Secondary prevention of myocardial infarction: role of beta-adrenergic blockers and angiotensin-converting enzyme inhibitors

Evaluation of proper prescribing of cardiac medications at hospital discharge for patients with acute coronary syndromes (ACS) in two Lebanese hospitals

Background

Coronary artery disease (CAD) is the major leading cause of death worldwide. The national practice guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) promote the use of several medical therapies for secondary prevention for patients with CAD. The purpose of this study was to evaluate whether ACS patients, admitted into two tertiary referral medical centers in Beirut, Lebanon, are discharged on optimal medical therapy based on the current AHA/ACC guidelines.

Methods

We reviewed the medical records of all patients with ACS who were admitted to the coronary care units (CCU) of two hospitals in Beirut, Lebanon between May and August 2012. Discharge prescriptions were reviewed and rating for the appropriateness of discharge cardiac medications was based on the AHA/ACC guidelines. We assessed whether patients were discharged on antiplatelet therapy, β-blockers, angiotensin converting enzymes inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), statins, and nitrates, unless contraindicated or not tolerated. In addition, we assessed whether patients and/or their caregivers were counseled about their disease(s) and discharge medications.

Results

186 patients with a mean age of 63 ± 11.78 years, 70.4% of which were males, were admitted with ACS and were included in the study. Fifty three (28.5%) patients had ST elevation MI (STEMI), 64 (34.4%) had non-ST-elevation myocardial infarction (NSTEMI) and 69 (37.1%) had unstable angina (USA). Sixty two patients (33.3%) were treated with medical therapy and 124 patients (66.7%) underwent percutaneous coronary intervention (PCI).

Among eligible patients, 98.9% were discharged on aspirin, 89.1% on dual antiplatelet therapy (aspirin + thienopyridine or ticagrelor), 90.5% on a β-blocker, 81.9% on an ACEI or ARB, 89.8% on a statin, and 19.4% on nitroglycerin. Overall, 62.9% of the patients received the optimal cardiovascular drug therapy (the combination of dual antiplatelet therapy, a β-blocker, an ACEIs or an ARB, and a statin), 55.1% were counseled on their disease state(s) and drug therapy, and 92.2% and 55.9% were counseled on smoking cessation and life style changes, respectively.

Conclusion

In patients admitted with ACS, discharge cardiac medications are prescribed at suboptimal rates. Education of healthcare providers and implementation of ACS discharge protocols may help improve compliance with ACC/AHA guidelines. In addition, clinicians should be encouraged to provide adequate patient counseling.

Management of Hypertension among Patients with Coronary Heart Disease

Evidence suggests that coronary heart disease (CHD) is the most common outcome of hypertension. Hypertension accelerates the development of atherosclerosis, and sustained elevation of blood pressure (BP) can destabilize vascular lesions and precipitate acute coronary events. Hypertension can cause myocardial ischemia in the absence of CHD. These cardiovascular risks attributed to hypertension can be reduced by optimal BP control. Although several antihypertensive agents exist, the choice of agent and the appropriate target BP for patients with CHD remain controversial. In this succinct paper, we examine the evidence and the mechanisms for the linkage between hypertension and CHD and we discuss the treatment options and the goals of therapy that are consistent with the report of the seventh Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and American Heart Association scientific statement. We anticipate changes in the recommendations of the forthcoming JNC 8.

Trends in in-hospital mortality and six-month outcomes in patients with a first acute myocardial infarction. Change over the last decade

INTRODUCTION AND OBJECTIVES

Treatment of acute myocardial infarction (AMI) has changed considerably in recent years. The objective of this study was to investigate differences in in-hospital mortality and 6-month outcomes after a first AMI between patients who participated in two trials, in 1992-1994 and 2001-2003, respectively.

METHODS

The study involved 1440 consecutive patients with a first AMI who were admitted to four university hospitals during 1992-1994 (the RESCATE-I trial) and 1288 with a first AMI who met the same diagnostic criteria and who were admitted to the same hospitals during 2001-2003 (the RESCATE-II trial). Patient management, in-hospital mortality and 6-month prognosis and outcomes were compared between the two trials.

RESULTS

Reperfusion therapy was carried out in 60.7% of patients in the first trial and in 72.6% in the second (P< .001). In the RESCATE-II trial, the median door-to-needle time was shorter (41 min vs. 93 min; P< .001) and patients more frequently underwent coronary angiography (65.2% vs. 28.1%; P< .001) and revascularization (34.9% vs. 8.1%; P< .001). In addition, in-hospital mortality was lower in RESCATE-II (7.5% vs. 10.9%; P< .001). After adjustment for age, sex, comorbidity, AMI severity and reperfusion therapy, the odds ratio for in-hospital mortality in RESCATE-II compared with the first trial was 0.52 (95% confidence interval, 0.31-0.86). In addition, mortality (1.4% vs. 3.6%; P=.001) and readmissions at 6 months were also lower in RESCATE-II.

CONCLUSIONS

Both in-hospital and 6-month mortality in patients with a first AMI decreased during the last decade, probably due to more frequent reperfusion and revascularization therapy and better medical treatment.

Quantitation of infarct size in patients with chronic coronary artery disease using rest-redistribution Tl-201 myocardial perfusion SPECT: correlation with contrast-enhanced cardiac magnetic resonance

BACKGROUND

Rest and rest-redistribution thallium 201 myocardial perfusion single photon emission computed tomography (SPECT) (MPS) has been incompletely validated in patients for determination of the total amount of scarred myocardium. We sought to determine whether rest or redistribution Tl-201 MPS provides an accurate determination of infarct size as defined by delayed contrast-enhanced cardiac magnetic resonance (CMR).

METHODS AND RESULTS

We studied patients (n = 44) with chronic coronary artery disease referred for rest-redistribution Tl-201 MPS, who were also studied by contrast-enhanced CMR within 3 +/- 4 days. Patients were considered retrospectively based on a series of patients referred for clinically indicated MPS. Defect size, as a percent of left ventricular mass (% LV), was determined by quantitative perfusion SPECT (QPS) and compared with the volume of delayed hyperenhancement on contrast-enhanced CMR, normalized to LV mass. Infarct size varied from 0% to 43% LV. Rest QPS defect size correlated with the amount of nonviable myocardium assessed by contrast-enhanced CMR (r = 0.76; mean difference, 4.3% +/- 8.0% LV). When delayed thallium data were considered, redistribution QPS was superior to rest QPS for determination of infarct size (redistribution r = 0.90; mean difference, 2.4% +/- 5.2% LV; P = .03 vs rest).

CONCLUSION

Rest-redistribution Tl-201 MPS provides a more accurate measurement of total infarct size than rest-only Tl-201 MPS and correlates with contrast-enhanced CMR.

Benefits and harms of perioperative beta-blockade

Cardiac events in patients undergoing surgery may have serious consequences for both short- and long-term postoperative prognosis. Recently conducted trials have not demonstrated beneficial effects of perioperative beta-blockade, although originally small trials with methodological flaws did suggest this. We evaluate the evidence for using perioperative beta-blockade in both cardiac and non-cardiac surgery, and conclude that there is no statistically significant effect on mortality and insufficient evidence for a reduction of the incidence of mycocardial infarction in meta-analyses of all randomized trials. However, confidence intervals of the intervention effects in the meta-analyses are wide, leaving room for both benefits and harms. The largest observational study performed suggests that perioperative beta-blockade is associated with higher mortality in patients with low cardiac risk or diabetes, and with lower mortality in patients with high cardiac risk undergoing non-cardiac surgery. Larger randomized trials are needed to determine dosage, optimal duration, and safety of therapy, and to identify populations in whom-and how-perioperative beta-blockade may be beneficial.

Analysis of Cause-Specific Mortality in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Background— Expectations that reestablishing and maintaining sinus rhythm in patients with atrial fibrillation might improve survival were disproved in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. This report describes the cause-specific modes of death in the AFFIRM treatment groups.

Methods and Results— All deaths in patients enrolled in AFFIRM underwent blinded review by the AFFIRM Events Committee, and a mode of death was assigned. In AFFIRM, 2033 patients were randomized to a rhythm-control strategy and 2027 patients to a rate-control strategy. During a mean follow-up of 3.5 years, there were 356 deaths in the rhythm-control patients and 310 deaths in the rate-control patients ( P =0.07). In the rhythm-control group, 129 patients (9%) died of a cardiac cause, and in the rate-control group, 130 patients (10%) died ( P =0.95). Both groups had similar rates of arrhythmic and nonarrhythmic cardiac deaths. The numbers of vascular deaths were similar in the 2 groups: 35 (3%) in the rhythm-control group and 37 (3%) in the rate-control group ( P =0.82). There were no differences in the rates of ischemic stroke and central nervous system hemorrhage. In the rhythm-control group, there were 169 noncardiovascular deaths (47.5% of the total number of deaths), whereas in the rate-control arm, there were 113 noncardiovascular deaths (36.5% of the total number of deaths) ( P =0.0008). Differences in noncardiovascular death rates were due to pulmonary and cancer-related deaths.

Conclusions— Management of atrial fibrillation with a rhythm-control strategy conferred no advantage over a rate-control strategy in cardiac or vascular mortality and may be associated with an increased noncardiovascular death rate.

Hypertension in people with Type 2 diabetes: knowledge-based diabetes-specific guidelines

The International Diabetes Federation (Europe) has updated these guidelines on hypertension management specifically in Type 2 diabetes in the light of recent results of the first prospective, randomized controlled studies to investigate clinical outcomes in people with diabetes and hypertension. The guidelines are knowledge based, i.e. based not only on evidence originating from clinical trials, but also from epidemiological and pathophysiological studies. A successful management strategy requires the following components: 1. Regular surveillance to detect developing hypertension and other cardiovascular (CV) risk factors. 2. Considering more frequent monitoring and review of CV risk factors if any single blood pressure (BP) measurement > 140/85 mmHg (or 130/75 if microalbuminuria); when appropriate, using ambulatory or home monitoring to establish the baseline BP. 3. Considering other CV risk factors, such as a raised albumin excretion rate, in setting the intervention threshold. 4. Individualizing the target BP in accordance with other CV risk factors. 5. Agreeing lifestyle and therapeutic interventions with the patient, with education and empowerment as required. 6. Implementing lifestyle modifications, including controlling calorie, salt and alcohol intake, increased physical activity, weight control and smoking cessation. 7. Therapeutic strategy: the primary goal of therapy is to reduce BP markedly. Combination therapy is often necessary, e.g. an angiotensin converting enzyme (ACE) inhibitor and a diuretic. Some classes are particularly useful for certain patients, notably longer-acting ACE inhibitors, angiotensin 2 receptor antagonists (A2RAs) and calcium antagonists in those at risk of diabetic nephropathy, loop diuretics and thiazides in those at risk of hyperkalaemia, beta-blockers and calcium antagonists (except short-acting dihydropyridines) in patients with angina, beta-blockers and ACE inhibitors after a myocardial infarction or in those with left ventricular dysfunction, and thiazide diuretics and long-acting dihydropyridine calcium antagonists for isolated systolic hypertension. A2RAs should be particularly considered when ACE inhibitors are not tolerated. alpha 1-Blockers should not be considered first line in the absence of outcome data. Cost of drugs will modify these strategies in developing countries. 8. Monitoring response to therapies and, if target levels are not achieved, either intensifying drug therapy if the CV risk justifies it, or reassessing the target. 9. Maintaining a quality assurance strategy. This strategy is summarized in a simple, practical management algorithm.

Post myocardial infarction treatment in the older adult

Treatments for acute myocardial infarctions (AMIs) have advanced over the past few decades. Although AMIs are considered medical emergencies, continuing research has provided protocols and guidelines that significantly decrease mortality and reinfarction rates. Beta-blockers and aspirin are considered standard treatment for post-AMI patients; however, studies involving the elderly reveal that this population is less likely to receive beta-blocker and aspirin therapy. This article discusses current recommendations and treatments for post-AMI elderly patients.

Macrophage death and the role of apoptosis in human atherosclerosis

The arterial disease atherosclerosis is responsible for severe morbidity and is the most common cause of death in the Western population. The complete pathogenesis of the disease is unknown, but multiple risk factors have been identified that correlate with the development of its complications such as heart attack and stroke. Evidence suggests that atherosclerosis is an inflammatory disease and the major cell types involved are smooth muscle cells, macrophages, and T lymphocytes. In this paper, we review the function of macrophages in the context of atherosclerosis and we also discuss the role and significance of macrophage death, including apoptosis. There is much evidence, certainly in vitro, suggesting that low-density lipoprotein becomes atherogenic when it undergoes cell-mediated oxidation within the artery wall. Besides inducing apoptosis in vitro, oxidized low-density lipoprotein may also cause extensive DNA damage in intimal cells, which might presage apoptosis. We review the results of experimental and clinical studies, which may indicate how the complications of atherosclerosis could be prevented by using different therapeutical strategies including bone marrow transplantation and gene therapy.

Management of perioperative ventricular dysfunction

With the recognition of the clinical importance of the right ventricle; the development of new techniques for the perioperative evaluation of RV function, particularly transesophageal echocardiography; and new treatment modalities (pharmacologic and mechanical), clinicians will be able to more accurately diagnose and precisely manage patients who have sustained RV injury.