Does Outpatient Telephone Coaching Add to Hospital Quality Improvement Following Hospitalization for Acute Coronary Syndrome?

Background  Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care. Objective  To test the effectiveness of a six-session outpatient telephone-based counseling intervention to improve secondary prevention (behaviors, medication) in patients with acute coronary syndrome (ACS) following discharge from hospital, and impact on physical functioning and quality of life at 8 months post-discharge. Design  Patient-level randomized trial of hospital quality improvement (QI-only) versus quality improvement plus brief telephone coaching in three months post-hospitalization (QI-plus). Data: medical record, state vital records, patient surveys (baseline, three and eight months post-hospitalization). Analysis: pooled-time series generalized estimating equations to analyze repeated measures; intention-to-treat analysis. Participants  Seven hundred and nineteen patients admitted to one of five hospitals in two contiguous mid-Michigan communities enrolled; 525 completed baseline surveys. Measurements  We measured secondary prevention behaviors, physical functioning, and quality of life. Results  QI-plus patients showed higher self-reported physical activity (OR = 1.53; p = .01) during the first three months, with decline after active intervention was withdrawn. Smoking cessation and medication use were not different at 3 or 8 months; functional status and quality of life were not different at 8 months. Conclusions  Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization.     

Vascular Closure Devices in Acute Coronary Syndromes: From Arbitrary to a Necessity?

Vascular closure devices (VCDs) were initially developed to improve access site hemostasis and allow for earlier ambulation in patients undergoing diagnostic catheterization and percutaneous coronary intervention (PCI). Though initially thought to be beneficial, large meta-analysis has shown conflicting data regarding whether VCDs alter access site bleeding in a variety of clinical settings. One area of particular interest for the adoption of VCDs has been in the setting of acute coronary syndromes (ACS) in which multiple antiplatelet strategies are often employed leading to a high risk of bleeding. Bleeding in ACS has been shown to be a powerful independent predictor of 30-day mortality. Recently, investigators have reported that VCDs reduce access site bleeding in the setting of ACS. In our review, we use several selected representative clinical trials to provide a historical account for the use of VCDs. We also provide for a review of data as it relates to access site bleeding in ACS along with analysis showing that VCDs may potentially provide for reductions in bleeding and vascular complications in patients with ACS undergoing PCI.     

Prognostic Value of Risk Factors,Calcium Score,Coronary CTA,Myocardial Perfusion Imaging,and Invasive Coronary Angiography in Kidney Transplantation Candidates

Objectives

This study sought to perform a prospective head-to-head comparison of the predictive value of clinical risk factors and a variety of cardiac imaging modalities including coronary artery calcium score (CACS), coronary computed tomography angiography (CTA), single-photon emission computed tomography (SPECT), and invasive coronary angiography (ICA) on major adverse cardiac events (MACE) and all-cause mortality in kidney transplantation candidates.

Do Diabetic Patients with Acute Coronary Syndromes Have a Higher Threshold for Ischemic Pain?

Background:

Data from over 4 decades have reported a higher incidence of silent infarction among patients with diabetes mellitus (DM), but recent publications have shown conflicting results regarding the correlation between DM and presence of pain in patients with acute coronary syndromes (ACS).

Objective:

Our primary objective was to analyze the association between DM and precordial pain at hospital arrival. Secondary analyses evaluated the association between hyperglycemia and precordial pain at presentation, and the subgroup of patients presenting within 6 hours of symptom onset.

Methods:

We analyzed a prospectively designed registry of 3,544 patients with ACS admitted to a Coronary Care Unit of a tertiary hospital. We developed multivariable models to adjust for potential confounders.

Results:

Patients with precordial pain were less likely to have DM (30.3%) than those without pain (34.0%; unadjusted p = 0.029), but this difference was not significant after multivariable adjustment, for the global population (p = 0.84), and for subset of patients that presented within 6 hours from symptom onset (p = 0.51). In contrast, precordial pain was more likely among patients with hyperglycemia (41.2% vs 37.0% without hyperglycemia, p = 0.035) in the overall population and also among those who presented within 6 hours (41.6% vs. 32.3%, p = 0.001). Adjusted models showed an independent association between hyperglycemia and pain at presentation, especially among patients who presented within 6 hours (OR = 1.41, p = 0.008).

Conclusion:

In this non-selected ACS population, there was no correlation between DM and hospital presentation without precordial pain. Moreover, hyperglycemia correlated significantly with pain at presentation, especially in the population that arrived within 6 hours from symptom onset.     

What Have We Learned About Plaque Rupture in Acute Coronary Syndromes?

The most common cause of acute coronary syndrome (ACS) is rupture of an atherosclerotic lesion containing a large necrotic core and a thin fibrous cap followed by acute luminal thrombosis because the rupture of the thin fibrous cap allows contact of the platelets with the highly thrombogenic necrotic core. Pathologic studies have suggested that the precursor of the ruptured plaque is the so-called thin cap fibroatheroma (TCFA). Unfortunately, true natural history studies of TCFAs and their transition to ruptured plaques are rare. Most of the data and concepts have been inferred from studies performed at a single point in time. Intravascular ultrasound (IVUS) studies have shown ruptured plaques in approximately two thirds of ACS culprit lesions and occur in predictable locations. The features that differentiate secondary, nonculprit plaque ruptures from those that cause ACS events appear to be superimposed thrombosis and lumen compromise, either from the thrombus or from the underlying lesion. Secondary plaque ruptures appear to heal with optimal medical therapy. In vivo definitions of TCFAs have been derived from pathology study to include positive remodeling, a fibrous cap less than 100 μm (and perhaps <65 μm) at its minimum thickness, macrophage infiltration especially in the thin fibrous cap, a large lipid/necrotic core often containing hemorrhage and/or speckled or diffuse calcification (not enough to increase plaque stability although the absence of any calcium is also rare in rupture-prone plaques), and abundant intraplaque vasa vasorum and/or hemorrhage. Early data from in vivo imaging have substantiated the pathologic observations, but have also suggested that spontaneous stabilization of TCFAs with medical therapy alone is possible.     

CT Coronary Calcification: What Does a Score of “0” Mean?

Calcium score (CS) is a useful tool in evaluating the risk of cardiovascular events in asymptomatic patients. The absence of detectable calcification determines excellent cardiovascular prognosis, with event rates lower than that of negative stress studies, probably due to the latter’s inability to detect nonobstructive coronary artery disease (CAD). There are few primary prevention medications that would be cost-effective in such a low-risk patient population. The interval for retesting patients with zero CS is still open for debate but it should not be in less than 4 to 5 years. CS should not be used to rule out obstructive CAD in symptomatic patients, as its correlation with coronary stenosis is poor and obstructive CAD is commonly found among symptomatic zero CS patients. Most studies have found very low specificity values for CS to detect obstructive CAD in symptomatic patients, meaning it has limited ability to detect the true negative cases (ie, zero CS without obstructive CAD).     

How Serious a Problem is Bleeding in Patients with Acute Coronary Syndromes?

Recent studies have highlighted the critical importance of bleeding complications on prognosis in patients with acute coronary syndromes (ACS). In fact, the hazard for an adverse cardiovascular event associated with bleeding is similar to that of a myocardial infarction. Several bleeding risk scores are now available that reliably quantify the probability of an ACS patient experiencing a bleeding complication. Consistent and strong correlates of bleeding include older age, female sex, renal impairment, and an invasive management approach. Although patients who tend to bleed are usually more morbid compared with their non-bleeding counterparts, several lines of experimental and clinical evidence suggest an independent and causal pathway for bleeding-associated cardiovascular risk. Given the frequency and adverse prognosis associated with bleeding, interventions that might reduce such complications are now a major emphasis in the current era of ACS treatment. Recent trials have shown that several novel antithrombotics, bivalirudin and fondaparinux, reduce bleeding risk while maintaining efficacy in reducing ischemic events during ACS. Other promising strategies that continue to be tested include the use of vascular closure devices and transradial arterial access during percutaneous coronary intervention.     

Is Hyperoxic Ventilation Important to Treat Acute Coronary Syndromes Such As Myocardial Infarction?

After reviewing the literature, I was unable to find hard evidence that the use of supplemental oxygen (hyperbaric or normobaric) in an uncomplicated acute myocardial infarction (AMI) is beneficial, and there is some evidence that it may be harmful.     

Prognostic Implication of Functional Incomplete Revascularization and Residual Functional SYNTAX Score in Patients With Coronary Artery Disease

Objectives

The aim of this study was to investigate the prognostic implication of functional incomplete revascularization (IR) and residual functional SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (rFSS) in comparison with 3-vessel fractional flow reserve (FFR) and residual SYNTAX score.

Does Statin Therapy Affect the Progression of Atherosclerosis Measured by a Coronary Calcium Score?

Coronary atherosclerosis is a leading cause of death in the United States and worldwide, accounting for close to 1 million deaths annually in the United States alone. The evaluation of coronary disease by CT-derived calcium scores is a rapidly evolving field of medical imaging. Furthermore, until recently, whether or not regression or progression of coronary disease could accurately be assessed by coronary calcium scores had been a question of considerable debate among experts in this field. If the medical treatment of coronary artery disease by statin pharmacotherapy could be accurately assessed by coronary calcium scoring, this would take much of the current guess work out of statin pharmacotherapy. Initial retrospective studies and observational data suggested that statin treatment resulted in reduction of coronary calcium. More recently, five randomized controlled trials have demonstrated that not only does statin treatment not reduce coronary calcium, but in fact, the progression of coronary calcium by CT scanning is indistinguishable from placebo treatment.     

Does immigration contribute to decreasing CHD incidence? Coronary risk factors among immigrants in Göteborg,Sweden

Abstract. Dotevall A, Rosengren A, Lappas G, Wilhelmsen L (Sahlgrenska University Hospital at Ostra, Göteborg University, Göteborg, Sweden). Does immigration contribute to decreasing CHD incidence? Coronary risk factors among immigrants in Göteborg, Sweden. J Intern Med 2000; 247: 331–339. Objectives. To investigate if an increasing proportion of immigrants may have contributed to the decreasing trend in coronary heart disease (CHD) in Sweden during the last few decades and to analyse the cardiovascular risk factor pattern in immigrants compared to Swedish‐born subjects. Population and methods. CVD risk factors were investigated within the framework of the WHO MONICA project. A random sample of 1618 men and women aged 25–64 years responded to the invitation to a screening procedure including questionnaires and physical and laboratory examination. Data on myocardial infarctions (MI) were collected from the Göteborg Myocardial Infarction Register. Data from the City Council secretariat were used to estimate the number of immigrants in the total population. Results. In 1995, immigrants constituted 22.4% of the population between 25 and 64 years of age in Göteborg. The incidence of MI in immigrants, 21.7%, was similar to that in Swedish‐born subjects. Non‐Finnish immigrants reported more unemployment, low physical activity during leisure time and psychological stress than Swedish subjects. Immigrant men also smoked more. BMI and WHR were significantly higher in immigrant women and Finnish immigrants had higher blood pressure than Swedes. Total‐ and LDL‐cholesterol were higher in Finnish men. HDL‐cholesterol was significantly lower and s‐triglycerides significantly higher in non‐Finnish immigrants of both genders. Conclusion. The decreasing trend in CHD in Sweden during the last few decades is not due to an increasing number of immigrants from ‘low‐risk countries’. On the contrary, the immigrants in the present study seem to have a worse CVD risk factor profile than Swedes.     

Does Ad Hoc Coronary Intervention Reduce Radiation Exposure? – Analysis of 568 Patients

Background

Advantages and disadvantages of ad hoc percutaneous coronary intervention have been described. However little is known about the radiation exposure of that procedure as compared with the staged intervention.

Objective

To compare the radiation dose of the ad hoc percutaneous coronary intervention with that of the staged procedure

Methods

The dose-area product and total Kerma were measured, and the doses of the diagnostic and therapeutic procedures were added. In addition, total fluoroscopic time and number of acquisitions were evaluated.

Results

A total of 568 consecutive patients were treated with ad hoc percutaneous coronary intervention (n = 320) or staged percutaneous coronary intervention (n = 248). On admission, the ad hoc group had less hypertension (74.1% vs 81.9%; p = 0.035), dyslipidemia (57.8% vs. 67.7%; p = 0.02) and three-vessel disease (38.8% vs. 50.4%; p = 0.015). The ad hoc group was exposed to significantly lower radiation doses, even after baseline characteristic adjustment between both groups. The ad hoc group was exposed to a total dose-area product of 119.7 ± 70.7 Gycm², while the staged group, to 139.2 ± 75.3 Gycm² (p < 0.001).

Conclusion

Ad hoc percutaneous coronary intervention reduced radiation exposure as compared with diagnostic and therapeutic procedures performed at two separate times.     

How to use the C-reactive protein in cardiac disease?

Inflammation is an important contributor to atherothrombosis. The C-reactive protein (CRP) is not only an excellent biomarker of inflammation, but it is also a direct participant in atherogenesis. CRP consistently predicts new coronary events, including myocardial infarction and death, in patients with ischemic heart disease. The predictive value of CRP is, in the majority of the studies, independent of and additive to that of the troponins and its levels can be modulated by statins. Prospective observational studies show that moderately elevated levels of CRP are associated with an adverse cardiovascular prognosis among healthy individuals. The availability of high sensibility assays for CRP should provide a valuable tool for identifying patients at risk of cardiovascular events in primary prevention in conjunction with lowering LDL cholesterol and may also have utility in the treatment of acute coronary syndromes with percutaneous coronary intervention (PCI) therapy. High CRP levels, associated with a higher risk, should suggest a more aggressive medical therapy in the long term and also an aggressive and invasive therapy in the short term, including the use of GP IIb/IIIa inhibitors, high doses of statins, and when a PCI is necessary, provisional stenting. Finally, CRP will provide a readily accessible marker for further testing of the inflammatory hypothesis in atherosclerosis.     

Individualised Assessment of Response to Clopidogrel in Patients Presenting with Acute Coronary Syndromes: A Role for Short Thrombelastography?

Introduction: There is considerable interindividual variation in response to the antiplatelet agent clopidogrel. Hyporesponse predicts negative outcomes in patients presenting with a variety of ischemic cardiac conditions and following intracoronary stent placement. Many tests of clopidogrel activity are time consuming and complex. Short thromboelastography (s‐TEG) allows rapid measurement of platelet clopidogrel response. Aims: We initiated this study to investigate the utility of s‐TEG in assessing the response to clopidogrel in patients presenting with acute coronary syndromes (ACS) and to compare these results with established clopidogrel monitoring techniques. Methods: Patients admitted with unstable angina (UA) or Non ST elevation myocardial infarction (NSTEMI) undergoing coronary angiography were recruited. After routine loading with clopidogrel, all patients were tested with s‐TEG and Accumetrics Verify‐Now rapid platelet function analyzer (VN‐RPFA). We used the modified TEG technique of measuring area under the curve at 15 min (AUC15), which allows a rapid estimation of antiplatelet response. Vasodilator‐stimulated phosphoprotein phosphorylation (VASP) was also tested in a subgroup of patients. Clinical follow‐up was obtained at 1 year. s‐TEG results were correlated with VN‐RPFA and VASP findings. Results: A total of 49 patients (33 male, mean age 63) were recruited and tested with s‐TEG and VN‐RPFA and a total of 39 patients were also assessed with VASP. s‐TEG readings correlated well with VN‐RPFA (r²= 0.54, P < 0.0001) and VASP (r²= 0.26, P= 0.001). Conclusion: s‐TEG provides timely results which compare to current tests of clopidogrel activity. This technique can also be used to measure a variety of other clotting parameters and as such could develop into a valuable near patient test for the interventional cardiologist.     

Intensity of Antiplatelet Therapy in Patients with Acute Coronary Syndromes and Percutaneous Coronary Intervention: the Promise of Prasugrel?

Platelet activation and aggregation play key roles in the management of ischemic complications of acute coronary syndromes and percutaneous coronary intervention. Dual antiplatelet therapy with aspirin and the thienopyridine clopidogrel has become the standard of care for prevention of such complications. Prasugrel, a novel thienopyridine antiplatelet agent, has been demonstrated to have favorable pharmacologic properties, including rapid onset and potent and consistent inhibition of platelet aggregation. When compared directly against clopidogrel in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38), prasugrel resulted in significant reductions in ischemic events including myocardial infarction and stent thrombosis, but with more bleeding.