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Cardiac rehabilitation (CR) is essential for secondary prevention, yet only 10%-30% of eligible patients attend as geographical proximity is a major barrier. We evaluated a 'virtual' CR program (vCRP) delivered by the Internet to patients in small urban and rural areas. In our study, in-patients (n=78) with acute coronary syndrome or post-revascularization were randomized to usual care (UC) or vCRP. The vCRP was a four-month program that included heart rate monitoring; physiologic data capture; education sessions; ask-an-expert sessions; and chat sessions with a nurse, exercise specialist and dietitian. Participants were assessed at baseline and four months, and followed for another 12 months. The primary outcome was change in maximal time on the treadmill stress test (MTT) between groups adjusted for age, sex, diabetes status and Internet use for health information. The vCRP resulted in a greater increase in MTT by 45.7 seconds (95% CI: 1.0, 90.5) compared to usual care (p=0.045). Cholesterol levels and dietary quality improved in the vCRP compared to the UC group. Participants perceived the vCRP to be an accessible, convenient and effective way to received healthcare. Eleven (30%) and 6 (18%) participants in the UC and vCRP groups, respectively, had cardiovascular-related events (p=0.275). In conclusion, the vCRP was safe and effective and resulted in sustainable risk reduction without the requirement of face-to-face visits and directly monitored exercise. [ABSTRACT FROM AUTHOR]

Cardiac rehabilitation programs (CRP) are medically supervised, multidisciplinary programs that provide secondary prevention aimed at addressing risk factors and improving lifestyle behaviours for patients following an acute cardiac event. CRPs have been demonstrated to be a cost-effective and evidence-based mechanism to improve patient outcomes, but despite the known benefits of these programs, uptake remains poor. Poor attendance has been linked to many factors, but geographical accessibility is a key concern, since many CRPs are limited to hospitals in urban areas. The widespread availability of the Internet has made it possible to provide virtual health services to populations that may have previously been hard to access. This paper examines the qualitative findings from a 16-month mixed methods randomized controlled trial examining the impact of a virtual CRP (vCRP). The vCRP was revealed to be an accessible, appropriate, convenient and effective way to deliver cardiac rehabilitation services, with patients experiencing both clinical improvements and a high level of satisfaction. To understand the experience of patients undertaking the vCRP, semi-structured interviews were undertaken with a purposive sample of 22 participants. An analysis of the qualitative interviews revealed that the vCRP improved participants' access to healthcare professionals, supported them to make healthy choices, and enhanced feelings of accountability due to greater surveillance. Barriers to participation, such as computer literacy, and general perceptions of a vCRP were also examined. Further investigation into the use and long-term effectiveness of virtual programs across a broader range of healthcare settings is warranted, particularly in those with multiple chronic diseases and those located in rural and remote communities. [ABSTRACT FROM AUTHOR]

Heart failure is the only cardiac syndrome still rising in prevalence. Even though heart failure severely affects quality of life and has a high mortality rate, patients with heart failure have less access to palliative care than patients with other life-threatening conditions such as cancer. To address this gap in care, the Heart Failure Supportive Care Clinic was introduced at St. Paul's Hospital in January 2011. The clinic's objective is to improve the quality of life for patients with advanced heart failure who are not candidates for cardiac transplantation or a ventricular assist device. Palliative care specialists can help patients and family members make well-informed and reasonable decisions about preferences for cardiopulmonary resuscitation and when to change to comfort care. Effective communication and a multidisciplinary, team-based approach are needed to ensure a smooth transition to palliative care. [ABSTRACT FROM AUTHOR]

With a prevalence rate of approximately 1 case in 500 people, heterozygous familial hypercholesterolemia is one of the most common genetic disorders encountered in clinical practice. Affected individuals have an impaired hepatic clearance of low-density lipoprotein particles and are thus predisposed to hypercholesterolemia, with a consequent twentyfold increased risk of premature vascular disease. Early disease modification through lifestyle changes and lipid-lowering therapy is highly effective: by treating three to four affected individuals, one premature event can be prevented. There are approximately 8000 people with heterozygous familial hypercholesterolemia in British Columbia, yet over 85% of those affected remain undiagnosed. The British Columbia Familial Hypercholesterolemia Registry has been established to address this gap in patient care. Through this registry we aim to improve identification and management of heterozygous familial hypercholesterolemia in BC, and to increase awareness of this potentially fatal yet highly treatable condition. [ABSTRACT FROM AUTHOR]

One of the main challenges for clinicians evaluating patients with systemic sarcoidosis is determining when and how to investigate for cardiac involvement. Owing to a low index of suspicion, and in some cases lack of pulmonary involvement, it may take many years before cardiac sarcoidosis is finally diagnosed. This is regrettable as cardiac sarcoidosis is readily treatable with corticosteroids, and because prompt diagnosis and treatment may prevent severe complications such as left ventricular dysfunction, heart failure, malignant arrhythmias, and even death. The literature supports screening for cardiac sarcoidosis with a clinical approach that includes history taking, physical examination, an electrocardiogram, an echocardiogram, and Holter monitoring. When the results of these investigations indicate abnormalities, cardiac MRI should be considered. While endomyocardial biopsy can confirm cardiac sarcoidosis, in most cases it is not required. Once cardiac sarcoidosis is confirmed, the patient should be monitored closely for the development of lethal arrhythmias and referred to an electrophysiologist if these are detected. [ABSTRACT FROM AUTHOR]

Dr D.S. Fredrickson is considered by many to be the founding father of lipidology. An exceptional scientist, Fredrickson discovered Tangier disease and cholesteryl ester storage disease, two genetic conditions caused by aberrant lipid metabolism. His identification of various apolipoprotein components contributed to our current understanding of lipid transport and physiology. His classification of lipoprotein abnormalities, established on the basis of electrophoretic plasma lipoprotein patterns, was accepted by the World Health Organization as a standard of clinical practice and provoked global interest in dyslipidemic disorders. Fredrickson was part of a remarkable trio of scientists who devised the formula for estimating low density lipoprotein cholesterol levels, a calculation that continues to be used in laboratories worldwide. He was also instrumental in the creation of the Lipid Research Clinics Program, which sponsored the landmark Coronary Primary Prevention Trial, the first major study to definitively demonstrate that lowering cholesterol reduces coronary heart disease risk. [ABSTRACT FROM AUTHOR]

Sixty years ago, smoking was a favorite pastime. Few suspected that this seemingly innocuous habit was responsible for the skyrocketing incidence of lung cancer in the UK following the Second World War. Dr Richard Doll pioneered research that demonstrated the link between smoking and lung cancer and showed its detrimental effect on the cardiovascular system. Today the health risks of smoking are well known, yet millions of people die prematurely each year due to the damaging effects of this habit. Smoking cessation can lead to dramatic improvements in health, so it is important for physicians to understand the factors that prevent patients from quitting and the resources available. The greatest success rates for smoking cessation result from combining medical and psychosocial support. [ABSTRACT FROM AUTHOR]

The benefits of vitamin D are well established for skeletal health, but its effects on other organ systems are less clear. Recent observational data suggest that vitamin D may promote cardiovascular health. Individuals with high serum 25(OH)D are less likely to suffer from hypertension, hyperlipidemia, diabetes, angina pectoris, stroke, and myocardial infarction compared with those with low serum 25(OH)D. Individuals with high intake of vitamin D are less likely to suffer from diabetes, myocardial infarction, and stroke. Large-scale randomized controlled trials are underway to further investigate these associations, but current evidence remains insufficient to draw any firm conclusions. In the meantime, a vitamin D intake of 600 IU per day is proven to be safe and effective at promoting bone health, and may provide an accessory benefit of improved cardiovascular health. [ABSTRACT FROM AUTHOR]

Metabolic syndrome increases the risk of all-cause mortality, cardiovascular mortality and cardiovascular events in patients with cardiovascular disease (CVD). This study assessed the predictors of metabolic syndrome, both its incidence and resolution in a cohort of cardiac rehabilitation program graduates. Methods. A total of 154 and 80 participants without and with metabolic syndrome respectively were followed for 48 months. Anthropometricmeasurements, metabolic risk factors, and quality of life were assessed at baseline and at 48 months. Logistic regression models were used to assess the predictors of metabolic syndrome onset and resolution. Results. Increasing waist circumference (OR 1.175, P = 0.001) was an independent predictor for incidentmetabolic syndrome (R2 formodel = 0.46). Increasing waist circumference (OR 1.234, P = 0.001), decreasing HDL-C (OR 0.027, P = 0.005), and increasing triglycerides (OR 3.005, P = 0.003) were predictors of metabolic syndrome resolution. Conclusion. Patients with CVD that further develop metabolic syndrome are particularly susceptible for the cascade of cardiovascular events and mortality. Increasing waist circumference confers a higher risk for future onset of metabolic syndrome in this group of patients. They will require closer follow-up and should be targeted for further prevention strategies after cardiac rehabilitation program completion. [ABSTRACT FROM AUTHOR]

Angiotensin-converting enzyme inhibitors (ACEIs) are commonly used to treat cardiovascular disorders. The use of ACEIs for hypertension is well established, although these agents have not proven to be superior to other antihypertensive agents. The use of ACEIs in heart failure is also well established, and has proven to reduce morbidity and mortality. ACEIs are now routinely used in myocardial infarction patients to reduce reinfarction and mortality risk, and are combined with a diuretic for secondary prevention in stroke patients. Proof that ACEIs also reduce the progression of diabetic nephropathy supports their use in all diabetic patients. With the evidence of efficacy now available, angiotensin-converting enzyme inhibitors should be considered for all patients with diabetes or a history of cardiovascular disease, except for those at low risk. [ABSTRACT FROM AUTHOR]

Data are scarce concerning the calcineurin inhibitor dose reduction required following introduction of everolimus in maintenance heart transplant recipients to maintain stable renal function. In a 48-week, multicenter, single-arm pilot study in heart transplant patients >12 months post-transplant, everolimus was started at 1.5 mg/day (subsequently adjusted to target C0 5–10 ng/ml). Mycophenolate mofetil or azathioprine was discontinued on the same day and cyclosporine (CsA) dose was reduced by 25%, with a further 25% reduction each time calculated glomerular filtration rate (cGFR) decreased to <75% of baseline. Of 36 patients enrolled, 25 were receiving everolimus at week 48. From baseline to week 48, there was a mean decrease of 44.5%, 50.9% and 44.6% in CsA dose, C0 and C2, respectively. Mean cGFR was 68.9 ± 14.5 ml/min at baseline and 61.6 ± 11.5 ml/min at week 48 ( P = 0.018). The prespecified criterion for stable renal function was met, i.e. a mean decrease ≤25% of cGFR from baseline. Two patients experienced biopsy-proven acute rejection Grade 3A (5.6%). Between baseline and week 48, there were significant increases in total cholesterol, LDL-cholesterol and triglycerides, and small but significant elevations in liver enzymes. This 1-year pilot study suggests that CsA dose reduction of ca. 40% after initiation of everolimus was associated with a decrease in cGFR, however, based on the prespecified criteria stable renal function was attained. [ABSTRACT FROM AUTHOR]

The article presents an overview of research which evaluated the use of the thienopyridine platelet antagonist clopidogrel in the treatment of acute coronary syndromes, and of guidelines on the use of clopidogrel which have been issued by several professional societies. A discussion of clopidogrel's chemical makeup, and of instances in which patients with acute coronary syndromes should be treated with clopidogrel, is presented. The proper duration of effective treatment with clopidogrel is discussed

Background: Previous reports indicate risk factors and lifestyle behaviors may deteriorate early after completion of a cardiac rehabilitation program (CRP). We hypothesized that a modest risk factor and lifestyle management intervention after a CRP would significantly reduce overall cardiovascular risk using the Framingham risk score compared with usual care after 4 years. Methods: Patients with ischemic heart disease (n = 302) were randomized after a CRP to either usual care or intervention (exercise sessions, telephone follow-ups, counseling sessions, and reports to the participants'' family physicians). The Framingham risk score, risk factors, and lifestyle behaviors were compared after 4 years. Results: Data were available for 130 intervention and 119 usual care participants. The intervention resulted in 15.5 hours of direct participant contact. Framingham score, total cholesterol, low-density lipoprotein cholesterol, and systolic blood pressure were significantly improved in the intervention group after adjusting for baseline factors. There were no significant differences with respect to lifestyle factors between the groups. Conclusions: A modest risk factor and lifestyle management intervention resulted in a significant reduction to global risk compared with usual care and should be considered after CRP. [Copyright &y& Elsevier]

Aim Previous studies have reported lifestyle and risk factor deterioration following completion of a cardiac rehabilitation program (CRP). We report the results of a one-year Extensive Lifestyle Management Intervention (ELMI) aimed at preventing these adverse changes.Methods and results A total of 302 men and women with ischaemic heart disease were recruited following completion of a CRP and randomized to either the ELMI (consisting of exercise sessions, telephone follow-ups and risk factor and lifestyle counselling) or usual care. The primary outcome was global cardiovascular risk using the Framingham and Procam risk scores. Secondary outcomes included risk factors and lifestyle behaviours. Baseline characteristics were similar between the two groups. Adherence to the ELMI was high. There was a non-significant trend in favour of the ELMI between for both the Framingham (6.6±3.1 to 6.2±2.9 vs 6.6±3.2 to 6.7±3.2, P=0.138) and Procam (20.0±20.0 to 20.6±19.5 vs 19.1±18.7 to 21.8±19.1, P=0.089) scores. There were no differences in secondary outcomes.Conclusions A one-year multi-factorial post-CRP intervention results in modest, non-significant benefits to global risk compared to usual care. The absence of deterioration in the usual care group may be due to improved practices in usual care. [ABSTRACT FROM PUBLISHER]