Control Of Vascular Risk Factors Research Articles

Heart failure: Current concepts

The clinical syndrome of heart failure is the final pathway for myriad diseases that affect the heart. Incidence of heart failure today is approaching 10 per 1000 population among persons older than 65 years of age. Heart failure is the reason for at least 20% of all hospital admissions among persons older than 65 years. Symptomatic heart failure has a one-year mortality of approximately 45%. Although there has been a substantial reduction in mortality of patients with systolic heart failure, overall death rates in large epidemiologic surveys have remained the same [1]. Why have the newer and successful therapies failed to result in a meaningful reduction in mortality due to heart failure? It is important to recognize that heart failure is a clinical syndrome arising from diverse causes. Not all patients with the condition have poorly contracting ventricles and a low ejection fraction. Many have uncorrected valvular disease, such as aortic stenosis or mitral regurgitation, or abnormal filling, resulting in diastolic heart failure. A large majority of patients with heart failure are elderly, and 75% of patients have a history of hypertension. Many patients have at least one serious coexisting condition, in addition to advanced age. Heart failure is largely preventable, primarily through the control of blood pressure and other vascular risk factors. The new approach to the classification of heart failure [2] emphasizes its evolution and progression and defines four stages: Stage A Patients with risk factors for the development of heart failure. Stage B Patients with structural abnormality of the heart. Stage C Patients with structural abnormality of the heart and current or previous symptoms of heart failure. Stage D Symptoms of endstage heart failure that are refractory to standard treatment.

Risk factor management in stable, insulin-treated patients with Type 2 diabetes: The Diabetes Outcomes in Veterans Study

Objectives: Describe the methodologies and study population of the Diabetes Outcomes in Veterans Study (DOVES). Research Design and Methods: Prospective, multicenter, observational study of Southwestern veterans with stable, insulin-treated Type 2 diabetes. Subjects were randomly selected from pharmacy records and were required to be using at least one long-acting insulin preparation daily. Baseline psychosocial evaluations included psychological status, social and cultural barriers to care, self-care behaviors, and vascular disease risk factors. Clinical measurements included self-reported vascular disease, hemoglobin A1c (HbA1c), blood pressure, blood lipids, and body mass index (BMI). A subset of subjects completed a protocol of four times daily self-monitored blood glucose testing for 8 weeks. Subjects were followed for 12 months. Principal endpoints included glycemic control, the occurrence of hypoglycemia, and control of vascular disease risk factors. Results: We enrolled 338 subjects. The mean (±S.D.) age was 65.1±9.7 years and 3.8% were women. At baseline, over two-thirds of subjects reported vascular disease complications. Nearly three-quarters had limited physical activity. Among subjects younger than 65 years, 53% considered themselves disabled for work. Despite the high prevalence of vascular disease, 43.8% had an HbA1c ≥8.0%. Many subjects were sedentary, 62.1% had a BMI of 30 kg/m 2 or above, and 22.2% were still smoking. Conclusions: Detailed measurements of psychological status, self-care behaviors, and risk factor control are feasible in this elderly, debilitated population. Although the prevalence of complications and self-rated disability was high, vascular disease risk factors were poorly controlled in a substantial proportion of subjects.

Role of vascular factors in osteoporosis.

Osteoporosis is a silent epidemic in the world today. With the increase in the elderly population, there will be an increase in the prevalence of osteoporosis, and so the need for focused preventive strategies should become a public health priority. Prophylactic therapy and risk-factor reduction is important, as this is likely to be cost effective. There are scientific observations that point out that vascular dysfunction seen with aging may be related to the pathogenesis of osteoporosis. Here we review this relationship from a different angle. We think aggressive control of vascular risk factors in addition to the known existing osteoporosis risk factors may help to reduce the morbidity and mortality associated with this disease.

Awareness, treatment, and control of vascular risk factors in African Americans with stroke.

To investigate control of risk factors in African American patients with previous stroke. The baseline history, physical examination, and laboratory data for 1,086 subjects enrolled in the African American Antiplatelet Stroke Prevention Study from 1995 to 1999 were studied. The level of awareness, pharmacologic treatment, and control of diabetes mellitus (casual plasma glucose level > or =200 mg/dL), hypertension (blood pressure > or =140/90 mm Hg), and hypercholesterolemia (serum total cholesterol level > or =240 mg/dL) were determined. Forty percent of subjects reported a history of diabetes mellitus or use of diabetic medication, and 2% of the remaining subjects had a serum glucose level of > or =200 mg/dL. Of those subjects known to be diabetic, 33% had a serum glucose level of > or =200 mg/dL. A history of hypertension or use of antihypertensive medication was reported in 87% of subjects, and 48% of the remaining subjects were found to have a blood pressure of > or =140/90 mm Hg on exam. Of those subjects known to be hypertensive by history, 73% were on antihypertensive medication, but only 30% of the treated subjects had a blood pressure under 140/90 mm Hg. A history of hypercholesterolemia or use of a lipid-lowering agent was reported in 40% of subjects, and 24% of the remaining subjects had a cholesterol level of > or =240 mg/dL. Use of a lipid-lowering agent was reported in 43% of subjects known to be hypercholesterolemic, and 38% of the hypercholesterolemic subjects had a cholesterol level of > or =240 mg/dL. Inadequate rates of awareness and control of cardiovascular disease and stroke risk factors are seen in a clinical trial of African American stroke patients and are comparable with those of previously published reports.

Tratamiento médico de la estenosis arterial intracraneal. ¿Es el mismo en prevención primaria que secundaria?

In this study we review the risk factors associated with the formation and progression of an atheroma plaque, the mechanism involved in cerebral ischemia secondary to intracranial atheromatosis and possible medical treatment in primary and secondary prevention.Medical treatment of intracranial stenoses (ICS) is aimed at stopping the progression of the atheroma plaque and at preventing recurrences in the case of symptomatic stenoses. It is based on the control of vascular risk factors, the use of statins and antithrombotic therapy (antiplatelet or anticoagulation drugs). Although antiplatelet agents have not proved to be beneficial in the primary prevention of stroke, they are recommended in patients with ICS in order to lower the risk of heart attack associated with this pathology. The use of antiplatelet drugs in the secondary prevention of ischemic stroke secondary to an ICS is based on clinical trials which have shown that antiaggregation prevents non-cardioembolic strokes. Nevertheless, several retrospective studies have observed that oral anticoagulation is better than antiaggregation with aspirin. Two prospective clinical trials are currently being conducted which will, in the next few years, help to determine what the first choice medical treatment is for this group of patients.Medical treatment of ICS patients must include the control of vascular risk factors and the use of statins. New studies are needed to be able to establish the first choice antithrombotic drug in secondary prevention.

Vascular dementia.

Vascular dementia (VaD) is a term used to describe a particular constellation of cognitive and functional impairment, and is now generally seen as a subset of the larger syndrome of vascular cognitive impairment (VCI). The latter is seen as cognitive impairment in the face of cerebrovascular disease. VCI can be classified clinically by whether patients meet criteria for dementia, and whether the syndrome is distinct or overlaps with primary neurodegenerative diseases, such as Alzheimer's disease. This clinical classification can be further classified by neuroimaging, with subgroups that show cortical infarction, subcortical infarction and white matter changes, each alone or in combination. Understood in this way, VCI is likely the most common form of cognitive impairment in the population. Attempts to treat VaD had varying degrees of success, but it now appears that many forms of VCI might be preventable, especially with good control of vascular risk factors in middle age.

Donepezil treatment of vascular dementia.

Cholinergic deficits are clinicopathological hallmarks of Alzheimer's disease (DAT) and during the past decade have been the sole target for clinically effective treatments. By contrast, vascular dementia subtypes (VaD) are heterogeneous clinical syndromes, and therapeutic approaches have been directed toward control of vascular risk factors. Little attention has been paid to cholinergic deficits as a mechanism contributing to cognitive impairments in VaD as a potential target for treatment. The purpose of the study was to determine whether there are therapeutic benefits from long-term treatment with cholinesterase inhibitors among VaD patients. Ten VaD patients were diagnosed according to DSM-III-R and NINDS-AIREN criteria and classified into subtypes by neuroimaging. All were treated with titrated doses of donepezil for a mean interval of 15 months. At baseline and follow-up clinic visits, patients underwent medical and neurological examinations, as well as neuropsychological testing including Mini-Mental Status Examinations (MMSE) and Cognitive Capacity Screening Examinations (CCSE). Cognitive statuses of 10 treated patients were then compared before and after treatment. Net changes were expressed as annual MMSE score changes (DeltaMMSE/year) and annual CCSE score changes (DeltaCCSE/year). Of the 10 treated VaD patients, cognitive improvements were found when comparisons were made before and after treatment. Ten treated patients also showed greater cognitive improvements, while untreated patients showed continued cognitive decline. This study suggests that cholinergic deficits in VaD are due to neuronal ischemic damage with loss of acetylcholine and that treatment of VaD with cholinesterase inhibitors is a rational therapy.

Cognitive performance after coronary artery bypass grafting: a follow-up study.

The authors studied 52 of an initial cohort of 91 patients who underwent coronary artery bypass grafting and survived the perioperative period without stroke or other comorbidities, after a median follow-up of 55 months. Baseline data of the followed patients were comparable to those lost for follow-up. No patient showed a decline in neuropsychological test performance as compared to baseline. Vascular risk factor control was good in all patients, possibly contributing to the favorable outcome.

Vascular dementia

The past decade has seen a renewed interest in vascular dementia. The search for a causal relationship between a vascular event or a vascular cerebral lesion and dementia has led to new classification schemes which no longer consider vascular dementia a homogeneous entity but acknowledge the diversity of the clinical and morphological substrates of this syndrome. Deviation from the term "multi-infarct dementia" is only one but many consequencies of these recent developments. Etiologically, vascular dementia may result from cerebral small vessel disease leading to extensive leucencephalopathy or lacunes or may be the consequence of strategically located infarcts or multiple infarcts in large vessel territories. It may also be the consequence of global cerebral hypoperfusion, intracerebral hemorrhage or other mechanisms such as vasculitis. There is no definitive medical or surgical treatment for vascular dementia. Thus, it appears that stroke prevention offers the most immediate and substantial solution to reduce the morbidity and mortality. This is best substantiated for treatment of arterial hypertension. Once vascular dementia occurs control of vascular risk factors may be useful but this contention will require larger scale studies to provide more definite proof. A number of metabolically active drugs has been used for the treatment of cognitive symptoms in vascular dementia. Yet, the data are conflicting und the effects described modest at most. There is epidemiological evidence for a more than incidental co-existence between vascular and primary degenerative dementia which suggests that therapies found to be effective in Alzheimer's disease may also prove beneficial at least in subgroups of vascular dementia. Lately, this concept is tested by several studies on the efficacy of acetylcholinesterase inhibitors in vascular dementia.

MANAGEMENT OF PATIENTS WITH SYMPTOMATIC CAROTID ARTERY OCCLUSION

The annual risk of stroke in patients with symptomatic carotid artery occlusion (CAO) and impaired cerebral blood flow (CBF) is approximately 10%. Increased oxygen extraction fraction measured by positron emission tomography (PET) and low cerebrovascular reactivity assessed by transcranial Doppler is associated with an increased risk of recurrent ischemic stroke in these patients. Recently, other risk factors have been identified: (1) symptoms of purported hemodynamic origin; (2) ongoing symptoms in the presence of documented symptomatic CAO; (3) leptomeningeal collaterals visible on angiography; and (4) low NAA/choline ratio on magnetic resonance (MR) spectroscopy.Evidence is growing that a second extracranial–intracranial (EC–IC) bypass trial might be worthwhile in patients with symptomatic CAO. Probably, only patients with ongoing symptoms and compromised CBF should be included in such a trial. Current evidence based therapeutic options for patients with symptomatic CAO include antithrombotic medication and control of vascular risk factors. For stenosis of the contralateral internal or ipsilateral external carotid artery endarterectomy may be considered.Ongoing symptoms may cease after tapering of antihypertensive medication.

The Scandinavian Multi-Infarct Dementia Trial: a double-blind, placebo-controlled trial on nimodipine in multi-infarct dementia

Vascular dementia is a major cause of mental and physical disability in Western countries. Treatment of vascular dementia is currently based on the recognition and control of vascular risk factors, while specific drugs have not been approved yet. The aim of the present multinational, double-blind, placebo-controlled study was to evaluate the safety and efficacy of nimodipine administered for as long as 26 weeks in improving cognition or slowing cognitive deterioration in patients defined as having multi-infarct dementia (DSM-III-R criteria). Two hundred and fifty-nine patients were included (128 nimodipine, 131 placebo), and 251 were available for the intention-to-treat analysis. No significant difference between drug-treated and placebo patients was noted on the Gottfries-Bråne-Steen scale score (primary efficacy criterion), the remaining neuropsychological tests (Zahlen-Verbindungs-Test, Fuld-Object-Memory Evaluation, Word Fluency Test, Digit Span, Mini-Mental State Examination), and the functional scales (index of Activity of Daily Living, Instrumental Activity of Daily Living, Rapid Disability Scale, Clinical Dementia Rating), although the majority of changes were in favor of the active drug group. A lower incidence of cerebrovascular and cardiac events was observed in the nimodipine-treated patients in comparison with the placebo group. This study failed to show a significant effect of nimodipine on cognitive, social or global assessments in patients defined as affected by multi-infarct dementia according to the DSM-III-R criteria. A post-hoc analysis (presented in an accompanying paper) suggests that nimodipine may have a favorable effect in the subgroup of patients defined as affected by subcortical (small vessel) vascular dementia.

Abstracts of Literature

Abstracts of Literature

Drug Treatment of Stroke in Patients with Antiphospholipid Antibodies

There are a number of therapeutic options for the prevention of stroke (primary or recurrent) or other thrombotic events in antiphospholipid antibody—positive individuals, although none is of proven benefit. Control of modifiable vascular risk factors and avoidance of thrombogenic drugs should be recommended for all persons with antiphospholipid antibodies, whether symptomatic or not. Therapies to prevent thrombosis include antiplatelet agents and anticoagulants, with warfarin the preferred choice in high risk patients who have recurrent events. Immune-based therapies, including plasma exchange, immunoglobulins, corticosteroids and immunosuppressants, are alternative treatment modalities for patients who have recurrent events despite receiving high-dosage anticoagulants.

The effect of treating people with reversible ischaemic attacks of the brain and eye on the incidence of stroke in Australia.

Reversible ischaemic attacks of the brain or eye (RIA) are a risk factor for stroke. Strategies of stroke prevention include vascular risk factor control, antithrombotic therapy, and carotid surgery. To determine the effectiveness, risks and costs of each stroke prevention strategy for patients with RIA and the Australian community, and the effect of treating people with RIA on the incidence of stroke in Australia. Review of data from prospective community-based studies to determine the prevalence of RIA, the incidence of stroke, and the proportion of stroke patients who report a RIA before their stroke; and data from randomised trials to determine the effectiveness, risks and costs of treatments for RIA. About 111,000 Australians have had a prior RIA. Each year, about 37,000 Australians suffer a stroke, of whom up to 8000 (22%) have had a prior ('warning') RIA. Targeting effective stroke prevention strategies to RIA patients with relevant treatable conditions may reduce the individual's stroke risk by two-thirds (individual strategies) and possibly further (combination strategies). However, because the attributable risk of RIA for stroke is only about 22% (and may be less, given the role of other causal risk factors for stroke), strategies of stroke prevention in RIA patients can only reduce stroke incidence by up to 15% (from 22% to 7%). The potential benefits of the 'high risk' approach to stroke prevention appear to be less than the 'population' approach, but both approaches are necessary and complementary. Indeed, the cost of implementing the 'high risk' approach may be less than the cost of the strokes prevented ($255 million; i.e. 15% of $1.7 billion).

Presence and Treatment of Vascular Risk Factors in Patients With Vascular Cognitive Impairment

To document the presence and treatment of selected vascular risk factors in patients with vascular cognitive impairment and elements affecting undertreatment of vascular risk factors. Secondary analysis of the Canadian Study of Health and Aging database, which is a national, representative, cross-sectional study of the epidemiologic distribution of dementia in elderly people in Canada. Survey. Institutionalized and community-dwelling elderly people. Vascular risk factors, dementia diagnosed by standard methods, and medication use. Treatable vascular risk factors occurred significantly more often in patients with vascular cognitive impairment (with and without dementia) than in patients with probable Alzheimer disease or normal cognitive function. For example, 76% of patients with vascular dementia and 57% of those with vascular cognitive impairment without dementia had a history of stroke, compared with only 5% of those with probable Alzheimer disease and 7% of those with no cognitive loss. (For hypertension, the comparable figures are 55%, 48%, 24%, and 38%, respectively.) Potential undertreatment of vascular risk factors had little effect on mean control of vascular risk factors. For example, the mean (+/- SD) systolic blood pressure in those being treated was 144 +/- 26 mm Hg, compared with 142 +/- 25 mm Hg in those not receiving pharmacological treatment. In each group (treated vs untreated), the proportion of patients with a systolic blood pressure higher than 160 mm Hg was 20% and 16%, respectively. Potential undertreatment occurred most often in those with severe dementia and those living in nursing homes. Vascular risk factors occurred more commonly in patients with vascular cognitive impairment compared with other patients, including those with other forms of dementia. When present, such risk factors were often treated pharmacologically, except in patients with severe dementia and those in long-term care institutions. Undertreatment does not, in general, result in worsened risk factor control.

Transient ischaemic attacks

Each day, about 25 Australians experience a transient ischaemic attack of the brain or eye. These people need to be distinguished from those who suffer "funny turns" due to other causes because, as a group, they have a significant risk of stroke and other vascular events. This risk can be substantially reduced through control of vascular risk factors, use of long term antithrombotic medication and, in some cases, carotid endarterectomy. Strategies for stroke prevention need to involve both the "high risk" and population "mass" approach, which are complementary.

Transient ischaemic attacks

Each day, about 25 Australians experience a transient ischaemic attack of the brain or eye. These people need to be distinguished from those who suffer “funny turns” due to other causes because, as a group, they have a significant risk of stroke and other vascular events. This risk can be substantially reduced through control of vascular risk factors, use of long term antithrombotic medication and, in some cases, carotid endarterectomy. Strategies for stroke prevention need to involve both the “high risk” and population “mass” approach, which are complementary.

The role of imaging in the management of cerebral and ocular ischaemia

The last decade has seen several major technological advances in vascular neuroradiology, the most clinically significant of which have been the facility to image the brain and the extracranial carotid bifurcation noninvasively with accuracy and safety. Another major advance has been unequivocal evidence from formal statistical overviews that antiplatelet therapy, particularly aspirin, reduces the risk of serious vascular events by about 25%. These advances have changed clinical practice such that most patients presenting with symptoms suggestive of cerebral ischaemia should now have cranial CT to exclude intracerebral hemorrhage, not only because the causes and prognosis of cerebral ischaemia differ from those of intracerebral hemorrhage, but because many patients with cerebral ischaemia should be considered for antiplatelet therapy. Besides the use of long term antiplatelet therapy and control of vascular risk factors, other acute treatment options are limited with the possible exception of anticoagulation, thrombolysis, cytoprotective agents and carotid endarterectomy. If, as seems likely, the current clinical trials show that carotid endarterectomy plus medical therapy improve upon the stroke-free survival of patients treated medically, at least in symptomatic patients with severe stenosis, the number of carotid endarterectomies performed will increase considerably because carotid bifurcation disease is the most common cause of cerebral and ocular ischemic events. It will then be even more important to be able to obtain accurate anatomical and physiological information about the extracranial and intracranial circulations with utmost safety. Duplex ultrasound is currently the noninvasive screening method of choice for carotid bifurcation disease because it is available, relatively cheap, and reasonably accurate. It not only images the vessel lumen and degree of stenosis, but also the morphology of the vessel wall and associated plaque, the relevance of which is still uncertain in the pathogenesis of cerebral and ocular ischaemia. A major limitation of duplex sonography is that it cannot reliably distinguish tight stenosis from occlusion and it does not image the proximal or distal carotid circulation. The aim of newer techniques will be to distinguish tight extracranial carotid stenosis from occlusion and to provide anatomical, physiological and pathological information about the intracranial circulation and ischemic lesions (in view of potential for thrombolytic therapy of major intracranial vessel occlusion) with safety and reproducible accuracy.