Stephanie J. Brister

Aspirin "resistance" and risk of cardiovascular morbidity: systematic review and meta-analysis

Objective To determine if there is a relation between aspirin “resistance” and clinical outcomes in patients with cardiovascular disease. Design Systematic review and meta-analysis. Data source Electronic literature search without language restrictions of four databases and hand search of bibliographies for other relevant articles. Review methods Inclusion criteria included a test for platelet responsiveness and clinical outcomes. Aspirin resistance was assessed, using a variety of platelet function assays. Results 20 studies totalling 2930 patients with cardiovascular disease were identified. Most studies used aspirin regimens, ranging from 75-325 mg daily, and six studies included adjunct antiplatelet therapy. Compliance was confirmed directly in 14 studies and by telephone or interviews in three. Information was insufficient to assess compliance in three studies. Overall, 810 patients (28%) were classified as aspirin resistant. A cardiovascular related event occurred in 41% of patients (odds ratio 3.85, 95% confidence interval 3.08 to 4.80), death in 5.7% (5.99, 2.28 to 15.72), and an acute coronary syndrome in 39.4% (4.06, 2.96 to 5.56). Aspirin resistant patients did not benefit from other antiplatelet treatment. Conclusion Patients who are resistant to aspirin are at a greater risk of clinically important cardiovascular morbidity long term than patients who are sensitive to aspirin.

Does the Use of Erythropoietin Reduce the Risk of Exposure to Allogeneic Blood Transfusion in Cardiac Surgery? A Systematic Review and Meta-Analysis

Abstractu2002 Background: The use of blood conservation techniques is important in cardiac surgery as postoperative bleeding is common and allogeneic blood transfusion carries the risk of transfusion reactions and infection transmission. Erythropoietin with and without preoperative autologous blood donation is one of the modalities to avoid allogeneic blood transfusion. The objective of this review was to assess the effectiveness of erythropoietin in reducing the risk of exposure to allogeneic blood transfusion during or after cardiac surgery. Methods: A meta‐analysis of 11 identified randomized controlled trials, reporting comparisons between erythropoietin and control, was undertaken. The primary outcome was the number of patients exposed to allogeneic blood transfusion during or after cardiac surgery. Results: Eleven studies, involving 708 patients, met the inclusion criteria for this review. In total, 471 patients were given erythropoietin, and 237 patients formed the control group. The administration of erythropoietin with and without preoperative autologous blood transfusion prior to cardiac surgery is associated with a significant risk reduction: RR = 0.28 (95% CI 0.18–0.44, P < 0.001) and RR = 0.53 (95% CI 0.32–0.88, P < 0.01), respectively. Conclusion: The administration of erythropoietin before cardiac surgery is associated with a significant reduction in the risk of exposure to allogeneic blood transfusion. Further studies are warranted to define the patients subgroups that may benefit the most from EPO administration.

Is South Asian ethnicity an independent cardiovascular risk factor

People of South Asian origin constitute a large, visible minority in Canada and are known to be at heightened risk for premature coronary artery disease. Conventional risk factors clearly confer risk in South Asians but do not adequately explain their excess risk compared with other populations. Rates of smoking, hypertension and levels of low density lipoprotein-cholesterol tend to be similar or lower in South Asians, although diabetes is more prevalent. Recent studies have suggested that the metabolic syndrome and abdominal obesity may play a causative role in both the prevalence of diabetes and the premature atherosclerosis noted in South Asians. It is possible that genetically susceptible individuals develop abdominal obesity and insulin resistance when exposed to a toxic environment of reduced energy expenditure and increased caloric consumption. This pattern is increasingly noted in parallel with urbanization, suggesting that the increased cardiovascular risk in South Asians may be preventable through lifestyle interventions and the judicious use of medicines to attain optimal levels of blood pressure, lipids and glucose.

Development and validation of Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients according to their blood transfusion needs.

BACKGROUND:u2002 Allogeneic blood transfusion is associated with transfusion reactions, infection transmission, and postoperative morbidity and mortality. The objective of this study was to develop and validate an accurate and simple clinical index to stratify cardiac surgery patients according to their blood transfusion needs.

Dual antiplatelet therapy in patients requiring urgent coronary artery bypass grafting surgery: A position statement of the Canadian Cardiovascular Society

UNLABELLEDnAcute coronary syndrome (ACS) guidelines recommend that most patients receive dual antiplatelet therapy with clopidogrel and acetylsalicylic acid (ASA) at the time of presentation to prevent recurrent ischemic events. Approximately 10% of ACS patients require coronary artery bypass grafting surgery (CABG) during the index admission. Most studies show that patients who receive ASA and clopidogrel within five days of CABG have an increase in operative bleeding. Current consensus guidelines recommend discontinuation of clopidogrel therapy at least five days before planned CABG to reduce bleeding-related events. However, high-risk individuals may require urgent surgery without delay, to reduce the risk of potentially fatal ischemic events. The present multidisciplinary position statement provides evidence- based recommendations for the optimal use of dual antiplatelet therapy to balance ischemic and bleeding risks in patients with recent ACS who may require urgent CABG.nnnRECOMMENDATIONSn1. All ACS patients should be considered for dual antiplatelet therapy with ASA and clopidogrel at the earliest opportunity, despite the possibility of a need for urgent CABG. 2. For patients who have received clopidogrel and ASA, and require CABG: * Those at high risk of an early fatal event (eg, with refractory ischemia despite optimal medical treatment, and with high-risk coronary anatomy (eg, severe left main stenosis with severe right coronary artery disease), should be considered for early surgery without discontinuation of clopidogrel. * In patients with a high bleeding risk (eg, previous surgery, complex surgery) who are also at high risk for an ischemic event, consideration should be given to discontinuing clopidogrel for three to five days before surgery. * Patients at a lower risk for ischemic events (most patients) should have clopidogrel discontinued five days before surgery. 3. For patients who have CABG within five days of receiving clopidogrel and ASA, the risk of major bleeding and transfusion can be minimized by applying multiple strategies before and during surgery. 4. Patients who receive clopidogrel pre-CABG for a recent ACS indication should have clopidogrel restarted after surgery to decrease the risk of recurrent ACS. 5. For patients with a recent coronary stent, the decision to continue clopidogrel until the time of surgery or to discontinue will depend on the risk and potential impact of stent thrombosis. Restarting clopidogrel after CABG will depend on whether the stented vessel was revascularized, the type of stent and the time from stent implantation. Clopidogrel should be restarted when hemostasis is assured to prevent recurrent acute ischemic events.

Degree and correlates of cardiac knowledge and awareness among cardiac inpatients

OBJECTIVEnTo investigate the degree of CHD awareness as well as symptom, risk factor, and treatment knowledge in a broad sample of cardiac inpatients, and to examine its sociodemographic, clinical and psychosocial correlates.nnnMETHODSn1308 CHD inpatients (351 [27.0%] female), recruited from 11 acute care sites in Ontario, participated in this cross-sectional study. Participants were provided with a survey which included a knowledge questionnaire among other measures, and clinical data were extracted from medical charts.nnnRESULTSn855 (68.8%) respondents cited heart disease as the leading cause of death in men, versus only 458 (37.0%) in women. Participants with less than high school education (p<.001), an annual family income less than

Psychometric validation of the Cardiac Rehabilitation Barriers Scale

50,000CAD (p=.022), low functional capacity (p=.042), who were currently smoking (p=.022), who had no family history of heart disease (p<.001), and who had a perception of low personal control (p=.033) had significantly lower CHD knowledge.nnnCONCLUSIONSnAwareness of CHD is not optimal, especially among women, South Asians, and those of low socioeconomic status. CHD patients have a moderate level of disease knowledge overall, but greater education is needed.nnnPRACTICE IMPLICATIONSnTailored educational approaches may be necessary for those of low socioeconomic status, particularly with regard to the nature of CHD, tests and treatments.

Surgical revascularization in women: Unique intraoperative factors and considerations

Objective: The purpose of this study was to investigate the factor structure and psychometric properties of the Cardiac Rehabilitation Barriers Scale (CRBS). Design, setting, and participants: In total, 2636 cardiac inpatients from 11 hospitals completed a survey. One year later, participants completed a follow-up survey, which included the CRBS. A subsample of patients also completed a third survey which included the CRBS, the Cardiac Rehabilitation Enrolment Obstacles scale, and the Beliefs About Cardiac Rehabilitation scale three weeks later. The CRBS asked participants to rate 21 cardiac rehabilitation barriers on a five-point Likert scale regardless of cardiac rehabilitation referral or enrolment. Results: Maximum likelihood factor analysis with oblique rotation resulted in a four-factor solution: perceived need/healthcare factors (eigenvalue = 6.13, Cronbach’s α = .89), logistical factors (eigenvalue = 5.83, Cronbach’s α = .88), work/time conflicts (eigenvalue = 3.78, Cronbach’s α = .71), and comorbidities/functional status (eigenvalue = 4.85, Cronbach’s α = .83). Mean total perceived barriers were significantly greater among non-enrollees than cardiac rehabilitation enrollees (P < .001). Convergent validity with the Beliefs About Cardiac Rehabilitation and Cardiac Rehabilitation Enrolment Obstacles scales was also demonstrated. Test-retest reliability of the CRBS was acceptable (intraclass correlation coefficient = .64). Conclusion: The CRBS consists of four subscales and has sound psychometric properties. The extent to which identified barriers can be addressed to facilitate greater cardiac rehabilitation utilization warrants future study.

Cardiac Rehabilitation Program Adherence and Functional Capacity Among Women: A Randomized Controlled Trial

See related articles on pages 929, 932, 950, and 959. C ardiovascular disease (CVD) is the leading cause of morbidity and mortality for women in the United States, Canada, and most developed countries. In developing countries it will be the leading cause of death in the next 20 years. It is a costly disease both in terms of health care dollars spent and patient lives. Approximately 250,000 women die each year in the United States, and women are 3 times as likely to die of CVD as they are of breast cancer. With the publication 10 years ago of 2 sentinel studies detailing the differences between men and women in the delivery of care to patients with CVD, there has been an increased awareness in the health care community and the lay public of issues relevant to the assessment and management of CVD in women. Perception of CVD by both communities is still evolving and is often influenced by insufficient or, worse, inaccurate information. The androcentric focus of much of cardiovascular research contributes to this problem. Only recently have women been included in sufficient numbers in clinical trials and databases or has there been a requirement for sex-based analysis of data such that specific information pertaining to results in women has been available. The problem is compounded when trying to analyze the results of coronary artery bypass grafting (CABG) in women because only 30% of all CABG operations are performed on women and fewer women than men are referred for operation, resulting in small sample sizes. Numerous studies have demonstrated increased hospital mortality after CABG in women when compared with men. Increased mortality in women in these studies has often been attributed to referral bias, smaller vessels, decreased body size, and an increased incidence of comorbidities. More recently, studies suggest that despite the obvious premorbid differences between men and women, women still clearly benefit from surgical revascularization. Despite good long-term results for women undergoing CABG, misperception of results still clearly influences their surgical treatment. For example, proportionally fewer women receive arterial grafts or reoperation. We review the intraoperative factors and considerations that are unique to women facing CABG in an attempt to raise awareness and to support the use of surgical revascularization in women.

Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study

OBJECTIVEnTo compare program adherence and functional capacity between women referred to supervised mixed-sex, supervised women-only, or home-based cardiac rehabilitation (CR).nnnPATIENTS AND METHODSnCardiac Rehabilitation for Heart Event Recovery (CR4HER) was a single-blind, 3 parallel-arm, pragmatic randomized controlled trial. The study took place between November 1, 2009, and July 31, 2013. Low-risk patients with coronary artery disease were recruited from 6 hospitals in Ontario, Canada. Consenting participants completed a preprogram survey, and clinical data were extracted from charts. Participants were referred to CR at 1 of 3 sites. After intake assessment, including a graded exercise stress test, eligible patients were randomized to supervised mixed-sex, supervised women-only, or home-based CR. Six months later, CR adherence and exit assessment data were ascertained.nnnRESULTSnOf the 264 consenting patients, 169 (64.0%) were eligible and randomized. Twenty-seven (16.0%) did not attend, and 43 (25.4%) attended a different model. Program adherence was moderate overall (54.46%±35.14%). Analysis of variance revealed no significant differences based on per-protocol analysis (P=.63), but as-treated, home-based participants attended significantly more than did women-only participants (P<.05). Overall, there was a significant increase in functional capacity preprogram to postprogram (P<.001). Although there were no significant differences in functional capacity by model at CR exit based on per-protocol analysis, there was a significant difference on an as-treated basis, which sustained adjustment. Women attending mixed-sex CR attained significantly higher post-CR functional capacity than did women attending home-based programs (P<.05).nnnCONCLUSIONnOffering women alternative program models may not promote greater CR adherence or functional capacity; however, replication is warranted. Other proven strategies such as action planning and self-monitoring should be applied.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT01019135.