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 Intramyocardial injection of autologous bone marrow mononuclear cells for patients with chronic ischemic heart disease and left ventricular dysfunction (First Mononuclear Cells injected in the US [FOCUS]): Rationale and design. Systematic Review of the Effect of Diet and Exercise Lifestyle Interventions in the Secondary Prevention of Coronary Heart Disease Aerobic interval training and continuous training equally improve aerobic exercise capacity in patients with coronary artery disease: the SAINTEX-CAD study. Exercise and well-being: a review of mental and physical health benefits associated with physical activity The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review. Cardiovascular Safety of Transdermal Nicotine Patches in Patients with Coronary Artery Disease who Try to Quit Smoking Effect of yoga regimen on lung functions including diffusion capacity in coronary artery disease patients: A randomized controlled study Percutaneous coronary intervention plus medical therapy reduces the incidence of acute coronary syndrome more effectively than initial medical therapy only among patients with low-risk coronary artery disease a randomized, comparative, multicenter study. Effect of oral administration of testosterone on brachial arterial vasoreactivity in men with coronary artery disease. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. Effectiveness of massage therapy on the mood of patients after open-heart surgery Usefulness of omega-3 fatty acids and the prevention of coronary heart disease. B-type natriuretic peptide and the risk of cardiovascular events and death in patients with stable angina: results from the AtheroGene study. Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults Rationale and design of a randomized trial on the effectiveness of aerobic interval training in patients with coronary artery disease: the SAINTEX-CAD study. Long-term survival in patients with refractory angina. Community-Based Lifestyle Intervention in Patients With Coronary Artery Disease: The RESPONSE-2 Trial. [Effects of metoprolol on perioperative cardiovascular events in patients with risk or at high risk for coronary artery disease undergoing non-cardiac surgery]. Effects of electrostimulation of the vagus afferent endings in patients with coronary artery disease Guidelines for the Management of Patients with Chronic Stable Angina: Diagnosis and Risk Stratification Combination of amlodipine and enalapril in hypertensive patients with coronary disease. Cardiac computed tomographic angiography in an outpatient setting: an analysis of clinical outcomes over a 40-month period. Effect of Positive Airway Pressure on Cardiovascular Outcomes in Coronary Artery Disease Patients with Nonsleepy Obstructive Sleep Apnea. The RICCADSA Randomized Controlled Trial. Contrast-enhanced whole-heart coronary magnetic resonance angiography at 3.0-T: a comparative study with X-ray angiography in a single center. Ivabradine in stable coronary artery disease without clinical heart failure. Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery The effect of t'ai chi exercise on autonomic nervous function of patients with coronary artery disease. Does serum ferritin correlate with coronary angiography findings?
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 BACKGROUND The increasing worldwide prevalence of coronary artery disease ( CAD ) continues to challenge the medical community . Management options include medical and revascularization therapy . Despite advances in these methods , CAD is a leading cause of recurrent ischemia and heart failure , posing significant morbidity and mortality risks along with increasing health costs in a large patient population worldwide . TRIAL DESIGN The Cardiovascular Cell Therapy Research Network ( CCTRN ) was established by the National Institutes of Health to investigate the role of cell therapy in the treatment of chronic cardiovascular disease . FOCUS is a CCTRN- design ed r and omized , phase II , placebo-controlled clinical trial that will assess the effect of autologous bone marrow mononuclear cells delivered transendocardially to patients with left ventricular ( LV ) dysfunction and symptomatic heart failure or angina . All patients need to have limiting ischemia by reversible ischemia on single-photon emission computed tomography assessment . RESULTS After thoughtful consideration of both statistical and clinical principles , we will recruit 87 patients ( 58 cell treated and 29 placebo )  to receive either bone marrow-derived stem cells or placebo .  Myocardial perfusion , LV contractile performance , and maximal oxygen consumption are the primary outcome measures . CONCLUSIONS The design ed clinical trial will provide a sound assessment of the effect of autologous bone marrow mononuclear cells in improving blood flow and contractile function of the heart . The target population is patients with CAD and LV dysfunction with limiting angina or symptomatic heat failure . Patient safety is a central concern of the CCTRN , and patients will be followed for at least 5 years The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease ( CHD ) remains unclear . This systematic review aim ed to determine their effectiveness and included r and omized controlled trials of lifestyle interventions , in primary care or community setting s , with a minimum follow-up of three months , published since 1990 . 21 trials with 10,799 patients were included ; the interventions were multifactorial ( 10 ) , educational ( 4 ) , psychological ( 3 ) , dietary ( 1 ) , organisational ( 2 ) , and exercise ( 1 ) . The overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes but no overall effect on smoking outcomes . In trials that examined mortality and morbidity , significant benefits were reported for total mortality ( in 4 of 6 trials ; overall risk ratio ( RR ) 0.75 ( 95 % confidence intervals ( CI ) 0.65 , 0.87 ) ) , cardiovascular mortality ( 3 of 8 trials ; overall RR 0.63 ( 95 % CI 0.47 , 0.84 ) ) , and nonfatal cardiac events ( 5 of 9 trials ; overall RR 0.68 ( 95 % CI 0.55 , 0.84 ) ) . The heterogeneity between trials and generally poor quality of trials make any concrete conclusions difficult . However , the beneficial effects observed in this review are encouraging and should stimulate further research BACKGROUND Exercise-based cardiac rehabilitation increases peak oxygen uptake ( peak VO₂ ) , which is an important predictor of mortality in cardiac patients . However , it remains unclear which exercise characteristics are most effective for improving peak VO₂ in coronary artery disease ( CAD ) patients . Proof of concept papers comparing Aerobic Interval Training ( AIT ) and Moderate Continuous Training ( MCT ) were conducted in small sample sizes and findings were inconsistent and heterogeneous . Therefore , we aim ed to compare the effects of AIT and Aerobic Continuous Training ( ACT ) on peak VO₂ , peripheral endothelial function , cardiovascular risk factors , quality of life and safety , in a large multicentre study . METHODS Two-hundred CAD patients ( LVEF > 40 % , 90 % men , mean age 58.4 ± 9.1 years ) were r and omized to a supervised 12-week cardiac rehabilitation programme of three weekly sessions of either AIT ( 90 - 95 % of peak heart rate ( HR ) ) or ACT ( 70 - 75 % of peak HR ) on a bicycle . Primary outcome was peak VO₂ ; secondary outcomes were peripheral endothelial function , cardiovascular risk factors , quality of life and safety . RESULTS Peak VO₂ ( ml/kg/min ) increased significantly in both groups ( AIT 22.7 ± 17.6 % versus ACT 20.3 ± 15.3 % ; p-time<0.001 ) . In addition , flow-mediated dilation ( AIT+34.1 % ( range -69.8 to 646 % ) versus ACT+7.14 % ( range -66.7 to 503 % ) ; p-time<0.001 ) quality of life and some other cardiovascular risk factors including resting diastolic blood pressure and HDL-C improved significantly after training . Improvements were equal for both training interventions . CONCLUSIONS Contrary to earlier smaller trials , we observed similar improvements in exercise capacity and peripheral endothelial function following AIT and ACT in a large population of CAD patients Purpose of review This review highlights recent work evaluating the relationship between exercise , physical activity and physical and mental health . Both cross-sectional and longitudinal studies , as well as r and omized clinical trials , are included . Special attention is given to physical conditions , including obesity , cancer , cardiovascular disease and sexual dysfunction . Furthermore , studies relating physical activity to depression and other mood states are review ed . The studies include diverse ethnic population s , including men and women , as well as several age groups ( e.g. adolescents , middle-aged and older adults ) . Recent findings Results of the studies continue to support a growing literature suggesting that exercise , physical activity and physical-activity interventions have beneficial effects across several physical and mental-health outcomes . Generally , participants engaging in regular physical activity display more desirable health outcomes across a variety of physical conditions . Similarly , participants in r and omized clinical trials of physical-activity interventions show better health outcomes , including better general and health-related quality of life , better functional capacity and better mood states . Summary The studies have several implication s for clinical practice and research . Most work suggests that exercise and physical activity are associated with better quality of life and health outcomes . Therefore , assessment and promotion of exercise and physical activity may be beneficial in achieving desired benefits across several population s. Several limitations were noted , particularly in research involving r and omized clinical trials . These trials tend to involve limited sample sizes with short follow-up periods , thus limiting the clinical implication s of the benefits associated with physical activity . Abbreviations CAD : coronary artery disease ; COPD : chronic obstructive pulmonary disease ; CRP : cardiac rehabilitation program ; CVD : cardiovascular disease ; GMCB : group-mediated cognitive – behavioural ; HRQOL : health-related quality of life OBJECTIVE The purpose of this systematic review was to highlight the effect of nurse-led 1:1 patient education sessions on Quality of Life ( QoL ) , readmission rates and healthcare costs for adults with heart failure ( HF ) living independently in the community . METHOD A systematic review of r and omised control trials was undertaken . Using the search terms nurse , education , heart failure , hospitalisation , readmission , rehospitalisation , economic burden , cost , expenditure and quality of life in PubMed , CINAHL and Google Scholar data bases were search ed . Papers pertaining to  nurse-led 1:1 HF disease management of education of adults in the community with a history of HF were review ed . RESULT The results of this review identified nurse-led education sessions for adults with HF contribute to reduction in hospital readmissions , reduction in hospitalisation and a cost benefit . Additionally , higher functioning and improved QoL were also identified . CONCLUSION These results suggest that nurse-led patient education for adults with HF  improves QoL and reduces hospital admissions and readmissions . PRACTICE IMPLICATION S Nurse-led education can be delivered utilising diverse methods and impact to reduce readmission as well as hospitalisation Nicotine patches are commonly used by people who try to quit smoking . Because high doses of nicotine may increase heart rate and potentiate cardiac arrhythmia or ischemia , its use in patients with coronary artery disease was investigated . The objective was to assess the cardiovascular safety of nicotine patches in patients with coronary artery disease ( CAD ) who try to quit smoking . The study was conducted in a double-blind , placebo-controlled , r and omized fashion over a 2-week period . One hundred and six patients with CAD who wished to stop smoking and were taking part in a smoking cessation program were included . Fifty-two patients received nicotine patches ( Nicotinell ® ) and 54 received placebo patches .  The cardiovascular effects of nicotine patches were assessed by repeated ambulatory ECG monitoring ( AEM ) and exercise testing . There were no changes in the resting heart rate and in the systolic or diastolic blood pressure between the screening and the two phases of the study in both the Nicotinell and placebo groups . Repeated 48-hour AEM revealed that there were no significant changes in the number and duration of ischemic episodes in both groups . There was no change in the frequency of atrial or ventricular arrhythmias . Exercise duration and time to 1-mm ST-segment depression increased in both groups during the double-blind treatment phase . More patients in the Nicotinell group cl aim ed tobacco abstinence compared with the placebo group ( 27 % vs. 13 % ) . The use of nicotine patches did not cause aggravation of myocardial ischemia or arrhythmia in coronary patients and therefore can be used as a method to promote smoking cessation in this high-risk group Background : Lung functions are found to be impaired in coronary artery disease ( CAD ) , congestive heart failure , left ventricular dysfunction , and after cardiac surgery . Diffusion capacity progressively worsens as the severity of CAD increases due to reduction in lung tissue participating in gas exchange . Aims and Objectives : Pranayama breathing exercises and yogic postures may play an impressive role in improving cardio-respiratory efficiency and facilitating gas diffusion at the alveolo-capillary membrane . This study was done to see the effect of yoga regimen on lung functions particularly diffusion capacity in CAD patients . Material s and Methods : A total of 80 stable CAD patients below 65 years of age of both sexes were selected and r and omized into two groups of 40 each . Group I CAD patients were given yoga regimen for 3 months which consisted of yogic postures , pranayama breathing exercises , dietary modification , and holistic teaching along with their conventional medicine while Group II CAD patients were put only on conventional medicine .  Lung functions including diffusion capacity were recorded thrice in both the groups : 0 day as baseline , 22nd day and on 90th day by using computerized MS medisoft Cardio-respiratory Instrument , HYP’AIR Compact model of cardio-respiratory testing machine was manufactured by P K Morgan , India . The recorded parameters were statistically analyzed by repeated measures ANOVA followed by Tukey 's test in both the groups . Cardiovascular parameters were also compared before and after intervention in both the groups . Results : Statistically significant improvements were seen in slow vital capacity , forced vital capacity , peak expiratory flow rate , maximum voluntary ventilation , and diffusion factor/ transfer factor of lung for carbon monoxide after 3 months of yoga regimen in Group I. Forced expiratory volume in 1st sec ( FEV1 ) , and FEV1 % also showed a trend toward improvement although not statistically significant . HR , SBP and DBP also showed significant improvement in Group-I patients who followed yoga regimen . Conclusions : Yoga regimen was found to improve lung functions and diffusion capacity in CAD patients besides improving cardiovascular functions . Thus , it can be used as a complimentary or adjunct therapy along with the conventional medicine for their treatment and rehabilitation OBJECTIVES This study sought to determine whether initial medical therapy ( MT ) only or percutaneous coronary intervention plus medical therapy ( PCI+MT ) is better for patients with low-risk stable coronary artery disease ( CAD ) indicated for intervention in Japan . BACKGROUND Several multicenter studies have suggested that in the above patients , an initial management strategy of PCI+MT does not reduce the long-term risk of cardiovascular events more effectively than initial MT only . METHODS We conducted a r and omized comparative study ( JSAP [ Japanese Stable Angina Pectoris ] study ) in the previously mentioned patients . RESULTS The patients were r and omized to PCI+MT ( n = 192 ) or initial MT only group ( n = 192 ) , and the patient characteristics were very similar in the 2 groups . During the 3.3-year follow-up , there was no significant difference in the cumulative death rate  between PCI+MT ( 2.9 % ) and MT ( 3.9 % ) . However , the cumulative risk of death plus acute coronary syndrome was significantly smaller in PCI+MT . CONCLUSIONS In stable low-risk CAD , PCI+MT may improve long-term prognosis more effectively than MT H igh and rogen levels in men have been regarded as a risk factor for coronary artery disease ( CAD ) . However , it has recently been demonstrated that supplements of and rogens inhibit atheroma formation in castrated male animals , suggesting that testosterone may be antiatherosclerotic . In men with angina pectoris , a significant inverse correlation was found between plasma testosterone levels and the extent of CAD , demonstrating that low testosterone levels could be a risk factor for CAD . Other reports suggest that testosterone replacement therapy in men with CAD has a beneficial effect on angina pectoris and exercise-induced ST-segment depression . Another study showed that testosterone enhanced endotheliumindependent coronary artery dilation and flow-mediated brachial arterial vasoreactivity in men with CAD . In this study , we assessed the effects of oral testosterone administration on brachial arterial vasoreactivity in men with CAD . • • • Thirty-five men ( aged 58 8 years ) with CAD were r and omized to placebo ( n 17 ) or treatment group ( n 18 ) . Demographics of the study group are summarized in Table 1 . Diagnostic criteria of CAD are a history of unstable and stable angina pectoris with angiographic evidence ( 50 % stenosis of lumen diameter ) . Exclusion criteria were inflammatory disease or malignancy , ejection fraction 45 % , clinical evidence of heart failure , and Q-wave myocardial infa rct ion within 3 months before the study . The treatment group completed oral administration of 160 mg of testosterone undecanoate ( And riol , N.V. Organon , Oss , The Netherl and s ) daily for 4 weeks followed by 80 mg testosterone undecanoate for 8 weeks , in addition to their current medication . Using high-resolution ultrasound , we assessed brachial arterial vasoreactivity to reactive hyperemia ( flow-mediated dilation ) and sublingual nitroglycerin ( nitroglycerin-mediated dilation ) at baseline and after 12 weeks of treatment . Patients taking nitrates discontinued therapy 24 hours before the study to avoid nitrate tolerance . A 10-MHz linear phased-array ultrasound transducer ( GE Vigmed Ultrasound , Horten , Norway ) was used to image the dominant arm brachial artery longitudinally 3 to 5 cm just above the antecubital fossa . All patients rested in the supine position for 10 minutes in a quiet room . After the depth and gain setting were optimized to identify the vessel wall , the brachial artery diameter was measured from the anterior to the posterior interface between the media and the adventitia and determined at end-diastole on B mode . Reactive hyperemia was induced by inflation and then deflation of a pneumatic cuff placed around the upper arm . The blood pressure cuff was inflated to 250 mm Hg for 5 minutes . After release of the cuff , brachial artery diameter was measured within the first 15 seconds of reactive hyperemia . The brachial artery was allowed to return to the baseline level until 10 minutes after cuff release . Then , a further baseline brachial artery diameter was obtained . Nitroglycerin , 0.6 mg , was then given sublingually , and the brachial artery diameter was measured for the ensuing 3 minutes . The percent change in diameter caused by reactive hyperemia was calculated by dividing the difference from baseline end-diastolic diameter by the baseline value . The percent change in diameter caused by nitroglycerin administration was also calculated in the same way . Blood pressure and heart rate were measured before the examination . All data were calculated as an average of 4 consecutive cardiac cycles . Early morning blood sampling for fasting lipid profiles was performed and plasma-free testosterone levels were obtained immediately before ultrasound imaging and 12 weeks later . A st and ard radioimmunoassay method was used for analysis ( DSL-4900 kit , Diagnostic System Laboratory Inc. , Houston , Texas ) . All descriptive data are presented as mean SD and analyzed using SPSS for Windows 9.0 ( SPSS Inc. , Chicago , Illinois ) From the Cardiology Division , Yonsei Cardiovascular Center and Cardiovascular Research Institute , College of Medicine , Seoul ; and Department of Food and Nutrition , College of Ecology , Yonsei University , Seoul , South Korea . Dr. Jang ’s address is : Cardiology Division , Yonsei Cardiovascular Center , Yonsei University College of Medicine , 134 , Shinchon-Dong , Seodaemun-Gu , Seoul 120 - 752 , South Korea . E-mail : jangys1212@yumc.yonsei.ac.kr . Manuscript received August 10 , 2001 ; revised manuscript received and accepted December 10 , 2001 . TABLE 1 Clinical Characteristics of Study OBJECTIVES The purpose of this study was to determine the prognostic accuracy of electron beam computed tomographic ( CT ) scanning of the coronary arteries and the relationship of coronary calcification to st and ard coronary disease risk factors and C-reactive protein ( CRP ) in the prediction of atherosclerotic cardiovascular disease ( ASCVD ) events in apparently healthy middle-age persons . BACKGROUND As a screening test for coronary artery disease ( CAD ) , electron beam CT scanning remains controversial . METHODS In a prospect i ve , population -based study , 4,903 asymptomatic persons age 50 to 70 years underwent  electron beam CT scanning of the coronary arteries . RESULTS At 4.3 years , follow-up was available in 4,613 participants ( 94 % ) , and 119 had sustained at least one ASCVD event . Subjects with ASCVD events had higher baseline coronary calcium scores ( median [ interquartile range ] , Agatston method ) than those without events : 384 ( 127 , 800 ) versus 10 ( 0 , 86 ) ( p < 0.0001 ) . For coronary calcium score threshold > or = 100 versus < 100 , relative risk ( 95 % confidence interval ) was 9.6 ( 6.7 to 13.9 ) for all ASCVD events , 11.1 ( 7.3 to 16.7 ) for all CAD events , and 9.2 ( 4.9 to 17.3 ) for non-fatal myocardial infa rct ion and death . The coronary calcium score predicted CAD events independently of st and ard risk factors and CRP ( p = 0.004 ) , was superior to the Framingham risk index in the prediction of events ( area under the receiver-operating characteristic curve of 0.79 + /- 0.03 vs. 0.69 + /- 0.03 , p = 0.0006 ) , and enhanced stratification of those falling into the Framingham categories of low , intermediate , and high risk ( p < 0.0001 ) . CONCLUSIONS The electron beam CT coronary calcium score predicts CAD events independent of st and ard risk factors , more accurately than st and ard risk factors and CRP , and refines Framingham risk stratification Background : Cardiovascular diseases have the highest death rates in human society . Coronary artery disease is among the most important of these diseases . No treatment of cardiovascular disease has as much impact on the quality of life of the patients as the heart surgery . The recovery from heart surgery is associated with symptoms of pain and psychological distress . In the early recovery period , the patients will face moderate symptoms of anxiety and depression . In this regard , various measures of nursing , as complementary therapy practice s have been performed to help the patients for overcoming the physical and psychological needs . One of these methods , in recent years has been the use of complementary and alternative therapies , particularly massage therapy , after heart surgery . Thus , the aim of this study was to determine the effectiveness of massage therapy on the mood of patients after open-heart surgery in Isfahan Chamran Hospital during 2010 - 11 . Material s and Methods : In this study 72 patients , who underwent coronary artery bypass surgery , were selected . They were r and omly assigned to the two case and control groups . The patients of the case group ( n = 36 ) received Swedish massage for 20 minutes in 4 sessions in 4 consecutive days , 3 to 6 days after the open-heart surgery . The patients in the control group received only the routine care . The mood question naire ( POMS ) which was used in this study has been completed the day before the start of the study and intervention and again after the last day of the intervention . SPSS software version 12 and descriptive and inferential statistical methods were used for data analysis . Findings : The comparison of study results showed that massage decreased the overall rating of the patients ’ mood after the surgery . Conclusions : The use of massage therapy as an effective nursing intervention can improve the patients ’ mood after open-heart surgery . Due to the low cost and simplicity of this method , it can perhaps be used as a complement to drug therapy and postoperative interventions used in these patients Clinical trial evidence exists that supports a role for the omega-3 polyunsaturated fatty acids in coronary heart disease prevention . However , the results from these clinical trials have varied and were conducted in diverse population groups using several different types of omega-3 polyunsaturated fatty acids , including eicosapentaenoic acid , docosahexaenoic acid , and alpha-linolenic acid ( ALA ) . Thus , we systematic ally review ed previously published reports assessing the different types of omega-3 polyunsaturated fatty acid interventions and cardiovascular outcomes . Fourteen r and omized clinical trials were included in the review . Six trials were included with fish oil , with 1 large trial ( 10,000 patients ) dominating the analysis . In aggregate , the fish oil trials demonstrated a reduction in total mortality and sudden death without a clinical ly significant reduction in nonfatal myocardial infa rct ion . The 6 trials with ALA supplements or an ALA-enriched diet were of poorer design than the fish oil trials and had limited power . Many of the trials with ALA involved other changes in dietary components . In aggregate , the ALA trials demonstrated possible benefits in reducing sudden death and nonfatal myocardial infa rct ion , but with wider confidence intervals than in the fish oil trials . In conclusion , the evidence suggests a role for fish oil ( eicosapentaenoic acid , docosahexaenoic acid ) or fish in secondary prevention because recent clinical trial data have demonstrated a significant reduction in total mortality , coronary heart disease death , and sudden death . The data on ALA have been limited by studies of smaller sample size and limited quality OBJECTIVES The aim of this study was to assess the predictive value of the cardiac hormone B-type natriuretic peptide ( BNP ) for long-term outcome in a large cohort of stable angina patients . BACKGROUND Recent data suggest a role of BNP in stable ischemic heart disease beyond its known value in heart failure and acute coronary syndromes . METHODS In 1,085 patients with coronary artery disease ( CAD ) baseline levels of BNP were prospect ively associated with cardiovascular ( CV ) events during a mean follow-up of 2.5 years . RESULTS  BNP concentrations were significantly elevated in patients with future CV events ( median [ 25th/75th interquartile range ] 119.2 [ 43.6/300.4 ] pg/ml vs. 36.2 [ 11.3/94.6 ] pg/ml ; p < 0.001 ) . Kaplan-Meier survival analysis showed a stepwise decrease in event-free survival across quartiles of BNP baseline concentration ( p(log rank ) < 0.001 ) . Patients in the highest quartile revealed a 6.1-fold increased risk ( p = 0.001 ) compared to patients in the lowest quartile after adjustment for potential confounders . For a cut-off value of 100 pg/ml , an independently increased risk of adverse outcome ( hazard ratio [ HR ] 4.4 ; p < 0.001 ) could be demonstrated . One st and ard deviation ( SD ) decrease in ejection fraction implied the most prominent increase in risk of future CV events ( HR 1.69 ; p < 0.001 ) followed by one SD increase in BNP ( HR 1.53 ; p < 0.001 ) . The highest prognostic accuracy could be demonstrated for BNP ( area under the curve 0.671 ) . CONCLUSIONS The data of this large group of CAD patients provide independent evidence that BNP is a strong predictor of cardiovascular risk  in patients with stable angina independent of left ventricular systolic performance and known risk factors Background Cardiovascular disease is the leading cause of death for adults in Australia . In recent years there has been a shift in health service delivery from institutional to community‐based care for chronic conditions , including cardiovascular disease . The general practice setting is seen to offer greater flexibility , higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector . It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management . To date , significant descriptive research has been conducted exploring the demographics , roles , educational needs and issues facing practice nurses . However , there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes , clinician satisfaction and cost‐effectiveness . Objectives This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults , as well as those with established cardiovascular disease or known cardiac risk factors . Search Strategy A systematic literature search was performed using Medline ( 1966 ‐ 2005 ) , CINAHL ( 1982 −2005 ) , Cochrane Controlled Trials Register ( Issue 4 , 2005 ) and the Joanna Briggs Institute Evidence Library . In addition , the reference lists of retrieved papers , conference proceedings and the Internet , were scrutinised for additional trials . Selection Criteria This review considered any English language r and omised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors . Interventions conducted by specialist cardiac nurses in general practice were excluded . Outcomes measured included blood pressure , smoking cessation , total cholesterol , exercise , body weight/body mass index and cost‐effectiveness . Results Eighteen trials , reported in 33 papers , were included in the review . Ten trials investigated multifaceted interventions , while the remaining eight trials reported targeted interventions . Of the trials that reported multifaceted interventions , three trials investigated risk reduction in those with established cardiovascular disease , four trials focused on those with known cardiovascular disease risk factors and three trials included the general community . The eight trials which examined the efficacy of targeted interventions focused upon dietary intake ( two trials ) , smoking cessation ( three trials ) , weight reduction ( one trial ) and physical activity ( two trials ) . The effect of both the multifaceted and targeted interventions on patient outcomes was variable . However , both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables . Improvements were demonstrated by most studies in blood pressure , cholesterol level , dietary intake and physical activity . The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions . Conclusions While interventions to reduce cardiovascular disease risk factors have produced variable results , they offer significant potential to assist patients in modifying their personal risk profile and should be developed . The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals . Further well‐ design ed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost‐effectiveness BACKGROUND Exercise-based cardiac rehabilitation is considered an important adjunct treatment and secondary prevention measure in patients with coronary artery disease ( CAD ) . However , the issues of training modality and exercise intensity for CAD patients remain controversial . OBJECTIVE Main aim of the present study is to test the hypothesis that aerobic interval training ( AIT ) yields a larger gain in peak aerobic capacity ( peakVO2 ) compared to a similar training programme of moderate continuous training ( MCT ) in CAD patients . STUDY DESIGN In this multicentre study stable CAD patients with left ventricular ejection fraction>40 % will be r and omized after recent myocardial infa rct ion or revascularization ( PCI or CABG ) to a supervised 12-week programme of three weekly sessions of either AIT ( 85 - 90 % of peak oxygen uptake [ peakVO2 ] , 90 - 95 % of peak heart rate ) or MCT ( 60 - 70 % of peakVO2 , 65 - 75 % of peak heart rate ) . The primary endpoint of the study is the change of peakVO2 after 12 weeks training . Secondary endpoints include safety , changes in peripheral endothelial vascular function , the evolution of traditional cardiovascular risk factors , quality of life and the number and function of circulating endothelial progenitor cells as well as endothelial microparticles . Possible differences in terms of long-term adherence to prescribed exercise regimens will be assessed by regular physical activity question naires , accelerometry and re assessment of peakVO2 12 months after r and omization . A total number of 200 patients will be r and omized in a 1:1 manner ( significance level of 0.05 and statistical power of 0.90 ) . Enrolment started December 2010 ; last enrolment is expected for February 2013 AIMS An increasing number of patients with severe coronary artery disease ( CAD ) are not c and i date s for traditional revascularization and experience angina in spite of excellent medical therapy . Despite limited data regarding the natural history and predictors of adverse outcome , these patients have been considered at high risk for early mortality . METHODS AND RESULTS The OPtions In Myocardial Ischemic Syndrome Therapy ( OPTIMIST ) program at the Minneapolis Heart Institute offers traditional and investigational therapies for patients with refractory angina . A prospect i ve clinical data base includes detailed baseline and yearly follow-up information . Death status and cause were determined using the Social Security Death Index , clinical data , and death certificates . Time to death was analysed using survival analysis methods . For 1200 patients , the mean age was 63.5 years ( 77.5 % male ) with 72.4 % having prior coronary artery bypass grafting , 74.4 % prior percutaneous coronary intervention , 72.6 % prior myocardial infa rct ion , 78.3 % 3-vessel CAD , 23.0 % moderate-to-severe left-ventricular ( LV ) dysfunction , and 32.6 % congestive heart failure ( CHF ) . Overall , 241 patients died  ( 20.1 % : 71.8 % cardiovascular ) during a median follow-up 5.1 years ( range 0 - 16 , 14.7 % over 9 ) . By Kaplan-Meier analysis , mortality was 3.9 % ( 95 % CI 2.8 - 5.0 ) at 1 year and 28.4 % ( 95 % CI 24.9 - 32.0 ) at 9 years . Multivariate predictors of all-cause mortality were baseline age , diabetes , angina class , chronic kidney disease , LV dysfunction , and CHF . CONCLUSION Long-term mortality in patients with refractory angina is lower than previously reported . Therapeutic options for this distinct and growing group of patients should focus on angina relief and improved quality of life BACKGROUND Among patients with coronary artery disease ( CAD ) , improvement of lifestyle-related risk factors ( LRFs ) reduces cardiovascular morbidity and mortality . However , modification of LRFs is highly challenging . OBJECTIVES This study sought to evaluate the impact of combining community-based lifestyle programs with regular hospital-based secondary prevention . METHODS The authors performed a r and omized controlled trial of nurse-coordinated referral of patients and their partners to 3 widely available community-based lifestyle programs , in 15 hospitals in the Netherl and s. Patients admitted for acute coronary syndrome and /or revascularization , with ≥1 LRF ( body mass index > 27 kg/m2 , self-reported physical inactivity , and /or smoking ) were included . All patients received guideline -based usual care . The intervention was based on 3 lifestyle programs for weight reduction , increasing physical activity , and smoking cessation . The primary outcome was the proportion of success at 12 months , defined as improvement in ≥1 qualifying LRF using weight ( ≥5 % reduction ) , 6-min-walking distance ( ≥10 % improvement ) , and urinary cotinine ( 200 ng/ml detection limit ) without deterioration in the other 2 . RESULTS The authors r and omized 824 patients . Complete data on the primary outcome were available in 711 patients .  The proportion of successful patients in the intervention group was 37 % ( 133 of 360 ) compared with 26 % ( 91 of 351 ) in the control group ( p = 0.002 ; risk ratio : 1.43 ; 95 % confidence interval : 1.14 to 1.78 ) . In the intervention group , partner participation was associated with a significantly greater success rate ( 46 % vs. 34 % ; p = 0.03 ) . CONCLUSIONS Among patients with coronary artery disease , nurse-coordinated referral to a comprehensive set of community-based , widely available lifestyle interventions , with optional partner participation , leads to significant improvements in LRFs . ( RESPONSE-2 : R and omised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 ; NTR3937 ) OBJECTIVE To assess the effects of metoprolol on perioperative cardiovascular events in patients with risk or at high risk for coronary artery disease ( CAD ) who were to undergo non-cardiac surgery . METHODS 102 patients with definite CAD or at high risk for CAD who were to undergo selective non-cardiac surgery were r and omized to 2 equal groups : Group A ( blank control group ) and Group B given metoprolol orally or intravenously from 2 h before surgery to 30 days after surgery . The dosage of metoprolol was adjusted according to the blood pressure and heart rate . The changes of peri-operative heart rate ( HR ) , level of creatine kinase (CK)-MB , cardiac events such as unstable angina pectoris ( UAP ) and myocardial infa rct ion ( MI ) , death , and stroke were recorded . RESULTS The HR values , intra-operative and 6 h , 1 d , and 2 d after operation of Group B were all significantly lower than those of Group A ( all P < 0.05 ) . One patient from each group had MI . One case of death and two cases of strokes occurred in Group A. The occurrence rate of at least one cardiovascular event were 9.8 % in Group A ( 5/51 ) and 2.0 % in Group B ( 1/51 ) without significant difference between these 2 groups ( P > 0.05 ) . CONCLUSIONS Metoprolol reduces the incidence of postoperative severe cardiovascular episodes in patients with risk of or at high risk for CAD undergoing non-cardiac surgery Background In rats , low-frequency electroneuro-stimulation ( ENS ) of the ear afferent vagus endings and bramstem structures via transauricular electro-acupuncture increases the parasympathetic tone of the autonomic nervous system . We examined the effects of ENS applied in the preoperative period in patients with coronary artery disease ( CAD ) who underwent coronary artery bypass grafting operations Methods ENS was performed in a group of 10 patients with CAD who were classified as Canadian Cardiovascular Society class IV before operation . A second group of 10 patients with a similar degree of CAD compnsed a control group . The efficacy of the procedure was evaluated on the basis of improvement in the patient 's clinical course before and after operation . The presence of major inducible stress protein ( HSP 70i ) and the ATP content of the myocardium was determined in atrial tissue ( part of the right heart auricle ) from both groups of patients . Tissue from patients with Wolff-Parkinson-White ( WPW ) syndrome served as a control , non-ischemic , cardiac tissue . Results A course of 10 ENS procedures improved the patients ' preoperative clinical course , producing a rapid reduction in their angina . By the end of the course , the patients no longer developed angina either at rest or after a moderate physical load , and their dependence on treatment with vasodilators had decreased considerably . Atnal tissue from patients with CAD who were treated with ENS was similar to that from patients with WPW in leaking HSP 70i and in ATP content . In contrast , tissue from the control group of patients with CAD contained HSP 70i and had an increased content of ATP . The antianginal effect of neurostimulation lasted for at least 2–3 weeks after completion of the procedures . The postoperative recovery of patients treated with ENS was characterized by stable hemodynamics and sinus rhythm . Conclusion We conclude that ENS had a central vagotonic/sympatholytic influence on the heart , leading to the development of three main effects in patients with CAD : relief of anginal symptoms , diminution of some biochemical myocardial signs of the disease , and an increase in the heart 's tolerance of operative reperfusion damage This article is the first of two papers about the care of patients with chronic stable angina . The second paper , which deals with the treatment of patients with chronic stable angina , will be published in a future issue . Both articles have been adapted from material s created by the Committee on Guidelines for Chronic Stable Angina sponsored by the American College of Cardiology ( ACC ) , the American Heart Association ( AHA ) , and the American College of PhysiciansAmerican Society of Internal Medicine ( ACPASIM ) ( 1 - 3 ) . The adaptations in these articles are intended to make the information more useful for clinicians who do not specialize in the care of patients with heart disease . The committee created the original material s after review ing published reports identified in part through MEDLINE search es of the English literature from 1975 through 1998 . The weight of the evidence was ranked high and given a grade of A if the data were derived from multiple r and omized clinical trials involving many patients . The weight of the evidence was ranked intermediate and given a grade of B if the data were derived from a few r and omized trials involving small numbers of patients , nonr and omized studies , or observational registries . A lower rank and a grade of C were given when an expert consensus was the primary basis for the recommendation . We used the following classification system for final recommendations . Class I referred to conditions for which there is evidence or general agreement that a given procedure or treatment is useful and effective ; class II referred to conditions for which there is conflicting evidence or a divergence of opinion about the usefulness or efficacy of a procedure or treatment ; class IIa referred to conditions for which the weight of evidence or opinion is in favor of usefulness or efficacy of a procedure or treatment ; class IIb referred to conditions for which usefulness or efficacy of a procedure or treatment is less well established by evidence or opinion ; and class III referred to conditions for which there is evidence or general agreement that the procedure or treatment is not useful or effective and in some cases may be harmful . For the sake of brevity , we have combined some original recommendations and omitted others , especially those that affect fewer patients , are based on weaker evidence , or recommend that interventions not be done . Scope of the Guidelines These recommendations are intended for adult patients with stable chest pain syndromes and known or suspected ischemic heart disease and patients who have ischemic equivalents , such as dyspnea or arm pain with exertion . Also , some recommendations about follow-up apply to patients who become asymptomatic during therapy . These guidelines are not intended for patients with acute ischemic syndromes , patients with chest pain after cardiac transplantation , patients with chest pain within 6 months of revascularization by percutaneous techniques or coronary artery bypass grafting ( CABG ) , patients with coronary artery disease ( CAD ) detected without symptoms , patients with nonanginal chest pain , or pediatric patients . The Initial Evaluation The initial evaluation of patients presenting with chest pain includes a detailed history , a focused physical examination , and performance of a few tests and procedures that are useful for estimating the probability of significant CAD ( Figure 1 ) . Significant CAD is defined as an obstruction of at least one major epicardial artery that occupies at least 70 % of the artery 's cross-sectional diameter or an obstruction of the left main coronary artery that occupies at least 50 % of its diameter . Figure 1 . Diagnosis of chest pain . Comorbid conditions and patient preferences . The history should elicit specific information about chest pain because accurate characterization helps determine whether CAD is the cause of angina . Angina usually occurs in patients with CAD , but it can occur in patients with unobstructed coronary arteries who have myocardial ischemia related to an arterial spasm or endothelial dysfunction . It also can occur in patients with other cardiovascular problems , such as aortic stenosis , hypertrophic cardiomyopathy , or uncontrolled hypertension . Symptoms that mimic angina can also occur in patients with noncardiac conditions involving the chest wall , esophagus , or lung . The following characteristics of chest pain should be determined : quality , location , duration , and the presence of factors that provoke and relieve the pain . Angina is characterized by a substernal pain or discomfort , although it may radiate to the neck , jaw , epigastrium , or arms . Patients often describe the quality of angina with characteristic terms , such as squeezing , grip-like , pressure-like , suffocating , or heavy . Angina usually lasts for minutes . Exertion or emotional stress provokes it , and rest or nitroglycerin relieves it , typically within 30 seconds to several minutes . After the history is obtained , the clinician should classify the chest pain . Typical angina has the following characteristics : 1 ) substernal chest discomfort with a characteristic quality and duration that is 2 ) provoked by exertion or emotional stress and 3 ) relieved by rest or nitroglycerin . Atypical angina has two of the three characteristics of typical angina , while noncardiac chest pain has one or none of the characteristics of typical angina . The term noncardiac chest pain means that the probability of CAD is low . The term nonspecific chest pain more accurately describes this situation , but tradition prevents its use . In patients with angina , the severity of pain should be grade d according to the Canadian Cardiovascular Society ( CCS ) classification system ( Table 1 ) ( 6 ) . Although grading chest pain is less useful for establishing a diagnosis or estimating risk , it is essential for evaluating the effects of therapy . Table 1 . Grading of Angina by the Canadian Cardiovascular Society Classification System In patients with angina , the stability of pain should be assessed . Patients have unstable angina if the pain started recently ; is more easily provoked ; or occurs with increased frequency , severity , or duration ( 7 ) . Some patients with unstable angina have a measurable risk for short-term death ( 8) . Those characterized as high risk have a 1.7 % probability of dying within 30 days , and those characterized as moderate risk have a 1.2 % probability . These patients have  pain at rest , nocturnal pain , signs or symptoms of heart failure , or new or ischemic changes on resting electrocardiography  ( ECG ) . They should be evaluated in the inpatient setting . However , patients with unstable angina whose pain has been present for at least 2 weeks and who lack any of angina 's more worrisome clinical features , including ECG changes , can be evaluated in an outpatient setting because their probability of death or myocardial infa rct ion within 30 days is indistinguishable from zero . The initial history should also include information about the risk factors for CAD , such as smoking , hyperlipidemia , diabetes , hypertension , and a family history of premature CAD . Findings on physical examination are often normal in patients with stable angina ( 9 ) . During an episode of pain , however , there uncommonly may be an S4 or S3 gallop , a mitral regurgitant murmur , a paradoxically split S2 , bibasilar rales , or a chest wall heave . Each of these findings makes CAD more likely , especially if the finding disappears when the pain goes away ( 10 ) . Evidence of noncoronary atherosclerotic disease , such as a carotid bruit , diminished pedal pulses , or an abdominal aneurysm , increases the likelihood of CAD . Elevated blood pressure , xanthomas , and retinal exu date s identify CAD risk factors . Table 2 lists recommendations for the tests and procedures that we believe should be used in the initial evaluation of patients with suspected chronic stable angina .  Resting , 12-lead ECG should be performed , although the results will be normal in 50 % of patients with chronic stable angina ( 11 ) . Therefore , results on normal resting ECG do not exclude CAD . Evidence on ECG of left ventricular hypertrophy or ST T-wave changes consistent with myocardial ischemia favor the diagnosis of angina ( 12 ) . The presence of arrhythmias , such as atrial fibrillation or ventricular tachyarrhythmias , also increases the probability of CAD , but other types of cardiac disease frequently cause these arrhythmias . Q waves suggesting a previous myocardial infa rct ion make CAD very likely , although an isolated Q wave in lead III or a QS pattern in lead V1 and V2 is often nonspecific . Atrioventricular block may suggest multivessel CAD but is also nonspecific . Table 2 . Recommendations for Initial Laboratory Tests , Electrocardiography , and Chest Radiography for the Diagnosis of Chronic Stable Angina Results on ECG performed during chest pain are abnormal in approximately 50 % of patients with angina who have normal results on resting ECG .  Sinus tachycardia occurs commonly ; bradyarrhythmias are less common . ST T-wave depression or inversion on resting ECG or pseudo-normalization of these abnormalities during pain is another indicator of CAD ( 13 ) . Tachyarrhythmias , atrioventricular blocks , left anterior fascicular block , or bundle-branch block occurring with chest pain also increases the probability of coronary heart disease . ST-segment elevation or depression also increases the probability of CAD , and it increases the risk for myocardial infa rct ion or death because there is ischemia at a low workload . Results of  chest radiography  are often normal in patients with stable angina , and its usefulness as a routine test is not well established . Ultra-fast electron-beam computed tomography is now frequently used to detect coronary artery calcification , which is a sensitive indicator of coronary stenosis ( 14 ) . However , the specificity of electron-beam computed tomography is in the range of 41 % to 76 % , which means that many results are false positive . Moreover , the BACKGROUND Patients ( pts ) with stable coronary artery disease ( CAD ) can benefit from a decrease in the blood pressure ( BP ) , according to recent studies . OBJECTIVE To evaluate the efficacy and tolerability of the fixed combination : amlodipine + enalapril , when compared to amlodipine in the normalization of the diastolic arterial pressure ( DAP ) ( < 85 mmHg ) , in pts with CAD and systemic arterial hypertension ( SAH ) . METHODS Double-blind and r and omized study , with two groups of pts with DAP > or = 90 and < 110 mmHg and CAD . Patients with left ventricular ejection fraction ( LVEF ) < 40 % , symptoms of heart failure or angina class III and IV , severe diseases and DAP > or = 110 mmHg during the four-week wash-out with atenolol treatment alone , were excluded . After the wash-out , pts were r and omly distributed for the use of the combination ( A ) or amlodipine ( B ) and were followed every four weeks up to 98 days . The initial doses ( in mg ) were , respectively : A- 2.5/10 and B- 2.5 ; the doses were increased when DAP > 85mmHg , at the visits . Statistical analysis was carried out with chi2 , Fischer and analysis of variance , for p < 0.05 . RESULTS Of the 110 selected pts , 72 ( A= 32 , B= 40 ) were r and omized . The decreases in DAP and systolic arterial pressure ( SAP ) were significant ( p < 0.01 ) , but with no difference between the groups in mmHg : SAP , A ( 127.7 + /- 13.4 ) and B ( 125.3 + /- 12.6 ) ( p= 0.45 ) and DAP , A ( 74.5 + /- 6.7 mmHg ) and B ( 75.5 + /- 6.7 mmHg ) ( p= 0.32 ) . Group A presented a lower incidence of lower-limb edema : ( 7.1 % vs 30.6 % , p=0.02 ) on the 98th day of follow-up . CONCLUSION The fixed combination of enalapril and amlodipine , as well as isolated amlodipine , was effective in the normalization of BP in pts with CAD and SAH stages I and II , adding blockage of the renin-angiotensin system BACKGROUND Cardiac computed tomographic angiography ( CTA ) provides for accurate noninvasive diagnosis of coronary artery disease ( CAD ) . OBJECTIVES We analyzed the clinical outcomes over 40 months in patients with and without CAD as determined by CTA in an outpatient setting . METHODS Consecutive symptomatic patients ( n = 493 ; mean age , 58 + /- 15 years ; 70 % men ) with an intermediate likelihood of CAD referred for outpatient CTA evaluation were prospect ively followed for a mean of 40 + /- 9 months . RESULTS Results of CTA included as normal ( defined as normal coronary lumen ) , found in 32 % ( 157 ) , nonobstructive disease ( < 50 % luminal stenosis ) in 41 % ( 204 ) , obstructive disease ( > or=50 % luminal stenosis ) in 19 % ( 93 ) . Eight percent ( n = 39 ) had > or=1 major nondiagnostic coronary artery segment . Follow-up identified 21 patients with myocardial infa rct ion ( MI ) in the significant obstructive CAD and nondiagnostic group . No patients with either normal coronary arteries or nonobstructive disease experienced an MI during follow-up . The 40-month event-free survival was 100 % for both the normal and nonobstructive disease groups , 97.5 % for the nondiagnostic study group , and 79 % for the group with obstructive CAD . After adjustment for age , sex , diabetes mellitus , hypertension , hypercholesterolemia , and baseline coronary artery calcium ( CAC ) , a stepwise multivariable model ( Cox regression ) showed that obstructive CAD was an independent predictor of cardiac events and had significant incremental value over clinical risk factors and CAC ( HR = 16.6 ; 95 % CI , 4.9 - 55.2 ; P = 0.0001 ) . CONCLUSION In symptomatic patients with an intermediate likelihood of CAD referred for CTA , normal coronary arteries or nonobstructive CAD portends an excellent prognosis . The finding of obstructive CAD identifies patients at higher risk of subsequent MI , independent of cardiovascular risk factors and coronary artery calcium RATIONALE Obstructive sleep apnea ( OSA ) is common in patients with coronary artery disease ( CAD ) , many of whom do not report daytime sleepiness . First-line treatment for symptomatic OSA is continuous positive airway pressure ( CPAP ) , but its value in patients without daytime sleepiness is uncertain . OBJECTIVES To determine the effects of CPAP on long-term adverse cardiovascular outcome risk in patients with CAD with nonsleepy OSA . METHODS This single-center , prospect i ve , r and omized , controlled , open-label , blinded evaluation trial was conducted between December 2005 and November 2010 . Consecutive patients with newly revascularized CAD and OSA ( apnea-hypopnea index ≥15/h ) without daytime sleepiness ( Epworth Sleepiness Scale score < 10 ) were r and omized to auto-titrating CPAP ( n = 122 ) or no positive airway pressure ( n = 122 ) . MEASUREMENTS AND MAIN RESULTS The primary endpoint was the first event of repeat revascularization , myocardial infa rct ion , stroke , or cardiovascular mortality . Median follow-up was 57 months . The incidence of the primary endpoint did not differ significantly in patients who did versus did not receive CPAP ( 18.1 % vs. 22.1 % ; hazard ratio , 0.80 ; 95 % confidence interval , 0.46 - 1.41 ; P = 0.449 ) . Adjusted on-treatment analysis showed a significant cardiovascular risk reduction in those who used CPAP for ≥4 versus < 4 hours per night or did not receive treatment ( hazard ratio , 0.29 ; 95 % confidence interval , 0.10 - 0.86 ; P = 0.026 ) . CONCLUSIONS Routine prescription of CPAP to patients with CAD with nonsleepy OSA did not significantly reduce long-term adverse cardiovascular outcomes in the intention-to-treat population . There was a significant reduction after adjustment for baseline comorbidities and compliance with the treatment . Clinical trial registered with www . clinical trials.gov ( NCT 00519597 ) OBJECTIVES The purpose of this study was to prospect ively evaluate the diagnostic performance of 3.0-T contrast-enhanced whole-heart coronary magnetic resonance angiography ( CMRA ) in patients with suspected coronary artery disease ( CAD ) . BACKGROUND A slow-infusion , contrast-enhanced whole-heart CMRA approach has recently been developed at 3.0-T. The accuracy of this technique has not yet been determined among patients with suspected CAD . METHODS The 3.0-T contrast-enhanced whole-heart CMRA was performed in 69 consecutive patients . An electrocardiography-triggered , navigator-gated , inversion-recovery prepared , segmented gradient-echo sequence was used to acquire isotropic whole-heart CMRA with slow infusion of 0.2 mmol/kg gadobenate dimeglumine . The diagnostic accuracy of whole-heart CMRA in detecting significant stenoses ( > or = 50 % ) was evaluated using X-ray angiography as the reference . RESULTS The CMRA examinations were successfully completed in 62 patients .  Acquisition time of whole-heart CMRA procedure was 9.0 + /- 1.9 min . The 3.0-T whole-heart CMRA correctly identified significant CAD in 32 patients and correctly ruled out CAD in 23 patients . The sensitivity , specificity , and accuracy of whole-heart CMRA for detecting significant stenoses were 91.6 % ( 87 of 95 ) , 83.1 % ( 570 of 686 ) , and 84.1 % ( 657 of 781 ) , respectively , on a per-segment basis . These values were 94.1 % ( 32 of 34 ) , 82.1 % ( 23 of 28 ) , and 88.7 % ( 55 of 62 ) , respectively , on a per-patient basis . CONCLUSIONS Contrast-enhanced whole-heart CMRA with 3.0-T allows for the accurate detection of coronary artery stenosis with high sensitivity and moderate specificity BACKGROUND An elevated heart rate is an established marker of cardiovascular risk . Previous analyses have suggested that ivabradine , a heart-rate-reducing agent , may improve outcomes in patients with stable coronary artery disease , left ventricular dysfunction , and a heart rate of 70 beats per minute or more . METHODS We conducted a r and omized , double-blind , placebo-controlled trial of ivabradine , added to st and ard background therapy , in 19,102 patients who had both stable coronary artery disease without clinical heart failure and a heart rate of 70 beats per minute or more ( including 12,049 patients with activity-limiting angina [ class ≥II on the Canadian Cardiovascular Society scale , which ranges from I to IV , with higher classes indicating greater limitations on physical activity owing to angina ] ) . We r and omly assigned patients to placebo or ivabradine , at a dose of up to 10 mg twice daily , with the dose adjusted to achieve a target heart rate of 55 to 60 beats per minute . The primary end point was a composite of death from cardiovascular causes or nonfatal myocardial infa rct ion . RESULTS At 3 months , the mean ( ±SD ) heart rate of the patients was 60.7±9.0 beats per minute in the ivabradine group versus 70.6±10.1 beats per minute in the placebo group . After a median follow-up of 27.8 months , there was no significant difference between the ivabradine group and the placebo group in the incidence of the primary end point ( 6.8 % and 6.4 % , respectively ; hazard ratio , 1.08 ; 95 % confidence interval , 0.96 to 1.20 ; P=0.20 ) , nor were there significant differences in the incidences of death from cardiovascular causes and nonfatal myocardial infa rct ion . Ivabradine was associated with an increase in the incidence of the primary end point among patients with activity-limiting angina but not among those without activity-limiting angina ( P=0.02 for interaction ) . The incidence of bradycardia was higher with ivabradine than with placebo ( 18.0 % vs. 2.3 % , P<0.001 ) . CONCLUSIONS Among patients who had stable coronary artery disease without clinical heart failure , the addition of ivabradine to st and ard background therapy to reduce the heart rate did not improve outcomes . ( Funded by Servier ; SIGNIFY Current Controlled Trials number , IS RCT N61576291 . ) Coronary artery bypass grafting (CABG)-related bleeding complications and perioperative coronary events are strongly influenced by the management of antithrombotic therapy before and after CABG . Bleeding but also blood products transfusion increase the risk of death and compromise the long-term benefits of CABG.1 The use of new P2Y12 inhibitors , increasing pre-CABG percutaneous coronary interventions ( PCI ) with drug eluting stents ( DES ) requiring specific antiplatelet regimens , and advances in surgical technique has prompted the ESC Working Group on Cardiovascular Surgery and the ESC Working Group on Thrombosis to review the evidence of peri-CABG recommendations on antithrombotic management . Due to the paucity of r and omized trials , most of the evidence is still derived from observational studies and expert consensus , further reinforcing the importance of a multidisciplinary consultation for optimal decision making . # # # Benefits of preoperative aspirin Aspirin ( acetylsalicylic acid , ASA ) is recommended as secondary prevention therapy for all patients with proven coronary artery disease ( CAD ) and without contraindications . Its indication is even stronger for post-CABG patients ( recommendation IA).2 The general consensus is that ASA treatment withdrawal has ominous prognostic implication s in patients with CAD , especially in those with intracoronary stents , and should be advocated only when the bleeding risk clearly outweighs that of atherothrombotic events.3 The benefits of continuing ASA until the day of CABG ( ‘ preoperative ASA ’ ) are less clear and may explain the wide variability in the management of ASA therapy in the perioperative period and differences between guidelines endorsed by different professional and scientific societies ( Supplementary material online , Table S1 ) . This was based on the demonstration that ASA started the day before surgery was no more effective than ASA started 6 h after surgery at improving early ( 7- to 10-day ) graft patency , but was associated with increased bleeding complications.4 More recent evidence suggests , however , that ASA use within 5–7 days prior to CABG OBJECTIVE The objective of this study was to evaluate the effect of t'ai chi ( TC ) on heart rate variability ( HRV ) from baseline to 9 months in patients with coronary artery disease ( CAD ) . DESIGN A comparative trial was undertaken comparing the acute and long-term effect of TC on HRV in patients with CAD . PARTICIPANTS Sixty-one ( 61 ) subjects with CAD undergoing percutaneous intervention or coronary bypass grafting for a period of more than 1 month were recruited from the clinics of cardiology and cardiovascular surgery at Chia-Yi Christian Hospital , Taiwan . INTERVENTIONS The experimental group ( n = 22 ) practice d weekly 90-minute Yang 's style TC for 9 months and the control group ( n = 39 ) continued their normal daily physical activity . MAIN OUTCOME MEASURES HRV was recorded at baseline , 3 months , 6 months , and 9 months in the control group . Resting HRV was recorded before TC exercise and recovery HRV was recorded 30 minutes post TC at the same four time points in the experimental group . RESULTS The change in the normalized low-frequency power , normalized high-frequency power , and the low-/high-frequency power ratio between resting and post-TC was significantly different at 9 months when compared with those at baseline , 3 , and 6 months . The mean difference in normalized low-frequency power and the low/high-frequency power ratio changed from positive values at baseline , 3 , and 6 months to negative values at 9 months . However , there were no significant differences in resting HRV between the patients in TC and control groups in either time domain or frequency domain HRV indices . CONCLUSIONS The change in heart rate and HRV between resting and post-TC suggested that TC exercise could enhance vagal modulation . The potential beneficial effect of long-term regular TC exercise in patients with CAD merits further investigation BACKGROUND A number of epidemiological studies have described a positive relationship between serum ferritin levels and coronary heart disease . In this prospect i ve study , we evaluated the association between serum ferritin levels and the angiographic extent of coronary atherosclerosis . METHOD We studied 307 consecutive patients ( 60.9 % male , age 60.1+/-11.0 years ) referred for diagnostic coronary angiography .  Risk factors for coronary artery disease , lipids and ferritin levels , as well clinical characteristics were recorded from all patients . Two experienced cardiologists blinded for clinical and laboratory data review ed the cinefilms . Angiographic significant coronary artery disease ( CAD ) was defined as any more than a 50 % diameter stenosis . RESULTS From the 307 patients , 196 ( 63.8 % ) were found to have angiographic significant CAD . The presence of significant CAD was associated with ferritin levels ( P=0.015 ) as well as patient age ( P<0.001 ) , male sex ( P<0.001 ) , smoking ( P<0.002 ) , and cholesterol levels ( P=0.028 ) . By multivariate analysis , however , ferritin level was not an independent risk factor for CAD ( P=0.27 ) , while the association with all the other factors remained significant . CONCLUSION In patients referred for coronary angiography  no independent relationship was found between angiographic significant coronary artery disease and serum ferritin levels
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 .