Andrew Pipe

Efficacy and Safety of Varenicline for Smoking Cessation in Patients With Cardiovascular Disease A Randomized Trial

Background— Smoking cessation is a key component of secondary cardiovascular disease prevention. Varenicline, a partial &agr;4&bgr;2 nicotinic acetylcholine receptor agonist, is effective for smoking cessation in healthy smokers, but its efficacy and safety in smokers with cardiovascular disease are unknown. Methods and Results— A multicenter, randomized, double-blind, placebo-controlled trial compared the efficacy and safety of varenicline with placebo for smoking cessation in 714 smokers with stable cardiovascular disease. Participants received varenicline (1 mg twice daily) or placebo, along with smoking-cessation counseling, for 12 weeks. Follow-up lasted 52 weeks. The primary end point was carbon monoxide–confirmed continuous abstinence rate for weeks 9 through 12 (last 4 weeks of treatment). The continuous abstinence rate was higher for varenicline than placebo during weeks 9 through 12 (47.0% versus 13.9%; odds ratio, 6.11; 95% confidence interval [CI], 4.18 to 8.93) and weeks 9 through 52 (19.2% versus 7.2%; odds ratio, 3.14; 95% CI, 1.93 to 5.11). The varenicline and placebo groups did not differ significantly in cardiovascular mortality (0.3% versus 0.6%; difference, −0.3%; 95% CI, −1.3 to 0.7), all-cause mortality (0.6% versus 1.4%; difference, −0.8%; 95% CI, −2.3 to 0.6), cardiovascular events (7.1% versus 5.7%; difference, 1.4%; 95% CI, −2.3 to 5.0), or serious adverse events (6.5% and 6.0%; difference, 0.5%; 95% CI, −3.1 to 4.1). As a result of adverse events, 9.6% of varenicline and 4.3% of placebo participants discontinued study drug. Conclusions— Varenicline is effective for smoking cessation in smokers with cardiovascular disease. It was well tolerated and did not increase cardiovascular events or mortality; however, trial size and duration limit definitive conclusions about safety. Clinical Trial Registration Information— URL: http://www.clinicaltrials.gov/ct2/show/NCT00282984. Unique identifier: NCT00282984.

Injuries in Team Sport Tournaments During the 2004 Olympic Games

Background Several authors have analyzed the incidence of injuries in a given sport, but only a few have examined the exposure-related incidence of injuries in different types of sports using the same methodology. Purpose Analysis of the incidence, circumstances, and characteristics of injuries in different team sports during the 2004 Olympic Games. Study Design Cohort study; Level of evidence, 2. Methods During the 2004 Olympic Games, injuries in 14 team sport tournaments (mens and womens soccer, mens and womens handball, mens and womens basketball, mens and womens field hockey, baseball, softball, mens and womens water polo, and mens and womens volleyball) were analyzed. After each match, the physician of the participating teams or the official medical representative of the sport completed a standardized injury report form. The mean response rate was 93%. Results A total of 377 injuries were reported from 456 matches, an incidence of 0.8 injuries per match (95% confidence interval, 0.75-0.91) or 54 injuries per 1000 player matches (95% confidence interval, 49-60). Half of all injuries affected the lower extremity; 24% involved the head or neck. The most prevalent diagnoses were head contusion and ankle sprain. On average, 78% of injuries were caused by contact with another player. However, a significantly higher percentage of noncontact (57%) versus contact injuries (37%) was expected to prevent the player from participating in his or her sport. Significantly more injuries in male players (46%) versus female players (35%) were expected to result in absence from match or training. The incidence, diagnosis, and causes of injuries differed substantially between the team sports. Conclusion The risk of injury in different team sports can be compared using standardized methodology. Even if the incidence and characteristics of injuries are not identical in all sports, prevention of injury and promotion of fair play are relevant topics for almost all team sports.

The Use of Dietary Supplements and Medications by Canadian Athletes at the Atlanta and Sydney Olympic Games

Objective:To learn more about the prevalence of dietary supplement and medication use by Canadian athletes in the Olympic Games in Atlanta 1996 and Sydney 2000. Setting and Participants:Data were collected from personal interviews with Canadian athletes who participated at the 1996 Atlanta and 2000 Sydney Olympic Games. The athletes were interviewed by Canadian physicians regarding the use of vitamins, minerals, nutritional supplements, and prescribed and over-the-counter medications. Of the 271 Canadian athletes who participated at the Atlanta Olympics, 257 athletes were interviewed; at the Sydney Olympics, 300 of 304 Canadian athletes were interviewed. Main Outcome Measurement:A quantitative and qualitative description of the use of dietary supplements by Canadian athletes at the Atlanta and Sydney Olympics. Results:At the Atlanta Games, 69% of the athletes used some form of dietary supplements, whereas 74% of the athletes used dietary supplements at the Sydney Games. Vitamins were taken by 59% of men and 66% of women in Atlanta, and 65% of men and 58% women in Sydney. Mineral supplements were used by 16% of men and 45% of women in Atlanta, and 30% of men and 21% of women in Sydney. Nutritional supplements were used by 35% of men and 43% of women in Atlanta, and 43% of men and 51% of women in Sydney. The most popular vitamins were multivitamins in both Olympics. The most popular mineral supplements were iron supplements. The most commonly used nutritional supplement in Atlanta was creatine (14%), but amino acids (15%) were the most commonly used nutritional supplement in Sydney. In Atlanta, 61% of the athletes were using some form of medication, 54% of the athletes were using medications in Sydney. Nonsteroidal antiinflammatory drugs (NSAIDS) were the most commonly used medications at both Olympic Games. Among all sports, the highest prevalence of vitamin use occurred in boxing (91%) in Atlanta and swimming (76%) in Sydney. Rowers (56%) and cyclists (73%) demonstrated the highest use of mineral supplements. Nutritional supplement use occurred most often in swimming (56%) and cycling (100%). The use of NSAIDs was highest in softball (60%) in Atlanta and gymnastics (100%) in Sydney. Conclusion:This review demonstrates that dietary supplement use was common among Canadian athletes at both the Atlanta and Sydney Olympic Games. There was a slight increase in total dietary supplement use at the Sydney Games. Widespread use of supplements, combined with an absence of evidence of their efficacy and a concern for the possibility of “inadvertent” doping, underscore the need for appropriately focused educational initiatives in this area.

Nutritional supplements and doping.

ContextThe problems of doping in sport and the increasing use of nutritional supplements by athletes are issues that intersect to the degree that a large number of supplements may contain substances that are banned in sport. Many supplements contain substances that are associated with significant health hazards. Athletes consuming such supplement products may jeopardize their sporting status, and their health. ObjectivesTo clarify and summarize the current status of dietary supplements in general, and to describe specific problems that can be associated with supplement use so that sport physicians might be better prepared to address these issues with their athlete-patients. Data SourceAn analysis of recent and relevant literature accessed through MEDLINE, and interactions with clinicians, laboratory scientists, colleagues, and athletes. ConclusionsThe dietary supplement industry is completely unregulated in the United States; as a consequence, an abundance of supplement products of dubious value, content, and quality are now available around the world. It is known that many supplement products contain substances that are prohibited in sport—typically stimulants or anabolic steroid precursors. Many supplements contain substances (e.g., ephedrine) that have been associated with significant morbidity and mortality. Sport practitioners have particular responsibilities in addressing this issue. Athletes need to be aware of the problems that can follow supplement use, and sport authorities need to ensure that nutritional education and guidance for athletes is of the highest standard. The need for the appropriate regulation of dietary supplements is emphasized.

Determinants of physical activity after hospitalization for coronary artery disease: the Tracking Exercise After Cardiac Hospitalization (TEACH) Study

Background Little is known about physical activity levels in patients with coronary artery disease (CAD) who are not engaged in cardiac rehabilitation. We explored the trajectory of physical activity after hospitalization for CAD, and examined the effects of demographic, medical, and activity-related factors on the trajectory. Design A prospective cohort study. Methods A total of 782 patients were recruited during CAD-related hospitalization. Leisure-time activity energy expenditure (AEE) was measured 2, 6 and 12 months later. Sex, age, education, reason for hospitalization, congestive heart failure (CHF), diabetes, and physical activity before hospitalization were assessed at recruitment. Participation in cardiac rehabilitation was measured at follow-up. Results AEE was 1948 ± 1450, 1676 ± 1290, and 1637 ± 1486 kcal/week at 2, 6 and 12 months, respectively. There was a negative effect of time from 2 months post-hospitalization on physical activity (P<0.001). Interactions were found between age and time (P = 0.012) and education and time (P = 0.001). Main effects were noted for sex (men more active than women; P<0.001), CHF (those without CHF more active; P<0.01), diabetes (those without diabetes more active; P<0.05), and previous level of physical activity (those active before hospitalization more active after; P<0.001). Coronary artery bypass graft patients were more active than percutaneous coronary intervention (PCI) patients (P = 0.033). Conclusions Physical activity levels declined from 2 months after hospitalization. Specific subgroups (e.g. less educated, younger) were at greater risk of decline and other subgroups (e.g. women, and PCI, CHF, and diabetic patients) demonstrated lower physical activity. These groups need tailored interventions.

Canadian Stroke Best Practice Recommendations: secondary prevention of stroke guidelines, update 2014

Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals. The 2014 update of the Canadian Secondary Prevention of Stroke guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. Notable changes in this 5th edition include an emphasis on treating the highest risk patients who present within 48 h of symptom onset with transient or persistent motor or speech symptoms, who need to be transported to the closest emergency department with capacity for advanced stroke care; a recommendation for brain and vascular imaging (of the intra- and extracranial vessels) to be completed urgently using computed tomography/computed tomography angiography; prolonged cardiac monitoring for patients with suspective cardioembolic stroke but without evidence for atrial fibrillation on electrocardiogram or holter monitoring; and de-emphasizing the need for routine echocardiogram. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations using a standardized approach. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographical barriers to ensure equity in access within a universal health-care system.

Coagulation factor changes following endurance exercise.

ObjectiveTo compare preexercise with immediate and 24 h postvalues of coagulation parameters in experienced athletes following a single, 42-km marathon run. DesignBlood samples were taken 18 h before, immediately after, and 24 h after a marathon race from 14 welltrained individuals, and coagulation factors were measured. SettingThe setting was a 42-km race on a cloudy day in May with an ambient temperature of 22°. SubjectsThe subjects were fourteen normal healthy individuals (12 men and 2 women) who regularly participated in runs of at least 20 km each week. InterventionThe subjects all undertook a 42-km marathon run followed by a 24-h rest period and a repeat assessment. Main outcome measuresCoagulation factors including factor VIII(FVIII) and von Willebrand factor (vWF) were measured, as was the platelet response to aggregating agents. These responses are all considered as primary outcome measures of hypercoagulability and reflect the prethrombotic state. ResultsThe hematocrit was not altered immediately after the race, but the platelet count (mean ± SD) was significantly elevated (p < 0.05) to 322 ± 54 x 109/L from 256 ± 70 x 109/L, and the mean platelet size increased by 24 h (p < 0.05). Platelet aggregation in response to epinephrine, adenosine diphosphate, and collagen was decreased by 40%, 15%, and 60%, respectively, at 24 h; the response to ristocetin was only slightly (10%) altered. There was a significant elevation of β-thromboglobulin in the plasma at the end of the race, and this elevation persisted for 24 h, indicating considerable release from the platelet αP granules. The effect on platelet function was further demonstrated by a decrease in the quantity of glycoprotein Ib at 24 h, but not immediately after the race. There was an approximately 300% increase in the levels of FVIII, vWF antigen (vWF;Ag), and ristocetin cofactor activity. In addition, the normal vWF:Ag multimer pattern was changed in the samples taken immediately after the race. ConclusionsThe data support the evidence of significant alteration of certain factors that are involved in coagulation following endurance exercise. Increases in FVIII and vWF are also noted in some prethrombotic conditions. The decreased platelet aggregation suggests early activation during the period of exercise.

Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease

Background: The CardioFit internet-based expert system was designed to promote physical activity in patients with coronary heart disease (CHD) who were not participating in cardiac rehabilitation. Design: This randomized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes. Methods: A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and randomly assigned to either CardioFit (n = 115) or usual care (n = 108). The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking. They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist. Usual care consisted of physical activity guidance from an attending cardiologist. Physical activity was measured by pedometer and self-reported over a 7-day period, 6 and 12 months after randomization. Results: The CardioFit internet-based physical activity expert system significantly increased objectively measured (p = 0.023) and self-reported physical activity (p = 0.047) compared to usual care. Emotional (p = 0.038) and physical (p = 0.031) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care. Conclusions: Patients with CHD using an internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care. Use of the CardioFit program could extend the reach of rehabilitation and secondary-prevention services.

Stepped care approach to smoking cessation in patients hospitalized for coronary artery disease.

PURPOSE Smoking cessation is an important goal for smokers with coronary artery disease (CAD) because it reduces cardiac morbidity and mortality. Effective interventions for cigarette smokers with CAD exist, but they often are considered to be intensive and expensive. Stepped-care interventions have been proposed as a promising way to allocate smoking cessation treatments in a cost-effective manner. Stepped care refers to the practice of initiating treatment with low-intensity intervention and then exposing treatment failures to successively more intense interventions. METHODS To address the efficacy of this approach, 254 cigarette smokers hospitalized with CAD were provided a brief cessation intervention. The participants then were assigned randomly to either a more intensive stepped-care treatment (counseling and nicotine patch therapy) or no additional treatment. Outcomes were point-prevalent abstinence measured 3 months and 1 year after hospital discharge. RESULTS Stepped-care treatment increased smoking cessation rates from 42% to 53% during a 3-month follow-up period (P =.05), but showed little effect at the 1-year follow-up assessment, as evidenced by a cessation rate for the minimal intervention group of 36% versus 39% for the stepped-care group (P =.36). CONCLUSIONS A stepped-care approach to smoking cessation increased short-but not long-term point-prevalent abstinence in patients with CAD. For improvement of long-term effectiveness, refinement of the timing and content of stepped-care interventions needs to occur.

Harmonization of guidelines for the prevention and treatment of cardiovascular disease: the C-CHANGE Initiative

Cardiovascular disease is the most prevalent chronic medical condition in Canada, and evidence-based management of risk factors for cardiovascular disease can reduce morbidity and mortality.[1][1] However, there are more than 400 individual recommendations for risk management of cardiovascular