2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: Executive Summary

Gender disparity in cardiovascular disease: bias or biology?

This article addresses gender disparity in cardiovascular disease, with selected examples used to explore whether these disparities represent bias, biology or both. Gender-specific basic and clinical cardiovascular research is needed to address these issues, with rigorous application required for the emerging knowledge. These explorations offer promise to improve cardiovascular outcomes for women and are the basis for the application of gender-based evaluation of pathophysiology, clinical presentations, preventive interventions, diagnostic strategies, therapies and outcomes of cardiovascular disease in women.

Exhaustion, immuno-inflammation, and pathogen burden after cardiac surgery: an exploratory study

BACKGROUND

Exhaustion, a consequence of prolonged stress characterized by unusual fatigue, is associated with increased risk of cardiac morbidity and mortality. In patients recovering from coronary artery bypass (CABG), little is known about the relationship of 1) immune-mediated inflammation and resultant endothelial activation, and 2) cumulative exposure to infectious pathogens (pathogen burden (PB)) implicated in coronary atherosclerosis to exhaustion.

AIM

The aim of this exploratory study was to investigate the association of PB, inflammatory markers (interleukin (IL)-6, IL-10) and a marker of endothelial activation (soluble intercellular adhesion molecule-1 (sICAM-1)) to exhaustion.

METHODS

One to two months post-CABG, 42 individuals who met inclusion criteria were assessed for exhaustion using the Maastricht Interview for Vital Exhaustion. Serum IgG antibodies to herpes simplex virus (HSV)-1, HSV-2, cytomegalovirus, Epstein Barr virus, and inflammatory and endothelial activation markers were measured by enzyme-linked immunosorbent assay. Pathogen burden was defined as the total number of seropositive exposures: low (0-1), moderate (2-3), and high (4).

RESULTS

Prevalence of exhaustion was 40.5%. Relative to non-exhausted patients, exhausted patients demonstrated a higher frequency of moderate PB (h=0.73, p=0.04) but lower frequency of high PB (h=1.05, p=0.03). Exhaustion showed a non-significant trend for positive correlations with IL-6 and sICAM-1 levels, and inverse relation to PB. In subgroup analysis, exhausted patients had stronger correlations with IL-6 and IL-6:IL-10 and a tendency towards higher serum IL-10 concentrations compared with their non-exhausted counterparts.

CONCLUSION

This hypothesis-generating study provides preliminary evidence that elevated post-CABG exhaustion may be associated with PB, inflammation, and endothelial activation.

Cost-effectiveness of ticagrelor in acute coronary syndromes

Ticagrelor is a reversibly binding oral P2Y(12) inhibitor, which belongs to a novel chemical class of antiplatelet agents named cyclopentyl-triazolo-pyrimidines. Ticagrelor administered with acetylsalicylic acid has been shown to reduce the rate of the composite end point of death from vascular causes, myocardial infarction or stroke without an increase in the rate of overall major bleeding compared with clopidogrel plus acetylsalicylic acid in patients with acute coronary syndromes. In addition to these clinical findings, it has been shown that the cost per quality-adjusted life year with ticagrelor is below the generally acceptable thresholds for cost-effectiveness compared with clopidogrel. Healthcare decision-makers need to consider the costs and cost-effectiveness when prioritizing treatments among scarce healthcare resources. This is of particular importance in cases similar to ticagrelor, where the novel treatment is expected to improve effectiveness at a higher acquisition cost. In this article, the authors review and discuss the health-economic evidence of ticagrelor.

Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: a contemporary and practical review

Research to date indicates that the number of coronary artery bypass graft (CABG) surgery patients affected by depression (i.e., major, minor, dysthymia) approximates between 30% and 40% of all cases. A longstanding empirical interest on psychosocial factors in CABG surgery patients highlights an association with increased risk of morbidity in the short and longer term. Recent evidence suggests that both depression and anxiety increase the risk for mortality and morbidity after CABG surgery independent of medical factors, although the behavioral and biological mechanisms are poorly understood. Though neither depression nor anxiety seem to markedly affect neuropsychological dysfunction, depression confers a risk for incident delirium. Following a comprehensive overview of recent literature, practical advice is described for clinicians taking into consideration possible screening aids to improve recognition of anxiety and depression among CABG surgery patients. An overview of contemporary interventions and randomized, controlled trials are described, along with suggestions for future CABG surgery research.