Effects of lifestyle modification on coronary artery calcium progression and prognostic factors in coronary patients--3-year results of the randomized SAFE-LIFE trial. Short-term effects of an intensive lifestyle modification program on lipid peroxidation and antioxidant systems in patients with coronary artery disease. Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery Psychological and Quality-of-Life Outcomes from a Comprehensive Stress Reduction and Lifestyle Program in Patients with Coronary Artery Disease: Results of a Randomized Trial Associations of egg and cholesterol intakes with carotid intima-media thickness and risk of incident coronary artery disease according to apolipoprotein E phenotype in men: the Kuopio Ischaemic Heart Disease Risk Factor Study. Effects of intensified lifestyle modification on the need for further revascularization after coronary angioplasty The prevalence of coronary artery disease in an urban population in Isfahan, Iran. Dietary carotenoids and risk of coronary artery disease in women. Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.). Dietary Patterns and Cognitive Health in Older Adults: A Systematic Review. Guidelines for the Management of Patients with Chronic Stable Angina: Diagnosis and Risk Stratification Exercise testing and training in physically disabled men with clinical evidence of coronary artery disease. alpha-Linolenic acid intake is not beneficially associated with 10-y risk of coronary artery disease incidence: the Zutphen Elderly Study. A population-based, longitudinal study of erectile dysfunction and future coronary artery disease. Prognostic value of 64-slice cardiac computed tomography severity of coronary artery disease, coronary atherosclerosis, and left ventricular ejection fraction. Computerized community cholesterol control (4C): meeting the challenge of secondary prevention. Difference in the mortality of the CABRI diabetic and nondiabetic populations and its relation to coronary artery disease and the revascularization mode. The West of Scotland Coronary Prevention Study: a trial of cholesterol reduction in Scottish men. Clinical effectiveness of coronary computed tomographic angiography in the triage of patients to cardiac catheterization and revascularization after inconclusive stress testing: results of a 2-year prospective trial Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease Biofeedback treatment increases heart rate variability in patients with known coronary artery 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). Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Synopsis of the 2013 American College of Cardiology/American Heart Association Cholesterol Guideline Impact of Ethnicity and Gender Differences on Angiographic Coronary Artery Disease Prevalence and In-Hospital Mortality in the American College of Cardiology–National Cardiovascular Data Registry Optimal medical therapy with or without percutaneous coronary intervention in older patients with stable coronary disease: a pre-specified subset analysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial. Exercise training improves conduit vessel function in patients with coronary artery disease. Effect of lifestyle changes on atherogenic lipids and endothelial cell adhesion molecules in young adults with familial premature coronary heart disease. Association of small low-density lipoprotein particles with the incidence of coronary artery disease in men and women.
OBJECTIVE Given the multimodal medical and interventional treatment options in coronary artery disease ( CAD ) , the current value of intensified lifestyle modification remains unclear . No r and omized studies have so far assessed the impact of lifestyle modification on coronary artery calcium ( CAC ) . We examined the long-term effects of a one-year comprehensive lifestyle modification on risk factors and CAC by means of a r and omized clinical trial . METHODS 96 participants ( age range 35 - 75 years , 22 women ) of the SAFE-LIFE r and omized trial in patients with established CAD completed 3-year follow-up . The active treatment was a one-year lifestyle modification and stress reduction intervention ( LG ) , while the control group received written advice only ( AG ) .  CAC ( derived from electron beam tomography ) , blood lipids , heart rate , blood pressure , anginal symptoms and quality -of-life were assessed on entry and at 3-year follow-up . RESULTS Lifestyle modification had no impact on change of CAC after three years ( median progression factor [ 25th,75th percentile ] 1.46 [ 1.16,2.19 ] in LG and 1.41 [ 1.20,1.79 ] in AG ; p=0.68 ) , but led to reductions of blood pressure , heart rate and to dose-reductions in anti-ischemic medications as compared to AG . Multiple regression analysis indicated that in the pooled study population increase of CAC was related to psychosocial factors and heart rate . CONCLUSION In the presence of modern treatments , complementary prescription of comprehensive lifestyle modification has no impact on CAC progression but sustainable benefit for blood pressure , heart rate and the need of anti-ischemic medication is demonstrated . A possible influence of stress reduction measures on CAC progression should be further evaluated The purpose of this study was to compare the short-term effects of an intensive lifestyle modification ( ILM ) program on lipid peroxidation and antioxidant systems in patients with coronary artery disease ( CAD ) . Twenty-two patients in the control group continued to receive their conventional treatment with lipid-lowering drugs , whereas 22 patients in the experimental group were assigned to intensive lifestyle modification ( ILM ) without taking any lipid-lowering agent . The ILM program comprised dietary advice on low-fat diets , high antioxidants and high fiber intakes , yoga exercise , stress management and smoking cessation . After 4 months of intervention , patients in the experimental group revealed a statistically significant increase in plasma total antioxidants , plasma vitamin E and erythrocyte glutathione ( GSH ) compared to patients in the control group . There was no significant change in plasma malondialdehyde ( MDA ) , a circulating product of lipid peroxidation , in either group . We concluded that the ILM program increased circulating antioxidants and reduced oxidative stress in patients with CAD 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 Background : Stress reduction and comprehensive lifestyle modification programs have improved atherosclerosis and cardiac risk factors in earlier trials . Little is known about the impact of such programs on quality -of-life ( QoL ) and psychological outcomes . Given recent significant improvements in cardiac care , we evaluated the current benefit of stress reduction/lifestyle modification on QoL and emotional distress in patients with coronary artery disease ( CAD ) . Methods : 101 patients ( 59.4 ± 8.6 years , 23 female ) with CAD were r and omized to a 1-year lifestyle/stress management program ( n = 48 ) or written advice ( n = 53 ) . QoL and psychological outcomes were assessed with the SF-36 , Beck Depression , Spielberger State/Trait Anxiety , Spielberger State/Trait Anger and Perceived Stress Inventories . Group repeated- measures analyses of variance were performed for all measures . Results : Adherence to the program was excellent ( daily relaxation practice 39 ± 5vs . 5 ± 8 min , respectively ; p < 0.001 ) . Both groups improved comparably in most dimensions of QoL , and significantly greater improvements for the lifestyle group were found for physical function and physical sum score ( p = 0.046 and p = 0.045 ) . Depression , anxiety , anger and perceived stress were reduced similarly in both groups . However , intervention × gender interaction effects revealed greater benefits among women in the lifestyle intervention vs. advice group for depression and anger ( p = 0.025 and p = 0.040 ) , but no effects for men . Conclusions : A comprehensive lifestyle modification and stress management program did not improve psychological outcomes in medically stable CAD patients . The program did appear to confer psychological benefits for women but not men . Further trials should investigate gender-related differences in coronary patient responses to behavioral interventions BACKGROUND In general population s , the effects of dietary cholesterol on blood cholesterol concentrations are modest . However , the relation is stronger in those with an ɛ4 allele in the apolipoprotein E gene ( APOE ) . There is little information on the association between cholesterol intake and the risk of coronary artery disease ( CAD ) among those with the ApoE4 phenotype . OBJECTIVE We investigated the associations of intakes of cholesterol and eggs , a major source of dietary cholesterol , with carotid intima-media thickness and the risk of incident CAD in middle-aged and older men from eastern Finl and . DESIGN The study included 1032 men aged 42 - 60 y in 1984 - 1989 at the baseline examinations of the prospect i ve , population -based Kuopio Ischaemic Heart Disease Risk Factor Study . Data on common carotid artery intima-media thickness ( CCA-IMT ) were available for 846 men .  Dietary intakes were assessed with 4-d food records . Associations with incident CAD and baseline CCA-IMT were analyzed by using Cox regression and ANCOVA , respectively . RESULTS The ApoE4 phenotype was found in 32.5 % of the men . During the average follow-up of 20.8 y , 230 CAD events occurred . Egg or cholesterol intakes  were not associated with the risk of CAD . Each 1 additional egg ( 55 g)/d was associated with a multivariable-adjusted HR of 1.17 ( 95 % CI : 0.85 , 1.61 ) in the ApoE4 noncarriers and an HR of 0.93 ( 95 % CI : 0.50 , 1.72 ) in the ApoE4 carriers ( P-interaction = 0.34 ) . Each 100-mg/d  higher cholesterol intake was associated with an HR of 1.04 ( 95 % CI : 0.89 , 1.22 ) in the ApoE4 noncarriers and an HR of 0.95 ( 95 % CI : 0.73 , 1.25 ) in the ApoE4 carriers ( P-interaction = 0.81 ) . Egg or cholesterol intakes were also not associated with increased CCA-IMT .  CONCLUSION Egg or cholesterol intakes were not associated with increased CAD risk , even in ApoE4 carriers ( i.e. , in highly susceptible individuals ) In patients with coronary artery disease ( CAD ) , a rate of restenosis as high as 50 % is observed after percutaneous transluminal coronary angioplasty ( PTCA ) . Frequently , this results in further revascularization procedures . Lifestyle intervention has been shown to slow the progression of CAD and to reduce cardiovascular events after myocardial infa rct ion . However , no information exists whether such treatment influences the rate of restenosis in patients with CAD . The present study was performed to investigate the effects of an intensified lifestyle intervention on the need for further revascularization procedures in patients with established CAD after successful PTCA OBJECTIVE Cardiovascular diseases , especially coronary artery disease ( CAD ) , are responsible for the highest mortality rate in Iran . This study was conducted to determine the prevalence of CAD in an urban sample in Isfahan by the Minnesota code of a 12-lead resting electrocardiogram ( ECG ) , the  Rose question naire on chest pain and a self-reported previous medical history . METHODS AND RESULTS Among the target sample of 6,470 men and women aged 35 - 79 years who were r and omly selected from 80 r and om clusters in Isfahan , 5,773 subjects ( about 90 % ) have participated . The WHO ( Rose ) question naires ( Q ) on chest pain were completed for all participants and 12-lead ECGs were taken . The overall prevalence of CAD based on the  Rose Q and /or ECG  was 19.4 % ( 95 % CI 18.4 % to 20.4 % ) which was significantly higher among women 21.9 % ( 95 % CI 20.5 % to 23.3 % ) than men 16.0 % ( 95 % CI 14.5 % to 17.5 % ) ( p < 0.05 ) . The prevalence of CAD increased with age in both sexes . The prevalence of definite and possible angina based on the question naire was higher among women compared to men ( p < 0.05 ) , also a greater prevalence of ECG-based possible ischaemia was observed among woman than men ( 12.3 % vs. 7.5 % ) ( p < 0.05 ) . However , definite and possible MI and definite ischaemia based on ECG abnormalities were higher among men than women ( p < 0.05 ) . The total prevalence of symptomatic CAD was 9.3 % and about 22 % of those with symptoms of CAD on Q have some evidence on ECG . The findings also showed that CAD is more common among people with less education , lower income and the unemployed ( p < 0.05 ) . CONCLUSION These findings indicate that there is a high prevalence of CAD among the Iranian population which need more programmes of health promotion and lifestyle changes and further studies to assess the used epidemiological methods for estimating CAD prevalence , especially among women BACKGROUND Numerous studies have shown that higher intakes or higher blood concentrations of carotenes are associated with a lower risk of  coronary artery disease ( CAD ) . Given the null results in trials of beta-carotene supplementation , considerable attention has focused on the potential role of other dietary carotenoids in the prevention of CAD . OBJECTIVE Our objective was to prospect ively examine the relation between dietary intakes of specific carotenoids and risk of CAD in women . DESIGN In 1984 , 73 286 female nurses completed a semiquantitative food-frequency question naire that assessed their consumption of carotenoids and various other nutrients . The women were followed for 12 y for the development of incident CAD ( nonfatal myocardial infa rct ion and fatal CAD ) , and dietary information was up date d in 1986 , 1990 , and 1994 . RESULTS During 12 y of follow-up ( 803 590 person-years ) , we identified 998 incident cases of CAD . After adjustment for age , smoking , and other CAD risk factors , we observed modest but significant inverse associations between the highest quintiles of intake of beta-carotene and alpha-carotene and risk of CAD but no significant relation with intakes of lutein/zeaxanthin , lycopene , or beta-cryptoxanthin .  For women in the highest compared with the respective lowest quintile of intake , the relative risks for beta-carotene and alpha-carotene were 0.74 ( 95 % CI : 0.59 , 0.93 ) and 0.80 ( 95 % CI : 0.65 , 0.99 ) , respectively . The association between the specific carotenoids and CAD risk did not vary significantly by current smoking status . CONCLUSION Higher intakes of foods rich in alpha-carotene or beta-carotene are associated with a reduction in risk of CAD BACKGROUND We evaluated the effectiveness of a low-cost group visit intervention for changing the dietary intake and lipid levels of patients with known coronary artery disease ( CAD ) . METHODS We performed a controlled r and om group assignment trial in 4 community outpatient clinics . The Dietary Intervention and Evaluation Trial r and omized 97 patients with CAD to either a control group that followed the National Cholesterol Education Program 's Step II-III diet plan ( n=48 ) or an experimental group that received meal plans , recipes , and nutritional information during monthly group office sessions ( n=49 ) . Both groups received lipid-lowering medications and were followed-up over 12 months . We assessed dietary intake , fasting lipid profiles , hemoglobin A1C levels , and per member per month ( PMPM ) expense data . RESULTS Food frequency data showed that eating fruits and vegetables and cooking with monounsaturated fat increased significantly in the experimental group compared with the control group at 1 year ( P=.0072 ; P=.0001 ; P=.0004 ) . The total PMPM expenses decreased for both groups ( 38 % for the experimental group and 10 % for the control group ) , but the cost difference was statistically nonsignificant ( P=.2975 ) . Both groups noted low-density lipoprotein reductions , significant only in the experimental group ( P=.0035 ) . CONCLUSIONS Our study suggests that using group office visits for patients with CAD was an effective method for helping subjects make dietary changes and for improving lipid levels .  Patients with known CAD and elevated lipid levels were willing to make significant lifestyle changes when offered a program that emphasizes healthy foods in a group visit format While the role of diet and nutrition in cognitive health and prevention of dementia  in older adults has attracted much attention , the efficacy of different dietary patterns remains uncertain . Previous review s have mainly focused on the Mediterranean diet , but either omitted other dietary patterns , lacked more recent studies , were based on cross-sectional studies , or combined older and younger population s. We followed PRISMA guidelines , and examined the efficacy of current research from r and omized controlled trials and cohort studies on the effects of different dietary patterns . We review ed the Mediterranean diet , Dietary Approach to Stop Hypertension ( DASH ) diet , the Mediterranean-DASH diet Intervention for Neurodegenerative Delay ( MIND ) diet , Anti-inflammatory diet , Healthy diet recommended by guidelines via dietary index , or Prudent healthy diets generated via statistical approaches , and their impact on cognitive health among older adults . Of 38 studies , the Mediterranean diet was the most investigated with evidence supporting protection against cognitive decline among older adults . Evidence from other dietary patterns such as the MIND , DASH , Anti-inflammatory , and Prudent healthy diets was more limited but showed promising results , especially for those at risk of cardiovascular disease . Overall , this review found positive effects of dietary patterns including the Mediterranean , DASH , MIND , and Anti-inflammatory diets on cognitive health outcomes in older adults . These dietary patterns are plant-based , rich in poly- and mono-unsaturated fatty acids with lower consumption of processed foods . Better underst and ing of the underlying mechanisms and effectiveness is needed to develop comprehensive and practical dietary recommendations against age-related cognitive decline among older adult 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 A prospect i ve , r and omized , controlled clinical trial in patients with coronary artery disease ( CAD ) and a concurrent physical disability evaluated the effects of a home exercise training program on cardiovascular function and blood lipids .  Eighty-eight men between the ages of 42 and 72 years ( mean 62 ) with documented CAD and a physical disability with functional use of > or = 2 extremities including 1 arm were r and omized to either a 6-month home exercise training program using wheelchair ergometry or to a control group that received usual and customary care .  Both groups received dietary instructions and were requested to follow a fat-controlled diet .  Exercise test variables with echocardiography and blood lipids were measured at baseline and at 6 months . The home exercise training group significantly improved both peak exercise left ventricular ejection fraction ( p = 0.007 ) and fractional shortening ( p = 0.01 ) between baseline to 6 months , whereas the control group showed no significant changes . Exercise training effects of decreased resting heart rate ( p = 0.03 ) and decreased peak rate pressure product ( p = 0.03 ) were also found in the treatment group . No exercise-related cardiac complications occurred . Both groups significantly ( p < or = 0.01 ) increased high-density lipoprotein cholesterol levels . These results indicate that physically disabled men with CAD can safely participate in a home exercise training program which may result in intrinsic cardiac benefits . The metabolic cost of activities of daily living imposed on this disabled population may also have a positive effect on high-density lipoprotein cholesterol levels BACKGROUND Data on the relation between alpha-linolenic acid intake and coronary artery disease ( CAD ) are limited . Other dietary components appear to modify the reported relation between alpha-linolenic acid intake and CAD . OBJECTIVE We examined whether dietary alpha-linolenic acid intake was inversely associated with risk of CAD . DESIGN We prospect ively studied 667 men aged 64 - 84 y from the Zutphen Elderly Study who were free of CAD at baseline .  Dietary intake was assessed by using a cross-check dietary history method . RESULTS During the 10-y follow-up , we documented 98 cases of CAD . After adjustment for age , st and ard coronary risk factors , and intake of trans fatty acids and other nutrients , alpha-linolenic acid intake was not significantly associated with CAD risk . The relative risk of CAD for the highest compared with the lowest tertile of alpha-linolenic acid intake was 1.68 ( 95 % CI : 0.86 , 3.29 ) . alpha-Linolenic acid intake from sources containing trans fatty acids was also nonsignificantly , yet positively , associated with CAD risk .  alpha-Linolenic acid intake from foods that did not contain trans fatty acids was not associated with CAD risk , the relative risk of CAD for the highest compared with the lowest tertile was 1.15 ( 95 % CI : 0.63 , 2.11 ) . CONCLUSION We did not observe a beneficial effect of dietary alpha-linolenic acid intake on the risk of 10-y CAD incidence . Investigating this hypothesis was complicated by the association between intakes of alpha-linolenic acid and trans fatty acids . Given the results of current prospect i ve studies , a protective cardiac effect of alpha-linolenic acid is question able OBJECTIVE To assess the association between  erectile dysfunction ( ED )  and the long-term risk of coronary artery disease ( CAD ) and the role of age as a modifier of this association . PARTICIPANTS AND METHODS From January 1 , 1996 , to December 31 , 2005 , we biennially screened a r and om sample of 1402 community-dwelling men with regular sexual partners and without known CAD for the presence of ED .  Incidence densities of CAD were calculated after age stratification and adjusted for potential confounders by time-dependent Cox proportional hazards models . RESULTS The prevalence of ED was 2 % for men aged 40 to 49 years , 6 % for men aged 50 to 59 years , 17 % for men aged 60 to 69 years , and 39 % for men aged 70 years or older . The CAD incidence densities per 1000 person-years for men without ED in each age group were 0.94 ( 40 - 49 years ) , 5.09 ( 50 - 59 years ) , 10.72 ( 60 - 69 years ) , and 23.30 ( > or = 70 years ) . For men with ED , the incidence densities of CAD for each age group were 48.52 ( 40 - 49 years ) , 27.15 ( 50 - 59 years ) , 23.97 ( 60 - 69 years ) , and 29.63 ( > or = 70 years ) . CONCLUSION ED and CAD may be differing manifestations of a common underlying vascular pathology . When ED occurs in a younger man , it is associated with a marked increase in the risk of future cardiac events , whereas in older men , ED appears to be of little prognostic importance . Young men with ED may be ideal c and i date s for cardiovascular risk factor screening and medical intervention OBJECTIVES We sought to determine the prognostic and incremental value of coronary artery disease ( CAD ) severity , coronary atherosclerosis , and left ventricular ejection fraction ( LVEF ) measured with cardiac computed tomography angiography ( CTA ) . BACKGROUND CTA is an emerging tool used for the detection of obstructive CAD . However , there are limited data supporting the prognostic value of 64-slice CTA and its ability to predict all-cause mortality and major adverse cardiac events such as cardiac death and nonfatal myocardial infa rct ion . METHODS Consecutive patients ( without history of revascularization , heart transplantation , and congenital heart disease ) were prospect ively enrolled . Each CTA was evaluated for CAD severity , total plaque score , and LVEF . Patients were followed , and all events were confirmed with death certificates or hospital or physician records and review ed by a clinical events committee . RESULTS Between February 2006 and February 2008 , 2,076 consecutive patients were prospect ively enrolled and followed for a mean of 16 + /- 8 months . At follow-up , a total of 31 ( 1.5 % ) patients had cardiac death or nonfatal myocardial infa rct ion and 47 ( 2.3 % ) had all-cause mortality or nonfatal myocardial infa rct ion . Multivariate analysis showed that CAD severity ( hazard ratio [ HR ] : 3.02 ; 95 % confidence interval [ CI ] : 1.89 to 4.83 ) was a predictor of major adverse cardiac events and that LVEF ( HR : 1.47 ; 95 % CI : 1.17 to 1.86 ) had incremental value over CAD severity . Total plaque score had incremental value over CAD severity and LVEF for all-cause mortality and nonfatal myocardial infa rct ion ( HR : 1.17 ; 95 % CI : 1.06 to 1.29 ) . CONCLUSIONS Using CTA , CAD severity , LVEF , and total plaque score seems to have prognostic and incremental value over routine clinical predictors . Cardiac CTA seems to be a promising noninvasive modality with prognostic value BACKGROUND Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease . The Computer-based Clinical Decision Support System provides an opportunity t close these gaps . OBJECTIVES To study the impact of computerized intervention on secondary prevention of CAD . METHODS The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an up date d  lipoprotein profile  and treatment with lipid-lowering drugs . The program produced automatic computer-generated monitoring and treatment recommendations . Adjusted primary clinics were r and omly assigned to intervention ( n=56 ) or st and ard care arms ( n=56 ) . Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment . Compliance and lipid levels were monitored . The study group comprised all patients with CAD who were alive at least 3 months after hospitalization . RESULTS Follow-up was available for 7448 patients ( median 19.8 months , range 6 - 36 months ) . Overall , 51.7 % of patients were adequately screened , and 55.7 % of patients were compliant with treatment to lower lipid level . In patients with initial low density lipoprotein  > 120 mg/dl , a significant decrease in LDL levels was observed in both arms , but was more pronounced in the intervention arm : 121.9 + /- 34.2 vs. 124.3 + /- 34.6 mg/dl ( P < 0.02 ) . A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs , 37 % vs. 40.9 % ( P < 0.001 ) . CONCLUSIONS This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines , presenting a major obstacle to implementing effective secondary prevention . Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation In diabetics with coronary artery disease ( CAD ) , there remains uncertainty as to whether revascularization by percutaneous transluminal coronary angioplasty ( PTCA ) or coronary artery bypass surgery ( CABG ) is preferable . To address this , 4-year mortality and level of pre- and postrevascularization angiographic CAD ( measured by a series of coronary scores ) were compared between both diabetics and nondiabetics and between revascularization modes in the Coronary Angioplasty versus Bypass Revascularization Investigation population as a whole , and then substratified by diabetic status and then by procedure to which they were r and omized . The 1,054 r and omized subjects contained 125 diabetics ( 11.9 % ) who had significantly greater mortality than nondiabetics ( RR 2.19 , p = 0.001 ) . Among diabetics or nondiabetics , there was no significant mortality difference between those r and omized to PTCA versus those to CABG . Diabetics r and omized to PTCA and those to CABG had higher mortalities than respective nondiabetics ; the association reached significance only in the former ( RR 2.41 , p = 0.002 ) . All subgroups had similar prerevascularization CAD . Postrevascularization residual CAD was consistently significantly greater in PTCA than in respective CABG subgroups . Most measurements of CAD were greater in diabetic than in nondiabetic subgroups , but none was significant . In the Coronary Angioplasty versus Bypass Revascularization Investigation , diabetics had double the mortality of nondiabetics ; this difference was statistically significant both for the entire population and for those r and omized to PTCA , but not for those r and omized to CABG . Among diabetics or nondiabetics , there was no significant mortality difference between PTCA and CABG . The higher diabetic mortality was more likely related to more rapid disease progression than to greater postrevascularization disease The West of Scotl and Coronary Prevention Study is a primary prevention trial design ed to test the hypothesis that reduction of serum cholesterol with pravastatin ( a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor ) over an average of 5 years will reduce the incidence of fatal and nonfatal myocardial infa rct ion . At entry , 6,595 men aged 45 - 64 years were r and omized to treatment with either pravastatin ( 40 mg/day ) or placebo . None of the men at entry had evidence of previous myocardial infa rct ion . All were given smoking and dietary advice throughout the study , which will terminate in 1995 . The principal endpoints are : ( 1 ) death due to coronary artery disease ( CAD ) plus nonfatal myocardial infa rct ion ; ( 2 ) death due to CAD ; and ( 3 ) nonfatal myocardial infa rct ion Background Management of patients with suspected coronary artery disease ( CAD ) and inconclusive stress imaging test findings may result in invasive coronary angiography ( ICA ) . Coronary computed tomographic angiography ( CCTA ) may be useful in defining the risk of CAD and adverse outcomes in this patient population , as well as in reducing the need for ICA . Methods We prospect ively enrolled 199 sequential patients referred by cardiologists for CCTA after either inconclusive or nondiagnostic stress imaging tests . Before CCTA , physicians identified a “ planned catheterization ” group of patients who would undergo invasive angiography if CCTA were not available . After CCTA testing , patients were followed for ≥2 years . We established the added diagnostic value of the CCTA and its prognostic power in prediction of intermediate-term follow-up events in this patient population as compared to available historical and clinical predictors of CAD , stress ECG , and stress imaging test results using a multivariable Cox proportional hazards survival analysis . Results Both observed data and results of the multivariable model for the prediction of obstructive CAD ( > 50 % stenosis ) , or major cardiac events ( death MI or revascularization ) , demonstrated that clinical , stress ECG , and imaging results were weakly predictive , whereas CCTA was found to be a strong independent and incremental predictor of the absence of either significant CAD or MACE in this population . None of the 93 patients with normal CCTA scans had MACE events , whereas 18 patients with evidence of CAD on the CCTA results underwent revascularization . Overall , physicians planned ICA in 125 patients ( 63.0 % ) ; after CCTA , ICA was performed in only 32 ( 16.0 % ) cases over 2 years . In this population with no other highly effective noninvasive clinical tools for diagnostic and prognostic estimation , the overall negative predictive value of CCTA for either CAD > 50 % or MACE for 2 years was 99 % . Conclusion Observations from this prospect i ve study demonstrate the significant added diagnostic value and prognostic potential of CCTA in patients with suspected CAD and either inconclusive or nondiagnostic stress test results in real-world setting s. Normal CCTA results are associated with excellent intermediate-term prognosis in this clinical subset , and invasive angiography can be safely avoided in the majority of these patients when the results of CCTA are available Background Lifestyle measures of coronary heart disease ( CHD ) prevention have been overshadowed by the efficacy of drug treatments . This is particularly the case in the setting of secondary prevention where the benefits of lipid lowering , anti-platelet and anti-hypertensive drugs have been emphasised in numerous trials . Lifestyle measures address several CHD risk factors at once and are generally free of serious side effects . Objectives The objective of the present study was to determine whether a comprehensive programme of lifestyle modification could favourably influence dietary and exercise habits in addition to smoking cessation over two years . In addition , an attempt was made to evaluate if this programme could favourably influence the five-year CHD-risk in the male population included in the study . Design A total of 197 patients with proven coronary heart disease were included and r and omised to a lifestyle intervention programme or to usual care . Follow-up was after a period of two years . Methods Intervention comprised a low fat diet , regular exercise , smoking cessation , psychosocial support and education , delivered by nurses on the rationale for pharmacological and lifestyle measures . Usual care comprised follow-up in the routine outpatient clinic . Both groups were given the same comprehensive medication according to recent guidelines . Results Patients in the lifestyle intervention group reduced the intake of saturated fat , sugar and cholesterol ( P<0.001 ) , increased their exercise level ( P<0.01 ) and stopped smoking ( P<0.05 ) when compared with the usual care group . A sub analysis of the influence of five-year CHD calculated risk in males result ed in a relative risk reduction of 22 % ( 95 % confidence intervals 9 - 35 ) . Although significant , this result must be interpreted with caution due to poor statistical power and reproducibility of the method . Conclusions In the presence of modern drug treatments for secondary cardiovascular disease prevention it remains possible through a favourable diet , exercise and smoking cessation to show an additional reduction in the five-year risk for CHD in males OBJECTIVES To determine if cardiorespiratory biofeedback increases heart rate variability ( HRV ) in patients with documented coronary artery disease ( CAD ) . BACKGROUND Diminished HRV has been associated with increased cardiac morbidity and mortality . Evidence suggests that various lifestyle changes and pharmacologic therapies can improve HRV . The objective of this study was to determine if biofeedback increases HRV in patients with CAD . METHODS Patients with established CAD ( n = 63 ; mean age , 67 years ) were r and omly assigned to conventional therapy or to 6 biofeedback sessions consisting of abdominal breath training , heart and respiratory physiologic feedback , and daily breathing practice .  HRV was measured by the st and ard deviation of normal-to-normal QRS complexes ( SDNN ) at week 1 ( pretreatment ) , week 6 ( after treatment ) , and week 18 ( follow-up ) . RESULTS Baseline characteristics were similar for the treatment and control groups . The SDNN for the biofeedback and control groups did not differ at baseline or at week 6 but were significantly different at week 18 . The biofeedback group showed a significant increase in SDNN from baseline to week 6 ( P < .001 ) and to week 18 ( P = .003 ) . The control subjects had no change from baseline to week 6 ( P = .214 ) and week 18 ( P = .27 ) . CONCLUSIONS Biofeedback increases HRV in patients with CAD and therefore may be an integral tool for improving cardiac morbidity and mortality rates 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 Atherosclerotic cardiovascular disease ( ASCVD ) is the leading cause of death , decreased quality of life , and medical costs in the United States . Nearly 1 in 3 Americans die of heart disease and stroke ( 1 ) . Most ASCVD is preventable through a healthy lifestyle and effective treatment of cholesterol and blood pressure . The 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association ( ACC/AHA ) provides an evidence -based approach to reducing ASCVD risk ( 2 ) . Guideline Development Process In 2008 , the National Heart , Lung , and Blood Institute ( NHLBI ) convened the Adult Treatment Panel ( ATP ) IV to up date the 2001 ATP-III cholesterol guidelines using a rigorous systematic process to identify and review r and omized , controlled trials ( RCTs ) with cardiovascular outcomes and meta-analyses of these RCTs . The panel comprised experts and clinicians from the fields of cardiology , epidemiology , primary care , and endocrinology ( 2 ) and received support from the Lifestyle Management and Risk Assessment Work Groups ( 3 , 4 ) . Systematic evidence review s conducted according to principles recommended by the Institute of Medicine ( 5 ) were performed to answer 3 questions relevant to clinical care . Two questions focused on the evidence supporting low-density lipoprotein cholesterol ( LDL-C ) and nonhigh-density lipoprotein cholesterol ( HDL-C ) levels as targets of treatment . One question examined the reduction in ASCVD events and adverse effects for each cholesterol-lowering drug class . The panel synthesized the evidence from these 3 review s as well as from Lifestyle Management and Risk Assessment Work Groups review s ( 3 , 4 ) that addressed 5 additional critical questions . Systematic electronic search es of relevant data bases of the peer- review ed English- language literature published from 1 January 1995 through 1 December 2009 for each critical question were conducted by an NHLBI-selected independent contractor and focused on RCTs and systematic review s and meta-analyses of RCTs assessed as fair to good quality . In addition , RCTs with ASCVD outcomes that included coronary heart disease , stroke , and cardiovascular deaths published after that date were eligible for consideration through July 2013 . Evidence tables were constructed , and the strength of evidence was rated according to the NHLBI ( Table 1 of the Supplement ) . Recommendations were grade d according to criteria from the NHLBI ( Table 2 of the Supplement ) and ACC/AHA ( Table 3 of the Supplement ) . Because of the inherent differences in grading systems and the clinical questions driving the recommendations , alignment between the NHLBI and ACC/AHA formats was imperfect . A complete description of the methods used and results of the evidence review are provided in the guideline ( 2 ) and the NHLBI evidence report ( www.nhlbi.nih.gov/ guidelines /cholesterol/ser/index.htm ) . Supplement . NHLBI and ACC/AHA Criteria for Rating Strength of Evidence To help clinicians estimate ASCVD risk , the risk assessment working group developed the Pooled Cohort Equations using data from 5 NHLBI-sponsored longitudinal , population -based cohorts of African American and non-Hispanic white men and women to estimate risk for a first myocardial infa rct ion , coronary heart disease death , or fatal or nonfatal stroke on the basis of age , sex , race , smoking status , total cholesterol level , HDL-C level , systolic blood pressure , antihypertensive therapy , and diabetes ( 4 , 6 ) . These equations significantly advance ASCVD risk estimation by providing sex- and race-specific estimates and including stroke as an outcome . The earlier Framingham equations calculated only coronary heart disease risk for non-Hispanic whites . The draft recommendations were review ed by 23 experts and representatives of federal agencies identified by the NHLBI . In September 2013 , the recommendations developed by the panel were transitioned to the ACC/AHA and had additional review by 4 experts nominated by the ACC Foundation and the AHA . The governing bodies of the ACC and AHA approved the guideline , which also received endorsement from the American Association of Cardiovascular and Pulmonary Rehabilitation , American Pharmacists Association , American Society for Preventive Cardiology , Association of Black Cardiologists , Preventive Cardiovascular Nurses Association , and WomenHeart : The National Coalition for Women with Heart Disease . Recommendations The guideline focuses on treatment of blood cholesterol to reduce ASCVD risk in adults . Major recommendations are summarized here and in Table 1 . The guideline report provides a complete listing of recommendations and supporting evidence behind each recommendation ( 2 ) . Table 1 . Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults * 1 . Encourage Adherence to a Healthy Lifestyle A healthy lifestyle is the foundation for cardiovascular health . The panel endorsed the 2013 ACC/AHA Lifestyle Management Guideline ( 3 ) for a diet that is low in saturated fat , trans fat , and sodium ; emphasizes vegetables , fruits , whole grains , low-fat dairy products , poultry , fish , legumes , nontropical vegetable oils , and nuts ; and limits sweets , sugar-sweetened beverages , and red meats and engage in regular aerobic physical activity . Adults also should maintain a healthy body weight , avoid smoking , and control hypertension and diabetes when present . 2 . Statin Therapy Is Recommended for Adults in Groups Demonstrated to Benefit Strong RCT evidence shows that reduction in ASCVD events from statin therapy exceeds adverse events for 4 patient groups : those with clinical ASCVD ( acute coronary syndromes , myocardial infa rct ion , stable angina , coronary or other arterial revascularization , stroke , transient ischemic attack , or peripheral arterial disease of atherosclerotic origin ) when  statins are used for secondary prevention , and those with LDL-C levels 190 mg/dL ; those aged 40 to 75 years with diabetes and LDL-C levels 70 to 189 mg/dL ; and those aged 40 to 75 years without diabetes and with a 10-year ASCVD risk 7.5 % when statins are used for primary prevention . Moderate evidence supports consideration of statin therapy for primary prevention in individuals with a 10-year ASCVD risk of 5 % to < 7.5 % . Routine initiation of statin therapy is not recommended in adults with New York Heart Association heart failure class II to IV or those receiving maintenance hemodialysis . R and omized , controlled trials in these groups showed no reduction in ASCVD . 3 . Statins have an Acceptable Margin of Safety When Used in Properly Selected Individuals and Appropriately Monitored Strong RCT evidence supports safety of statins when they are used as directed in conjunction with regular follow-up assessment s in properly selected patients . Adjustment of statin intensity is recommended in individuals older than 75 years with a history of statin intolerance or other characteristics ( 2 ) or those receiving drug therapy that may increase statin adverse events . Routine monitoring of hepatic aminotransferase level or creatine kinase level is not recommended unless clinical ly indicated by symptoms suggesting hepatotoxicity or myopathy . Given the potential for decreasing ASCVD events and death , the relationship of muscle and other symptoms to statin treatment must be confirmed . Therefore , eliciting a history of muscle symptoms before statin initiation and carefully monitoring symptoms during statin discontinuation and rechallenge is recommended . Severe myopathy , rhabdomyolysis , and possibly hemorrhagic stroke are rare complications of statin therapy . Although statin therapy modestly increases the risk for type 2 diabetes , ASCVD risk reduction outweighs the excess risk for diabetes for high-intensity statins in secondary prevention or for 10-year ASCVD risk 7.5 % . Similarly , ASCVD risk reduction outweighs the excess risk for diabetes for moderate-intensity statin therapy in adults with a 10-year ASCVD risk 5 % . 4 . Engage in a ClinicianPatient Discussion Before Initiating Statin Therapy , Especially for Primary Prevention in Patients With Lower ASCVD Risk Decisions to initiate statin therapy in primary prevention should be based on clinical judgment and preferences of informed patients . In adults without clinical ASCVD or diabetes whose LDL-C level is < 190 mg/dL , calculating the estimated 10-year ASCVD risk should be the start of the clinicianpatient discussion and should not automatically lead to statin initiation . As the absolute risk for ASCVD events decreases , so does the net benefit of the intervention . Therefore , discussion of the potential for ASCVD event reduction , adverse effects , drugdrug interactions , and patient preferences is especially important for lower-risk primary prevention . The discussion provides the opportunity to encourage healthy lifestyle habits and control other risk factors . Additional factors may be considered when a risk-based decision is uncertain , including LDL-C levels 160 mg/dL , family history of premature ASCVD , elevated  lifetime ASCVD risk  , high-sensitivity C-reactive protein level 2.0 mg/L ,  coronary artery calcification score  > 300 Agatston units , and anklebrachial index < 0.9 . After age 75 years , comorbid conditions , anticipated longevity , safety considerations , and patient preferences should play a large role in decision making . 5 . Use the Newly Developed Pooled Cohort Equations for Estimating 10-Year ASCVD Risk The Pooled Cohort Equations are currently the best available method for estimating 10-year ASCVD risk to guide statin initiation ( 4 , 6 ) . Application of the inclusion and exclusion criteria from RCTs is cumbersome and results in underidentifying high-risk and overidentifying low-risk individuals for statin treatment . The Pooled Cohort Equations were developed using recent data from 5 NHLBI-sponsored , longitudinal , population -based cohorts of African American and white men and women ( ARIC [ Background — Although population s referred for  coronary angiography  are increasingly diverse , there is limited information on coronary artery disease ( CAD ) prevalence and in-hospital mortality other than for predominately white male patients . Methods and Results — We examined gender and ethnic differences in CAD prevalence and in-hospital mortality in a prospect i ve cohort of patients referred for angiographic evaluation of stable angina ( n=375 886 ) or acute coronary syndromes ( ACS ; unstable angina or myocardial infa rct ion , n=450 329 ) at 388 US hospitals participating in the American College of Cardiology – National Cardiovascular Data Registry , an angiographic registry . Univariable and multivariable ( with covariates that included risk factors , symptoms , and comorbidities ) logistic regression models were used to estimate significant CAD , defined as ≥70 % stenosis , and in-hospital mortality . Within stable angina and ACS cohorts , 7 % of patients were black , 2 % were Hispanic , 0.3 % were Native American , 1 % were Asian , and 90 % were white , respectively . In stable angina , the risk-adjusted OR for significant CAD was 0.34 for women compared with men ( P<0.0001 ) , with black women having the lowest risk-adjusted odds ( P<0.0001 ) compared with other females . Among ACS patients , the risk-adjusted OR of significant CAD was 0.47 for women compared with men ( P<0.0001 ) ; similarly , black women had the lowest risk-adjusted odds ( P<0.0001 ) compared with other females . Higher in-hospital mortality was reported for white women presenting with stable angina ( P<0.00001 ) . White women had a 1.34-fold ( 95 % CI 1.21 to 1.48 ) higher risk-adjusted odds ratio for mortality than white men with stable angina ( P<0.0001 ) , with higher rates noted for white women who were older or had significant CAD ( both P<0.0001 ) . Lower utilization of elective coronary revascularization , aspirin , and glycoprotein IIb/IIIa inhibitors  ( all P<0.0001 ) may have contributed to higher in-hospital mortality for white women . In ACS , higher in-hospital mortality was reported for Hispanic ( P=0.015 ) and white ( P<0.0001 ) women ; however , neither white ( P=0.51 ) or Hispanic ( P=0.13 ) women had higher in-hospital risk-adjusted mortality . Conclusions — The likelihood for significant CAD at coronary angiography and for in-hospital mortality varied significantly by ethnicity and gender . Future clinical practice guidelines should be tailored to gender subsets of the population , in particular for black women , to improve the efficient use of angiographic laboratories and to target at-risk population s of women and men OBJECTIVES Our aim was to access clinical effectiveness of percutaneous coronary intervention ( PCI ) when added to optimal medical therapy ( OMT ) in older patients with stable coronary artery disease ( CAD ) . BACKGROUND While older patients with CAD are at increased risk for cardiac events compared with younger patients , it is unclear whether PCI may mitigate this risk more effectively than OMT alone or , alternatively , may be associated with more complications . METHODS We conducted a pre-specified analysis of outcomes in stable CAD patients stratified by age and r and omized to PCI+OMT or OMT alone  in the COURAGE ( Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation ) trial . RESULTS A total of 1,381 patients ( 60 % ) were < 65 years of age ( mean 56+/-6 years ) and 904 patients ( 40 % ) were > or=65 years of age ( mean 72+/-5 years ) . Achieved treatment targets for blood pressure , low-density lipoprotein cholesterol , adherence to diet and exercise , and angina-free status did not differ by age or treatment assignment . Among older patients , there was a 2- to 3-fold higher death rate , but similar rates of myocardial infa rct ion , stroke , and major cardiac events compared with younger patients . The addition of PCI to OMT did not improve or worsen clinical outcomes in patients > or=65 years of age during a median 4.6 year follow-up . CONCLUSIONS These data support adherence to American College of Cardiology/American Heart Association clinical practice guidelines that advocate OMT as an appropriate initial management strategy , regardless of age . ( Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [ COURAGE ] ; NCT00007657 ) It is well established that endothelial dysfunction is present in coronary artery disease ( CAD ) , although few studies have determined the effect of training on peripheral conduit vessel function in patients with CAD . A r and omized , crossover design determined the effect of 8 wk of predominantly lower limb , combined aerobic and resistance training , in 10 patients with treated CAD .  Endothelium-dependent dilation of the brachial artery was determined , by using high-resolution vascular ultrasonography , from flow-mediated vasodilation ( FMD ) after ischemia . Endothelium-independent vasodilation was measured after administration of glyceryl trinitrate ( GTN ) . Baseline function was compared with that of 10 control subjects . Compared with matched healthy control subjects , FMD and GTN responses were significantly impaired in the untrained CAD patients [ 3.0 + /- 0.8 ( SE ) vs. 5.8 + /- 0.8 % and 14.5 + /- 1.9 vs. 20.4 + /- 1.5 % , respectively ; both P < 0.05 ] . Training significantly improved FMD in the CAD patients ( from 3.0 + /- 0.8 to 5.7 + /- 1.1 % ; P < 0.05 ) but not responsiveness to GTN ( 14.5 + /- 1.9 vs. 12.1 + /- 1.4 % ; P = not significant ) . Exercise training improves endothelium-dependent conduit vessel dilation in subjects with CAD , and the effect , evident in the brachial artery , appears to be generalized rather than limited to vessels of exercising muscle beds . These results provide evidence for the benefit of exercise training , as an adjunct to routine therapy , in patients with a history of CAD Guidelines have recommended that a family history of premature coronary heart disease ( CHD ) warrants screening and preventive efforts , including lifestyle change . The objective of this study was to evaluate the effects of a lifestyle modification program on lipids and novel risk markers in young relatives of patients with premature CHD . In a parallel , r and omized , intervention trial , intensified support to quit smoking and dietary modification was compared with general lifestyle advice in 172 men and women aged 18 to 39 years with a total cholesterol of 5 to 8 mmol/L and > or=1 lipid abnormality ( high low-density lipoprotein [ LDL ] cholesterol , triglycerides or lipoprotein(a ) , or low high-density lipoprotein cholesterol ) . All had a first-degree relative with premature CHD or with hyperlipidemia and other relative(s ) with premature CHD , and 40 % were daily smokers . After a mean of 8 months , the intervention group reduced the dietary intake of saturated fat and cholesterol compared with controls ( p = < 0.01 ) . Ten smokers in the intervention group quit , whereas 2 subjects in the control group started and none quit . LDL cholesterol ( p = 0.007 ) , oxidized LDL ( p = 0.03 ) , and E-selectin ( p = 0.02 ) concentrations were reduced in the intervention group compared with controls . In subjects who quit smoking , concentrations of intercellular adhesion molecule-1 decreased ( 261 + /- 66 to 228 + /- 30 ng/ml ) compared with that in continuing smokers ( 308 + /- 106 ng/ml to 304 + /- 109 ng/ml ) ( p = 0.05 between groups ) . These findings indicate that dietary modification and smoking cessation are feasible in young adults with familial premature CHD and document novel mechanisms by which lifestyle modification may reduce CHD risk OBJECTIVE To investigate the prospect i ve association of low-density lipoprotein ( LDL ) particle diameter with the incidence of fatal and nonfatal coronary artery disease ( CAD ) . DESIGN A nested case-control study . SETTING Cases and controls were identified from a population -based sample of men and women combining all of the 5 cross-sectional surveys conducted from 1979 to 1990 of the Stanford Five-City Project ( FCP ) . PARTICIPANTS Incident CAD cases were identified through FCP surveillance between 1979 and 1992 . Controls were matched by sex , 5-year age groups , survey time point , ethnicity , and FCP treatment condition . The sample included 124 matched pairs : 90 pairs of men and 34 pairs of women . MAIN OUTCOME MEASURES LDL peak particle diameter ( LDL size ) was determined by gradient gel electrophoresis on plasma sample s collected during the cross-sectional surveys ( stored at 70 degrees C for 5 - 15 years ) . Established CAD risk-factor data were available from FCP baseline measurements . RESULTS LDL size was smaller among CAD cases than controls ( mean + /- SD ) ( 26.17 + /- 1.00 nm vs 26.68 + /- 0.90 nm ; P<.001 ) . The association was grade d across control quintiles of LDL size . The significant case-control difference in LDL size was independent of levels of high-density lipoprotein cholesterol ( HDL-C ) , non-HDL cholesterol ( non-HDL-C ) , triglyceride , smoking , systolic blood pressure , and body mass index , but was not significant after adjusting for the ratio of total cholesterol ( TC ) to HDL-C ( TC : HDL-C ) . Among all the physiological risk factors , LDL size was the best differentiator of CAD status in conditional logistic regression . However , when added to the physiological parameters above , the TC : HDL-C ratio was found to be a stronger independent predictor of CAD status . CONCLUSION LDL size was significantly smaller in CAD cases than in controls in a prospect i ve , population -based study . These findings support other evidence of a role for small , dense LDL particles in the etiology of atherosclerosis
Available studies show convincingly the health benefits of lifestyle changes in CAD patients .
Effect estimates of combined dietary changes look promising .
BACKGROUND Guidelines for lifestyle and dietary modification in patients with coronary artery disease ( CAD ) are mainly supported by evidence from general population studies .
CAD patients , however , differ from the general population in age ( older ) and treatment with preventive drugs .
This review seeks to provide evidence for a prognostic benefit of lifestyle and dietary recommendations from studies in CAD patients .