors. The prototype falipamil (2) has been submitted to further optimization mainly by manipulation of the phthalmidine moiety. This has resulted in a second generation of specific bradycardic agents with increased potency and selectively and prolonged duration of action represented by the benzazepinone-derivative UL-FS 49 (4). Structure-activity relationships within this novel class of compounds have revealed a marked dependence of activity on the substitution pattern of the aromatic rings, the nature of the central nitrogen atom, and the length of the connecting alkyl chains. The crucial role of the benzazepinone ring for bradycardic activity can be best explained by its special impact on the overall molecular conformation.

Topics: Animals; Anti-Arrhythmia Agents; Benzazepines; Calcium Channel Blockers; Cardiovascular Agents; Chemical Phenomena; Chemistry; Coronary Disease; Guinea Pigs; Heart Rate; Isoindoles; Molecular Conformation; Muscle, Smooth, Vascular; Myocardial Contraction; Nifedipine; Phthalimides; Rabbits; Rats; Structure-Activity Relationship; Verapamil

Central hemodynamic parameters under the effect of mildronate were examined in 62 patients suffering from coronary heart disease, 35 of these with acute myocardial infarction complicated by acute left-ventricular insufficiency and 20 with atherosclerotic cardiosclerosis with chronic cardiac insufficiency. The drug effect was assessed in two groups of patients after a single intravenous injection of 0.5-3 g. In group 1 (n = 53) mildronate effect on central hemodynamic parameters was assessed in spontaneous cardiac rhythm. Variously directed statistically unreliable hemodynamic shifts were revealed, related to heart rhythm changes. In group 2 (n = 9) the drug effect on heart rhythm was eliminated with the use of two-chamber electrocardiostimulation, and various hemodynamic regimens with hypo-, eu-, and hyperkinetic circulation types were artificially created by changing the A-V interval. Mildronate had no effect on the hemodynamics during two-chamber electrocardiostimulation.

Topics: Adult; Aged; Aged, 80 and over; Cardiac Pacing, Artificial; Cardiovascular Agents; Coronary Disease; Electrocardiography; Female; Heart Rate; Hemodynamics; Humans; Male; Methylhydrazines; Middle Aged

Topics: Aged; Cardiovascular Agents; Coronary Disease; Heart Failure; Hemoglobins; Humans; Ligands; Male; Methemoglobin; Methylhydrazines; Middle Aged; Oxyhemoglobins

In control anaesthetized baboons subjected to 30 min occlusion of the left anterior descending coronary artery, followed by 5.5 h reperfusion, total plasma levels for creatine kinase (CK) and lactate dehydrogenase (LDH) were markedly elevated in a time-related manner. In a second group of baboons pretreated 10 min prior to ischaemia with ranolazine [(+/-)-N-(2,6-dimethyl-phenyl)-4[2-hydroxy-3-(2-methoxyphenoxy)propyl]-1 - piperazine acetamide dihydrochloride; RS-43285-193] at 500 micrograms kg-1 i.v., followed by continuous infusion of 50 micrograms kg-1 min-1, neither enzyme was significantly elevated at any time point. Similarly, serum levels of the cardiospecific isoenzyme CK2 were 8 fold greater in the controls than in the ranolazine-treated animals at 6 h. The results indicate that ranolazine pretreatment abolished cardiac enzyme release over a 5.5 h reperfusion period, indicating a potential protective effect.

Topics: Acetanilides; Animals; Cardiovascular Agents; Coronary Disease; Creatine Kinase; L-Lactate Dehydrogenase; Male; Myocardial Reperfusion; Myocardium; Papio; Piperazines; Ranolazine

The influence of nifedipine (20 nM) and mioflazine (300 nM), i.e. concentrations inducing a 60-70% recovery of cardiac function during reperfusion of globally ischaemic guinea-pig working hearts, on the mitochondrial calcium content was investigated in normoxic, globally ischaemic and reperfused globally ischaemic guinea-pig working hearts. Mitochondrial calcium was determined electronmicroscopically with oxalate-pyroantimonate method. In normoxic hearts both nifedipine and mioflazine reduced the mitochondrial calcium content. Global ischaemia for 45 min and subsequent reperfusion for 25 min resulted in a pronounced mitochondrial calcium overload and damage to the cellular structure. In ischaemic and in reperfusion hearts the drugs maintained mitochondrial calcium at pre-ischaemic levels and decreased the damage to the cellular structure.

Topics: Animals; Antimony; Calcium; Cardiovascular Agents; Coronary Disease; Guinea Pigs; Homeostasis; In Vitro Techniques; Mitochondria, Heart; Myocardial Reperfusion; Nifedipine; Oxalates; Piperazines

Alinidine is a new bradycardic agent that interferes with ion channels and the if pacemaker current. To determine if alinidine had antiischemic effects unrelated to its bradycardic action, myocardial metabolism was studied during a pacing-stress test in 20 patients with coronary artery disease and angina pectoris, before and after intravenous infusion of alinidine (10 mg, n = 10; 50 mg, n = 10). When compared to the control pacing-stress test, the low dose of alinidine had no significant effect on aortic pressure, coronary sinus flow (-3%, NS), myocardial oxygen extraction, or myocardial lactate uptake. After the high dose of alinidine, aortic pressure and coronary sinus flow remained unchanged but the arteriocoronary sinus difference in oxygen content increased (12.2 +/- 1.3 to 12.7 +/- 1.4 ml/100 ml; p less than 0.0002) above the values observed during the control pacing-stress test, while both the chemical lactate extraction fraction (-19 +/- 30 to 15 +/- 21%; p less than 0.025) and the L-[1-14C]lactate extraction fraction increased. Accordingly, the net myocardial lactate uptake (corrected for production) had increased from 14 +/- 32 during the control pacing-stress test to 29 +/- 24 mumol/min during the pacing repeated after the high dose of alinidine (p less than 0.05). After the high dose of alinidine, the free fatty acid uptake also rose slightly (+23%; NS) and the alanine production was reduced in 7 of 10 patients (-3.6 +/- 1.7 to -1.4 +/- 0.6 mumol/min; NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Aged; Anti-Arrhythmia Agents; Cardiac Pacing, Artificial; Cardiovascular Agents; Clonidine; Coronary Disease; Dose-Response Relationship, Drug; Female; Heart Rate; Hemodynamics; Humans; Injections, Intravenous; Lactates; Male; Middle Aged; Oxygen Consumption

The influence of PGE1, iloprost and a combination of both on high energy phosphate levels in isolated rat hearts reperfused 1 h following 20 min of global ischemia was investigated employing 31P-NMR-spectroscopy. Whereas PGE1 induced a slight reduction in the decline of the creatine phosphate/inorganic phosphate. ATP/inorganic phosphate ratio and NMR-energetic index during ischemia, iloprost application was followed predominantly by a temporary but marked improvement of the creatine phosphate/inorganic phosphate ratio during the early period of reperfusion. The best results in preservation of high energy phosphates were achieved after simultaneous application of PGE1 and iloprost. It is presumed that the accelerated normalization of the heart function observed immediately after ischemia in the eicosanoid treated hearts is related to the more rapid recovery of intracardial high energy phosphate level.

Topics: Adenosine Triphosphate; Alprostadil; Animals; Cardiovascular Agents; Coronary Disease; Epoprostenol; Heart; Iloprost; Kinetics; Magnetic Resonance Spectroscopy; Male; Myocardial Reperfusion; Myocardium; Phosphates; Phosphocreatine; Phosphorus; Rats; Rats, Inbred Strains; Reference Values

Topics: Animals; Cardiovascular Agents; Coronary Disease; Creatine Kinase; Epoprostenol; Iloprost; Myocardial Infarction; Myocardial Reperfusion Injury; Swine

A study was made of the effect of beta 1-adrenoblockers (metoprolol, atenolol, talinolol) on bronchial patency in patients with concomitant bronchial asthma (BA) under acute drug use and in the course of continuous therapy. Broncho-obstructive complications occurring in part of the patients were not associated with the disease gravity or with the pathogenetic variety of BA. Besides, they were not associated with the drug dose either (use was made of the mean therapeutic dosage range). The rate and the intensity of bronchial patency abnormalities occurring in the course of the continuous treatment with beta 1-adrenoblockers (with metoprolol, in particular) depended on the initial status of the adrenergic regulation of the body. Significant disorders of bronchial patency including clinically marked ones were naturally observed with initially low excretion of cAMP in the morning portion of urine (less than 3 mmole/1).

Topics: Administration, Sublingual; Adrenergic beta-Antagonists; Angina Pectoris; Asthma; Bronchi; Cardiovascular Agents; Coronary Disease; Drug Evaluation; Humans; Middle Aged; Time Factors

Topics: Adult; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Humans; Hypertension; Male; Middle Aged; Prognosis

A new native cardioprotector mildronat was used for the treatment of cardiac insufficiency due to ischemic heart disease. It was established that mildronate produced a positive effect on the hemodynamics and gaseous composition of the blood. The patients also showed normalization of the nitrogen metabolism and activity of the membrane-bound erythrocytic enzymes.

Topics: Cardiovascular Agents; Chronic Disease; Coronary Disease; Drug Evaluation; gamma-Butyrobetaine Dioxygenase; Heart Failure; Humans; Male; Middle Aged; Mixed Function Oxygenases

A number of cardiotropic preparations (verapamil, obsidan, pyroxan) were studied in glycerinated fibres (GF) in the experiments on rats during five twenty four hours after ligation of coronary artery. Their ability in different degree to preserve cardiomyocyte contractile fibers from the injury of ischemic processes is revealed. Positive influence of antianginal therapy was also confirmed in the experiments with coronary artery ligation on awake animals, and in experiments on the identification of actomyosin complex components.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Coronary Disease; Disease Models, Animal; Drug Evaluation, Preclinical; Glycerol; Heart; Male; Myocardial Contraction; Myocardium; Rats

Topics: Antihypertensive Agents; Calcium Channel Blockers; Cardiac Glycosides; Cardiomyopathy, Dilated; Cardiovascular Agents; Coronary Disease; Diuretics; Drug Evaluation; Drug Therapy, Combination; Humans; Hypertension; Nitrates; Vasodilator Agents

In anesthetized swine, the left anterior descending coronary artery was cannulated and perfused at constant blood flow levels during two grades of ischemia. In one group (n = 10), moderate ischemia reduced percent systolic wall thickening (by sonomicrometry) from 25 +/- 7% to 6 +/- 2%, whereas in the other group (n = 7), severe ischemia reduced percent wall thickening from 24 +/- 6% to -0.5 +/- 4%. Heart rate was paced in both groups at 91 beats/min. After reperfusion and complete return to control conditions, administration of the bradycardic agent UL-FS 49 (0.37 mg/kg i.v.) decreased the heart rate to 55 +/- 5 beats/min. During subsequent ischemia at the same coronary inflow as before bradycardia, percent wall thickening in the ischemic zone during moderate ischemia was increased from 6 +/- 2% to 25 +/- 6% (p less than 0.01) (not significantly different from control without ischemia), and during severe ischemia, percent wall thickening increased from -0.5 +/- 4% to 13 +/- 7% (p less than 0.01). During moderate ischemia, bradycardia caused an increase in the subendocardial blood flow from 0.24 +/- 0.60 to 0.42 +/- 0.17 (ml/min)/g (p less than 0.009) and during severe ischemia, bradycardia caused an increase from 0.14 +/- 0.08 to 0.2 +/- 0.1 (ml/min)/g (p less than 0.001). At each level of ischemia, a more marked improvement occurred in subendocardial blood flow per beat ([(ml/min)/g]/heart rate). The relation between myocardial blood flow and wall function at a heart rate of 55 beats/min (n = 14) was plotted and compared with that studied at a heart rate of 122 beats/min in another group of pigs (n = 14). The increase in subendocardial blood flow per minute during bradycardia was not sufficient to explain the striking increase in function; thus, an independent relation (p less than 0.05) between blood flow per minute and contractile function (percent wall thickening) was found for for each heart rate. In contrast, when myocardial blood flow was normalized for heart rate and expressed per beat, data from both heart rate groups could be described by a single relation. Thus, the subendocardial blood flow per beat predicted wall function independently of heart rate and accounted for changes in both oxygen supply and demand.

Topics: Animals; Benzazepines; Biomechanical Phenomena; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Depression, Chemical; Heart; Heart Rate; Swine

There has been a gradual decrease in hospital mortality rate following myocardial infarction (MI) since 1950, possibly due to improved therapy. For a valid comparison of mortality rates in various countries, it will, however, be necessary to know the characteristics of the individual patient populations. Factors such as age, time of admission to the CCU, use of thrombolytic agents, patency of the infarct related artery, left ventricular ejection fraction, smoking status as well as conventional risk factors need to be assessed before a valid comparison can be made or conclusions reached concerning trends in mortality after MI. As new and effective therapy for reducing mortality in patients with infarcts are introduced such as Beta blockers, thrombolysis, aspirin, and converting enzyme inhibitors one should be cautious in drawing conclusions as to trends in mortality from the results of clinical trials of these agents until one has a clear understanding of the risk factors of the population studied. Without this information, we may be no closer to an understanding of the cause of changing trends in mortality over the next decade than to understanding the trends over the last two decades.

Topics: Cardiovascular Agents; Coronary Care Units; Coronary Disease; Humans; Monitoring, Physiologic; Mortality; Myocardial Infarction; Platelet Aggregation Inhibitors; Thrombolytic Therapy

In this study we attempted to determine whether administration of iloprost (ZK 36374), a chemically stable prostacyclin analogue, would reduce infarct size after experimental coronary artery occlusion and reperfusion. One hour of coronary artery occlusion was performed in 28 open-chest, anesthetized rabbits++, followed by 5 hours of reperfusion. Two minutes after occlusion, 99mTc-labeled albumin microspheres were injected into the left atrium for later assessment of the area at risk of infarction. Fifteen minutes after occlusion animals were randomly assigned to either the treatment group (iloprost, 1.2 micrograms/kg/min intravenously for 6 hours; n = 14) or the control group (n = 14). In vitro platelet aggregation was inhibited in rabbits receiving iloprost. In 10 rabbits (five treated and five control) regional myocardial blood flow was also measured by means of differentially labeled radioactive microspheres. Infarct size was significantly smaller in treated rabbits (53.6 +/- 4.1% of the risk zone vs 89.4 +/- 3.8% in control rabbits; p less than 0.001). Flow to the nonischemic myocardium was higher in treated animals, that is, 1.87 +/- 0.20 ml/min/gm of tissue 50 minutes after occlusion and 1.90 +/- 0.20 ml/min/gm of tissue 4 hours after reperfusion, compared with 1.54 +/- 0.20 and 1.64 +/- 0.30 ml/min/gm of tissue, respectively, in control rabbits (p less than 0.01). Collateral flow to the ischemic region was not affected by the drug. Mean arterial blood pressure, heart rate, and pressure-rate product in treated rabbits were not significantly different from values in control rabbits. In conclusion, administration of iloprost reduced myocardial infarct size in this model of myocardial ischemia and reperfusion in absence of major hemodynamic effects.

Topics: Animals; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Disease Models, Animal; Drug Administration Schedule; Epoprostenol; Hemodynamics; Iloprost; Male; Myocardial Infarction; Platelet Aggregation; Rabbits; Random Allocation

Topics: Animals; Cardiovascular Agents; Coronary Disease; Drug Evaluation, Preclinical; Epoprostenol; Heart; Iloprost; Myocardial Infarction; Myocardium; Necrosis; Rabbits; Radionuclide Imaging; Technetium Tc 99m Aggregated Albumin

The cardio-protective effects of neutrophil depletion or inhibition of neutrophil activation early in the course of myocardial reperfusion has been established. Whether these treatments would be effective during extended periods of reperfusion has not been ascertained. Open-chest anesthetized dogs were subjected to left circumflex artery (LCX) occlusion for 90 minutes followed by 72 hours of reperfusion. Dogs were randomized into one of four groups: 1) control; 2) Ilo-2 (iloprost 100 ng/kg/min administered via the left atrium beginning 10 minutes after LCX occlusion and continuing 2 hours into reperfusion); 3) Ilo-48 (iloprost 100 ng/kg/min administered as above until 1 hour after reperfusion then 25 ng/kg/min for 48 hours of reperfusion; or 4) antibody (neutrophil antibody administered before occlusion and 1/2 hourly for 2 hours of reperfusion and then every 24 hours). Myocardial infarct size, as a percentage of the area at risk assessed after 72 hours of reperfusion, was significantly smaller in the antibody-treated group (32.1 +/- 5.0% mean +/- SEM) or Ilo-48 (22.6 +/- 4.0%) treatment group compared with control (48.7 +/- 5.6%) or Ilo-2 (57.6 +/- 5.2%) groups. Regional myocardial blood flow studies demonstrated that all groups developed similar degrees of ischemia. The iloprost-treated groups had lower mean arterial blood pressures during occlusion and reperfusion than groups 1 and 4 (p less than 0.05). Circulating neutrophil counts were increased in groups 1 and 2 at 24 and 48 hours after reperfusion compared to groups 3 and 4 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Animals; Cardiovascular Agents; Cell Count; Coronary Circulation; Coronary Disease; Dogs; Epoprostenol; Hemodynamics; Iloprost; Inflammation; Male; Myocardial Infarction; Myocardial Reperfusion; Myocardial Reperfusion Injury; Myocardium; Neutrophils; Peroxidase; Time Factors

The influence of iloprost, PGE1 and of the combined application of iloprost and PGE1 on high energy phosphate contents was investigated in isolated rat hearts perfused aerob at 37 degrees C in Langendorff mode. Changes in creatine phosphate, ATP and inorganic phosphate were registered during 20 minutes of global ischemia and 56 minutes of reperfusion with 31P-NMR-spectroscopic methods starting drug application prior to ischemia simultaneously with onset of heart perfusion. Most effective in preservation of high energy phosphates was the combined application of PGE1 and iloprost resulting in a creatine phosphate/inorganic phosphate ratio of 103.2 +/- 30.9% of pre-ischemia values compared to 52.5 +/- 6.1% in control group without drug application 0-5 minutes after onset of reperfusion, 148.8 +/- 24.8% vs 78.8 +/- 15.2% at 6-11 minutes of reperfusion and 116.6 +/- 16% vs 68.9 +/- 12.7% at 12-17 minutes of reperfusion. The same trend was observed employing ATP/inorganic phosphate ratio. The improved energy state in reperfused hearts following application of PGE1 and iloprost in combination is presumed to be supported by a reduction of the loss of high energy phosphates (HEP) during global ischemia and by a cytoprotective effect of iloprost immediately after starting reperfusion.

Topics: Alprostadil; Animals; Cardiovascular Agents; Coronary Disease; Drug Interactions; Energy Metabolism; Epoprostenol; Heart; Iloprost; Magnetic Resonance Spectroscopy; Male; Myocardium; Perfusion; Phosphorus; Rats; Rats, Inbred Strains

The structure of consumption and need in cardiovascular drugs were studied in a hospital and in the Kirghiz Scientific Research Institute of Cardiology according to a scheme developed in the USSR Cardiology Research Center. Use of cardiovascular drugs was studied with respect to optimal results of therapy in 361 patients with main cardiac pathology (ischemic heart disease, essential hypertension and their combination) who had received 1125 courses of drug treatment. The prescriptions were analysed according to their intensity, regularity and optimal effect. The authors assessed provision of cardiological patients of Frunze with drugs and gave recommendations on its improvement, in particular, satisfaction of need in some active drugs (prolonged nitrates, calcium antagonists, cardiac glycosides).

Topics: Cardiovascular Agents; Coronary Disease; Drug Utilization; Humans; Hypertension; Kyrgyzstan; Urban Population

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Drug Evaluation; Humans; Male; Middle Aged; Physical Exertion; Time Factors

Information on drug consumption was collected in May 1987 within the framework of the 10 year follow-up survey of a coronary risk factor detection programme in the Tyrolean village of Oberperfuss. Data were obtained from the entire cohort born between 1913 and 1927. On average, men took 1.7 and women 2.8 different types of drugs. Blood pressure lowering substances, including diuretics, were the most frequently consumed drugs, followed by digitalis.

Topics: Aged; Antihypertensive Agents; Austria; Cardiovascular Agents; Coronary Disease; Digoxin; Drug Interactions; Drug Therapy, Combination; Female; Humans; Male; Middle Aged; Risk Factors

Topics: Animals; Calcium; Cardiovascular Agents; Coronary Disease; Female; Hemodynamics; In Vitro Techniques; Lidoflazine; Male; Myocardium; Piperazines; Rabbits

Topics: Cardiovascular Agents; Chronic Disease; Coronary Artery Bypass; Coronary Disease; Humans

This study reports coronary and systemic hemodynamics, and metabolic responses to atrial pacing, prostacyclin (PGI2), and iloprost, its stable analogue, in 16 patients with severe coronary obstruction as well as predominant narrowing in the left anterior descending artery. PGI2 caused ischemia in six patients with low anginal threshold during pacing. In three of them ischemia was also precipitated by iloprost. Drugs were infused at therapeutic doses and were discontinued when pain occurred. Angina disappeared promptly (less than or equal to 3 minutes) and spontaneously after the infusion of PGI2, whereas after the analogue it was long lasting (greater than or equal to 5 minutes) and was relieved by 125 mg intravenous aminophylline, an antagonist of dipyridamole-induced coronary dilation. Ischemia was associated with a drug-induced decrease in arterial blood pressure and reflex tachycardia, and occurred despite increased great cardiac vein (GCV) blood flow and decreased resistance, which is consistent with either a failure of regional flow to increase proportionally to the metabolic demand or a subendocardial-subepicardial steal. However, the following findings favor the latter hypothesis: heart rate and rate-pressure product at the onset of pain were lower with drugs than with pacing, and GCV blood flow, measured at a comparable heart rate, was less with pacing than with drugs. In conclusion, PGI2 and analogues may induce ischemia in patients with advanced coronary artery disease. The mechanism appears to be related to a dipyridamole-like maldistribution of flow. Counteraction of ischemia can be achieved by aminophylline.

Topics: Cardiovascular Agents; Coronary Disease; Epoprostenol; Hemodynamics; Humans; Iloprost; Injections, Intravenous; Pacemaker, Artificial; Prostaglandins

Intravenous injection of mioflazine, a nucleoside transport antagonist, caused maximal coronary vasodilation in canine hearts. This was completely reversed by intravenous injection of the enzyme adenosine deaminase. Coronary vasodilation was induced again by the adenosine deaminase inhibitor EHNA [Erythro-9(2-hydroxy-3-nonyl)adenine]; however, without previous injection of mioflazine, EHNA did not produce coronary vasodilation. Mioflazine-induced coronary vasodilation was antagonized by theophylline, but it was not associated with increased plasma levels of adenosine. Under the influence of mioflazine, ischemic myocardium contained adenosine and inosine at a ratio of 65:30, which is the reverse of the control ratio. Total nucleoside content following mioflazine showed reduced nucleoside losses as compared with control. A significant amount of the accumulated adenosine is extracellular since it was accessible to exogenous adenosine deaminase. Reperfusion of ischemic myocardium did not result in increased rates of adenosine phosphorylation, another indicator of its extracellular accumulation. The data are best explained by assuming release of adenosine by mioflazine in addition to its known effect of inhibiting nucleoside transport. The adenosine release occurs most probably into the interstitial space where it occupies smooth muscle adenosine receptors. The existence of nonsymmetric transport (uptake is more inhibited than release) is postulated for the myocyte, as well as for the endothelial cell plasma membrane.

Topics: Adenine Nucleotides; Adenosine; Adenosine Triphosphate; Animals; Blood Pressure; Cardiovascular Agents; Chromatography, High Pressure Liquid; Coronary Circulation; Coronary Disease; Dogs; Female; Heart Rate; Hemodynamics; Male; Piperazines

Topics: Adrenergic beta-Antagonists; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Drug Evaluation; Humans; Myocardial Infarction; Nitrites

Topics: Cardiovascular Agents; Coronary Disease; Hemodynamics; Humans; Long-Term Care

Topics: Cardiovascular Agents; Coronary Disease; Hemodynamics; Humans

Although unstable angina is an extremely common and often initial manifestation of coronary disease, few controlled studies of its treatment have been carried out. This relative dearth of information is due to the methodological problems raised by the evaluation of unstable angina. Unlike the definition of myocardial infarction, that of unstable angina--i.e. of a population of coronary patients who from time to time are at a high risk of myocardial infarction or death--is neither unequivocal nor easy to standardize. It follows that the patient population ultimately selected for controlled trials is but a small part of all unstable angina patients. The representativeness of patients involved in therapeutic trials is probably approximate. Moreover, the current criteria for assessment of effectiveness are either the clinical signs of angina in the short term or the incidence of myocardial infarction and changes in survival curves in the mid- and long terms. A more precise definition of criteria of inclusion, leading to an homogeneous population, and the development of a simple and reliable method for detecting and quantifying myocardial ischaemia, both being used as intermediate criteria of assessment, would undoubtedly improve the quality of therapeutic trials in unstable angina and, mostly, their applicability to daily therapeutic practice.

Topics: Angina Pectoris; Angina, Unstable; Cardiovascular Agents; Clinical Trials as Topic; Coronary Angiography; Coronary Disease; Exercise Test; Humans

The authors examined peculiarities of the central and cerebral hemodynamics before and after treatment in 108 patients with cerebral infarction and acute or chronic ischemic heart disease (IHD). When myocardial and cerebral infarctions were combined, as well as in most cases of cerebral ischemia in the post-infarction period, the heart worked in conditions of hypodynamia. Disorders of the cerebral circulation were expressed in hypo- and hyperperfusion of the cerebral vessels. Patients with acute versus chronic IHD displayed differences in changes of hemocirculatory parameters in the process of treatment.

Topics: Adult; Aged; Cardiovascular Agents; Cerebral Infarction; Cerebrovascular Disorders; Coronary Disease; Female; Hemodynamics; Humans; Male; Middle Aged

Topics: Cardiovascular Agents; Coronary Disease; Hemodynamics; Humans

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Hypertension

Topics: Animals; Cardiovascular Agents; Coronary Disease; Emulsions; Fluorocarbons; Guinea Pigs; Heart; In Vitro Techniques; Myocardial Contraction; Poloxalene; Polyethylene Glycols; Rabbits; Ranidae; Rats

Topics: Acebutolol; Adult; Aged; Cardiovascular Agents; Coronary Disease; Delayed-Action Preparations; Drug Evaluation; Female; Flavonoids; Hemodynamics; Humans; Hypertension; Isosorbide Dinitrate; Male; Middle Aged; Phenethylamines; Tablets; Time Factors

We have previously demonstrated that the beneficial effect of cardioselective beta-blockade on exercise-induced ischemia is due entirely to negative chronotropism. Therefore we studied the effect of a new bradycardiac agent (UL-FS 49) in 10 dogs with chronic coronary artery stenosis produced by an ameroid constrictor. Regional myocardial function (sonomicrometers, wall thickness) and blood flow (microspheres) were measured during a control treadmill exercise bout and an identical run 3 hr later after the administration of UL-FS 49 (1.0 mg/kg iv). In the control run, heart rate increased from 114 +/- 20 to 230 +/- 19 beats/min and systolic wall thickening (%WT) in the poststenotic myocardium decreased from 23.3 +/- 5.2% at rest to 9.3 +/- 5.0%, a 60% reduction. Subendocardial blood flow in the ischemic area decreased from 1.04 +/- 0.30 to 0.55 +/- 0.40 ml/min/g, blood flow per beat decreased from 9.1 X 10(-3) to 2.5 X 10(-3) ml/g, and mean transmural flow failed to increase (1.06 +/- 0.30 vs 1.08 +/- 0.39 ml/min/g). During exercise with UL-FS 49, heart rate increased from 89 +/- 10 to only 139 +/- 10 beats/min. End-diastolic left ventricular pressure was increased compared with that during the control run (35.7 +/- 3.0 vs 28.9 +/- 5.5 mm Hg) but left ventricular peak systolic pressure and dP/dt were unchanged. %WT in the ischemic zone did not change significantly during exercise with UL-FS 49 (23.3 +/- 7.9% at rest, 21.5 +/- 8.4% during the run), and in the nonischemic zone it increased to the same extent as during the control run.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Animals; Benzazepines; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Depression, Chemical; Dogs; Heart Rate; Myocardial Contraction; Physical Exertion

Ligation of the left anterior descending coronary artery in open-chest pigs for 20 min caused a complete loss of regional myocardial function, which did not recover during the first two hours of reperfusion. Infusion of the stable prostacyclin analogue Iloprost (100 ng kg-1 min-1) did not prevent the loss of systolic wall function during ischaemia. Recovery of regional myocardial function during the first two hours of reperfusion was enhanced to 40% of baseline by Iloprost. This effect of Iloprost cannot be explained by a decreased O2-demand during ischaemia or an enhanced recovery of myocardial ATP content.

Topics: Adenosine Triphosphate; Animals; Blood Pressure; Cardiovascular Agents; Coronary Disease; Epoprostenol; Heart; Iloprost; Perfusion; Swine

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Disease; Drug Evaluation; Electrocardiography; Epoprostenol; Exercise Test; Female; Humans; Iloprost; Male; Middle Aged; Syndrome

If myocardial ischemia always results from an imbalance between the needs and supplies in oxygen of the myocardium cells, the physiopathology of this process seems today infinitely more complex than the mere diminution or interruption of the output in a coronary artery. The extension of atheromatous lesions, the platelets aggregation, thrombosis, the coronary spasm, the release of products from the arachidonic cascade, the reactivity of the vascular endothelium, the profibrinolytic activity of the tissues are many of the intricate factors inducing myocardial ischemia. Cellular alterations, of which some are triggered by the release of oxygenated free radicals, lead then to an irreversible necrosis. The medications used until now in the treatment of angina are oxygen scavengers and research goes on in this direction with vaso-dilators beta-blockers, prolonged action nitro-compounds (nicorandil) or nitro-compounds with an action reinforced by N-acetyl-cysteine, bradycardiac derivates of alinidine and the new calcium antagonists dihydropyridine. However, the new physiopathological concepts of ischemia have opened new directions for the research: products which modify the arachidonic cascade by increase of synthesis or release of PGI2 (nafazatrom, defibrotide), by inhibition of TXA2 synthesis or blocking of TXA2 receptors, and similar products of PGI2 (iloprost); thrombolytic agents more specific of thrombin (PTA) or fibrinolysis activators (defibrotide), and anticoagulants with extended action; chelating agents of oxygenated free radicals (peroxide dismutase, catalase, peroxidase) or xanthine oxidase inhibitors; platelets anti-aggregates like ticlopidine which blocks the platelets receptors to fibrinogen, or inhibitors of the synthesis of pro-aggregating agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adrenergic beta-Antagonists; Animals; Calcium Channel Blockers; Cardiovascular Agents; Chelating Agents; Coronary Disease; Coronary Vasospasm; Epoprostenol; Fibrinolytic Agents; Humans; Nitrites; Platelet Aggregation; Thromboxane A2

A prospective five-year study and medicinal treatment were conducted in 317 coronary patients with stable angina in the absence of any signs of heart failure, and stenosing coronary arterial atherosclerosis as evidenced by selective coronary angiography. Total mortality was 2.8%, and the incidence of documented non-fatal myocardial infarction was 3.8% per year. The mortality was mostly dependent on the severity of angina's functional class and the number of affected major coronary arteries (narrowed by more than 70%). A group of patients with unfavorable prognosis was identified (functional class III to IV, low physical stress tolerance, the involvement of two or three major coronary arteries). The results demonstrate the efficiency of long-term medication in coronary patients with stable angina due to stenosing coronary atherosclerosis.

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Coronary Disease; Drug Therapy, Combination; Electrocardiography; Humans; Male; Middle Aged; Prognosis; Prospective Studies

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Humans; Time Factors

From 1293 patients who underwent thallium stress testing and 1099 patients who had coronary angiography, a consecutive series of 122 who had both studies is evaluated. This group includes suboptimally exercised patients and those receiving one or several cardiovascular drugs that were not discontinued prior to exercise. When compared with the EKG stress test, thallium stress imaging was superior in sensitivity (80% vs 68%), specificity (84% vs 49%), accuracy (81% vs 62%), positive predictive value, (92% vs 75%), and negative predictive value (65% vs 45%) in this group, with 71% prevalence of angiographically significant coronary artery disease.

Topics: Angiography; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Electrocardiography; Exercise Test; Female; Heart; Humans; Male; Physical Exertion; Radioisotopes; Radionuclide Imaging; Thallium

Topics: Adult; Attitude of Health Personnel; Cardiovascular Agents; Coronary Disease; Diet; Humans; Middle Aged; Poland; Smoking Prevention

Topics: Age Factors; Aged; Anesthesia; Cardiovascular Agents; Coronary Disease; Heart Diseases; Hemodynamics; Humans; Middle Aged; Postoperative Complications; Preoperative Care; Risk; Surgical Procedures, Operative

Ligation of the left anterior descending coronary artery was performed in open-chest anaesthetized rats and mortality as well as changes in ECG were evaluated for 30 min thereafter. Saline or drugs were administered 15 min prior to ligation. In the control group, following a 4 min lag period ventricular arrhythmias as single ectopic beats, ventricular tachycardia and ventricular fibrillation (VF) appeared, reaching a maximum between 10 and 20 min and disappearing after 30 min. Mortality (40% in the control group) coincided with the period of maximal arrhythmias, with VF more common in animals that died than in those surviving. Alinidine, a drug which reduces sino-atrial rate specifically but has no conventional antiarrhythmic properties, reduced mortality and VF. By means of order statistics the quantity 'risk of death' was used for evaluation of drug effects, considering incidence of death and VF as well as duration of VF. This quantity was reduced in correlation with the dose of alinidine (1-6 mg/kg i.v.) and in correlation with the reduction of heart rate. Mexiletine, an antiarrhythmic drug with membrane-depressant properties, also reduced the 'risk of death' dose dependently (1-10 mg/kg i.v.), but there was no correlation with a decrease in heart rate. It is suggested that alinidine reduced 'risk of death' by means of a reduced oxygen demand due to a decrease in heart rate.

Topics: Animals; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Cardiovascular Agents; Clonidine; Coronary Disease; Electrocardiography; Heart Rate; Hemodynamics; Male; Mexiletine; Rats; Rats, Inbred Strains; Risk; Ventricular Fibrillation

Experiments were made on 56 white noninbred male rats with transitory coronary insufficiency (duration of myocardial ischemia 10, 40 and 120 min, the length of subsequent reperfusion 10 and 40 min). It was discovered that there were changes in the ultrastructure of cardiocytes and vessels of the microcirculatory bed both in the area of ischemia and reperfusion and in the distant heart regions, an increase in myocardial cell and microvessel lesions during postischemic reperfusion not only in the area of ischemia but also in distant zones. In addition, a reduction was noted in the degree of ischemic and reperfusion myocardial injury during the prophylactic use of myophedrine. The mechanisms of the protective action of myophedrine in acute transitory coronary insufficiency are discussed.

Topics: Animals; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Drug Evaluation, Preclinical; Heart; Male; Microcirculation; Microscopy, Electron; Myocardium; Oxyfedrine; Propiophenones; Rats; Time Factors

The one year mortality of patients with severe congestive heart failure ranges between 30 and 70%. The effect was investigated of a stepped care program, including weekly monitoring and frequent adjustment of medical treatment, on the prognosis of 18 consecutive outpatients with severe congestive heart failure (NYHA class III and IV, 60 +/- 3.5 years). The diagnosis of congestive heart failure was proven by an invasively measured cardiac index below 2.5 l/min/m2 or by a left ventricular ejection fraction below 30%. Plasma adrenaline and noradrenaline values and plasma renin activity were substantially increased in all patients compared with 20 normals. 11 of the heart failure patients had coronary heart disease, 10 with a large left ventricular aneurysm, 6 patients had congestive cardiomyopathy and one patient had valvular heart disease with aortic insufficiency. In 9 patients ventricular tachycardias were registered, four had recurrent syncopes, and in 7 other patients atrial fibrillation, atrial flutter and paroxysmal supraventricular tachycardias were found. Medical treatment in all patients included pre- and afterload reduction by vasodilators. 11 patients received digoxin and 8 antiarrhythmic drugs. After a mean follow-up of 25 +/- 3.3 months, the one-year mortality was 7% and the two year mortality 15%. The favorable prognosis in patients in this special care program shows the favorable effects of individualized therapy, of frequent patient monitoring and the influence of strict compliance on survival and symptoms in patients with chronic congestive heart failure.

Topics: Adult; Anti-Arrhythmia Agents; Cardiac Glycosides; Cardiomyopathy, Dilated; Cardiovascular Agents; Coronary Disease; Diuretics; Heart Failure; Humans; Middle Aged; Patient Compliance; Prospective Studies; Vasodilator Agents

The hypothesis that prostacyclins exert a membrane stabilizing action on the ischemic myocardium was examined in isolated rabbit hearts by measuring the elimination half-time of labelled catabolites after injection of 17-(131I)-heptadecanoic acid. During normoxia, a rapid washout of labelled lipids was observed along with a slower exponential elimination of I- from beta-oxidation. After 90 min of ischemia, lipid washout was increased over 6-fold. Infusion of iloprost (1.1 nmol/min) significantly reduced the lipid washout half-time. Iloprost preserved functional myocardial integrity as evidenced by a greater recovery of left ventricular pressure and attenuation of the increase in coronary resistance after reperfusion. These results indicate that the poor recovery of the heart after ischemia is associated with significant changes in membrane integrity and permeability. These data support the hypothesis that the biochemical and functional myocardial preservation by prostacyclin(s) is by a membrane stabilizing mechanism.

Topics: Animals; Blood Pressure; Cardiovascular Agents; Cell Membrane; Coronary Disease; Epoprostenol; Iloprost; In Vitro Techniques; Membrane Lipids; Rabbits

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Humans; Nitrates

Topics: Adrenergic beta-Antagonists; Ambulatory Care; Antihypertensive Agents; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Death, Sudden; Diuretics; Humans; Hypertension; Myocardial Infarction

Topics: Aged; Amyloidosis; Antihypertensive Agents; Arrhythmias, Cardiac; Body Weight; Cardiac Glycosides; Cardiovascular Agents; Cardiovascular Diseases; Cardiovascular System; Coronary Circulation; Coronary Disease; Heart Valve Diseases; Hemodynamics; Humans; Hypertension; Myocardial Contraction; Organ Size

[(5Z,13E,9 alpha,11 alpha,15S)-2,3,4-Trinor - 1,5 - inter-m - phenylene - 6,9 - epoxy - 11,5 - dihydroxy - 15 - cyclohexyl - 16,17,18,19,20-pentanor]- prosta-5,13-dienoic acid (sodium salt) (CG 4203) is a new stable epoprostenol (prostacyclin) analogue with a relative platelet antiaggregatory potency of 0.46 (ADP aggregation in vitro) and a hypotensive potency of 0.14 (anaesthetized rat i.v.) as compared to epoprostenol. In isolated perfused rat hearts, CG 4203 (4.64 X 10(-9) mol/l) significantly attenuated arrhythmias and loss of left ventricular creatine kinase (CK) activity observed in control hearts after 30 min perfusion with hypoxic and 30 min reperfusion with oxygenated Krebs-Ringer solution. In anaesthetized rats, CG 4203 (1.0 microgram X kg-1 X min-1 i.v.) significantly reduced incidence of ventricular fibrillation and increase in plasma CK activity after ligation of the left coronary artery. Infusion of 1.0 and 2.15 micrograms X kg-1 X min-1 CG 4203 i.v. in anaesthetized rats dose-dependently inhibited electrocardiographic changes, i.e. ST depression observed after i.v. injection of 1.0 IU X kg-1 vasopressin. In rat models of sustained myocardial hypoxia, myocardial infarction, and transient cardiac ischemia, CG 4203 thus exerts cardioprotective effects which, depending on the model considered, may be ascribed to either its vasodilatory, coronary dilatory, antiaggregatory or epoprostenol-like cytoprotective activity.

Topics: Animals; Cardiovascular Agents; Coronary Disease; Creatine Kinase; Epoprostenol; In Vitro Techniques; Male; Myocardial Contraction; Nitroglycerin; Oxygen; Perfusion; Rats; Rats, Inbred Strains; Vasopressins

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Echocardiography; Heart Failure; Humans; Hypertension; Kidney Failure, Chronic; Pericarditis; Renal Dialysis

Prostacyclin (PGI2) can protect the heart against ischemia, i.e. it can reduce myocardial damage [9, 10]. PGI2 protects the myocardium in vivo by preventing platelets from clumping and by dispersing preformed platelet aggregates [1,14]. However, also in the absence of platelets, PGI2 was shown to protect the myocardium against ischemia at concentrations that did not affect smooth muscle tone in the vessel wall [2]. This protective effect of PGI2 in vitro might be related to a stabilization of cell membranes in adrenergic nerve endings and hence to the prevention of ischemia-induced catecholamine release [13]. The instability of PGI2, both in vitro and in vivo, limits its application during long ischemic periods. Recently, a stable prostacyclin analogue, ZK 36 374, was demonstrated to have several prostacyclin-mimetic activities, both in vitro and in vivo [11,12]. In this communication we report upon the beneficial effect of this stable prostacyclin analogue at a low concentration (4 nM) on the extent of ischemic damage, on the recovery of myocardial function and on the occurrence of arrhythmias in the isolated rat heart after 24 h hypothermic cardiac arrest.

Topics: Animals; Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Electrophysiology; Epoprostenol; Heart; Heart Arrest; Hypothermia, Induced; Iloprost; Male; Rats; Rats, Inbred Strains

Topics: Aged; Cardiovascular Agents; Chronic Disease; Coronary Disease; Drug Tolerance; Humans; Middle Aged

Topics: Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Disease; Heart Diseases; Heart Failure; Heart Valve Diseases; Humans

Topics: Angina Pectoris; Angina, Unstable; Cardiovascular Agents; Coronary Disease; Humans; Myocardial Infarction

Topics: Cardiovascular Agents; Coronary Disease; Costs and Cost Analysis; Drug Prescriptions; Humans; Pharmaceutical Services; United States

The medical management of angina pectoris requires a comprehensive approach to the patient and his family, including attention not only to established physiologic and pharmacologic principles, but also to the emotional aspects of his illness. When comprehensive management is systematically and rigorously applied to the patient with angina pectoris, excellent relief of the symptoms of angina pectoris can be achieved in a high percentage of patients, although there are significant numbers of patients who are refractory to the most intensive management using presently available drugs. The same fundamental principles of care apply to patients with coronary heart disease who undergo aortocoronary bypass surgery and to those treated medically.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Diagnostic Errors; Humans; Nitrates; Nitroglycerin; Patient Education as Topic; Prognosis; Risk

Mortality during the first six to eight months after acute myocardial infarction is primarily due to sudden cardiac death and myocardial reinfarction. Therefore any secondary preventive measures have to be aimed at these complications of coronary heart disease and should be effective during the first six months after myocardial infarction. Results of comprehensive studies permit the following conclusions: application of beta-blocking agents may result in a significant reduction of total mortality, sudden cardiac death and the incidence of reinfarction in the old patient. They should be used as the regimen of first choice in a general routine prevention after myocardial infarction. In special cases coronary artery surgery provides an additional means for effective prevention. Compared to this platelet aggregation inhibitors, modification (resp. treatment) of risk factors and physical methods are of minor importance for secondary prevention after myocardial infarction in old patients.

Topics: Adrenergic beta-Antagonists; Age Factors; Aged; Cardiovascular Agents; Coronary Disease; Female; Humans; Male; Myocardial Infarction; Physical Exertion; Platelet Aggregation; Recurrence; Sex Factors

Topics: Animals; Cardiovascular Agents; China; Coronary Disease; Female; Heart Rate; Male; Mice; Oils, Volatile; Plants, Medicinal; Rats

Topics: Adult; Age Factors; Aged; Cardiovascular Agents; Coronary Disease; Drugs, Chinese Herbal; Female; Humans; Male; Middle Aged; Plant Extracts; Sex Factors

This case is typical of cardiovascular drug regimens in the elderly. Indeed, patients are often on several additional drugs for cardiovascular problems as well as other diseases. Familiarity with the pharmacology of all drugs is mandatory. Interactions of drugs can be complex, and a clinical pharmacologist can be a helpful resource. The classic interaction in cardiovascular drug regimens, as in this case, is with the combination of digoxin and potassium-depleting diuretics. The special interactions of cardiovascular and psychotropic drugs will be discussed elsewhere in this symposium. General clinical concerns in the care of patients taking cardiovascular drugs include scrutiny of drug choice, dosage, and combination. The dosage of drugs may need to be altered as the client ages. Drug types and combinations also may need to be changed to meet the needs of the patient's altered physiologic responses. The patient's response to drug therapy must be continuously evaluated. The best rule is to ensure that the patient takes the least number of drugs at the minimum dose required for desired effects. Starting drug dosages low and increasing them gradually often prevent toxicity. The nurse's assessment of subtle behavior or physical changes is important for the early detection of toxicity and adverse reactions. The possibility that a noted change is drug precipitated should always be considered. Health education of the client, family, or appropriate others is a significant nursing contribution to care. Awareness of drug side effects and specific offsetting interventions can prevent many discomforts and complications. Often making the patient aware of his changing body needs helps to elicit cooperation.

Topics: Aged; Aging; Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Disease; Female; Heart Failure; Humans; Hypertension; Kinetics; Middle Aged

Reported here are 162 cases of atrial ectopic tachycardia, a specific type of the supraventricular arrhythmia, which is characterized by the distinct P waves on the ECG, which follow at the rate of 400 and more per minute. Although atrial ectopic tachycardia is similar to the supraventricular paroxysmal tachycardia and atrial flutter, it differs from them by the mechanism of the development. Atrial ectopic tachycardia is caused by the failure or weakening the sinus node and the appearance of the ectopic focus in the atria. Such arrhythmia occurs in the following 4 types: with atrial to ventricular excitation ratio 1:1; with incomplete atrio-ventricular block; with complete atrioventricular block; and in combination with atrial fibrillation. Atrial ectopic tachycardia often takes lingering course and is hardly responsive to the medical treatment. The cases of arrhythmia, characterized by the broad P waves on the ECG tend to the progressive course. 17 cases of atrial ectopic tachycardia treated by electrostimulation (ES) which had 100% positive effect are presented and ES advantages over the drug therapy are underlined. The frequent transition of this arrhythmia into the atrial fibrillation is outlined.

Topics: Cardiovascular Agents; Coronary Disease; Electric Countershock; Electrocardiography; Female; First Aid; Heart Atria; Humans; Male; Rheumatic Heart Disease; Tachycardia

Topics: Animals; Benzoquinones; Cardiovascular Agents; Citric Acid Cycle; Coronary Circulation; Coronary Disease; Electron Transport; Hypoxia; Malates; Mice; Myocardium; Quinones; Rats; Succinates; Ubiquinone

Topics: Animals; Cardiovascular Agents; Coronary Disease; Myocardium

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Disease; Heart Function Tests; Humans; Vasodilator Agents

Topics: Animals; Calcium; Cardiovascular Agents; Coronary Disease; Dogs; Humans; Resuscitation; Ventricular Fibrillation

Topics: Adult; Cardiovascular Agents; Coronary Disease; Hemostasis; Humans; Hypertension; Magnetics; Middle Aged

The result of an exercise ECG can be represented on an XY chart by four monovariate (normal) distributions: heart rate (divided by X axis); blood pressure (divided by Y axis); Working time deficit (-X axis); ST depression (-Y axis); and two bivariate (elliptic) distributions: double product (divided by X divided by Y quadrant); ST X time-deficit index (-X -Y quadrant). Charts for 100 normal men, 100 normal women, 100 coronary men, and 100 coronary women were first of all built up. Charts of 100 patients under propanolol, 33 under atenolol, 47 under nidefipine, 13 under verapamil, and 44 under isosorbide dinitrate were then compared with those from coronary men. Beta blockers produced a shift in all six parameters; nifedipine modified blood pressure, double product, ST and time deficit; verapamil only changed blood pressure and time deficit; isosorbide changed ST, time deficit and the ST X time-deficit index.

Topics: Atenolol; Blood Pressure; Cardiovascular Agents; Coronary Disease; Electrocardiography; Exercise Test; Female; Heart Rate; Humans; Isosorbide Dinitrate; Male; Middle Aged; Nifedipine; Propranolol; Verapamil

The medicamentous therapy of the angina pectoris vera and of the chronic ischaemic heart disease is at present based on three groups of medicaments: nitrate compounds, beta-blocking agents and calcium antagonists. The underlying therapeutic principle which is common for them consists in the reduction of the oxygen requirement of the myocardium so that an improvement of the complaints and a larger load capacity may be achieved. The improvement may be objectified also at the behaviour of the haemodynamics and the ECG under load. The so-called coronary dilating remedies and the beta-stimulators did not prove clinically. In the acute attack rapidly acting nitroglycerin compounds remain the remedies of choice. Also the permanent treatment should at first again use longer acting nitrate preparations. When despite a sufficient dosage no satisfying improvement takes place an additional prescription of beta-blocking agents is recommended. Calcium antagonists are suitable particularly for the vasospastic form of the angina pectoris. They can be used also as basis medicaments, however, according to the hitherto yielded experiences they do not possess any advantages in contrast to the proved nitrates and beta-blocking agents. When apart from the ischaemic heart disease a hypertension exists, the beta-blocking agents are particularly indicated. This is further important for certain forms of tachycardiac disturbances of rhythm, which partly also well response to calcium antagonists. In patients with disturbances of conduction (sinus node and atrioventricular nodes, bifascicular block) beta-blocking agents are contraindicated. If there are no signs of cardiac decompensation and radiologically the heart proves to be normally large, so there is no indication for the prescription of glycosides.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Arrhythmias, Cardiac; Calcium; Cardiovascular Agents; Coronary Disease; Digitalis Glycosides; Humans; Nitroglycerin; Vasodilator Agents

On the basis of clinical examination and the results of bicycle ergometry and echocardiography in 58 patients with chronic ischemic heart disease the authors determined the contingent of patients in whom long-acting nitrates were most effective. The high clinical effectiveness of the agents in patients with symptoms of the initial stage of cardiac insufficiency is proved and the absence of any essential differences between long-acting nitrates in the character of their effect on hemodynamics is shown. It is established that nitroglycerin and long-acting nitrates cause a qualitatively similar effect on myocardial contractile function and intracardiac hemodynamics in patients with ischemic heart disease.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Disease; Delayed-Action Preparations; Drug Evaluation; Female; Hemodynamics; Humans; Male; Middle Aged; Nitrates; Nitro Compounds; Nitroglycerin

Topics: Animals; Blood Pressure; Cardiac Output; Cardiovascular Agents; Cardiovascular System; Cats; Coronary Disease; Dogs; Dose-Response Relationship, Drug; Electric Stimulation; Female; Guinea Pigs; Heart Rate; In Vitro Techniques; Male; Myocardial Contraction; Pyrrolidines

Seventy-seven patients with chronic ischemic heart disease were treated in single-seater oxygen hyperbaric chambers; 52 patients had angina pectoris of effort or angina of effort and at rest while 25 patients with macrofocal postinfarction cardiosclerosis had insufficiency of pulmonary or systemic circulation. Treatment consisted of 12--15 procedures. The use of hyperbaric oxygenation in a complex with drug therapy makes it possible to alleviate or arrest the attack of angina pectoris and relieve considerably the symptoms of cardiac decompensation. The initial condition of central hemodynamics affects greatly the results of barotherapy. Normal parameters of hemodynamics hardly change after treatment. At the same time, in patients with markedly reduced myocardial contractility hyperbaric oxygenation causes evident positive changes in hemodynamics. The combination of hyperbaric oxygenation with drug therapy improves the effect of treatment significantly.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Disease; Drug Therapy, Combination; Evaluation Studies as Topic; Female; Heart Failure; Humans; Hyperbaric Oxygenation; Male; Middle Aged

Effects of Theo-Esberiven, a coronary vasodilator, on the development of collateral circulation were investigated in dogs with their left anterior descending artery chronically occluded. The drug was administered i.v. at 0.1 ml/kg once a day for 1 to 4 weeks after the occlusion. Left circumflex coronary flow in dogs treated with the drug was increased over the value in control ones when measured one week after the occlusion. At the same time, the ratio of retrograde pressure to perfusion pressure, which correlates negatively with the collateral vascular resistance, significantly exceeded the value in control (P less than 0.05). On the basis of observations with blood vessel casts of hearts, distinct anastomoses between the circumflex and anterior descending arteries had already been observed in all preparations from dogs treated for 2 weeks in contrast to the findings seen in control ones. There were less histological changes in myocardial tissue obtained from dogs treated for one week than those in control ones. From these results, Theo-Esberiven appears possibly to accerelate the collateral development at the earlier stages after the coronary occlusion.

Topics: Aminophylline; Animals; Cardiovascular Agents; Collateral Circulation; Coronary Circulation; Coronary Disease; Coronary Vessels; Coumarins; Dogs; Drug Combinations; Female; Heart; Hemodynamics; Male; Rutin; Time Factors

Topics: Adult; Cardiovascular Agents; Coronary Disease; Humans; Myocardial Contraction; Systole

Topics: Angina Pectoris; Biomedical Research; Cardiovascular Agents; Coronary Disease; Drug Therapy; Geriatrics; Muscle Relaxants, Central; Parasympatholytics; Placebos; Vasodilator Agents

Topics: Cardiovascular Agents; Coronary Disease; Humans; Prenylamine

Topics: Biphenyl Compounds; Cardiovascular Agents; Coronary Disease; Humans; Lactates; Lactic Acid; Prenylamine; Propylamines

Topics: Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Ergonovine; Ergot Alkaloids

Topics: Cardiovascular Agents; Coronary Disease; Prenylamine

Topics: Cardiovascular Agents; Coronary Disease; Ergonovine; Ergot Alkaloids; Heart Diseases; Humans; Nitrites; Nitroglycerin; Oxytocics

Topics: Cardiovascular Agents; Coronary Disease; Coronary Vessels; Microsurgery; Reserpine; Vasodilator Agents

Topics: Cardiovascular Agents; Coronary Disease; Vasoconstrictor Agents; Vasodilator Agents

Topics: Animals; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Ergonovine; Ergot Alkaloids; Exercise Test; Oxytocics; Rabbits

Topics: Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Hexamethonium; Humans; Muscle Relaxants, Central

Topics: Analgesics; Cardiovascular Agents; Coronary Disease; Muscle Relaxants, Central; Promedol

Topics: Animals; Arteriosclerosis; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Ergonovine; Ergot Alkaloids; Exercise Test

Topics: Ballistocardiography; Cardiovascular Agents; Coronary Disease; Humans; Muscle Relaxants, Central; Papaverine; Vasodilator Agents

Topics: Barbiturates; Cardiovascular Agents; Coronary Disease; Diuretics; Pentaerythritol Tetranitrate; Theophylline

Topics: Cardanolides; Cardiovascular Agents; Coronary Disease; Ergoloid Mesylates; Ergot Alkaloids; Peripheral Vascular Diseases

Topics: Anti-Arrhythmia Agents; Cardiovascular Agents; Coronary Disease; Ergot Alkaloids