Clinical implications of C-reactive protein as a predictor of vascular risk

PURPOSE: To describe the role of C-reactive protein (CRP) as a marker of risk for coronary heart disease (CHD) and its role in risk reduction and disease prevention for the primary care provider. DATA SOURCES: Extensive review of scientific literature on CRP and CHD. CONCLUSIONS: Despite the scientific knowledge we have gained about prevention, risk factors, detection, and treatment, there are still high rates of CHD and acute coronary syndromes in the United States. With greater understanding of the role of inflammation in atherothrombotic disease, much attention has been given to monitoring CRP as a marker of risk for CHD. Guidelines for the use of CRP in clinical practice have been developed by the American Heart Association and Centers for Disease Control and Prevention; however, there is little specific guidance on how primary care providers should apply pharmaceutical strategies to reduce elevated levels of CRP. IMPLICATIONS FOR PRACTICE: There is increasing evidence that CRP is an independent risk factor for CHD, can be a valuable tool in assessing at-risk populations, and provide additional information for the prevention of cardiovascular disease, which can assist the nurse practitioner target patients who may need lifestyle modifications that traditional screening tests may not identify.     

Coronary heart disease prevention and lifestyle interventions: cultural influences

Unless action is directed to address the multiple influences on coronary heart disease (CHD) risk reduction behaviors, across all population groups, the aims of Healthy People 2010 with regard to CHD will not be realized. Health-promotion and disease-prevention models, including a framework for primordial, primary, and secondary prevention provided by an American Heart Association task force, and a model for interventions to eliminate health disparities are reviewed. The role of culture, ethnicity, race, and socioeconomic status and how these concepts have been studied in recent lifestyle interventions aimed at CHD risk reduction is explored. Finally, these findings are synthesized to provide suggestions for nursing care delivery in primary and tertiary care settings.     

对冠心病患者实施康复护理的现状与进展

众所周知，在大多数国家中，冠心病已经成为普遍存在的发病率较高的疾病和主要的致死疾病之一。对冠心病的主要危险因素调查通过康复护理治疗，有效的社区普及卫生教育，同时对高危个体进行目标跟踪管理，这三者相结合形成了一个有效的治疗监督手段。     

Assessment of the impact of fibrates and diet on survival and their cost-effectiveness: evidence from randomized, controlled trials in coronary heart disease and health economic evaluations

The fibrates are one of several classes of lipid-reducing agents commonly prescribed to reduce hypercholesterolemia and prevent coronary heart disease. In today's evidence-based, cost-conscious health care environment, interventions promoted by policymakers must provide clear clinical benefits and economic value. We assessed the evidence regarding the impact of fibrates and diet on survival and the cost-effectiveness of these interventions. A literature search was conducted for randomized, controlled trials of diet, fibrates, and heart disease that were published after 1971; both primary and secondary prevention clinical trials were reviewed, and recent literature reviews and meta-analyses were searched. The evidence that diet alone improves survival is poor, although specifically increasing intake of polyunsaturated fatty acid (including n-3 fatty acids) relative to saturated fatty acid intake may provide some clinical benefit in the secondary prevention of coronary heart disease. The cost-effectiveness of dietary intervention is also questionable because compliance is extremely poor. There is no consistent evidence from primary or secondary prevention trials that fibrates improve survival; in fact, fibrates may increase the risk of death from noncoronary causes. No consistent data suggest that fibrates are a cost-effective therapy. Because diet and fibrates do not appear to improve survival or provide value, policymakers should promote the use of alternative drug interventions that have consistently been proved to reduce mortality and are cost-effective.     

Update on using coronary calcium screening by computed tomography to measure risk for coronary heart disease

Coronary artery disease (CAD) is the number one killer of adults in the United States, claiming one-half million deaths annually. Early detection and prevention strategies clearly remain a top priority for health care providers in order to reduce the high mortality rate of heart disease. As an unequivocal reflection of arteriosclerosis, coronary arterial calcium (CAC) may provide a means to qualitatively assess the overall disease severity and likewise serve as a means to assess risk for CHD. It is known that patients with heavy calcium burdens have more advanced CAD, a concomitantly a higher likelihood of coronary stenoses, and a concomitant higher risk for acute cardiac events. Computed tomography has been shown to be an accurate, non-invasive method to quantify coronary calcification burden in patients. Evidence shows that calcium measurements by CT correlate well with histological plaque analyses, and that CAC measurements accurately reflect disease severity and can be useful to assess individual risk for CHD. The purpose of this article is to summarize the currently available evidence that has attempted to validate CAC screening as a screening exam and risk predictor for coronary heart disease.     

Fostering prevention in the pediatric population

Although cardiovascular disease is seldom manifested clinically before the fourth or fifth decade of life, atherosclerotic cardiovascular disease processes begin in early childhood. Fatty streaks and atherosclerotic lesions have been found post-mortem in the aorta and coronary vessels of children as young as 6 years of age. The modifiable risk factors for heart and vascular disease that are found in adults, such as hypertension, dyslipidemia, smoking, obesity, and physical inactivity, are also present in children. Available evidence emphasizes the need for both population-based and individual approaches to primary prevention of CVD beginning in childhood. This article summarizes this evidence and outlines strategies for promoting primary prevention in children and adolescents.     

Intussusception

The death rate from coronary heart disease, the major cause of death in the United States, is declining. Dr Watkins explores risk factor reduction and other probable reasons for this decline and uses data from clinical trials to demonstrate which interventions are effective and should be undertaken by primary care physicians.     

A case study approach to evaluation of cardiac disease in women

Women rarely consider coronary heart disease as a health concern despite the fact that it is the leading cause of death in women in the United States. We have just recently begun to appreciate the gender and age differences related to coronary heart disease presentation and management in women. Management challenges often relate to the unusual or atypical disease presentation and course, and are frequently misunderstood by the practicing clinician. Comorbidities and prevention strategies in the female patient must be carefully considered. Early risk reduction and counseling should be incorporated into every well-woman exam so that women receive the timely and appropriate care they need and deserve.     

A concise review of the cost-effectiveness of coronary heart disease prevention

Coronary heart disease is one of the largest sources of morbidity, mortality, and health care expenditure in the United States. This article reviews a number of studies that estimate the cost per unit of health benefits associated with different primary and secondary prevention strategies for coronary heart disease. Although prevention does not provide a panacea for rising health care spending, many preventive strategies are cost-effective when compared to other common clinical interventions. Prevention should be incorporated into regular clinical practice.     

Prevention of coronary heart disease. Part II. Secondary prevention, detection of subclinical disease, and emerging risk factors

The prevention of CHD should be a major priority among primary care physicians and subspecialists who have any dealing with the cardiovascular system. There is ample evidence from epidemiologic studies for the impact of specific risk factors on CHD events. There is also ample evidence from observational studies and clinical trials that interventions of lifestyle and pharmacologic therapy can decrease morbidity and mortality from CHD before or after the first event. It behooves the physician who wishes to practice good medicine to understand the pathophysiologic roles of the risk factors and the evidence from epidemiologic studies and clinical trials for their association with cardiovascular disease. It is important to determine the efficacy of interventions, both lifestyle and pharmacologic, in modifying CHD risk. To be effective in doing so, the practicing physician has to have the motivation to determine target goals for risk factor modification in each patient, to understand the patient's own motivations in modifying risk factors, and to define clearly with the patient the expectations of such interventions. Although there are guidelines for risk factor modification in modification of cholesterol and in hypertension, the periodic renewal of these guidelines reflects the changing concepts of risk and its modification. A cardiovascular risk factor intervention categorization is presented in Table 12. The physician must be convinced that such intervention is beneficial to the patient, cost-effective, and thus fulfills the expectations of medical practice. The practice of medicine in the evaluation and treatment of coronary heart disease has always been challenging and stimulating. The prevention of CAD disease should ultimately provide the greatest accomplishment.     

Diet and coronary heart disease: advice on a cardioprotective diet

Coronary heart disease is a major disease leading to early morbidity and mortality in the UK. The causes are multifactorial, a combination of modifiable and non-modifiable risk factors. Although recent statistics show a reduction in the coronary heart disease mortality rate, the disease continues to be a major focus in health care, with strategies being developed to improve prevention and treatment. Dietary modification has a role to play in both primary and secondary prevention.     

Preventing coronary heart disease: the implementation of healthy lifestyle strategies for children and adolescents

Extensive epidemiologic, clinical, and laboratory data accumulated over the past 3 decades provide convincing rationale for primary prevention of coronary heart disease (CHD) beginning early in life. This article focuses on evidence-based strategies designed to promote cardiovascular health in children and adolescents and reduce the risk and burden of CHD in adult life. Emphasis is placed on healthful lifestyle training and behavioral change interventions applicable in health care and school-based and community-based settings.     

Schizophrenia, obesity, and antipsychotic medications: what can we do?

Obesity is one of the most common physical health problems among patients with severe and persistent mental illnesses, such as schizophrenia. Multifactorial in origin, obesity can be attributed to an unhealthy lifestyle as well as the effects of psychotropic medications such as second-generation antipsychotics. Excess body weight increases the risk for many medical problems, including type 2 diabetes mellitus, coronary heart disease, osteoarthritis, hypertension, and gallbladder disease. A PubMed search revealed 403 English-language citations to the query "schizophrenia" AND "obesity" and 469 citations to the query "obesity" AND "antipsychotics." The evidence is that different antipsychotics have different propensities for weight gain, and that children, adolescents, and fi rst-episode patients are at higher risk for weight gain associated with antipsychotic treatment. Monitoring body weight early in treatment will help predict those at high risk for substantial weight gain. Switching antipsychotic medication may or may not be clinically feasible, but can lead to a reduction in body weight. Lifestyle therapies and other nonpharmacological interventions have been shown to be effective in controlled clinical trials, but the evidence base for adjunctive medication strategies such as with orlistat, sibutramine, amantadine, nizatidine, metformin, topiramate, and others, is confl icting. At the very least, a "small-steps approach" to managing weight should be offered to all patients who are overweight or obese.     

Quality of life when living with heart failure

Heart failure is a chronic condition and consumes a huge portion of health care expenditures. Increased life expectancy combined with increasingly effective treatments for coronary artery disease and hypertension will increase the number of patients with heart failure. Efforts are aimed at helping patients better care for themselves. Nurses can design interventions that focus on education and self-management of complex treatments, spiritual support, and clinical relationships based on trust. It is essential that health care providers direct and evaluate interventions that promote improved QOL for patients and families. Nurses also need to continue to study the effects of education and self-care interventions so that care for heart failure patients is evidence based.     

Hypercholesterolemia in diabetes and glucose intolerance in the U.S. population

The prevalence of hypercholesterolemia, according to the guidelines of the National Cholesterol Education Program, has been determined in a national survey of diabetes and glucose intolerance. Rates of elevated total cholesterol in people with diabetes in the United States are only slightly greater than in those without diabetes after adjusting for age and sex. Nevertheless, high or borderline high total cholesterol is common in diabetes and is present in 70% of adults with diagnosed diabetes and 77% with undiagnosed diabetes in the U.S. population. Of these individuals, 95% have evidence of coronary heart disease or two or more risk factors for heart disease and should therefore have their low-density lipoprotein (LDL) cholesterol measured. Based on our national data, LDL cholesterol levels warranting dietary treatment for hypercholesterolemia would be expected in 85% of these people. Although elevated LDL cholesterol is uncommon in people with diabetes who have total cholesterol of less than 200 mg/dl, other risk factors for coronary heart disease are very frequent (100% of men, 73% of women), and low total and LDL cholesterol may mask low high-density lipoprotein cholesterol. Therefore, investigation of blood lipid levels and coronary heart disease risk factors should be routine in all patients with diabetes, and treatment strategies should include management of lipid disorders and the multiple other risk factors for coronary heart disease that are highly prevalent in these patients.     

Rationale, design, and methods for the risk evaluation and communication health outcomes and utilization trial (REACH OUT)

OBJECTIVE: To test the primary study hypothesis that a physician-delivered coronary heart disease risk evaluation and communication program can lower patients' predicted 10-year risk of myocardial infarction or death due to coronary heart disease by 10% within 6 months compared to usual care. DESIGN: Prospective, parallel group, open-label, controlled, cluster-randomized multinational trial; the study site is the unit of randomization. SETTING: Patients were recruited from 106 general practices located in nine European countries. PATIENTS: Men and women aged 45 to 64 (N=1500) with a documented history of hypertension (treated or untreated), systolic blood pressure > or =140 mmHg (or > or =130 mmHg in the presence of renal or kidney disease), no history of cardiovascular disease, and a predicted 10-year risk of myocardial infarction or death due to coronary heart disease > or =10%. INTERVENTION: Sites were randomized to deliver a physician-directed coronary heart disease risk communication and education program or usual care. The intervention program included informing patients of their 10-year risk of myocardial infarction or death due to coronary heart disease, educating patients about modifiable risk factors and their control, and three follow-up phone calls by a physician or study nurse. MAIN OUTCOME MEASURE: Predicted 10-year risk of myocardial infarction or death due to coronary heart disease at 6 months. CONCLUSIONS: REACH OUT will evaluate a novel, patient-focused, physician-implemented application of coronary heart disease risk equations. Results of the study will be of practical relevance to physicians, health care organizations, and those who issue clinical guidelines for the reduction of cardiovascular risk.     

Announcements

Abstract

Obesity is one of the most common physical health problems among patients with severe and persistent mental illnesses, such as schizophrenia. Multifactorial in origin, obesity can be attributed to an unhealthy lifestyle as well as the effects of psychotropic medications such as second-generation antipsychotics. Excess body weight increases the risk for many medical problems, including type 2 diabetes mellitus, coronary heart disease, osteoarthritis, hypertension, and gallbladder disease. A PubMed search revealed 403 English-language citations to the query “schizophrenia” AND “obesity” and 469 citations to the query “obesity” AND ''antipsychotics.” The evidence is that different antipsychotics have different propensities for weight gain, and that children, adolescents, and first-episode patients are at higher risk for weight gain associated with antipsychotic treatment. Monitoring body weight early in treatment will help predict those at high risk for substantial weight gain. Switching antipsychotic medication may or may not be clinically feasible, but can lead to a reduction in body weight. Lifestyle therapies and other nonpharmacological interventions have been shown to be effective in controlled clinical trials, but the evidence base for adjunctive medication strategies such as with orlistat, sibutramine, amantadine, nizatidine, metformin, topiramate, and others, is conflicting. At the very least, a “small-steps approach” to managing weight should be offered to all patients who are overweight or obese.     

Optimal therapy for reduction of lipoprotein(a)

What is known and Objective: There is a growing body of experimental and clinical evidence for the atherogenic and pro‐thrombotic potential of Lipoprotein(a) [Lp(a)], as well as for its causative role in coronary heart disease and stroke. We comment on novel strategies for reducing Lp(a) levels. Comment: Irrespective of the underlying biological mechanisms explaining the athero‐thrombotic potential of this lipoprotein, most work has focused on the identification of suitable therapies for hyperlipoproteinemia(a). These include apheresis techniques, nicotinic acid and statins. None of these strategies have been shown to be definitely effective or convenient for the patient and new strategies are being attempted. Promising results are emerging with therapeutic interventions targeting the ‘inflammatory pathways’ by inhibition of Interleukin‐6 (IL‐6) signalling with natural compounds (e.g., Ginko biloba) or the IL‐6 receptor antibody Tocilizumab. These may both lower Lp(a) and cardiovascular risk of the patients. Besides inhibiting platelet function, antiplatelet therapy with aspirin may also decrease the plasma concentration of Lp(a) and modulate its influence on platelets. What is new and Conclusion: We highlight the inadequacy of current approaches for lowering Lp(a) and draw attention to novel insights that may lead to better treatment.     

The importance of reaching lipid targets: statins and the prevention of atherosclerosis

To help prevent the development of coronary heart disease (CHD), the European and NCEP guidelines have recommended target cholesterol levels for all individuals. Lifestyle changes are advocated for individuals not achieving these targets. Intervention with lipid-modifying agents may be required for patients at high risk of a cardiovascular event and statins are generally recognised as first-line therapy. Unfortunately, large numbers of patients at risk of cardiovascular events are not being treated to the guideline targets. Primary care physicians are in a good position to improve lipid management by assessing risk factors, implementing lipid management strategies, monitoring whether targets are being reached and amending treatment appropriately. Furthermore, by educating and motivating patients,primary care physicians may improve compliance with lifestyle changes and medication. These approaches may help more patients to achieve recommended lipid levels and prevent the development of cardiovascular disease.     

Antioxidants for vascular disease

The epidemiologic data do not support a strong role for vitamin C in reducing risk of coronary disease. The evidence supporting a protective effect for the family of dietary carotenoids is stronger, but any important protective effect attributable to the specific supplementation of beta-carotene can be excluded. Conversely, results from observational and experimental studies consistently support an effect of vitamin E supplementation on reducing risk of coronary heart disease. The evidence suggests that the major effect, if any, is found at supplemental intake levels at or greater than 100 IU/d. If confirmed in further trials, the net benefit of vitamin E supplementation among populations with existing coronary disease may be substantial, although the current available evidence is insufficient to warrant a change in public policy recommendations.