Stroke and coronary heart disease in mild hypertension: risk factors and the value of treatment

Further analyses of the Medical Research Council''s trial of drug treatment of mild hypertension were carried out to provide more detailed information on the benefits associated with treatment in various subgroups. The four main considerations in establishing a rational treatment policy were, firstly, the significant reduction in the stroke rate with active treatment; secondly, the absence of a significant overall treatment effect on myocardial infarction; thirdly, the knowledge that of 100 untreated men in the highest risk group (those aged 55-64 with high systolic pressure at entry who smoked), five would be expected to suffer a stroke and 10 a coronary event within five years; and, fourthly, the cost, in clinical and financial terms, of prolonged treatment. In the high risk group of 100 men treatment with bendrofluazide would result in the prevention of three or four of the five strokes but would have little effect on the expected numbers of myocardial infarctions. Treatment with propranolol in non-smoking men in the highest age and blood pressure categories would lead to a reduction in the number having strokes from three to one or two and might possibly reduce the number experiencing myocardial infarction from seven to four. Smokers treated with propranolol would not be expected to benefit. In women avoiding smoking was particularly important. The considerations for preventing stroke were similar to those in men, but no clear guideline was possible on the effect of lowering blood pressure for preventing myocardial infarction in women.Drug treatment reduces the attack rate of certain events in mild hypertension but should not be prescribed routinely for all patients with the disorder.     

Cytomegalovirus infection and coronary heart disease risk: a meta-analysis

The chronic inflammatory process including cytomegalovirus (CMV) infection has been hypothesized to induce the progression of atherosclerosis in coronary heart disease (CHD). Numbers studies were conducted to analyze the association between CMV infection and risk of CHD, but no clear consensus had been reached. To assess this relationship more precisely, a meta-analysis was performed. The electronic databases PubMed, Embase, and CNKI were searched; data were extracted and analyzed independently by two investigators. Ultimately, 55 studies, involving 9,000 cases and 8,608 controls from six prospective studies (all with a nested case–control design) and 49 retrospective case–control studies were included. Overall, people exposed to CMV infection had an odds ratio (OR) of 1.67 (95% CI, 1.56–1.79) for CHD risk, relative to those not exposed. CMV infection was clearly identified as a risk factor for CHD in both prospective studies (OR, 1.31; 95% CI, 1.132–1.517) and retrospective studies (OR, 1.79; 95% CI, 1.659–1.939), and in both Asian group (OR, 2.69; 95% CI, 2.304–3.144) and non-Asian group (OR, 1.48; 95% CI, 1.371–1.600). Interestingly, in the subgroup analyses by detection methods of CMV, the increased risk (OR, 8.121) was greater among studies using polymerase chain reaction than the risk (OR, 1.561) among studies using enzyme-linked immunosorbent assay. In conclusion, this meta-analysis suggested that CMV infection is associated with an increased risk for CHD, especially among Asian populations.     

Screening persons aged 65 and older for coronary heart disease risk factors.

Because of limited clinical investigations addressing the effectiveness of intervention to reduce known risk factors, it is difficult for primary care physicians to decide on which coronary heart disease risk factors to continue to screen for among older patients. The recently published report of the United States Preventive Services Task Force, using explicit screening criteria, has recommended that several risk factors be investigated for use among older adults. Recent longitudinal studies have found that a number of risk factors persist with advancing age-hypertension, left ventricular hypertrophy, impaired glucose metabolism, elevated cholesterol levels, obesity, smoking, physical inactivity, decline in vital capacity, and increased heart rate. Screening to identify many of these risks and treatment and counseling to modify them appear to improve survival. Evidence is less clear that diabetes mellitus and elevated cholesterol levels have the same significance for men and women as they age. Left ventricular hypertrophy and diabetes seem particularly important as risk factors for older women, whereas a high heart rate may be a greater risk for men.     

Gender-modulated risk of coronary heart disease,diabetes and coronary mortality among Turks for three major risk factors,and residual adiposity risk

Background

We determined the proportion of the effects of body mass index (BMI) or its categories on cardiometabolic outcomes mediated through systolic blood pressure (SBP), total cholesterol and fasting glucose.

Methods

Cox regression analyses were performed for incident outcomes among Turkish Adult Risk Factor study participants in whom the three mediators had been determined (n?=?2158, age 48.5?±?11 years). Over a mean 10.2-years’ follow-up, new coronary heart disease (CHD) developed in 406, diabetes in 284 individuals, and 149 CHD deaths occurred.

Results

Hazard ratios (HR) of BMI for incident diabetes were no more than marginally attenuated by the 3 mediators including glucose, irrespective of gender. Compared to “normal-weight”, sex- and age-adjusted RRs for incident CHD of overweight and obesity were 1.40 and 2.24 (95 % CI 1.68; 2.99), respectively, in gender combined. Only three-tenths of the excess risk was retained by BMI in men, six-tenths in women. No mediation of glycemia was discerned in males, in contrast to greatest mediation in females. HR of age-adjusted continuous BMI was a significant but modest contributor to CHD mortality in each gender. While the BMI risk of CHD death was abolished by mediation of SBP in men, HR strengthened to over two-fold in women through mediation of fasting glucose.

Conclusions

Mediation of adiposity by 3 traditional factors exhibited among Turkish adults strong gender dependence regarding its magnitude for CHD risk and the mediation by individual risk factors. Retention of the large part of risk for diabetes in each sex and for CHD in women likely reflects underlying autoimmune activation.

     

Prevention of cardiovascular disease in general practice: a proposed model.

A screening model based in general practice for the detection of subjects at risk of premature cardiovascular disease is described. Opportunistic screening is performed by a trained nurse who also gives initial advice on management. Immediate feedback to patients is possible since a rapid dry chemistry technique is used to measure blood cholesterol concentrations. The collation and analysis of data are achieved using a microcomputer. A central deidentified database is incorporated to allow epidemiological studies and intervention strategy evaluations to be made. Nineteen health centres have evaluated the model, and 40,000 subjects have been screened: 10% had diastolic blood pressures of over 95 mm Hg and 15% had a blood cholesterol concentration over 7 mmol/l (270 mg/100 ml) and 2% over 9 mmol/l (347 mg/100 ml). The initial data suggest that the model is acceptable to both health centre personnel and the general public and that the offer of screening is taken up by all elements of the target population.     

Comparison of estimates and calculations of risk of coronary heart disease by doctors and nurses using different calculation tools in general practice: cross sectional study

ObjectiveTo assess the effect of using different risk calculation tools on how general practitioners and practice nurses evaluate the risk of coronary heart disease with clinical data routinely available in patients'' records.DesignSubjective estimates of the risk of coronary heart disease and results of four different methods of calculation of risk were compared with each other and a reference standard that had been calculated with the Framingham equation; calculations were based on a sample of patients'' records, randomly selected from groups at risk of coronary heart disease.SettingGeneral practices in central England.Participants18 general practitioners and 18 practice nurses.ResultsOnly a minority of patients'' records contained all of the risk factors required for the formal calculation of the risk of coronary heart disease (concentrations of high density lipoprotein (HDL) cholesterol were present in only 21%). Agreement of risk calculations with the reference standard was moderate (κ=0.33-0.65 for practice nurses and 0.33 to 0.65 for general practitioners, depending on calculation tool), showing a trend for underestimation of risk. Moderate agreement was seen between the risks calculated by general practitioners and practice nurses for the same patients (κ=0.47 to 0.58). The British charts gave the most sensitive results for risk of coronary heart disease (practice nurses 79%, general practitioners 80%), and it also gave the most specific results for practice nurses (100%), whereas the Sheffield table was the most specific method for general practitioners (89%).ConclusionsRoutine calculation of the risk of coronary heart disease in primary care is hampered by poor availability of data on risk factors. General practitioners and practice nurses are able to evaluate the risk of coronary heart disease with only moderate accuracy. Data about risk factors need to be collected systematically, to allow the use of the most appropriate calculation tools.

What is already known on this topic

Recent guidelines have recommended determining the risk of coronary heart disease for targeting patients at high risk for primary preventionEstimates of risk have been shown to be inaccurateGeneral practitioners and practice nurses can use risk calculation tools accurately when given patient data in the form of scenarios

What this study adds

Many patients do not have adequate information in their records to allow the risk of coronary heart disease to be calculatedWhen data about risk factors were available, risk calculations made by general practitioners and practice nurses were moderately accurate compared to a reference calculationWhen adequate information about risk factors is not available, subjective estimates are a reasonable alternative to calculating risk     

Exercise-based cardiac rehabilitation in patients with coronary heart disease: a practice guideline

Background

To improve the quality of exercise-based cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) the CR guideline from the Dutch Royal Society for Physiotherapists (KNGF) has been updated. This guideline can be considered an addition to the 2011 Dutch Multidisciplinary CR guideline, as it includes several novel topics.

Methods

A systematic literature search was performed to formulate conclusions on the efficacy of exercise-based interventions during all CR phases in patients with CHD. Evidence was graded (1–4) according the Dutch evidence-based guideline development (EBRO) criteria. In case of insufficient scientific evidence, recommendations were based on expert opinion. This guideline comprised a structured approach including assessment, treatment and evaluation.

Results

Recommendations for exercise-based CR were formulated covering the following topics: preoperative physiotherapy, mobilisation during the clinical phase, aerobic exercise, strength training, and relaxation therapy during the outpatient rehabilitation phase, and adoption and monitoring of a physically active lifestyle after outpatient rehabilitation.

Conclusions

There is strong evidence for the effectiveness of exercise-based CR during all phases of CR. The implementation of this guideline in clinical practice needs further evaluation as well as the maintenance of an active lifestyle after supervised rehabilitation.     

Dietary flavonoids and risk of coronary heart disease

Flavonoids, a group of phenolic compounds found naturally in fruit, vegetables, nuts, flowers, seeds and bark are an integral part of the human diet. They have been reported to exhibit a wide range of biological effects, including antiischemic, antiplatelet, antineoplastic, antiinflammatory, antiallergic, antilipoperoxidant or gastroprotective actions. Furthermore, flavonoids are potent antioxidants, free radical scavengers and metal chelators, and inhibit lipid peroxidation. Oxidative modification of low-density lipoproteins (LDLs) is believed to play a crucial role in atherogenesis. Epidemiological studies have shown that the consumption of fruits and vegetables, and regular red wine consumption is related with a reduced risk of cardiovascular diseases.     

Relation between cardiorespiratory fitness and selected risk factors for coronary heart disease in a population of Canadian men and women.

OBJECTIVE: To determine the relation between cardiorespiratory fitness, as determined with the Canadian Aerobic Fitness Test (CAFT), and selected risk factors for coronary heart disease (CHD) in a Canadian population. DESIGN: Cross-sectional study. On the basis of age-specific and sex-specific national percentile scores, subjects were classified as being in the low-fitness, moderate-fitness or high-fitness category according to maximum oxygen consumption (VO2 max) predicted from performance on the CAFT. PARTICIPANTS: A total of 4082 male and 1205 female Canadian federal public servants aged 30 to 59 years who participated in a voluntary fitness testing program between 1984 and 1991. OUTCOME MEASURES: Body composition (body mass index, triceps skinfold thickness, sum of four skinfold measurements, predicted percentage of body fat and waist-hip ratio), blood lipid levels (total cholesterol, triglycerides, high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol and ratio of total cholesterol to HDL-C) and hemodynamic measurements (heart rate and blood pressure at rest and during exercise and predicted VO2 max). MAIN RESULTS: For both men and women the mean anthropometric measurements, blood lipid levels and blood pressure measurements at rest and after exercise were significantly associated with fitness category (p less than 0.05). CONCLUSIONS: In both men and women a higher level of aerobic fitness, as defined by VO2 max predicted from performance on the CAFT, is associated with a more favourable CHD risk profile. The results support the use of VO2 max predicted from performance on the CAFT as a valid procedure for classifying people according to fitness level.     

Diabetes and other coronary heart disease risk equivalents

The close association between diabetes and cardiovascular disease suggests that current predictions of a massive increase in the prevalence of type 2 diabetes foreshadow an equally daunting rise in the incidence of vascular disease. The limited cardiovascular benefits obtained by glucose-lowering treatments, although perhaps not surprising, indicate that other cardiovascular risk factors must be given serious consideration as therapeutic targets. The impressive reductions in the number of vascular events observed in diabetic patients, albeit in small patient populations, participating in various drug trials amply justify such an approach. A necessary prerequisite, however, is a clear understanding of the clinical importance of individual risk factors to the occurrence of vascular disease in type 2 diabetic patients. This would appear essential for defining treatment strategies in the face of a bewildering array of potential therapeutic targets. The present review considers recent studies that have assessed the predictive value of risk factors against a diabetic background.     

Dental disease and risk of coronary heart disease and mortality.

OBJECTIVE--To investigate a reported association between dental disease and risk of coronary heart disease. SETTING--National sample of American adults who participated in a health examination survey in the early 1970s. DESIGN--Prospective cohort study in which participants underwent a standard dental examination at baseline and were followed up to 1987. Proportional hazards analysis was used to estimate relative risks adjusted for several covariates. MAIN OUTCOME MEASURES--Incidence of mortality or admission to hospital because of coronary heart disease; total mortality. RESULTS--Among all 9760 subjects included in the analysis those with periodontitis had a 25% increased risk of coronary heart disease relative to those with minimal periodontal disease. Poor oral hygiene, determined by the extent of dental debris and calculus, was also associated with an increased incidence of coronary heart disease. In men younger than 50 years at baseline periodontal disease was a stronger risk factor for coronary heart disease; men with periodontitis had a relative risk of 1.72. Both periodontal disease and poor oral hygiene showed stronger associations with total mortality than with coronary heart disease. CONCLUSION--Dental disease is associated with an increased risk of coronary heart disease, particularly in young men. Whether this is a causal association is unclear. Dental health may be a more general indicator of personal hygiene and possibly health care practices.     

Self screening for risk of melanoma: validity of self mole counting by patients in a single general practice.

OBJECTIVE--To validate self screening by patients of high mole counts, assess the within family association of sun protection behaviour and mole counts, and estimate prevalence of risk factors for melanoma. SETTING AND SUBJECTS--Systematic sample of families from a single affluent general practice population in Wessex. DESIGN--Subjects completed a questionnaire about risk factors for melanoma and counted their moles. Subsequently a mole count was done by a general practitioner trained at dermatology clinics. MAIN OUTCOME MEASURES--Validation of self counts by observer''s count. Within family association of sun protection behaviour and mole counts; self reported risk factors. RESULTS--199/237 subjects (84%) returned the questionnaire; 212/237 (89%) were examined. High counts by patients on the front of the trunk (> 7 moles of > or = 2 mm) were reasonably sensitive (79%), predictive (75%), and specific (97%) of the observer''s mole counts (kappa = 0.74), unlike arm or total body counts. Sun protection behaviour correlated between individuals and other family members (Spearman''s coefficient r = 0.50, P < 0.01). In the past three months 15/114 adults (13.2%, 95% confidence interval 7.0% to 19.4%) reported any change in a mole and 6/114 (5.3%, 2.0% to 11.1%) "major" changes; 6/109 adults (5.5%, 2.1% to 11.6%) had both high mole counts and freckling. CONCLUSIONS--Asking patients to count trunk moles could be a feasible way of identifying patients at high risk of melanoma. Concentrating on reported major changes in moles should avoid considerable workload in general practice. The generalisability of these findings and the adverse effects, net benefit in earlier diagnosis and prevention, and workload implications of such self screening need further research.