Single photon emission computed tomography for the diagnosis of coronary artery disease: an evidence-based analysis. Differentiation of Heart Failure Related to Dilated Cardiomyopathy and Coronary Artery Disease Using Gadolinium‐Enhanced Cardiovascular Magnetic Resonance Baroreflex activation therapy for the treatment of heart failure with reduced ejection fraction in patients with and without coronary artery disease. Heart failure with preserved ejection fraction: treat now by treating comorbidities. Lifestyle interventions reduce cardiovascular risk in patients with coronary artery disease: A randomized clinical trial Renal function is associated with arterial stiffness and predicts outcome in patients with coronary artery disease. A systematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure Relationship of physical fitness vs body mass index with coronary artery disease and cardiovascular events in women. Prognostic impact of ß-blocker use in patients with stable coronary artery disease Long-term association of brachial artery flow-mediated vasodilation and cardiovascular events in middle-aged subjects with no apparent heart disease. Community-based comprehensive lifestyle programs in patients with coronary artery disease: Objectives, design and expected results of Randomized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 trial (RESPONSE 2). Effects of low-dose angiotensin II receptor blocker candesartan on cardiovascular events in patients with coronary artery disease. Effectiveness of nurse-led cardiac clinics in adult patients with a diagnosis of coronary heart disease. The effectiveness of telephone‐based post‐discharge nursing care in decreasing readmission rate in patients with heart failure: a systematic review Prediction of 1-year clinical outcomes using the SYNTAX score in patients with prior heart failure undergoing percutaneous coronary intervention: sub-analysis of the SHINANO registry Stress echo 2020: the international stress echo study in ischemic and non-ischemic heart disease Inpatient and outpatient costs in patients with coronary artery disease and mental disorders: a systematic review A stepwise psychotherapy intervention for reducing risk in coronary artery disease (SPIRR-CAD) - rationale and design of a multicenter, randomized trial in depressed patients with CAD. Women and cardiovascular risk. Benefits of obstructive sleep apnoea treatment in coronary artery disease: a long-term follow-up study. Effects of phase III cardiac rehabilitation on mortality and cardiovascular events in elderly patients with stable coronary artery disease. Effect of handgrip on coronary artery disease and myocardial infarction: a Mendelian randomization study Effect of almond consumption on vascular function in patients with coronary artery disease: a randomized, controlled, cross-over trial
UNLABELLED In July 2009 , the Medical Advisory Secretariat ( MAS ) began work on Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease ( CAD ) , an evidence -based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients suspected of having CAD . This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of non-invasive cardiac imaging modalities . After an initial review of the strategy and consultation with experts , MAS identified five key non-invasive cardiac imaging technologies for the diagnosis of CAD . Evidence -based analyses have been prepared for each of these five imaging modalities : cardiac magnetic resonance imaging , single photon emission computed tomography , 64-slice computed tomographic angiography , stress echocardiography , and stress echocardiography with contrast . For each technology , an economic analysis was also completed ( where appropriate ) . A summary decision analytic model was then developed to encapsulate the data from each of these reports ( available on the OHTAC and MAS website).The Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease series is made up of the following reports , which can be publicly accessed at the MAS website at : www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.htmlSINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE : An Evidence -Based Analysis STRESS ECHOCARDIOGRAPHY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE : An Evidence -Based Analysis STRESS ECHOCARDIOGRAPHY WITH CONTRAST FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE : An Evidence -Based Analysis 64-Slice Computed Tomographic Angiography for the Diagnosis of Coronary Artery Disease : An Evidence -Based Analysis CARDIAC MAGNETIC RESONANCE IMAGING FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE : An Evidence -Based Analysis Pease note that two related evidence -based analyses of non-invasive cardiac imaging technologies for the assessment of myocardial viability are also available on the MAS website : POSITRON EMISSION TOMOGRAPHY FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY : An Evidence -Based Analysis MAGNETIC RESONANCE IMAGING FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY : an Evidence -Based Analysis The Toronto Health Economics and Technology Assessment Collaborative has also produced an associated economic report entitled : The Relative Cost-effectiveness of Five Non-invasive Cardiac Imaging Technologies for Diagnosing Coronary Artery Disease in Ontario [ Internet ] . Available from : http://theta.utoronto.ca/reports/?id=7 OBJECTIVE The objective of the analysis is to determine the diagnostic accuracy of single photon emission tomography ( SPECT ) in the diagnosis of coronary artery disease ( CAD ) compared to the reference st and ard of coronary angiography ( CA ) . The analysis is primarily meant to allow for indirect comparisons between non-invasive strategies for the diagnosis of CAD , using CA as a reference st and ard . SPECT : Cardiac SPECT , or myocardial perfusion scintigraphy ( MPS ) , is a widely used nuclear , non-invasive image acquisition technique for investigating ischemic heart disease . SPECT is currently appropriate for all aspects of detecting and managing ischemic heart disease including diagnosis , risk assessment /stratification , assessment of myocardial viability , and the evaluation of left ventricular function . Myocardial perfusion scintigraphy was originally developed as a two-dimensional planar imaging technique , but SPECT acquisition has since become the clinical st and ard in current practice . Cardiac SPECT for the diagnosis of CAD uses an intravenously administered radiopharmaceutical tracer to evaluate regional coronary blood flow usually at rest and after stress . The radioactive tracers thallium ( 201Tl ) or technetium-99 m ( 99mTc ) , or both , may be used to visualize the SPECT acquisition . Exercise or a pharmacologic agent is used to achieve stress . After the administration of the tracer , its distribution within the myocardium ( which is dependent on myocardial blood flow ) is imaged using a gamma camera . In SPECT imaging , the gamma camera rotates around the patients for 10 to 20 minutes so that multiple two-dimensional projections are acquired from various angles . The raw data are then processed using computational algorithms to obtain three-dimensional tomographic images . Since its inception , SPECT has evolved and its techniques/applications have become increasingly more complex and numerous . Accordingly , new techniques such as attenuation correction and ECG gating have been developed to correct for attenuation due to motion or soft-tissue artifact and to improve overall image clarity . RESEARCH QUESTIONS What is the diagnostic accuracy of SPECT for the diagnosis of CAD compared to the reference st and ard of CA?Is  SPECT cost-effective compared to other non-invasive cardiac imaging modalities for the diagnosis of CAD?What are the major safety concerns with SPECT when used for the diagnosis of CAD ? METHODS A preliminary literature search was performed across OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for all systematic review s/meta- analysis published between January 1 , 2004 and August 22 , 2009 . A comprehensive systematic review was identified from this search and used as a basis for an up date d search . A second comprehensive literature search was then performed on October 30 , 2009 across the same data bases for studies published between January 1 , 2002 and October 30 , 2009 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also h and - search ed for any additional studies . Inclusion Criteria Exclusion Criteria Systematic review s , meta-analyses , controlled clinical trials , and observational studies Minimum sample size of 20 patients who completed coronary angiographyUse of CA as a reference st and ard for the diagnosis of CAD Data available to calculate true positives ( TP ) , false positives ( FP ) , false negatives ( FN ) and true negatives (TN)Accuracy data reported by patient not by segmentEnglish language Non- systematic review s , case reportsGrey literature and abstract sTrials using planar imaging onlyTrials conducted in patients with non-ischemic heart disease Studies done exclusively in special population s ( e.g. , patients with left branch bundle block , diabetics , minority population s ) unless insufficient data available SUMMARY OF FINDINGS Eighty-four observational studies , one non-r and omized , single arm controlled clinical trial , and one poorly reported trial that appeared to be a r and omized controlled trial ( RCT ) met the inclusion criteria for this review . All studies assessed the diagnostic accuracy of myocardial perfusion SPECT  for the diagnosis of CAD using CA as a reference st and ard . Based on the results of these studies the following conclusions were made : According to very low quality evidence , the addition of attenuation correction to traditional or ECG-gated SPECT greatly improves the specificity of SPECT  for the diagnosis of CAD although this improvement is not statistically significant . A trend towards improvement of specificity was also observed with the addition of ECG gating to traditional SPECT.According to very low quality evidence , neither the choice of stress agent ( exercise or pharmacologic ) nor the choice of radioactive tracer ( technetium vs. thallium ) significantly affect the diagnostic accuracy of SPECT  for the diagnosis of CAD although a trend towards accuracy improvement was observed with the use of pharmacologic stress over exercise stress and technetium over thallium . Considerably heterogeneity was observed both within and between trials . This heterogeneity may explain why some of the differences observed between accuracy estimates for various subgroups were not statistically significant . More complex analytic techniques such as meta-regression may help to better underst and which study characteristics significantly influence the diagnostic accuracy of SPECT Background Heart failure treatment depends partly on the underlying cause of the disease . We evaluated cardiovascular magnetic resonance ( CMR ) for the problem of differentiating dilated cardiomyopathy ( DCM ) from left ventricular ( LV ) dysfunction caused by coronary artery disease ( CAD ) . Methods and Results Late gadolinium enhancement with CMR was performed in 90 patients with heart failure and LV systolic dysfunction ( 63 patients with DCM and unobstructed coronary arteries and 27 with significant CAD at angiography ) . We also studied 15 control subjects with no coronary risk factors and /or unobstructed coronary arteries . None ( 0 % ) of the control subjects had myocardial gadolinium enhancement ; however , all patients ( 100 % ) with LV dysfunction and CAD had enhancement , which was subendocardial or transmural . In patients with DCM , there were 3 findings : no enhancement ( 59 % ) ; myocardial enhancement indistinguishable from the patients with CAD ( 13 % ) ; and patchy or longitudinal striae of midwall enhancement clearly different from the distribution in patients with CAD ( 28 % ) . Conclusions Gadolinium CMR is a powerful technique to distinguish DCM from LV dysfunction related to CAD and yields new insights in DCM . These data suggest that using the coronary angiogram as the arbiter for the presence of LV dysfunction caused by CAD could have lead to an incorrect assignment of DCM cause in 13 % of patients , possibly because of coronary recanalization after infa rct ion . The midwall myocardial enhancement in patients with DCM is similar to the fibrosis found at autopsy ; it has not previously been visualized in vivo and warrants further investigation . CMR may become a useful alternative to routine coronary angiography in the diagnostic workup of DCM . ( Circulation . 2003;108:54‐59 . BACKGROUND In a r and omized trial , baroreflex activation therapy ( BAT ) improved exercise capacity , quality of life and NT-proBNP in patients with heart failure with reduced ejection fraction ( HFrEF ) . In view of different mechanisms underlying HFrEF , we performed a post-hoc subgroup analysis of efficacy and safety of BAT in patients with and without coronary artery disease ( CAD ) . METHODS AND RESULTS Patients with left ventricular ejection fraction < 35 % and NYHA Class III were r and omized 1:1 to guideline -directed medical and device therapy alone or plus BAT .  Patients with a history of CAD , prior myocardial infa rct ion or coronary artery bypass graft were assigned to the CAD group with all others assigned to the no-CAD group . Of 71 BAT treated patients , 52 had CAD and 19 had no CAD . In the control group , 49 of 69 patients had CAD and 20 had no CAD . The system- or procedure-related major adverse neurological or cardiovascular event rate was 3.8 % in the CAD group vs. 0 % in the no-CAD group ( p = 1.0 ) . In the whole cohort , NYHA Class , Minnesota Living with Heart Failure score , 6-minute hall walk distance and NTproBNP were improved in BAT treated patients compared with controls . Statistical analyses revealed no interaction between the presence of CAD and effect of BAT ( all p > 0.05 ) . CONCLUSION No major differences were found in  BAT efficacy or safety between patients with and without CAD , indicating that BAT improves exercise capacity , quality of life and NTproBNP in patients with ischemic and non-ischemic cardiomyopathy . CLINICAL TRIALS . GOV IDENTIFIER NCT01471860 and NCT01720160 HEART FAILURE ( HF ) IS A MAJOR PUBLIC HEALTH PROBlem , with a prevalence of more than 5 million cases and an incidence of 660 000 new cases per year in the United States alone . Among patients older than 65 years , HF has become the most common discharge diagnosis and the primary cause of readmission within 60 days of discharge , result ing in estimated costs of $ 34.8 billion per year . Nearly half of all patients with HF have a preserved ejection fraction ( HFPEF ) . Patients with HFPEF have a high all-cause mortality after hospitalization for HF : 2.9 % , in-hospital mortality ; 9.5 % , 60to 90-day mortality ; 22 % to 29 % , 1-year mortality ; and 65 % , 5-year mortality . These data underscore the urgent need to find ways to improve outcomes for these patients . Unlike patients with HF and reduced ejection fraction , few large r and omized controlled trials have been specifically design ed for patients with HFPEF . These trials have shown minimal benefit , result ing in persons concluding that there is little evidence on which treatments to use for patients with HFPEF . Underlying the belief that there are few evidence -based therapies for patients with HFPEF is the implication that adverse outcomes in these patients are driven by worsening HF , which may not necessarily be accurate . Although recent large observational studies have shown high rates of morbidity and mortality in patients with HFPEF , these studies have not documented causes of rehospitalization or death . However , data from prior observational studies and clinical trials suggest that these outcomes are driven by important comorbidities that are common in patients with HFPEF . Patients diagnosed with HFPEF are typically elderly ( mean age , 74 - 76 years ) , more often women ( 62%-66 % ) , and frequently have multiple comorbidities , including hypertension ( 55%-77 % ) , coronary artery disease ( CAD ) ( 36%-53 % ) , atrial fibrillation ( 32%-41 % ) , diabetes mellitus  ( 32%-45 % ) ,  chronic kidney disease ( 23%-26 % ) , cerebrovascular disease ( 15 % ) , as well as obesity and anemia . In the Acute Decompensated Heart Failure National Registry ( ADHERE ) study , 91 % of patients with HFPEF had a diagnosis of hypertension , CAD , or diabetes . Secular trends demonstrate that the prevalence of comorbidities in patients with HFPEF is continuing to increase . CAD may be especially important in patients with HFPEF . Although CAD appears to be less common in patients with HFPEF than in patients with HF and reduced ejection fraction , the prevalence and severity of angiographically documented CAD in patients with HFPEF has not been well studied . In the Coronary Artery Surgery Study ( CASS ) , in which CAD was documented by coronary angiography , the presence and extent of CAD was a major determinant of prognosis in patients with HFPEF . Similarly , in the Duke Cardiovascular Data bank of patients with angiographically documented CAD , the presence of severe multivessel coronary disease has been associated with increased mortality in patients with HFPEF . Unlike recent large outcome studies of patients with HFPEF that have primarily examined all-cause rehospitalization and all-cause mortality , prior studies have ascertained the specific causes of adverse events , which help inform the cause of morbidity and mortality in patients with HFPEF . Two large r and omized clinical trials of patients with HFPEF and mortality data have been completed to date : the C and esartan in Heart Failure — Preserved ( CHARMPreserved ) and the Ancillary Digitalis Investigation Group ( Ancillary DIG ) trial , which showed that an angiotensinreceptor blocker and digoxin , respectively , did not improve survival . Although susceptible to selection bias , the CHARM-Preserved trial and Ancillary DIG trial provide important insight into the causes of morbidity and mortality in patients with HFPEF . In each trial , during Background : Nurse-led interventions have proven beneficial to reduce estimated cardiovascular risk . Aim : The purpose of this study was to evaluate the effect of systematic , nurse-led individual lifestyle counseling sessions on the reduction of 10-year cardiovascular risk scores in patients with coronary artery disease ( CAD ) . Methods : This was a r and omized clinical trial of CAD patients treated at a tertiary referral hospital . The intervention group received nurse-led guidance by means of five face-to-face sessions and telephone contact over the course of one year , starting three months after hospital discharge . Exercise and dietary goals were set for each patient and monitored at each session . The control group received st and ard medical advice . Patients were stratified by Framingham risk score and compared at the end of the follow-up period . Results : The final sample comprised 74 patients , 38 in the intervention group and 36 in the control group . Mean age was 58±9 years ; 74 % of patients were male . A 1.7 point ( −13.6 % ) reduction in risk score was recorded in the intervention group , vs a 1.2 point increase in risk score ( + 11 % ) in the control group ( p=0.011 ) . Significant between-group differences were detected for weight ( intervention , 78±14 kg at baseline vs 77±14 kg at study end ; control , 78±15 kg vs 79±15 kg ; p=0.04 ) , systolic blood pressure ( intervention , 136±22 mm Hg vs 124±15 mm Hg ; control , 126±15 mm Hg vs 129±16 mm Hg ; p=0.005 ) , and diastolic blood pressure ( intervention , 82±10 mm Hg vs 77±09 mm Hg ; control , 79±09 mm Hg vs 80±10 mm Hg ; p=0.02 ) . Conclusion : Structured and systematic nurse-led lifestyle counseling effectively reduced cardiovascular risk score BACKGROUND Arterial stiffness ( AS ) is associated , and a predictor of , outcome in patients with cardiovascular and renal disease . AIM In this study , we estimated glomerular filtration rate ( eGFR ) and measured indices of AS in patients with suspected coronary artery disease ( CAD ) , and assessed their predictive value on outcome . DESIGN Prospect i ve cohort study . METHODS AS was measured using pulse wave velocity ( PWV ) and pulse wave analysis in patients with no known renal disease who had recently undergone coronary angiography .  Renal function was assessed using serum creatinine concentration [creat](sr ) and eGFR ( Cockcroft & Gault , C&G ) . The primary endpoint was a combination of hospitalization due to cardiovascular disease and all-cause mortality . RESULTS Two hundred eighty-four subjects ( 210 men , 74 women , mean age 62 years ) were followed-up for a mean of 1.5 years . PWV was negatively associated with eGFR ( r(2 ) = 0.09 , P < 0.001 ) , even in patients with an eGFR > or = 60 ml/min/m(2 ) ( r(2 ) = 0.04 , P < 0.01 ) . PWV was determined by age , heart rate , systolic blood pressure , body mass index and [creat](sr ) ( r(2 ) = 0.38 , P < 0.001 ) . A lower eGFR ( P < 0.01 ) , PWV above the median ( P < 0.05 ) and degree of CAD ( P < 0.001 ) predicted a shorter time to the primary endpoint . eGFR and degree of CAD remained independent determinants of outcomes ( P < 0.01 ) , even in patients with normal renal function ( P < 0.01 ) . CONCLUSION This study suggests that even minor reductions in eGFR , within the normal range , are an additional independent risk marker in patients with CAD Background  Readmission rates for patients with heart failure are a major concern for hospitals worldwide . The importance of patient education and a structured care plan to ease the transition from hospital to home has been the focus of many intervention strategies to reduce readmission rates . The use of transitioning of care plans is believed to improve medication reconciliation , communication , patient education , and follow‐up . To date , the evidence has not been systematic ally evaluated to support the effectiveness of a nurse coordinated transitioning of care for patients with heart failure in reducing readmission rates . Objective The objective of the systematic review was to identify the best available evidence on the effectiveness of nurse coordinated transitioning of care between hospital and home on hospital readmission rates for all causes in adult patients hospitalised with heart failure . Search strategy The search strategy aim ed to find both published and unpublished studies in the English language from January 1975 through July 2010 . A search of MEDLINE , CINAHL , PsycINFO , Health source Nursing/academic edition , EMBASE , the Cochrane Library , and the Joanna Briggs Institute Library of Systematic Review s was conducted followed by a reference search of relevant studies . The initial key words search ed were : heart failure , readmission , and transitional care . Inclusion criteria R and omised controlled trials that evaluated the effect of nurse coordinated transitioning of care from hospital to home in adult patients with heart failure on  readmission  rates were selected . The outcome was defined as hospital readmissions for all causes following an initial admission for heart failure . Data collection and analysis Studies selected for retrieval were critically evaluated by two independent review ers for method ological validity using st and ardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument ( JBI‐MAStARI ) . Data were extracted and analysed using the JBI‐MAStARI program . Results A total of 16 r and omised controlled studies were included . Ten of the 16 studies included in the review show that a nurse led transitioning of care intervention can reduce the rate of readmission for patients with heart failure . Interventions utilising home visits , or home visits coupled with telephone follow‐up , show a more favourable reduction in readmission rates . Conclusions Reduced readmissions occur when transitioning of care interventions are carried out by a heart failure trained nurse who conducts at least one home visit and follows the patient at least weekly for a minimum of 30 days post discharge with either additional home visits or telephone contact . Implication s for practice This review supports the development of a nurse coordinated transitioning of care plan which will require improvements in communication , in addition to changes in health policy and payment systems that align incentives and performance measures in caring for patients with heart failure . Implication s for research Future research should evaluate the effect of the intensity and duration of the transitioning of care intervention on readmission rates in a large r and omised control trial on an adult population with heart failure to determine the ideal frequency and duration of the post discharge interventions CONTEXT Individual contributions of obesity and physical fitness ( physical activity and functional capacity ) to risk of coronary heart disease in women remain unclear . OBJECTIVE To investigate the relationships of measures of obesity ( body mass index [ BMI ] , waist circumference , waist-hip ratio , and waist-height ratio ) and physical fitness ( self-reported Duke Activity Status Index [ DASI ] and Postmenopausal Estrogen-Progestin Intervention question naire [ PEPI-Q ] scores ) with coronary artery disease ( CAD ) risk factors , angiographic CAD , and adverse cardiovascular ( CV ) events in women evaluated for suspected myocardial ischemia . DESIGN , SETTING , AND PARTICIPANTS The National Heart , Lung , and Blood Institute-sponsored Women 's Ischemia Syndrome Evaluation ( WISE ) is a multicenter prospect i ve cohort study . From 1996 - 2000 , 936 women were enrolled at 4 US academic medical centers at the time of clinical ly indicated coronary angiography and then assessed ( mean follow-up , 3.9 [ SD , 1.8 ] years ) for adverse outcomes . MAIN OUTCOME MEASURES Prevalence of obstructive CAD ( any angiographic stenosis > or=50 % ) and incidence of adverse CV events ( all-cause death or hospitalization for nonfatal myocardial infa rct ion , stroke , congestive heart failure , unstable angina , or other vascular events ) during follow-up . RESULTS Of 906 women ( mean age , 58 [ SD , 12 ] years ) with complete data , 19 % were of nonwhite race , 76 % were overweight ( BMI > or=25 ) , 70 % had low functional capacity ( DASI scores < 25 , equivalent to < or=7 metabolic equivalents [ METs ] ) , and 39 % had obstructive CAD . During follow-up , 337 ( 38 % ) women had a first adverse event , 118 ( 13 % ) had a major adverse event , and 68 ( 8 % ) died . Overweight women were more likely than normal weight women to have CAD risk factors , but neither BMI nor abdominal obesity measures were significantly associated with obstructive CAD or adverse CV events after adjusting for other risk factors ( P = .05 to.88 ) . Conversely , women with lower DASI scores were significantly more likely to have CAD risk factors and obstructive CAD ( 44 % vs 26 % , P<.001 ) at baseline , and each 1-MET increase in DASI score was independently associated with an 8 % ( hazard ratio , 0.92 ; 95 % confidence interval , 0.85 - 0.99 ; P = .02 ) decrease in risk of major adverse CV events during follow-up . CONCLUSIONS Among women undergoing coronary angiography for suspected ischemia , higher self-reported physical fitness scores were independently associated with fewer CAD risk factors , less angiographic CAD , and lower risk for adverse CV events . Measures of obesity were not independently associated with these outcomes Objective To assess the association of ß-blocker use with cardiovascular mortality in patients with stable coronary artery disease ( CAD ) . Methods We analysed the data of 4184 out patients included in a prospect i ve cohort study on stable CAD . Two groups were formed based on ß-blocker use at enrolment . Two propensity score analyses were performed to control for differences in covariates : one with adjustment among the entire cohort , and the other with propensity score matching . The outcome variable was cardiovascular mortality after a 2-year follow-up . Results There were 3320 patients with ß-blocker use . Younger age , hypertension , diabetes , prior myocardial infa rct ion , multivessel CAD , prior coronary revascularisation , prior stroke , prior hospitalisation for heart failure and a low LVEF were associated with ß-blocker use . Clinical follow-up data were obtained for 4149 patients ( 99.2 % ) . When adjusted on propensity score , ß-blocker use was associated with a HR for cardiovascular mortality of 0.64 ( 0.42–0.98 ) in the whole cohort ( p=0.04 ) . After one-to-one propensity score matching , both groups ( n=839 in each group ) were well matched on covariates . The cardiovascular mortality rate in the propensity-matched cohort was significantly lower in patients with ß-blocker use with a HR of 0.43 ( 0.22–0.82 ) ( p=0.011 ) . Non-cardiovascular mortality was similar in both groups . These results were consistent across different subgroups . Conclusions In this observational study of patients with stable CAD , the use of ß-blockers was associated with a lower risk of cardiovascular mortality BACKGROUND Endothelial dysfunction is considered an important prognostic factor in atherosclerosis . The aim of this study was to detect the long-term association of peripheral vascular endothelial function and clinical outcome in healthy subjects without apparent coronary artery disease ( CAD ) . METHODS We prospect ively assessed brachial flow-mediated  dilation ( FMD ) in 435 consecutive healthy subjects : 281 ( 65 % ) men , mean age 54+/-12 years and body mass index 28+/-4 kg/m(2 ) . After overnight fasting and discontinuation of all medications for > or = 12 h ,  FMD and endothelium-independent nitroglycerin-mediated vasodilation were assessed using high resolution linear array ultrasound . RESULTS Subjects were divided into 2 groups : below ( n=221 ) and above ( n=214 ) the median FMD of 10.7 % , and were comparable regarding CAD risk factors , lipoproteins , fasting glucose , C-reactive protein , and concomitant medications , with a mean clinical follow-up of 32+/-2 months . Composite cardiovascular endpoints ( all-cause mortality , non-fatal myocardial infa rct ion , heart failure or angina pectoris hospitalization , stroke , coronary artery bypass grafting and percutaneous coronary interventions ) were significantly more common in subjects with below median FMD of 10.7 % , than above ( 11.8 % vs 4.7 % , p=0.007 , respectively ) . Univariate analysis demonstrated that median FMD significantly predicted cardiovascular events [ odds ratio ( OR ) of 2.78 and 95 % CI 1.35 to 5.71 ( p=0.003 ) ] . After multivariate analysis including conventional CAD risk factors , median FMD was the best independent predictor of long-term cardiovascular adverse events [ OR of 2.70 and 95 % CI 1.16 to 6.32 ( p=0.011 ) ] . CONCLUSIONS Brachial artery median FMD independently predicts long-term adverse cardiovascular events in healthy subjects in addition to traditional risk factor assessment UNLABELLED Patients with coronary artery disease ( CAD ) are at high risk of recurrent events . A healthy lifestyle can significantly reduce this risk . A previous trial , R and omized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists ( RESPONSE ) , demonstrated that nurse-coordinated outpatient clinics improve drug treatment of cardiovascular risk factors . However , lifestyle-related risk factors , including smoking , overweight , and physical inactivity , were common and remained largely unchanged at follow-up in most patients ( 66 % ) . The aim of the current study is to evaluate the impact of 3 community-based lifestyle programs in patients after hospitalization for CAD . We are conducting a multicenter ( n = 15 ) , r and omized trial that will recruit 800 patients to test the efficacy of up to 3 widely available commercial lifestyle programs , aim ed at patients and their partners , on top of usual care . These programs are aim ed at smoking cessation ( Luchtsignaal ( ® ) ) , weight loss ( Weight Watchers ( ® ) ) , and improving physical activity ( Philips DirectLife ( ® ) ) . OUTCOMES The primary outcome at 12months is the proportion of patients in whom at least 1 lifestyle risk factor is improved without deterioration in any of the other 2 , and a relative increase of at least 30 % in this proportion is considered clinical ly relevant OBJECTIVES The purpose of this study was to investigate the effects of angiotensin II receptor blockers on the prevention of cardiovascular events in patients with coronary artery disease ( CAD ) . BACKGROUND Angiotensin II may contribute to the pathogenesis of CAD . Long-term clinical trials have shown that blockade of the renin-angiotensin system can reduce cardiovascular events in patients with acute myocardial infa rct ion complicated by heart failure . METHODS Patients with a history of coronary intervention and no significant coronary stenosis on follow-up angiography 6 months after intervention were r and omly assigned into a c and esartan group ( n = 203 ; baseline treatment plus c and esartan 4 mg/d ) or a control group ( n = 203 ; baseline treatment alone ) . The primary end point was a composite of revascularization , nonfatal myocardial infa rct ion , or cardiovascular death . The secondary end point was hospitalization for cardiovascular causes . RESULTS There were no changes in blood pressure and in other coronary risk factors in either group during a mean follow-up of 24 months . Primary end point risk was significantly lower in the c and esartan group ( n = 12 ) than in control group patients ( n = 25 ) ( P = .03 ) . C and esartan treatment reduced primary end point risk ( 5.9 % vs 12.3 % for control subjects ; relative risk , 0.47 ; 95 % CI , 0.24 to 0.93 ) . The incidence of all events including secondary end points and noncardiovascular death was significantly lower in the c and esartan group than in control group patients ( 23 vs 40 cases ) ( P = .02 ) . CONCLUSIONS Relatively low-dose c and esartan , which did not alter blood pressure levels , reduces cardiovascular risk in high-risk patients with CAD BACKGROUND Coronary heart disease is the major cause of illness and death in Western countries and this is likely to increase as the average age of the population rises . Consumers with established coronary heart disease are at the highest risk of experiencing further coronary events . Lifestyle measures can contribute significantly to a reduction in cardiovascular mortality in established coronary heart disease . Improved management of cardiac risk factors by providing education and referrals as required has been suggested as one way of maintaining quality care in patients with established coronary heart disease . There is a need to ascertain whether or not  nurse-led clinics would be an effective adjunct for patients with coronary heart disease to supplement general practitioner advice and care . OBJECTIVES The objective of this review was to present the best available evidence related to nurse-led cardiac clinics . INCLUSION CRITERIA This review considered any r and omised controlled trials that evaluated cardiac nurse-led clinics . In the absence of r and omised controlled trials , other research design s such as non-r and omised controlled trials and before and after studies were considered for inclusion . Participants were adults ( 18 years and older ) with new or existing coronary heart disease . The interventions of interest to the review included education , assessment , consultation , referral and administrative structures . Outcomes measured included adverse event rates , readmissions , admissions , clinical and cost effectiveness , consumer satisfaction and compliance with therapy . RESULTS Based on the search terms used , 80 papers were initially identified and review ed for inclusion ; full reports of 24 of these papers were retrieved . There were no papers included that addressed cost effectiveness or adverse events ; and none addressed the outcome of referrals . A critical appraisal of the 24 remaining papers identified a total of six r and omised controlled trials that met the inclusion criteria . Two studies addressed nurse-led clinics for patients diagnosed with angina , one looked at medication administration and the other looked at educational plans . A further four studies compared secondary preventative care with a nurse-led clinic and general practitioner clinic . One specifically compared usual care versus shared care introduced by nurses for patients awaiting coronary artery bypass grafting . Of the remaining three studies , two have been combined in the results section , as they are an interim report and a final report of the same study . Because of inconsistencies in reporting styles and outcome measurements , meta- analysis could not be performed on all outcomes . However , a narrative summary of each study and comparisons of specific outcomes assessed from within each study has been developed . Although not all outcomes obtained statistical significance , nurse-led clinics were at least as effective as general practitioner clinics for most outcomes . Recommendations The following recommendations are made Background The importance of comprehensive discharge planning plus post discharge support intervention studies have been advocated for patients with heart failure .  Telephone‐based post‐discharge nursing care was reported as a significant nursing care approach that is believed to promote continuity of care . However , there is a lack of systematic ally examined evidence to support the effectiveness of nurse‐led telephone‐based post‐discharge care for the heart failure patients . Objective The purpose of this study was to examine the best available evidence to determine the effectiveness of telephone‐based post‐discharge nursing care of patient with HF and to quantify the effect on all‐cause readmission rates of these patients . Search strategy A thorough search of published and unpublished literature was conducted from 1990 to 2009 . First , computer data bases such as CINAHL , MEDLINE , COCHRANE EMBASE , and Dissertation Abstract s International were included and then , reference search was conducted with relevant studies . Initial keywords were “ readmission , ” “ heart failure , ” “ * tele * ” , “ nurs * , “ post‐discharge ” , telephone‐based . ” Selection criteria R and omized controlled trial studies using the telephone‐based post‐discharge nursing care was selected . Outcome was defined as frequency of unplanned HF symptoms associated all‐cause hospital readmission rate during the 6 months after discharge . Data collection and analysis Included studies were critically evaluated for method ological quality by independent two review ers . Data were extracted and then analyzed using the JBI‐MASTARI and the RevMan 5 program . Main results A total of 10 r and omized controlled trial studies were included for this study . The study result showed that telephone‐based post‐discharge nursing care was a significant intervention especially decreasing hospital readmission rate among HF patients . Conclusion The findings of this review suggest a positive effect of telephone‐based post‐discharge nursing care and that it is an effective intervention in decreasing readmission rate among HF patients . Implication s for practice / research The results of this systematic review indicate the need for well design ed studies that examine other aspects of post‐discharge nursing telephone interventions to decrease hospital readmission rate among HF patients including : cost‐effectiveness , feasibility and appropriateness Although coronary artery disease ( CAD ) is common in patients with heart failure ( HF ) , little is known about the prognostic significance of coronary lesion complexity in patients with prior HF undergoing percutaneous coronary intervention ( PCI ) . The aim of this study was to investigate whether the coronary Synergy between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery ( SYNTAX ) score could improve risk stratification in HF patients with CAD . Two hundred patients ( mean age 73 ± 11 years , left ventricular ejection fraction 49 ± 15 % ) with prior HF who underwent PCI  were divided into two groups stratified by SYNTAX score ( median value 12 ) and tracked prospect ively for 1 year . The study endpoint was the composite of major adverse cardiovascular events ( MACE ) , including all-cause death , myocardial infa rct ion , stroke , and hospitalization for worsening HF . Adverse events were observed in 39 patients ( 19.5 % ) . Patients with high SYNTAX scores ( n = 100 ) showed worse prognoses than those with low scores ( n = 100 ) ( 26.0 vs. 13.0 % , respectively , P = 0.021 ) . In multivariate Cox-regression analysis , SYNTAX score ≥12 was significantly associated with MACE ( hazard ratio : 1.99 , 95 % confidence interval : 1.02–3.97 ; P = 0.045 ) . In patients with prior HF and CAD , high SYNTAX scores predicted a high incidence of MACE . These results suggest that the SYNTAX score might be a useful parameter for improving risk stratification in these patients Background Stress echocardiography ( SE ) has an established role in evidence -based guidelines , but recently its breadth and variety of applications have extended well beyond coronary artery disease ( CAD ) . We lack a prospect i ve research study of SE applications , in and beyond CAD , also considering a variety of signs in addition to regional wall motion abnormalities . Methods In a prospect i ve , multicenter , international , observational study design , > 100 certified high-volume SE labs ( initially from Italy , Brazil , Hungary , and Serbia ) will be networked with an organized system of clinical , laboratory and imaging data collection at the time of physical or pharmacological SE , with structured follow-up information . The study is endorsed by the Italian Society of Cardiovascular Echography and organized in 10 subprojects focusing on : contractile reserve for prediction of cardiac resynchronization or medical therapy response ; stress B-lines in heart failure ; hypertrophic cardiomyopathy ; heart failure with preserved ejection fraction ; mitral regurgitation after either transcatheter or surgical aortic valve replacement ; outdoor SE in extreme physiology ; right ventricular contractile reserve in repaired Tetralogy of Fallot ; suspected or initial pulmonary arterial hypertension ; coronary flow velocity , left ventricular elastance reserve and B-lines in known or suspected CAD ; identification of sub clinical familial disease in genotype-positive , phenotype- negative healthy relatives of inherited disease ( such as hypertrophic cardiomyopathy ) . Results We expect to recruit about 10,000 patients over a 5-year period ( 2016 - 2020 ) , with sample sizes ranging from 5,000 for coronary flow velocity/ left ventricular elastance/ B-lines in CAD to around 250 for hypertrophic cardiomyopathy or repaired Tetralogy of Fallot . This data -base will allow to investigate technical questions such as feasibility and reproducibility of various SE parameters and to assess their prognostic value in different clinical scenarios . Conclusions The study will create the cultural , informatic and scientific infrastructure connecting high-volume , accredited SE labs , sharing common criteria of indication , execution , reporting and image storage of SE to obtain original safety , feasibility , and outcome data in evidence -poor diagnostic fields , also outside the established core application of SE in CAD based on regional wall motion abnormalities . The study will st and ardize procedures , vali date emerging signs , and integrate the new information with established knowledge , helping to build a next-generation SE lab without inner walls Background To systematic ally review in- and outpatient costs in patients with coronary artery disease ( CAD ) and comorbid mental disorders . Methods A comprehensive data base search was conducted for studies investigating persons with CAD and comorbid mental disorders ( Medline , EMBASE , PsycINFO , Psyndex , EconLit , IBSS ) . All studies were included which allowed a comparison of in- and outpatient health care costs ( assessed either monetarily or in terms of health care utilization ) of CAD patients with comorbid mental disorders ( mood , anxiety , alcohol , eating , somatoform and personality disorders ) and those without . R and om effects meta-analyses were conducted and results reported using forest plots . Results The literature search result ed in 7,275 potentially relevant studies , of which 52 met inclusion criteria . Hospital readmission rates were increased in CAD patients with any mental disorder ( pooled st and ardized mean difference ( SMD ) = 0.34 [ 0.17;0.51 ] ) . Results for depression , anxiety and posttraumatic stress disorder pointed in the same direction with heterogeneous SMDs on a primary study level ranging from −0.44 to 1.26 . Length of hospital stay was not increased in anxiety and any mental disorder , while studies on depression reported heterogeneous SMDs ranging from −0.08 to 0.82 . Most studies reported increased overall and outpatient costs for patients with comorbid mental disorders . Results for invasive procedures were non-significant respectively inconclusive . Conclusions Comorbid mental disorders in CAD patients are associated with an increased healthcare utilization in terms of higher hospital readmission rates and increased overall and outpatient health care costs . From a health care point of view , it is requisite to improve the diagnosis and treatment of comorbid mental disorders in patients with CAD to minimize incremental costs OBJECTIVE Depressive symptoms are highly relevant for the quality of life , health behavior , and prognosis in patients with coronary artery disease ( CAD ) . However , previous psychotherapy trials in depressed CAD patients produced small to moderate effects on depression , and null effects on cardiac events . In this multicentre psychotherapy trial , symptoms of depression are treated together with the Type D pattern ( negative affectivity and social inhibition ) in a stepwise approach . METHODS Men and women ( N=569 , age 18 - 75 years ) with any manifestation of CAD and depression scores ≥ 8 on the Hospital Anxiety and Depression Scale ( HADS ) , will be r and omized ( allocation ratio 1:1 ) into the intervention or control group . Patients with severe heart failure , acutely life-threatening conditions , chronic inflammatory disease , severe depressive episodes or other severe mental illness are excluded . Both groups receive usual medical care . Patients in the intervention group receive three initial sessions of supportive individual psychotherapy . After re-evaluation of depression ( weeks 4 - 8 ) , patients with persisting symptoms receive an additional 25 sessions of combined psychodynamic and cognitive-behavioral group therapy . The control group receives one psychosocial counseling session . Primary efficacy variable is the change of depressive symptoms ( HADS ) from baseline to 18 months . Secondary endpoints include cardiac events , remission of depressive disorder ( SCID ) and Type D pattern , health-related quality of life , cardiovascular risk profile , neuroendocrine and immunological activation , heart rate variability , and health care utilization , up to 24 months of follow-up ( IS RCT N : 76240576 ; NCT00705965 ) . Funded by the German Research Foundation Cardiovascular disease mortality rates have decreased in men during the past 20 years , but have steadily increased in women . In the United States , > 500,000 women die of coronary artery disease ( CAD ) every year . Although many factors can influence an individual 's risk for CAD , some factors are unique to women , including reproductive status . Menopause is associated with significant elevations in serum cholesterol levels and a 3-fold increase in the risk of CAD . It has been suggested that these changes result from a reduction in the level of estrogen . However , recent data from prospect i ve clinical trials have not found any evidence that hormone replacement therapy protects against cardiovascular disease . On the other h and , several studies have shown that , in women , lipid lowering with statin therapy can reduce coronary events . On the strength of these findings , the Beyond Endorsed Lipid Lowering with Electron-Beam Computed Tomography Scanning ( BELLES ) trial-a 1-year , multicenter , r and omized , double-blind , parallel-group study -has been specifically design ed to determine the benefits of aggressive statin therapy on the progression of atherosclerosis in postmenopausal women AIM The aim of this long-term prospect i ve study was to evaluate the effect of treating obstructive sleep apnoea ( OSA ) on the rate of cardiovascular events in coronary artery disease ( CAD ) . METHODS AND RESULTS We prospect ively studied 54 patients ( mean age 57.3 + /- 10.1 years ) with both CAD ( > or = 70 % coronary artery stenosis ) and OSA ( apnoea-hypopnoea index > or = 15 ) . In 25 patients , OSA was treated with continuous positive airway pressure ( n=21 ) or upper airway surgery ( n=4 ) ; the remaining 29 patients declined treatment for their OSA . The median follow-up was 86.5 + /- 39 months . The two groups were similar at baseline in age , body mass index , smoking history , hypertension , hypercholesterolaemia , diabetes mellitus , number of diseased vessels , left ventricular ejection fraction , and CAD therapy . Treatment of risk factors other than OSA was similar in the two groups . The endpoint ( a composite of cardiovascular death , acute coronary syndrome , hospitalisation for heart failure , or need for coronary revascularisation ) was reached in 6 ( 6/25 , 24 % ) and 17 ( 17/29 , 58 % ) patients with and without OSA treatment , respectively ( P<0.01 ) . OSA treatment significantly reduced the risk of occurrence of the composite endpoint ( hazard ratio 0.24 ; 95 % confidence interval , 0.09 - 0.62 ; p<0.01 ) and of each of its components . CONCLUSIONS Our data indicate that the treatment of OSA in CAD patients is associated with a decrease in the occurrence of new cardiovascular events , and an increase in the time to such events BACKGROUND Cardiac rehabilitation ( CR ) has numerous benefits , including reduction of mortality and cardiovascular events , in patients with coronary artery disease ( CAD ) . However , the long-term effect of phase III CR in elderly patients with stable CAD is still unknown . METHODS AND RESULTS The 111 elderly male CAD patients ( > or=65 years ) , including 37 subjects participating in supervised CR for 6 months and 74 age-matched controls , were analyzed . The patients were followed for up to 3,500 days , until the occurrence of death or 1 of the following major adverse cardiovascular events ( MACE ) : cardiovascular death , acute coronary syndrome , refractory angina requiring revascularization , admission for congestive heart failure , or stroke . All-cause mortality tended to be lower in the CR group than in the Control group ( 14 % vs 28 % , P=0.081 ) . The MACE incidence was significantly lower in the CR group than in the Control group ( 30 % vs 62 % , P=0.001 ) . Multivariate Cox proportional hazard analysis showed that the MACE incidence was significantly lower in the CR group than in the Control group [ adjusted hazard ratio 0.43 ( 95 % confidence interval 0.20 - 0.91 ) , P=0.027 ] . CONCLUSIONS Phase III CR has the beneficial effect of reducing cardiovascular events even in elderly patients with stable CAD Observational studies have reported an association of h and grip strength with risk of cardiovascular disease . However , residual confounding and reverse causation may have influenced these findings . A Mendelian r and omization ( MR ) study was conducted to examine whether h and grip is causally associated with cardiovascular disease . Two single nucleotide polymorphisms ( SNPs ) , rs3121278 and rs752045 , were used as the genetic instruments for h and grip . The effect of each SNP on coronary artery disease/myocardial infa rct ion ( CAD/MI ) was weighted by its effect on h and grip strength , and estimates were pooled to provide a summary measure for the effect of increased h and grip on risk of CAD/MI . MR analysis showed that higher grip strength reduces risk for CAD/MI , with 1-kilogram increase in genetically determined h and grip reduced odds of CAD by 6 % ( odds ratio ( OR ) = 0.94 , 95 % confidence interval ( CI ) 0.91–0.99 , P = 0.01 ) , and reduced odds of MI by 7 % ( OR = 0.93 , 95 % CI 0.89–0.98 , P = 0.003 ) . No association of grip strength with type 2 diabetes , body mass index , LDL- and HDL-cholesterol , triglycerides and fasting glucose was found . The inverse causal relationship between h and grip and the risk of CAD or MI suggests that promoting physical activity and resistance training to improve muscle strength may be important for cardiovascular health Objective Almonds reduce cardiovascular disease risk via cholesterol reduction , anti-inflammation , glucoregulation , and antioxidation . The objective of this r and omized , controlled , cross-over trial was to determine whether the addition of 85 g almonds daily to a National Cholesterol Education Program ( NCEP ) Step 1 diet ( ALM ) for 6 weeks would improve vascular function and inflammation in patients with coronary artery disease ( CAD ) . Research design and methods A r and omized , controlled , crossover trial was conducted in Boston , MA to test whether as compared to a control NCEP Step 1 diet absent nuts ( CON ) , incorporation of almonds ( 85 g/day ) into the CON diet ( ALM ) would improve vascular function and inflammation . The study duration was 22 weeks including a 6-weeks run-in period , two 6-weeks intervention phases , and a 4-weeks washout period between the intervention phases . A total of 45 CAD patients ( 27 F/18 M , 45–77 y , BMI = 20 - 41 kg/m2 ) completed the study . Drug therapies used by patients were stable throughout the duration of the trial . Results The addition of almonds to the CON diet increased plasma α-tocopherol status by a mean of 5.8 % , reflecting patient compliance ( P ≤0.05 ) . However , the ALM diet did not alter vascular function assessed by measures of flow-mediated dilation , peripheral arterial tonometry , and pulse wave velocity . Further , the ALM diet did not significantly modify the serum lipid profile , blood pressure , C-reactive protein , tumor necrosis factor-α or E-selectin . The ALM diet tended to decrease vascular cell adhesion molecule-1 by 5.3 % ( P = 0.064 ) and increase urinary nitric oxide by 17.5 % ( P = 0.112 ) . The ALM intervention improved the overall quality of the diet by increasing calcium , magnesium , choline , and fiber intakes above the Estimated Average Requirement ( EAR ) or Recommended Dietary Allowance ( RDA ) . Conclusions Thus , the addition of almonds to a NECP Step 1 diet did not significantly impact vascular function , lipid profile or systematic inflammation in CAD patients receiving good medical care and polypharmacy therapies but did improve diet quality without any untoward effect . Trial registration The trial was registered with the Clinical Trials . Gov with the identifier : NCT00782015
However , there were no consistent relationships observed between intervention characteristics and the effects of interventions .
Most trials review ed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure .
OBJECTIVE This systematic review of recent r and omized trials was conducted to determine if cardiovascular nursing interventions improve outcomes in patients with coronary artery disease ( CAD ) and /or heart failure .