R. Rajaratnam

Attenuation of anti-ischemic efficacy during chronic therapy with nicorandil in patients with stable angina pectoris

After 2 weeks of nicorandil therapy, time to ischemia on stress testing was significantly less than on day 1 and not different from placebo. These data are consistent with attenuation of the anti-ischemic effects of this drug and suggest that the potassium channel-opening properties do not compensate for development of attenuation to the nitrate component of nicorandil.

Cardiovascular safety of non-insulin pharmacotherapy for type 2 diabetes

Patients with type 2 diabetes mellitus have a twofold increased risk of cardiovascular mortality compared with non-diabetic individuals. There is a growing awareness that glycemic efficacy of anti-diabetic drugs does not necessarily translate to cardiovascular safety. Over the past few years, there has been a number of trials evaluating the cardiovascular effects of anti-diabetic drugs. In this review, we seek to examine the cardiovascular safety of these agents in major published trials. Metformin has with-stood the test of time and remains the initial drug of choice. The sulfonylureas, despite being the oldest oral anti-diabetic drug, has been linked to adverse cardiovascular events and are gradually being out-classed by the various other second-line agents. The glitazones are contraindicated in heart failure. The incretin-based drugs have been at the fore-front of this era of cardiovascular safety trials and their performances have been reassuring, whereas the meglitinides and the alpha-glucosidase inhibitors still lack cardiovascular outcomes data. The sodium glucose cotransporter-2 inhibitors are an exciting new addition that has demonstrated a potential for cardiovascular benefit. Many of the currently available oral anti-diabetic agents have clinically relevant cardiovascular effects. The optimal approach to the reduction of cardiovascular risk in diabetic patients should focus on aggressive management of the standard cardiovascular risk factors rather than purely on intensive glycemic control.

Tailoring the Novel Anticoagulants to the Stroke Patient â One Size Does Not FitAll Novel Anticoagulants in Stroke

Warfarin has been the mainstay of anticoagulation therapy for stroke prophylaxis in patients with non-valvular AF for past decades. Recent times have seen the release of four alternative novel anticoagulants that overcome many of the limitations that plagued patients on warfarin in the past. These agents have gained rapid acceptance and are now considered first line therapies for this indication in international guidelines. The approval of dabigatran, rivaroxaban and apixaban by US and European medication authorities has resulted in widespread uptake of these agents. In this review, we seek to examine the major trials pertaining to these agents with particular attention to patients that have already suffered a stroke (secondary prevention). Issues relevant to stroke physicians including thrombolysis in patients on these agents, timing of initiation of these agents after an acute stroke, reversibility in the setting of haemorrhage and alternative agents will be addressed. Finally, with an expanding choice of available agents, we offer some pragmatic advice regarding tailoring therapy to an individual patient.

Lung cancer mimicking left atrial mass.

Cardiac involvement in lung cancer is found in up to 25% of autopsy cases. However, despite the considerable mortality and morbidity associated with cardiac metastasis, antemortem diagnosis is unusual. A rare case of lung cancer presenting as a left atrial mass is reported.

Goal setting in cardiac rehabilitation: implications for clinical practice.

Abstract Background: Effective goal setting is a vital component of cardiac rehabilitation (CR) programs. Objective: The objectives of this study were to investigate the types of goals set by patients attending a CR program in a tertiary teaching hospital and the compatibility of the goals set with the patient’s risk factor profile. Methods: A descriptive, cross sectional, retrospective audit of the medical records of patients who attended the CR program in a tertiary teaching hospital in Sydney NSW between January 2007 and December 2009 was undertaken. The medical records of 355 patients who attended CR within the stipulated time frame were audited. Results: Short and long term goals were set by 104 and 50 patients, respectively. Four themes identified in the analysis of the goal data were reducing behavioural risk factors for further cardiovascular events, improvements in physical symptoms, enhancing mental well being and return to normal life. The majority of the goals related to physical activity (82%). Conclusion: Collaborative goal setting and the need to establish goals that are attainable and correspond with the patient’s health behaviours and clinical measures that require modification is vital.

Risk Factors for Coronary Heart Disease Among Asian Indians Living in Australia

The aim of this study was to assess the coronary heart disease risk factors in the Asian Indian community living in a large city in Australia. A cross-sectional survey was conducted at the Australia India Friendship Fair in 2010. All people of Asian Indian descent who attended the Fair and visited the health promotion stall were eligible to participate in the study if they self-identified as of Asian Indian origin, were aged between 18 and 80 years, and were able to speak English. Blood pressure, blood glucose, waist circumference, height, and weight were measured by a health professional. Smoking, cholesterol levels, and physical activity status were obtained through self-reports. Data were analyzed for 169 participants. More than a third of the participants under the age of 65 years had high blood pressure. Prevalence of diabetes (16%) and obesity (61%) was significantly higher compared with the national average. Ten women identified themselves as smokers. Physical activity patterns were similar to that of the wider Australian population. The study has provided a platform for raising awareness among nurses and promoting advocacy on the cardiovascular risk among Asian Indians. Strategies involving Asian Indian nurses and other Asian Indian health professionals as well as support from the private and public sectors can assist in the reduction of the coronary heart disease risk factors among this extremely susceptible population.

Safety and Efficacy of Same-Day Discharge Following Elective Percutaneous Coronary Intervention, Including Evaluation of Next Day Troponin T Levels

BACKGROUND As patients are increasingly undergoing elective percutaneous coronary intervention (PCI) with same-day discharge (SDD), and as post-PCI troponin T (TnT) elevations are associated with increased rates of death/myocardial infarction (MI) following elective PCI, we examined late outcomes with respect to post-PCI TnT elevations in patients undergoing SDD. METHODS AND RESULTS We studied 303 patients (mean age 62±9years, 89% male) who underwent elective-PCI between October 2007 and September 2012, of whom 149 had SDD and 154 stayed overnight (ON) who were age-and sex-matched. Eligibility for SDD excluded patients with: multi-vessel PCI, proximal LAD lesions, chronic total occlusions, side branch occlusions, or access site complications. Femoral access rates were 72% and 96% among SDD and ON patients respectively. Post-PCI, SDD patients left at 4.40[4.13-5.30]hours, and ON patients left at 23.44[21.50-25.41]hours (p<0.001). Overall 8.45% met the 2012 universal MI definition. No patients were re-hospitalised within 48hours. At 30-days, unplanned cardiac re-hospitalisation rates were 3.4% and 0.7% among SDD and ON patients (p=0.118); the only event was MI in an SDD patient. At 16[9-32] months, rates of death, MI, target vessel revascularisation, stroke, were 1.3%,1.3%,2.7% and 1% respectively; the composite rate was 6%(6.1% SDD; 6% ON; p=0.965). Late death/MI rates among patients with, and without, post-PCI TnT levels≥5xURL were 3.4% and 2.8% respectively (p=0.588). CONCLUSION SDD following elective PCI among low risk patients appears to be safe and ≥5 fold post-PCI TnT elevations did not appear to confer incremental short and long term risk. A larger cohort is required to confirm this observation.

The current and future role of the novel oral anticoagulants : indications beyond atrial fibrillation

The direct thrombin inhibitors and Factor-Xa inhibitors are novel oral anticoagulants which are gaining rapid acceptance not only as alternatives to warfarin, but also as recommended first line agents for use as stroke prophylaxis in patients with non-valvular atrial fibrillation. There are, however, other patient settings in which anticoagulation is either indicated or has a potential role. Warfarin is still the predominant anticoagulant used for the treatment and prevention of venous thromboembolic events including deep vein thrombosis and pulmonary embolism as well as in patients with mechanical prosthetic heart valves. In this article, we review the current evidence for the use of dabigatran, rivaroxaban, apixaban and edoxaban in these settings. A summary of suggested regimens utilising these agents is provided. Importantly, in addition, attention is also drawn to clinical scenarios in which use of such agents is considered inappropriate.

Evaluation of a Policy of Selective Drug-eluting Stent Implantation for Patients at High Risk of Restenosis

Drug-eluting stent (DES) deployment during percutaneous coronary intervention (PCI) has reduced target-vessel revascularisation rates (TVR). The selective use of DES in patients at highest risk of restenosis may allay concerns about universal compliance of dual antiplatelet therapy for one year, and potentially reduce costs. If this strategy achieved acceptably low TVR rates, such an approach could be attractive. Late clinical outcomes were examined in 2115 consecutive patients (mean age 63±12 years, 75% male, 22% diabetics) who underwent PCI in the first three years from October 2003, after commencing the following selective criteria for DES use: left main stenosis; ostial lesions of major epicardial arteries; proximal LAD lesions; lesions≥20mm in length with vessel diameter≤3.0mm; lesions in vessels≤2.5mm; diabetics with vessel(s)≤3.0mm; and in-stent restenosis. Among patients undergoing PCI, 2075 (98%) patients received stents (29%≥1 DES and 71% bare metal stent [BMS]), and among those who received DES, there was a 92% compliance with these criteria. There were no differences in clinical outcomes between the two stent groups except for definite stent thrombosis, which occurred in 2% after DES, and 0.6% after BMS at one year (p=0.002). With BMS, large coronary arteries (≥3.5mm), intermediate (3-3.49mm) and small arteries (<3mm) in diameter had a TVR rate at one year of 3.6%, 7.2% and 8.2% respectively (p=0.005). It is possible to use selective criteria for DES while maintaining low TVR rates. The TVR rate with BMS was low in those with stent diameters≥3.5mm. The higher DES stent thrombosis rate reflects first generation DES use, though whether routine second generation DES use reduces these rates needs confirmation.

Oral health and cardiovascular care: Perceptions of people with cardiovascular disease

Main objective The aim of this study was to explore the perception of patients with cardiovascular disease towards oral health and the potential for cardiac care clinicians to promote oral health. Method A needs assessment was undertaken with twelve patients with cardiovascular disease attending cardiac rehabilitation between 2015 and 2016, in three metropolitan hospitals in Sydney, Australia. These patients participated in face-to-face semi-structured interviews. Data was analysed using thematic analysis. Results Results suggested that while oral health was considered relevant there was high prevalence of poor oral health among participants, especially those from socioeconomic disadvantaged background. Awareness regarding the importance of oral health care its impact on cardiovascular outcomes was poor among participants. Oral health issues were rarely discussed in the cardiac setting. Main barriers deterring participants from seeking oral health care included lack of awareness, high cost of dental care and difficulties in accessing the public dental service. Findings also revealed that participants were interested in receiving further information about oral health and suggested various mediums for information delivery. The concept of cardiac care clinicians, especially nurses providing education, assessment and referrals to ongoing dental care was well received by participants who felt the post-acute period was the most appropriate time to receive oral health care advice. The issues of oral health training for non-dental clinicians and how to address existing barriers were highlighted by participants. Relevance to clinical practice The lack of oral health education being provided to patients with cardiovascular disease offers an opportunity to improve care and potentially, outcomes. In view of the evidence linking poor oral health with cardiovascular disease, cardiac care clinicians, especially nurses, should be appropriately trained to promote oral health in their practice. Affordable and accessible dental care services for people with cardiovascular disease should be considered and offered by health services in Australia.