Secondary Prevention Of Heart Disease Research Articles

State of the Heart: Building Science to Improve Women’s Cardiovascular Health

Cardiovascular disease is the No. 1 killer of women in the United States, and marked disparities in cardiovascular health exist between women and men and among groups of women. Coronary heart disease is underdiagnosed, undertreated, and under-researched in women. Women with suspected heart disease are less likely than men to receive indicated diagnostic tests and procedures; sex-based biases in treatment of myocardial infarction persist; and women continue to be underrepresented in cardiovascular research. An accumulating body of literature points to 3 major explanations: sex-based physiology, provider bias, and psychosocial influences. Women's acute and prodromal signs and symptoms of myocardial infarction have been described, yet women have difficulty recognizing and acting on these indications. Primary and secondary prevention of heart disease in women is imperative; although the science is lacking in several areas, existing evidence on diet, hormone therapy, aspirin, physical activity and obesity, and diabetes can serve as the basis for interventions. Potentially, large impacts could be made on women's morbidity and mortality if current scientific knowledge were implemented. The state of the science of women and heart disease is reviewed, with a focus on those areas with the greatest potential to address the needs of women's cardiovascular status. Key gaps in the science and remaining questions are presented as a research agenda for the coming decade.

Participants' willingness to consume soy foods for lowering cholesterol and receive counselling on cardiovascular disease by nutrition professionals

To determine if participants would be interested in consuming soy foods to lower cholesterol in primary and secondary prevention of heart disease, and to identify the role physicians and registered dietitians have in providing dietary advice, about soy foods or other foods, for participants with elevated cholesterol. Qualitative data from 12 focus groups were gathered from a convenience sample of 74 adults, aged 18-91 years, with and without high cholesterol (total cholesterol >200 mg dl(-1)). Participants were recruited from Minneapolis/St. Paul mainstream and natural foods grocery stores. Focus group interviews were taped and transcribed verbatim. Common themes were identified, coded and compared using NVivo computer software. Participants believed diet, lifestyle and genetics were the cause of high cholesterol and cardiovascular disease (CVD). Few participants were aware of the Food and Drug Administration health claim for soy protein, yet many were willing to consume soy as part of lifestyle modification to prevent CVD. They reported preferring food and exercise over medication to treat high cholesterol. Few participants had ever received dietary advice from physicians on treating high cholesterol or CVD, and most doubted the accuracy of such advice. They believed registered dietitians were the most credible source of nutrition counselling and expressed an interest in physician referrals to dietitians. A collaboration and referral system between physicians and registered dietitians could increase CVD patients' consumption of soy foods as a means potentially leading to a reduced risk of heart disease in participants.

The Fish in Secondary Prevention of Heart Disease (FISH) Survey--Primary Care Physicians and 3 Fatty Acid Prescribing Behaviors

Consumption of fish oil has been shown to reduce mortality in patients with cardiovascular disease (CVD). This study aims to determine the frequency and associations of dietary fish prescribing by family physicians. A 22-item survey mailed to randomly selected Washington State family physicians. Nearly all agreed that nutrition is important in CVD prevention (99%) and felt that they have an essential role in giving dietary advice (92%). The majority (57%) knew of fish oil's effectiveness in secondary prevention of CVD. However, only 17% of respondents were identified as high fish prescribers. Knowledge of fish oil's benefit in sudden death reduction was associated with higher fish prescribers in bivariate (P = .005) and multivariate analysis (OR = 2.77; 95th CI: 1.32 to 5.82). High fish prescribers were more likely to report having sufficient time to discuss dietary therapies in bivariate (P = .018) and multivariate analysis (OR = 1.43; 95th CI: 1.03 to 1.98). Despite knowledge of fish oil's benefit and favorable attitudes toward nutritional therapy, family physicians infrequently recommend fish oils for their CVD patients. Strategies improving awareness of fish oil's effects on sudden death and reducing time barriers associated with dietary counseling should be explored further to increase recommendation of this important advice.

Effects of Transdermal Estrogen Replacement Therapy on Cardiovascular Risk Factors

The prevalence of hypertension and cardiovascular disease increases dramatically after menopause in women, implicating estrogen as having a protective role in the cardiovascular system. However, recent large clinical trials have failed to show cardiovascular benefit, and have even demonstrated possible harmful effects, of opposed and unopposed estrogen in postmenopausal women. While these findings have led to a revision of guidelines such that they discourage the use of estrogen for primary or secondary prevention of heart disease in postmenopausal women, many investigators have attributed the negative results in clinical trials to several flaws in study design, including the older age of study participants and the initiation of estrogen late after menopause.Because almost all clinical trials use oral estrogen as the primary form of hormone supplementation, another question that has arisen is the importance of the route of estrogen administration with regards to the cardiovascular outcomes. During oral estrogen administration, the concentration of estradiol in the liver sinusoids is four to five times higher than that in the systemic circulation. This supraphysiologic concentration of estrogen in the liver can modulate the expression of many hepatic-derived proteins, which are not observed in premenopausal women. In contrast, transdermal estrogen delivers the hormone directly into the systemic circulation and, thus, avoids the first-pass hepatic effect.Although oral estrogen exerts a more favorable influence than transdermal estrogen on traditional cardiovascular risk factors such as high- and low-density lipoprotein-cholesterol levels, recent studies have indicated that oral estrogen adversely influences many emerging risk factors in ways that are not seen with transdermal estrogen. Oral estrogen significantly increases levels of acute-phase proteins such as C-reactive protein and serum amyloid A; procoagulant factors such as prothrombin fragments 1+2; and several key enzymes involved in plaque disruption, while transdermal estrogen does not have these adverse effects.Whether the advantages of transdermal estrogen with regards to these risk factors will translate into improved clinical outcomes remains to be determined. Two ongoing clinical trials, KEEPS (Kronos Early Estrogen Prevention Study) and ELITE (Early versus Late Intervention Trial with Estradiol) are likely to provide invaluable information regarding the role of oral versus transdermal estrogen in younger postmenopausal women.

Plasma Clearance of Lovastatin Versus Chinese Red Yeast Rice in Healthy Volunteers

It is now accepted that inhibition of cholesterol biosynthesis is effective in the primary and secondary prevention of heart disease. However, the perceived side-effects on muscle and liver reduce the general acceptance of statin drug therapy as well as compliance over the long term, which is necessary for prevention efforts to be successful. Chinese red yeast rice (CRYR) is a supplement containing lovastatin (monacolin K), eight other monacolins, pigments, tannins, and other phytochemicals. The authors previously reported on a double- blind placebo-controlled trial of CRYR supplement in 80 individuals demonstrating a significant decrease in cholesterol levels from 250 mg/dL to 210 mg/dL over 8 weeks independent of diet. The current study compared the pharmacokinetics of CRYR with lovastatin at the same bioeffective dose for lowering cholesterol. Eleven (11) healthy volunteers were randomized to a crossover study taking 2400 mg CRYR or 20 mg of lovastatin. The Cmax and area under the curve (AUC) of lovastatin were 22.42 ng/mL, and 80.47 higher than CRYR (p = 0.001 and 0.002, respectively). The Cmax for lovastatin hydroxy-acid was 36.63 ng/mL higher than the Cmax of CRYR hydroxy-acid (p = 0.001). The AUC of lovastatin hydroxy-acid was 258.5 greater than that of CRYR (p = 0.001). The results suggested that the effect of CRYR on the cholesterol concentration might be caused by the additive and/or synergistic effects of monacolin K with other monacolins and substances in CRYR. It may lead to the ultimate development of a botanical supplement based on CRYR.

Affect and an Effective Online Therapeutic Community

Affect and an Effective Online Therapeutic Community

Assessment of a register‐based rheumatic heart disease secondary prevention program in an Australian Aboriginal community

Objective: To assess specific performance indicators relating to a register‐based acute rheumatic fever and rheumatic heart disease (ARF/RHD) prevention program in a remote Australian Aboriginal community in order to identify the most appropriate avenues for improvements in delivery of services.Methods: Information kept on the central ARF/RHD register was compared with an amalgamated dataset from three other sources. The community clinic charts of identified patients were reviewed for information regarding accuracy of diagnosis and the number of doses of benzathine penicillin received in the last year. Specific follow‐up arrangements were assessed and compared with practice guidelines.Results: The central ARF/RHD register contained the names of 58 of the 72 (81%) people identified in the community as eligible for inclusion. Only 42% (22/52) of people receiving antibiotic prophylaxis had received 80% or more of the recommended doses in the previous year; service delivery was significantly better for females than males (p=0.004). Individuals in priority category 1 (most severe disease) were found to be receiving follow‐up and investigation according to guidelines. About half the people in categories 2 (moderate disease) and 3 (mild disease) had been inadequately investigated and/or missed out on follow‐up appointments.Conclusions: The ARF/RHD prevention program in this large remote Aboriginal community is struggling to deliver services to a substantial proportion of people who require them. Specific interventions, especially those related to men's health, may be required to correct the problems.

Analysis of inequalities in secondary prevention of coronary heart disease in a universal coverage health care system

The purpose of this study was to analyse whether differences exist in social class or education level in coronary heart disease (CHD) secondary prevention and in cardiovascular risk factor control in a universal coverage health care system. Cross-sectional multi-centre study. 1022 CHD patients recruited from residents in the catchment areas covered by 23 primary health care facilities in Catalonia, Spain. Demographic data, cardiovascular co-morbidity, smoking, blood pressure, fasting blood glucose, triglycerides, total cholesterol, HDL and LDL cholesterol, body mass index (BMI), drug therapy used for secondary prevention, educational level, and social class based on occupation. Patients at the lowest educational level were more frequently women, older, and diabetic. Patients in the middle educational level were more frequently smokers than those in the highest or the lowest level (24.7, 8.7, and 12.0%, respectively; P = 0.008) and had better systolic blood pressure levels (125 mmHg (15), 135 mmHg (16), and 134 mmHg (17), respectively; P = 0.001). All educational levels and social classes had similar adjusted rates of risk factor control. Therapeutic management was also similar among all educational levels and social classes, after adjusting for confounders. CHD patients in the lower SES received similar treatment for secondary prevention and achieved similar control of risk factors. No social inequalities were found in secondary prevention in CHD patients using the National Health System in Spain.

The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411

BackgroundThe aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.MethodsSPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions.The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires.The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Racial/Ethnic and Socioeconomic Disparities in Multiple Risk Factors for Heart Disease and Stroke—United States, 2003

Heart disease and stroke are the first and third leading causes of death, respectively, in the United States. Certain modifiable risk factors, including high blood pressure, high cholesterol, diabetes, tobacco use, obesity, and lack of exercise, are the main targets for primary and secondary prevention of heart disease and stroke. A substantial proportion of the population has multiple risk factors, increasing their likelihood of cardiovascular disease. To assess the prevalence of multiple risk factors for heart disease and stroke and to identify disparities in risk status among population subgroups, CDC analyzed data from the 2003 Behavioral Risk Factor Surveillance System (BRFSS) survey. This report summarizes the results of that analysis, which indicated that approximately 37% of the survey population had two or more risk factors for heart disease and stroke and that considerable disparities in risk factors existed among socioeconomic groups and racial/ethnic populations. To decrease morbidity and mortality from heart disease and stroke, public health programs should improve identification of persons with multiple risk factors and focus interventions on those populations disproportionately affected.

Social position and ethnic origin do not affect access to medical care in people with coronary heart disease

QuestionDo people from different social and ethnic groups have the same access to appropriate medical care for coronary heart disease?Study designProspective cohort study.Main resultsCoronary heart disease was higher in people from low social position than people from high social position, and was higher in South Asians than Caucasians (data not shown). Although exercise electrocardiography, angiography and revascularisation were used more often by people with lower social status, adjusting for clinical need showed no association between the use of cardiac procedures and social status (see Results table 1). The use of cardiac procedures was higher for South Asians than Caucasians (see Results table 2), and South Asians were more likely to take secondary heart disease prevention drugs.Authors’ conclusionsSocial status and ethnicity do not affect access to medical care for people with coronary heart disease. The use of medical care reflects people's clinical needs and does not explain why people from low social position or with South Asian ethnicity have a high risk of coronary heart disease.

Switching of Prescription Drugs to Over-the-Counter Status

Prescription medicines are increasingly being switched to over-the-counter (OTC, nonprescription) status in the developed world, with the support of government policy. These changes may provide greater choice for individuals and offer potential savings in government spending on health while expanding the market for pharmaceutical companies. However, there is concern regarding the safety of these reclassifications. Elderly people are the largest consumers of prescription and OTC medicines and are more vulnerable to drug adverse effects and the risks of multiple or inappropriate medications. Commonly purchased agents such as NSAIDs have recognised adverse effects which have been shown to be more common in the elderly. Furthermore, all sedatives, including antihistamines, have a propensity to cause falls in older people. As many doctors do not ask patients about OTC medicine use, problems related to use of these drugs may go undetected. Furthermore, the increased availability of OTCs may result in a delay in patients consulting medical practitioners for potentially serious conditions, although this has not so far been investigated. In the UK, the recent switch of a low-dose HMG-CoA reductase inhibitor (statin) to OTC status has caused concern. Although there might theoretically be some benefits from improved access to medications used in primary and secondary prevention of heart disease, the actual outcomes of use of this reduced dose of the statin will be difficult or impossible for patients or practitioners to monitor. OTC drug use implies a mutual responsibility for communication between patients and health professionals that in practice is not always achieved. Epidemiological research is needed to investigate patterns of OTC use and evaluate the potential risks of OTC medicines in elderly people. Governments, regulatory bodies, professionals and the drug industry have a responsibility to ensure that robust systems are in place if the increased use of OTC medicines by elderly people is to be safe and effective.

Interview With Jerry Stamler, MD

Interview With Jerry Stamler, MD

Analysis of Recent Papers in Hypertension

Analysis of Recent Papers in Hypertension

Assessment of risk factors in coronary patients being followed by cardiologists: control of risk factors in coronary patients.

Control of risk factors for coronary heart disease secondary prevention is still very unsatisfactory. This study assessed 104 patients referred by cardiologists to discover how carefully National Cholesterol Education Program II recommendations were being followed. Average age of the cohort was 60.9+/-10.8 years, and 67.3% were men. A total of 57(54.8%) experienced a previous myocardial infarction and 83 (80.3%) a revascularization procedure. They saw their doctors 4.4+/-2.9 times a year and had blood tests 2.8+/-1.7 times a year. Blood pressure was >/=140/90 mm Hg in 57.8%, body mass index >/=25 kg/m2 in 62.5%, and the weight-to-hip ratio >/=0.95 in 42.9% of men, and >/=0.85 in 47.0% of women. Total, low-density lipoprotein, and high-density lipoprotein cholesterol and triglyceride values were 222.9+/-47.3 mg/dL, 144.9 mg/dL, 44.8+/-11.5 mg/dL, and 176+/-119.41 mg/dL, respectively. Low-density lipoprotein cholesterol was <100 mg/dL in 8.1%, and <130 mg/dL in 47.1%; the total cholesterol/high-density lipoprotein cholesterol ratio was 5.1+/-1.5 (>/=5 in 51%). In these patients, the control of major risk factors like high blood pressure, overweight, and high low-density lipoprotein cholesterol was poor.

Hormone replacement therapy for primary and secondary prevention of heart disease

Cardiovascular disease is the leading cause of death in women. In pooled analysis, observational studies have shown a 50% reduction in death and myocardial infarction among users of hormone replacement therapy (HRT) for the primary and secondary prevention of cardiovascular disease. The first randomized trial of HRT for secondary prevention of heart disease found no benefit to therapy (Heart and Estrogen/progestin Replacement Study ). Even after 6.8 years of follow-up, there was still no cardiovascular benefit from the use of HRT (HERS II). HRT was associated with a 50% increased risk of heart attacks within the first year as well as an increased risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) (relative risk 2.89) and gallbladder disease (RR 1.38). The Estrogen Replacement and Atherosclerosis trial found no evidence that HRT slowed the progression of subclinical angiographic disease either. This was despite a favorable effect on high-density lipoprotein and low-density lipoprotein. The first randomized trial of HRT for the primary prevention of heart disease found no overall benefit (Women's Health Initiative). The combination of estrogen and progestin resulted in a 29% increase in heart attacks, 41% increase in stroke, a doubling of thrombotic events (DVT and PE), as well as a 26% increase in breast cancer. The risk for thrombotic events was greatest in the first year whereas the risk of breast cancer increased progressively with duration of therapy. HRT is no longer recommended for the primary or secondary prevention of cardiovascular disease or stroke. It may still be considered for short-term relief of menopausal symptoms in women without high-risk conditions, but alternatives exist.

Modulation of monocyte-macrophage function with alpha-tocopherol: implications for atherosclerosis.

Cardiovascular disease is the leading cause of morbidity and mortality in the Western world. Monocyte-macrophages are crucial cells in atherogenesis. Several lines of evidence suggest that antioxidants, especially alpha-tocopherol, have beneficial effects with regard to cardiovascular disease. Alpha-tocopherol has beneficial effects on cell functions that are pivotal in atherogenesis. Alpha-tocopherol inhibits platelet aggregation and proinflammatory activity of monocytes. In vitro data also support an effect of alpha-tocopherol on smooth muscle cell proliferation and endothelial function. Finally, recent data support an effect of alpha-tocopherol on macrophage function. The mounting evidence from in vitro and in vivo studies provides a sound scientific basis for alpha-tocopherol supplementation. Further clinical trials are required, however, before a definitive recommendation can be made for primary and secondary prevention of heart disease.

Cholestin inhibits cholesterol synthesis and secretion in hepatic cells (HepG2).

Hyperlipidemia is a well-known risk factor for atherosclerosis and statins are widely used to treat patients with elevated levels of lipids in their plasma. Notwithstanding the proven benefits of statin drugs on both primary and secondary prevention of heart disease, the high cost of statin treatment, in addition to possible side effects such as liver function abnormalities, may limit their widespread use. We conducted a study on a natural product as an alternative to statin treatment. Cholestin, a dietary supplement, is prepared from rice fermented with red yeast (Monascus purpureus), which has been shown to significantly decrease total cholesterol levels in hyperlipidemic subjects. Our objective was to determine the cellular effect of Cholestin on cholesterol synthesis in human hepatic cells (HepG2) and the mechanism by which it caused a change in lipid metabolism. Cholestin had a direct inhibitory effect on HMG-CoA reductase activity (78-69% of control). Cholesterol levels in HepG2 cells treated with Cholestin (25-100 microg/mL) were significantly reduced in a dose-dependent manner (81-45% of control, respectively). This reduction was associated with decreased synthesis and secretion of both unesterified cholesterol (54-31 and 33-14% of control, respectively) and cholesteryl ester (18-6 and 37-19% of control, respectively). These results indicate that one of the anti-hyperlipidemic actions of Cholestin is a consequence of an inhibitory effect on cholesterol biosynthesis in hepatic cells and provide the first documentation of a biomolecular action of red yeast rice.

Prevención secundaria de cardiopatía isquémica a nivel lipídico en atención primaria Aragón. Estudio PRECIAR 1

Despite the existing evidence of the effectiveness of secondary prevention by modifying lifestyles or using the different drugs which have shown themselves to be clinically beneficial for heart patients, there is little, not highly accurate information available regarding the handling of the treatment of these patients within the scope of primary care in our country. The purpose of this study is that of ascertaining the current status of secondary prevention of heart disease as far as lipid control is concerned. A review was made of the clinical records of all of the patients diagnosed at some point in time of their life as having ischemic heart disease, including those under the heading of acute myocardial infarction and angina pectoris within the 11 groups of patients assigned to three urban Health Care Centers in Area II in Zaragoza. The population in question totaled 19,692 patients, 388 cases of ischemic heart disease having been found in the record files data. Based on a study of the lipid control data, 60.8% of the cases analyzed in this study showed a complete lipid profile for the last year. Solely 4.7% of these patients had LDL < 100, the control objective having to be limited to c-LDL < 130 to find a 31.3% of patients with a lower than optimum control of this parameter. The results of our study reveal that the diagnosis of dyslipemias as well as the control of all other heart disease risk factors in secondary care have not been in keeping, for the most part, with the quality criteria of this health care procedure and therefore reveal the existence of a major degree of room for improvement.

Alpha-tocopherol and atherosclerosis.

Cardiovascular disease is the leading cause of morbidity and mortality in the Western world. There is compelling evidence incriminating oxidative stress in the pathogenesis of the atherosclerotic lesion. Several lines of evidence suggest that antioxidants, especially alpha-tocopherol, have potential beneficial effects with regard to cardiovascular disease. In vitro, alpha-tocopherol has been shown to inhibit platelet adhesion and aggregation and smooth muscle cell proliferation, exert anti-inflammatory effects on monocytes, and improve endothelial function. Also, supplementation with alpha-tocopherol has been shown to decrease lipid peroxidation, platelet aggregation, and pro-inflammatory activity of monocytes. However, clinical trials with alpha-tocopherol supplementation to date have been equivocal. Thus, although mounting in vitro evidence and animal models provide a sound scientific basis for alpha-tocopherol supplementation, further clinical trials are required before a definitive recommendation can be made with respect to the primary and secondary prevention of heart disease.