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PubMed2004

The role of aspirin in cardiovascular diseases--forgotten benefits?

The increasing burden of cardiovascular diseases in developed, as well as developing countries, underscores the need for the more widespread and appropriate use of aspirin in secondary prevention of occlusive vascular events during acute evolving myocardial infarction (MI) and in primary prevention. Aspirin should be far more widely used in a wide range of patients who have suffered a prior occlusive vascular event and in all patients suffering acute MI or occlusive stroke. Finally, in primary prevention, aspirin should be considered for individuals whose 10-year risks of a coronary event are > or = 10%, as an adjunct not alternative to the management of other risk factors. The more widespread and appropriate use of aspirin will avoid many premature deaths in secondary prevention and MIs in primary prevention.

Aspirin↗
PubMed2005

Management of coronary heart disease: stable angina, acute coronary syndrome, myocardial infarction.

Stable angina should first be treated medically, particularly with aspirin and beta-blockers. Diagnostic stress tests are used in patients who have intermediate probability of CHD to further assess the likelihood of disease,with catheterization reserved for patients who have symptoms despite optimal medical therapy or are at risk for multivessel CHD. The work-up for low-risk unstable angina can involve medical management followed by stress testing. Moderate-to-high risk unstable angina and NSTEMI should be treated with an integrated approach, using medical therapy, cardiac catheterization, and revascularization. Patients who have STEMI require urgent reperfusion either with thrombolytic agents or primary angioplasty. Follow-ing a diagnosis of CHD, patients should undergo intense coronary risk-fac-tor modification to reduce the risk of future events.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

[Anti-aggregants in 1990].

Antiplatelet drugs are increasingly used in the prevention of arterial thrombosis. Aspirin in doses of circa 300 mg day may be recommended for the primary prevention of myocardial infarction, but only in subjects at moderate to high risk of cardiovascular disease. Antiplatelet agents are useless in stable angina, but aspirin reduced by about 50% the risk of myocardial infarction and the overall mortality rate among patients with unstable angina. A lower dose of aspirin (150 mg/day) also reduces mortality by 23% in the acute phase of myocardial infarction. In doses of 300 mg/day, aspirin is useful in the secondary prevention of myocardial infarction and reduces the overall mortality rate by 15%. Various antiplatelet agents, including aspirin (alone or combined with dipyridamole) and ticlopidine, have proved useful to avoid thrombosis in aorto-coronary grafts, provided treatment begins at the latest 6 hours after surgery. The usefulness of antiplatelets has been well established in the prevention of immediate reocclusion following coronary angioplasty, but not in the prevention of late reocclusion. Aspirin and ticlopidine are useful in the extracorporeal circulation techniques. In patients with cardiac valve prosthesis, antivitamin K anticoagulants are still indispensable, but their antithrombotic effect can be reinforced by dipyridamole or aspirin. Diuretics probably provide the best primary protection against cerebrovascular accidents, although medium doses of aspirin may be considered in elderly people at high risk of such accidents. Aspirin (alone or combined with dipyridamole) and ticlopidine may be recommended for the secondary prevention of cerebral ischaemic accidents.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed2005

Effects of anemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease.

Left ventricular hypertrophy (LVH) and anemia are highly prevalent in moderate chronic kidney disease (CKD). Because anemia may potentiate the adverse effects of LVH on cardiovascular outcomes, the effect of both anemia and LVH on outcomes in CKD was examined. Data from four community-based longitudinal studies were pooled: Atherosclerosis Risk in Communities Study, Cardiovascular Health Study, Framingham Heart Study, and Framingham Offspring Study. Serum creatinine levels were calibrated indirectly across studies, and GFR was estimated using the Modification of Diet in Renal Disease equation. CKD was defined as GFR between 15 and 60 ml/min per 1.73 m(2). LVH was based on electrocardiogram criteria. Anemia was defined as hematocrit <36% in women and 39% in men. The primary outcome was a composite of myocardial infarction, stroke, and death; a secondary cardiac outcome included only myocardial infarction and fatal coronary heart disease. Among 2423 patients with CKD, 96% had electrocardiogram and anemia data. Median follow-up was 102 mo. In adjusted analysis, LVH was associated with increased risk for composite and cardiac outcomes (hazard ratio [HR], 1.67 [95% confidence interval (CI), 1.34 to 2.07] and 1.62 [95% CI, 1.18 to 2.24], respectively), whereas anemia was associated with increased risk for the only composite outcome (HR, 1.51 [95% CI, 1.27 to 1.81]). The combination of anemia and LVH was associated with an increased risk for both study outcomes compared with individuals with neither risk factor (HR, 4.15 [95% CI, 2.62 to 6.56] and 3.92 [95% CI, 2.05 to 7.48]; P = 0.02 and 0.01 for interaction term, respectively). The combination of anemia and LVH in CKD identifies a high-risk population.

Aged↗
PubMed1993

Valve replacement for aortic stenosis: the curative potential of early operation.

Concentric hypertrophy of the left ventricular wall is the primary consequence of acquired aortic stenosis (AS). Reduced left ventricular (systolic) function usually returns to normal after aortic valve replacement (AVR) in AS. Afterload mismatch prior to AVR, and not reduced contractility, is thought to be the explanation. Together with "the prosthetic valve disease" the afterload mismatch theory is used conceptually to postpone AVR until severe symptoms prevail. However, latent or manifest myocardial ischaemia/hypoxia is a central abnormality in concentric hypertrophy, also in the absence of coronary artery disease (CAD); impaired left ventricular diastolic function due to both reduced (active) relaxation and passive qualities of hypertrophied muscle is the primary cause of congestive failure symptoms. Reduced systolic function (ejection fraction) develops in succession, and dilation of the ventricle is an end-stage phenomenon. With the present timing of operative intervention significant late excess mortality from congestive heart failure is the rule after AVR in AS. Early functional improvement is probably related to reduced myocardial oxygen demand associated with afterload reduction caused by AVR, irrespective of irreversible myocardial disease. Employing a 22-year surgical series, multivariate predictive models were made for the following effect measures of AVR: early mortality, long term survival, prosthesis related complications, sudden heart related events, recurrence of congestive heart failure, heart pathology at autopsy, and left ventricular systolic and diastolic function 12 years after AVR. A prognostic index was calculated for each patient from variables related to pre-AVR degree of heart disease. A low prognostic index corresponding to operative intervention early in the course of AS predicted an operative mortality approaching zero, a normal sex and age specific long term survival, a normal rate of the quantitatively most important prosthesis related complications, a normal rate of heart related events, complete symptom freedom early after the operation without late return of congestive heart failure, and normal left ventricular function late after the operation. Complete regression of left ventricular hypertrophy was a dominant underlying mechanism. Imparied diastolic function of the left ventricle at late reinvestigation, being related to significant residual hypertrophy, was the sole predictor of fatal congestive heart failure irrespective of (a usually normal) ejection fraction. A policy of consistent coronary artery bypass grafting concomitant with AVR in case of CAD reduced early mortality rate in such patients, including the elderly, to the (low) level of those without CAD. A normal survival can, however, not be anticipated in AS patients with concomitant CAD.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1997

Continuous retrograde cardiac perfusion decreases risk of reoperative coronary artery bypass grafting.

Embolization of atheromatous debris from old saphenous vein grafts is a major factor that increases the risk of reoperative coronary artery bypass grafting (CABG) when compared with primary CABG. To decrease this risk, a technique consisting of minimal dissection of the heart prior to cross clamping, continuous retrograde coronary sinus perfusion with 32 degrees C blood, and temporary posterior cardiac interventricular vein occlusion, during which time all dissection and anastomoses are performed, was evaluated prospectively in 130 consecutive patients from January 2, 1991, through February 28, 1995. This group was compared with a cohort of 1107 patients undergoing primary CABG performed concurrently. The two groups were similar in age (median sixty-eight years), incidence of hypercholesterolemia, peripheral vascular disease, smoking history, and left main stem stenosis. More patients undergoing reoperative CABG had previous myocardial infarctions (61.5% vs 54.5%), a higher incidence of triple-vessel coronary artery disease (89.2% vs 77.1%, P = 0.002), and a lower ejection fraction (54.0% vs 56.9%). The median interval from primary CABG to reoperative CABG was one hundred twenty-seven months with a range of 2.5 to two hundred seventy-nine months. The cross clamp time (median one hundred three vs sixty-nine minutes, P = 0.000001) and perfusion time (median one hundred thirty-four vs ninety-four minutes, P = 0.000001) were significantly higher in the reoperative CABG group. The requirements for inotropic support postoperatively, perioperative myocardial infarction (1.5% vs 2.4%, P = 0.397), and mortality (3.1% vs 3.4%, P = 0.54) were statistically equivalent in the two groups. These data reveal that continuous retrograde coronary sinus perfusion, posterior cardiac interventricular vein occlusion, and single cross-clamping technique improve outcomes of reoperative CABG to that approaching primary CABG.

Aged↗
PubMed1977

Family planning and the primary care physician.

Family planning has become an important issue in modern life. The physician must be prepared to advise patients on the advantages and risks of both old and new methods and to determine which method is most acceptable and will therefore be most effective.

Abortion, Induced↗
PubMed2003

Effects of ACE inhibition versus non-ACE inhibitor antihypertensive treatment on myocardial fibrosis in patients with arterial hypertension. Retrospective analysis of 120 patients with left ventricular endomyocardial biopsies.

BACKGROUND AND PURPOSE: In experimental arterial hypertension, left ventricular hypertrophy (LVH) becomes pathologic with impaired myocardial function if myocardial fibrosis occurs. Myocardial fibrosis is associated with activated circulating or local renin-angiotensin-aldosterone systems. The primary objective of this retrospective study was to determine whether patients with arterial hypertension treated with angiotensin-converting enzyme inhibitors (ACEI) have less myocardial fibrosis than patients on non-ACEI treatment. MATERIAL AND METHODS: We examined left ventricular (LV) endomyocardial biopsies of 97 consecutive patients with hypertensive heart disease due to primary hypertension treated with either any ACEI for at least 6 months (n = 34; HTN + ACEI) or non-ACEI antihypertensive drugs (n = 63; HTN). Normal hearts designated for heart transplantation served as controls (n = 23; CTR). Myocyte diameter (MyoD) and collagen volume fraction (CVF) were measured by morphometry, and pro-matrix metalloproteinases (proMMPs) 2 and 9 by zymography. In a subset of 35 patients, LV myocardial stiffness was determined by left heart catheterization with calculation of stiffness constant k. RESULTS: In HTN + ACEI or HTN, MyoD (21.8 +/- 0.3 micro m and 22.4 +/- 0.3 micro m, respectively) and CVF (5.3 +/- 0.6% and 7.6 +/- 0.7%, respectively) were increased (p < 0.01) compared with CTR (16.0 +/- 0.4 micro m and 0.5 +/- 0.2%, respectively). In HTN + ACEI, CVF was significantly lower (p < 0.02) and proMMP 2 was higher (0.063 +/- 0.013 OD/mg) compared with HTN (0.037 +/- 0.006 OD/mg; p < 0.05) while no significant difference of MyoD was evident. We found no correlation between CVF and MyoD (r = 0.13; p = 0.47), a positive correlation between k and CVF (r = 0.71; p < 0.00001), and no correlation between k and MyoD (r = 0.22; p = 0.24). CONCLUSION: In patients with hypertensive heart disease, myocyte hypertrophy and myocardial fibrosis are present. Myocardial fibrosis and not myocyte hypertrophy determines myocardial stiffness. ACEI appear to diminish myocardial fibrosis associated with enhanced collagen degradation irrespective of LVH regression.

Aged↗
PubMed2000

[Economic evaluation of different treatment strategies in patients with stable angina pectoris or asymptomatic myocardial ischemia on basis of results from the Asymptomatic-Cardiac-Ischemia Pilot study (ACIP)].

BACKGROUND: In patients with stable angina pectoris or silent myocardial ischemia, who had signs of ischemia in ECG during exercise, the Asymptomatic Cardiac Ischemia Pilot (ACIP) study compared 2 types of medication strategies (ischemia-guided and angina-guided) and a strategy of primary revascularization by PTCA or CABG. ACIP substantiated, after 2 years of observation, a clear advantage of the revascularization strategy compared to both drug strategies in terms of clinical effectiveness. This advantage is even more distinct in patients with very severe angiographic results. PATIENTS AND METHODS: This is a retrospective, incremental cost-effectiveness analysis from the perspective of the German third party payer (statutory sick funds) on the basis of the ACIP study. RESULTS: The direct costs of the revascularization strategy after 2 years are about 2 to 3 times higher than those of the drug therapies. The incremental cost-effectiveness of the ischemia-guided strategy versus an angina-guided strategy is DM 2,600 per life-year saved. Furthermore, the cost-effectiveness of a revascularization strategy versus an angina guided therapy is DM 15,100 per life-year saved. CONCLUSION: A primary revascularization strategy is cost-effective in patients with stable coronary artery disease with proven myocardial ischemia and positive angiographic signs.

Aged↗
PubMed2000

[Prognosis after primary acute myocardial infarction].

Results from many clinical trials have changed treatment strategies, but due to considerable selection caused by extensive inclusion- and exclusion criteria the results are only valid for smaller groups, while the majority of the patients still suffer from high mortality with conservative treatment. We have during eight years followed 933 patients with first myocardial infarction and found that the group who tolerated treatment with thrombolytic agents had a lower mortality than the rest. On the other hand, infarct patients are generally old, often with concomitant chronic diseases which affect mortality, and this in combination with heart-failure and cardiac arrhythmias determines outcome. Better prophylactic and treatment measures are needed to improve survival of ischaemic heart disease.

Acute Disease↗
PubMed1985

Antihypertensive therapy and myocardial infarction: focus on calcium antagonists.

Effective antihypertensive therapy has recently been shown to reduce not only the incidence of stroke, but also myocardial infarction irrespective of the drug(s) used. The well-documented preventive effect of beta-blockers in patients who suffered a myocardial infarction (secondary prevention) cannot be extended to patients with hypertension without overt coronary artery disease (primary prevention), except perhaps for non-smoking men. Despite strong experimental evidence, information on a possible secondary preventive effect of calcium antagonists in man is scant, and two double-blind placebo-controlled trials in secondary prevention with verapamil (320 mg) in a total of 1436 patients and nifedipine (30 mg) in 2279 patients did not reveal an overall treatment benefit. There are another six on-going trials. In the management of hypertension, large-scale trials may never help in selecting a particular drug for cardiac event reduction, and probably for many years the goals will be to normalize blood pressure with increased emphasis on the need to remedy other cardiovascular risk factors, in particular smoking.

Adrenergic beta-Antagonists↗
PubMed2000

[Effect of cholesterol reducing therapy with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor on secondary prevention after myocardial infarction in Japanese patients].

Lowering the blood cholesterol level is a safe method to improve survival for primary and secondary prevention of coronary heart disease. However, there is no evidence for any effectiveness in Japanese. This study was designed to evaluate the effect of cholesterol lowering therapy with 3-hydroxy-3-methylglutaryl coenzyme A(HMG-CoA) reductase inhibitor on cardiac events(death and reinfarction) in Japanese patients after myocardial infarction. A total of 290 patients after myocardial infarction were studied retrospectively. The patients were divided into 2 groups with or without HMG-CoA reductase inhibitor therapy for lowering blood cholesterol levels. The cumulative cardiac events and percentage change of cholesterol levels[total cholesterol and low-density lipoprotein (LDL) cholesterol level] were compared between the 2 groups. HMG-CoA reductase inhibitor therapy lowered plasma cholesterol levels significantly (total cholesterol level--11 +/- 20%, LDL cholesterol level--23 +/- 26%) in patients with hypercholesterolemia, whereas there was no change(total cholesterol level 4.3 +/- 22%, LDL cholesterol level--7.2 +/- 24%) in patients without hypercholesterolemia. HMG-CoA reductase inhibitor therapy reduced cardiac events significantly compared in patients with hypercholesterolemia(p = 0.0008), but there was no benefit in patients without hypercholesterolemia. We suggest that treatment with HMG-CoA reductase inhibitor therapy for lowering cholesterol levels was effective for secondary prevention after myocardial infarction in Japanese patients with hypercholesterolemia.

Anticholesteremic Agents↗
PubMed1985

Patients with malignant or potentially malignant ventricular arrhythmias: opportunities and limitations of drug therapy in prevention of sudden death.

Almost 90% of patients resuscitated from out of hospital cardiac arrest have coronary heart disease and can be categorized in one of three groups: acute myocardial infarction, ischemic event or primary arrhythmic event. The patients who have acute myocardial infarction have the best prognosis, and those with primary arrhythmic events have the worst. Recent studies show that ventricular arrhythmias after myocardial infarction are associated with mortality independent of any association with left ventricular dysfunction. Ventricular arrhythmias that have caused cardiac arrest or hemodynamic collapse, that is, malignant arrhythmias, should be treated aggressively and evaluated carefully with one of two methods that have high predictive accuracy for outcome: 1) the Holter recording/exercise test approach, or 2) the electrophysiologic approach. It is not yet known whether treating potentially malignant ventricular arrhythmias after myocardial infarction with class I or III antiarrhythmic drugs will reduce mortality, but two clinical trials are under way in the United States to address this question. Beta-adrenergic blocking drugs do reduce mortality, probably as a result of both antiischemic and antiarrhythmic effects. Calcium channel blocking agents, various antiplatelet drugs and alpha-adrenergic blocking drugs are under investigation to determine their value in secondary prevention of ventricular fibrillation.

Animals↗
PubMed2000

Treatable cardiomyopathies.

Cardiomyopathy is defined as primary myocardial dysfunction which is not due to hypertensive, valvular, congenital, coronary or pulmonary vascular disease. This term usually denotes a dismal prognosis short of cardiac transplantation. However, several organic diseases of the heart can result in right or left ventricular dysfunction resulting in congestive heart failure and prompting the physician to label them as cardiomyopathy; the etiological factor is overlooked as it produces very subtle features. Therefore, before labelling any child as cardiomyopathic, all possible causes of ventricular dysfunction must be excluded by clinical and investigative means. The causes of "treatable cardiomyopathy" include mechanical factors as critical aortic stenosis and pulmonic stenosis, severe coarctation of aorta in an infant and aortaarteritis is an older child. Some of the persistent arrhythmias like atrial tachycardia, fibrillation, paroxysmal junctional re-entrant tachycardia are also known for causing ventricular dysfunction producing tachycardiomyopathy. Treatment of arrhythmia improves the ventricular function. Myocardial ischemia as a result of congenital coronary anomaly (commonest being anomalous origin of left coronary artery from pulmonary artery) can also present with a cardiomyopathy like picture. Early surgical correction is very rewarding. Finally, some of the metabolic conditions like creatinine and thiamine deficiency can also produce ventricular dilatation and dysfunction. In conclusion, the so called cardiomyopathy like picture can be produced because of several reasons and an attempt must be made to identify them.

Cardiomyopathies↗
PubMed1998

[Current indications for implantable automatic defibrillators].

Since the first implantation in man in 1980 implantable cardioverter defibrillator technology has greatly improved and the number of devices implanted has increased considerably in recent years. Non-thoracotomy lead systems and biphasic shocks are now the approach of choice, offering nearly a 100% success rate. This paper version reviews the current indications for the implantation of implantable cardioverter defibrillator and is an upgraded of an article previously published by the Arrhythmia's Section of the Spanish Society of Cardiology. Recommendations for qualification of centres implanting defibrillators and follow up are also addressed.

Aged↗
PubMed1999

Increasing inequality in ischaemic heart disease morbidity among employed men in Denmark 1981-1993: the need for a new preventive policy.

BACKGROUND: In the mid 1980s European governments committed themselves to the WHO goal 'reduced inequality in health by year 2000' according to which inequality in health should be reduced by 25% by the year 2000. The study aim is to estimate the time trend in relative risk due to ischaemic heart disease (IHD) morbidity in employment status groups in Denmark in the period from 1981 to 1993 and to recommend a strategy to reduce inequality in health. MATERIAL AND METHODS: The study dealt with change in relative risk of IHD in main employment status AND groups as measured in three successive cohorts. The cohorts were defined as all METHODS: gainfully employed men in Denmark as of 1 January 1981, 1986 and 1991, respectively. Information on employment was retrieved for the three previous years. The cohorts were followed for first admissions with IHD as the principal cause during 5, 5, and 3 years respectively. RESULTS: Managers and white collar workers had an average or low and decreasing relative risk while male blue collar workers had a high and increasing relative risk. Thus the social inequality in IHD is rapidly increasing. Some occupational groups are known to be at high risk. Some of these high-risk groups, such as bus drivers, even have an increasing relative risk. CONCLUSIONS: The general health education has been successful in the prevention of IHD in the high-status groups but has failed to reduce the risk among blue collar workers. Preventive measures against IHD should focus on occupational groups at high, increasing risk and the measures should tailor to their 'subculture.'

Adult↗
PubMed2001

Trial to show the impact of nicorandil in angina (IONA): design, methodology, and management.

OBJECTIVE: IONA (impact of nicorandil in angina) is a randomised, double blind, placebo controlled trial that will test the hypothesis that nicorandil (target dose of 20 mg twice daily) will reduce the incidence of cardiovascular events in a cohort of men and women with effort angina and additional risk factors. METHODS: The primary composite end point of the study is coronary heart disease death, non-fatal myocardial infarction or unplanned hospital admission for cardiac chest pain, and the secondary end point is the combined outcome of coronary heart disease death or non-fatal myocardial infarction. Other cardiovascular outcomes and all cause mortality will also be reported. RESULTS: More than 5000 subjects have been randomised to receive nicorandil or placebo in addition to normal antianginal treatment. The target population, the assessments made, and the management of the trial are described in detail. CONCLUSIONS: The IONA study has achieved its first aim of randomising more than 5000 high risk subjects with effort angina. Subject follow up will be complete in the third quarter of 2001.

Angina Pectoris↗