Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of coronary heart disease

To determine the cost-effectiveness of HMG-CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors (such as lovastatin) for the primary and secondary prevention of coronary heart disease, we used the Coronary Heart Disease Policy Model, a computer-stimulated model that estimates the risk factor-specific annual incidence of coronary heart disease and the risk of recurrent coronary events in persons with prevalent coronary heart disease. When used for secondary prevention, 20 mg/d of lovastatin was estimated to save lives and save costs in younger men with cholesterol levels above 250 mg/dL (6.47 mmol/L) and to have a favorable cost-effectiveness ratio regardless of the cholesterol level except in young women with cholesterol levels below 250 mg/dL (6.47 mmol/L). Doses of 40 mg/d of lovastatin had favorable incremental cost-effectiveness ratios in men with cholesterol levels above 250 mg/dL (6.47 mmol/L). By comparison, primary prevention had favorable cost-effectiveness ratios only in selected subgroups based on cholesterol levels and other established risk factors. We conclude that current national recommendations regarding medication for secondary prevention are not as aggressive as our projections would suggest, while recommendations regarding the use of medications for primary prevention should consider the cost of medication as well as the risk factor profile of the individual patient.     

The paediatrician's responsibility for the prevention of coronary heart disease

A strong case exists in favour of encouraging children not to smoke, to be reasonably physically active and to eat in moderation to avoid obesity. The principal role of the paediatrician is in the education of health personnel who are in a position to influence children and their families to adopt these measures. Paediatricians will also be involved with children at special risk of ischaemic heart disease. They have a responsibility to promote reasearch to determine the efficacy of these measures in the prevention of coronary heart disease.     

Cost-effectiveness of vitamin therapy to lower plasma homocysteine levels for the prevention of coronary heart disease: effect of grain fortification and beyond

Context  A high homocysteine level has been identified as an independent modifiable risk factor for coronary heart disease (CHD) events and death. Since January 1998, the US Food and Drug Administration has required that all enriched grain products contain 140 µg of folic acid per 100 g, a level considered to decrease homocysteine levels. Objectives  To examine the potential effect of grain fortification with folic acid on CHD events and to estimate the cost-effectiveness of additional vitamin supplementation (folic acid and cyanocobalamin) for CHD prevention. Design and Setting  Cost-effectiveness analysis using the Coronary Heart Disease Policy Model, a validated, state-transition model of CHD events in adults aged 35 through 84 years. Data from the third National Health and Nutrition Examination Survey (NHANES III) were used to estimate age- and sex-specific differences in homocysteine levels. Intervention  Hypothetical comparison between a diet that includes enriched grain products projected to increase folic acid intake by 100 µg/d with the same diet without folic acid fortification; and a comparison between vitamin therapy that consists of 1 mg of folic acid and 0.5 mg of cyanocobalamin and the diet that includes grains fortified with folic acid. Main Outcome Measures  Incidence of myocardial infarction and death from CHD, quality-adjusted life-years (QALYs) saved, and medical costs. Results  Grain fortification with folic acid was predicted to decrease CHD events by 8% in women and 13% in men, with comparable reductions in CHD mortality. The model projected that, compared with grain fortification alone, treating all patients with known CHD with folic acid and cyanocobalamin over a 10-year period would result in 310 000 fewer deaths and lower costs. Over the same 10-year period, providing vitamin supplementation in addition to grain fortification to all men aged 45 years or older without known CHD was projected to save more than 300 000 QALYs, to save more than US $2 billion, and to be the preferred strategy. For women without CHD, the preferred vitamin supplementation strategy would be to treat all women older than 55 years, a strategy projected to save more than 140 000 QALYs over 10 years. Conclusions  Folic acid and cyanocobalamin supplementation may be cost-effective among many population subgroups and could have a major epidemiologic benefit for primary and secondary prevention of CHD if ongoing clinical trials confirm that homocysteine-lowering therapy decreases CHD event rates.      

The dietary prevention of coronary heart disease: dietary cholesterol and fat.

Epidemiological, laboratory and experimental studies make it clear that dietary cholesterol (DC) and saturated fat, independently and together, are hypercholesterolaemic and atherogenic. Some work suggests that DC, usually given as egg yolk, is the more important, but often they are consumed together. There is a threshold, usually between 100 and 200 mg/day, below which small increments do not affect plasma cholesterol (PC) and another, usually between 500 and 600 mg/day, above which there is little additional change. However, there is considerable individual variation. Recent work suggests that regression of atherosclerosis can occur in the human as in the non-human primate. An alternative, phased, preventive diet has been designed which is nutritionally adequate, ecologically sound, and economical. It also has an historical basis.     

Optimal diets for prevention of coronary heart disease

Context  Coronary heart disease (CHD) remains the leading cause of mortality in industrialized countries and is rapidly becoming a primary cause of death worldwide. Thus, identification of the dietary changes that most effectively prevent CHD is critical. Objective  To review metabolic, epidemiologic, and clinical trial evidence regarding diet and CHD prevention. Data Sources and Study Selection  We searched MEDLINE through May 2002 for epidemiologic and clinical investigations of major dietary factors (fat, cholesterol, omega-3 fatty acids, trans-fatty acids, carbohydrates, glycemic index, fiber, folate, specific foods, and dietary patterns) and CHD. We selected 147 original investigations and reviews of metabolic studies, epidemiologic studies, and dietary intervention trials of diet and CHD. Data Extraction  Data were examined for relevance and quality and extracted by 1 of the authors. Data Synthesis  Compelling evidence from metabolic studies, prospective cohort studies, and clinical trials in the past several decades indicates that at least 3 dietary strategies are effective in preventing CHD: substitute nonhydrogenated unsaturated fats for saturated and trans-fats; increase consumption of omega-3 fatty acids from fish, fish oil supplements, or plant sources; and consume a diet high in fruits, vegetables, nuts, and whole grains and low in refined grain products. However, simply lowering the percentage of energy from total fat in the diet is unlikely to improve lipid profile or reduce CHD incidence. Many issues remain unsettled, including the optimal amounts of monounsaturated and polyunsaturated fats, the optimal balance between omega-3 and omega-6 polyunsaturated fats, the amount and sources of protein, and the effects of individual phytochemicals, antioxidant vitamins, and minerals. Conclusions  Substantial evidence indicates that diets using nonhydrogenated unsaturated fats as the predominant form of dietary fat, whole grains as the main form of carbohydrates, an abundance of fruits and vegetables, and adequate omega-3 fatty acids can offer significant protection against CHD. Such diets, together with regular physical activity, avoidance of smoking, and maintenance of a healthy body weight, may prevent the majority of cardiovascular disease in Western populations.      

冠心病防治中社区医生应掌握的基本策略

在过去的10年，针对冠心病终末期（有症状或有事件）患者的血管重建技术（经皮介入或冠状动脉旁路移植术）在我国有了长足的发展和推广。但冠心病是一个持续发展的疾病过程，在血管壁上存在多处弥漫病变，并且同一患者可有不止一处的不稳定性斑块。而我国目前对冠心病的防治实践中存在的一个关键问题是只重救治，而对发生心绞痛或心肌梗死之前不防，救治之后也不管。这种落后的模式忽略了病前预防，导致医疗资源严重浪费。基于半数左右的冠心病患者的初期临床表现为急性心肌梗死或心脏性猝死，只治不防的策略必然导致大量患者的突发死亡或致残。由于重救治、轻救治后的疾病管理，因此缺血与再梗死的发生率也高，并且很多患者逐渐进入慢性心力衰竭的队伍。     

Cost-effectiveness of beer versus red wine for the prevention of symptomatic coronary artery disease

BACKGROUND: Until now, red wine has been the cardioprotective beverage of choice, but the convenience and lack of adverse effects make beer a more cost-effective, safe and widely available choice. A paucity of evidence in support of this led to our study. METHODS: During a 6-month period, 11,780 consecutive patrons at 18 randomly selected urban and community liquor distributors were recruited. Participants were randomly assigned to receive either beer or wine daily for 5 years. Of the 10,078 people who met the inclusion criteria, 5033 were assigned to receive red wine and 5039 to receive beer every day. RESULTS: Effectiveness and adverse effects were equal in the 2 groups. However, costs for beer were substantially lower. INTERPRETATION: In view of its effectiveness, low cost, acceptable adverse-event profile and the fact that it is available in convenient single-dose dispensers, beer should replace red wine as the cardioprotective beverage of choice.     

Primary and secondary prevention trials in coronary heart disease

Trials in primary and secondary prevention of coronary heart disease (CHD) are reviewed. The results of completed primary prevention trials suggest that dietary changes in middle-aged men may lower the incidence of CHD. Multifactorial trials may achieve an even greater reduction in CHD. Secondary prevention trials indicate that stopping smoking and the use of beta-blocking agents are effective in reducing recurrence rates.     

Concepts and controversies about the prevention of coronary heart disease

Congruent evidence from several medical disciplines provides compelling argument for a preventive approach to atherosclerotic diseases. Intervention trials and community health education programmes are under way. Reasonable, safe and practical approaches are available for hygienic interventions within the medical system. But major impediments to medical and community researches and action in prevention include professional controversy and public confusion about risk factors and their management. It is suggested here that most of this controversy and confusion is unnecessary and much of it due to professional attitudes and experience. These attitudes appear to result from failure to distinguish adequately the risk, diagnosis and therapeutic decisions appropriate to a culture, in the population-at-large.     

冠心病的调脂治疗

目前,心血管病的发病率和病死率在不断的上升,已居 我国人口病死率的首位,而冠状动脉粥样硬化性心脏病(冠心病)是危害健康最严重的心血管病之一。大量的流行病学、基础及临床研究已经公认,血脂异常系冠心病(CHD)发病与进展的重要危险因素之一。随着对血脂异常与冠心病关系方面认识的提高,调脂治疗受到人们越来越多的关注。     

生活方式的干预对冠心病二级预防的应用调查

目的:通过对冠心病患者不良生活方式进行干预,探讨对冠心病二级预防的效果。方法:选取住院患者56例,入院时、住院时和出院后共进行为期24周的生活方式干预,观察干预前后的情况。结果:生活方式干预前后,患者情绪波动、肥胖、高脂饮食、吸烟、饮酒、生活节奏的不良行为下降(P﹤0.05),体育活动和遵医嘱服药的行为上升(P﹤0.01),患者高血脂、高血糖、高血压和心绞痛等病症明显下降(P﹤0.05或P﹤0.01)。结论:生活方式的干预可促进患者建立健康的生活习惯,有利于冠心病的二级预防。