Kopecky, Stephen L.

Background— Aspirin is beneficial in the setting of atherosclerotic cardiovascular disease. There are limited data evaluating preoperative aspirin administration preceding coronary artery bypass grafting and associated postoperative outcomes. Methods and Results— Using prospectively collected data from 1636 consecutive patients undergoing first-time isolated coronary artery bypass surgery at our institution from January 2000 through December 2002, we evaluated the association between aspirin usage within the 5 days preceding coronary bypass surgery and risk of adverse in-hospital postoperative events. A logistic regression model, which included propensity scores, was used to adjust for remaining differences between groups. Overall, there were 36 deaths (2.2%) and 48 adverse cerebrovascular events (2.9%) in the postoperative hospitalization period. Patients receiving preoperative aspirin (n=1316) had significantly lower postoperative in-hospital mortality compared with those not receiving preoperative aspirin [1.7% versus 4.4%; adjusted odds ratio (OR), 0.34; 95% CI, 0.15 to 0.75; P =0.007]. Rates of postoperative cerebrovascular events were similar between groups (2.7% versus 3.8%; adjusted OR, 0.67; 95% CI, 0.32 to 1.50; P =0.31). Preoperative aspirin therapy was not associated with an increased risk of reoperation for bleeding (3.5% versus 3.4%; P =0.96) or requirement for postoperative blood product transfusion (adjusted OR, 1.17; 95% CI, 0.88 to 1.54; P =0.28). Conclusions— Aspirin usage within the 5 days preceding coronary artery bypass surgery is associated with a lower risk of postoperative in-hospital mortality and appears to be safe without an associated increased risk of reoperation for bleeding or need for blood product transfusion.

Introduction: Up to 20% of outpatients receiving HMG-CoA reductase inhibitors (statins) experience treatment reluctance on the basis of side effects, leaving a large population at increased risk of CVD. We hypothesized that a practical food-based approach can be utilized to lower LDL-C in statin reluctant patients and that the lipid response can be predicted based upon CYP7A1-rs3808607 (CYP7A1) and APOE genetic isoforms. Methods: This was a multicenter, randomized, double-blind, free-living cross-over study composed of 2 phases of 4 wk each, separated by a 4 wk washout. Participants (n=54) received an assortment of individually packaged, shelf stable snacks along with printed instructions to ingest 2 servings of the foods per day as a substitute for similar items they were eating already. No other dietary or behavior adjustments were requested. Treatment products supplied at least 1800 mg alpha-linoleic acid (ALA), 5 g of fiber and 1g of phytosterols per serving. Control products were calorie-matched like items drawn from the general grocery marketplace. Lipid parameters were measured and averaged over 2 d at baseline and at 4 wk of each phase. Ingestion of study foods was confirmed by C18:3n3 serum level assessment. Single nucleotide polymorphisms and APOE isoform were assessed by Taqman genotyping assay. Results: As compared to control, LDL-C decreased 8.8% in the treatment arm (p<0.0001, range -37.6% to +20.5%) and total cholesterol fell 5.1% (p<0.004). No significant change was seen in HDL-C, TG or fasting glucose levels. LDL-C was reduced by diet in CYP7A1 T/T homozygotes (-0.3924+0.1271mmol/l, p = 0.0033) and APOE4 carriers ( -0.3808+0.098 mmol/l, p = 0.0003). Conclusions: Significant LDL-C reductions can be affected through a simple food intervention supplying high levels of phytosterols, fiber and ALA. CYP7A1 and APOE isoforms influence the variability in LDL-C response and can help identify individual patients especially appropriate for a food-based LDL-C lowering approach. Given the large number of patients unable/unwilling to take statins, our findings have significant impact for management of this challenging population.

This poster presents an expert consensus position on the current controversy regarding calcium supplement use and risk of myocardial infarction. In November 2011, The CRN Foundation with the support of the National Osteoporosis Foundation and National Bone Health Alliance convened an expert panel of scientists from the nutrition and medical communities to review the total body of evidence and specifically studies relating calcium supplements to an increased risk of myocardial infarction. Because of the many data limitations present in the supporting studies relating calcium supplements to an increased risk of myocardial infarction and contrast to the large majority of the literature accompanied with recent reanalyses of the data, no change in prescribing practice is currently recommended. Prescribers should consider the potential benefits of calcium supplements for prevention of osteoporotic fractures based on an individual's personal dietary intake. Positive outcomes of calcium supplementation such as prevention of obesity and colorectal cancers may also carry weight in support of calcium supplements when individual dietary intakes are inadequate to meet IOM recommendations.

Electronic health record (EHR)-based clinical decision support (CDS) can address the low awareness and undertreatment of familial hypercholesterolemia (FH), a disorder associated with a markedly increased risk of coronary heart disease. We aimed to incorporate provider perspectives into the development and implementation of a CDS tool for FH. An implementation science framework and a user-centered design process were used to create a CDS tool for FH. Primary care physicians and specialist physicians participated in qualitative interviews, usability testing and an implementation survey. The CDS was configured in two formats—a best practice alert (BPA) and an in-basket message and subsequently deployed in the EHR in silent mode. The key themes that emerged from the analysis of interview transcripts included understanding and awareness of FH, clinical workflow, physician preferences and value of CDS tools, perspectives on patient needs and values and dissemination and implementation. Recommendations related to usability included preferred CDS format and placement, content, timing and frequency, and level of alert urgency/prioritization. In response to the survey, 84.6% of physicians agreed that the CDS would improve early FH diagnosis and 92.3% agreed that it would help them identify and manage FH patients. Physician feedback led to iterative CDS refinement. In summary, we developed a CDS tool for FH using an implementation science framework and physician feedback. Initial deployment revealed a significant burden of FH and the potential for the CDS tool to have a large impact.

Abstract Objective The study sought to characterize the evaluation of patients who present following detection of an abnormal pulse using Apple Watch. Materials and Methods We conducted a retrospective review of patients evaluated for abnormal pulse detected using Apple Watch over a 4-month period. Results Among 264 included patients, clinical documentation for 41 (15.5%) explicitly noted an abnormal pulse alert. Preexisting atrial fibrillation was noted in 58 (22.0%). Most commonly performed testing included 12-lead echocardiography (n = 158; 59.8%), Holter monitor (n = 77; 29.2%), and chest x-ray (n = 64; 24.2%). A clinically actionable cardiovascular diagnosis of interest was established in only 30 (11.4%) patients, including 6 of 41 (15%) patients who received an explicit alert. Discussion False positive screening results may lead to overutilization of healthcare resources. Conclusions The Food and Drug Administration and Apple should consider the unintended consequences of widespread screening for asymptomatic (“silent”) atrial fibrillation and use of the Apple Watch abnormal pulse detection functionality by populations in whom the device has not been adequately studied.