Decrease In Cardiovascular Mortality Research Articles

Cardiac rehabilitation today: programs, their effects and practical guidelines

Cardiac rehabilitation programs started to develop in the early 1970s. At that time the emphasis was on physical training. The goal was early return to work and lowering of mortality. Today, cardiac rehabilitation also includes risk factor modification and stress management. From 1972 to 1986, 22 randomized, controlled trials were performed to evaluate whether cardiac rehabilitation would be able to decrease mortality and improve people's ability to return to work. Although all of them reported an increase in physical working capacity, only one reported a decrease in mortality. However, a meta-analysis of the 22 trials was reported in 1989. The study found a 20% decrease in total mortality and a 22% decrease in cardiovascular mortality, both significant. This article describes the principles of cardiac rehabilitation and different types of program models with a detailed description of 3 different programs. It also reviews the effect of cardiac rehabilitation on mortality and its use in primary prevention.

Aspirin prevents stroke but not MI in women; vitamin E has no effect on CV disease or cancer.

Low-dose aspirin taken every other day helps prevent stroke in women aged 45 years and older, but does not prevent a first myocardial infarction (MI) or cardiovascular death among healthy women. Women receive no benefit from alternate-day vitamin E in the primary prevention of cardiovascular disease or cancer. These were the findings of the Women's Health Study, in which investigators followed 39,876 female health professionals over 10 years. The women were randomized to receive either 100 mg of aspirin or a placebo tablet every other day; they were also randomized to take 600 IU of vitamin E or a placebo capsule on the intervening days. No statistically significant differences were seen between the aspirin and placebo groups in the primary cardiovascular end point, which was the combined number of nonfatal MIs, nonfatal strokes, and cardiovascular deaths. Analysis of secondary cardiovascular end points revealed that aspirin use was associated with no significant effect on the number of total MIs, fatal MIs, and nonfatal MIs, and a nonsignificant decrease in cardiovascular mortality. However, aspirin users did experience significantly fewer strokes, in particular ischemic strokes. Vitamin E had very little impact on the primary prevention of both cardiovascular events and cancer.

Angiotensin-Converting Enzyme Inhibitors in Coronary Artery Disease and Preserved Left Ventricular Systolic Function: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This study sought to assess the efficacy of angiotensin-converting enzyme inhibitors (ACEIs) in patients with coronary heart disease and preserved left ventricular (LV) function. The ACEIs have been shown to improve outcomes in patients with heart failure and myocardial infarction (MI). However, there is conflicting evidence concerning the benefits of ACEIs in patients with coronary artery disease (CAD) and preserved LV systolic function. An extensive search was performed to identify randomized, placebo-controlled trials of ACEI use in patients with CAD and preserved LV systolic function. Of 61 potentially relevant articles screened, 6 trials met the inclusion criteria. They were reviewed to determine cardiovascular mortality, nonfatal MI, all-cause mortality, and revascularization rates. We performed random-effect model meta-analyses and quantified between-studies heterogeneity with I(2). There were 16,772 patients randomized to ACEI and 16,728 patients randomized to placebo. Use of ACEIs was associated with a decrease in cardiovascular mortality (relative risk [RR] 0.83, 95% confidence interval [CI] 0.72 to 0.96, p = 0.01), nonfatal MI (RR 0.84, 95% CI 0.75 to 0.94, p = 0.003), all-cause mortality (RR 0.87, 95% CI 0.81 to 0.94, p = 0.0003), and revascularization rates (RR 0.93, 95% CI 0.87 to 1.00, p = 0.04). There was no significant between-studies heterogeneity. Treatment of 100 patients for an average duration of 4.4 years prevents either of the adverse outcomes (one death, or one nonfatal myocardial infarction, or one cardiovascular death or one coronary revascularization procedure). The cumulative evidence provided by this meta-analysis shows a modest favorable effect of ACEIs on the outcome of patients with CAD and preserved LV systolic function.

Cardiac Rehabilitation in Patients With Myocardial Infarction: a 10-Year Follow-up Study

Very little information is available on the effect of cardiac rehabilitation programs on long-term survival. The primary aim of this study was to assess the effect of a structured cardiac rehabilitation program on mortality in patients who had suffered acute myocardial infarction. The secondary endpoint was the effect on morbidity. The study included 180 low-risk male patients aged under 65 years. Patients were randomly assigned to one of 2 groups: 90 entered into a comprehensive cardiac rehabilitation program, and 90 served as a control group. The mean follow-up period was 10 years. All-cause mortality was significantly lower in the intervention group: the 10-year survival rate was 91.8% in the intervention group compared with 81.7% in the control group (P=.04). There was also a decrease in cardiovascular mortality, though it was not statistically significant: the 10-year survival rate was 91.8% in the intervention group compared with 83.8% in the control group (P=.10). The incidence of non-fatal complications was lower in the intervention group (35.2% vs 63.2%, P=.03), as was the incidence of unstable angina (15.7% vs 33.9%, P =.02) and cardiac heart failure (3.0% vs 14.4%, P=.02), and the need for coronary intervention (8.4% vs 22.9%, P=.02). The application of a comprehensive cardiac rehabilitation program significantly decreased long-term mortality and morbidity in low-risk patients after acute myocardial infarction.

Impact of Achieved Blood Pressure on Cardiovascular Outcomes in the Irbesartan Diabetic Nephropathy Trial

Elevated arterial pressure enhances the risk for cardiovascular (CV) events in patients with diabetic nephropathy. The optimal BP and the component of the elevated BP that affect the risk have not been defined. A post hoc analysis was performed to assess the impact of achieved systolic, diastolic, and pulse pressures on CV outcomes in 1590 adults who had overt diabetic nephropathy and were enrolled in the Irbesartan Diabetic Nephropathy Trial (IDNT) and had a baseline serum creatinine above the normal range, up to 266 micromol/L (3.0 mg/dL), 24-h urine protein >900 mg/d, and at least 6 mo of follow-up. Patients were randomized to irbesartan, amlodipine, or placebo, with other antihypertensive agents to a BP goal of < or =135/85 mmHg. Progressively lower achieved systolic BP (SBP) to 120 mmHg predicted a decrease in CV mortality and congestive heart failure (CHF) but not myocardial infarctions (MI). A SBP below this threshold was associated with increased risk for CV deaths and CHF events. Achieved diastolic BP <85 mmHg was associated with a trend to increase in all-cause mortality, significant increase in MI, but decreased risk for strokes. Increased pulse pressure predicted increased all-cause mortality, CV mortality, MI, and CHF. It is concluded that achieved SBP approaching 120 mmHg and diastolic BP of 85 mmHg are associated with the best protection against CV events in these patients. BP < or =120/85 may be associated with an increase in CV events.

Recognition and Prevention of Cardiovascular Disease in Women

Cardiovascular disease (CVD) is the leading cause of mortality for women and among women, the number of deaths secondary to CVD is nearly twice the number of all cancer-related deaths. Mortality trends from 1979 to 2001 have shown a consistent decrease in cardiovascular mortality among men; however, cardiovascular mortality trends have remained steady or increased among women. This disparity in outcomes, in part, is secondary to a lack of awareness among women and their health care providers regarding a woman's risk for CVD. A woman's risk for CVD should be assessed at routine evaluation. Primary prevention, including lifestyle and medical interventions, should be undertaken based on risk assessment. Initiation of menopausal hormone therapy is not recommended for the prevention of coronary heart disease or stroke in women.

Écart d’espérance de vie entre les sexes : les raisons du recul de l’avantage féminin

After a large increase during the 19th and the 20th century, for two decades the gap in life expectancy between sexes has been reducing in most industrialised countries. In France, where it was specially large, it stopped increasing in the early 1980s and decreased in the most recent years. The paper investigates reasons for these recent trends in France and in the industrialised countries. Two types of data are used for analysis. Death probabilities from life tables are used for calculating male excess mortality by age and estimating the role of various age groups in life expectancy differences by sex. Sex- and cause-specific mortality rates from INED database for France and from WHO database for other countries are used to assess the part played by various causes of death in the gender gap and its evolution. In France, the stabilisation of the gap is mainly related to the decrease in cardiovascular mortality for men who benefit from the same progress but later than women. In the most recent years, the reduction of the gap is due to the trend reversal of male cancer mortality which is now decreasing, specially because of the reduction of lung cancer mortality. In European countries, taken as examples (England & Wales, Sweden, Switzerland, Italy) cardiovascular mortality is also the main responsible for the decreasing differences. Conversely, in Japan, the gap is still increasing specially for mortality from cancer and respiratory diseases. The recent gap narrowing between male and female life expectancy in France is not a specific case. It does not mean that female health situation is worsening but it is related to an acceleration of progress for males. This reduction will most probably go on in the next years, except if females would enjoy dramatic progression in old age mortality.

Cardiovascular Endocrinology

Cardiovascular disease (CVD) is a major cause of morbidity and mortality all over the world. Despite growing knowledge about the origins of CVD, only a modest decrease in cardiovascular mortality, as a percentage of total mortality, has been found in recent decades. Several factors have been proposed to explain this trend in the epidemiology of CVD, such as adaptation of a Western lifestyle and the abundant availability of dietary calories. Cardiovascular prevention programs that should decrease the occurrence of cardiovascular disease have less than expected results: Initial decrease in smoking behavior is again growing among young individuals, with weight gain and, subsequently, an alarming growth in obesity. Moreover, patients who have classic risk factors, such as hypertension and dyslipidemia, are still insufficiently treated, leading the intervention programs to consequently have a smaller effect.

Impact of diabetes mellitus on long-term survival in patients with congestive heart failure.

To test the hypothesis that diabetic status may be used as a prognostic indicator in heart failure (HF) patients. We studied 1246 consecutive patients with left ventricular dysfunction. All patients had a cardiopulmonary exercise test and an echocardiogram. Cardiac catheterisation was systematically performed to define HF aetiology. Twenty-two percent of the patients were diabetic (hypoglycaemic drugs or fasting blood glucose >126 mg/dL); in diabetic patients, HF aetiology was ischaemic in 58% vs. 40% in non-diabetic patients ( p < 0.0001). Clinical follow-up (median 1200 days) was obtained for 1241 patients. There was a statistically significant effect of diabetes mellitus on cardiac survival that differed according to HF aetiology (interaction p > 0.01). Diabetes mellitus was an independent predictor of cardiovascular mortality in ischaemic patients (HR=1.54 [1.13; 2.09]; P = 0.006) but not in non-ischaemic patients (HR=0.65 [0.39; 1.07];p = 0.09). When diabetic patients were defined as patients receiving hypoglycaemic drugs at baseline, diabetes mellitus remained an independent predictor of cardiovascular mortality in ischaemic patients (HR=1.43 [1.03; 1.98]; p = 0.03) while diabetes mellitus was associated with a statistically significant decrease in cardiovascular mortality in non-ischaemic patients (HR=0.46 [0.23; 0.88]; p = 0.02). The prognostic impact of diabetes mellitus in HF patients is markedly influenced by the underlying aetiology and is particularly deleterious in those with ischaemic cardiomyopathy.

Early aldosterone up-regulated genes: New pathways for renal disease?

The use of aldosterone antagonists has important beneficial effects on the progression of renal and cardiac disease reflected in a decrease of cardiovascular mortality and renal failure. Nevertheless, the incidence of heart and end-stage renal failure continues to increase. This leads to the conclusion that mechanisms independent of the classical aldosterone/mineralocorticoid receptor system may contribute to the pathogenesis of cardiac and renal disease. The mRNA expression profile of human renal epithelial cells in response to aldosterone was characterized using cDNA arrays covering approximately 1430 genes. Differentially expressed genes were further evaluated by quantitative reverse transcription-polymerase chain reaction (RT-PCR), Northern blotting, and estimating the gene products by Western blotting. Aldosterone treatment of cells resulted in significant up-regulation of several genes within 1 hour, with sgk, p21/waf1, gadd45, and gadd153 being the most significant ones. Long-term treatment (>4 hours) with aldosterone induced the mRNA expression of pparalpha and puralpha. The mineralocorticoid receptor inhibitor spironolactone decreased the mRNA levels of sgk, p21/waf1, and gadd45, whereas the glucocorticoid receptor inhibitor RU 486 reduced the mRNA level of sgk and p21/waf1. Gadd153 was not affected by any of the inhibitors, probably indicating regulation by nonclassic mechanisms. Among the early genes investigated in this study, one transcript has been identified that is not suppressed by antagonists of either glucocorticoid or mineralocorticoid receptor. Further studies should be able to identify other genes regulated in a similar manner that could explain the inefficacy of spironolactone in some cases of aldosterone-mediated kidney disease.

Traditional and Non-Traditional Risk Factors for Cardiovascular and Renal Disease in African Americans: A Project of the Jackson Heart Study Investigators

Advances in the diagnosis and management of cardiovascular disease (CVD) have resulted in a decrease in cardiovascular mortality over the last 2 to 3 decades. However, despite these advances, African Americans continue to shoulder a disproportionate share of the CVD burden in the United States. There are several hypotheses for this discrepancy, yet few have been rigorously studied. These include poorer access to healthcare; increased incidence of CVD risk factors such as hypertension, diabetes, and obesity; and, possibly, genetic influences. The Jackson Heart Study (JHS) is focused on identifying the reasons for this racial disparity in CVD.

Alcohol Consumption And Cardiovascular Mortality In Hypertensive Patients

P83 Background: Alcohol drinking is associated with a dose-dependent increase in blood pressure, and JNC VI advises limiting alcohol consumption in patients with hypertension. Data are sparse on relationship between alcohol consumption and mortality in hypertensive patients. We therefore assessed whether alcohol consumption is associated with decrease in total, and cardiovascular mortality among subjects with hypertension. Methods: From the enrollment cohort of 89,251 men from the Physicians’ Health Study who provided self-reported information on alcohol intake and were free of myocardial infarction, stroke, cancer or liver disease at baseline, we identified a group of 14,125 persons with a history of current or past treatment for hypertension. Results: During 75,710 person-years of follow up, there were 1,018 deaths including 579 from cardiovascular disease and 224 from cancer. In multivariate analyses that controlled for several potential confounders, moderate alcohol intake was associated with significant decrease in cardiovascular mortality (P&lt;0.001 for linear trend). Compared with non-drinking men, those who drank 1 to 3 drinks per month had a RR for cardiovascular mortality of 0.86 (CI 0.63-1.18, P=0.35); for 1 to 6 drinks per week, the RR was 0.64 (CI 0.51-0.81, P&lt;0.001); for &gt;= 1 drink per day the RR was 0.57 (CI 0.44-0.72, P&lt;0.001). RR values for all-cause mortality in the same groups were respectively 0.89 (CI 0.70-1.15, P=0.38); 0.73 (CI 0.60-0.88, P=0.001); and 0.73 (CI 0.61-0.89, P=0.0014)(P=0.0025 for linear trend). On the other hand, we found no significant association between moderate alcohol consumption and cancer mortality (P=0.68 for linear trend). Conclusion: These results suggest that light to moderate alcohol consumption is associated with a significant reduction in cardiovascular and all-cause mortality in patients with hypertension.

Changes in socioeconomic inequalities in mortality during an economic boom and recession among middle-aged men and women in Finland

Background: Socioeconomic inequalities in mortality increased in several countries in the 1980s, but little is known about more recent trends. This study looks at how social class differences in mortality changed in Finland during 1981–1995, a period which saw drastic economic fluctuations. Methods: The study is based on the person records of the Finnish censuses of 1980, 1985 and 1990, to which the death records for 1981–1985, 1986–1990 and 1991–1995 respectively were linked. Men and women aged 35–64 years were classified into manual and non-manual classes on the basis of current or former occupation or the occupation of head of household. Results: Class differences in mortality Increased during the 1980s among both men and women due to a more rapid decrease in cardiovascular mortality in the non-manual class and to a more rapid increase in mortality from alcohol-related causes of death, accidents and suicide in the manual class. In the 1990s, a period of severe economic recession, the increase in the relative mortality gap was clearly smaller than in the 1980s. This was due to the convergence between classes of trends for cardiovascular mortality and for mortality from alcohol-related causes, accidents and suicide. Conclusion: In Finland, economic recession slowed down rather than sped up the growth of relative inequalities among middle-aged men and women. Changes in mortality and socioeconomic inequalities in mortality result from a complex combination of different and even opposite trends in mortality from various causes of death. In the light of this complexity it seems unlikely that there exists any major single explanation for changes in inequalities in mortality.

Cardiovascular disease in the Netherlands, 1975 to 1995: decline in mortality, but increasing numbers of patients with chronic conditions

OBJECTIVETo examine the relation between trends over time in mortality and hospital morbidity caused by various cardiovascular diseases in the Netherlands.DESIGNTrend analysis by Poisson regression of national data on mortality...

Gender Differences in Coronary Artery Diameter Involve Estrogen, Nitric Oxide, and Ca 2+ -Dependent K + Channels

During their reproductive years, women have a much lower incidence of coronary heart disease compared with men of similar age. Estrogen appears to be largely responsible for this decrease in cardiovascular mortality in women. In the present study, isolated pressurized coronary arteries from rats were used to assess the role of gender and circulating estrogen on coronary vascular function. Pressure-induced constrictions ("myogenic tone") were greater (approximately 2-fold) in isolated coronary arteries from estrogen-deficient male or ovariectomized (OVX) rats compared with similar arteries obtained from female rats or OVX rats receiving physiological levels of estrogen replacement (OVX+E group). These differences in coronary artery diameter were abolished by removal of the vascular endothelium or chemical inhibition of NO synthase. The anti-estrogen, tamoxifen, increased pressure-induced constrictions of coronary arteries from female and OVX+E rats. Dilations of pressurized coronary arteries from female and OVX animals to sodium nitroprusside, a nitrovasodilator that generates NO, were reduced by > 50% by iberiotoxin (IBTX), an inhibitor of Ca(2+)-dependent K+ (KCa) channels. Sodium nitroprusside (10 mumol/L) hyperpolarized coronary arteries by 13 +/- 2 mV, an effect that was greatly diminished (approximately 80%) by IBTX. Coronary arteries isolated from female rats produced greater constrictions in response to IBTX and KT 5823, an inhibitor of cGMP-dependent protein kinase, compared with coronary arteries from OVX rats. cGMP-dependent protein kinase increased the activity of KCa channels 16.5 +/- 5-fold in excised membrane patches from smooth muscle cells enzymatically isolated from these small coronary arteries. We propose that physiological levels of circulating 17 beta-estradiol elevate basal NO release from the endothelial cells, which increases the diameter of pressurized coronary arteries. Further, our results suggest that part of the effect of this NO is through activation of KCa channels in the smooth muscle cells of the coronary arteries.

Delayed progression or regression of coronary atherosclerosis with intensive risk factor modification. Effects of diet, drugs, and exercise.

Until the mid 1980s, secondary prevention of coronary atherosclerosis focused primarily on early ambulation, exercise training, and a 'prudent' diet. These regimens generally resulted in improved functional capacity, reduced myocardial demands at submaximal workrates, and modest decreases in cardiovascular mortality. However, reinfarction rates and the course of atherosclerotic heart disease remained largely unchanged with traditional treatment or usual care. Contemporary studies now suggest that multifactorial risk factor modification, and especially more intensive measures to control hyperlipidaemia with diet, drugs, and exercise, may slow, halt, and even reverse the progression of atherosclerotic coronary artery disease. Added benefits include a reduction in anginal symptoms, decreases in exercise-induced myocardial ischaemia, fewer recurrent cardiac events, and a diminished need for coronary revascularisation procedures. Several mechanisms may contribute to these improved clinical outcomes, including partial (albeit small) anatomic regression of coronary artery stenoses, a reduced incidence of plaque rupture, and improved coronary artery vasomotor function. These findings suggest a new paradigm in the treatment of patients with coronary artery disease.

Prognostic value of training-induced change in peak exercise capacity in patients with myocardial infarcts and patients with coronary bypass surgery

An inverse association between mortality and exercise capacity has been demonstrated previously in patients with coronary artery disease. Physical training generally increases exercise capacity. Only 1 study investigated the prognostic value of exercise capacity after training, but only in a limited number of patients. No data are available on the relation between mortality and the change in exercise performance with training. Peak oxygen uptake (VO 2) was measured before and after a 3-month, predominantly dynamic training period in 417 patients with coronary artery disease. Apart from peak VO 2, several patient characteristics, risk factors for cardiovascular disease, and exercise data were considered in a Cox proportional-hazards model. Peak VO 2 had increased by 33% after the training period. During the total follow-up of 2,583 patient-years, 37 patients died. The cause of death was cardiovascular in 21. The prognostic value of peak VO 2 was higher after training than before training, even after adjustment for age and other significant covariates. Cardiovascular mortality decreased more with greater increases in peak VO 2 after training. The relative hazard rate of 0.98 indicates that a 1% greater increase in peak VO 2 after training would be associated with a decrease in cardiovascular mortality of 2%. No differences in prognostic value and in training effects were observed between patients with myocardial infarcts and patients after coronary bypass grafting. Peak VO 2, evaluated after a physical training program, and its change in response to training are independent predictors for cardiovascular mortality in patients with coronary artery disease.

Hypertension and cardiac disease in minorities

Despite recent advances in both prevention and treatment, cardiovascular disease remains the leading cause of mortality in the United States. One of the major modifiable risk factors for cardiovascular disease, hypertension, is a leading cause of stroke, kidney disease, and diseases of the heart and coronary circulation. Essential hypertension is the most common cause of systemic blood pressure elevation and it responds readily to both pharmacologic and non-pharmacologic treatment. More patients visit physicians and receive prescriptions for the treatment of hypertension than for any other medical disorder. Nevertheless, more than a million Americans die each year from the direct or indirect effects of hypertension. Over the last two decades, significant progress has been made in reducing mortality from cardiovascular disease. Through public health programs like the National High Blood Pressure Education Program, increasing numbers of hypertensive patients have been detected, treated and controlled. As a result, the number of deaths from stroke, kidney disease, and coronary artery disease has declined significantly. For both blacks and Hispanics, however, the decreases in cardiovascular mortality have been less striking. Many factors could account for this disparity, among them the availability of healthcare facilities in minority neighborhoods, and the health-care-seeking behavior of the patients themselves. Understanding epidemiologic and pathophysiologic data regarding differences between blacks, Hispanics, and non-Hispanic whites will help reduce hypertension-related morbidity and mortality.

Diuretics ??? a risk in the long-term treatment of hypertensive patients?

The trial of the European Working Party on High blood pressure in the Elderly (EWPHE) revealed an overall decrease in cardiovascular mortality and morbidity in the actively treated patients. They received as first-line drugs a combination of hydrochlorothiazide and triamterene; methyldopa was added as necessary. The present post hoc analysis examined the effect of the diuretic treatment on cardiovascular events, both when given alone and in conjunction with methyldopa, by calculating the relative hazard rates (RHR) for cardiovascular mortality and morbidity. Using the Cox proportional hazard model, compared with placebo, a 34% reduction in cardiovascular mortality in the intention-to-treat analysis was demonstrated in the diuretic (hydrochlorothiazide and triamterene) group with an RHR of 0.66 and a 95% confidence interval (CI) of 0.44-0.97; the 16% decrease in the group treated with diuretics and methyldopa was not significant (RHR, 0.84; 95% CI, 0.56-1.25). The effect of treatment in the latter combined group became significant (RHR, 0.62; 95% CI, 0.40-0.95) when all cardiovascular study terminating events were considered; they were reduced by 38%. No effect of treatment on mortality from all causes was detected.

Cutting Into Cholesterol

To the Editor.— In the April 15 issue ofJAMA, Drs Kinosian and Eisenberg1published an analysis of the cost-effectiveness of treating elevated levels of total serum cholesterol. Treatment regimens using cholestyramine resin, colestipol, and oat bran were compared. Based on the outcome of the Lipid Research Clinics Coronary Primary Prevention Trial, the cost per year of life saved was determined for each of these three agents. To date, there is no primary prevention trial that demonstrates that treating elevated serum cholesterol with hypolipidemic agents prolongs life. The Lipid Research Clinics Coronary Primary Prevention Trial2and more recently the Helsinki Heart Study3have demonstrated a significant decrease in cardiovascular mortality at the termination of the trials, using cholestyramine in the former and gemfibrozil in the latter. Unfortunately, overall mortality was unchanged in both trials owing to an excess of violent and accidental deaths in the treated groups.