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PubMed2004

Kidney disease as a risk factor for recurrent cardiovascular disease and mortality.

BACKGROUND: Chronic kidney disease (CKD) is highly prevalent in the United States and is an independent risk factor for adverse cardiovascular disease (CVD) and all-cause mortality outcomes in patients with acute coronary syndromes. Few studies have evaluated the effect of CKD on cardiovascular events in a diverse community-based population with underlying CVD. METHODS: Data for subjects with preexisting CVD were pooled from 4 publicly available, community-based, longitudinal studies: Atherosclerosis Risk in Communities, Cardiovascular Health Study, Framingham Heart Study, and Framingham Offspring Study. CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m2 (<1 mL/s/1.73 m2). The primary study outcome was a composite of myocardial infarction (MI), fatal coronary heart disease (CHD), stroke, and all-cause mortality. The secondary outcome included only MI and fatal CHD. RESULTS: A total of 4,278 subjects satisfied inclusion criteria, and 759 subjects (17.7%) had CKD. Mean follow-up was 86 months. The primary and secondary outcomes were observed in 1,703 (39.8%) and 857 subjects (20.0%), respectively. Incidence rates for the primary and secondary outcomes were greater in persons with CKD compared with those without CKD (62.5% versus 34.9% and 30.6% versus 17.8%, respectively). Adjusted hazard ratios for the primary and secondary outcomes were 1.35 (95% confidence interval [CI], 1.21 to 1.52) and 1.32 (95% CI, 1.12 to 1.55), respectively. CONCLUSION: The presence of CKD in a community-based population with preexisting CVD is associated with an increased risk for recurrent CVD outcomes. This increased risk persists after adjustment for traditional CVD risk factors.

Aged↗

PubMed1994

[Meta-analysis: its role in clinical decision making in cardiology].

Clinical decision-making in cardiology requires accurate estimates of the efficacy of diagnostic and therapeutic procedures. Defined as the quantitative integration of results from different studies on the same scientific question, meta-analyses are well-suited to summarize the evidence on the efficacy of clinical interventions. Meta-analyses aim at obtaining combined estimates of effect using all relevant information in a systematic fashion, complementing narrative reviews and expert committee reports. In this paper, the advantages and limitations of meta-analyses and their usefulness in clinical decision making in cardiology are illustrated using three recent examples in the literature--i.e., use of beta-blockers in secondary prevention of ischemic heart disease, intravenous streptokinase in acute myocardial infarction and fish intake in primary prevention of cardiovascular mortality. The steps to follow when conducting a meta-analysis are also discussed. Finally, a list of the most important meta-analyses in cardiology published to date is included for easy reference.

Adrenergic beta-Antagonists↗

PubMed2005

Outcomes in hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril.

CONTEXT: Few cardiovascular outcome data are available for blacks with hypertension treated with angiotensin-converting enzyme (ACE) inhibitors or calcium channel blockers (CCBs). OBJECTIVE: To determine whether an ACE inhibitor or CCB is superior to a thiazide-type diuretic in reducing cardiovascular disease (CVD) incidence in racial subgroups. DESIGN, SETTING, AND PARTICIPANTS: Prespecified subgroup analysis of ALLHAT, a randomized, double-blind, active-controlled, clinical outcome trial conducted between February 1994 and March 2002 in 33,357 hypertensive US and Canadian patients aged 55 years or older (35% black) with at least 1 other cardiovascular risk factor. INTERVENTIONS: Antihypertensive regimens initiated with a CCB (amlodipine) or an ACE inhibitor (lisinopril) vs a thiazide-type diuretic (chlorthalidone). Other medications were added to achieve goal blood pressures (BPs) less than 140/90 mm Hg. MAIN OUTCOME MEASURES: The primary outcome was combined fatal coronary heart disease (CHD) or nonfatal myocardial infarction (MI), analyzed by intention-to-treat. Secondary outcomes included all-cause mortality, stroke, combined CVD (CHD death, nonfatal MI, stroke, angina, coronary revascularization, heart failure [HF], or peripheral vascular disease), and end-stage renal disease. RESULTS: No significant difference was found between treatment groups for the primary CHD outcome in either racial subgroup. For amlodipine vs chlorthalidone only, HF was the only prespecified clinical outcome that differed significantly (overall: relative risk [RR], 1.37; 95% confidence interval [CI], 1.24-1.51; blacks: RR, 1.46; 95% CI, 1.24-1.73; nonblacks: RR, 1.32; 95% CI, 1.17-1.49; P<.001 for each comparison) with no difference in treatment effects by race (P = .38 for interaction). For lisinopril vs chlorthalidone, results differed by race for systolic BP (greater decrease in blacks with chlorthalidone), stroke, and combined CVD outcomes (P<.001, P = .01, and P = .04, respectively, for interactions). In blacks and nonblacks, respectively, the RRs for stroke were 1.40 (95% CI, 1.17-1.68) and 1.00 (95% CI, 0.85-1.17) and for combined CVD were 1.19 (95% CI, 1.09-1.30) and 1.06 (95% CI, 1.00-1.13). For HF, the RRs were 1.30 (95% CI, 1.10-1.54) and 1.13 (95% CI, 1.00-1.28), with no significant interaction by race. Time-dependent BP adjustment did not significantly alter differences in outcome for lisinopril vs chlorthalidone in blacks. CONCLUSIONS: In blacks and nonblack subgroups, rates were not lower in the amlodipine or lisinopril groups than in the chlorthalidone group for either the primary CHD or any other prespecified clinical outcome, and diuretic-based treatment resulted in the lowest risk of heart failure. While the improved outcomes with chlorthalidone were more pronounced for some outcomes in blacks than in nonblacks, thiazide-type diuretics remain the drugs of choice for initial therapy of hypertension in both black and nonblack hypertensive patients.

Aged↗

PubMed1997

Design & rationale of the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS).

The Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) is a randomized, double-blind, placebo-controlled primary prevention trial. It is designed to test the hypothesis that in addition to a lipid-lowering diet, treatment with lovastatin is more effective than placebo in reducing acute major coronary events (i.e., sudden cardiac death, fatal and nonfatal myocardial infarction, and unstable angina) in a cohort with normal to mildly elevated total (180 to 264 mg/dl) and low-density lipoprotein (LDL) cholesterol (130 to 190 mg/dl) and low high-density lipoprotein (HDL) cholesterol (< or =45 mg/dl for men and < or =47 mg/dl for women). Two sites in Texas, Lackland Air Force Base in San Antonio and the University of North Texas Health Science Center in Fort Worth, will conduct the study. After at least 12 weeks of an American Heart Association Step 1 diet and 2 weeks placebo run-in, 6,605 men and women, ages 45 to 73 and 55 to 73 years, respectively, without clinical evidence of coronary heart disease, are randomized in equal numbers to either lovastatin (20 mg/day) or placebo. Study procedures maintain the blind, allowing titration of lovastatin from 20 to 40 mg/day to achieve an LDL cholesterol goal of < or = 110 mg/dl. All participants are followed until study completion, when 320 participants have had a primary end point or a minimum of 5 years after the last participant is randomized, whichever occurs last. All end points are adjudicated by an independent committee using prespecified criteria. Unique features of this trial are (1) the inclusion of unstable angina in the primary end point to reflect the increasing trend to treat coronary heart disease aggressively before a myocardial infarction has occurred, (2) aggressive pharmacologic intervention, with titration, to attain an LDL cholesterol goal less than the current National Cholesterol Education Panel guidelines for primary prevention, and (3) a cohort that includes women, the elderly, and those with mild to moderate hyperlipidemia and low HDL cholesterol. Compared with earlier studies, results will be applicable to a broader population and may help clarify the role of aggressive LDL cholesterol reduction measures in primary prevention. Treatment of this population is likely to realize the greatest cumulative long-term benefit in the prevention of acute major coronary events.

Aged↗

PubMed1998

[Prognostic value of pre-discharge exertion echocardiography after acute myocardial infarct].

OBJECTIVE: The aim of the present work was to ascertain the usefulness of exercise echocardiography performed prior to discharge following acute non-complicated myocardial infarction in the prognosis and detection of multi-vessel disease. PATIENTS AND METHODS: Sixty-five consecutive patients with primary episode of acute non-complicated myocardial infarction, with normal or slightly depressed ventricular function, were studied. Submaximal exercise test including echocardiogram pre- and immediately post-exercise were performed 7 to 10 days after infarction. Mean follow-up was 15 +/- 8 months; 15 patients presented angina, 9 revascularization and 1 died. RESULTS: Electrocardiographic ischaemia had low sensitivity and negative predictive value regarding complications (44% and 73% respectively); however, its specificity and positive predictive values were high (97% and 92%). In contrast, echocardiography-detected ischaemia showed much better sensitivity and negative predictive values (72% and 83%), with a slight decrease in specificity and positive predictive values (87% and 78%). Both remote ischaemia and the increase in global score > 0.25 during exercise were of high prognostic value (p < 0.001). Remote echocardiographic ischaemia yielded the diagnosis of multi-vessel disease with greater sensitivity than electrocardiographic ischaemia (84% vs 41%). CONCLUSIONS: Exercise echocardiography is highly useful in the prognostic assessment of patients prior to discharge following acute non-complicated myocardial infarction. The ischaemia detected on sub-maximal exercise and assessed by echocardiography was much more sensitive than that detected by electrocardiography in the prediction of new coronary events and multi-vessel disease.

Aged↗

PubMed2001

Clinical trials: surrogate endpoints or hard endpoints?

A man, aged 50, has about a 50% risk and a 50-year-old woman a 35% risk of having a myocardial infarction during their lifetime. The extent of atherosclerosis is the primary determinant of the risk of myocardial infarction. We will be unable to substantially reduce the lifetime risk of coronary artery disease without primary prevention of atherosclerosis. Noninvasive methods to measure subclinical atherosclerosis and its progression offer a unique opportunity to improve individual patient preventive strategies, based both on pharmacologic and nonpharmacologic therapies, as well as an opportunity to study and develop new drug therapies. The use of subclinical disease as a surrogate marker of atherosclerosis and the study of plaque characteristics will greatly enhance our understanding of the role of new risk factors for atherosclerosis, lipoprotein metabolism, and genetic-lifestyle interactions.

Biomarkers↗

PubMed1984

[Value of inpatient rehabilitation measures following myocardial infarct].

The primary goal of rehabilitation is to slow down the progression of coronary heart disease via secondary preventive efforts and to reduce the negative social and psychosomatic sequelae of a myocardial infarction to the unavoidable minimum. Cardiac rehabilitation has developed into an active strategy of secondary prevention, based on sufficient diagnostic evaluation, aiming at the modification of risks factors and including the entire psychosocial field into the long-term therapeutic concept. After myocardial infarction the patient carries, in comparison to the normal population, approximately a tenfold risk to die suddenly or to suffer another myocardial infarction. Following a first infarction, risk factors such as smoking, hypercholesterolemia and hypertension are of increased epidemiologic importance. A lower social class will in itself lead to an increase of the incidence of reinfarction and to a decrease in life expectancy. One of the central goals therefore is to convey the importance of a health-oriented behavior pattern, which is achieved in single and group-therapy sessions as well as with the help of physiotherapy. Controlled physical exercise, however, does not only serve as an educational vehicle, but also has direct effects on cardiovascular physiology, leading to a decrease in heart rate and blood pressure for a given work load and thus to an increase of the angina pectoris threshold. Moreover, controlled physical exercise has a substantial antidepressive effect in the critical phase following acute myocardial infarction, and will lead to increased self-confidence.(ABSTRACT TRUNCATED AT 250 WORDS)

Adaptation, Psychological↗

PubMed1994

Thrombosis and fibrinolysis in acute myocardial infarction.

The development of coronary thrombosis in response to rupture of atherosclerotic plaques is the primary determinant of the evolution of stable atherosclerotic coronary disease to unstable ischemic syndromes and acute myocardial infarction. Activation of the tissue factor pathway of coagulation and adhesion of platelets are critical events in the initiation of thrombosis. However, subsequently, other factors may determine the extent of thrombosis by modulating the intensity of procoagulant and fibrinolytic activity. Marked procoagulant activity, attenuation of physiologic fibrinolytic activity, or both appear to be risk factors for myocardial infarction. The results of recent studies have provided considerable insight into potential mechanisms for thrombosis in response to rupture of atherosclerotic plaque and have identified potential novel antithrombotic interventions to inhibit the progression of coronary thrombosis.

Animals↗

PubMed1997

A low molecular weight, selective thrombin inhibitor, inogatran, vs heparin, in unstable coronary artery disease in 1209 patients. A double-blind, randomized, dose-finding study. Thrombin inhibition in Myocardial Ischaemia (TRIM) study group.

BACKGROUND: Unstable coronary artery disease, i.e. unstable angina or non-Q wave myocardial infarction, is caused by rupture of atheromatous plaques initiating thrombus formation. Thrombin is thought to be pivotal in platelet activation and thrombus growth. The aim of the present study was to compare the effect of three different doses of a novel, low molecular weight, selective thrombin inhibitor (inogatran) with that of heparin in unstable coronary artery disease. The composite primary end-point was death, incidence of myocardial infarction, refractory angina or recurrent angina after 7 days. Secondary end-points were the same after 3 and 30 days, as were death and myocardial infarction with or without refractory angina on all three occasions. METHODS: Patients (n = 1209) admitted with suspected unstable angina, or non-Q wave myocardial infarction, were randomly assigned to double-blind treatment with inogatran or heparin bolus doses. This was followed by a 3 day infusion with a low (LDI), medium (MDI), or high (HDI) dose of inogatran, aiming at plasma concentrations of 0.15, 0.4 or 0.8 micromol.l-1, or heparin initiated at 1200 U.h-1. FINDINGS: Treatment with inogatran resulted in median activated partial thromboplastin times after 24 h of 36, 44 and 53 s in the low, medium and high dose inogatran groups, respectively, as compared to 54 s in the heparin group (ns). At the end of the infusion, after 3 days, heparin-treated patients had fewer composite events (29.5%) than inogatran-treated patients (LDI = 39.4%, MDI = 37.6%, HDI = 36.1%; P = 0.01). The event rate after 7 days with respect to the primary end-point, however, did not differ between the groups (heparin = 41.0%, LDI = 45.7% MDI = 45.9%, HDI = 45.5%; ns). Death and myocardial infarction occurred less frequently in the heparin group (0.7%) than in the three inogatran groups (LDI = 3.6%, MDI = 2.0%, HDI = 4.0%; P < 0.05) after 3 days. After 7 days, this difference was attenuated (heparin = 2.6% vs LDI = 4.0%, MDI = 4.3%, HDI = 6.7%; P = 0.10). After 30 days there were no significant differences in event rates between the four groups. Major bleeding occurred in 1.1% of the patients within 7 days, with no differences between the groups. CONCLUSIONS: During study drug infusion the event rate was very low in the heparin group, and none of the inogatran dosages were better than heparin in preventing ischaemic events. Furthermore, there was no relationship between event rate and inogatran dosage. Thus, this study does not indicate that the efficacy of inogatran would improve with higher doses, despite a clear dose-effect as regards the prolongation of activated partial thromboplastin time. After cessation of heparin or inogatran there was an increase in event rates, suggestive of a rebound phenomenon.

Aged↗

PubMed1989

A clinical role for right ventricular endomyocardial biopsy.

There is considerable uncertainty about the value of endomyocardial biopsy (EMB) in the diagnosis and management of patients with suspected primary myocardial dysfunction. To determine the clinical utility of this procedure in patients referred to our centre, we reviewed the clinical records and biopsy findings of the first 21 consecutive patients in whom we performed right ventricular EMB. Patients were divided into four groups according to the clinical indications for EMB: unexplained congestive cardiac failure and a dilated heart (Group 1: 11 patients); unexplained congestive cardiac failure and a non dilated heart (Group 2: three patients); unexplained cardiomegaly in the absence of cardiac failure (Group 3: one patient); suspected hypertrophic cardiomyopathy (HCM) (Group 4: six patients). Histological examination of EMB tissue obtained from all patients in Group 1 as well as the single patient in Group 3 showed non specific features judged to be compatible with a diagnosis of dilated cardiomyopathy. Accordingly, in all patients in Groups 1 and 3, a potentially treatable cause of primary myocardial dysfunction was excluded. Biopsy examination demonstrated the presence of a specific disease process in two of three patients in Group 2 (one patient had amyloidosis, the other endomyocardial fibrosis). In five of the six patients in Group 4, the biopsy findings were either diagnostic or suggestive of HCM. Our results suggest that EMB is a clinically useful tool in patients presenting with features suggestive of a primary myocardial disorder.

Biopsy↗

PubMed1993

The use of aspirin in cardiovascular disease.

Aspirin has many uses in cardiovascular disease. It is used for primary prophylaxis; as an adjunctive therapy in angina, acute myocardial infarction, and thrombolytic therapy; and to promote vessel patency after angioplasty and coronary artery bypass grafting. This article reviews the recent research findings on the use of aspirin in cardiovascular disease and discusses remaining questions and nursing implications.

Aspirin↗

PubMed1996

Myocardial revascularization procedures on multisegment diseased left anterior descending artery: endarterectomy or multiple sequential anastomoses (jumping)?

Complete revascularization is the primary goal in coronary surgery because of its superior long term results. However, in some patients the extent of the coronary artery disease is such that the usual coronary bypass technique may not allow to perform a complete myocardial surgical revascularization and, consequently, a satisfactory myocardial perfusion: so complementary revascularization techniques may become mandatory, especially when the diseased vessel is LAD or its branches. As a consequence, alternative procedures should be undertaken: coronary endarterectomy (EA) and multiple sequential anastomoses on a single vessel (jump), which guidelines are actually somehow controversial. Between January, 1989, and May, 1992, 53 patients underwent a myocardial revascularization procedure on LAD system unsuitable for single distal bypass; of them 35 (66%) underwent coronary endarterectomy, while in 18 (34%) multiple sequential anastomoses (jumping) were performed on the same vessel. About preoperative variables, average NYHA class (2.7 jump vs 2.1 EA group, p < 0.05), the history of more than 1 myocardial infarction (22.2% jump vs 2.9% EA, p < 0.04) and the presence of preoperative nitrates e.v (33.3% vs 8.6%, p < 0.04) were statistically higher in the jump group, suggesting a more unstable clinical status, while other clinical echocardiographic and catheterization features were not statistically different. For what operative and postoperative features are concerned, the number of anastomoses performed was statistically higher in the jump group, as exasperated (3.8 vs 2.7, p < 0.002) while perfusion (138 vs 141 min) and crossclamp time (103 vs 106 min) were similar. Furthermore we found a statistically lower incidence of perioperative myocardial infarction (0% jump is 22.8% EA group, p < 0.04); the postperfusion inotropic drugs requirement (22.2% vs 37.1%), the need of an intraaortic counterpulsation (0% vs 2.9%) and the in-hospital mortality (0% vs 5.7%) were lower in the jumping group too, also if they didn't reach statistical significance. Our experience suggest, also with the limits imposed by a retrospective case review and by a low number of cases reported, that myocardial revascularization of a multisegment diseased LAD system may be safely performed with the jumping technique with a low incidence of postoperative complications: it should be the first choice technique when conventional revascularization procedures are not enough to achieve complete myocardial revascularization. We advocate the use of EA technique only in that cases characterized by a diffuse atherosclerotic core and a well delimited plane of dissection, associated to a very poor runoff, which really excludes any chance to multiple anastomoses.

Aged↗

PubMed1996

Thirty-day case-fatality rates for pulmonary embolism in the elderly.

BACKGROUND: Short-term race- and sex-specific case- fatality rates for pulmonary embolism (PE) in the elderly have not been studied previously, to our knowledge. OBJECTIVES: To examine 30-day race- and sex-specific case-fatality rates of PE in the Medicare population and to determine the risk of fatality when PE was a secondary diagnosis in 6 primary concurrent conditions and 3 surgical procedures. METHODS: Case-fatality rates were determined using the Medicare Provider Analysis and Review Record tiles from 1984 through 1991. All Medicare Part A beneficiaries aged 65 years or older were included, yielding more than 400,000 patients with PE. Case-fatality rates 30 days from hospital admission were calculated for both a primary discharge diagnosis of PE and a secondary discharge diagnosis of PE. RESULTS: Blacks with PE as a primary discharge diagnosis had an overall age-adjusted case-fatality rate of 16.1% compared with a rate of 12.9% for whites. When PE was a secondary diagnosis, blacks also had higher rates than whites (34.7% vs 30.2%). Men had a fatality rate of 13.7% whereas women had a rate of 12.8% when PE was the primary diagnosis. For a secondary diagnosis of PE, men had a rate of 32.8% compared with a rate of 28.6% for women. The risk of fatality was very high when PE was a secondary discharge diagnosis in 6 primary concurrent conditions (congestive heart failure, cancer, chronic obstructive pulmonary disease, myocardial infarction, hip fracture, and stroke) and 3 common surgical procedures (coronary artery bypass graft, hip replacement, and knee replacement) relative to the case-fatality rate when PE was not present in these conditions. CONCLUSIONS: Our results indicate that there are racial and gender differences in 30-day case-fatality rates for PE in elderly patients. The high fatality risk associated with PE as a comorbid factor among common primary concurrent conditions and procedures calls attention to the need for more effective prophylaxis of deep vein thrombosis and rapid diagnosis and treatment of PE when it occurs.

Age Distribution↗

PubMed2005

Azithromycin for the secondary prevention of coronary events.

BACKGROUND: Epidemiologic, laboratory, animal, and clinical studies suggest that there is an association between Chlamydia pneumoniae infection and atherogenesis. We evaluated the efficacy of one year of azithromycin treatment for the secondary prevention of coronary events. METHODS: In this randomized, prospective trial, we assigned 4012 patients with documented stable coronary artery disease to receive either 600 mg of azithromycin or placebo weekly for one year. The participants were followed for a mean of 3.9 years at 28 clinical centers throughout the United States. RESULTS: The primary end point, a composite of death due to coronary heart disease, nonfatal myocardial infarction, coronary revascularization, or hospitalization for unstable angina, occurred in 446 of the participants who had been randomly assigned to receive azithromycin and 449 of those who had been randomly assigned to receive placebo. There was no significant risk reduction in the azithromycin group as compared with the placebo group with regard to the primary end point (risk reduction, 1 percent [95 percent confidence interval, -13 to 13 percent]). There were also no significant risk reductions with regard to any of the components of the primary end point, death from any cause, or stroke. The results did not differ when the participants were stratified according to sex, age, smoking status, presence or absence of diabetes mellitus, or C. pneumoniae serologic status at baseline. CONCLUSIONS: A one-year course of weekly azithromycin did not alter the risk of cardiac events among patients with stable coronary artery disease.

Aged↗

PubMed2005

[MR imaging in cardiomyopathies].

According to the WHO classification, cardiomyopathies are a group of diseases which are associated with myocardial dysfunction and can be classified either as primary or secondary cardiomyopathies. Genetic disorders have been identified in certain primary cardiomyopathies, however often the etiology remains unknown. The term "secondary cardiomyopathy" is used to specify diseases with the clinical indications of a cardiomyopathy, but can be attributed to a certain pathophysiological mechanism such as exposure to toxic substances, metabolic syndromes or systemic diseases. Based on morphological and functional criteria, primary cardiomyopathies are divided into dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC) and restrictive cardiomyopathy (RCM). During the last two decades MR imaging has emerged to a well established diagnostic tool for the understanding and treatment of cardiomyopathies. Morphological and functional information can be achieved with a high level of accuracy and reproducibility. Tissue alteration of the myocardium can be detected assessing regional contrast enhancement, T1- and T2-signal intensities and chemical shift phenomena. This article describes characteristic aspects of MR imaging for the diagnosis of primary and secondary cardiomyopathies.

Adult↗

PubMed2003

Low-dose aspirin for primary prevention of cardiovascular disease.

Progressive atherosclerosis followed by plaque rupture is the leading cause of acute cardiovascular events. Inhibition of platelet aggregation by acetylsalicylic acid (aspirin) reduces recurrent cardiovascular events in secondary prevention trials. By extracting data from available randomized trials that examined aspirin prevention in persons without previously known cardiovascular disease, we evaluated the use of aspirin as a primary prevention measure. Using the raw data presented in the source publication on death, fatal and nonfatal myocardial infarctions, and cerebrovascular accidents, all relative and absolute risk reductions were recalculated with confidence intervals. In healthy men above 45 years of age, men with an increased cardiovascular risk profile, and persons with diabetes mellitus or hypertension, the use of aspirin reduces the incidence of myocardial infarction and has a neutral effect on cerebrovascular events. The protective effect of aspirin is apparently most prominent in those persons with an increased risk of manifest atherosclerotic vascular disease. Notwithstanding these results, for each patient it remains essential to balance the cardiovascular risk profile against the small increased risk of bleeding complications when prescribing aspirin.

Aspirin↗

PubMed2002

Overweight and obesity as determinants of cardiovascular risk: the Framingham experience.

BACKGROUND: To our knowledge, no single investigation concerning the long-term effects of overweight status on the risk for hypertension, hypercholesterolemia, diabetes mellitus, and cardiovascular sequelae has been reported. METHODS: Relations between categories of body mass index (BMI), cardiovascular disease risk factors, and vascular disease end points were examined prospectively in Framingham Heart Study participants aged 35 to 75 years, who were followed up to 44 years. The primary outcome was new cardiovascular disease, which included angina pectoris, myocardial infarction, coronary heart disease, or stroke. Analyses compared overweight (BMI [calculated as weight in kilograms divided by the square of height in meters], 25.0-29.9) and obese persons (BMI > or =30) to a referent group of normal-weight persons (BMI, 18.5-24.9). RESULTS: The age-adjusted relative risk (RR) for new hypertension was highly associated with overweight status (men: RR, 1.46; women: RR, 1.75). New hypercholesterolemia and diabetes mellitus were less highly associated with excess adiposity. The age-adjusted RR (confidence interval [CI]) for cardiovascular disease was increased among those who were overweight (men: 1.21 [1.05-1.40]; women: 1.20 [1.03-1.41]) and the obese (men: 1.46 [1.20-1.77]; women: 1.64 [1.37-1.98]). High population attributable risks were related to excess weight (BMI > or =25) for the outcomes hypertension (26% men; 28% women), angina pectoris (26% men; 22% women), and coronary heart disease (23% men; 15% women). CONCLUSIONS: The overweight category is associated with increased relative and population attributable risk for hypertension and cardiovascular sequelae. Interventions to reduce adiposity and avoid excess weight may have large effects on the development of risk factors and cardiovascular disease at an individual and population level.

Adult↗

PubMed2003

Genetics of arrhythmogenic right ventricular cardiomyopathy--status quo and future perspectives.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a primary myocardial disorder of unknown origin. In recent years, the disease has been recognized as a major cause of ventricular tachyarrhythmias and sudden cardiac death in young patients with apparently normal hearts. Although characteristic structural, imaging and electrocardiographic features are included in a proposed catalogue of diagnostic criteria, the correct diagnosis of ARVC often remains difficult. Much effort has been undertaken to enlarge the knowledge on pathophysiological mechanisms of the disease. The role of molecular genetics for the pathogenesis of ARVC is discussed in the following review. On the basis of linkage analyses in large families affected by ARVC, there is growing evidence for genetic alterations in ARVC, which, in the majority of chromosomal loci (seven) reported so far, follow a Mendelian autosomal-dominant pattern of inheritance with variable penetrance and polymorphic phenotype. Besides this, two autosomal-recessive forms of ARVC are known. These can be differentiated from the autosomal-dominant forms not only in terms of the mode of inheritance but also as to their specific phenotype: patients with Naxos disease exhibit characteristic hair and skin abnormalities and experience a more severe course of disease. Patients with another autosomal-recessive form display the typical but milder signs of ARVC together with opacifications of the crystalline lens. So far, two mutations in cardiac genes responsible for the development of ARVC have been reported. A homozygous two base pair deletion in the gene encoding for the cytoskeletal protein plakoglobin seems to account for the evolution of Naxos disease. The second mutation affecting the cardiac ryanodine receptor gene was found in patients with ARVC-2. Routine genetic testing of patients or relatives with a suspected diagnosis of ARVC is not available at present but may become the future gold standard with potential implications for a better understanding of the pathogenesis and management of the disease.

Abnormalities, Multiple↗