Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes

Background: The persistence of depressive symptoms after hospitalization is a strong risk factor for mortality after acute coronary syndromes (ACS). Poor adherence to secondary prevention behaviors may be a mediator of the relationship between depression and increased mortality. Objective: To determine whether rates of adherence to risk reducing behaviors were affected by depressive status during hospitalization and 3 months later. Design: Prospective observational cohort study. Setting: Three university hospitals. Participants: Five hundred and sixty patients were enrolled within 7 days after ACS. Of these, 492 (88%) patients completed 3-month follow-up. Measurements: We used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and 3 months after discharge. We assessed adherence to 5 risk-reducing behaviors by patient self-report at 3 months. We used χ2 analysis to compare differences in adherence among 3 groups: persistently nondepressed (BDI<10 at hospitalization and 3 months); remittent depressed (BDI ≥10 at hospitalization; <10 at 3 months); and persistently depressed patients (BDI ≥10 at hospitalization and 3 months). Results: Compared with persistently nondepressed, persistently depressed patients reported lower rates of adherence to quitting smoking (adjusted odds ratio [OR] 0.23, 95% confidence interval [95% CI] 0.05 to 0.97), taking medications (adjusted OR 0.50, 95% CI 0.27 to 0.95), exercising (adjusted OR 0.57, 95% CI 0.34 to 0.95), and attending cardiac rehabilitation (adjusted OR 0.5, 95% CI 0.27 to 0.91). There were no significant differences between remittent depressed and persistently nondepressed patients. Conclusions: Persistently depressed patients were less likely to adhere to behaviors that reduce the risk of recurrent ACS. Differences in adherence to these behaviors may explain in part why depression predicts mortality after ACS. Key Words: cardiovascular diseases, depression, medication adherence, prevention, self car

Antithrombotic therapy for coronary artery disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

This chapter about antithrombotic therapy for coronary artery disease (CAD) is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients presenting with non-ST-segment elevation (NSTE) acute coronary syndrome (ACS), we recommend immediate and then daily oral aspirin (Grade 1A). For patients with an aspirin allergy, we recommend immediate treatment with clopidogrel, 300-mg bolus po, followed by 75 mg/d indefinitely (Grade 1A). In all NSTE ACS patients in whom diagnostic catheterization will be delayed or when coronary bypass surgery will not occur until > 5 days, we recommend clopidogrel as bolus therapy (300 mg), followed by 75 mg/d for 9 to 12 months in addition to aspirin (Grade 1A). In NSTE ACS patients in whom angiography will take place within 24 h, we suggest beginning clopidogrel after the coronary anatomy has been determined (Grade 2A). For patients who have received clopidogrel and are scheduled for coronary bypass surgery, we recommend discontinuing clopidogrel for 5 days prior to the scheduled surgery (Grade 2A). In moderate- to high-risk patients presenting with NSTE ACS, we recommend either eptifibatide or tirofiban for initial (early) treatment in addition to treatment with aspirin and heparin (Grade 1A). For the acute treatment of NSTE ACS, we recommend low molecular weight heparins over unfractionated heparin (UFH) [Grade 1B] and UFH over no heparin therapy use with antiplatelet therapies (Grade 1A). We recommend against the direct thrombin inhibitors as routine initial antithrombin therapy (Grade 1B). For patients after myocardial infarction, after ACS, and with stable CAD, we recommend aspirin in doses from 75 to 325 mg as initial therapy and in doses of 75 to 162 mg as indefinite therapy (Grade 1A). For patients with contraindications to aspirin, we recommend long-term clopidogrel (Grade 1A). For primary prevention in patients with at least moderate risk for a coronary event, we recommend aspirin, 75 to 162 mg/d, over either no antithrombotic therapy or vitamin K antagonist (VKA) [Grade 2A]; for patients at particularly high risk of events in whom the international normalized ratio (INR) can be monitored without difficulty, we suggest low-dose VKA (target INR, 1.5) [Grade 2A]

The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

The following chapter devoted to antithrombotic therapy for chronic coronary artery disease (CAD) is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading see the "Grades of Recommendation" chapter by Guyatt et al in this supplement, CHEST 2008; 133[suppl]:123S-131S). Among the key recommendations in this chapter are the following: for patients with non-ST-segment elevation (NSTE)-acute coronary syndrome (ACS) we recommend daily oral aspirin (75-100 mg) [Grade 1A]. For patients with an aspirin allergy, we recommend clopidogrel, 75 mg/d (Grade 1A). For patients who have received clopidogrel and are scheduled for coronary bypass surgery, we suggest discontinuing clopidogrel for 5 days prior to the scheduled surgery (Grade 2A). For patients after myocardial infarction, after ACS, and those with stable CAD and patients after percutaneous coronary intervention (PCI), we recommend daily aspirin (75-100 mg) as indefinite therapy (Grade 1A). We recommend clopidogrel in combination with aspirin for patients experiencing ST-segment elevation (STE) and NSTE-ACS (Grade 1A). For patients with contraindications to aspirin, we recommend clopidogrel as monotherapy (Grade 1A). For long-term treatment after PCI in patients who receive antithrombotic agents such as clopidogrel or warfarin, we recommend aspirin (75 to 100 mg/d) [Grade 1B]. For patients who undergo bare metal stent placement, we recommend the combination of aspirin and clopidogrel for at least 4 weeks (Grade 1A). We recommend that patients receiving drug-eluting stents (DES) receive aspirin (325 mg/d for 3 months followed by 75-100 mg/d) and clopidogrel 75 mg/d for a minimum of 12 months (Grade 2B). For primary prevention in patients with moderate risk for a coronary event, we recommend aspirin, 75-100 mg/d, over either no antithrombotic therapy or vitamin K antagonist (Grade 1A)

Deception Through Disguise in the Joseph Story to Complete Midah K'neged Midah

This paper will examine the role of clothing and its relation to the theme of midah k'neged midah, often translated as a type of measure for measure punishment, as it unfolds in the Joseph story in Genesis. While Joseph’s brothers and father seem to receive proportional punishments for the sins that they commit, due to ambiguities in the story regarding God’s role, it is unclear who or what is driving this “measure for measure punishment” scheme. Is it Joseph, God, or perhaps simply nature’s equilibrium? This paper will  investigate each of these three possible mechanisms for the ultimate fulfillment of midah k'neged midah based on textual clues of divine presence and human agency. Based on a close textual reading and analysis, this paper will conclude that while divine intervention appears to play a role in providing Joseph with opportunities, ultimately, Joseph is the one who capitalizes on these opportunities in order to complete his revenge scheme.  This narrative also illustrates the concept of maaseh avot siman l’banim (the actions of the forefathers are a sign for the children), representing how the mistakes of earlier generations have a cyclical effect on their descendents. This principle serves as a timeless warning to future generations, cautioning individuals to avoid past mistakes of their ancestors. Although the text contains many ambiguities, it seems clear that humans, like Joseph, certainly play some role in shaping their own destiny, and thus can hopefully break the cycle of sinning that began with the forefathers

Laughter in the Isaac Narrative: Who Has the Last Laugh?

This article tackles the question of the nature of Sarah’s laughter. It argues that it is imperative to go beyond labeling the laughter as either incredulous or joyous, as it is a reductive approach. The nuanced approach of this paper appreciates the “both and-ness” of the laughter demonstrating its larger significance in the Genesis narrative.

Weaving Textual Tapestries: The Role of the Biblical Intertext

In Medieval Iberia, Arabic was perceived as the most communicative, practical, and beautiful language. Forced to contend with this, authors of Hebrew works sought to raise the caliber of the Hebrew language. This paper will explore the use of these Biblical intertexts through an intertextual analysis of Judah Halevi’s poem “Song of Farewell.” These intertexts utilized the contexts of their original stories to convey a deeper meaning to the literary works as well as create additional layered meaning subsequently aiding in the reinvigoration of the Hebrew language.</jats:p

Deception Through Disguise in the Joseph Story to Complete Midah K'neged Midah

This paper will examine the role of clothing and its relation to the theme of midah k'neged midah, often translated as a type of measure for measure punishment, as it unfolds in the Joseph story in Genesis. While Joseph’s brothers and father seem to receive proportional punishments for the sins that they commit, due to ambiguities in the story regarding God’s role, it is unclear who or what is driving this “measure for measure punishment” scheme. Is it Joseph, God, or perhaps simply nature’s equilibrium? This paper will&nbsp; investigate each of these three possible mechanisms for the ultimate fulfillment of midah k'neged midah based on textual clues of divine presence and human agency. Based on a close textual reading and analysis, this paper will conclude that while divine intervention appears to play a role in providing Joseph with opportunities, ultimately, Joseph is the one who capitalizes on these opportunities in order to complete his revenge scheme.&nbsp; This narrative also illustrates the concept of maaseh avot siman l’banim (the actions of the forefathers are a sign for the children), representing how the mistakes of earlier generations have a cyclical effect on their descendents. This principle serves as a timeless warning to future generations, cautioning individuals to avoid past mistakes of their ancestors. Although the text contains many ambiguities, it seems clear that humans, like Joseph, certainly play some role in shaping their own destiny, and thus can hopefully break the cycle of sinning that began with the forefathers

Weaving Textual Tapestries: The Role of the Biblical Intertext

In Medieval Iberia, Arabic was perceived as the most communicative, practical, and beautiful language. Forced to contend with this, authors of Hebrew works sought to raise the caliber of the Hebrew language. This paper will explore the use of these Biblical intertexts through an intertextual analysis of Judah Halevi’s poem “Song of Farewell.” These intertexts utilized the contexts of their original stories to convey a deeper meaning to the literary works as well as create additional layered meaning subsequently aiding in the reinvigoration of the Hebrew language