Current perspectives on coronary revascularization in the diabetic patient.

In the last few decades, the increase in the prevalence of type 2 diabetes mellitus has reached epidemic proportions in the Western world. A similar, though delayed, pattern is seen in developing countries. Chronic hyperglycemia, dyslipidemia, and insulin resistance have been associated with an accelerated form of atherogenesis, characterized by a prothrombotic state, enhanced inflammation, and endothelial dysfunction. Diabetic patients undergoing coronary revascularization have worse outcomes compared to nondiabetic individuals, both in the setting of percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG). Though subgroup analyses of randomized trials and registries have suggested that CABG is superior to PCI in diabetic patients with multivessel disease, the results of ongoing large randomized trials focusing for the first time on diabetic patients should be awaited in order to establish the optimal revascularization strategy in this patient population. In the setting of acute coronary syndromes, diabetic patients are also at high short- and long-term risk for cardiovascular morbidity and mortality. Despite deriving greater benefit than nondiabetic counterparts from aggressive management, including early revascularization and potent platelet inhibition, diabetic patients are often undertreated.

Early statin therapy in elderly patients presenting with acute coronary syndrome causing less heart failure.

OBJECTIVES: Elderly patients are less likely to receive statin therapy because of concerns about their side-effects. However, 80% of deaths related to coronary heart disease occur in patients above the age of 65 years. This study evaluated the potential benefit of early administration of statins in elderly patients presenting with an acute coronary syndrome. METHODS: This was a prospective cohort study of 774 elderly patients (>65 years) with acute coronary syndrome. The patients were divided into two groups. The first group, consisting of 611 patients, received statins within the first 24 hours of admission, while the second group, consisting of 163 patients, received statins after the first 24 hours. The end points studied included death, heart failure/pulmonary edema, stroke and recurrent myocardial infarction during hospitalization. RESULTS: Multivariable logistic regression analysis, adjusting for baseline demographics, co-morbidities and chronic statin therapy, showed that the occurrence of heart failure/pulmonary edema during hospitalization was relatively lower among those who received statins within 24 hours of admission (odds ratio: 0.5, 95% CI: 0.27-0.94, p=0.03). The C statistic for the model was 0.79. CONCLUSION: Elderly patients presenting with acute coronary syndrome seem to benefit from early statin therapy, and have significantly lower rates of heart failure and pulmonary edema than those who are administered statins at a later stage.

Low utilization of secondary preventive medications and its potential impact in patients with chronic kidney disease and acute coronary syndromes.

BACKGROUND: An estimated 11% of the population of the USA has chronic kidney disease. Cardiovascular morbidity and mortality are high among these individuals. We evaluated the impact of evidence-based, secondary preventive medications on the overall clinical outcome among this population. METHODS: We observed 2,627 consecutive patients admitted to our institution for acute coronary syndrome. The glomerular filtration rate was estimated by the four-component Modification of Diet in Renal Disease equation and the patients were stratified into groups on the basis of the guidelines of the National Kidney Foundation. Mortality and the composite event rate of death, myocardial infarction and stroke were assessed at six months. We evaluated the impact of evidence-based medications as an independent predictor of outcomes, using a logistic regression analysis. RESULTS- Patients with a relatively greater decline in the glomerular filtration rate had poorer outcomes, both in hospital and at six-month follow-up. Among those with stages III-V of chronic kidney disease, the use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) was associated with 44% lower odds of death (95% CI: 0.14-0.63), as well as 40% lower odds of the composite end-point (95% CI: 0.13-0.59) at six months. CONCLUSION: Chronic kidney disease was independently associated with mortality and major adverse cardiovascular events in a hospital registry of consecutive patients with acute coronary syndrome. Our results add to the existing body of evidence that more appropriate use of evidence-based medications, particularly statins, may significantly improve clinical outcomes in these highndash;risk patients. We should aim to improve the quality of treatment options available to patients suffering from both conditions.

Smoking cessation in patients with acute coronary syndrome.

BACKGROUND, In patients with acute coronary syndrome, smoking cessation rates, demographics, and management strategies havenot been well described. We hypothesized that hospitalized patients with acute coronary syndrome would have higher smoking cessation rates than other currently available therapies. In-hospital counseling and referral to cardiac rehabilitation may further improve cessation rates. METHODS, We reviewed 1098 consecutive admissions for acute coronary syndrome at the University of Michigan; 254 of thesepatients reported active smoking status on admission. Patients were divided into (i) those who continued smoking and (ii) those who quit smoking based on a 6-month telephonic interview. Clinical variables, management and therapies were com-pared for the two cohorts. RESULTS, The mean age of the 254 patients was 56 years and 65% were male. At six months, 49.2% of patients had quit smok-ing. Significant predictors of smoking cessation were coronary artery bypass grafting, pulmonary artery catheter placement, and need for mechanical ventilation. Patients who underwent cardiac rehabilitation post-discharge had a trendtoward higher cessation rates. Formal counseling during hospitalization did not seem to affect cessation rates. CONCLUSIONS, In this study, patients with acute coronary syndrome had a higher 6-month smoking cessation rate than previously published rates seen in ambulatory practice, and the more severely ill patients had higher cessation rates. Smoking cessation rates were not higher in those who received in-patient smoking counseling.