Prevention works; so does treatment (if you make it to the doctor)

Abstract

In 1995, clinical trials in cardiology brought good news to both the interventionalist hawks and the diet-conscious, psychosocially minded doves. Hypertension highlights included case-control studies suggesting that nifedipine increases mortality of hypertensive patients with coronary artery disease, and that diuretics sparing magnesium and potassium (triamterene, spironolactone, amiloride) have a third to a half the risk of sudden cardiac death of thiazide or loop diuretics. Atherosclerosis research was dominated by the revelation that statins ~educe progression of atherosclerosis, infarction, and mortality from all causes in men (non-significant trend in women) up to 70 years of age with known coronary disease. Benefit was apparent even in those with average cholesterol, which by definition can no longer be called normal. In the West of Scotland trial of men aged 45-64 with moderate hypercholesterolaemia, normal blood pressures, and no previous infarction, pravastatin reduced total mortality by 22% at 5 years. Nine randomised trials have now compared bypass with angioplasty. Mortality overall is identical; bypass is probably preferable for patients with left main or multiple severe stenoses, particularly with ventricular dysfunction or diabetes. Those with two or three vessel disease with little ventricular dysfunction may opt for angioplasty because of the reduced morbidity (including stroke) and earlier return to work; costs are slightly lower. These trials preceded the introduction of stents, which should further reduce costs and need for reintervention. Restenosis is now less of a problem in the larger coronary segments amenable to stenting. Ticlopidine has reduced the need for warfarin, and heparin coating of stents reduces reocclusion. Other new approaches to overcome restenosis include local delivery of radiation and toxins, the antisense oligonucleotide to c-myc, and growth factors to accelerate endothelial regeneration. Myocardial infarction trials showed improved survival with angiotensin-converting enzyme inhibitors given in the first 24 hours. Routine angioplasty and intra-aortic balloon pumping seem to save lives. Heart failure trials were notable for the 67% reduction in mortality with carvedilol, a p-blocker with some o!-blocking and antioxidant properties. Low starting doses are advised. Atrial fibrillation now seems amenable to atrioventricular node modification to reduce the ventricular response. Atrial flutter responds to ablation of the reentrant circuit; ventricular tachycardia less so. Preliminary results from trials of the automatic implanted cardioverter defibrillator suggests that lives will be saved although benefits relative to amiodarone and [3-blockers will not be