Large Scale, Multifactorial Studies of Risk Factors
Risk factor prevalence and any therapeutic and lifestyle alterations that had been undertaken by patients aged seventy or less in nine European countries were compared over two five year spans, in the EUROASPIRE I and EUROASPIRE II study (Kotseva, Wood, DeBacket et al 2001). Unlike the case in the US, smoking levels in Europe failed to decline, but as in the US, obesity significantly increased. The taking of aspirin, thiazides, ACE inhibitors, and beta-blockers as cardioprotective strategies increased, but overall these improvements did not offset persistent adverse lifestyle trends in terms of blood pressure and blood chemistry. A EUROASPIRE III update (Kotseva, Wood, DeBacker et al 2009) disclosed that prescriptions taken to reduce high blood pressure and adverse lipid profiles increased significantly, but still brought levels down to acceptable levels in only half the case. Furthermore diabetes prevalence actually increased.
The INTERHEART study (Yussuf, Hawken, Ounpuu et al 2004) examined 52 countries, including some from every continent. It demonstrated that the same risk factors (particularly an increase in obesity and in smoking) leading to cardiovascular disease and death that applied in economically prosperous portions of the US and Western Europe, existed in both countries with emerging economies (People’s Republic of China) and Third World states in economic dire straits (Bangladesh) across the globe.
The SCORE project (Conroy, Pyorala , Fitzgerald et al., 2003), which analyzed the factors contributing to the cardiac-related deaths of 5652 patients out of a population sample of 200,000 Europeans, canonized the notion that number of years of duration of a risk factor (five years of being 40 lbs. overweight) , rather than just simply having a risk factor checked off (40 lbs. overweight today) , was a significantly better predictor of those who would die within a ten-year span.
Specific Risk Factors: Metabolic Syndrome & Diabetes
A strategic approach to combating a complex condition that encompasses adult onset diabetes and that typically involves obesity with abdominal fat concentration leading to hypertension, coronary artery disease and a propensity toward strokes was formalized under the term “Metabolic Syndrome ‘ (Alberti, Zimmer and Shaw 2006) and prevention guidelines increasingly took this pre-diabetic/pre-cardiovascular disease syndrome into consideration (Ruyden, Standl, Bartnik et al 2007). Indeed, diabetes was identified as the greatest single factor predisposing a patient to atherosclerosis, and since most diabetics actually die from complications of atherosclerosis, rather than from the diabetes itself, early and aggressive intervention with the aims of reducing lower density (LdL) cholesterol and triglyceride levels to stave off heart attacks was forcefully recommended (Beckman, Creager & Libby, 2002). In 2008 (Willer, Sanner, Jackson et al.) an even stronger genetic basis that underlies both predisposition to diabetes and higher concentrations of the bad heart-disease-contributing LdL was uncovered via an analysis of almost 18,000 persons with both conditions.
However, a more intense effort to manage insulin and glucose levels after a heart attack, did not seem to lengthen lives as compared to the standard metabolic monitoring (Malmberg, Ryden, Wedel et al 2005). However, advantages may still be realized from an aggressive approach in terms of reduced microvascular damage particularly in the kidneys and retinas (Skyler, Bergenstal, Bonow et al 2009).
Other Risk Factors:
High Blood Pressure, Sleep Apnea, Kidney Disease, Peripheral Artery Disease
In 2003, guidelines for what constitutes high blood pressure that predisposes to elevated risk of cardiovascular disease, particularly in patients 50 and older, were significantly revised downward, suggesting that many more Americans were at risk than was formerly thought (Chobanian, Bakris, Black et al.)
Sleep apnea, particularly the obstructive type common among the obese and especially among those with metabolic syndrome, has now now officially been designated another clear warning sign of rising risk for heart attack and stroke (Somers, White, Amin et al 2008).
Kidney disease was not far behind in statements on both predisposition and the need for proactive treatment (Sarnak, Levey, Schoolwerth et al 2003). Fowkes, Murray, Butcher et al (2008) and Smith, Allen, Blair et al ( 2006) added peripheral artery disease and blocked carotids to more generalized atherosclerosis as indicators for stepped up preventive therapy. Patients receiving cancer chemotherapy or suffering from certain immune disorders became a recognized class of at-cardiac-risk patients, often placed in that situation because drugs used for these conditions impaired heart function (Yeh 2006).
Preventive Measures: Exercise and Omega-3 Fatty Acids
A consensus recommendation for adults 18-65 from cardiologists, exercise physiologists and strength and conditioning trainers for 3-5 days of moderately energetic walking for 30 minutes or aerobics workouts lasting as little as 20 minutes per session emerged as an effective lifestyle strategy to decrease significantly the chance of heart attack and stroke (Haskell, Lee, Pale et al 2007). Another consensus finding was that the increased consumption of omega-3 fatty acids (classically available in oily fish, but now widely available in foods engineered for it such as omega-3 eggs and assorted supplements) seems to decrease in a small but a statistically significant way the mortality and admissions of hospital of patients who already had heart failure ( Tavazzi, Maggioni, Marchioli et al 2008).
The Drive for Evidence-Based Medicine Affects Cardiology Advice
Members of the American Heart Association and the American College of Cardiology have undertaken a thorough review of how many of their 7196 recommendations are based on hard science, and how many are based on well-meaning, ad hoc expert opinion issued in the absence of more rigorous studies, with the goal of increasing the proportion based on the latter (Tricoci, Allen, Kramer et al, 2009).
Heart Failure: The Knife Edge Balance of Good & Bad Inflammation
Heart failure, usually beginning after an infarct, is a progressive, downwardly spiraling disease, and a call for creative flexibility in treatment and deeper insight through basic research was issued (Hunt, Baker, Chin et al 2001). Cohn, Ferrari and Sharpe et al, 2000, had identified the heart’s unassisted and sometimes inept attempt at repairing the damaged areas, a process ironically benignly termed “remodeling” as the main culprit. Frangogiannis, Anderson, Benjamin et al (2002) provided an excellent explanation of why bypass surgery and related artery clearing surgeries work better: A paradoxically beneficial inflammatory response is triggered by the surgery, setting off a cascade of immune responses that ultimately promote the proliferation of fibroblasts and their subsequent conversion into well functioning cardiomyocytes, reducing the amount of necrotic or malfunctioning heart muscle that would be left by “remodeling” without intervention. Libby and Theroux (2005) however, demonstrated that ongoing inflammatory processes can lead to a proliferation of plaques elsewhere in the arterials system and that after addressing the initial blockages via bypass, medications that seek to stabilize other high-risk plaques in place, to prevent them from breaking free and causing another infarct, need to have the highest priority.
A Molecular Level Understanding of
Botched Attempts By the Heart to Repair Itself
& Handle Its Electrochemical Circuits
A key to modulating inflammation and enhancing the outcomes of the heart’s own repair attempts via reduced modeling appears to lay in a deeper understanding of the Matrix Metalloproteins (MMPs) and the enzymes that control them (Nagase, Visse and Murphy 2006). Sarbassov, Ali, Sengupta et al (2006) reported on the underlying mechanisms of a drug (rapamycin) often used in controlling cancer cells through regulating natural cell death (apoptosis) that increasingly serves a similar role in regulating the factors that lead to adverse cardiac remodeling.
Molecular genetic markers of heart disease, and ion channelpathies were finally introduced into a newly revised classification of heart diseases, a concession to contributions made using cardiac genomics, proteomics, and cellular level electrophysiology ( Maron, Towbin, Thiene et al 2006).
Comparing Medications to Reduce Blood Pressure
In a three way comparison (ALLHAT 2002) among blood-pressure lowering diuretics (typically thiazides) , Angiotensin-Converting Enzyme inhibitors (ACE inhibitors, e.g. lisinopril), and calcium channel blockers (Beta Blockers) among high-risk hypertensive patients, the thiazides were judged the best first choice for reasons of at least equal efficacy and significantly lower costs, although combination therapies were later to become the norm (Mancia, DeBacker, Dominiczak et al 2007).
In the Losaratan (Cozaar™) Intervention for Endpoint Reduction for Hypertension, best known as the LIFE trial, 8851 patients were monitored for onset on new cases of atrial fibrillation, with the longer-established comparison drug used for prevention and management, atenolol (Tenormin™) coming up on the short side.
ACE inhibitors (Yusuf, Sleight, Pogue et al 2000) and beta-blockers showed some early promise in forestalling inappropriate remodeling within the heart in damaged areas that leads to progressive heart failure (Cohn, Ferrari, Sharpre et al, 2000). ACE inhibitors and angiotensin receptor blockers (ARBs) appear to prevent atrial fibrillation, particularly in those patients who already have left ventricular dysfunction or hypertrophy (Healey, Baranchuk, Crystal et al 2005).
“Statin Island”
The use of a wide variety of competing statin (bad-cholesterol and triglyceride lowering) drugs vastly increased in this decade, but results favoring one over another were not always unambiguous. One of the most anticipated studies of competing drugs intended to lower LdL-C (the bad cholesterol) involved 8888 patients in northern Europe who had a previous heart attack. This IDEAL study (Pedersen, Faergeman,Kastelein et al 2005) demonstrated that high doses of atorvastatin (aka Lipitor™ ) did lower this bad cholesterol significantly better than simvastatin (aka Zocor™) and resulted in fewer subsequent nonfatal heart attacks, but there was ultimately no significant difference in death rates from either cardiac or non-cardiac causes. In another study, rosuvastatin (Crestor™) clearly lowered the adverse blood chemistry of patients in heart failure, but that it did not actually lifespan or hospital admission for cardiovascular reasons (Tavazzi, Maggioni, Marchiolo 2008).
Blood Thinners
In the blood thinning drug domain, Yusuf, Zhao, Meta et al (2001) report that the taking of a combination aspirin and other anti-coagulants, such as clopidogrel ( e.g. Plavix™) worked better than taking either one alone, particularly after any type of cardiac catheterization to avoid blood clots ( Steinhubl, Berger, Mann et al, 2002). The same group (Serebruanny, Steinhubl, Berger et al 2005) was later to develop a laboratory test for predicting which patients taking clopidogrel would underreact with insufficient blood thinning (about 4%) or overreact with excessively long clotting times (about 5%).
Avoiding Gastrointestinal Bleeding When on Blood Thinners
Nonetheless concern over limiting gastrointestinal side effects of combinations of aspiring and anticoagulants like clopidogrel have been investigated and the concurrent use of proton pump inhibitors (Prilosec™, Prevacid™) has now been strongly recommended (Bhatt, Scheiman, Abraham et al 2008).
Interventional Cardiology Using Catheterization
Atrial fibrillation was better controlled when a catheter, inserted via blood vessels in the groin and then threaded to heart, was used to sense and then burn misfiring centers within the heart (Nademanne, McKenzie, Kosar et al. 2004). Indeed, cardiac catheterization for a wide variety of pathologies had become so very widespread by the mid-2000s, that new and greatly enlarged guidelines had to be rewritten (Silber, Albertsson Aviles et al 2005, Silber, Albertsson, Blair et al 2006).
Cardiac Vessel Stents
The use of stents, coiled tubes placed via catheter, to keep open clogged coronary arteries also became commonplace in the early 2000s, particularly those which eluted drugs to control scarring or plaque build up, and promote healing (Woods and Marks 2004) . Nonetheless, controversies flared over whether plain or drug eluting stents were generally safer (Lagerqvist, James, Stenestrand et al 2007, Moreno, Fernandez, Hernandez et al 2005, Ong, McFadden, Regar et al 2005), and a call for standardization of clinical trials was issued (Cutlip, Windecker, Mehran et al 2007).
Autologous Transplantation of Heart Cells To Stimulate Cardiac Repair
Demonstrating that cardiac repair after a heart attack improves significantly when a plentiful supply of myoblasts is available, Menasche, Hagege, Vilquin et al provided patients with a transplant of their own myoblasts, derived from thigh biopsies that were further cultured in the lab, via injection into heart scar tissue. This procedure, while widely cited, has not yet become widespread.
The Cabbage (CABG) Patch
While less invasive procedures predominate today, the thoracic surgical management of heart disease , with Coronary Artery Bypass Graft Surgery, and valve replacement are still common and important procedures (Descoutures, Himbert, Lepage et al 2008, Smith, Allen, Blair et al 2006, Vahannian, Baumgartner, Bax et al 2007, Zeltsman and Acker 2002).
Pacemakers
The use of implanted devices (both the conventional implantable cardioverter and biventricular cardiac resynchronizers) grew almost exponentially in this decade (Matchett, Sears, Hazelton et al 2009, van Veldhuisen, Maass, Priori et al 2009) but the larger number of cases also disclosed some pitfalls, particularly in the durability of the wire leads (Haqqani and Mond 2009), but expert opinion remains optimistic about newer, electronically simplified models with greater ease of insertion and a single more durable lead (Santini, Cappato, Anfresen et al 2009).
Looking Into the Beating Heart
The most traditional of major instrumental measures of heart function, the echocardiogram, saw further standardization in terms of recommended uses and terminology (Lang, Bierig, Devereux et al 2005).
Leber, Knez, von Ziegler et al (2005) would eventually demonstrate the advantages of 64-slice computer tomography of the heart over ultrasonic techniques, and a generally upbeat assessment was provided in 2006 (Budoff, Achenbach, Blumenthal et al 2006). Nonetheless, Miller, Rochitte, Dewewy et al (2008) suggest that it is still essentially on a par with conventional coronary angiography, and owing to a few residual drawbacks, does not clearly replace it. Arad, Goodman, Roth et al (2005) showed that electron beam tomography, a further refinement, was even better for the determination of coronary calcification associated with atherosclerotic cardiovascular events, and had a higher predictive value than tests for C-Reactive Proteins, a common measure of the progression of this disease process. However, it was also determined that the Lifetime Risk Attributable (LAR) to any ionizing radiation (e.g. x-rays) during these probes was not negligible, particularly among those at risk of lung and breast cancer already (Einstein, Henzlova and Rajgopalan 2007). This was not an entirely unsurprising finding, and guidelines that recommended its continued use, with precautions, and that of an emerging technology at that time, cardiac magnetic resonance, which does not involve ionizing radiation, were issued in 2006 (Hendel, Patel, Kramer et al).
Non-Pedal P.A.D. – Peripheral Artery Disease
(This Time In the Arms Not in the Feet or Legs)
High-resolution brachial artery ultrasonic imaging for peripheral artery disease was regarded as particularly promising but only if carefully interpreted (Correti, Anderson, Benjamin et al 2002), and its adaptation as a model for clogged coronary arteries progressed (Mintz, Nissen Anderson et al, 2001).
Stroke
Guidelines for stroke prevention were drawn up in 2006 (Goldstein, Adams, Alberts et al). Guidelines for the management of strokes caused by arterial blockages in the brain in the first 48 hours were drawn up in 2007 (Adams, del Zoppo, Alberts et al).
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Thanks for the info. Anywhere else I can find more information on aortic valve replacement?
Posted by: Aortic Valve Replacement | July 29, 2011 at 01:35 PM
Veins carry blood from the body back to the heart, and have one-way valves that prevent blood from flowing backward. If the valves become weakened, some blood can remain in the vein, causing the vein to enlarge and bulge. Larger congested veins found mostly in the legs are commonly called varicose veins.
Posted by: Heart and Vein Center | June 19, 2011 at 06:42 PM
Heart disease or cardiovascular diseases is the class of diseases that involve the heart or blood vessels (arteries and veins).Thank you so much for the wealth of information.
mjd
Posted by: cardiology emr | June 16, 2010 at 10:25 PM