ITEMS IN AFP WITH MESH TERM:
ABSTRACT: With growing concern about the use of hormone replacement therapy, some women are looking for alternative treatments for menopausal symptoms and preventing postmenopausal cardiovascular disease and osteoporosis. In observational trials, exercise has been associated with decreased vasomotor symptoms. One trial suggested that black cohosh may reduce menopausal symptoms. Soy has been shown to decrease vasomotor symptoms, lower lipid levels, and increase bone density. However, large amounts of soy must be consumed, and it is not clear whether soy consumption causes a decrease in cardiovascular events or fractures. The evidence for St. John's wort is equivocal. Fish oil is helpful for secondary prevention of coronary artery disease.
Using ACE Inhibitors Appropriately - Article
ABSTRACT: When first introduced in 1981, angiotensin-converting enzyme (ACE) inhibitors were indicated only for treatment of refractory hypertension. Since then, they have been shown to reduce morbidity or mortality in congestive heart failure, myocardial infarction, diabetes mellitus, chronic renal insufficiency, and atherosclerotic cardiovascular disease. Pathologies underlying these conditions are, in part, attributable to the renin-angiotensin-aldosterone system. Angiotensin II contributes to endothelial dysfunction. altered renal hemodynamics, and vascular and cardiac hypertrophy. ACE inhibitors attenuate these effects. Clinical outcomes of ACE inhibition include decreases in myocardial infarction (fatal and nonfatal), reinfarction, angina, stroke, end-stage renal disease, and morbidity and mortality associated with heart failure. ACE inhibitors are generally well tolerated and have few contraindications. (Am Fam Physician 2002;66:473.)
Chronic Illness and Sexual Functioning - Article
ABSTRACT: Chronic illness and its treatments can have a negative impact on sexual functioning. The mechanism of interference may be neurologic, vascular, endocrinologic, musculoskeletal, or psychologic. Patients may mistakenly perceive a medical prohibition to the resumption of sexual activity, or they may need advice on changes in sexual activity to allow satisfactory sexual functioning. Family physicians must be proactive in diagnosing and managing the alterations in sexual functioning that can occur with chronic illness. Patient education and reassurance are essential. Before sexual activity is resumed, patients with cardiovascular disease should be stratified according to risk. Patients with musculoskeletal disease should be educated about positional changes that may improve comfort during sexual activity. Psychosocial concerns should be addressed in patients with human immunodeficiency virus infection or acquired immunodeficiency syndrome. In patients with cancer, it is important to discuss sexual problems that may arise because of negative body image and the effects of chemotherapy. Patients who have disabilities can benefit from the use of muscle relaxants, technical adaptations, and expansion of their sexual repertoire.
ABSTRACT: Cardiovascular disease is responsible for 65 percent of deaths in persons with type 2 diabetes. However, awareness of cardiovascular disease risk factors among patients with diabetes remains low, resulting in missed opportunities to lower risks for coronary events and strokes. The National Diabetes Education Program has begun a campaign to increase patient participation in risk-reduction practice s by promoting the "ABCs" of diabetes care: A(1c) level, Blood pressure, and Cholesterol level. By increasing patient awareness of the link between diabetes and heart disease, family physicians can encourage patients to take medications (including aspirin), stop smoking, lower blood pressure, and lower cholesterol and blood glucose levels.
Treatment of Cholesterol Abnormalities - Article
ABSTRACT: Cardiovascular disease and its subset coronary heart disease are leading causes of morbidity and mortality in the United States and worldwide. In general, higher levels of low-density lipoprotein cholesterol are associated with an increased risk of coronary heart disease, myocardial infarction, and stroke. Reducing dietary fat can improve total cholesterol levels, but consequent reductions in cardiovascular outcomes are not well documented. The Mediterranean diet is the only dietary intervention associated with a reduction in all-cause mortality. Treatment with cholesterol-lowering medications decreases the rate of cardiovascular events, but a reduction in all-cause mortality with these agents has been found only in patients with pre-existing coronary heart disease. Drug treatment in patients with a history of heart disease and average-to-high cholesterol levels can decrease the risk for stroke. In patients with peripheral vascular disease, treatment of elevated cholesterol levels may slow disease progression.
Diagnosing the Cause of Chest Pain - Article
ABSTRACT: Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. Risk of pulmonary embolism can be determined with a simple prediction rule, and a D-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire. Clinical prediction rules can help clarify many of these diagnoses.
ABSTRACT: Physicians face several barriers to counseling their patients about nutrition, including conflicting evidence of the benefit of counseling, limited training and understanding of the topic, and imperfect and varied guidelines to follow. Because cardiovascular disease remains the leading cause of death in industrialized nations, family physicians should provide more than pharmacologic interventions. They must identify the patient's dietary habits and attitudes and provide appropriate counseling. Tools are available to help, and a seven-step approach to nutritional therapy for the dyslipidemic patient may be useful. These steps include recommending increased intake of plant proteins; increased intake of omega-3 fatty acids; modification of the types of oils used in food preparation; decreased intake of saturated and trans-fatty acids; increased intake of whole grains and dietary fiber (especially soluble fiber) and decreased intake of refined grains; modification of alcohol intake, if needed; and regular exercise. Recommendations should be accompanied by patient information handouts presenting acceptable substitutions for currently identified detrimental food choices.
ABSTRACT: Cardiovascular disease (CVD) has been the primary cause of death in women for almost a century, and more women than men have died of CVD every year since 1984. Although CVD incidence can be reduced by adherence to a heart-healthy lifestyle and detection and treatment of major risk factors, preventive recommendations have not been consistently or optimally applied to women. The American Heart Association guidelines for CVD prevention in women provide physicians with a clear plan for assessment and treatment of CVD risk and personalization of treatment recommendations. The emphasis of preventive efforts has shifted away from treatment of individual CVD risk factors in isolation toward assessment of a woman's overall or "global" CVD risk. In addition to accounting for the presence or absence of preexisting coronary heart disease or its equivalents (e.g., diabetes, chronic kidney disease), cardiovascular risk can be further calculated with the Framingham risk score, which is based on age, sex, smoking history, and lipid and blood pressure levels. Intervention intensity and treatment goals are tailored to overall risk, with those at highest risk receiving the most intense risk-lowering interventions. Women at high risk for CVD and without contraindications should receive aspirin, beta blockers, and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in addition to pharmacologic therapy for hyperlipidemia, hypertension, and diabetes. Women who already are at optimal or low risk for CVD should be encouraged to maintain or further improve their healthy lifestyle practices. Optimal application of these preventive practices significantly reduces the burden of death and disability caused by heart attack and stroke in women.
ABSTRACT: Approximately 20 to 40 percent of patients at high risk of cardiac-related morbidity develop myocardial ischemia perioperatively. The preferred approach to diagnostic evaluation depends on the interactions of patient-specific risk factors, surgery-specific risk factors, and exercise capacity. Stress testing should be reserved for patients at moderate to high risk undergoing moderate- or high-risk surgery and those who have poor exercise capacity. Further cardiovascular studies should be limited to patients who are at high risk, have poor exercise tolerance, or have known poor ventricular function. Medical therapy using beta blockers, statins, and alpha agonists may be effective in high-risk patients. The evidence appears to be the strongest for beta blockers, especially in high-risk patients with proven ischemia on stress testing who are undergoing vascular surgery. Many questions remain unanswered, including the optimal role of statins and alpha agonists, whether or not these therapies are as effective in patients with subclinical coronary artery disease or left ventricular dysfunction, and the optimal timing and dosing regimens of these medications.