B. Daniel Lucas

Impact of Pharmacy Counseling on Compliance and Effectiveness of Combination Lipid-Lowering Therapy in Patients Undergoing Coronary Artery Revascularization: A Randomized, Controlled Trial

This randomized, controlled trial evaluated the impact of personalized follow‐up on compliance rates in high‐risk patients receiving combination lipid‐lowering therapy over 2 years. A random sample of 30 patients 7–30 days after cardiac surgery had baseline fasting low‐density lipoprotein levels higher than 130 mg/dl. All patients received lovastatin 20 mg/day and colestipol 5 g twice/day. Weekly telephone contact was made with each patient for 12 weeks. Short‐ and long‐term compliance was assessed by pill and packet counts and refill records. Compliance and lipid profile results were significantly better in the intervention group (p<0.05) up to 2 years after the start of therapy than in the control group for all parameters except high‐density lipoprotein. However this effect was not apparent during the first 12 weeks of therapy. Short‐term telephone follow‐up favorably affected compliance and lipid profile results up to 2 years after start of therapy.

Subendocardial ischemia without coronary artery disease: is elevated left ventricular end diastolic pressure the culprit?

SUMMARY Background: The aim was to investigate the association between elevated left ventricular end diastolic pressure (LVEDP) and subendocardial ischemia. Methods: A retrospective chart review was performed of 1846 consecutive patients admitted between January and September 2002 who had chest pain, stress testing and coronary angiography. Results: 1592 patients were excluded due to a positive coronary angiogram for coronary artery disease (CAD), 254 patients had an angiogram compatible with non-significant CAD and an ejection fraction >45%; of whom 210 (82.7%) had a positive stress test (study group) and the others 44 (17.3%) had a negative stress test (control group). The mean LVEDP value for the study group (11.8 ± 6.1 mmHg) was significantly higher than the mean LVEDP value for the control group (7.8 ± 4.6mmHg) (p < 0.001). In addition, there were more people with abnormal LVEDP (>12 mmHg) in the study group (n = 103,49.05%) compared with the control group (n = 10, 22.73%) (p < 0.001). Furthermore, the results of logistic regression revealed that patients with abnormal LVEDP values were 11 times more likely to have had a positive stress test. Conclusions: There appears to be a positive association between elevated LVEDP and subendocardial ischemia that manifests as a positive stress test in patients without evidence of significant CAD.

Detection of stress-induced myocardial ischemia from the depolarization phase of the cardiac cycle—a preliminary study

BACKGROUND Electrocardiogram (ECG)-based detection of ischemia is typically dependent on identifying changes in repolarization. Analysis of high-frequency QRS (HFQRS) components, related to the depolarization phase of the cardiac action potential, has been reported to better identify ischemia. Our aim was to test the hypothesis that HFQRS analysis is both more sensitive and specific than standard ECG for detecting exercise-induced ischemia in patients undergoing exercise myocardial perfusion imaging (MPI). METHODS Exercise MPI was performed in 133 consecutive patients (age, 63 +/- 12; 100 males) and used as the gold standard for ischemia. Patients with QRS duration more than 120 milliseconds (n = 20), technical problems (n = 8), or inconclusive MPI (n = 4) were excluded, leaving 101 patients for analysis. Conventional ECG was combined with high-resolution ECG acquisition that was digitized and analyzed using the HyperQ System (BSP, Tel Aviv, Israel). The relative HFQRS intensity change during exercise was used as an index of ischemia. RESULTS Of the 101 patients who were included in the analysis, 19 exhibited MPI ischemia. The HFQRS index of ischemia was found to be more sensitive (79% vs 41%; P < .05) and more specific (71% vs 57%; P < .05) than conventional ST analysis. CONCLUSIONS The HFQRS analysis was more sensitive and specific than conventional ECG interpretation in detecting exercise-induced ischemia and exhibited enhanced diagnostic performance in both women and men. Thus, it may aid in the noninvasive diagnosis of ischemic heart disease.

Angiotensin‐Converting Enzyme Inhibitors and Stroke Risk: Benefit Beyond Blood Pressure Reduction?

Hypertension, a leading cause of morbidity and mortality, accounts for 25–49% of all strokes. Randomized placebo‐controlled trials primarily with diuretics and β‐blockers administered in patients with hypertension have demonstrated a 38% reduction in primary stroke. Placebo‐controlled trials with angiotensin‐converting enzyme (ACE) inhibitors have not been conducted in patients with hypertension. However, in a meta‐analysis of four placebo‐controlled trials of ACE inhibitors in patients with coronary heart disease and/or diabetes mellitus, the overall risk of primary stroke was significantly reduced. Results of the Heart Outcomes Prevention Evaluation trial, which produced a substantial reduction in stroke with an apparently small reduction in blood pressure, suggest that the benefit of ACE inhibitors may be related to their effects on the renin‐angiotensin‐aldosterone system more than on blood pressure reduction. In active‐control comparisons in patients with hypertension, ACE inhibitors have demonstrated reductions in primary stroke risk similar to reductions with diuretics, β‐blockers, and calcium channel blockers. The data suggest that for primary prevention of stroke antihypertensive therapy should be individualized in patients. Relatively few data are available concerning the benefit of antihypertensive therapy in the secondary prevention of stroke. In patients who had experienced a stroke or transient ischemic attack, therapy with a diuretic or a combination of a diuretic plus an ACE inhibitor could be recommended based on available outcome studies conducted in this patient population. It is premature to conclude that the benefit of ACE inhibitor therapy in primary or secondary prevention of stroke is an effect independent of blood pressure reduction. Hypertension detection, treatment, and control in patients still must be the principal focus of clinicians for both primary and secondary prevention of stroke.

Aspirin Under Fire: Aspirin Use in the Primary Prevention of Coronary Heart Disease

The issue of aspirin use in the primary prevention of cardiovascular disease is still debated because of conflicting opinions on risks versus benefits. Recently, a United States Food and Drug Administration (FDA) panel rejected the approval of aspirin in the setting of primary prevention in moderate‐risk patients. However, the United States Preventive Services Task Force recommends that clinicians discuss aspirin therapy with patients at increased risk for having a future coronary event. During the past 15 years, many large randomized trials have specifically addressed this issue and helped shape the decisions of the FDA panel and the Preventive Services Task Force. These trials lend a handful of experiences and results, with no clear recommendations for antiplatelet therapy in the setting of primary prevention of coronary heart disease (CHD). Recently, trial results have been assimilated into practical tools for risk stratification to guide aspirin use in this setting. An overview and critical evaluation of the work performed thus far is provided in order to lend insight into the ongoing debate and, through use of the Framingham CHD risk prediction score sheets, to better equip practitioners faced with the decision of giving aspirin to “relatively” healthy individuals for CHD primary prevention.

Outcomes and Costs of Positron Emission Tomography: Comparison of Intravenous Adenosine and Intravenous Dipyridamole

The objective of this study was to compare the cost of intravenous adenosine and intravenous dipyridamole in positron emission tomography (PET) in patients with coronary artery disease. A retrospective, open-label, case-control, cost-effectiveness analysis was performed in the out-patient nuclear medicine department of a university hospital. Thirty-six patients underwent dipyridamole PET, and 72 matched patients underwent adenosine PET. A cost-effectiveness analysis was conducted using a direct cost accounting approach to estimate institutional costs. Key costs evaluated included acquisition cost, administration cost, monitoring cost, cost of management of side effects, and cost of follow-up care. The total cost of adenosine PET and dipyridamole PET was divided by their respective predictive accuracies to provide a total cost adjusted for efficacy. Adenosine increased heart rate and lowered systolic blood pressure to a significantly greater extent than dipyridamole. The number of patients experiencing adverse drug reactions was significantly greater for adenosine (82%) than for dipyridamole (67%), but the frequency of prolonged (> 5 minutes) and late-onset side effects was significantly greater for dipyridamole than for adenosine. The frequency of side effects requiring medical intervention was also significantly greater for dipyridamole (53%) than for adenosine (6%). Although adenosine had a significantly greater acquisition cost than dipyridamole, costs of monitoring, management of side effects, and follow-up care were significantly less for adenosine than for dipyridamole. As a result, the total cost of using dipyridamole is significantly greater (

Comparison of 24-Hour Ambulatory Blood Pressure Data in Hypertensive Patients Switched from Nifedipine-GITS to Nifedipine-CC

928.00 per patient) than the total cost of using adenosine (

Similar Success Rates with Bivalirudin and Unfractionated Heparin in Bare-Metal Stent Implantation

672.00 per patient). Based on these results, adenosine may be the drug of choice for pharmacologic vasodilation for PET.

Effect of Oral H2‐Receptor Antagonists on Left Ventricular Systolic Function and Exercise Capacity in Patients with Chronic Stable Heart Failure

Study Objective. To evaluate 24‐hour blood pressure control and frequency of adverse effects in patients with mild to moderate hypertension switched from nifedipine gastrointestinal therapeutic system (Nif‐GITS) to nifedipine coat core (Nif‐CC).

Rationale for Increasing the Starting Dose of Simvastatin

BackgroundUnfractionated heparin (UFH) is the traditional agent utilized during percutaneous peripheral interventions (PPIs) despite its well-known limitations. Bivalirudin, a thrombin-specific anticoagulant, overcomes many of the limitations of UFH and has consistently demonstrated comparable efficacy with significantly fewer bleeding complications. The purpose of this study was to compare procedural success in patients undergoing bare-metal stent implantation for atherosclerotic blockage of the renal, iliac, and femoral arteries and receiving either bivalirudin (0.75 mg/kg bolus/1.75 mg/kg/hr infusion) or UFH (50–70 U/kg/hr bolus) as the primary anticoagulant.MethodsThis study was an open-label, nonrandomized retrospective registry with the primary endpoint of procedural success. Secondary endpoints included incidence of: death, myocardial infarction (MI), urgent revascularization, amputation, and major and minor bleeding.ResultsOne hundred and five consecutive patients were enrolled (bivalirudin = 53; heparin = 52). Baseline demographics were comparable between groups. Patients were pretreated with clopidogrel (approx. 71%) and aspirin (approx. 79%). Procedural success was achieved in 97% and 96% of patients in the bivalirudin- and heparin-treated groups, respectively. Event rates were low and similar between groups.ConclusionBivalirudin maintained an equal rate of procedural success in this cohort without sacrificing patient safety. Results of this study add to the growing body of evidence supporting the safety and efficacy of bivalirudin as a possible substitute for UFH in anticoagulation during peripheral vascular bare-metal stent implantation.