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For at least a few centuries, if not millennia, psychological stress has been popularly believed to contribute to heart disease. Does psychological stress really contribute to heart disease? Are anecdotal, patient, and lay press reports that angina, heart attack, and even cardiac death are caused by stress based on fact, or are they just folklore? In this review, the study data supporting associations between stress and cardiovascular risk, as well as potential mechanisms by which psychological stress might contribute to heart disease and precipitate myocardial ischemia and infarction, are critically reviewed and summarized.

The 2017 American Heart Association Scientific Statement on meditation and cardiovascular risk suggested that meditation may be considered as an adjunct to guideline-directed cardiovascular risk-reduction interventions. Meditation could potentially increase physical and mental relaxation, leading to improved outcomes after a major cardiovascular event. We hypothesized that meditation is associated with lower cardiovascular risk in the US general population. Using data from the 2012 and 2017 National Health Interview Survey, we identified all patients with hypercholesterolemia, systemic hypertension (SH), diabetes mellitus (DM), stroke, and coronary artery disease (CAD), as well as those who reported that they meditate. Multivariable logistic regression analyses were performed to evaluate the association between meditation and risk of hypercholesterolemia, SH, DM, stroke, and CAD, adjusting for potential confounders. Of 61,267 the National Health Interview Survey participants, 5,851 (9.6%) participated in some form of meditation. After adjusting for age, gender, body mass index, race, marital status, cigarette smoking, sleeping duration, and depression, meditation was independently associated with a lower prevalence of hypercholesterolemia (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.54 to 0.79; p = 0.001), SH (OR 0.86; 95% CI 0.75 to 0.99; p = 0.04), diabetes (OR 0.70; 95% CI 0.59 to 0.84; p = 0.0001), stroke (OR 0.76; 95% CI 0.58 to 0.99; p = 0.04), or CAD (OR 0.51; 95% CI 0.39 to 0.66; p0.001), compared with those who did not meditate. In conclusion, using a large national database, we found that meditation is associated with a lower prevalence of cardiovascular risks factors and disease.

Antiplatelet therapy for patients with coronary artery disease has evolved dramatically over the last decade. P2Y12 inhibitors offering more potent and consistent platelet inhibition than clopidogrel are now widely available, dual antiplatelet therapy (DAPT) duration can be tailored to individual ischemic and bleeding risks, and strategies to personalize antiplatelet therapy have been developed when concomitant oral anticoagulation (OAC) is indicated. Scientific societies from Canada, the United States, and Europe have all published updated recommendations addressing antiplatelet therapy in the recent years. The purpose of this review is to put the Canadian guidelines into perspective vis-à-vis international recommendations by highlighting similarities and critically analyzing differences. We focus on 3 major topics relevant for clinical practice: DAPT duration following drug-eluting stent implantation, DAPT following percutaneous coronary intervention in patients with concomitant indications for OAC, and DAPT management for noncardiac surgery following drug-eluting stent implantation. Although guidelines broadly agree on the majority of recommendations, the justifications for major differences were contrasted in the manuscript. Unanswered questions remain, including the place of aspirin in secondary prevention of coronary artery disease in the contemporary era, aspirin-free strategies early after percutaneous coronary intervention, and the safe minimal duration of DAPT with newer generation stents.

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health [(1)][1]. These guidelines, based on systematic methods to evaluate and classify

Dual antiplatelet therapy (DAPT) is the cornerstone of pharmacological treatment aimed at preventing the atherothrombotic complications in patients with a variety of coronary artery disease...

The CHA2DS2-VASc score has been widely adopted as a risk stratification tool for strokes in patients with atrial fibrillation and to help in deciding when anticoagulation therapy for stroke prophylaxis may be beneficial. The score as a whole has been well validated and has been included in the current major practice guidelines. An advantage of the CHA2DS2-VASc score is its ease of use, allowing clinicians to quickly estimate risk based on a short set of criteria. However, the benefit of simplicity may also be a weakness. Studies on individual components of the score suggest that only a subset of patients deemed to be at risk based on the current definition are actually at risk for stroke. Thus, users of the score should be aware of the nuances based on available evidence and avoid over-generalization. Accurate assessment of stroke risk has important clinical implications as it influences decision-making on initiation of anticoagulation.

An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC, FAHA Joaquin E. Cigarroa, MD, FACC Lesley H. Curtis, PhD

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair [∗∗][1] Nancy M. Albert, PhD, RN, FAHA[∗∗][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD

Preamble 2356 1. Introduction 2357 2. Overview of Acs 2358 3. Initial Evaluation and Management: Recommendations 2358 4. Early Hospital Care: Recommendations 2363 5. Myocardial Revascularization: Recommendations 2369 6. Late Hospital Care, Hospital Discharge, and Posthospital Discharge Care: Recommendations 2371

Jeffrey L. Anderson, MD, FACC, FAHA, Chair Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect Nancy M. Albert, PhD, RN, FAHA Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC Lesley H. Curtis, PhD, FAHA David DeMets, PhD[††][1] Lee A. Fleisher, MD, FACC, FAHA Samuel

Granting clinical staff privileges to physicians is the primary mechanism institutions use to uphold quality care. The Joint Commission requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians themselves are charged with defining the

The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can

Background: Obese patients are at increased risk of acute coronary syndromes (ACS). We evaluated the prevalence of obesity in a large ACS population, as well as the relationship between body mass index (BMI) and the use of cardiac medications and procedures, clinical outcomes, and treatment effects between enoxaparin and unfractionated heparin (UFH). Methods: Using the database of the SYNERGY trial, we identified 9978 patients in 12 countries who were randomly assigned to receive enoxaparin or UFH. Patient weight at baseline and 30-day follow-up was recorded. BMI information was available on 9837 patients. BMI was analyzed in clinically meaningful categories ( = 35 kg/m(2)) and as a continuous variable. Results: Thirty-two percent of patients were obese ( BMI >= 30), with a greater proportion of patients with obesity from North America (36%) compared with other regions. Enoxaparin was dosed as 1 mg/kg regardless of body weight without maximum. The first dose of enoxaparin was underdosed in 15% of patients assigned enoxaparin, and obese patients were more likely to be underdosed than non-obese patients. Obese patients were younger, less often white, had more diabetes, hypertension, hyperlipidemia, family history of coronary artery disease, and congestive heart failure but fewer strokes, less peripheral vascular disease, and less often smoked. After adjustment, increased BMI was not an independent predictor of bleeding outcomes or 30-day death/myocardial infarction (MI), but increased BMI was predictive of lower 1-year mortality in the subgroup of patients with BMI at baseline below approximately 30 kg/m(2). No statistical interaction term was observed between obesity and randomized therapy for the outcomes of death/MI at 30 days and 6 months; death at 30 days, 6 months, and 1 year; and GUSTO or TIMI bleeding. Conclusions: Nearly one third of patients in SYNERGY were obese. Despite multiple comorbidities, obese patients had better unadjusted short- and long-term outcomes. After adjustment, higher BMI was not an independent predictor of in-hospital bleeding events or 30-day death/MI, but increased BMI was an independent predictor of 1-year mortality in patients with lower BMI but not in heavier patients. No interaction between the randomized treatment and obesity for efficacy and safety outcomes was observed across the range of BMI in this dataset. Standard dosing of enoxaparin should be used in patients without extreme obesity due to limited outcome data in these patients. (C) 2008 Elsevier Ireland Ltd. All rights reserved.

The role of endomyocardial biopsy (EMB) in the diagnosis and treatment of adult and pediatric cardiovascular disease remains controversial, and the practice varies widely even among cardiovascular centers of excellence. A need for EMB exists because specific myocardial disorders that have unique

Objectives The aim of this study was to discern a target range of anticoagulation for enoxaparin during percutaneous coronary intervention (PCI) as measured by the Rapidpoint ENOX (Pharmanetics Inc., Morrisville, North Carolina), a new point-of-care test. Background In the U.S., enoxaparin has been used in only a small proportion of PCI procedures, partly because a rapid enoxaparin-specific assay was unavailable. Methods We analyzed data from 445 enrolled patients receiving subcutaneous or intravenous enoxaparin in a prospective, multicenter study. Serial anticoagulation measurements and clinical outcomes were recorded. Results The in-hospital composite occurrence of death, myocardial infarction, and urgent target vessel revascularization was 5.4%, and Thrombolysis In Myocardial Infarction (TIMI) major bleeding, minor bleeding, and any reported bleeding occurred in 0.2%, 1.3%, and 7.9% of patients, respectively. No significant association between procedural ENOX times and ischemic events was observed (p = 0.222), although the event rate was 4.0% among those with ENOX times between 250 to 450 s versus 7.2% for those outside this range (p = 0.134). Increasing ENOX time at sheath removal was correlated with any bleeding (p = 0.010) with a 1% increase for every ∼30-s rise. Conclusions Ischemic events were infrequent, and the rate appeared lowest in the mid-range of ENOX times. Bleeding events increased with increasing ENOX times. These observations, combined with a suggested procedural anti-Xa level of 0.8 to 1.8 IU/ml, translate into a recommended ENOX time range of 250 to 450 s for PCI and

OBJECTIVES We evaluated the relationship between the degree of heparin anticoagulation and clinical efficacy and bleeding in patients undergoing contemporary percutaneous coronary intervention (PCI) with stent implantation. BACKGROUND Despite universal acceptance of heparin anticoagulation as a standard of care in PCI, considerable controversy still exists regarding the appropriate dosing of heparin. METHODS The study population (n = 2,064) comprised all patients enrolled in the Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) trial. The index activated clotting time (ACT) was defined as the ACT measured after the last heparin dose and before first device activation and was correlated with outcome and bleeding events. RESULTS No association was observed between decreasing ACT levels and the rate of ischemic events in the treatment or placebo arms. The incidence of the primary composite end point (death, myocardial infarction, urgent target vessel revascularization, and thrombotic bailout glycoprotein IIb/IIIa inhibitor therapy at 48 h) was actually lowest in the lowest ACT tertile for both the placebo (10.0%) and treatment groups (6.1%). When analyzed by tertile, major bleeding rates did not increase in the lowest ACT tertile in patients given placebo (0.6%) versus those receiving eptifibatide (0.7%). Major bleeding rates increased as the ACT increased in the eptifibatide-treated patients. CONCLUSIONS Ischemic end points in patients undergoing contemporary PCI with stent placement do not increase by decreasing ACT levels, at least to a level of 200 s. Bleeding events do increase with increasing ACT levels and are enhanced with eptifibatide treatment. An ACT of 200 to 250 s is reasonable in terms of efficacy and safety with the use of contemporary technology and pharmacotherapy.

Background: Measurement of enoxaparin's anticoagulant activity has been limited to specialized coagulation laboratories and has been impractical for areas needing rapid results, such as during coronary angioplasty. A new point-of-care device, Rapidpoint® ENOX®, was recently developed to measure clotting times with enoxaparin use. Objectives: To correlate ENOX times with anti-Xa levels among patients receiving enoxaparin. Methods: A total of 166 patients receiving enoxaparin for the prevention of deep venous thrombosis or as treatment during acute coronary syndromes or angioplasty were prospectively studied. Citrated and non-citrated whole-blood (CWB and NCWB) samples were obtained at baseline and peak enoxaparin activity. ENOX times were measured with whole-blood, and the Stachrom® anti-Xa assay was performed on the plasma from the remainder of the samples. The Pearson correlation coefficient was used to assess the relationship between these two assays. Results: There was a strong linear correlation between the ENOX times and the anti-Xa activities for both CWB (r=0.89, p

We examined the relation between diabetes mellitus and outcomes in patients undergoing percutaneous coronary revascularization in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I), a randomized trial comparing treatment with either percutaneous transluminal coronary angioplasty or directional atherectomy for de novo lesions in native coronary arteries. Acute success and complication rates, 6-month angiographic restenosis rates, and 1-year clinical outcomes were compared between diabetic and nondiabetic patients undergoing each procedure. Acute success rates between diabetic (n = 191) and nondiabetic (n = 821) patients were similar for both revascularization techniques. Except for the need for dialysis, complication rates were also similar. Six months after atherectomy, diabetic patients had significantly more angiographic restenosis than nondiabetics (59.7% vs 47.4%) and significantly smaller minimum luminal diameters (1.20 vs 1.40 mm). Diabetics undergoing atherectomy required more frequent bypass surgery (12.8% vs 8.5%) and more repeat percutaneous revascularizations (36.5% vs 28.1%) than nondiabetics undergoing atherectomy. Restenosis rates, minimum luminal diameters and repeat revascularizations between diabetics and nondiabetics undergoing angioplasty were similar. The higher restenosis and repeat revascularization rates and the smaller minimum luminal diameter at follow-up in diabetic patients suggest that atherectomy may provide only modest benefit for these patients. The increased restenosis rate in diabetics undergoing atherectomy (but not angioplasty) requires further evaluation.

Three cases of rapidly reversible severe myocardial depression are described in patients with status asthmaticus. Initial echocardiograms obtained within 1 day of hospital admission revealed global left ventricular hypokinesis with ejection fractions of 11 to 34%. Follow-up echocardiograms obtained only 3 to 8 days later revealed marked improvement of left ventricular function. Possible mechanisms responsible for the observed rapidly reversible myocardial depression and the clinical implications of this finding are discussed.

The importance of blood viscosity in ischemic heart disease is becoming increasingly well established. Blood viscosity directly affects shear rates in the coronary arteries and perfusion pressure across coronary stenoses. Abnormalities of blood rheology, particularly elevated whole blood viscosity (WBV), have been associated with coronary artery disease (CAD), and have been prospectively shown to be an independent predictor of adverse cardiac events. There is, as yet, no established method for modifying this newly established risk factor, although regular exercise has been shown to improve blood viscosity in healthy subjects. To determine if exercise training, as prescribed in standard cardiac rehabilitation programs, has beneficial effects on blood viscosity in patients with CAD, we prospectively studied WBV and the factors that affect it, as well as exercise tolerance (ETT), before and after a ten week program of moderate intensity dynamic exercise in fifteen patients (aged 58 ± 9). WBV was measured in triplicate at six different physiologic shear rates. There were no intercurrent events or medication changes during the study period. Before After p En Time (sec) 497 ± 118 648 ± 144 l0.001 Peak Vo 2 (ml/mg/min) 23.8 ± 6.93 31.6 ± 6.04 l0.001 HR at matched workrate (bpm) 118 ± 25 102 ± 17 0.012 Average WBV (cP) 5.20 ± 058 5.46 ± 1.00 NS Plasma viscosity (cP) 1.41 ± 0.10 1.46 ± 0.09 NS Hematocrit (%) 39.7 ± 2.50 41.0 ± 3.50 NS Fibrinogen (mg/dl) 307 ± 55.4 322 ± 89.5 NS Sedimentation rate (mm/hr) 26 ± 15 24 ± 14 NS The standard ten week cardiac rehabilitation program of moderate intensity dynamic exercise leads to a highly significant improvement in exercise tolerance, but does not have a beneficial effect on blood viscosity in patients with ischemic heart disease.

To determine the impact of new technology on the management of patients with significant ( g 70% stenosis) coronary artery disease (CAD), we compared treatment strategies in patients undergoing diagnostic cardiac catheterization during the years 1987 – 1989 (group 1) and 1992 – 1994 (group 2). Patients with significant congenital and valvular disease, left main disease, and insignificant coronary artery disease were excluded from analysis. Although there was a higher prevalance of hypertension (60.6% vs 66.6%, P = 0.024), hypercholesterolemia (32.5% vs 51.5%, P = 0.001), and female gender (27% vs 33%, P l 0.001), and a lower prevalance of unstable angina at the time of the procedure (26.8% vs 17.9%. P = 0.001) in group 2, there were no differences between the two groups in mean age (61.0 yrs vs 62.5 yrs), incidence of diabetes (26.5% vs 25.2%), tobacco use (58.4% vs 56.1%), peripheral vascular disease (16.3% vs 17.3%) or cerebrovascular disease (7.8% vs 6.8%). Although there were more female patients in group 2, the percent of women and men undergoing revascularization was similar. Treatment strategies were classified as either medical therapy; percutaneous revascularization; or coronary artery bypass surgery (CABG). Group 1 (1987–1989) n (%) Group 2 (1992–1994) n (%) p value Medical Therapy 573 (38%) 808 (49%) 0.001 Percutaneous Revascularization 453 (30%) 472(29%) NS CABG 490 (32%) 370 (22%) 0.001 Despite technologic advances in percutaneous revascularization, the percentage of patients undergoing percutaneous revascularization has not increased. There has been a significant reduction in the percentage of patients referred for CABG, which may be due to an increasing number of patients being treated medically. This change in treatment strategy may reflect better medical therapy and/or increased concern about the risks of revascularization.