PubMed · 15618079
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David Rott. 2004-11-30. Revascularization for everyone?. https://doi.org/10.1093/eurheartj%2Fehi047
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BACKGROUND: The prevention and treatment of coronary heart disease (CHD) is complex. A variety of models have therefore been developed to try and explain past trends and predict future possibilities. The aim of this systematic review was to evaluate the strengths and limitations of existing CHD policy models. METHODS: A search strategy was developed, piloted and run in MEDLINE and EMBASE electronic databases, supplemented by manually searching reference lists of relevant articles and reviews. Two reviewers independently checked the papers for inclusion and appraisal. All CHD modelling studies were included which addressed a defined population and reported on one or more key outcomes (deaths prevented, life years gained, mortality, incidence, prevalence, disability or cost of treatment). RESULTS: In total, 75 articles describing 42 models were included; 12 (29%) of the 42 models were micro-simulation, 8 (19%) cell-based, and 8 (19%) life table analyses, while 14 (33%) used other modelling methods. Outcomes most commonly reported were cost-effectiveness (36%), numbers of deaths prevented (33%), life-years gained (23%) or CHD incidence (23%). Among the 42 models, 29 (69%) included one or more risk factors for primary prevention, while 8 (19%) just considered CHD treatments. Only 5 (12%) were comprehensive, considering both risk factors and treatments. The six best-developed models are summarised in this paper, all are considered in detail in the appendices. CONCLUSION: Existing CHD policy models vary widely in their depth, breadth, quality, utility and versatility. Few models have been calibrated against observed data, replicated in different settings or adequately validated. Before being accepted as a policy aid, any CHD model should provide an explicit statement of its aims, assumptions, outputs, strengths and limitations.
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Patients with diabetes mellitus and ischemic heart disease more frequently develop heart failure and have a greater amount of myocardial ischemia, often silent, compared with patients without diabetes. Furthermore, patients with coronary artery disease (CAD) and diabetes or insulin resistance have altered myocardial metabolism and accelerated and diffuse atherogenesis with involvement of distal coronary segments that causes chronic hypoperfusion and hibernation. Therefore, in patients with diabetes and CAD, the ischemic metabolic changes are heightened by the metabolic changes in patients with diabetes. An important metabolic alteration in patients with diabetes is the increase in free fatty acid (FFA) concentrations and the increased skeletal muscle and myocardial FFA uptake and oxidation. The increased uptake and utilization of FFA and the reduced utilization of glucose as a source of energy during stress and ischemia contribute to the increased susceptibility of diabetic hearts to myocardial ischemia and to a greater decrease of myocardial performance for a given amount of ischemia compared with nondiabetic hearts. A therapeutic approach aimed at an improvement in cardiac metabolism through manipulations of the use of metabolic substrates should result in an improvement in myocardial ischemia and left ventricular (LV) function. The inhibition of FFA oxidation with trimetazidine improves cardiac metabolism at rest, increases cardiac resistance to ischemia, and therefore reduces the decrease of LV function caused by chronic hypoperfusion and repetitive episodes of myocardial ischemia in patients with and without diabetes. Thus, modulation of myocardial FFA metabolism should be the key target for metabolic interventions in patients with CAD with and without diabetes. In patients with diabetes, the effects of modulation of FFA metabolism should be even greater compared with those observed in patients without diabetes. Because of its effect on cardiac metabolism at rest and its effects on myocardial ischemia and LV function, trimetazidine should always be considered for the treatment of patients with diabetes with CAD with or without LV dysfunction.