Items in AFP with MESH term: Coronary Disease
ABSTRACT: Cardiovascular disease is the leading cause of death in women, as well as an important cause of disability, although many women and their physicians underestimate the risk. Exercise, hypertension treatment, smoking cessation and aspirin therapy are effective measures for the primary prevention of coronary artery disease in women. The roles of lipid-lowering agents and hormone replacement therapy in primary prevention are not well established. In secondary prevention, hormone replacement therapy has not been effective in lowering the risk of recurrent myocardial infarction, but several lipid-lowering agents have been shown to reduce this risk and to lower mortality rates in women with known coronary artery disease. Other secondary prevention measures, including aspirin, beta blockers, angiotensin-converting enzyme inhibitors, revascularization and rehabilitation, have proven benefits in women but are underused, especially in minority women. Family physicians should emphasize the use of proven treatments, with particular attention given to underserved populations.
ABSTRACT: Coronary heart disease, the leading cause of death in women, is largely preventable. Lifestyle modifications (e.g., diet and exercise) are the cornerstone of primary and secondary prevention. Elevated levels of low-density lipoprotein cholesterol and triglycerides and low levels of high-density lipoprotein cholesterol are significant risk factors for coronary heart disease. Abundant data show inadequate utilization of lipid-lowering therapy in women. Even when women are given lipid-lowering agents, target levels often are not achieved. Recent guidelines from the American Heart Association and the American College of Cardiology encourage a more aggressive approach to lipid lowering in women. The National Cholesterol Education Program Adult Treatment Panel III also supports this strategy and significantly expands the number of women who qualify for intervention.
ABSTRACT: Obesity has reached epidemic proportions in the United States. More than 60 percent of U.S. adults are now overweight or obese (defined as at least 30 lb [13.6 kg] overweight), predisposing more than 97 million Americans to a host of chronic diseases and conditions. Physical activity has a positive effect on weight loss, total body fat, and body fat distribution, as well as maintenance of favorable body weight and change in body composition. Many of the protective aspects of exercise and activity appear to occur in overweight persons who gain fitness but remain overweight. Despite the well-known health and quality-of-life benefits of regular physical activity, few Americans are routinely active. Results of research studies have shown that physician intervention to discuss physical activity (including the wide array of health benefits and the potential barriers to being active) need not take more than three to five minutes during an office visit but can play a critical role in patient implementation. This article describes elements of effective counseling for physical activity and presents guidelines for developing physical activity programs for overweight and obese patients.
Cholesterol Treatment Guidelines Update - Article
ABSTRACT: Hypercholesterolemia is one of the major contributors to atherosclerosis and coronary heart disease in our society. The National Cholesterol Education Program of the National Institutes of Health has created a set of guidelines that standardize the clinical assessment and management of hypercholesterolemia for practicing physicians and other professionals in the medical community. In May 2001, the National Cholesterol Education Program released its third set of guidelines, reflecting changes in cholesterol management since their previous report in 1993. In addition to modifying current strategies of risk assessment, the new guidelines stress the importance of an aggressive therapeutic approach in the management of hypercholesterolemia. The major risk factors that modify low-density lipoprotein goals include age, smoking status, hypertension, high-density lipoprotein levels, and family history. The concept of "CHD equivalent" is introduced-conditions requiring the same vigilance used in patients with coronary heart disease. Patients with diabetes and those with a 10-year cardiac event risk of 20 percent or greater are considered CHD equivalents. Once low-density lipoprotein cholesterol is at an accepted level, physicians are advised to address the metabolic syndrome and hypertriglyceridemia.
Preoperative Cardiac Risk Assessment - Article
ABSTRACT: Heart disease is the leading cause of mortality in the United States. An important subset of heart disease is perioperative myocardial infarction, which affects approximately 50,000 persons each year. The American College of Cardiology (ACC) and American Heart Association (AHA) have coauthored a guideline on preoperative cardiac risk assessment, as has the American College of Physicians (ACP). The ACC/AHA guideline uses major, intermediate, and minor clinical predictors to stratify patients into different cardiac risk categories. Patients with poor functional status or those undergoing high-risk surgery require further risk stratification via cardiac stress testing. The ACP guideline also starts by screening patients for clinical variables that predict perioperative cardiac complications. However, the ACP did not feel there was enough evidence to support poor functional status as a significant predictor of increased risk. High-risk patients would sometimes merit preoperative cardiac catheterization by the ACC/AHA guideline, while the ACP version would reserve catheterization only for those who were candidates for cardiac revascularization independent of their noncardiac surgery. A recent development in prophylaxis of surgery-related cardiac complications is the use of beta blockers perioperatively for patients with cardiac risk factors.
Omega-3 Fatty Acids - Article
ABSTRACT: Omega-3 fatty acids have been shown to significantly reduce the risk for sudden death caused by cardiac arrhythmias and all-cause mortality in patients with known coronary heart disease. Fatty fish, such as salmon and tuna, and fish oil are rich sources of the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid. Flaxseed, canola oil, and walnuts also are good dietary sources of omega-3 fatty acids. In addition to being antiarrhythmic, the omega-3 fatty acids are antithrombotic and anti-inflammatory. In contrast, omega-6 fatty acids, which are present in most seeds, vegetable oils, and meat, are prothrombotic and proinflammatory. Omega-3 fatty acids also are used to treat hyperlipidemia, hypertension, and rheumatoid arthritis. There are no significant drug interactions with omega-3 fatty acids. The American Heart Association recommends consumption of two servings of fish per week for persons with no history of coronary heart disease and at least one serving of fish daily for those with known coronary heart disease. Approximately 1 g per day of eicosapentaenoic acid plus docosahexaenoic acid is recommended for cardioprotection. Higher dosages of omega-3 fatty acids are required to reduce elevated triglyceride levels (2 to 4 g per day) and to reduce morning stiffness and the number of tender joints in patients with rheumatoid arthritis (at least 3 g per day). Modest decreases in blood pressure occur with significantly higher dosages of omega-3 fatty acids.
ABSTRACT: Coronary heart disease remains a leading cause of mortality in the United States, with 84 percent of persons 65 years or older dying from this disease. Secondary preventive measures, including lifestyle modification and pharmacotherapy, are important for elderly patients because of the variable impacts on morbidity and mortality rates and quality of life. Participating in light to moderate activities significantly decreases mortality rates in elderly patients. Smoking cessation translates into a reduction in overall mortality and morbidity rates at least equal to that of other preventive measures such as aspirin or beta-blocker therapy. Recent studies on the effects of lowering low-density lipoprotein cholesterol levels to below 100 mg per dL have shown a substantial reduction in coronary heart disease mortality and nonfatal myocardial infarction rates, with a persistent effect in patients older than 75 years. Hypertension, manifesting mostly as isolated systolic blood pressure elevation, also should be treated aggressively. Conventional medical therapies for hypertension (e.g., diuretics, beta blockers) and newer agents (e.g., calcium channel blockers, angiotensin-converting enzyme inhibitors), together with sodium restriction, have had a positive effect on cardiovascular mortality and morbidity rates in older patients. With the increasing prevalence of obesity, insulin resistance, and type 2 diabetes, interventions targeting weight reduction and glucose control should be emphasized. Whereas weight-loss strategies are poorly defined in this population, the management of diabetes through dietary modification, exercise, and medications is similar across age groups. The target hemoglobin A1C level is less than 7 percent. Elderly patients are prone to depression and social isolation, and they are more likely to have a lower socioeconomic status than younger patients, which may negatively affect participation in rehabilitation programs and compliance with medical advice and therapy. Strategies aimed at these factors have shown variable results and remain ill-defined.
Noninvasive Cardiac Imaging - Article
ABSTRACT: Noninvasive cardiac imaging can be used for the diagnostic and prognostic assessment of patients with suspected or known coronary artery disease. It is central to the treatment of patients with myocardial infarction, coronary artery disease, or acute coronary syndromes with or without angina. Radionuclide cardiac imaging; echocardiography; and, increasingly, cardiac computed tomography and cardiac magnetic resonance imaging techniques play an important role in the diagnosis of coronary artery disease, which is the leading cause of mortality in adults in the United States. Contemporary imaging techniques, with either stress nuclear myocardial perfusion imaging or stress echocardiography, provide a high sensitivity and specificity in the detection and risk assessment of coronary artery disease, and have incremental value over exercise electrocardiography and clinical variables. They also are recommended for patients at intermediate to high pretest likelihood of coronary artery disease based on symptoms and risk factors. Cardiac magnetic resonance imaging and cardiac computed tomography are newly emerging modalities in the evaluation of patients with coronary artery disease. Cardiac magnetic resonance imaging is useful in the assessment of myocardial perfusion and viability, as well as function. It also is considered a first-line tool for the diagnosis of arrhythmogenic right ventricular dysplasia. Cardiac computed tomography detects and quantifies coronary calcium and evaluates the lumen and wall of the coronary artery. It is a clinical tool for the detection of subclinical coronary artery disease in select asymptomatic patients with an intermediate Framingham 10-year risk estimate of 10 to 20 percent. In addition, cardiac computed tomography is evolving as a noninvasive tool for the detection and quantification of coronary artery stenosis. Although guidelines can help with treating patients, treatment ultimately should be tailored to each person based on clinical judgment of the a priori risk of a cardiac event, symptoms, and the cardiac risk profile.
ABSTRACT: Combination therapy of hypertension with separate agents or a fixed-dose combination pill offers the potential to lower blood pressure more quickly, obtain target blood pressure, and decrease adverse effects. Antihypertensive agents from different classes may offset adverse reactions from each other, such as a diuretic decreasing edema occurring secondary to treatment with a calcium channel blocker. Most patients with hypertension require more than a single antihypertensive agent, particularly if they have comorbid conditions. Although the Joint National Committee guidelines recommend diuretic therapy as the initial pharmacologic agent for most patients with hypertension, the presence of "compelling indications" may prompt treatment with antihypertensive agents that demonstrate a particular benefit in primary or secondary prevention. Specific recommendations include treatment with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, beta blockers, or aldosterone antagonists for hypertensive patients with heart failure. For hypertensive patients with diabetes, recommended treatment includes diuretics, beta blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or calcium channel blockers. Recommended treatment for hypertensive patients with increased risk of coronary disease includes a diuretic, beta blockers, angiotensin-converting enzyme inhibitors, and/or calcium channel blocker. The Joint National Committee guidelines recommend beta blockers, angiotensin-converting enzyme inhibitors, and aldosterone antagonists for hypertensive patients who are postmyocardial infarction; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for hypertensive patients with chronic kidney disease; and diuretic and angiotensin-converting enzyme inhibitors for recurrent stroke prevention in patients with hypertension.
ABSTRACT: The exercise stress test is a useful screening tool for the detection of significant coronary artery disease. Documentation of the patient's symptoms, medications, past and current significant illnesses, and usual level of physical activity helps the physician determine if an exercise stress test is appropriate. The physical examination must include consideration of the patient's ability to walk and exercise, along with any signs of acute or serious disease that may affect the test results or the patient's ability to perform the test. The test report contains comments about the maximal heart rate and level of exercise achieved, and symptoms, arrhythmias, electrocardiographic changes and vital signs during exercise. This report allows the clinician to determine if the test was "maximal" or "submaximal." The quality of the test and its performance add to the validity of the results. The conclusion section of the test report indicates whether the test results were "positive," "negative," "equivocal" or "uninterpretable." Further testing may be indicated to obtain optional information about coronary artery disease and ischemic risk if the test results were equivocal or uninterpretable.