Receipt of Cardiac Medications Upon Discharge Among Men and Women With Acute Coronary Syndrome and Nonobstructive Coronary Artery Disease

Background Management of acute coronary syndrome (ACS) patients with nonobstructive epicardial coronary artery disease (CAD) remains poorly understood. Hypothesis Acute coronary syndrome patients with nonobstructive CAD are less likely to receive effective cardiac medications upon discharge from the hospital. Methods We identified patients hospitalized with ACS that underwent coronary angiography and had a 6-month follow-up. Patients were grouped by CAD severity: nonobstructive CAD (<50% blockage in all vessels) or obstructive CAD (≥50% blockage in ≥ 1 vessels). Data were collected on demographics, medications at discharge, and adverse outcomes at 6 months, for all patients. Results Of the 2264 ACS patients included in the study: 123 patients had nonobstructive CAD and 2141 had obstructive CAD. Cardiac risk factors including hypertension and diabetes were common among patients with nonobstructive CAD. Men and women with nonobstructive CAD were less likely to receive cardiac medications compared to patients with obstructive CAD including aspirin (87.8% vs 95.0%, P = 0.001), Β-blockers (74.0% vs 89.2%, P < 0.001), or statins (69.1% vs 81.2%, P = 0.001). No gender-related differences in discharge medications were observed for patients with nonobstructive CAD. However, women with nonobstructive CAD had similar rates of cardiac-related rehospitalization as men with obstructive CAD (23.3% and 25.9%, respectively). Conclusions Patients with nonobstructive CAD are less likely to receive evidence-based medications compared to patients with obstructive CAD, despite the presence of CAD risk factors and occurrence of an ACS event. Further research is warranted to determine if receipt of effective cardiac medications among patients with nonobstructive CAD would reduce cardiac-related events. Copyright © 2010 Wiley Periodicals, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/64902/1/20701_ftp.pd

A Prior Myocardial Infarction: How Does it Affect Management and Outcomes in Recurrent Acute Coronary Syndromes?

Background Despite improved secondary prevention efforts, acute coronary syndrome (ACS) recurrence among patients with prior history of coronary events remains high. The differences in presentation, management, and subsequent clinical outcomes in patients with and without a prior myocardial infarction (MI) and presenting with another episode of ACS remain unexplored. Methods A total of 3,624 consecutive patients admitted to the University of Michigan with ACS from January 1999 to June 2006 were studied retrospectively. In-hospital management, outcomes, and postdischarge outcomes such as death, stroke, and reinfarction in patients with and without a prior MI were compared. Results Patients with a prior MI were more likely to be older and have a higher incidence of diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease. In-hospital outcomes were not significantly different in the 2 groups, except for a higher incidence of cardiac arrest (4.3% versus 2.5%, p < 0.01) and cardiogenic shock (5.7% versus 3.9%, p = 0.01) among patients without a prior MI. However, at 6 mo postdischarge, the incidences of death (8.0% versus 4.5%, p < 0.0001) and recurrent MI (10.0% versus 5.1%, p < 0.0001) were significantly higher in patients with a prior history of MI compared with those without. Conclusion Patients with prior MI with recurrent ACS remain at a higher risk of major adverse events on follow-up. This may be partly explained by the patients not being on optimal medications at presentation, as well as disease progression. Increased efforts must be directed at prevention of recurrent ACS, as well as further risk stratification of these patients to improve their overall outcomes. Copyright © 2008 Wiley Periodicals, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61452/1/20356_ftp.pd

CHD1 Remodels Chromatin and Influences Transient DNA Methylation at the Clock Gene frequency

Circadian-regulated gene expression is predominantly controlled by a transcriptional negative feedback loop, and it is evident that chromatin modifications and chromatin remodeling are integral to this process in eukaryotes. We previously determined that multiple ATP–dependent chromatin-remodeling enzymes function at frequency (frq). In this report, we demonstrate that the Neurospora homologue of chd1 is required for normal remodeling of chromatin at frq and is required for normal frq expression and sustained rhythmicity. Surprisingly, our studies of CHD1 also revealed that DNA sequences within the frq promoter are methylated, and deletion of chd1 results in expansion of this methylated domain. DNA methylation of the frq locus is altered in strains bearing mutations in a variety of circadian clock genes, including frq, frh, wc-1, and the gene encoding the frq antisense transcript (qrf). Furthermore, frq methylation depends on the DNA methyltransferase, DIM-2. Phenotypic characterization of Δdim-2 strains revealed an approximate WT period length and a phase advance of approximately 2 hours, indicating that methylation plays only an ancillary role in clock-regulated gene expression. This suggests that DNA methylation, like the antisense transcript, is necessary to establish proper clock phasing but does not control overt rhythmicity. These data demonstrate that the epigenetic state of clock genes is dependent on normal regulation of clock components