Cardiovascular Disease Holistic Treatments

The Big Heart Disease Lie

The Big Heart Disease Lie is a book written by doctors who are members of the International Truth In Medicine Council they are also the authors of The Big Diabetes Lie. In this book you will be getting over 500 pages of scientifically proven, doctor verified information that you will not find anywhere else, not even bookstores.If you have high blood pressure or cholesterol, fatigue, shortness of breath, irregular heartbeat, swollen feet or ankles, chest pain, fainting, diabetes, asthma or allergies, pain, fatigue, inflammation, any troubling health issue, or simply want to discover the most powerful health and anti-aging program, then you really need to read this book. The book is a step by step guide that contains techniques scientifically verified and proven by doctors to reverse the symptoms of heart disease, and normalize blood pressure and cholesterol levels. These techniques have been used successfully by tens of thousands of people all over the world, and allowed them to take health into their own hands, ending the need for drugs, hospitals, doctors' visits, expensive supplements or grueling workouts. More here...

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Acute myocardial infarction failed thrombolysis

Gravity Sewer System Layout

Reperfusion strategies in the early phase of treatment of acute myocardial infarction aim to rapidly normalise and maintain tissue perfusion. Primary angioplasty is probably the best current treatment but it can only be applied to a minority of patients and has its own problems. Thrombolysis remains the most commonly used treatment. It has well demonstrated benefits, saving lives and reducing left ventricular damage, but is far from perfect.1 The mega-trials have sent a clear message that the greatest benefits are seen with patients who are treated early. Clinical efforts have therefore been concentrated on educating the population to heed the early symptoms, encouraging rapid admission to hospital (sometimes with thrombolytic treatment being administered in the ambulance) and minimising door to needle times. Continuous and widespread use of audit increases the number of patients treated and the speed with which treatment is administered. Measurement of cardiac enzyme release has...

Myocardial Infarction and Unstable Angina

Diagnosis Rule out myocardial infarction 3 Condition -Heparin 70 U kg IV push, then 15-17 U kg hr by continuous IV infusion for 48 hours to maintain aPTT of 50-70 seconds. Check aPTTq6h x 4, then qd. Repeat aPTT 6 hours after each heparin dosage change. Glycoprotein IIb IIIa Blockers for Acute Coronary Syndromes Absolute Contraindications to Thrombolytics Active internal bleeding, history of hemorrhagic stroke, head trauma, pregnancy, surgery within 2 wk, recent non-compressible vascular puncture, uncontrolled hypertension ( 180 110 mmHg).

Developmental Origins of Cardiovascular Disease Type 2 Diabetes and Obesity in Humans

Fetal Origins Adult Disease

Fetal growth restriction and low weight gain in infancy are associated with an increased risk of adult cardiovascular disease, type 2 diabetes and the Metabolic Syndrome. The fetal origins of adult disease hypothesis proposes that these associations reflect permanent changes in metabolism, body composition and tissue structure caused by undernutrition during critical periods of early development. An alternative hypothesis is that both small size at birth and later disease have a common genetic aetiology. These two hypotheses are not mutually exclusive. In addition to low birthweight, fetal 'overnutrition caused by maternal obesity and gestational diabetes leads to an increased risk of later obesity and type 2 diabetes. There is consistent evidence that accelerated BMI gain during childhood, and adult obesity, are additional risk factors for cardiovascular disease and diabetes. These effects are exaggerated in people of low birthweight. Poor fetal and infant growth combined with recent...

Emergency Department Care Of Symptomatic Valvular Heart Disease

There is little that the emergency physician can do to change the structural abnormality of the diseased cardiac valve. The exception to this rule is acute mitral incompetence due to myocardial infarction. The infusion of thrombolytic therapy may reestablish blood flow to the papillary muscle, with restoration of function. 9 The alternative to thrombolytic therapy is coronary angioplasty.10 The majority of treatments are directed toward symptomatic relief of the manifestations of valvular disease. However, there are certain medical treatments that can reduce the consequences of the mechanical defect. The regurgitation of aortic and mitral incompetence may be lessened by reducing afterload. When the cause of mitral incompetence is myocardial ischemia, regurgitation can be lessened by treatment with nitrates. setting. Patients with valvular heart disease and acute pulmonary edema should be considered for Swan-Ganz catheter insertion. The presence of valvular disease, especially...

STSegment Elevation Myocardial Infarction

Diagnosis Rule out myocardial infarction 3 Condition Absolute Contraindications to Thrombolytics Active internal bleeding, suspected aortic dissection, known intracranial neoplasm, previous intracranial hemorrhagic stroke at any time, other strokes or cerebrovascular events within 1 year, head trauma, pregnancy, recent non-compressible vascular puncture, uncontrolled hypertension ( 180 110 mm Hg). Relative Contraindications to Thrombolytics Severe hypertension, cerebrovascular disease, recent surgery (within 2 weeks), cardiopulmonary resuscitation.

Coronary artery disease

Although atherosclerosis is a polygenic disease, certain susceptible genes have been ascertained through association studies in populations enriched for coronary artery disease. The results of these studies are still regarded as preliminary until causation is proved. Nevertheless, these susceptibility genes have shed light on the pathogenesis and are likely to be incorporated into future genetic profiles for risk stratification and treatment. There are obviously several components to coronary artery disease, namely, lipids and coagulation factors. The list of potential candidate genes for coronary atherosclerosis is extensive (Table 23.4). Two examples, ABCA1 and CYBA, are discussed briefly. Plasma levels of high density lipoprotein C (HDL-C) and its apolipoprotein A1 are under tight control of genetic factors, which are largely Table 23.4 Selected candidate genes for coronary atherosclerosis and myocardial infarction Grade B3

Cardiovascular Disease

The beneficial effects of potassium on blood pressure should reduce the occurrence of blood pressure-related cardiovascular disease. Potassium may also have protective effects that are independent of blood pressure reduction. This possibility has been tested in experimental studies conducted in rodents. In a series of animal models, the addition of either potassium chloride or potassium citrate markedly reduced mortality from stroke. Interestingly, these reductions occurred when blood pressure was held constant. Such data indicate that potassium has both blood pressure-dependent and blood pressure-independent properties that are cardioprotective. In many, but not all, epidemiologic studies, an inverse relationship between dietary potassium intake and subsequent stroke-associated morbidity and mortality has been noted. A few observational studies have also shown an inverse association between potassium intake and coronary heart disease. In a 12-year follow-up of 859 men and women...

Subacute Ischemic Stroke

EMBOLIC STROKE Patients with embolic stroke who have minor deficits should undergo anticoagulation. Older studies, which included patients with mechanical valves, found that 12 to 14 percent of stroke patients had recurrent emboli within 2 weeks of the initial event, some within 24 h. More recent trials found that only 1.5 percent of patients had recurrent embolism in the first 7 days,20 suggesting immediate administration of anticoagulants is unnecessary. The exact timing, method, and degree of anticoagulation following a stroke remain controversial, with little clear data guiding its use. Consultation and or locally approved specific protocols on its use are recommended. Anticoagulation with heparin should be withheld for 3 to 4 days following large cardioembolic stroke, because of the increased risk of spontaneous hemorrhagic changes associated with heparin in these types of strokes. The use of low-molecular-weight heparin and heparinoids in improving outcome remains to be proven....

Evaluation Of Fever In Infants With Heart Disease

Infants and children with known heart disease are prone to the same illnesses as other children. When they are brought to the emergency department for treatment of febrile illnesses, they are most likely to be hemodynamically stable and capable of handling the illness. Any signs of congestive heart failure are indications for an admission. Otherwise, blood cultures should be obtained, as well as a complete blood count, as would be performed for any infant between the ages of 6 months and 24 months. Although occult bacteremia has the same probability for occurrence in a child with congenital heart disease, concern for bacterial endocarditis must be greater. Oral or parenteral antibiotics should be administered with great care if presumptively treating early bacteremia or subacute bacterial endocarditis. It is more prudent to arrange admission, repeated cultures, and expectant therapy for such infants than to begin antibiotic therapy blindly simply because of the presence of congenital...

Congenital Heart Disease

Despite technical advances, neurologic complications of open heart surgery are estimated to occur in up to 24 of cases.111 The association between SDH and congenital heart disease (CHD) in infants is related to surgery and the postoperative period rather than a complication of untreated CHD. Humphreys et al.112 drew

Acute myocardial infarction in hospital

Yet another problem in identification of the natural history of acute myocardial infarction is that fully 25 of non-fatal infarctions are silent.8 Silent infarction can be detected only when a subject is seen more than once at annual intervals or longer, and an ECG performed on the second occasion shows new pathological Q waves. Most clinicians can remember such cases, but an estimate of the incidence can be made only when a cohort of the population free from coronary heart disease is followed for a number of years. This happened in the Framingham study a unique and prestigious study which has taught us more than any other about the changing pattern of coronary heart disease during the latter half of the 20th century.9

Adult Congenital Heart Disease In General Echocardiography Practice

Tga Echocardiography View

The spectrum of adult congenital heart defects seen in echocardiography practice varies according to institutional practice and expertise. Half a century ago, survival with severe congenital heart disease was less common. Today, nearly 80 of such patients in industrialized societies now survive into adulthood. Most are followed up in centers that specialize in adult congenital heart diseases (CHDs), but it is not uncommon for such adults to be seen in general echocardiography practice. Congenital Heart Disease in Adults Compatible With Survival to Adulthood With No Prior Surgery or Intervention Superimposed acquired age-related heart disease, e.g., hypertension, coronary artery disease. Spectrum of Congenital Heart Disease Modified from Kisslo JA, Adams DB, Leech GJ. Essentials of Echocardiography Congenital Heart Disease. New York Ceiba-Geigy, 1988. Fig. 5. Morphological left and right ventricle. What defines right vs left ventricle are the morphological characteristics. On...

Arteriosclerotic Heart Disease ASHD

The healthy heart and cardiovascular system tolerates even extreme hypoxia very well. Numerous ECG studies, echocardiograms, heart catheterizations and exercise tests do not demonstrate cardiac ischemia or cardiac dysfunction in healthy persons at high altitude, even when arterial Pa O2 was less than 30 mmHg. Those with arteriosclerotic disease may not have the same adaptive capabilities and intuitively seem more likely to suffer from acute cardiac events. Epidemiologic data, however, do not support this supposition. Morbidity and mortality from arteriosclerotic heart disease is reduced in persons with long-term residence at high altitude, and visitors apparently do not have increased risk of acute myocardial infarction. Recent work, however, suggested earlier onset of angina at high altitude compared with sea level during the first few days at 2500 m. After five days, an elderly group with CAD acclimatized well, and performed at sea-level exercise capacity without increased or...

Stroke Transient Ischemic Attack And Other Central Focal Conditions

The use of tissue plasminogen activator for select patients with ischemic stroke requires a high level of involvement by emergency physicians. The etiology of stroke is diverse, ranging from cardiac emboli to a rupture of a congenital berry aneurysm. Effective treatment for one stroke type may be disastrous when applied to another stroke type. The anatomic location of the lesion and the mechanism of the stroke must be determined before effective treatment can be administered.

Acute myocardial infarction

It is difficult now to perceive why coronary thrombosis was regarded 25 years ago as an inconstant and irrelevant consequence of acute infarction rather than its prime cause. Once angiography was carried out soon after the onset of infarction, and it was realised that the subtending artery was totally blocked but spontaneously reopened with time in many cases (and that this reopening was accelerated by fibrinolytic treatment), thrombosis was seen as a major causal factor in occlusion. Suddenly the clinical world found thrombi to be both dynamic and important. Pathologists had thought thrombi were important but did not realise how dynamic they could be. Sequential angiograms taken over some years in patients with chronic ischaemic heart disease also changed perceptions. It was realised that a significant proportion of the thrombotic occlusions causing infarction did not develop at sites where there was pre-existing high grade stenosis, or even a plaque identified at all. Sixty eight...

Biological programming a new theoretical model about the aetiology of heart disease

The dawn of modern epidemiology came after the second world war, first with ecological studies comparing CVD incidence and mortality, and subsequently multicentre cross sectional and follow up studies on CVD.w3 The studies showed that populations with high CVD mortality have high cholesterol and high blood pressure, and that smoking and obesity are common among these populations. 4 This led to the lifestyle model in understanding the aetiology of chronic diseases, where the key issues are health behaviour and the interaction between genes and an adverse environment in adult life. This was consequently followed by intervention programmes, which have significantly improved heart disease risk status in many countries.w3 However, lifestyle factors only explain part of the heart disease risk, which is why other reasons have been sought. For example, in the mid 1980s Rose pointed out that the well established risk factors for coronary heart disease (CHD) cigarette smoking, high serum...

Other possible models in the evolution of heart diseases and limitations of the studies

Figure 27.1 shows a simplified framework for the diVerent associations between the various factors in the prenatal period and their eVect on adult health. It is evident that no single model is able to explain heart disease risk. 2. Forsdahl A. Are poor living conditions in childhood and adolescence an important risk factor for arteriosclerotic heart disease Br J Prev Social Med 1977 31 91-5. 3. Barker DJP, Osmond C. Infant mortality, childhood nutrition, and ischaemic heart disease in England and Wales. Lancet 1986 i 1077-81. 4. Barker DJP, Winter PD, Osmond C, et al. Weight in infancy and death from ischaemic heart disease. Lancet 1989 ii 577-80. 5. Barker DJP. Fetal origins of coronary heart disease. BMJ 1995 311 171-4. relation of small head circumference and thiness at birth to death from cardiovascular disease. BMJ 1993 306 422-6. 9. Osmond C, Barker DJP, Winter PD. Early growth and death from cardiovascular disease in women. BMJ 1993 307 1519-24. 10. Vagero D, Leon D. Ischemic...

Myocardial Infarction

However in some patients, perhaps due to the hypercoagulable state associated with surgery, acute coronary syndromes will occur and present dramatically with extreme ST-elevation infarctions and even abrupt cardiac arrest. Treatment includes moving the patient to a monitored setting, and following ACLS protocols as indicated. In all cases, pain control, oxygenation, nitroglycerin, and aspirin therapy should be addressed or considered. Unless contraindicated, all patients should receive beta-blockers. Also, use of heparin and other thrombolytic therapy may be considered and cardiology consultation is appropriate.

The Genetic Origin of Congenital Heart Disease in Down Syndrome

Heart disease and defects of the cardiovascular system are responsible for the majority of premature deaths caused by congenital defects (Clark, 1987). Congenital heart disease (CHD) is particularly common in individuals with DS. It is detectable in 40-60 of individuals with DS and at autopsy in almost 70 of DS individuals. The schematic view of heart development shown in Figure 20.7 illustrates many of the regulatory molecules that play FIGURE 20.8. To identify the genes responsible for DS congenital heart disease (CHD), we compared the regions of chromosome 21 duplicated in eight different individuals with DS (represented by the black lines). The white box represents a single-copy region in individual DUP21ZSC. The region of overlap (candidate region) spans from D21S3 to at least PFKL and contains at least 35 known genes (shown on the right) (Hattori et al., 2000). Five of these genes are known to be expressed in the heart and may therefore contribute to heart disease in DS SH3BGR,...

General Approach to Treatment of Ischemic Stroke

Upon entry of patients with ischemic stroke into the emergency medical service (EMS) or emergency department setting, priority should be given to airway management and oxygenation. Patients should be placed on oxygen, the head of the bed slightly elevated, and a monitor and intravenous line established. Unless there is hypotension, fluids should be administered judiciously to prevent cerebral edema. Volume depletion in patients with ischemic stroke deserves prompt treatment, because it may contribute to decreased cerebral blood flow in the ischemic region. Avoidance of dextrose-containing solutions is warranted except in those with proven hypoglycemia. Hyperglycemia has been associated with an increase in infarct volume and poor long-term outcome. 67 Patients with fever should have antipyretics promptly administered. Experimental studies suggest that hyperthermia increases CNS metabolic demands, whereas hypothermia has demonstrated neuroprotective effects. The use of anticonvulsants...

Serum cholesterol and ischemic heart disease

Evidence from genetics, animal studies, experimental pathology, epidemiologic studies and clinical trials indicates conclusively that increasing serum cholesterol is an important cause of ischemic heart disease and that lowering serum cholesterol reduces the risk,5,6 and the results of six large randomized trials of statins have ensured that this is now widely accepted.1,7-11 Three important practical questions arise the nature of the dose-response relationship, the size of the effect, and the speed of the reversal of risk. To answer these questions data from both observational epidemiology (cohort studies) and randomized controlled trials are necessary. The two are complementary examining trial data alone is misleading. Table 12.1 summarizes the advantages of each. In cohort (or prospective) studies serum cholesterol is measured in a large number of individuals and subsequent heart disease mortality (or incidence of myocardial infarction) is recorded. Cohort studies are easier to...

Large Scale Community Coronary Heart Disease and Diabetes Prevention Trials

The results of early large-scale community CVD prevention trials, such as the Stanford Three Community and Five Community studies as well as the Minnesota Heart Health Program, had limited impact on weight status and reinforced the difficulty of preventing weight gain in the community. However, later programs, such as the Pawtucket Heart Health Program, were able to make a modest impact on weight gain in the intervention community after 10 years. These programs demonstrate the time lag that can be expected between the implementation of a truly community-wide program and the extent of behavior change likely to be required to impact upon the weight status of the community. It has been suggested that unless weight is the primary outcome of the intervention, it is unlikely that sufficient focus will be placed on achieving the level of change required to impact on energy balance and community weight status.

TABLE 473 Short Term Risk of Death or Nonfatal Myocardial Infarction in Patients with Unstable Angina

Myocardial ischemia and its sequelae usually occur as a result of fixed atheroscerotic lesions or secondary reduction in myocardial blood flow due to coronary arterial spasm, disruption of atherosclerotic plaques, and platelet aggregation or thrombus formation. Nonatherosclerotic etiologies of acute myocardial infarction are considerably less common (TabjeiZ-l).

Ischaemic heart disease

Overt hypothyroidism is associated with hyper-lipidaemia and coronary artery disease. Approximately 3 of patients with longstanding hypothyroidism report angina, and a similar proportion report it during treatment with thy-roxine. In most patients the angina does not change, diminishes or disappears when thyrox-ine is introduced however, it may worsen and up to 40 of those patients who present with hypothyroidism and angina cannot tolerate full replacement treatment. Moreover, myocardial infarction and sudden death are well recognised complications of starting treatment, even in patients receiving as little as 25 ig of thyrox-ine daily. For these reasons it is customary to begin treatment with thyroxine in patients with symptomatic ischaemic heart disease in a dose of 25 ig daily, increasing by 25 ig increments every three weeks until a dose of 100 ig daily is reached. After a further six weeks, serum free T4 and TSH should be measured and the dose of thyroxine adjusted to ensure that...

Acute coronary syndromes presentationclinical spectrum and management

Cardiac Enzymes

Acute coronary syndromes define a spectrum of clinical manifestations of acute coronary artery disease. These extend from acute myocardial infarction through minimal myocardial injury to unstable angina. This spectrum shares common underlying patho-physiological mechanisms. The central features consist of fissuring or erosion of atheromatous plaque with superimposed platelet aggregation and thrombosis. This is complicated by microfragmentation and distal embolisation with alterations in vascular tone in affected myocardium. As a consequence, clinical manifestations are dependent upon the severity of obstruction in the affected coronary artery (fig 3.1), the presence or absence of collateral perfusion, and the volume and myocardial oxygen demand within the affected territory. Thus, the spectrum extends from abrupt occlusion with acute ischaemia leading to infarction, through Table 3.1 Acute coronary syndromes The distinction between acute myocardial infarction and minimal myocardial...

Part B Acute Coronary Syndromes

Coronary artery disease is the most common cause of death in the United States, accounting for approximately 600,000 deaths annually. Of 6.0 million ED visits per year for chest pain, about 1.2 million people are diagnosed with myocardial infarction and another million with unstable angina. It has been estimated that the overall cost of coronary artery disease exceeds 100 billion dollars annually in the U.S. There is also a significant cost in terms of malpractice claims, with missed myocardial infarction and acute coronary syndromes continuing to constitute a large percentage of both claims and costs. Mortality and morbidity continue to decrease with advances in therapy. There was a 54 reduction in age-adjusted mortality from myocardial infarction in the U.S. from 222 100,000 in 1963 to 101 100,000 in 1990. Coronary artery disease (CAD) is a spectrum of disease that ranges clinically from asymptomatic or silent to one of the following clinical syndromes stable angina, variant angina...

Prevention of cardiovascular diseases89

9 Global perspective on cardiovascular disease 91 K Srinath Reddy 11 Tobacco and cardiovascular disease achieving smoking cessation 114 Godfrey H Fowler 12 Lipids and cardiovascular disease 121 Malcolm Law 13 Use of lipid lowering agents in the prevention of cardiovascular disease 130 Jeffrey L Probstfield 14 Blood pressure and cardiovascular disease 146 Curt D Furberg, Bruce M Psaty 15 Glucose abnormalities and cardiovascular disease dysglycemia as an emerging 161 cardiovascular risk factor 16 Physical activity and exercise in cardiovascular disease prevention and rehabilitation 170 Erika S Froelicher, Roberta K Oka, Gerald F Fletcher 17 Psychosocial factors in the primary and secondary prevention of coronary heart disease 181 an updated systematic review of prospective cohort studies 20 Postmenopausal hormone therapy and cardiovascular disease 244 Jacques E Rossouw 21 Ethnicity and cardiovascular disease 259 Sonia S Anand, Stephanie Ounpuu, Salim Yusuf 22 The fetal origins of...

Acute Coronary Syndromes

Increased left ventricular end-diastolic pressure increases the workload of the heart. Wall tension is one of the greatest determinants of myocardial oxygen needs. Increases in oxygen demand secondary to hypertension may result in angina. Myocardial infarction may also develop particularly among those with fixed lesions in coronary arteries, preventing appropriate delivery of required oxygen. Acute left ventricular failure with pulmonary edema may also develop. Treatment of left-sided heart failure should include agents that decrease both preload and afterload. other agents that have been used as adjuvant therapy include oxygen, morphine sulfate, and diuretics. The use of agents that increase myocardial oxygen demand, such as diazoxide, hydralazine, and minoxidil, should be avoided.

Role Of Diet In Cardiovascular Disease

Improper eating habits accompanied by the lack of exercise increase the risk of gaining excess weight, a major risk factor for heart disease, high blood pressure, and diabetes (14). Diet also affects plasma cholesterol levels. Cholesterol is carried in the blood associated with two major types of lipoproteins LDL and HDL. LDL cholesterol has been Table 7. Major Risk Factors for Cardiovascular Disease correlated with increased risk of cardiovascular disease. For many years it has been recognized that dietary cholesterol has only a limited effect on plasma cholesterol levels (17). Absorption of ingested cholesterol is poor, and part of the cholesterol in plasma is synthesized in the liver. High levels of dietary carbohydrate, especially complex carbohydrate, are associated with a decreased risk of cardiovascular disease (17). A recent study found rice bran as well as oat bran to have a hypocholesterolemic effect (26). Increasing intakes of a number of vitamins have also been shown to be...

Stroke Risk Factors

The Stroke Belt States Affected

Stroke risk factors are very well understood. Both modifiable and nonmodifiable risk factors are important. The nonmodifiable stroke risk factors are age, ethnicity, and sex. There are several modifiable stroke risk factors, including hypertension, hypotension, diabetes, atrial fibrillation, congestive heart failure, coronary artery disease, smoking, hyperlipidemia, The most important modifiable stroke risk factor, hypertension, is estimated to affect approximately 50 million Americans (23 of the U.S. population), or 44 of Americans at least 65 years of age. Approximately one-third of all strokes directly relate to the impact of hypertension. Hypertension increases the risk of stroke up to 400 the relative risk of stroke among persons with hypertension is four times higher than that among individuals lacking this risk factor. As many as 246,500 strokes might be prevented by eliminating the adverse impact of hypertension (i.e., 35 of 700,000 annual strokes). The odds that a person with...

Glucose levels and the risk for cardiovascular disease in nondiabetic patients

Many prospective studies have consistently showed that the relationship between glucose levels and the subsequent risk of cardiovascular disease extends well below the diabetic threshold. For example, after 10 years of follow up in the Whitehall study of 18050 non-diabetic male civil servants, there was up to a twofold increase in coronary heart disease and stroke mortality in subjects whose 2 hour postload capillary glucose value was greater than 5-4 mmol l compared to those with lower glucose levels. This increase was independent of age, smoking, blood pressure, cholesterol, and occupation.26,27 The relationship of non-diabetic-range hyperglycemia and cardiovascular disease was also clearly noted after 14 years in the Rancho Bernardo study.28 In this prospective study of 3458 non-diabetic men and women aged 40-70 with a fasting plasma glucose

Risk of cardiovascular disease in patients with diabetes

As noted above, diabetes is an independent risk factor for cardiovascular disease.2 People with diabetes have a two- to fourfold higher risk of coronary, cerebrovascular, and peripheral vascular disease than non-diabetic people.1 The relative risk is greater for women than for men.1,19 Diabetes is also a poor prognostic factor post myocardial infarction (MI) diabetic patients have a higher inhospital mortality, and postdischarge mortality than non-diabetic patients, and a higher risk of infarct-related complications.20,21 Just as the risk of eye, kidney, and nerve disease increases with the degree of glycemia, a growing number of studies of diabetic patients suggest that the risk of cardiovascular disease also rises with the degree of glycemia. For example, the Wisconsin Epidemiologic Study of Diabetic Retinopathy followed a population-based sample of 1210 patients with diabetes presenting before the age of 30 and 1780 patients with diabetes presenting at or after the age of 30.22 In...

Benefits Coronary Heart Disease

A large number of investigators have studied the relation between alcohol intake and coronary heart disease. Studies indicate that the descending leg of the curve is mainly attributable to death from coronary heart disease, as mentioned previously. The lowest risk seems to be among subjects reporting an average intake of one to four drinks daily. Several studies have found plausible mechanisms for the apparent cardioprotective effect of a light to moderate intake of alcohol. Subjects with a high alcohol intake have a higher level of high-density lipopro-tein, which has been found to be a mediator of the effect of alcohol on coronary heart disease. Thus, 40-60 of the effect of alcohol on coronary heart disease is likely to be attributable to the effect on high-density lipoprotein. Furthermore, drinkers have a lower low-density lipoprotein. Also, alcohol has a beneficial effect on platelet aggregation, and thrombin level in blood is higher among drinkers than among nondrinkers....

Viral Infections with Congenital Heart Disease

Although few normal children have problems with common viral pathogens such as influenza virus, parainfluenza virus, or respiratory syncytial virus, children with congenital heart disease are at unique risk for major sequelae. Distinguishing minor early infections with these agents and differentiating them from the symptoms of congestive heart failure is a challenge, even for seasoned clinicians. Children with lesions that increase pulmonary blood flow are far more at risk because of pooling of alveolar secretions. The pooled secretions allow for stasis and secondary bacterial overgrowth. Dramatic increases in mortality and morbidity are evident among affected infants. No effective therapy is available for parainfluenza and influenza virus, and prophylaxis against influenza B with amantadine analogues is not approved for small children. Hospitalization and specific treatment of infants affected by respiratory syncytial virus has been difficult to justify due to conflicting studies...

Phytochemicals And Cardiovascular Disease

Oxidative reactions have been linked to atherosclerosis through several different mechanisms. The most widely studied hypothesis of lipid oxidation and atherosclerosis involves the formation of oxidized, cytotoxic lipoproteins, particularly low-density lipoprotein (LDL) (37). During the oxidation of LDL, the lipoproteins become modified through either direct free-radical attack or formation of adducts between proteins and lipid oxidation products. The oxidized LDL can then be recognized and engulfed by macrophages, leading to the formation of foam cells that accumulate in arterial walls and form plaques (Fig. 2). Oxidized LDL has also been postulated to cause vascular inflammation and stimulate autoimmune reactions. Evidence supporting the relationship between LDL oxidation and cardiovascular disease is increasing however, the importance of this mechanism to the development of cardiovascular disease has yet to be fully understood. Figure 2. The proposed mechanism for promotion of...

Endothelial Function Atherosclerosis and Cardiovascular Disease

Differences in n-6 fatty acid intake have the potential to influence several chronic diseases and disorders. This article will focus on the effects of n-6 fatty acids on cardiovascular disease and atherosclerosis. Atherosclerosis is an inflammatory disease involving multiple cellular and molecular responses that lead to an alteration in vascular function and structure, and the development and progression of cardiovascular disease. Atherosclerosis is characterized by degenerative changes, deposition of cholesterol, proliferation of smooth muscle cells, involvement of a range of circulating proinflamma-tory cell types, and fibrosis. Resulting atheromatous plaques cause narrowing of arteries and increase the likelihood of thrombosis and occlusion. When this process occurs in the coronary arteries, the outcome is myocardial infarction and with possible death.

Studies on the Role of Exercise Fitness in the Etiology of Coronary Heart Disease

Coronary heart disease (CHD) has a multifactorial etiology, and major 'biological' risk factors include elevated concentrations of blood total and low-density lipoprotein (LDL) cholesterol, reduced concentration of high-density lipoprotein (HDL) cholesterol, high blood pressure, diabetes mellitus, and obesity. In addition, 'behavioral' risk factors for CHD include cigarette smoking, a poor diet, and low levels of physical activity and physical fitness associated with the modern, predominantly sedentary way of living. Among these risk factors, a sedentary lifestyle is by far the most prevalent according to data from both the United States and England (Figure 1).

S Pediatric Heart Disease

Vaginal Cuff Cellulitis Treatment

Assessment of, Children,, Suspected, ofMaving, Heart Disease Pediatric cardiovascular disorders are decidedly uncommon in emergency medicine. The incidence of congenital heart disease is only about eight cases per 1000 live births and contrasts sharply with the increasing prevalence of cardiovascular disease in adult populations. 1 Because of the relative unfamiliarity of such disorders, most emergency medicine physicians have encountered these disorders only in their initial training. The combination of the low incidence and the age-related differences in clinical presentation make timely recognition, stabilization, and appropriate tertiary referral a challenge for primary care physicians. In the emergency department, problems may range from an asymptomatic discovery of a murmur to the life-threatening presentation of a cyanotic infant in cardiogenic shock. Congenital heart disease is usually classified based on physiology (presence or absence of cyanosis, with or without persistent...

Ablation of VT after myocardial infarction

Saline irrigation of the ablation electrode (cooled RF ablation) may create larger lesions to reach deep portions of re-entry circuits by allowing current delivery without excessive heating at the surface of the tissue, which can cause formation of coagulum that prevents further energy application. A recent multicen-tre trial evaluated a saline irrigated RF ablation catheter (Cardiac Pathways Corp, Sunnyvale, California, USA) in 146 patients (prior myocardial infarction in 82 average (SD) left ventricular ejection fraction 31 (13) ) who had an average of 25 (31) episodes of VT in the two months before ablation despite antiarrhythmic drug treatment.10 All mappable VTs were eliminated in 75 of patients. During a follow up of 243 days 54 of patients remained free of spontaneous VT 81 experienced a more than 75 reduction in the number of VT episodes in the two months after ablation, as compared to before ablation. comitant illnesses. Ablation is often a late attempt in controlling...

Angiotensin receptor blockers for chronic heart failure and acute myocardial infarction

The question arises, therefore, as to what the role of the newest agents available for RAAS inhibition, the angiotensin II receptor antagonists or blockers (ARBs), might be in CHF and acute myocardial infarction A number of other key randomised, controlled, trials have also shown that ACE inhibitors reduce the risk of all cause mortality and major clinical events (sudden death, reinfarction, heart failure) after myocardial infarction.w1-3 These benefits are most clearly seen in patients with left ventricular systolic dysfunction or clinical evidence of heart failure.w4 LVEF, left ventricular ejection fraction NYHA, New York Heart Association ACE-I, angiotensin converting enzyme IHD, ischaemic heart disease LVIDD, left ventricular internal dimension. SOLVD-T Treatment arm of the Studies Of Left Ventricular Dysfunction SPICE Study of Patients Intolerant of Converting Enzyme Inhibitors STRETCH Symptom, Tolerability, Response to Exercise Trial of Candesartan cilexetil in Heart failure...

TABLE 475 Electrocardiographic Criteria for Acute Myocardial Infarction

Reciprocal ST-segment changes (such as ST-segment depressions in the anterior precordial leads in the setting of an inferior wall AMI) predict a larger infarct distribution, an increased severity of underlying coronary artery disease, more severe pump failure, a higher likelihood of cardiovascular complications, and increased mortality. In general, the more elevated the ST segments and the more ST segments that are elevated, the more extensive the injury. The ECG can also be used to predict the infarct-related vessel. Inferior wall myocardial infarctions can result from occlusion of the left circumflex artery or the right coronary artery. In the setting of an inferior wall AMI, ST-segment elevation in at least one lateral lead (V 5, V6, or aVL) with an isoelectric or elevated ST segment in lead I is strongly suggestive of a left circumflex lesion. The presence of ST-segment elevation in lead III greater than that in lead II predicts a right coronary artery occlusion. When accompanied...

Ace Inhibition In Heart Failure And Ischaemic Heart Disease

Many clinical trials demonstrate the therapeutic benefit of ACE inhibition in heart failure and ischaemic heart disease. It is of note, however, that the effects of ACE inhibitors are dose related. Large clinical trials, by necessity, use only one dose of any drug. The results of such trials are just as much a measure of the effect of the dose as they are a measure of the effect of the drug. Use of a less than optimal dose may fail to reveal a drug's true therapeutic potential. This is of particular concern in a head-to-head comparison of two active drugs, where the result may be more due to choice of dose than to choice of drug. Clinicians should strive to achieve drug doses that have proven to be of benefit in clinical trials. At present, a large proportion of patients receiving ACE inhibitor therapy are receiving less than optimal doses (Lenzen et al 2005). Measurement of plasma Ang peptide levels is not feasible for the monitoring of ACE inhibitor therapy, but measurement of...

Methods For Lowering Perioperative Cardiac Risk Coronary bypass surgery

Recently, attention has turned to evaluating the effectiveness of methods for intervening to lower risk of cardiac complications during elective surgery. Coronary revascularisation is one such intervention. A retrospective review by Eagle and colleagues of the CASS (coronary artery surgery study) registry data supports such a protective effect.7 These data demonstrate that patients undergoing elective vascular surgery, who had previously undergone coronary artery bypass grafting, did better than control patients who had similar amounts of coronary disease, but no surgical coronary revascularisation. This type of analysis does not take into consideration the cumulative risk of both coronary and peripheral revascularisation, and so does not necessarily argue for prophylactic surgical coronary revascularisation before elective peripheral vascular surgery. But it does suggest a protective effect of prior coronary bypass surgery. Data from the Cleveland Clinic showed similar findings that...

Early life factors and intermediate heart disease risk factorsconditions

Measures and heart disease measures and heart disease CHD, coronary heart disease CVD, cardiovascular disease LDL, low density lipoprotein. CHD, coronary heart disease CVD, cardiovascular disease LDL, low density lipoprotein. which is an important risk factor for heart diseases. Observations are not consistent weak, non-linear or insignificant correlations between birth weight and blood pressure have been reported,20 w22 particularly among younger populations. Figure 27.1. Intrauterine programming by prenatal determinants and life course factors in heart diseases (GF, growth factor). ADULT HEALTH Hyperglycaemia Glucose intolerance Hypertension Coronary heart disease Stroke Figure 27.1. Intrauterine programming by prenatal determinants and life course factors in heart diseases (GF, growth factor). The main associations between birth weight and other growth measures and heart disease are summarised in table 27.2.

Suggested biologicalenvironmental mechanisms underlying the evolution of heart disease risk

The growth of the fetus is a complex process which is still insufficiently understood. A key concept in the fetal origin hypothesis is fetal undernutrition, and its relation with adult diseases. The human evidence, as described above, is based on studies where birth measures have been related to different adult heart disease outcomes in different populations. This is strongly supported by the animal experiments, and stresses the importance of the feto-maternal environment. Barker5 has differentiated undernutrition during pregnancy by trimesters, and he suggests that the down regulation of growth during the first trimester leads to a proportionately small child who has increased risk of raised blood pressure and may possibly die of haemorrhagic stroke. Under-nutrition during the second trimester leads to a disturbed fetoplacental relation, and insulin resistance or deficiency consequently birth weight is reduced and the baby is thin, and has an increased risk of raised blood pressure,...

Finding Genes for Cardiovascular Disease

Genetics studies of cardiovascular disease involve searches for genes in two general classes causative genes and disease-susceptibility (or disease-modifying) genes. These are sought through gene-linkage analysis or candidate-gene studies, respectively. Identifying causative genes for this disease is likely several years away at best. Before that time, however, a new understanding will have been reached regarding the relationship between inherited risks and outcomes in cardiovascular disease. With the development of new technology, we also have the promise of a detailed catalogue of disease-modifying genes that may open the door to therapeutic advances. Gene-linkage analyses involve the study of families that express the cardiovascular trait of interest. In such studies, it is important also to establish the relative risk. Relative risk is defined as the probability of developing a condition (such as cardiovascular disease) if a risk factor (such as a gene) is present, divided by the...

Thrombolysis in Acute Ischemic Stroke

BACKGROUND Significant progress has been achieved in the last 10 years toward identifying potential therapies for ischemic stroke. The most important single step, however, has been the 1995 publication of the results of the NIH National Institute of Neurologic Disorders and Stroke (NINDS) trial evaluating the use of intravenous recombinant rt-PA. This trial demonstrated, for the first time, that stroke was a treatable disease in carefully selected patients who received rt-PA within 3 h of symptom onset. The time-critical nature of thrombolytic therapy highlights the need for the involvement of emergency medicine in a coordinated, multidisciplinary approach to the treatment of stroke patients. The NIH NINDS study was a randomized, double-blind, placebo-controlled trial conducted at 40 geographically diverse hospitals (30 community and 10 university settings) comparing intravenous rt-PA (0.9 mg kg maximum dose, 90 mg) against placebo in 624 patients meeting specific enrollment criteria....

Myocardial infarction and other nonfatal end points

Registry studies have suggested a favorable effect on late myocardial infarction only among the highest risk subsets, such as patients with three vessel disease and severe angina pectoris.12 In the meta-analysis, no overall effect of CABG on subsequent infarction could be demonstrated, primarily because of an excess of infarction in the perioperative period (10-3 incidence of death or myocardial infarction at 30 days) among those assigned to surgery.7 Although the risk of subsequent myocardial infarction was lower during extended follow up, this was not statistically significant (24-4 incidence of death or myocardial infarction at 5 years for the CABG group v 30-7 for the medical group).7 Most trials did not prospectively collect data on rehospitalization for unstable angina, stroke, quality of life, or cost.

Frequency of coronary artery disease in patients with calcified aortic stenosis

The frequency of coronary artery disease in patients with calcified aortic stenosis can be correctly assessed only in studies comprising systematic coronary angiography, regardless of the symptoms. The frequency of associated coronary disease varies according to the characteristics of the population involved, in particular age and, to a lesser degree, the geographic origin. Series of patients with calcific aortic stenosis whose mean age is between 60 and 70 years reported 30-50 of associated significant coronary artery disease (at least one stenosis 50 or 70 of vessel diameter). Coronary artery disease has been reported in more than 50 of patients aged 70 years2 and, of patients aged 80 years, in 65 in series from the USA3 and 41 in a British series.

Acute myocardial infarction primary angioplasty

Angioplasty For Embolism

The treatment of myocardial infarction has evolved considerably over the past decades. Reported mortality rates have fallen as a result of a variety of factors, including earlier diagnosis and treatment of the acute event, improved management of complications such as recurrent ischaemia and heart failure, and general availability of pharmacological treatments such as aspirin, P blockers, and angiotensin converting enzyme inhibitors.1 Most attention, however, has been focused on treatments that may restore antegrade coronary blood flow in the culprit artery of the patient with evolving acute myocardial infarction. The two methods to achieve this goal are thrombolytic treatment and immediate coronary angiography followed by primary angio-plasty if appropriate.1 History of angioplasty for acute myocardial infarction Angioplasty for acute myocardial infarction was first described as a rescue treatment in the case of failed intracoronary thrombolysis, and was studied extensively as...

Secondary Stroke Prevention Transient Ischemic Attacks

Although limited proven pharmacologic interventions exist to reverse an acute ischemic stroke, considerable options have been identified with regard to secondary stroke prevention in patients with a completed stroke or TIA. Agents preventing platelet aggregation form the cornerstone of secondary prevention of stroke in those patients without atrial fibrillation or high-grade carotid stenosis as a contributing factor. The use of acetylsalicylic acid (aspirin) is associated with a stroke risk reduction of 20 to 25 percent compared with placebo. Aspirin decreases the synthesis of thromboxane A2 by irreversibly inhibiting cyclooxygenase for the life of the platelet, causing decreased platelet aggregation. No dose-effect statistically significant 0.5 percent absolute reduction in the annual risk of ischemic stoke, myocardial infarction, or vascular death when compared with aspirin (325 mg day).24 No combination studies have been reported. The use of clopidogrel is ideal for those patients...

Gender and cardiovascular disease

In the United States the number of women who die annually from cardiovascular disease is higher than men. The cardiovascular disease burden is particularly high in older women. In women aged 55 and older, major cardiovascular diseases (ICD 390-448-9) accounted for 473569 deaths in 1997 compared to 402310 deaths in older men.1 Major cardiovascular diseases accounted for 44 of all deaths in older women and 40 of all deaths in older men. The number of deaths from coronary heart disease (CHD) was only slightly higher in older women (229 628) than in men (223 246), but the number of deaths from stroke was considerably higher in women (88768 compared to 55 149 respectively). There were 4607 deaths from pulmonary embolism in older women compared to 3465 in men. As exemplified by these absolute numbers of deaths, cardiovascular disease now represents a larger health problem in older women than in older men. Figure 20.1 Annual mortality rates by 10 year age groups for CHD, stroke, and...

Evidence for an association between childhood factors and heart disease risk

Heart disease morbidity and mortality Forsdahl. Are poor living conditions in childhood and adolescence an important risk factor for arteriosclerotic heart disease 2 Barker et al. Infant mortality, childhood nutrition, and ischaemic heart disease in England and Wales.3 In the counties where infant mortality (INFmo) was high, the same generation had both a high total mortality and ischaemic heart disease (IHD) mortality in middle age. Variations in IHD mortality rate between counties is linked to variations in poverty in childhood and adolescence because INFmo is a reliable index of standard of living. Forsdahl suggested that poverty followed by prosperity is a risk factor for IHD. Barker et al. Weight in infancy and death from ischaemic heart disease.4 thinness at birth to death for cardiovascular disease in adult In children at 10 years and adults at 36 years systolic blood pressure was inversely related to birth weight (independent of gestational age). Within England and Wales 10...

Assessment Of Children Suspected Of Having Heart Disease

The physical examination of children with significant congenital heart disease is often not as dramatic as the diagnosis of congestive heart failure in adolescents. In the author's experience, unrecognized congenital heart disease in small infants is often not diagnosed until the second or third visit to the emergency department for the same illness. Most often, that illness is misdiagnosed as a viral upper respiratory illness or a feeding intolerance.

Single gene cardiovascular disorders

Several cardiovascular disorders have been shown to have a familial basis. These diseases cover a wide spectrum, from structural defects such as familial atrial septal defects to functional defects such as long QT syndrome (Table 23.1). For most of these diseases the chromosomal location (locus) has been mapped but the gene has not yet been identified. However, diseases such as the cardiomyopathies, particularly hypertrophic cardiomyopathy, have undergone major investigations, with elucidation of the pathogenesis. Animal models of human familial HCM have been developed and therapies have been evaluated. There is considerable progress in the identification of genes responsible for ventricular arrhythmias, particularly the long QT and Brugada syndromes. It is still premature to manage these disorders based on their genetic etiology. This is partly because genetic screening is not available and the populations studied have not yet been adequately characterized to provide generalized...

Sudden death in children with postoperative congenital heart disease

In the 1960s and 1970s sudden cardiac death most often occurred in children with irreversible pulmonary vascular disease associated with unoperated congenital heart disease or in children with unoperated aortic valve stenosis.w8 w9 In recent years surgical repair has been performed earlier and more effectively so that those most at risk of sudden death now are children with repaired heart disease. In a population based study of late postoperative sudden death, Silka and colleagues identified an average risk of 0.9 per 1000 patient-years follow up for the most common surgically repaired malformations.7 Those patients with a risk above the average had aortic valve stenosis, transposition of the great arteries, tetralogy of Fallot or coarctation of the aorta. Death was attributed to arrhythmia in the majority, based on the history, but in only a few was an arrhythmia identified in life.

The declining mortality from coronary heart disease

There is no doubt that mortality from coronary heart disease is falling. Figure 6.410 shows that age specific mortality for males aged 35-44 years during 1997 was about one third, and of those aged 65-74 years about two thirds of the figures for 1968 when the coronary epidemic was at its height. Age groups 45-54 and 55-64 showed intermediate changes and the picture was similar in women. Data in fig 4 stop at age 75, however. If evidence from death certificates is to be believed, more than 60 of coronary deaths occur in people aged 75 years.10 Death is being postponed, not prevented it has been estimated that the global burden of coronary heart disease will continue to increase up to the year 2020.11 Although the incidence of new events is falling, the prevalence of coronary heart disease in the community is increasing.10 For the hospital clinician there is much less difficulty in the definition of acute myocardial infarction. Most clinicians will accept that infarction should be...

Indications for PCI in chronic coronary artery disease

The indications for PCI have expanded during the past two decades, and no absolute contraindications remain (table 8.3). Single vessel coronary artery disease (CAD) remains the principal indication for PCI, with over 80 w74 of procedures performed in Europe and over 90 in the USA. This exponential growth of PCI has been largely at the expense of medical treatment rather than surgical revascularisa-tion. Beside clinical and angiographic factors, operator volume has been recognised as a major determinant ofoutcome in several recent studies.w75-78 There is no upper patient age limit to the applicability of PCI however, the threshold is shifted in favour of PCI compared with CABG in the very elderly owing to the higher perioperative morbidity and mortality in this patient population. Initial concerns of a sex difference in the outcome of PCI with women, There are no differences in death or myocardial infarction between patients undergoing PCI compared with CABG. Patients undergoing PCI...

Complications Of Myocardial Infarction And Ischemia

Myocardial perfusion and cardiac function affect blood flow to the entire body. As a result, any end organ can be damaged when cardiac pump function is decreased. In this section, discussion of the complications of acute coronary syndromes is limited to the direct effects on the heart. The systemic effects of cardiac function are discussed in organ-appropriate chapters of this book. The treatment of these complications is discussed in the following chapter. The genesis, diagnosis, and treatment of dysrhythmias are presented in Chap 24. The effect dysrhythmias have in complicating the course of patients with acute coronary syndromes is the subject of this section.

Mechanisms relating hyperglycemia to cardiovascular disease

Possible explanations for a glucose-cardiovascular disease relationship include an association of dysglycemia with other recognized and unrecognized risk factors for cardiovascular disease, including dyslipidemia, hypertension, abdominal obesity, renal damage, and coagulation abnormalities.

Lycopene and Cardiovascular Disease

The European Multicentre Euramic Study, which reported that risk of developing myocardial infarct was inversely related to lycopene intake, after appropriate adjustment for other cardiovascular risk factors. Some Scandinavian studies have subsequently supported this claim moreover, lycopene is capable of reducing LDL-cholesterol levels, possibly by inhibiting hydroxymethylglutaryl CoA reductase (HMGCoA reductase), the rate-limiting enzyme for cholesterol synthesis.

Ischaemic Heart Disease IHD

In the UK 12-20 of patients undergoing surgery have pre-operative evidence of myocardial disease. This is almost always due to atheroma although rarely other disease processes may be responsible. With increasing age atheromatous plaques form in the intima of arteries. These plaques grow and evolve with time, decreasing blood flow through a vessel and possibly occluding it. The rate of progression of individual plaques within any patient is variable and explains why although peripheral vascular and cerebrovascular disease will often co-exist with coronary artery disease, the patient may be asymptomatic of these other conditions. IHD may be diagnosed from a history of angina or myocardial infarction (MI). It may also be the underlying cause of a conduction defect or arrhythmia. A guide to the severity of angina is the exertion necessary to precipitate an attack. The distance that is regularly walked on the flat before an attack occurs should be elicited in the history. It may be that...

Tocopherols and Cardiovascular Disease Epidemiological Evidence

The effects of dietary vitamin E have been examined in several studies, many of which have reported a clear association between the reduction in the relative risk of CVD and high intake or supplement of vitamin E, although some have shown no such association. The Vitamin Substudy of the WHO MONICA Project showed that in European populations whose classical risk factors for CVD were very similar, the 7-fold differences in CVD mortality could be explained at least to approximately 60 by differences in the plasma levels of vitamin E and up to 90 by the combination of vitamins E, A, and C. The Edinburgh Case Control Study and Basel Prospective Study consistently revealed an increased risk of ischemic heart disease and stroke for low plasma levels of vitamin E. However, other European population studies have not found an association between blood levels of vitamin E and end points of CVD. In the EURA-MIC study, the adipose levels of vitamin E did not correlate with the relative risk of...

Coronary Heart Disease

Most epidemiologic studies and clinical trials using n-3 fatty acids in the form of fish or fish oil have been carried out in patients with coronary heart disease. However, studies have also been carried out on the effects of ALA in normal subjects and in patients with myocardial infarction. Another important consideration is the finding that during chronic fish oil feeding postprandial triacylgly-cerol concentrations decrease. Furthermore, consumption of high amounts of fish oil blunted the expected rise in plasma cholesterol concentrations in humans. These findings are consistent with the low rate of coronary heart disease found in fish-eating populations. Studies in humans have shown that fish oils reduce the rate of hepatic secretion of very low-density lipoprotein (VLDL) triacylglycerol. In normolipidemic subjects, n-3 fatty acids prevent and rapidly reverse carbohydrate-induced hypertriglyceridemia. There is also evidence from kinetic studies that fish oil increases the...

TABLE 11S1 Clinical Presentation of Pediatric Heart Disease

Children with previously undiagnosed heart disease can be broadly classified into three categories unstable, stable but symptomatic, and stable and asymptomatic. Unstable infants usually require immediate and decisive stabilization and aggressive management before diagnostic studies or tertiary referral can be made. Pediatric cardiology consultation should be emergently sought from the regional tertiary care center before pharmacologic intervention, if at all possible. Stable and symptomatic infants require less aggressive measures, so there is time to focus on physiologic derangement and correction of abnormalities of oxygenation and metabolism and time for tertiary referral. A baseline electrocardiogram (ECG) and chest radiograph are indicated in such infants particularly when a murmur appears to be pathologic (grade 3 or louder, holosystolic or diastolic in timing, and or radiating away from the heart). Stable but asymptomatic infants can easily be referred routinely based on...

Heart disease and pregnancy

Pregnancy in most women with heart disease has a favourable maternal and fetal outcome. With the exception of patients with Eisenmenger syndrome, pulmonary vascular obstructive disease, and Marfan syndrome with aortopathy, maternal death during pregnancy in women with heart disease is rare.1-4 However, pregnant women with heart disease do remain at risk for other complications including heart failure, arrhythmia, and stroke. Women with congenital heart disease now comprise the majority of pregnant women with heart disease seen at referral centres. The next largest group includes women with rheumatic heart disease. Peripartum cardiomyopathy, though infrequent, will be discussed in view of its unique relation to pregnancy. Two groups of conditions not discussed further are coronary artery disease, infrequently encountered, and isolated mitral valve prolapse, which generally has an excellent outcome. Cyanotic heart disease unrepaired and repaired In uncorrected or palliated pregnant...

TABLE 4711 Likelihood of Significant Coronary Artery Disease in Patients with Symptoms Suggesting Unstable Angina

Patients at high risk of coronary artery disease, AMI, or death should be admitted to an intensive care unit (ICU). Moderate risk patients should be admitted to a non-ICU monitored setting. Patients at low risk can be treated in a non-ICU monitored setting or can be observed in an ED observation unit. Both ED observation units and non-ICU monitored settings are safe and cost-effective for patients with normal ECGs and other low-risk clinical features. Prior invasive and noninvasive assessments of cardiac function should be taken into account in making disposition decisions. Patients known to have severe coronary artery disease or depressed left ventricular function might be triaged to a more intensive setting than patients with a similar presentation without such dysfunction. Results of prior cardiac catheterization are very useful for risk stratification. Patients who have previously been documented to have minimal (less than 25 percent) stenosis or normal coronary arteriograms have...

TABLE 478 Frequency of Occurrence of Arrhythmias during Acute Myocardial Infarction

Early in the course of AMI, patients frequently exhibit evidence of increased autonomic nervous system activity. Sinus bradycardia, atrioventricular block, and hypotension may occur from increased vagal tone. Activation of atrial and ventricular receptors in the myocardium may result in enhanced efferent sympathetic activity, increased circulating catecholamines, and increased local catecholamine release. These increased catecholamines in the setting of a sensitive myocardium form the substrate for the generation of tachyarrhythmias. Electrical instability during acute myocardial infarction results in ventricular premature beats, ventricular tachycardia, ventricular fibrillation, accelerated idioventricular rhythms, and some AV junctional tachycardias. The significance of cardiac dysrhythmias during acute myocardial infarction is the subject of some debate. Sinus bradycardia during the early phases of AMI may predispose to hypotension and repetitive ventricular dysrhythmias. On the...

Myocardial scarring secondary to coronary artery disease

The risk of ventricular arrhythmia both near and distant to myocardial infarction is well established. Myocardial re-entry is allowed by the complex interaction of viable myocardium with scarred myocardium in and around infarct territories. These patients represent the majority of patients presenting with ventricular arrhythmias. Antiarrhythmic drug treatment may have a role in suppressing arrhythmia occurrence and thereby reduce the morbidity of such arrhythmias, but the data to support protection from SCD are increasingly weak.12 71617 Most such patients will therefore receive device therapy. However, while ICD therapy may be effective in reducing SCD risk, patients may have an unacceptable morbidity related to either frequency of antitachycardia pacing or delivery of defibrillating shock therapy. In this circumstance adjunctive ablation treatment may reduce this burden. Because such arrhythmias are frequently haemody-namically poorly tolerated, use of novel mapping techniques for...

Inflammation and cardiovascular disease

Elevated serum CRP has been associated with cardiovascular events in primary and secondary prevention cohorts, and in patients presenting with acute coronary syndromes. In a meta-analysis of 14 prospective studies, with 2557 cases (mean age of 58 years and mean follow up of 8 years), CRP concentrations in the highest versus lowest third were associated with an adjusted relative risk of 2-0 (95 CI 1-6-2-5) in primary prevention cohorts, and 1-9 (95 CI 1-5-2-3) in secondary prevention cohorts.59 Higher serum CRP concentrations may identify patients more likely to respond to aspirin or statin therapy. Among 543 cases and matched controls in the Physicians', Health Study, aspirin reduced myocardial infarction by 56 among those with the highest quarter of baseline CRP level, versus a 14 reduction in those in the lowest quarter.60 In the CARE61 and AFCAPS Texas CAPS62 studies, patients with high CRP levels benefitted from statin therapy even in the presence of low to normal LDL cholesterol....

Overall outcome in unstable anginanonST elevation myocardial infarction

Based upon prospective international registry data among 8000 patients in six countries, the risk of death or myocardial infarction is approximately 10 at six months and almost a quarter of patients sustain these events or acute refractory angina within six months of initial presentation (OASIS registry).2 Overall, half of these events occur within the first seven days of presentation. Based on those included in clinical trials, and excluding those with normal ECGs, about 10 suffer death or myocardial infarction at 30 days (GUSTO II data).3 These events occur despite aspirin treatment and antianginal medications. Recent data from the PRAISE UK registry indicate rates of death myocardial infarction of 12.2 at six months.4

Ischemic Stroke

Ischemic stroke can be subdivided into three major categories thrombotic, embolic, and hypoperfusion. The majority of all strokes are caused by vessel thrombosis, which occurs when clot formation is superimposed upon gradual vessel narrowing or alterations in the luminal lining of the vessel. Atherosclerotic disease is the most common cause of thrombotic stroke in the United States. Atherosclerosis primarily affects the larger intracranial and extracranial arteries and causes hyperplasia and fibrous deposition in the subintimal area with plaque formation. Plaques cause luminal narrowing and platelet adhesion, which lead to vessel thrombosis. Other causes of thrombosis include vasculitis, dissection, polycythemia, and hypercoagulable states. Less common causes are infectious diseases, such as HIV, syphilis, tuberculosis, aspergillosis, and trichinosis, that lead to vessel wall injury. The signs and symptoms of a thrombotic stroke usually develop gradually over minutes to hours and may...

Heart Disease

A high zinc copper ratio has been linked to hypercholesterolemia 103 . Thus, by virtue of its ability to bind these divalent cations and potentially alter their balance and availability 7,8 , PA may also affect serum cholesterol levels Figure 14.3(C) . In fact, some foods rich in PA, such as bengal gram beans, have been shown to have hypocholesterolemic effects 104 . Although cereal fiber has been associated with decreased coronary heart disease risk 105 and wheat fiber left over from the amylolytic digestion of wheat flakes, which may contain some PA, have been suggested to favorably affect serum cholesterol 106 , wheat bran, a rich source of PA, has not been shown to reduce blood lipid levels 107,108 . A reduction of serum cholesterol as a result of PA supplementation has been shown in animal studies 109-111 . Sharma 110 showed that the addition of 0.2 PA to a high-cholesterol diet in hypercholesterolemic rats reduced serum cholesterol along with serum triglycerides. Jariwalla et...

Assessing processes of care

The interpretive challenges of such descriptive studies are illustrated by evidence assembled with clinical and or administrative data showing sex differences in treatments for patients hospitalized with acute myocardial infarction (AMI).29-31 Sex differences in care have been found in several nations, but the relationship between gender and service intensity is not consistent.32-34 The debate about the gender gap in service intensity is likely to continue until there is clearer evidence from randomized trials to delineate whether and how men and women with otherwise similar cardiovascular disease should be managed differently.

Patency centric approaches

Beyond contrast echocardiography, other investigators have used imaging modalities such as magnetic resonance or intracoronary Doppler flow velocity to assess microvascular obstruction. During extended follow up of a cohort of patients after myocardial reperfusion treatment,8 the finding of microvascular obstruction carried a fourfold increase in adverse events including death, reinfarction, or the development of congestive heart failure. In a randomised trial of 200 patients undergoing primary stenting for acute myocardial infarction, Doppler assessment of the infarct vessel showed a notable increase in peak velocity with the use of abciximab, a potent platelet glyco-protein IIb IIIa inhibitor.9 ADMIRAL Abciximab associateD with priMary angIoplasty and stenting in acute myocaRdiAL infarction RAPID 2 Reteplase (r-PA) versus Alteplase Patency Investigation During myocardial infarction RAPPORT ReoPro in Acute myocardial infarction and Primary PTCA Organization and Randomized Trial TIMI...

Prognosis of hospital treated infarction

Age specific death rates from coronary heart disease in men 1968 to 1997, plotted as a percentage of the rates in 1968. Reproduced from British Heart Foundation Coronary Heart Disease Statistics 1999, with permission. Figure 6.4. Age specific death rates from coronary heart disease in men 1968 to 1997, plotted as a percentage of the rates in 1968. Reproduced from British Heart Foundation Coronary Heart Disease Statistics 1999, with permission. Figure 6.6. Thirty day fatality (red bars), lives saved by resuscitation from cardiac arrest (green bars), and lives estimated to have been saved by thrombolytic treatment (yellow bars) according to delay in presentation to the hospital. Numbers above the bars refer to the numbers of patients in each group. Reproduced from UK heart attack study17 with permission of BMJ Publishing Group. has proved to be remarkably robust in predicting relative although not absolute risk. This is shown by a study of 830 patients treated between 1995...

Conclusion future prospects for improving the natural history

Many years ago the Framingham investigators concluded that the only road to substantial reduction in premature mortality from coronary heart disease lay in prevention of the disease. Primary prevention in the UK by a population strategy to encourage people to reduce their dietary fat intake has had limited success, although smoking has declined in the coronary age group.10 Nevertheless, at least some of the decline in mortality must presum- The natural history of acute myocardial infarction As far as the treatment of myocardial infarction is concerned, it is probably true to say that better application of treatments already known to be eVective in the year 2000 have more to oVer than the development of new treatments. Reduction of patient delay in calling for help through public education on the symptoms of heart attack and the importance of access to emergency services, and improved response time of ambulances, are of paramount importance. The search for better thrombolytic and...

Practical advice on managing psychological factors

Patients what they think the main cause of the heart attack was. Particular care should be taken to avoid unintentionally reinforcing the common cardiac misconceptions, especially about stress and the value of rest, that many patients have. Advice should be realistic, practical, and concrete (that is, specifying exactly what should be done for example, eat five portions of fresh fruit or vegetables every day instead of try and eat more fruit ). Advice should take account of social and cultural needs. Every patient should be helped to develop an individualised and concrete plan for recovery to be carried out in the weeks following the MI. The resumption of small amounts of activity should be encouraged from the first full day home. Vague advice such as listen to your body or do what you can manage is unhelpful. Patients and their families should be warned about the common physical and psychological sequelae. The primary physical problems are unexpected weakness caused by...

Cardiac rehabilitation

Is an activity requiring a range of health skills to bring together medical treatment, education, counselling, exercise training, risk factor modification and secondary prevention, in order to limit the harmful physical and psychological effects of heart disease, reduce the risk of death or recurrence of the cardiac event, and enhance the psychosocial and vocational state of pa-tients.6 Cardiac rehabilitation has been defined by the World Health Organization as .the sum of activities required to influence favourably the underlying cause of the disease, as well as to ensure that patients' best possible physical, mental and social conditions so that they may, by their own efforts, preserve, or resume when lost, as normal a place as possible in the life of the community. 7 The WHO definition is, of course, all embracing but is endorsed by countries in Europe and beyond. In essence, cardiac rehabilitation services are comprehensive programmes involving education, exercise, risk factor...

Stephan Windecker Bernhard Meier

Percutaneous transluminal coronary angioplasty (PTCA) was introduced into clinical practice more than 20 years ago.1 The breathtaking growth of percutaneous coronary interventions (PCI) during the 1990s in Europe (fig 8.1) reflects their widespread acceptance for coronary revascularisation, challenging coronary artery bypass grafting (CABG). This review provides an overview of current coronary interventional techniques with emphasis on adjunctive pharmacologic treatments and indications of PCI in patients with chronic coronary artery disease.

Other circulatory diseases

Table 12.4 shows a strong association between serum cholesterol and all circulatory diseases other than ischemic heart disease and stroke. Deaths from peripheral arterial disease and abdominal aortic aneurysm are too infrequent to account fully for this association. It is probably attributable also to poorly certified ischemic heart disease deaths certified due to atrial fibrillation, heart failure, myocardial degeneration and atherosclerosis, for example, are in many cases due to ischemic heart disease.

Depolarisationrepolarisation abnormalities

ECG abnormalites are detected in up to 90 of ARVC patients.5 The most common abnormality consists of T wave inversion in the precordial leads exploring the right ventricle (V1-V3) (fig 14.2). Inversion of T waves is often associated with a slight ST segment elevation ( 0.1 mV). These repolarisation changes are not specific and are considered only minor diagnostic criteria because they may be a normal variant in females and in children aged less than 12 years, or may be secondary to a right bundle branch block, either isolated or in the setting of a congenital heart disease accounting for a right ventricular overload.

Direct toxic effects of glucose

Glycation of a variety of proteins may directly promote cardiovascular disease.42-45 Glycated albumin promotes albuminuria and endothelial cell dysfunction glycated red cell membranes are less deformable glycated LDL apoproteins are more susceptible than non-glycated LDL uptake by scavenger cells (which would increase foam cell formation), oxidation, and increase platelet aggregation glycated HDL is less able to transport cholesterol, and glycated fibrin and platelet membranes adversely affect vascular homeostasis. AGE (advanced glycation end product) proteins also accumulate on vessel walls and in the vessel matrix, and may adversely affect endothelial cell function and promote atherosclerosis.44-46

Evidence for benefits of regular exercise in adults

An accumulation of scientific evidence provides consistent substantiation to the assertion that light to moderate physical activity in healthy adults reduces the risk for all-cause mortality and cardiovascular disease (CVD) in men and women.1-3 However, approximately 60 of US adults are not regularly physically active and 25 are inactive.4 Physical inactivity is a serious, nationwide problem. It poses a major public health challenge with a national burden of unnecessary illnesses and premature death. Physical activity and exercise are pivotal in health promotion and disease prevention, especially now that the evidence for the hazards of being physically inactive are clear.5 These statistics, representing low levels of exercise in the US population, call for urgent action by health professionals. Primary care physicians, internists, and cardiologists in particular need to provide evidence-based physical activity recommendations to their patients. reduces risk of dying from heart...

Evidence for benefits from regular exercise in the coronary population

A recent comprehensive evidence-based review has been completed on the benefits of exercise in the coronary popu-lation.6 For brevity, this consensus document will be used as a source of evidence along with other consensus documents. The major focus of this review was on coronary patients (including myocardial infarction (MI), coronary artery bypass surgery (CABG), and percutaneous transluminal coronary angioplasty (PTCA)), with a lesser focus on heart failure and cardiac transplantation literature and special populations such as elderly people, women, and those with physical disabilities (see Figure 16.1 for the criteria guiding this review).

Jordi Soler Soler Enrique Galve

Valvar heart disease is a paradigm of the changing aetiology of human disease. In particular, we have witnessed dramatic changes in the incidence of rheumatic heart disease (fig 15.1) such changes have been limited mostly to industrialised countries, highlighting the role of factors other than microorganisms in this disease. Interestingly, the frequency of valvar heart disease is still high in industrialised countries, as new types of valve disease become increasingly prevalent (fig 15.2). The most important of them is degenerative valve disease, which relates directly to the increased lifespan of people living in industrialised countries compared to those in developing countries. On the other hand, aetiologies related to the relative wealth of industrialised countries have also appeared, the most dramatic example being valve disease related to appetite suppressant drugs.

Rheumatic valve disease

A variety of epidemiologic studies have shown that the incidence of rheumatic fever and the prevalence of rheumatic heart disease have declined dramatically over the last decades in the developed countries. A number of reasons (table 15.1) have been postulated to explain such a decrease improvement in living standards, better access to medical care, wider use of antibiotics, as well as natural changes in the streptococcal strains. In the developing countries, the situation is similar to that of industrialised nations in the early 20th century, when rheumatic fever was still one of the leading causes of death and disability in young people. An accurate evaluation of trends of rheumatic fever in these countries is not possible because of a lack of reliable health statistics, but there is overwhelming evidence that the disease continues unabated. The existing information indicates that the magnitude of the problem may not have changed during the last years or may have actually increased...

Can drug safety be a primary trial outcome

Of an offsetting increase in major vascular events. CLASS also reported a GI benefit, but only after redefining the study outcome post-hoc and excluding the data from the second 6 months of the one-year trial. The increase in major thrombotic events (mainly acute myocardial infarction) with the coxibs, a recognized class effect, was confirmed in 2004 in two placebo-controlled trials in patients with colon polyps.2'10 The manufacturer of rofecoxib decided on a voluntary recall of the drug from the market, whereas the manufacturer of celecoxib did not.

General safety issues

Patients with chronic health problems, such as heart disease or diabetes, should first obtain medical clearance before beginning a new exercise program. Skeletal muscle and other injury can be avoided by beginning exercises slowly and gradually building up to the desired amount of exercise (duration, frequency, and intensity) to give skeletal muscles and the cardiovascular system time to adapt. It is recommended that men over 40 and women over 50 consult a physician prior to beginning a vigorous physical activity program. This is to ensure that the patient does not have un-diagnosed heart disease or other health problems that may place them at increased risk and that may require special modification in the exercise prescription or the monitoring of their response to the exercise.5 The ACSM,24 AHA,25 and AACVPR26 have issued guidelines for assessment of an exercise facility prior to beginning an exercise program. A medical evaluation, including an exercise test, is recommended for...

Adherence to exercise

The evidence for exercise interventions for cardiovascular risk reduction has been provided in the preceding pages. However, the extent to which exercise is effective may depend in large part on adherence.27 Burke and colleagues,27 in their comprehensive review on adherence, further concluded that non-adherence, whether it occurs early or late in the treatment course, is one mediator of clinical outcomes. Hence, specific attention is given to adherence here. Barriers to exercise are twofold the lack of physicians' exercise prescription and patient non-adherence. Since physicians have had limited clear evidence on reduction of hard events until recently, coronary patients have not consistently received physician recommendations regarding exercise or have received suggestions that were too general to be beneficial. Cardiac rehabilitation programs are available for referral by the physician in virtually every major city throughout the USA.

Aortic stenosis with left ventricular systolic dysfunction

Another difficult clinical situation is the patient with aortic stenosis and left ventricular systolic dysfunction. When stenosis is severe and there is a high pressure gradient across the aortic valve (maximum gradient 50 mm Hg), surgery is indicated regardless of the degree of left ventricular systolic dysfunction. In the series from the Mayo clinic of 154 patients with an ejection fraction 35 , operative mortality was only 9 and overall survival was 69 at five years in those with coexisting coronary artery disease, compared to 77 in those with isolated aortic stenosis (fig 16.2).4 Since left ventricular afterload is increased when aortic stenosis is present, with relief of obstruction, ventricular function improved in 76 of patients, with an increase in mean (SD) ejection fraction from 27 (6) to 39 (14) . Figure 16.2. Kaplan-Meier survival curves for patients with aortic stenosis and reduced left ventricular function with and without significant coronary artery disease (two vessel...

Are psychosocial CHD associations causal

An initial question to ask of an epidemiologic association between psychosocial factors and CHD is, Can it be explained by bias Most attention has been paid to bias intrinsic to study design as reported within a publication. One example is self-report bias that may arise if study participants tend to report adversely on both the psychosocial exposures and symptoms of heart disease. Our review addresses this issue by emphasizing death and non-fatal myocardial infarction (MI) as outcomes rather than softer end points, such as angina, which may be more prone to reporting bias. However, for a systematic review, a potentially more important set of biases lies extrinsic to individual published reports in the stages between hypothesis specification and communication to the scientific community. Of all the existing psychosocial CHD data, an unknown amount remains unreported. Positive studies may be more likely to be published than negative studies and, once published, positive studies may...

How may selection bias affect trial findings

Exclusion of high-risk patients in clinical trials has other ramifications. Several post myocardial infarction studies that evaluated prophylactic beta-blocker therapy included patients with a broader spectrum of risk. Contrary to what one would expect, these trials showed that the benefits of beta-blockade were more pronounced in patients with complicated infarcts (and no contraindications to beta-blocker therapy) than in patients with uncomplicated infarcts.1 By excluding high-risk patients, beneficial effects may be missed. Selection bias may also increase the chances of finding favorable treatment effects. Study subjects typically have above-average education, as well as a personal interest in the research project. As a consequence, their level of adherence with the study medication is usually high. Additionally, since study subjects are usually free of other conditions and take few if any other medications (healthy volunteer effect), the likelihood of drug- drug interactions is...

Type A behavior pattern TABP and hostility

In the current review 18 etiologic studies were included. As mentioned above, the three early studies provided moderate support for the hypothesis,21-23 although two of these studies were published from the Western Collaborative Group Study,21,22 and this association disappeared with extended follow up.25 Subsequently, 12 studies that did not show a clear effect were published, including two very large studies (MRFIT26 and the Scottish Heart Health Study27), one of which showed evidence for a protective effect of TABP on CHD risk in women.27 Last, the three smallest studies strongly supported the hypothesis,12'28'29 although for one the association was found only in women29 and for the other only with respect to angina incidence.28 Table 17.1 Studies of type A behavior pattern and hostility and coronary heart disease

Concept of risk factor adjusted prosthesis specific intensity of anticoagulation

The concept of risk factor adjusted, prosthesis specific intensity of anticoagulation was first proposed by Butchartw4 in regard to mechanical valve prosthesis, and was included in the recommendations by the working group on valvar heart disease.2 Within certain limits the degree of reduction in thromboembolic events is higher with increasing intensity of anticoagulation, yet at the expense of an exponential rise in bleeding risk with increasing intensity. Three major groups of risk factors for thromboembolic events and strokes should be taken into account when defining the intensity of oral anticoagulant treatment in valvar heart disease. These risk factors are related to the

Patient related risk factors

The type and severity of the underlying valve disease are important risk factors. Patients with the highest risk for thromboembolism are patients with mitral stenosis, particularly those who develop atrial fibrillation. In these patients the risk of thromboembolism increases to 20 per year. Atrial fibrillation is a very potent risk factor for thromboembolic events, particularly in patients with heart valve disease and after valve replacement. Whereas atrial fibrillation without associated heart disease is associated with a minimal increase in thromboembolic risk to 0.5 per year, the association with other cardiovascular diseases such as hypertension increases the risk of stroke to about 4-6 per year. Atrial fibrillation associated with mitral valve disease leads to an 18 fold increase in embolic risk.

Diagnosis of associated coronary stenosis in patients with aortic valve stenosis

Myocardial perfusion imaging using thallium. Such examinations generally have a rather low specificity, because of the possibility of a false positive result related to myocardial hypertrophy. Moreover, sensitivity is 100 , meaning significant coronary artery disease can be missed. However, the main concern about the use of stress tests on patients with aortic valve stenosis is safety. Stress tests may be performed with specific protocols in patients with asymptomatic aortic stenosis, in order to evaluate their functional capacity accurately. Nevertheless, the presence of symptomatic aortic stenosis remains a contraindication for a stress test in current guidelines. Tests using dipyridamole have the same limitations regarding specificity, sensitivity, and also safety. Stress echocardiography has also been shown to be non-specific of coronary disease in patients with aortic stenosis. The detection of thoracic aortic plaque by transoesophageal echocardio-graphy is a strong predictor of...

Treatment of aortic stenosis associated with coronary arteriosclerosis

It is widely accepted that the treatment for symptomatic aortic stenosis is aortic valve replacement (AVR). Balloon dilatation provides only a limited and transient improvement and does not influence the natural history of the disease. However, concern remains as regards the optimal treatment of aortic stenosis and associated coronary artery disease according to the respective severity of both pathologies. Symptomatic aortic stenosis associated with significant coronary artery disease Although the benefits are not irrevocably proven, it is generally accepted that patients with significant aortic stenosis associated with significant coronary artery disease (stenosis 50 or 70 of vessel diameter) should be treated by combined AVR and coronary artery bypass grafting (CABG).1 Many series have reported immediate and late results of combined valvar and coronary surgery in patients with aortic and coronary disease and compared these results with those obtained after isolated AVR in patients...

What if the component benefits differ

In LIFE,2 first-line treatment with the angiotensin receptor blocker losartan (Cozaar) was reported to be more effective than the beta-blocker atenolol (Tenor-min) in reducing the composite outcome -- cardiovascular mortality, stroke and acute myocardial infarction (see discussion about atenolol in Chapter 17). The major contributor to the modest 13 reduction in the composite outcome (p 0.02) was a 25 reduction in stroke risk (p 0.001). There was no significant decrease in the risk of cardiovascular (CV) mortality or myocardial infarction and, in fact, there were more infarctions in the losartan group. How should these findings be interpreted, regulated and promoted Would it be fair to conclude that losartan reduced the risk of CV mortality, stroke and myocardial infarction (with the latter trending in the wrong direction) A more rational conclusion would be to say that compared to atenolol, losartan reduced the risk of stroke, but only if the statistically significant stroke...

Does blood pressure lowering predict clinical benefit

Blood pressure lowering is one of the most well-known surrogate markers. It is well established that hypertension increases the risks of stroke, acute myocardial infarction and heart failure. A very large number of clinical trials of antihypertensive agents have documented that lowering blood pressure reduces the risk of these vascular complications. But can we conclude that the entire benefit of treatment is mediated through blood pressure lowering Or do antihypertensive agents have meaningful actions that are unrelated to blood pressure lowering Growing evidence indicates that the latter is the case, so the choice of antihypertensive may be important.

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