Age, sex, and secondary prevention of ischaemic heart disease in everyday practice.

BACKGROUND: Many researchers have studied age- and sex-related differences in the management of patients with coronary artery disease. However, the results are inconsistent. AIM: To assess sex- and age-related bias in the secondary prevention in patients hospitalised due to ischaemic heart disease. METHODS: Five hospitals with departments of cardiology serving a city and surrounding districts in southern Poland participated in the study. Consecutive patients hospitalised from 1 April 2005 to 31 July 2006 due to acute coronary syndrome or for a myocardial revascularisation procedure and aged ≤ 80 years were recruited and interviewed 6-18 months after hospitalisation. RESULTS: The hospital records of 640 patients were reviewed and 513 (80.2%) patients participated in the follow-up interview. Women were older and less educated than their male counterparts. Sex was not independently associated with the control of major risk factors in the post-discharge period, whereas age was related to a higher probability of having high blood pressure and a lower chance of smoking. Multivariate analysis showed that females were prescribed calcium antagonists (odds ratio [OR] 2.13; 95% confidence intervals [CI] 1.34-3.39) and diuretics (OR 1.52; 95% CI 1.00-2.31) more often than males. Age was independently related to the prescription rate of diuretics (≥ 70 years vs. < 60 years; OR 1.61; 95% CI 1.19-2.20). The prescription rate of antiplatelets, beta-blockers, angiotensin converting enzyme-inhibitors/sartans, lipid-lowering drugs, and anticoagulants was not related to age or sex. CONCLUSIONS: We found no major sex-related difference in the frequency of achieving recommended goals in secondary prevention, whereas age was related to a lower prevalence of smoking and a higher probability of having high blood pressure in subjects after hospitalisation for coronary artery disease.

Tissue Doppler indexes of left ventricular systolic function in relation to the pulsatile and steady components of blood pressure in a general population.

OBJECTIVES: To our knowledge, no population study described the association of the radial and longitudinal components of left ventricular strain with blood pressure (BP) components in continuous analyses. We therefore investigated these associations in participants randomly recruited from the general population in the framework of the family-based European Project on Genes in Hypertension. METHODS: In 334 participants (55.4% women; mean age, 43.6 year), using tissue Doppler imaging (TDI), we measured the end-systolic longitudinal strain (mean 20.9%) and peak systolic strain rate (1.29 s) from the basal portion of the left ventricular inferior and posterior free walls and radial stain (51.1%) and strain rate (3.40 s) of the left ventricular posterior wall. Models included in addition to covariables and confounders both SBP and DBP or both pulse pressure (PP) and mean arterial pressure (MAP). Effect sizes were expressed per 1-SD increase in BP. RESULTS: Longitudinal strain (-0.62%; P = 0.04 and -0.64%; P = 0.007), but not strain rate, decreased with DBP and MAP. Radial strain (4.0 and -3.4%; P ≤ 0.001) and strain rate (0.38 and -0.18 s; P ≤ 0.04) independently increased with SBP and decreased with DBP. Accordingly, radial strain (2.9%; P < 0.0001) and strain rate (0.22 s; P = 0.0005) increased with higher PP, but were not related to MAP. CONCLUSION: In the general population, BP is an independent determinant of left ventricular systolic function as measured by TDI. Radial function increased with PP, the pulsatile BP component, whereas longitudinal function decreased with the steady component of BP as expressed by MAP or DBP.

Half of coronary patients are not instructed how to respond to symptoms of a heart attack.

BACKGROUND: The delayed treatment of acute coronary syndrome has a significant impact on survival. Due to improved organization and the use of reperfusion therapies, inhospital delay has been shortened in recent years. However, the time between the onset of chest pain and the call for medical help is still too long. The aim of this study was to assess the proportion of coronary patients instructed how to behave in case of chest pain and to find what factors relate to a lower probability of being counselled. METHODS: Patients aged < 80 years, hospitalized due to coronary artery disease (CAD) were identified retrospectively on the basis of a medical records review and were invited for a follow-up examination. Two hundred and nineteen patients agreed to participate in the study. Data on the prehospital delay was obtained using a standard questionnaire. RESULTS: The study group consisted of 149 men and 70 women. The mean time between discharge and the follow-up examination was 1.1 ± 0.4 years. Of 219 study participants, 106 (48.4%) declared they had been instructed about the symptoms of a heart attack and how to respond to it. Men, smokers, non-diabetics, and those with previously diagnosed CAD had been instructed more frequently. The independent predictors of being instructed were: percutaneous coronary intervention during the index hospitalization, diabetes, smoking, male sex and previously diagnosed CAD. CONCLUSIONS: About half of patients after hospitalization due to CAD are not instructed how to respond to heart attack symptoms. This has not changed over the last decade and may contribute to the lack of shortening of prehospital delay.

Effects of cardiac resynchronization therapy on sleep apnea, quality of sleep and daytime sleepiness in patients with chronic heart failure.

BACKGROUND: Sleep-related breathing disorders are common in patients with chronic heart failure (CHF) and contribute to exacerbation of CHF. The effects of biventricular stimulation (CRT) seem to exceed the improvement of mechanical heart performance and are likely to affect other aspects of CHF pathophysiology. The aim of the study was to assess the influence of CRT on subjective and objective sleep features. MATERIAL AND METHODS: Twenty seven consecutive patients (aged 67.7 +/- 8.7 years, 23 men - 85%) with chronic heart failure (62.9% with ischaemic background and 37.1% of non-ischaemic etiology) in stable for at least 3 months NYHA class III - IV despite optimized pharmacotherapy, with left ventricular end-diastolic diameter (LVEDd) > 55 mm, left ventricular ejection fraction (LVEF) < or = 35% and wide QRS complex (> or = 120 ms) were appraised before and 12-16 weeks after CRT introduction clinically (including 6-minute walk test--6-MWT), echocardiographically and in polisomnography. The apnea-hypopnea index (AHI) and apnea indexes (AI) of central, obstructive and mixed types were calculated. The sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), daytime sleepiness with the Epworth Sleepiness Scale (ESS). RESULTS: LVEF increased, 6-MWT distance rose. Left ventricular diameters and left ventricular end-systolic volume decreased. PQSI and ESS fell (9.3 +/- 4.2 vs 6.2 +/- 3.2, p < 0.001 and 8.4 +/- 4.1 vs 7.0 +/- 3.4, p < 0.001, respectively). AHI, obstructive AL and mixed AL did not alter but significant reduction of central AL was noted (9.6 +/- 13.0 vs 3.7 +/- 6.2, p = 0.023). CONCLUSIONS: CRT decreases central sleep apnea and improves quality of sleep and daytime sleepiness in patients with CHF.

Secondary prevention of coronary artery disease in hospital practice over the decade 1996-2006. Results of the Cracovian Program for Secondary Prevention of Ischaemic Heart Disease and Polish parts of the EUROASPIRE II and EUROASPIRE III surveys.

BACKGROUND: Both in the European and Polish guidelines the highest priority for preventive cardiology was given to patients with established cardiovascular disease. The Cracovian Program for Secondary Prevention of Ischaemic Heart Disease was initiated in 1996. The main goal of the program was to assess and improve the quality of clinical care in the secondary prevention of ischaemic heart disease. Later, the same centres joined the EUROASPIRE (European Action on Secondary and Primary Prevention Intervention to Reduce Events) II and III surveys. AIM: To compare the quality of secondary prevention in Krakow cardiac departments in 1996/1997, 1998/1999 and 2005/2006. METHODS: Five hospitals serving the area of the city of Krakow and surrounding districts (former Krakow Voivodship), inhabited by 1,200,000 persons, took part in the surveys. Consecutive patients hospitalised from July 1, 1996 to September 31, 1997 (first survey), from March 1, 1998 to March 30, 1999 (second survey), and from April 1, 2005 to July 31, 2006 (third survey) due to acute myocardial infarction, unstable angina or for myocardial revascularisation procedures, below the age of <71 years were recruited and included to the present analysis. All medical records were reviewed by trained reviewers using standardised data collection forms. RESULTS: Medical records of 536 patients treated in 1996/1997, 515 treated 1998/1999, and 540 treated in 2005/2006 were reviewed and analysed. Proportions of medical records with available information on risk factors prior to hospitalisation as well as proportions of medical records with available information on blood pressure (by 10%, p < 0.05) and lipids (by over 30%, p < 0.05) measurements during the first 24 h of hospitalisation as well as on weight and height measurements (by 16%, p < 0.05) increased significantly from 1996/1997 to 2005/2006. Antiplatelets prescription rate at discharge increased from 87% to 97% (p < 0.05), prescription rate for beta-blockers increased from 66% to 91% (p < 0.05), ACE inhibitors/sartans from 50% to 89% (p < 0.05), and lipid lowering drugs from 27% to 96% (p < 0.05) between 1996/1997 and 2005/2006, respectively. CONCLUSIONS: The implementation of secondary prevention guidelines into clinical practice in the Krakow cardiac departments improved in 2005/2006 as compared to 1996/1997 and 1998/1999. Our results suggest that recent decade brought significant improvement in the approach to secondary prevention of ischaemic heart disease in hospital practice.

Changes in secondary prevention of coronary artery disease in the post-discharge period over the decade 1997-2007. Results of the Cracovian Program for Secondary Prevention of Ischaemic Heart Disease and Polish parts of the EUROASPIRE II and III surveys.

BACKGROUND: Both in the European and Polish guidelines, the highest priority for preventive cardiology was given to patients with established coronary artery disease (CAD). The Cracovian Program for Secondary Prevention of Ischaemic Heart Disease was introduced in 1996 to assess and improve the quality of clinical care in secondary prevention. Departments of cardiology of five participating hospitals serving the area of the city of Kraków and surrounding districts (former Kraków Voivodship) inhabited by a population of 1 200 000 took part in the surveys. In 1999/2000 and 2006/2007 the same hospitals joined the EUROASPIRE (European Action on Secondary Prevention through Intervention to Reduce Events) II and III surveys. The goal of the EUROASPIRE surveys was to assess to what extent the recommendations of the Joint Task Force of International Scientific Societies were implemented into clinical practice. AIM: To compare the quality of secondary prevention in the post-discharge period in Kraków in 1997/1998, 1999/2000 and 2006/2007. METHODS: Consecutive patients hospitalised from 1 July 1996 to 31 September 1997 (first survey), from 1 March 1998 to 30 March 1999 (second survey), and from 1 April 2005 to 31 July 2006 (third survey) due to acute myocardial infarction, unstable angina or for myocardial revascularisation procedures, below the age of 71 years were identified and then followed up, interviewed and examined 6-18 months after discharge. RESULTS: The number of patients who participated in the follow-up examinations was 418 (78.0%) in the first survey, 427 (82.9%) in the second and 427 (79.1%) in the third survey. The use of cardioprotective medication increased significantly: antiplatelets from 76.1% (1997/1998) to 86.9% (1999/2000) and 90.1% (2006/2007), beta-blockers from 59.1% (1997/1998) to 63.9% (1999/2000) and 87.5% (2006/2007), and ACE inhibitors/sartans from 45.9% (1997/1998) to 79.0% (2006/2007). The proportion of patients taking lipid lowering agents increased from 34.0% (1997/1998) to 41.9% (1999/2000) and 86.8% (2006/2007). Simultaneously, a significant improvement in the control of hyperlipidemia could be noted. In 2006/07, over 60% had a serum LDL cholesterol < 2.5 mmol/l. No significant change was found in the proportion of subjects with well-controlled hypertension or diabetes. In 2006/2007, elevated blood pressure was found in 46.6% of participants and glucose > 7 mmol/l in 13.4%. There was no significant change in smoking rates (16.3 vs. 15.9 vs. 19.2%). The proportion of obese patients increased reaching 33.9% in 2006/2007. CONCLUSIONS: The implementation of CAD prevention guidelines into clinical practice over the decade from 1997/1998 to 2006/2007 changed significantly. The use of cardioprotective drugs increased largely but among risk factors a significant improvement could be found only in the case of hypercholesterolemia. No improvement in the control of hypertension and diabetes, no change in smoking rates and increasing prevalence of obesity suggest insufficient lifestyle modifications in CAD patients.

Pulsatile but not steady component of blood pressure predicts cardiovascular events in coronary patients.

Although the differences between central and peripheral blood pressure (BP) values have been known for decades, the consequences of decision making based on peripheral rather than central BP have only recently been recognized. There are only a few studies assessing the relationship between intraaortic BP and cardiovascular risk. In addition, the relationship between central BP and the risk of cardiovascular events in a large group of coronary patients has not yet been evaluated. Therefore, the aim of the study was to determine the prognostic significance of central BP-derived indices in patients undergoing coronary angiography. Invasive central BPs were taken at baseline, and study end points were ascertained during over a 4.5-year follow-up in 1109 consecutive patients. The primary end point (cardiovascular death or myocardial infarction or stroke or cardiac arrest or heart transplantation or myocardial revascularization) occurred in 246 (22.2%) patients. Central pulsatility was the most powerful predictor of the primary end point (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.14 to 1.48). Central pulse pressure was also independently related to the primary end point (HR 1.25, 95% CI 1.09 to 1.43). Central mean BP as well as peripheral BP parameters were not independently related to the primary end point risk. Central pulsatility was also related to risk of cardiovascular death or myocardial infarction or stroke. The pulsatile component of BP is the most important factor related to the cardiovascular risk in coronary patients. It is more closely associated with cardiovascular risk than steady component of BP.

Ezetimibe: New perspectives in lipid lowering treatment.

Therapeutic goals for lipid lowering treatment in the prevention of ischemic heart disease are often not reached in clinical practice. Even the highest doses of statins do not guarantee good control of hypercholesterolemia in all patients. Therefore, new lipid lowering drugs are being investigated. One of them is ezetimibe - intestinal cholesterol absorption inhibitor. Treatment with ezetimibe results in significant reduction of total cholesterol and LDL cholesterol levels. It is hoped that concomitant treatment with ezetimibe and other lipid lowering drugs (particularly statins) will be more effective. In large randomized clinical trials, co-administration of ezetimibe with atorvastatin and simvastatin proved to be more effective in lowering cholesterol levels and reaching target therapeutic levels than treatment with statin alone. In addition, combined treatment with ezetimibe and simvastatin was more effective compared to treatment with today's most effectively used statin (rosuvastatin) alone. Reduction of statin dose, due to the combined treatment with ezetimibe, lowers the risk of adverse events. Results of the published studies suggest that ezetimibe is safe and when administered together with statin does not increase the risk of liver or muscle damage. Treatment with ezetimibe may be regarded as a new option in the management of patients who need lipid lowering treatment. (Cardiol J 2007; 14: 232-237).