Salutary effects of aspirin in coronary artery disease are not limited to its platelet inhibitory effects

Aspirin is widely used in the treatment and prevention of coronary artery disease (CAD). However, other platelet inhibitory agents, which inhibit platelet activation, have not been found to be effective or as effective as aspirin. The discrepancy between the efficacy of these compounds and aspirin suggests that the therapeutic efficacy of aspirin may not be limited to its platelet inhibitory effect. In this review, the basis for a unique place for aspirin in the therapy of patients with CAD is discussed. The author believes that the nonplatelet-mediated effects of aspirin could be more important than the platelet inhibitory effect, or at least may complement the platelet inhibitory effects of aspirin in patients with acute myocardial ischemia and in others undergoing intracoronary procedures.     

Effect of aspirin on mortality in women with symptomatic or silent myocardial ischemia. Israeli BIP Study Group

The benefit of aspirin therapy among women with coronary artery disease (CAD) is not well established. Previous studies have shown conflicting results among women. Data from 2,418 women with CAD screened for participation in the ongoing Bezafibrate Infarction Prevention (BIP) study were analyzed: 45% reported aspirin therapy. Baseline characteristics were similar in both groups. Cardiovascular mortality at 3.1 +/- 0.9 years of follow-up was 2.7% in the aspirin treated group versus 5.1% in the non-aspirin-treated women (p = 0.002). All cause mortality was 5.1% and 9.1%, respectively (p = 0.0001). Treatment with aspirin emerged as an independent predictor of reduced cardiovascular (RR = 0.61, 95% confidence interval [CI] 0.38 to 0.97) and all cause (RR = 0.66, 95% CI 0.47 to 0.93) mortality after multiple adjustment for possible confounders such as age, history of myocardial infarction, systemic hypertension, diabetes mellitus, peripheral vascular disease, current smoking, New York Heart Association classification, and concomitant treatment with digitalis. Women who benefited the most from aspirin therapy were older, diabetic, symptomatic, or had a previous myocardial infarction. Thus, treatment with aspirin was associated with reduced mortality among women with CAD. This study suggests that women with CAD should be treated with aspirin, unless specific contraindications exist.     

Secondary prevention of arteriosclerosis

Secondary prevention of arteriosclerosis tries to inhibit progression of the atherosclerotic process. Therapeutic measures focus on modification of cardiovascular risk factors and antithrombotic treatment. Hypercholesterolemia is the main risk factor for coronary artery disease. The risk of a coronary event is correlated to the plasma cholesterol level. Lowering plasma cholesterol results in reduction of vascular morbidity and mortality. Cigarette smoking is the predominant risk factor for peripheral arterial occlusive disease (PAOD). Smoking cessation reduces progression of PAOD and lowers cardiovascular morbidity and mortality. The preventive effect of antihypertensive therapy in hypertensive patients is most pronounced for cerebrovascular events. Antihypertensive measures improve prognosis after stroke and myocardial infarction. The increased cardiovascular risk in diabetics is in part explained by hyperglycemia and hyperinsulinemia, but also depends on coexisting dyslipidemia and hypertension. Intensive treatment of elevated blood glucose levels, dyslipidemia and hypertension are important preventive measures. Aspirin is highly effective in secondary prevention of vascular events. For the coronary arteries, low-dose aspirin is well established. Whether low-dose aspirin is equally effective for reducing progression of arteriosclerosis in the cerebrovascular and in the peripheral vessels is questionable. Ticlopidine serves as an alternative to aspirin; however, neutropenia may occur, which requires supervision of the patient.     

Oral verapamil inhibits platelet thrombus formation in humans

BACKGROUND: Calcium antagonists such as verapamil are potent coronary and systemic vasodilators that are used in the treatment of coronary disease. They have also been shown to inhibit platelet aggregation in vitro, but whether they have beneficial antithrombotic effects in humans is unclear, and whether they can potentiate the antithrombotic effects of aspirin is unknown. METHODS AND RESULTS: Platelet thrombus formation and whole blood platelet aggregation were measured in 18 stable coronary patients on three separate occasions: at baseline when receiving no active medications, after 7 days of receiving oral verapamil SR (240 mg/d), and after 7 days of receiving a combination of oral verapamil SR and aspirin (325 mg/d). Thrombus formation on porcine aortic media that were placed into cylindrical flow chambers and exposed to flowing antecubital venous blood for 3 minutes was assessed morphometrically at a shear rate of 2546 s-1, which is typical of arterial flow at sites of stenoses. Thrombus formation under basal conditions was 7.0 +/- 1.6 microns 2, and this was decreased to 3.1 +/- 0.5 microns 2 (P < .05) after 7 days of treatment with oral verapamil SR and to 2.6 +/- 0.5 microns 2 (P < .05) after 7 days of treatment with oral verapamil and aspirin. Whole blood platelet aggregation levels in response to 0.050 and 0.075 U of thrombin at baseline were 10.8 +/- 1.0 and 11.9 +/- 1.0 omega; aggregation was inhibited after 7 days of treatment with verapamil to 6.5 +/- 1.1 and 7.8 +/- 0.9 omega (P < .05 versus baseline) and after 7 days of treatment with verapamil and aspirin to 6.1 +/- 1.1 and 7.2 +/- 1.0 omega (P < .05), respectively. CONCLUSIONS: The present study demonstrates that part of the benefit of verapamil in ischemic heart disease may occur by inhibition of platelet aggregation and thrombus formation. This beneficial antithrombotic effect may be important in preventing acute coronary ischemic events resulting from thrombus formation at sites of plaque rupture.     

Aspirin use in middle-aged men with cardiovascular disease: are opportunities being missed?

BACKGROUND: Since the 1980s, clinical trial evidence has supported aspirin use in the secondary prevention of cardiovascular disease (CVD). AIM: To explore aspirin use among British men with known CVD in a population-based study. METHOD: Longitudinal study (British Regional Heart Study), in which subjects have been followed up for cardiovascular morbidity and mortality since 1978-1980. Aspirin use was assessed by questionnaires to study participants in November 1992 (Q92); cardiovascular diagnoses are based on general practice notifications to October 1992. A total of 5751 men aged 52-73 years (87% of survivors) completed questions on aspirin use. RESULTS: Overall, 547 men (9.5%) were taking aspirin daily, of whom 321 (59%) had documented CVD. Among men with pre-existing disease, 153 out of 345 (44%) men with myocardial infarction, 42 out of 109 (39%) with stroke, and 75 out of 247 (29%) with angina were taking aspirin daily. Among men with angina (54% versus 26%) or myocardial infarction (59% versus 42%), those who had undergone coronary artery bypass surgery (CABG) or angioplasty were more likely to be receiving aspirin. Higher rates of aspirin use were also found in those whose last major event occurred after January 1990 (47% versus 34%). There was no association between aspirin use and social class or region of residence. CONCLUSION: Despite strong evidence of its effectiveness, many patients with established CVD were not receiving aspirin. Daily aspirin treatment was less likely in men with less recent major CVD events and in those who had not received invasive treatment.     

Drug therapy before coronary artery surgery: nitrates are independent predictors of mortality and beta-adrenergic blockers predict survival

We conducted this study to evaluate whether there is an association between preoperative drug therapy and in-hospital mortality in patients undergoing coronary artery graft surgery. We collected data on 1593 consecutive patients undergoing coronary artery surgery. The relative risk of in-hospital mortality was determined by logistic regression with in-hospital mortality as the dependent variable, and independent variables that included known risk factors and preoperative cardioactive or antithrombotic drug treatment, i.e., age; left ventricular function; left main coronary artery disease; urgent priority; gender; previous cardiac surgery; concurrent cardiovascular surgery; chronic lung disease; creatinine concentration; hemoglobin concentration; diabetes; hypertension; cerebrovascular disease; recent myocardial infarction; prior vascular surgery; number of arteries bypassed; and regular daily treatment with beta-blockers, aspirin within 5 days, calcium antagonists, angiotensin converting enzyme (ACE) inhibitors, digoxin, or warfarin. In-hospital mortality was 3.3%. The relative risk of in-hospital mortality (with 95% confidence intervals of the relative risk) associated with the following drug treatments was: nitrates 3.8 (1.5-9.6), beta-blockers 0.4 (0.2-0.8), aspirin within 5 days 1.0 (0.5-1.9), calcium antagonists 1.1 (0.6-2.1), ACE inhibitors 0.8 (0.4-1.5), digoxin 0.7 (0.2-1.8), and warfarin 0.3 (0.1-1.6). We conclude that in-hospital mortality is positively associated with preoperative nitrate therapy and negatively associated with beta-adrenergic blocker therapy. A significant association between in-hospital mortality and the preoperative use of calcium antagonists, ACE inhibitors, aspirin, digoxin, and warfarin was not confirmed. Implications: We examined the association between common drug treatments for ischemic heart disease and short-term survival after cardiac surgery using a statistical method to adjust for patients' preoperative medical condition. Death after surgery was more likely after nitrate therapy and less likely after beta-blocker therapy.     

Hetero-duplication type of cancerous mitosis

In order to delineate the efficacy of plasmin-treated intravenous gamma-globulin (IVGG) in the treatment of Kawasaki syndrome, we compared the frequency of coronary artery abnormalities in children treated or not with IVGG for Kawasaki syndrome. Among 291 cases of Kawasaki syndrome diagnosed during the period of 1987 to 1991 without coronary abnormalities within 10 days of the onset of illness, 128 were treated with IVGG and aspirin and were compared with 163 treated with aspirin alone. IVGG was given in a dosage of 400 mg/kg/day for 4 consecutive days. The detection of coronary abnormalities was monitored by two dimensional echocardiography. Two weeks after enrollment coronary artery abnormalities were present in 37 (22.7%) of 163 children in the aspirin group and in 9 (9%) of 128 in the gamma-globulin group (P < 0.05). Seven weeks after enrollment, abnormalities were present in 20 (12.3%) of 163 children in the aspirin group and in 6 (4.6%) of 128 in the IVGG group (P < 0.05). We conclude that plasmin-treated IVGG is effective in reducing the prevalence of coronary artery abnormalities in Kawasaki syndrome and suggest a predominant role of the Fc gamma fragment of IgG in the therapeutic effect.     

Evaluation of the efficacy of treatment of Kawasaki disease before day 5 of illness

We evaluated the efficacy of treating Kawasaki disease earlier than Day 5 of illness with a standard dose of immunoglobulin and aspirin. We performed a case-control study of patients with Kawasaki disease admitted to Princess Margaret Hospital from 1994 to 1999. Patients with pretreatment coronary aneurysm or those treated after day 10 of illness were excluded. All patients received immunoglobulin (2 g/kg) and aspirin (80-100 mg/kg/day) until fever subsided for 48 hours. Immunoglobulin retreatment was given for persistent fever 48 hours after the first dose of immunoglobulin or recrudescent fever. The case group consisted of 15 patients who received treatment earlier than day 5 of illness, and the control group consisted of 66 patients who were treated on or after day 5. Patients' sex, age, duration of posttreatment fever, need for additional immunoglobulin, and coronary artery status were noted. Treatment efficacy was assessed by the duration of posttreatment fever and the prevalence of coronary artery aneurysms. Eighty-one patients were included in this study. There were 15 patients in the case group and 66 in the control group. No significant difference was noted in age and sex between the case and control groups. Thirty-three percent (5/15) and 8% (5/66) of the case and control groups, respectively, had persistent/ recrudescent fever 48 hours after the first dose of immunoglobulin that required retreatment ( p = 0.017). Thirteen percent (2/15) and 5% (3/66) of the case and control groups, respectively, had coronary aneurysms ( p = 0.158). Treatment of Kawasaki disease before day 5 of illness was associated with persistent/recrudescent fever that required retreatment. However, there was no significant increase in the prevalence of coronary aneurysm if retreatment was given.     

Does coronary artery screening by electron beam computed tomography motivate potentially beneficial lifestyle behaviors?

We evaluated the extent to which cardiovascular risk-reducing behaviors are initiated as a result of knowledge of newly detected coronary artery disease, based on test results from noninvasive electron beam computed tomography (EBCT). A total of 703 men and women, aged 28 to 84 years, asymptomatic and without prior coronary disease, who had a baseline EBCT coronary artery scan and basic medical history and risk factor information completed a follow-up survey questioning them about health behaviors undertaken since their scan. Baseline calcium scores were significantly higher in those who subsequently reported consulting with a physician, or reported new hospitalization, coronary revascularization, beginning aspirin usage, blood pressure medications, cholesterol-lowering therapy, decreasing dietary fat, losing weight, beginning vitamin E, and under more worry (all p <0.01). Other factors, including reducing time worked, obtaining life insurance, losing employment, increased work absenteeism, increasing exercise, or stopping smoking were not associated with coronary calcium. In logistic regression, after adjusting for age, gender, pre-existing high cholesterol, high blood pressure, cigarette smoking, and a positive family history of coronary disease, the natural log of total calcium score remained associated with new aspirin usage, new cholesterol medication, consulting with a physician, losing weight, decreasing dietary fat, new coronary revascularization (all p <0.01), but also new hospitalization (p <0.05) and increased worry (p <0.001). The results suggest that potentially important risk-reducing behaviors may be reinforced by the knowledge of a positive coronary artery scan, independent of preexisting coronary risk factor status.     

Low molecular weight heparins: a valuable tool in the treatment of acute coronary syndromes

Standard heparin, low molecular weight heparin and aspirin are at present the only antithrombotic agents of proven value in the initial treatment of patients with an acute coronary syndrome. The combined use of aspirin and one of the heparins for at least 6 days should be considered for all such patients. With their high bio-availability after subcutaneous injection and prolonged half-life, low molecular weight heparins simplify short-term treatment in the acute phase and enable long-term therapy to be maintained on an outpatient basis without the need for repeated laboratory monitoring of anticoagulant effects. Such long-term therapy would appear to be beneficial, at least in high-risk patients, in the light of increasing evidence that the underlying lesion in acute coronary syndromes resolves over a period of weeks or months.     

Kawasaki disease: a dangerous acute childhood illness

Kawasaki disease is an acute febrile illness most commonly seen in children under the age of 5. It is characterized by fever, rash, cervical lymphadenopathy, bilateral nonexudative conjunctivitis, oropharyngeal mucosal changes, and erythema of the hands and feet followed by desquamation. However, a child with Kawasaki disease may not exhibit all of these symptoms. The disease resembles many other childhood illnesses, such as measles and scarlet fever, and misdiagnosis is common. Left untreated, Kawasaki disease has potential life-threatening consequences; 20% to 25% of children develop coronary artery aneurysms as a result. Although no specific laboratory tests exist that identify Kawasaki disease definitively, there are clinical and laboratory findings that guide diagnosis and treatment. Treatment includes the hospitalization of the child and subsequent administration of high doses of aspirin and intravenous immunoglobulin. With recovery, aspirin doses are reduced and the child may be monitored at home with outpatient follow-up. It is imperative that the health care provider be aware of the symptoms of Kawasaki disease in order to make the diagnosis and treat the child before cardiac sequelae ensue.     

Inhibitory effects of aspirin on coronary hyperreactivity to autacoids after arterial balloon injury in miniature pigs

We examined the effects of aspirin on coronary hyperreactivity to autacoids after arterial balloon injury in miniature pigs. Coronary vasoconstriction induced by histamine and serotonin were examined angiographically before, 1 h, 1 week, and 1 month after balloon injury in 29 hypercholesterolemic miniature pigs. The animals were divided into three groups: group A, no treatment (n = 16); group B, pretreated with aspirin 50 mg/day for 2 days before injury (n = 7); and group C, treated with aspirin 50 mg/day for 2 days before and 5 days after injury (7 days in all) (n = 6). In group A, coronary vasoconstriction induced by autacoids was significantly greater at the injured than at the noninjured site at all times examined (p < 0.01). Hyperconstriction induced by the autacoids 1 h after injury were significantly less in groups B and C than in group A (p < 0.01). Hyperconstriction induced by autacoids 1 week after injury were significantly less in group B than in group A (p < 0.01) and were significantly less in group C than in group A (p < 0.01) or group B (p < 0.05). Treatment with aspirin for 2 or 7 days had no effect on the constrictive responses at the injured site 1 month after injury or on those at the noninjured site at all times examined. These results suggest that platelet-vessel wall interaction may play an important role in coronary hyperconstrictive responses to autacoids 1 h and 1 week after injury.     

Major depression and medication adherence in elderly patients with coronary artery disease.

Little is known about the effects of depression on adherence to medical treatment regimens in older patients with chronic medical illnesses. Poor adherence may explain the increased risk of medical morbidity and mortality found in depressed medical patients. Ten of 55 patients over the age of 64 with coronary artery disease met the criteria for major depression from the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., American Psychiatric Association, 1987). All patients were prescribed a twice-per-day regimen of low dose aspirin to reduce their risk for myocardial infarction. Medication adherence was assessed for 3 weeks by an unobtrusive electronic monitoring device. Depressed patients adhered to the regimen on 45% of days, but nondepressed patients, on 69% (p?     

Prevention of preeclampsia with heparin and antiplatelet drugs in women with renal disease

In a retrospective cohort study of women with renal disease in pregnancy we investigated if: 1. low dose aspirin reduced the prevalence of preeclampsia and improved fetal outcome compared to no anticoagulant therapy. 2. heparin plus low dose aspirin and/or dipyridamole reduced the prevalence of preeclampsia and improved fetal outcome compared to i. no treatment ii. low dose aspirin alone. Women with renal disease were allocated into 3 groups according to the treatment received during their pregnancies: I. no prophylactic heparin or antiplatelet drugs, n = 76 II. prophylactic low-dose aspirin 75(50-150)mg, n = 27 III. prophylactic subcutaneous heparin 10,000 (5000-12,500) IU b.d. combined with low-dose aspirin 50 (50-150)mg and/or dipyridamole 400 (200-400)mg, n = 44. Preeclampsia and fetal outcome was analysed according to treatment group. Preeclampsia was less common in the heparin group (2.3%) compared with 27.6% in the no treatment group [O.R. 0.06 (0.01-0.30)] and 25.9% in the aspirin group [O.R. 0.07 (0.01-0.38)]. Women on aspirin, who developed preeclampsia, delivered later in pregnancy [35.4 (33-38.2) weeks] than preeclamptic women on no treatment [29 (22-38) weeks], p = 0.04. There was a trend to reduced perinatal deaths in the heparin + antiplatelet drug group, [2.3%; O.R., 0.17 (0.02-1.4)] and in the aspirin group [0%, O.R., 0.13 (0.01-2.3)] compared with 11.7% perinatal deaths in the no treatment group. Heparin with anti-platelet drugs may prevent preeclampsia in high risk women with renal disease. Further investigation in a randomized trial is indicated.     

Administration of abciximab during percutaneous coronary intervention reduces both ex vivo platelet thrombus formation and fibrin deposition: implications for a potential anticoagulant effect of abciximab

Abciximab (c7E3 Fab, ReoPro), a platelet glycoprotein (GP) IIb/IIIa inhibitor, decreases acute ischemic complications after percutaneous coronary interventions. Recently, abciximab was shown to decrease thrombin generation in vitro in a static system. To assess whether abciximab can decrease fibrin formation in blood from patients, we quantified both platelet thrombi and fibrin deposition by using an ex vivo flow chamber model. We prospectively studied 18 consecutive patients who underwent percutaneous interventions for unstable coronary syndromes. Blood was perfused directly from the patient through an ex vivo perfusion chamber at a high shear rate, thus mimicking mildly stenosed coronary arteries. Perfusion chamber studies were performed when patients were being treated with heparin plus aspirin before the procedure (baseline) and then repeated after the procedure, when patients were on either aspirin plus heparin alone (group 1, no abciximab, control) or aspirin plus heparin plus abciximab (group 2, abciximab treated). Each patient served as his or her own control. Specimens were stained with combined Masson's trichrome-elastin and antibodies specific for fibrinogen, fibrin, and platelet GP IIIa. Total thrombus area and areas occupied by platelet aggregates and fibrin layers were quantified by planimetry. Group 1 demonstrated no significant change in thrombus area before versus after the procedure; in contrast, treatment with abciximab reduced total thrombus area by 48% in group 2 (after the procedure versus baseline, P=0.01). This decline was due to significant reductions in both platelet aggregates (55%, P=0.005) and fibrin layers (45%, P=0.03). The addition of abciximab to heparin and aspirin in patients undergoing coronary interventions significantly decreases ex vivo thrombus formation on an injured vascular surface. Treatment with abciximab appears to reduce both the platelet and the fibrin thrombus components. This finding supports a potential role for GP IIb/IIIa receptor blockade in decreasing fibrin formation in addition to inhibition of platelet aggregation. Thus, potent inhibitors of GP IIb/IIIa may also act as anticoagulants.     

Introduction to coronary artery stents and their pharmacotherapeutic management

OBJECTIVE: To provide an introduction to coronary artery stents and their pharmacologic management, including anticoagulant therapy and newer antiplatelet regimens. DATA SOURCES: A MEDLINE and current journal search of relevant articles that evaluated coronary stent success rates and anticoagulation or antiplatelet regimens. STUDY SELECTION: Data from the use of primarily the Palmaz-Schatz stent were included. Studies using vitamin K antagonists that are not commercially available in the US were excluded unless they compared an antiplatelet regimen with anticoagulation using the international normalized ratio (INR). DATA SYNTHESIS: Limitations with percutaneous transluminal coronary angioplasty (PTCA), such as ischemic complications and restenosis, have led to the advent of intracoronary stenting. However, the placement of a stent within the coronary artery lumen is associated with a risk of thrombotic events. Despite current postprocedural anticoagulation and antiplatelet regimens, thrombosis occurs at rates ranging from 0.6% to 21%. When anticoagulation is deemed appropriate, it should be used for 1-2 months and the INR should be maintained between 2 and 3.5. Anticoagulation appears to have no effect on the development of restenosis, but has been shown to cause significant hemorrhagic events in 5-13.5% of patients. Newer data continue to define the subsets of patients who may be managed with antiplatelet agents alone. Combinations of aspirin and ticlopidine or aspirin alone may be used to manage patients who fulfill the following criteria: optimal stent placement, high-pressure inflation, and adequate coronary size. CONCLUSIONS: Coronary artery stenting is a novel approach for the management of coronary artery disease, but is associated with the complication of stent thrombosis. Anticoagulation reduces the risk of stent thrombosis, but is associated with bleeding risk. Selected patients may be successfully managed with antiplatelet agents only. More data are needed to better define the optimal antithrombotic regimen.     

Concentration of endogenous tPA antigen in coronary artery disease: relation to thrombotic events, aspirin treatment, hyperlipidemia, and multivessel disease

Tissue plasminogen activator (tPA) is the major plasminogen activator responsible for dissolving blood clots found in blood vessels. However, elevated concentrations of tPA antigen were found to be related to adverse events in patients with coronary artery disease (CAD). Considerable controversy about the significance of these results exists. The goal of this cross-sectional study was to identify independent determinants for tPA antigen concentrations in patients with CAD, to possibly clarify the above paradoxical relationship. The baseline tPA antigen concentrations of 366 patients with angiographic evidence of coronary sclerosis were determined. Univariate analysis showed that age (P=0.013), angiographic extent of disease (P<0.001), presence of angina at rest (P<0.001), diabetes mellitus (P=0.004), hypercholesterolemia (P=0. 045), hypertriglyceridemia (P=0.015), and chronic intake of nitrates (P<0.001) were significantly and positively related to tPA antigen concentration, while the chronic intake of aspirin was inversely related to tPA antigen (P<0.001). In addition, plasminogen activator inhibitor type 1 (PAI-1) activity was found to be significantly and positively associated with tPA antigen concentration (P<0.001). A multivariate analysis identified chronic low-dose aspirin therapy (P<0.001), PAI-1 activity (P<0.001), hypertriglyceridemia (P=0.005), the type of angina (P=0.026), multivessel disease (P=0.041), and hypercholesterolemia (P=0.043) as significant and independent determinants of tPA antigen. While hypertriglyceridemia and hypercholesterolemia both are related to the underlying disease, the type of angina and the number of involved vessels are linked to the severity and extent of disease, and all of them are indicators of a prothrombotic state found during the progression of CAD. In contrary, low-dose aspirin rather would decrease the likelihood of thrombotic events. The relation of tPA antigen to PAI-1 activity furthermore underlines the relation between tPA antigen concentration and a prothrombotic state. Therefore, the positive or-in case of aspirin therapy-negative correlation of these parameters with tPA antigen concentration would indicate that thrombus formation and simultaneous endothelial cell activation might be major determinants for tPA antigen concentration in CAD.     

Diurnal variation in total and undercarboxylated osteocalcin: influence of increased dietary phylloquinone

OBJECTIVE: To evaluate whether nurse run clinics in general practice improve secondary prevention in patients with coronary heart disease. DESIGN: Randomised controlled trial. SETTING: A random sample of 19 general practices in northeast Scotland. PATIENTS: 1173 patients (685 men and 488 women) under 80 years with working diagnoses of coronary heart disease, but without terminal illness or dementia and not housebound. INTERVENTION: Nurse run clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow up. MAIN OUTCOME MEASURES: Components of secondary prevention assessed at baseline and one year were: aspirin use; blood pressure management; lipid management; physical activity; dietary fat; and smoking status. A cumulative score was generated by counting the number of appropriate components of secondary prevention for each patient. RESULTS: There were significant improvements in aspirin management (odds ratio 3.22, 95% confidence interval 2.15 to 4.80), blood pressure management (5.32, 3.01 to 9.41), lipid management (3.19, 2.39 to 4.26), physical activity (1.67, 1.23 to 2.26) and diet (1.47, 1.10 to 1.96). There was no effect on smoking cessation (0.78, 0.47 to 1.28). Of six possible components of secondary prevention, the baseline mean was 3.27. The adjusted mean improvement attributable to intervention was 0.55 of a component (0.44 to 0.67). Improvement was found regardless of practice baseline performance. CONCLUSIONS: Nurse run clinics proved practical to implement in general practice and effectively increased secondary prevention in coronary heart disease. Most patients gained at least one effective component of secondary prevention and, for them, future cardiovascular events and mortality could be reduced by up to a third.     

Clinical characteristics determining the mode of presentation in patients with acute coronary syndromes

OBJECTIVES: The purpose of this study was to examine clinical characteristics of patients with acute coronary syndromes to identify factors that influence the mode of presentation. BACKGROUND: In acute coronary syndromes, presentation with myocardial infarction or unstable angina has major prognostic implications, yet clinical factors affecting the mode of presentation are not well defined. METHODS: A prospective cohort study was made of 1,111 patients with acute coronary syndromes. Baseline demographic, clinical and biochemical data were compared in groups with myocardial infarction (n = 633) and unstable angina (n = 478). RESULTS: The risk of myocardial infarction relative to unstable angina was increased by age >70 years (odds ratio [OR] 2.21; 95% confidence interval [CI] 1.33 to 3.66), male gender (OR 1.56; CI 1.13 to 2.16) and cigarette smoking (OR 1.49; CI 1.09 to 2.03). A rise in admission creatinine from the 10th to the 90th centile of the distribution also increased the odds of myocardial infarction (OR 1.30; CI 1.05 to 1.94). Conversely, the risk of myocardial infarction relative to unstable angina was reduced by previous treatment with aspirin (OR 0.37; CI 0.27 to 0.52), hypertension (OR 0.64; CI 0.47 to 0.86) and previous acute coronary syndromes (OR 0.36; CI 0.26 to 0.51) and revascularization procedures (OR 0.36; CI 0.21 to 0.62). CONCLUSIONS: The clinical presentation of acute coronary syndromes may be influenced by various factors that have the potential to influence the coagulability of the blood, the collateralization of the coronary circulation and myocardial mass. Myocardial infarction is favored by cigarette smoking, advanced age and renal impairment, while unstable angina is favored by treatment with aspirin, hypertension, previous revascularization and previous coronary syndromes.