Prevention Of Cardiac Disease Research Articles

Vitamin E and Cardiovascular Health

THE CRITICAL IMPORTANCE OF PREVENTIVE MEDICINE for all people has long been recognized, as documented in the writings of Hippocrates and Osler. Moreover, in preventive health, it is clear that sex matters, as the 2001 Institute of Medicine report concluded after reviewing the basis for biological differences in health. The goal of preventing cardiovascular disease is similar in men and women. However, the strategies and recommendations to achieve this goal differ, as exemplified in the 2004 American Heart Association Guidelines for Cardiovascular Disease Prevention in Women. Although it is increasingly well known and appreciated that heart disease is the leading cause of death in both women and men, it is also true that researchers are increasingly discovering sex differences in how cardiovascular disease may be prevented and treated. All prevention, as well as treatment, involves some degree of balancing benefit and risk. The attractiveness of a particular strategy depends on the magnitude of the risk/ benefit ratio. Put simply, it is difficult to improve the health of individuals who largely (apparently) have nothing wrong with them. Yet from a societal viewpoint, it is still reasonable to recommend a preventive therapy to individuals at very low risk; even though individual patient benefits are very small, the population benefits are huge. This principle is applied in legislation mandating use of childhood vaccines. However, this strategy only works if the possible risks are trivial—even a low risk of harm (eg, Guillain-Barre syndrome from swine flu shots) cannot be justified. Sex-specific benefits and risks can differ for many reasons, such as that the incidence and prevalence of coronary heart disease are lower in women than in men until after the sixth decade. For example, according to recent data from the Women’s Health Study (WHS), aspirin provides no benefit in healthy women (except in the subgroup of those aged 65 years or older), even though previous studies have shown abenefit inhealthymen.Similarly, like studies inmen,numerous statin trials in the last decade have not shown a benefit on total or coronary heart disease mortality in women. In this issue of JAMA, Lee et al report on another promising prevention strategy, vitamin E, which earlier epidemiologic and observational studies suggest provides cardiovascular benefits in men and women. Vitamin E is a powerful biological antioxidant that can protect cells against the ravages of free radicals. Thus, there has been great interest in the value of vitamin E for preventing heart disease and cancer. Vitamin E is found in vegetable oils, nuts, green leafy vegetables, and fortified cereals, among other foods. So how does vitamin E supplementation compare with other primary prevention strategies for women? Until publication of the Heart and Estrogen/progestin Replacement Study (HERS) in 1998, followed by the Women’s Health Initiative (WHI) a few years later, postmenopausal hormone therapy was the most popular primary prevention strategy for women. Hormone therapy has plausible pathophysiological mechanisms for cardiovascular risk reduction, such as lipid lowering and favorable vascular effects. In addition, epidemiologic and observational studies have suggested a benefit of hormone therapy on cardiovascular disease. However, after randomized controlled trials showed no benefit on total or cardiovascular mortality and in fact found increased cardiovascular events in the first year of use, hormone therapy has plummeted from 90 million US prescriptions annually between 1999 and 2002 to a drug with a black box warning on its label. Like hormone therapy, vitamin E has plausible mechanisms and data from observational studies to support a meaningful role in prevention of cardiac disease. Data from approximately 90 000 women in the Nurses’ Health Study showed a 30% to 40% decrease in heart disease for women taking vitamin E supplements, after adjustment for risk factors for coronary disease and use of other antioxidant nutrients. In this issue of JAMA, Lee et al report their findings from the WHS on the effects of 600 IU of vitamin E vs placebo every other day in 39 876 healthy women followed up for an average of 10 years. The investigators found no benefit

Cardiovascular Morbidity and Mortality in Children with Chronic Kidney Disease in North America: Lessons from the Usrds and Naprtcs Databases

Cardiovascular (CV) disease mortality has not changed in the past three decades, remaining the second most common cause of death in children with end-stage renal disease (ESRD). This article reviews pediatric data pertaining to CV disease obtained from the two largest renal databases in North America. The data indicate high incidence and prevalence of CV complications and cardiac risk factors in children with ESRD, accounting for high cardiac mortality in this patient population. Early identification and intervention to treat modifiable risk factors and asymptomatic cardiac disease might lead to prevention of cardiac disease and to a decrease in CV morbidity and mortality in young adults who developed chronic kidney disease during childhood.

Improving women’s quality of care for cardiovascular disease and diabetes: the feasibility and desirability of stratified reporting of objective performance measures

Despite growing recognition of significant morbidity and mortality among women from cardiovascular disease, management of primary and secondary cardiac risk factors continues to be suboptimal for many women. Although there is a good deal of room to improve the care for cardiovascular disease and diabetes in men, existing gender differences in performance suggest much can be gained by specifically assessing and monitoring quality of care for these conditions in women. In this paper, we describe recent work showing gender differences in quality of ambulatory care in managed care plans with some plans having substantial gender differences on widely used measures of the quality of primary and secondary prevention of cardiac disease. We then discuss potential benefits of and barriers to routine reporting of objective measures of the quality of care, such as Health Plan Employer Data and Information Set (HEDIS) measures, by health plans.

Postmenopausal hormone replacement therapy and the prevention of cardiovascular disease: a review.

The role of hormone replacement therapy (HRT) for the prevention of cardiac disease is contentious. In this review the epidemiological evidence for the role of HRT in primary and secondary prevention of cardiac disease is assessed. Although current studies suggest very little role for HRT in women with established cardiac disease, its use in the 'healthy woman' without vascular disease until recently was not clear. HRT for the sole purpose of prevention of cardiac disease is now not indicated.

Postmenopausal Hormone Replacement Therapy and the Prevention of Cardiovascular Disease: A Review

The role of hormone replacement therapy (HRT) for the prevention of cardiac disease is contentious. In this review the epidemiological evidence for the role of HRT in primary and secondary prevention of cardiac disease is assessed. Although current studies suggest very little role for HRT in women with established cardiac disease, its use in the 'healthy woman' without vascular disease until recently was not clear. HRT for the sole purpose of prevention of cardiac disease is now not indicated.

Prevention of cardiac disease in the elderly.

There is much evidence for identifying and altering certain risk factors, such as hypertension, diabetes, raised cholesterol levels, smoking, obesity, hormone changes and exercise to reduce the incidence of cardiovascular disease; certain drugs have also been shown to be of benefit. Although the elderly population is most likely to suffer cardiovascular disease, very little of the trial evidence has looked at this patient group. It is important that the interventions we recommend for young patients have a comparable risk/benefit profile in the elderly so that we can offer them the most appropriate treatment.

Complications of chronic renal insufficiency: Beyond cardiovascular disease

The less rigorous attention to the management of the complications of chronic renal insufficiency (CRI) and its comorbid conditions has potentially tragic consequences. In fact, with early recognition and intervention, many of the complications of CRI and its comorbid conditions can be ameliorated or prevented. We review here the most prevalent, troublesome, and potentially preventable complications and comorbidities of CRI with a view toward developing high-quality, cost-effective strategies for delivering early interventional care. Complications of CRI include malnutrition, anemia, disorders of divalent ion metabolism and osteodystrophy, metabolic acidosis, and dyslipidemia. Important comorbid conditions of CRI are hypertension, diabetes mellitus, and cardiovascular disease. Clinical intuition suggests that early intervention will avert morbidity related to the hypoalbuminemia and other nutritional disorders of CRI, the metabolic acidosis, and the dyslipidemias, but prospective data are lacking at present. Correction of anemia, usually with recombinant human erythropoietin, may be key to the prevention of cardiac disease and other comorbidities of CRI. Incipient disorders of bone and mineral metabolism are managed prospectively using such measures as protein restriction to reduce phosphorus intake, phosphate binders, calcium supplementation, and vitamin D analogues. Hypertension, whatever its original etiology, is clearly an important risk factor for the progression of kidney failure and for the development of diffuse vascular disease; appropriate and aggressive treatment is essential. In patients with diabetic nephropathy, the principles of both primary and secondary prevention have been validated in several large trials of glycemic and blood pressure control. The seeds of these insidious, challenging, and costly comorbid conditions are sown very early in CRI, at a time when they are—in theory—most amenable to intervention. We therefore must be as proactive as possible in the timely implementation of relatively simple therapies that have the potential to prevent some of these adverse outcomes of CRI.

Necrotizing Fasciitis Associated with Nonsteroidal Antiinflammatory Drug Use

Objective: To describe a case of necrotizing fasciitis (NF) that occurred following minor clean surgery in a seemingly otherwise healthy man who was taking over-the-counter (OTC) ibuprofen 200 mg and aspirin 325 mg before surgery. Case Summary: A 71-year-old white man underwent an uncomplicated laparoscopic cholecystectomy. His only medical disorder prior to surgery was osteoarthritis, for which he took OTC-strength ibuprofen; his only other regular medication was one aspirin 325-mg tablet daily for prevention of cardiac disease. Within 48 hours of the surgery, the onset of NF was apparent, and extensive tissue excision and debridement was required 1 week after the operation. All nonsteroidal antiinflammatory drugs (NSAIDs) were withheld. The patient survived a complicated clinical course over the next month. Discussion: A review of proposed risk factors for the development of NF in the patient indicated surgery and NSAID use. Analysis of the probability of NSAID use as a causative factor for the adverse reaction of NF suggests a possible role. This case suggests that NSAID use in lower OTC dosages may contribute to the onset or course of NF. The case report adds to existing literature suggesting an association between NSAID use and the development or course of NF. Conclusions: NSAIDs are widely used drugs, and any association as a causative or provocative factor for NF is a rare finding. However, practitioners should be aware of the proposed association.

Combining Case Management, Pathways, and Report Cards for Secondary Cardiac Prevention

Many disease treatment tools can be shifted into prevention. Many cardiac rehabilitation programs have focused on a 12-week exercise plan with minimal long-term follow-up. In 1995 Butterworth Hospital established a cardiac prevention and rehabilitation program focusing on long-term modification of cardiovascular risk factors. The pathway was created as the outpatient extension of three inpatient cardiovascular pathways. Unlike inpatient pathways, the outpatient pathway was integrated into the medical record as a major care planning and documentation tool. Since the entry of the first group of patients in January 1995, average quarterly enrollment has increased from less than 15% to 32% of eligible patients. Butterworth adopted Dartmouth Medical Center's (Hanover, NH) value compass and instrument panel approach under the rubric of report card. As an internal, clinical quality improvement tool, the report card is not used for public reporting, although prevention and rehabilitation report cards are provided to payers. Information on cost and utilization, patient satisfaction, functional health status, and clinical outcomes, as well as the current improvement activities, are covered. Report cards have been issued in June 1996, September 1996, and January 1997, each highlighting activities that drive program improvements. The combination of case management, pathways, an outcomes database, and report cards creates a marketable program for secondary prevention of cardiac disease.

Molecular genetics: cardiac disease and risk-related genes.

Molecular genetics is playing an increasing role in the diagnosis, treatment, and prevention of cardiac disease. Moreover, most of the genes that may cause cardiac disease or predispose an individual to cardiac disease are anticipated to be identified within the next 10 years. Several genes with risk for heart disease have been identified, such as the ACE genotype DD. Replacement gene therapy as well as use of promoter-specific drugs to act on genetic regulatory elements will encompass the future treatment of cardiovascular disease. This article provides a summary of the potential roles of genetic screening for cardiac risk factors and genetic interventions in cardiovascular disease.

Dietary modulation of Kupffer cell and splenocyte function during a Salmonella typhimurium challenge in mice.

Oils from cold-water fish are rich in (n-3) polyunsaturated fatty acids, in particular eicosapentaenoic acid (20:5) and docosahexaenoic acid (22:6). Although those fatty acids are beneficial in the prevention of cardiac disease and have anti-inflammatory properties, they can also decrease survival rates of mice during challenges with food-borne pathogens. This study was designed to determine dietary fat effects on Kupffer cells and splenocytes during a Salmonella typhimurium challenge. Mice were fed a low corn oil diet (3%, control), high corn oil diet (20%, HCO), or a menhaden fish oil diet (17% + 3% corn oil, FO) for 28 days and then orally given 3.1 x 10(8) colony-forming units of S. typhimurium. Kupffer cells and splenocytes were separated immediately prior to and on days 6, 10, and 14 postchallenge. Fish oil decreased Kupffer cell phagocytosis and oxidative burst early in the infection and adhesion molecule (CD18) expression at the end of the infection. In splenocytes, fish oil affected Ia expression prior to and late in the infection and depressed CD18 expression late in the infection. These data suggest that the diet affected Kupffer cells most early in the infection but affected splenocytes primarily later in the infection. Therefore, because the greatest death rate during an S. typhimurium infection occurs early, the reduced function of the Kupffer cells is probably a major factor.

Polyunsaturated fatty acids increase neutrophil adherence and integrin receptor expression

Fish oils are abundant in polyunsaturated fatty acids of the n-3 series (in particular eicosapentaenoic, 20:5 and docosahexaenoic acid, 22:6). Such fatty acids are generally considered to be beneficial in the prevention of cardiac disease and to have anti-inflammatory properties. Neutrophil adherence is an essential early event in an acute inflammatory response, and we have demonstrated that both 20:5 and 22:6 stimulate adherence in vitro. Arachidonic acid (20:4, n-6) was also stimulatory. Significant simulation of adherence was seen from 5 to 80 microM (nontoxic concentrations) 22:6, 20:5, or 20:4. At the lower fatty acid concentrations tested (< or = 40 microM) 20:5 was less active than 22:6 or 20:4 at stimulating adherence. Above 40 microM there was no difference in the ability of the three fatty acids to stimulate adherence. At the lower fatty acid concentrations tested (< or = 10 microM) 22:6 was less active than 20:4, whereas above 10 microM they were equally active. Immunofluorescent flow cytometric analysis of neutrophil integrin (adherence) receptors showed that the complement C3bi receptor (CD11b) was up-regulated by these fatty acids. There was no change in CD11a or CD11c. Saturated fatty acids of the same chain length were without effect on adherence or receptor expression. The findings suggest that these polyunsaturated fatty acids may, under certain conditions, be proinflammatory with respect to their acute effects on the interaction of neutrophils with microbes, endothelium, and other tissues.

Prevention of cardiac disease by subcutaneous deferoxamine in patients with thalassemia major.

We examined the efficacy of long-term subcutaneous deferoxamine therapy in the prevention of iron-related cardiac disease in patients with thalassemia major who began treatment after the age of 10 years. Of 36 such patients without preexisting cardiac disease, 19 did not comply with the program of chelation therapy. Over the course of treatment (1977 to 1983) serum ferritin and aspartate aminotransferase levels fell in the compliant group, from mean values (+/- S.D.) of 4765 +/- 2610 to 2950 +/- 1850 ng per milliliter and 58.1 +/- 22 IU to 30 +/- 20 IU per liter, respectively (P less than 0.05), but rose in the noncompliant group, from 5000 +/- 2316 to 6040 +/- 2550 ng per milliliter and 56.6 +/- 20 to 90 +/- 35 IU per liter, respectively. Only one patient in the compliant group acquired cardiac disease and died of fulminant congestive heart failure. In contrast, 12 noncompliant patients acquired cardiac disease, and 7 died. In addition, the mean age of the compliant population (18.9 +/- 4.5 years) now approaches the mean age of acquisition of cardiac disease in the noncompliant group (19 +/- 4.3). These data demonstrate that compliance with treatment with deferoxamine may protect patients from cardiac disease induced by iron overload.

CHELATION THERAPY IN OLDER PATIENTS WITH THALASSEMIA MAJOR

To determine the utility of chronic subcutaneous Desferal (SCDF) therapy (Rx) in the prevention of cardiac disease in patients with thalassemia major who began treatment after the age of 10, we evaluated 36 patients; all of whom were started on SCDF when they were 10 years of age or older and had no pre-existing cardiac disease (defined as clinical congestive heart failure or abnormal left ventricular function). There were 17 compliant patients (mean age 12.3 years at onset of Rx) who used SCDF at least 5 days a week; 8-12 hours each day. Nineteen patients were noncompliant (mean age 16.6 years), they used SCDF periodically. In the group of compliant patients, the mean number of years on Desferal Rx was 4.8 years, in the noncompliant group, 4.0 years. All patients have been on a hypertransfusion regimen (maintaining a hemoglobin of 11%), at least since they began SCDF. Only one patient in the compliant group developed cardiac disease (at age 11) and she died of congestive heart failure at age 18. In contrast, 12 in the noncompliant group developed cardiac disease. Two of these patients have died. The mean age of development of cardiac disease in the noncompliant patients was 20.3 years ± 4.2 years. Therefore, the lack of cardiac complications in the compliant group suggests that compliance with SCDF Rx may reduce the risk of cardiac disease in older patients.

Effect of STP on knowledge, attitude and practice of menopausal women regarding the prevention of cardiac disease and osteoporosis in selected health center of Kannur district

Menopause is described as a period of psychological difficulties that changes the life style of women in multiple ways. Menopausal women require more information about their physical and psychological needs. Women who constitute half of world population. Identification of awareness and practice of menopausal women about menopausal complications is important factor which realized the investigators to conduct a study to assess the effect of structured teaching programme on knowledge, attitude and practice of menopausal women regarding the prevention of cardiac disease and osteoporosis in selected health center of Kannur was given and data was analyzed by using descriptive and inferential statistics.

ROLE OF THE TONSILS IN EXPERIMENTAL ENDOCARDITIS

The advisability of removing the palatine tonsils as a prophylactic measure for the various forms of endocarditis has long been a subject of controversy among clinicians. The advocates of tonsillectomy point out the decreased incidence of chronic cardiac disease in tonsillectomized persons, as borne out by certain studies.¹Their opponents, basing their opinions on studies of other groups, maintain that routine removal of tonsils for the prevention of cardiac disease is not based on conclusive data.²Furthermore, some clinicians contend that actual harm can be done by removal of the tonsils,³not only in the operative mortality but also in respect to the development of infections of the respiratory tract. In a previously reported study,⁴it was shown that a virulent hemolytic streptococcus obtained from a pneumonic lesion in a dog produced endocarditis in 10 of 25 dogs, i. e., in 40 per cent when injected intravenously. In veiw of