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Background: Long-term nitrate treatment of stable angina is associated with side effects that can interfere with health-related quality of life (HRQoL) and medication adherence. The aim of the present study was to compare HRQoL and adherence to treatment in patients with stable angina undergoing nitrate withdrawal or maintenance., Methods: This study is a randomized clinical trial. Patients were allocated to an intervention group (nitrate withdrawal followed by introduction of placebo) or a control group (nitrate maintenance). The assessments were made at baseline and 30 and 120 days using the Short Form Health Survey and the Seattle Angina Questionnaire. Treatment adherence was measured on the basis of the Morisky scale and pill count., Results: A total of 105 patients with stable angina were randomized for replacement of nitrate with placebo (n=51) and for maintenance of treatment with nitrate (n=54). After 4 months, Short Form Health Survey scores increased for bodily pain (P=0.005) and general health (P=0.004) in the nitrate maintenance group. Decreased Seattle Angina Questionnaire scores were also noted for physical limitations (P=0.039) and angina frequency (P=0.011) in the nitrate maintenance group. However, the effect size was small (≤0.44) when the intervention and control groups were compared. At the end of the study, adherence was significantly higher in the placebo group (P=0.041), but no difference was detected between the groups with the pill count method., Conclusion: HRQoL was similar in patients with stable angina using nitrate regularly as compared with patients undergoing nitrate withdrawal. However, adherence to treatment was lower in nitrate users according to the Morisky scale.

Background: Atherosclerosis is a chronic inflammatory process, and myeloperoxidase (MPO) seems to contribute directly to the pathogenesis of acute coronary syndrome (ACS)., Objective: To compare MPO levels among the patients with stable and unstable ischemic heart disease and to evaluate their independent prognostic value for cardiovascular events., Methods: MPO and C-reactive protein (CRP) were assessed in two cohorts of coronary artery disease patients, including 178 patients with stable angina and 130 patients with ACS evaluated at the emergency department., Results: MPO and CRP levels were significantly higher among patients with ACS [MPO 93 (54-127) vs. 9.9 pmol/l (5-21) and high sensitivity-CRP 11 (3-27) vs. 2.6 mg/l (1-5)]. Among patients with stable angina, high sensitivity-CRP levels greater than 3 mg/l were associated with a three-fold risk of further cardiovascular events during a mean follow-up period of 13+/-4 months, although there was no significant association between MPO levels and outcomes. Among patients with ACS, baseline MPO level was an independent predictor of major adverse cardiac events during hospitalization, odds ratio of 3.8 (95% confidence interval: 1.2-12) for the combined endpoint (death, recurrent angina, heart failure, and arrhythmia). CRP levels were associated with hospital mortality in patients with ACS, but were not independently related to cardiovascular events., Conclusion: Elevated MPO levels among the ACS patients suggest that this marker may participate in plaque vulnerability and instability process, whereas higher CRP levels were predictive of cardiac events only among the stable angina patients. These findings suggest distinct role of the inflammatory markers studied in the pathophysiology of coronary artery disease.

Background: Interleukin-18 (IL-18), a proinflammatory cytokine, has been associated with atherogenesis and plaque rupture in acute coronary syndrome (ACS). Recent studies suggest that IL-18 may have a long-term prognostic value. The aim of this study was to evaluate the relationship between IL-18 levels and major adverse cardiovascular events within 6 months of follow-up in post-ACS patients., Methods: One hundred and twelve consecutive patients admitted to a university hospital with ACS were included in the study. IL-18 and C-reactive protein were measured within the first 24 h of admission. Six months after hospital discharge, the incidence of major adverse cardiovascular events (cardiovascular death, new episode of ACS, and need for unplanned revascularization) was assessed., Results: Mean age of patients was 64 +/- 11 years, and 58 (52%) were male. During the 6 months of follow-up, 33 patients (31.4%) experienced major adverse cardiovascular events. Median IL-18 serum levels were higher among patients who had events than among those who did not: 271.7 pg/ml (interquartile range: 172.9-389.6) and 139.7 pg/ml (interquartile range: 99.9-265.7), respectively (P < 0.01). In the Cox multivariate analysis, after adjustment for clinical risk factors and serum troponin, elevated levels of IL-18 were associated with higher incidence of events (hazard ratio: 2.5; 95% confidence interval: 1.14-5.52; P = 0.023). In this population, C-reactive protein was of borderline significance for events., Conclusion: Serum IL-18 levels in ACS patients were independent predictors of long-term cardiovascular events. These findings support the association between inflammation and prognosis of ACS patients, as well as the clinical impact of this biomarker.

Background: Although anemia is pathophysiologically associated with myocardial ischemia, there are scarce data on its clinical impact in patients with stable coronary artery disease on contemporary treatment. This study aims to describe the prevalence of anemia, and its association with symptoms and outcomes in this population., Methods: We conducted a prospective cohort study in stable documented coronary artery disease patients. Anemia criteria was hemoglobin (Hb) <12 g/dl in women and <13 g/dl in men. Hemoglobin levels were divided in quartiles (Q) adjusted for sex. Major events included acute coronary syndromes, stroke and cardiovascular deaths. Secondary outcomes were presence of angina and chronic use of nitrates. Cox regression models were used to evaluate the independent effect of anemia on clinical outcomes., Results: Among 310 patients, 71 (23%) met criteria for anemia. After a mean follow-up of 44+/-23 months, hemoglobin levels had a marked association with occurrence of major events (27% in Q1, 7% in Q2, 8% in Q3 and 12% in Q4; P<0.01). In multivariate analysis, anemia was independently associated with an increased risk of death [hazard ratio (HR) 6.5, 95% confidence interval (1.7-24.2)], major events [HR 3.3 (1.7-6.5)] and revascularization procedures [HR 2.3 (1.3-4.1)]. Persistent of angina symptoms (32 vs. 18%, P=0.01) and chronic use of nitrates (35 vs. 21%, P=0.02) were also more frequent among patients with anemia at baseline., Conclusions: In patients with stable ischemic heart disease, presence of anemia, even mild, is associated with a worse prognosis. Strategies aiming at identifying reversible causes of anemia or new treatments should be evaluated in prospective clinical trials.