Secondary Prevention Of Mortality Research Articles

Effect of bempedoic acid on mortality and cardiovascular events in primary and secondary prevention: A post-hoc analysis of the CLEAR-outcomes trial

BackgroundThe effects of bempedoic acid on mortality in the secondary prevention setting have not been examined. MethodsWe used data from the overall and primary prevention reports of CLEAR – Outcomes to reconstruct data for the secondary prevention population. A Bayesian analyses was employed to calculate the posterior probability of benefit or harm for the outcomes of all-cause mortality, cardiovascular mortality, and major adverse cardiovascular events (MACE). Relative effect sizes are presented as risk ratios (RR) with 95% credible intervals (CrI), which represent the intervals that true effect sizes are expected to fall in with 95% probability, given the priors and model. ResultsIn primary prevention, the posterior probability of bempedoic acid decreasing all-cause and cardiovascular mortality was 99.4% (RR: 0.70; 95% CrI: 0.51 to 0.92) and 99.7% (RR: 0.58; 95% CrI: 0.38 to 0.86) respectively. In secondary prevention, the posterior probability of bempedoic acid increasing all-cause and cardiovascular mortality was 96.6% (RR: 1.15; 95% CrI: 0.99 to 1.33) and 97.2% (RR: 1.21; 95% CrI: 1.00 to 1.45) respectively. The probability of bemepdoic acid reducing MACE in the primary and secondary prevention settings was 99.9% (RR: 0.70; 95% CrI: 0.54 to 0.88) and 95.8% (RR: 0.92; 95% CrI: 0.84 to 1.01) respectively. ConclusionIn contrast to its effect in the primary prevention subgroup of CLEAR – Outcomes, bempedoic acid resulted in a more modest MACE reduction and a potential increase in mortality in the secondary prevention subgroup. Whether these findings represent true treatment effect heterogeneity or the play of chance requires further evidence.

Polypill in cardiovascular disease prevention: recent advances.

Triple therapy with lipid‑lowering, antihypertensive, and antiplatelet agents reduces the risk of recurrent cardiovascular fatal and nonfatal events, cardiovascular mortality, and total mortality in secondary prevention. In real life, however, effective implementation of these optimal treatments both in primary and secondary prevention is low, and thus their contribution to cardiovascular prevention is much lower than it could be, based on research data. One of the main barriers to the adequate implementation of these strategies is low adherence to the elevated number of pills, as adherence is adversely affected by the complexity of the prescribed treatment regimen, and can be considerably improved by treatment simplification. This review updates the findings provided by recent epidemiological and clinical studies favoring a polypill‑based approach to cardiovascular prevention. The increased prevalence of patients with multiple cardiovascular risk factors and comorbidities provides the rationale for a therapeutic strategy based on a combination of drugs against different risk factors in a single pill. Pharmacologic studies have demonstrated that different cardiovascular drugs can be combined in a single pill with no loss of their individual efficacy, and this favors adherence to and persistence of treatment, as well as multiple risk factor control. Recently, a randomized clinical trial SECURE (Secondary Prevention of Cardiovascular Disease in the Elderly) has shown a significant, 30% reduction in cardiovascular events, and a 33% reduction in cardiovascular death in patients after myocardial infarction treated with a polypill, as compared with usual care, thus supporting the polypill use as an integral part of any cardiovascular prevention strategy.

The Risks and Benefits of Aspirin for Primary and Secondary Prevention of Mortality, Cardiovascular Disease, and Kidney Failure

The Risks and Benefits of Aspirin for Primary and Secondary Prevention of Mortality, Cardiovascular Disease, and Kidney Failure

Aspirin for Primary and Secondary Prevention of Mortality, Cardiovascular Disease, and Kidney Failure in the Chronic Renal Insufficiency Cohort (CRIC) Study

Chronic kidney disease is a risk enhancing factor for cardiovascular disease (CVD) and mortality, and the role of aspirin use is unclear in this population. We investigated the risk and benefits of aspirin use in primary and secondary prevention of CVD in the Chronic Renal Insufficiency Cohort Study. Prospective observational cohort. 3,664 Chronic Renal Insufficiency Cohort participants. Aspirin use in patients with and without preexisting CVD. Mortality, composite and individual CVD events (myocardial infarction, stroke, and peripheral arterial disease), kidney failure (dialysis and transplant), and major bleeding. Intention-to-treat analysis and multivariable Cox proportional hazards modelto examine associations of time varying aspirin use. The primary prevention group was composed of 2,578 (70.3%) individuals. Mean age was 57±11 years, 46% women, 42% Black, and 47% had diabetes. The mean estimated glomerular filtration rate was 45mL/min/1.73m2. Median follow-up was 11.5 (IQR, 7.4-13) years. Aspirin was not associated with all-cause mortality in those without preexisting cardiovascular disease (CVD) (HR, 0.84; 95% CI, 0.7-1.01; P=0.06) or those with CVD (HR, 0.88; 95% CI, 0.77-1.02, P=0.08). Aspirin was not associated with a reduction of the CVD composite in primary prevention (HR, 0.97; 95% CI, 0.77-1.23; P=0.79) and in secondary prevention because the original study design was not meant to study the effects of aspirin. This is not a randomized controlled trial, and therefore, causality cannot be determined. Aspirin use in chronic kidney disease patients was not associated with reduction in primary or secondary CVD events, progression to kidney failure, or major bleeding.

Mediterranean-Style Diet for the Primary and Secondary Prevention of Cardiovascular Disease: A Cochrane Review.

Background:Diet plays a major role in cardiovascular disease (CVD) risk.Objectives:To determine the effectiveness of a Mediterranean-style diet for the primary and secondary prevention of CVD.Methods:We searched for randomised controlled trials (RCTs) of Mediterranean-style diets in healthy adults and those at increased risk of CVD (primary prevention) and with established CVD (secondary prevention).Results:Thirty RCTs were included, 22 in primary prevention and eight in secondary prevention. Clinical endpoints were reported in two trials where there was moderate quality evidence for a reduction in strokes for primary prevention, and low quality evidence for a reduction in total and CVD mortality in secondary prevention. We found moderate quality evidence of improvement in CVD risk factors for primary prevention and low quality evidence of little or no effect in secondary prevention.Conclusions:There is still some uncertainty regarding the effects of a Mediterranean-style diet in CVD prevention.

Low Vitamin D Levels Predict Mortality in Ankylosing Spondylitis Patients: A Nationwide Population-Based Cohort Study.

In this study, we aimed to examine the effect of vitamin D deficiency on all-cause mortality in ankylosing spondylitis (AS) patients and in the general population. This is a retrospective-cohort study based on the electronic database of the largest health-maintenance organization in Israel. AS patients who were first diagnosed between 2002–2007 were included. Controls were matched by age, gender and enrollment-time. Follow-up continued until death or end of study follow-up on 1 July 2019. Laboratory measures of serum 25-hydroxyvitamin-D levels during the entire follow-up period were obtained. A total of 919 AS patients and 4519 controls with a mean time of follow-up of 14.3 years were included. The mean age at the time of enrollment was 52 years, and 22% of them were females. AS was associated with a higher proportion of vitamin D deficiency (odds ratio 1.27 [95% confidence-interval (CI) 1.03–1.58]). In AS patients, insufficient levels of vitamin D (<30 ng/mL) were significantly associated with increased incidence of all-cause mortality (hazard ratio (HR) 1.59 [95% CI 1.02–2.50]). This association was more prominent with the decrease in vitamin D levels (< 20 ng/mL, HR 1.63 [95% CI 1.03–2.60]; <10 ng/mL, HR 1.79 [95% CI 1.01–3.20]) and among male patients (<30 ng/mL, HR 2.11 [95% CI 1.20–3.72]; <20 ng/mL, HR 2.12 [95% CI 1.19–3.80]; <10 ng/mL, HR 2.23 [95% CI 1.12–4.43]). However, inadequate levels of vitamin D among controls were not associated with an increased all-cause mortality. Our study has shown that vitamin D deficiency is more common in AS patients than controls and is linked to an increased risk for all-cause mortality. These results emphasize the need for randomized-controlled trials to evaluate the benefits of vitamin D supplementation as a secondary prevention of mortality in patients with chronic inflammatory rheumatic disease.

Meta-analysis of Randomized Controlled Trials Assessing the Impact of Proprotein Convertase Subtilisin/Kexin Type 9 Antibodies on Mortality and Cardiovascular Outcomes

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition by monoclonal antibodies has been shown to reduce low density lipoprotein (LDL-C) but its effects on cardiovascular (CV) outcomes have not been fully described. The aim of this study is to assess the impact of PCSK9 inhibition on mortality and CV outcomes by pooling data from all available randomized clinical trials (RCT) of PCSK9 inhibitors. We conducted a comprehensive search of electronic databases, up to December 1, 2018, for all RCTs comparing PCSK9 inhibition to placebo or ezetimibe in patients with hypercholesterolemia or coronary artery disease receiving maximally tolerated statin for primary or secondary prevention of mortality and cardiovascular outcomes. We used random-effects meta-analyses to summarize the studies. We retained 23 RCTs having included 88,041 patients in primary and secondary prevention. The follow-up ranged from 6 to 36 months. PCSK9 inhibition was not significantly associated with reductions in total mortality (odds ratio [OR] 0.91, 95% confidence interval [CI] 078 to 1.06; p = 0.22) and CV mortality (OR 0.95, 95% CI 0.84 to 1.07; p = 0.37). In contrast, PCSK9 inhibition was associated with reductions in myocardial infarction (OR 0.80, 95% CI 0.71 to 0.91; p <0.0001), stroke (OR 0.75, 95% CI 0.65 to 0.85; p <0.0001), and coronary revascularization (OR 0.82, 95% CI 0.77 to 0.88; p <0.0001). In conclusion, PCSK9 inhibition was associated with reductions in myocardial infarction, stroke, and coronary revascularization. Future analyses may identify high-risk patients who may benefit more from these agents and longer follow-up of current or new trials may show a mortality benefit.

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high vascular risk

ObjectiveACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are widely prescribed in patients with high cardiovascular (CV) risk. However, whether both classes have equivalent effectiveness to prevent CV events remains...

Frontiers in lipid research.

Lipoproteins are major mediators of atherosclerosis, myocardial infarction, and cardiovascular death. While lowering of LDLs has convincingly been shown to reduce cardiovascular events, the role of(HDLs as a therapeutic target is less clear. Indeed, HDL is much more heterogenous in its size and composition than LDL. This may at least in part explain why attempts to reduce cardiovascular events by pharmacologically increasing HDL plasma levels have failed.1–5 Even for LDL, particle size may matter. Furthermore, although statins are able to reduce LDL plasma levels and cardiovascular events successfully, there is considerable remaining risk. Thus, novel approaches to lower LDL levels further are of great interest. The current issue of the European Heart Journal addresses these important issues in four clinical and basic science papers. The first paper ‘ HDL cholesterol subclasses, myocardial infarction, and mortality in secondary prevention: the Lipoprotein Investigators Collaborative ’ by Seth Shay Martin et al . from Johns Hopkins University School of Medicine in Baltimore,6 commented on in an Editorial by Jean-Claude Tardif from the Montreal Heart Institute,7 concerns the heterogeneity of HDL and the link of its subclasses to prognosis. The authors analysed data from two, complementary prospective cohorts: the TRIUMPH study of 2465 patients with acute myocardial infarction, and the IHCS study involving 2414 patients who underwent coronary angiography. All patients had baseline HDL subclassification by vertical-spin density gradient ultracentrifugation stratified by tertiles of HDL-cholesterol (HDL-C) and its two major subclasses …

HDL cholesterol subclasses, myocardial infarction, and mortality in secondary prevention: the Lipoprotein Investigators Collaborative.

High-density lipoprotein (HDL) is highly heterogeneous and the link of its subclasses to prognosis remains controversial. We aimed to rigorously examine the associations of HDL subclasses with prognosis in secondary prevention. We collaboratively analysed data from two, complementary prospective cohorts: the TRIUMPH study of 2465 acute myocardial infarction patients, and the IHCS study of 2414 patients who underwent coronary angiography. All patients had baseline HDL subclassification by vertical-spin density gradient ultracentrifugation. Given non-linearity, we stratified by tertiles of HDL-C and its two major subclasses (HDL2-C, HDL3-C), then compared multivariable-adjusted hazard ratios for mortality and mortality/myocardial infarction. Patients were middle-aged to elderly (TRIUMPH: 58.2 ± 12.2 years; IHCS: 62.6 ± 12.6 years), and the majority were men (TRIUMPH: 68.0%; IHCS: 65.5%). IHCS had lower mean HDL-C levels (34.6 ± 10.1 mg/dL) compared with TRIUMPH (40 ± 10.6 mg/dL). HDL3-C accounted for >3/4 of HDL-C (mean HDL3-C/HDL-C 0.78 ± 0.05 in both cohorts). During 2 years of follow-up in TRIUMPH, 226 (9.2%) deaths occurred, while death/myocardial infarction occurred in 401 (16.6%) IHCS patients over 5 years. No independent associations with outcomes were observed for HDL-C or HDL2-C. In contrast, the lowest tertile of HDL3-C was independently associated with >50% higher risk in each cohort (TRIUMPH: with middle tertile as reference, fully adjusted HR for mortality of HDL3-C, 1.57; 95% CI, 1.13-2.18; IHCS: fully adjusted HR for mortality/myocardial infarction, 1.55; 95% CI, 1.20-2.00). In secondary prevention, increased risk for long-term hard clinical events is associated with low HDL3-C, but not HDL2-C or HDL-C, highlighting the potential value of subclassifying HDL-C.

NT-proBNP Best Predictor of Cardiovascular Events and Cardiovascular Mortality in Secondary Prevention in Very Old Age: The Leiden 85-Plus Study

BackgroundIn the aging population cardiovascular disease (CVD) is highly prevalent. Identification of very old persons at high risk of recurrent CVD is difficult, since traditional risk markers loose predictive value with age. MethodsIn a population-based sample of 282 85-year old participants with established CVD from the Leiden 85-plus Study, we studied predictive values of traditional cardiovascular risk markers, a history of major CVD (myocardial infarction, stroke or arterial surgery), and new cardiovascular biomarkers (estimated glomerular filtration rate (MDRD), C-reactive protein (CRP), homocysteine and N-terminal pro B-type natriuretic peptide (NT-proBNP)) regarding 5-year risk of recurrent cardiovascular events and mortality (composite endpoint).ResultsDuring complete 5-year follow-up 157 (56%) participants died. 109 (39%) had a cardiovascular event or died from cardiovascular causes. Individually related to the composite endpoint were: a history of major CVD (HR 1.5 (95%CI 1.03-2.3)), CRP (HR 1.3 (95%CI 1.03-1.5)), homocysteine (HR 1.4 (95%CI 1.2-2.6)) and NT-proBNP (HR 1.7 (95%CI 1.4-2.1)). A prediction model including all traditional risk markers yielded a C-statistic of 0.59 (95%CI 0.52-0.66). Of all five new markers only addition of NT-proBNP improved the C-statistic (0.67 (95%CI 0.61-0.74, p=0.023)). The categoryless net reclassification improvement for NT-proBNP was 39% (p=0.001), for a history of major CVD 27.2% (p=0.03) and for homocysteine 24.7% (p=0.04). ConclusionsAmong very old subjects with established CVD, NT-proBNP was the strongest risk marker for cardiovascular events and cardiovascular mortality. When estimating risk in secondary prevention in very old age, use of NT-proBNP should be considered.

NT-proBNP best predictor of cardiovascular events and cardiovascular mortality in secondary prevention in very old age: The Leiden 85-plus Study

NT-proBNP best predictor of cardiovascular events and cardiovascular mortality in secondary prevention in very old age: The Leiden 85-plus Study

Effect of Statins on Total Cholesterol Concentrations, Cardiovascular Morbidity, and All-Cause Mortality in Chronic Obstructive Pulmonary Disease: A Population-Based Cohort Study

BackgroundThe benefit of statin use on total cholesterol (TC) concentration has not been studied previously in patients with chronic obstructive pulmonary disease (COPD). ObjectiveOur study aimed to evaluate statin-associated TC-concentration reduction and subsequent risk for cardiovascular (CV) morbidity and mortality in COPD. MethodsWe performed a population-based cohort study using a record-linkage database in Tayside, Scotland. A total of 1017 COPD patients who had at least 2 separate TC measurements between 1993 and 2007 were studied. They were categorized into statin-exposed and statin-unexposed groups according to their statin use status during follow-up. Main outcomes were TC-concentration change from baseline, CV events, and all-cause mortality during follow-up. Multivariate Cox regression models with a time-dependent variable for statins were used to assess risk for outcomes. ResultsStatin-associated TC concentrations decreased by 0.86 mmol/L (16%) in patients treated for primary prevention (PP) (n = 1274) and 0.52 mmol/L (11%) in patients treated for secondary prevention (SP) (n = 443), from 5.30 mmol/L and 4.68 mmol/L at baseline, respectively. TC concentrations also declined by 2% in patients free from established CV disease and by 5% in patients with established CV disease in the statin-unexposed groups. A risk reduction of recurrent CV events with statins was observed (adjusted hazard ratio [HR] = 0.35; 95% CI, 0.15−0.87), but not for PP (adjusted HR = 0.84; 95% CI, 0.37−1.89). Statins reduced CV mortality (adjusted HR = 0.32; 95% CI, 0.13−0.77) in SP but not PP. There were statistically significant reductions in all-cause mortality in both PP (adjusted HR = 0.61; 95% CI, 0.43−0.85) and SP (adjusted HR = 0.58; 95% CI, 0.35−0.97). ConclusionsIn patients with COPD, statins were protective from CV events and CV mortality in SP but not PP, and statins improved all-cause mortality in both PP and SP.

Impact of Comprehensive and Intensive Treatment of Risk Factors Concerning Cardiovascular Mortality in Secondary Prevention: MIRVAS Study

Introduction and objectives The aim was to determine whether secondary prevention involving the comprehensive and intensive treatment of cardiovascular risk factors reduces cardiovascular events and cardiovascular mortality at 3-year follow up. Methods The study design comprised a randomized, controlled, open trial in a routine clinical practice setting. In total, 247 patients who presented with acute coronary syndrome or stroke were selected. They were randomized to comprehensive and intensive treatment of cardiovascular risk factors (n=121) or to follow-up based on usual care (n=126). The main study outcomes were the number of cardiovascular events and cardiovascular mortality at 3-year follow-up. The percentage of patients in whom each risk factor was successfully controlled was a secondary outcome. Results Overall, 88.8% of patients assigned to the intensive treatment group had a low-density lipoprotein cholesterol level <100 mg/dl compared with 56.4% of the usual-care group (relative risk [RR]=1.57; 95% confidence interval [CI], 1.28-1.93), and 75.7% of diabetics had a hemoglobin A 1c <7% compared with 28.6% of the usual-care group (RR=2.65; 95% CI, 1.13-6.19). There were four deaths due to cardiovascular causes and 26 nonfatal events in the intensive treatment group versus 17 deaths and 54 nonfatal events in the usual-care group. The cumulative survival rate at 3 years was 97.4% in the intervention group and 85.5% in the control group ( P=.003). Conclusions Secondary prevention involving comprehensive and intensive treatment of cardiovascular risk factors reduced both morbidity and mortality at 3-year follow up.

Meta‐analysis: isosorbide‐mononitrate alone or with either beta‐blockers or endoscopic therapy for the management of oesophageal varices

The evidence concerning the use of isosorbide-mononitrate (IsMn) for oesophageal varices is equivocal. To assess the effects of IsMn for patients with oesophageal varices and no previous bleeding (primary prevention) or previous variceal bleeding (secondary prevention). Systematic review with meta-analyses of randomized trials on IsMn alone or with beta-blockers or endoscopic therapy for oesophageal varices. Electronic and manual searches were combined. Randomized trials on primary and secondary prevention were included. The primary outcome measure was mortality. Intention-to-treat random effects meta-analyses were performed. The robustness of the results was assessed in trial sequential analyses. Ten randomized trials on primary and 17 on secondary prevention were included. Evidence of bias was identified. No apparent effect of IsMn on mortality compared with placebo or beta-blockers or IsMn plus beta-blockers vs. beta-blockers was identified. Compared with endoscopic therapy, IsMn plus beta-blockers had no apparent effect on bleeding, but did seem to reduce mortality in secondary prevention (RR 0.73, 95% CI 0.59-0.89), but not in primary prevention. The effect of IsMn plus beta-blockers on mortality in secondary prevention was not confirmed in trial sequential analysis. Isosorbide-mononitrate used alone or in combination with beta blockers does not seem to offer any reduction in bleeding in the primary or secondary prevention of oesophageal varices. Compared with endoscopic therapy, there may be a survival advantage in using IsMn and beta-blockers, but additional large multicentre trials are needed to verify this finding.

Continuation of Statin Treatment and All-Cause Mortality

The beneficial effects of statins on cardiovascular mortality in secondary prevention have been established in several long-term, placebo-controlled trials. However, the value of statin therapy in reduction of overall mortality in patients without coronary heart disease (CHD) is questionable. This study evaluated the effect of statin therapy in subjects with no indication of cardiovascular disease (primary prevention) and patients with known CHD (secondary prevention). This retrospective cohort study included 229 918 adult enrollees in a health maintenance organization in Israel who initiated statin treatment from 1998 through 2006 (mean age, 57.6 years; 50.8% female). Proportion of days covered (PDC) with statins was measured by the number of dispensed statin prescriptions during the interval between the date of the first statin prescription and the end of follow-up. During a mean of 4.0 and 5.0 years of follow-up, there were 4259 and 8906 deaths among the primary prevention and secondary prevention cohorts, respectively. In both cohorts, continuity of treatment with statins (PDC, > or =90%) conferred at least a 45% reduction in risk of death compared with patients with a PDC of less than 10%. A stronger risk reduction was calculated among patients with high baseline low-density lipoprotein cholesterol level and patients initially treated with high-efficacy statins. Better continuity of statin treatment provided an ongoing reduction in mortality among patients with and without a known history of CHD. The observed benefits from statins were greater than expected from randomized clinical trials.

Studies of the outcome of the treatment with beta-blockers in secondary prevention of the ischemic heart disease

Convincing evidence of the decline of mortality has been achieved with beta-blockers in patients with an acute myocardial infarction and in post-infarction follow-up. The beta-blockers are also the most efficient antianginal medications for the decrease of ischemia in outpatients. They are highly efficient as a monotherapy for angina and are also a medication of choice for angina after the coronary. The objective of this work was an estimate of the use of beta-blockers in secondary prevention of the ischemic heart disease and eliminating doubts concerning their prescription. The method of the analysis sums up the results of a twenty-five-year study on of the outcome of the treatment with beta-blockers in secondary prevention of the ischemic heart disease. The method of the work implies an examination of the professional literature and the data-bases, such as MEDLINE, Pub-Med and KOBSON. The first studies concerned non-selective beta-blockers, used orally. The following studies concerned cardioselective beta-blockers, metoprolol and atenolol. Several studies followed also the effect of beta-blockers and heparin, or beta-blockers and antagonists of calcium towards placebo, in patients with an unstable angina pectoris. Beta-blockers are an essential drug in secondary prevention of the myocardial infarction and in chronic heart failure. The necessary condition for the efficiency of beta-blockers is an early use. Beta-blockers should be given within 12 hours after the appearance of pain. The continuation of the therapy with beta-blockers after the acute phase is considered to be important in the decrease of the infarction zone expansion. Prophylactic use of beta-blockers after the coronary has an excellent effect, above all in patients with a minor, uncomplicated coronary. Though certain groups of beta-blockers have some special characteristics, when it comes to the treatment of angina pectoris, all beta-blockers are efficient. Generally, patients react well to them. Preference is given to cardioselective remedies, in patients with diabetes or lung disease. Exhaustive controlled clinical studies affirm beta-blockers as drugs that reduce mortality in secondary prevention of the ischemic heart disease.

Implantable cardioverter defibrillator therapy in postinfarction patients

In the past few years, new clinical trials were conducted to determine the effectiveness of implantable cardioverter defibrillators (ICDs) for prevention of mortality in patients with ischemic and nonischemic cardiomyopathies. This paper aims to provide an overview of the current state of knowledge regarding ICD therapy in postinfarction patients. Postinfarction patients with severe left ventricular dysfunction are at high risk of sudden cardiac death. Antiarrhythmic therapy does not improve survival in such patients and, therefore, ICDs emerged as treatment of choice for both primary and secondary prevention of mortality after MI. The MADIT (Multicenter Automatic Defibrillator Implantation Trial) and MUSTT (Multicenter Unsustained Tachycardia Trial) trials were the first primary prevention ICD trials documenting a substantial reduction in mortality with an ICD in postinfarction patients with depressed ejection fraction, nonsustained ventricular tachycardia, and inducible sustained ventricular tachycardia. The recently completed MADIT II trial broadened indications for prophylactic use of ICD in postinfarction patients with ejection fraction of 30% or less without a requirement for additional risk stratifiers. The benefit from ICD therapy in patients with low ejection fraction was recently confirmed by results from the SCD-HeFT (Sudden Cardiac Death in Heart Failure) and COMPANION (Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure) trials. Recent clinical trials established ICD as an important therapeutic modality for primary and secondary prevention of mortality in postinfarction patients.

Pharmacological management of high triglycerides and low high-density lipoprotein cholesterol.

Elevated serum triglycerides and low high-density lipoprotein (HDL) cholesterol are part of a metabolic syndrome that is increasingly being recognized as an important risk factor for cardiovascular disease. Several classes of pharmacological agents including fibrates, niacin and statins, can modify the triglyceride-HDL axis. Fibrates in particular have recently been shown in clinical trials not only to increase HDL, but also to reduce cardiovascular mortality in secondary prevention. More research is needed to further define the role of fibrates when used alone and in combination with statins in high-risk individuals.

High risk strategies for atherosclerosis

Calculating a person’s chances of developing coronary heart disease (CHD) is not simple, as many risk factors interact in a complex fashion. Thus many markers, though significant in univariate comparisons, are no longer so when multivariate analysis is performed. Those factors contributing independently to risk can be identified only in prospective investigations such as the Münster Heart (PROCAM) or the Framingham studies. In the Münster Heart study, follow-up of middle-aged men for eight years identified the following nine independent risk variables: age, smoking history, personal history of angina pectoris, family history of myocardial infarction, systolic blood pressure, raised plasma low density lipoprotein cholesterol (LDL-C), low plasma high density lipoprotein cholesterol, raised fasting plasma triglyceride and presence of diabetes mellitus. These have been used to generate an algorithm for prediction of first coronary events which is available in interactive fashion on the internet11This algorithm is available in interactive fashion on the website of the International Task Force for Prevention of Coronary Heart Disease at http://www.chd-taskforce.com.. Large trials have shown that lowering LDL-C reduces the risk of CHD, and diminishes CHD morbidity and mortality in persons without prior evidence of coronary atherosclerosis (primary prevention). This is even more the case in patients with such evidence (secondary prevention). It appears that lowering of LDL-C also reduces all-cause mortality in secondary prevention.