人群心血管病原发预防及效果评价

为了探讨在我国人群中进行心血管病防治的有效方法,我们在两所高等院校来用人群对照设计开展了心血管病原发预防。一年后的结果示:两组的血压、胆固醇水平改变及吸烟和饮食习惯改善情况,干预组优于常规组,但组间无统计学意义。分析原因可能有:研究人群的危险因素水平偏低;对干预组的干预强度尚不足;常规组人群本身对其危险因素现状敏感性提高和社会影响的作用。     

大庆糖尿病前期人群糖耐量改善对心血管事件和死亡率的影响——一项20年随访研究

目的 探讨糖尿病前期人群中改善或减缓糖耐量恶化是否可能降低心血管事件和死亡率.方法 1986年大庆市577例糖耐量受损者被随机分到对照组和3个干预组(饮食、运动和饮食加运动组)进行6年(1986～1992)生活方式干预后又随访14年.本研究将全部受试者按1992年生活干预结束时糖负荷后2 h血糖(2hPG)分为4组(Quartiles,2hPG均值分别为6.17、9.00、12.07和16.96 mmol/L),分析血糖水平高低与随访期间心血管事件及死亡率有无相关.结果 20年随访中共有142例死亡,68例死于心血管疾病(CVD).有首次CVD事件211次(145次脑卒中、66次心梗).从血糖水平最高到血糖最低的4组中全因死亡(17.8、12.7、10.9和9.7/1 0130人年)、CVD死亡(9.1、5.9、6.1和4.9/1 000人年)、CVD事件(30.4、24.0、18.8和19.7/1000人年)和脑卒中(26.6、18.5、16.3和18.1/1 000人年)发生率明显依次递减.多因素分析调整基线年龄、性别、体重指数、血压、吸烟和干预分组的影响后,强化生活方式干预结束时(1992年)2hPG升高5 mmol/L可使全因死亡(HR 1.335,P=0.005)、CVD事件(HR 1.227,P=0.012)和脑卒中(HR1.213.P=0.026)发生率显著升高.结论 在糖尿病前期人群,如果生活干预的强度足以改善或减缓该人群糖耐量的恶化,就可能降低心血管事件和死亡率.     

A novel approach to cardiovascular health by optimizing risk management (ANCHOR): a primary prevention initiative examining the impact of health risk factor assessment and management on cardiac wellness

Cardiovascular disease (CVD) represents an increasing burden to health care systems. Modifiable risk factors figure prominently in the population-attributable risk for premature coronary artery disease. Primary care is well placed to facilitate CVD risk improvement. We plan to evaluate the ability of a novel primary care intervention providing systematic risk factor screening, risk-weighted behavioural counselling and pharmacological intervention to achieve 2 objectives: (1) optimized management of global CVD risk of patients and (2) increased patient adherence to lifestyle and pharmaceutical interventions aimed at decreasing global CVD risk. A pre-post longitudinal prospective design with a nonrandomized comparison group is being undertaken in 2 geographically diverse primary care practices in Nova Scotia with differing reimbursement models. Participants will complete a readiness to change and pre-post health risk assessment (HRA), that will trigger a 1-year intervention individualized around risk and readiness. The primary outcome will be the proportion of participants with Framingham moderate and high-risk strata that reduce their absolute risk by 10% and 25%, respectively. The secondary outcome will be the proportion of moderate and high-risk participants who reduce their risk category. The impact of the intervention on clinical and behavioural variables will also be examined. Low risk participants will be separately analyzed. Data from participants unable to change from the high risk category because of diabetes mellitus or established atherosclerotic disease will also be analyzed separately, with changes in clinical measures from baseline being assessed. A health economic analysis is planned.     

Effekte einer multimodalen Intervention zur Prim?rpr?vention kardiovaskul?rer Krankheiten auf Depressivit?t, Angst und Typ-D-Muster

Depression, anxiety, and Type-D pattern are associated with the earlier development and faster progression of cardiovascular disease (CVD). The aim of the randomized controlled PreFord trial was to improve multiple biological and psychosocial risk factors in the primary prevention of CVD. A total of 447 women and men with an ESC risk score >5% were randomly assigned to either multimodal or routine care groups. Somatic and psychosocial variables (HADS, DS-14) were assessed before and after the intervention, and annually for 2 years thereafter. The intervention showed no significant effects on the symptoms of depression, anxiety, and type D personality, either in the whole sample or in those with elevated scores at baseline. Thus, our study did not provide evidence that symptoms of depression, anxiety, or Type D personality can be effectively treated by multimodal behavioral interventions for the primary prevention of CVD.     

Coronary angiogram and intervention through transulnar approach

BACKGROUND: This study was conducted to assess the safety and feasibility of a transulnar approach in performing diagnostic and interventional percutaneous coronary procedures. METHODS AND RESULTS: In the year 2004, a total of 100 patients underwent diagnostic angiography (n=64) and percutaneous coronary interventions (n=36) through transulnar approach. The patients' age ranged from 40 to 70 years and male to female ratio was 7.3:1. The cases of percutaneous coronary interventions were mostly elective procedures and emergency intervention was done in only 2 patients. The procedure was successful in 95 (95%) patients and unsuccessful in 5 (4 diagnostic and 1 percutaneous coronary intervention). The procedure was done through right ulnar artery in all except one patient in whom it was done through left ulnar artery. The total procedure time ranged between 25-45 min. Among the cases of percutaneous coronary interventions, single vessel angioplasty was performed in 23 (65.7%) patients, double vessel in 11 (31.4%) patients and triple vessel in 1 (3%) patient. All percutaneous coronary intervention patients received aspirin, clopidogrel and intravenous enoxaparin. Glycoprotein IIb/IIIa inhibitors were used in 7 patients. Complications such as local hematoma, ulnar artery perforation and reversible parasthesia occurred in one patient each. CONCLUSIONS: Tansulnar approach is a safe and easy alternative technique to perform diagnostic and therapeutic coronary interventions.     

Global cardiovascular health: urgent need for an intersectoral approach

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with more than 80% of CVD deaths occurring in low- and middle-income countries (LMICs). There have been several calls for action to address the global burden of CVD, but there remains insufficient investment in and implementation of CVD prevention and disease management efforts in LMICs. To catalyze the action needed to control global CVD, the Institute of Medicine recently produced a report, Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. This paper presents a commentary of the Institute of Medicine's report, focusing specifically on the intersectoral nature of intervention approaches required to promote global cardiovascular health. We describe 3 primary domains of intervention to control global CVD: 1) policy approaches; 2) health communication programs; and 3) healthcare delivery interventions. We argue that the intersectoral nature of global CVD interventions should ideally occur at 2 levels: first, all 3 domains of intervention must be activated and engaged simultaneously, rather than only 1 domain at a time; and second, within each domain, a synergistic combination of interventions must be implemented. A diversity of public and private sector actors, representing multiple sectors such as health, agriculture, urban planning, transportation, finance, broadcasting, education, and the food and pharmaceutical industries, will be required to collaborate for policies, programs, and interventions to be optimally aligned. Improved control of global CVD is eminently possible but requires an intersectoral approach involving a diversity of actors and stakeholders.     

The EGIR-RISC STUDY (The European group for the study of insulin resistance: relationship between insulin sensitivity and cardiovascular disease risk): I. Methodology and Objectives

Aims/hypotheses Insulin resistance is thought to be a key predictor for the development of Type 2 diabetes mellitus and cardiovascular disease (CVD), a leading cause of morbidity and premature mortality in Europe. Insulin resistance is influenced by both genetic and lifestyle factors (e.g. obesity and physical inactivity). The RISC (Relationship between Insulin Sensitivity and Cardiovascular disease) Study is using the infrastructure of an extended European collaborative research group to study insulin resistance and CVD risk in 1500 healthy people aged 30 to 60 years from 20 centres in 13 countries.Methods Baseline measurements of glucose tolerance and insulin sensitivity are made by the oral glucose tolerance test and the euglycaemic insulin clamp, respectively; carotid artery intima-medial thickness (by ultrasound), ankle/brachial pressure index and electrocardiography will enable evaluation of subclinical CVD at baseline and at follow-up. Classic CVD risk factors, as well as socioeconomic and lifestyle factors will be recorded at baseline; samples for measurement of biochemical and genetic markers will be collected and stored for future analyses. Investigations will be repeated after 3 and 10 years to evaluate the relationship between insulin resistance and the development of atherosclerosis as measured by carotid artery intima-media thickness. Development of Type 2 diabetes, dyslipidaemia, obesity, hypertension and cardiovascular events are additional endpoints.Conclusions This study will evaluate the importance of insulin resistance in the development of CVD and diabetes, and has implications for the development of prevention and treatment strategies.Abbreviations CVD Cardiovascular disease - cIMT carotid intima-medial thickness - CCA common carotid arteries - CB carotid bifurcation - ICA internal carotid arterySee the Acknowledgements for the full list of members of the EGIR-RISC Study Group     

Sustaining the Control of Schistosoma mansoni in Western C?te d'Ivoire: Baseline Findings before the Implementation of a Randomized Trial

We report baseline findings before the implementation of a 4-year intervention trial designed to assess the impact of three different school-based treatment schedules with praziquantel to sustain the control of intestinal schistosomiasis. The baseline survey was conducted in 75 schools of western Côte d''Ivoire previously identified with moderate Schistosoma mansoni endemicity (prevalence: 10–24% in children aged 13–14 years). Three stool samples collected over consecutive days were subjected to duplicate Kato-Katz thick smears each. A questionnaire was administered to collect village-specific information that is relevant for schistosomiasis transmission. Overall, 4,953 first graders (aged 5–8 years) and 7,011 school children (aged 9–12 years) had complete parasitologic data. The overall prevalence of S. mansoni was 5.4% among first graders and 22.1% in 9- to 12-year-old children. Open defecation was practiced in all villages. The current baseline findings will be important to better understand the dynamics of S. mansoni prevalence and intensity over the course of this trial that might be governed by village characteristics and specific treatment interventions.     

Mobile health and cardiac rehabilitation in older adults

With the ubiquity of mobile devices, the availability of mobile health (mHealth) applications for cardiovascular disease (CVD) has markedly increased in recent years. Older adults represent a population with a high CVD burden and therefore have the potential to benefit considerably from interventions that utilize mHealth. Traditional facility-based cardiac rehabilitation represents one intervention that is currently underutilized for CVD patients and, because of the unique barriers that older adults face, represents an attractive target for mHealth interventions. Despite potential barriers to mHealth adoption in older populations, there is also evidence that older patients may be willing to adopt these technologies. In this review, we highlight the potential for mHealth uptake for older adults with CVD, with a particular focus on mHealth cardiac rehabilitation (mHealth-CR) and evidence being generated in this field.     

Secular trends in cardiovascular mortality in Iran, with special reference to Isfahan

OBJECTIVE: There has been a general decline in mortality from cardiovascular diseases (CVDs) in most of the developed countries since the beginning of the 1970s. Still, in recent years developing countries have seen an increasing frequency in CVD mortality. However, mortality rate studies in these populations are scarce. Here we report all-cause and CVD mortality rates for men and women aged 25-74 years over a 16-year period in 24 cities in Iran with special reference to the city of Isfahan. METHODS AND RESULTS: The study was based on national death records using the ninth international classification of diseases and age standardization was performed using the total population of Iran in 1985 as a standard. Due to limitations in available data, mortality rates for the specific categories of CVD for the whole country could not be provided. The in-hospital death rates following myocardial infarction in coronary care units (CCUs) and cardiology departments in Isfahan hospitals were also assessed. The completed medical records from hospitals or the relatives of decedents were reviewed by physicians certified in internal medicine, cardiology and neurology to assess the reliability of death certificate data regarding CVD by determining the sensitivity and specificity of the death certificates against the standard of the reviewers. The official circulatory diseases proportional mortality ratio continues to rise since 1981 with a steep increase since 1987, constituting 26.6% and 47.3% of all deaths in 1981 and 1995, respectively. Age-adjusted all-cause and CVD mortality data were decreasing since 1981 and increasing since 1990. During those years age-adjusted CVD, stroke and other CVD mortality rates were decreasing in Isfahan with a slight increase in ischaemic heart disease (IHD) death rates in both sexes. Mortality rates based on sex showed a 38% and 24.8% decline in all-cause and CVD mortality in men between 1981 to 1995, and a 35% and 34.9% decline for female mortality rates for the same period, respectively. The in-hospital death rate following myocardial infarction in Isfahan was increasing between 1993 and 1995 with a slight decrease thereafter. The results of death certification assessment showed a specificity of 0.89 and a sensitivity of 0.43 with the positive and negative predictive values of 0.82 and 0.57, respectively. CONCLUSION: These data indicate that circulatory diseases remain a serious public health threat in Iran. It suggests the ongoing need for more regular, systematic and innovative surveillance data to improve the capability of measuring, explaining and predicting the disease trend on which the national public health policy depends.     

Physical activity and reducing the risk of cardiovascular morbidity and mortality in older men and women: Lessons learned in 2006

This review provides an overview of some of the recent research, in particular studies published in 2006, examining the impact of physical activity on cardiovascular disease (CVD) morbidity and mortality in older adults. In 2006, a number of cross-sectional and intervention studies provided insight into the mechanisms by which physical activity influences CVD risk by influencing a number of traditional and nontraditional CVD risk factors. Additional prospective observational studies in older adults with CVD demonstrated a clear negative dose-response relation between physical activity levels and morbidity and mortality risk in this patient group. Finally, a number of cardiac exercise rehabilitation interventions were tested. Although these intervention studies had mixed findings, some exciting observations were made. Hopefully, the methods employed in the effective exercise rehabilitation studies will be translated into clinical practice in the near future.     

Nutritional interventions in cardiovascular disease: New challenges and opportunities

New opportunities for control of cardiovascular disease (CVD) through nutritional interventions can be divided into three areas: nutritional intervention on newly identified causes of CVD; nutritional strategies to more efficiently or equitably employ current, proven interventions; and nutritional approaches to reduce costs and improve effectiveness so that benefits can be expanded to more of the population. Examples of newly identified causes of CVD amenable to nutritional intervention include fetal/early childhood malnutrition and gene-environment interactions. Examples of more efficient or equitable nutritional strategies include better nutrition education for healthcare providers, patient education resources on the Internet, and widely available functional foods or nutriceuticals. Nutritional approaches to improve cost-effectiveness include better availability of foods associated with reduced CVD risk (eg, fruits, vegetables, fish) and supplementation of the American diet. The advances in nutritional strategies described in this monograph have the potential for population-wide CVD risk reduction.     

Impact of a community based intervention program on awareness,treatment and control of hypertension in a rural Panchayat,Kerala, India

ObjectiveCommunity based intervention to control hypertension is extremely limited in India. We conducted this study to find the effectiveness of a community based intervention program on the awareness, treatment and control of hypertension.MethodsA baseline survey was conducted among 4627 adults aged ≥30 years (men 44%) selected by cluster sampling. Information was collected using a structured interview schedule by trained local volunteers. They measured weight, height, waist circumference and blood pressure using standard protocol. The volunteers monitored blood pressure at least once a month and educated the people in neighborhood groups on the need for regular medication and reducing risk factors of hypertension for a period of six years. A post intervention survey was conducted among 2263 adults aged ≥30 years (men 49%). Stepwise logistic regression analysis was done to find the odds of change in awareness, treatment and control of hypertension.ResultsThe odds of awareness (OR 4.18, 95% CI 3.44–5.08), treatment (OR 3.44 CI 2.81–4.22) and control (OR 4.39 CI 3.36–5.73) of hypertension increased significantly in the post intervention survey compared to the baseline survey. Baseline hypertension prevalence of 34.9% (CI 33.8–36.1) was reduced to 31.0% (CI 29.1–32.9) in the post intervention survey based on age adjusted analysis.ConclusionOur community based intervention using trained community based volunteers could increase awareness, treatment and control of hypertension among adult hypertensives.     

Circulating citric acid cycle metabolites and risk of cardiovascular disease in the PREDIMED study

Background and aimPlasma citric acid cycle (CAC) metabolites might be likely related to cardiovascular disease (CVD). However, studies assessing the longitudinal associations between circulating CAC-related metabolites and CVD risk are lacking. The aim of this study was to evaluate the association of baseline and 1-year levels of plasma CAC-related metabolites with CVD incidence (a composite of myocardial infarction, stroke or cardiovascular death), and their interaction with Mediterranean diet interventions.Methods and resultsCase-cohort study from the PREDIMED trial involving participants aged 55–80 years at high cardiovascular risk, allocated to MedDiets or control diet. A subcohort of 791 participants was selected at baseline, and a total of 231 cases were identified after a median follow-up of 4.8 years. Nine plasma CAC-related metabolites (pyruvate, lactate, citrate, aconitate, isocitrate, 2-hydroxyglutarate, fumarate, malate and succinate) were measured using liquid chromatography-tandem mass spectrometry. Weighted Cox multiple regression was used to calculate hazard ratios (HRs). Baseline fasting plasma levels of 3 metabolites were associated with higher CVD risk, with HRs (for each standard deviation, 1-SD) of 1.46 (95%CI:1.20–1.78) for 2-hydroxyglutarate, 1.33 (95%CI:1.12–1.58) for fumarate and 1.47 (95%CI:1.21–1.78) for malate (p of linear trend <0.001 for all). A higher risk of CVD was also found for a 1-SD increment of a combined score of these 3 metabolites (HR = 1.60; 95%CI: 1.32–1.94, p trend <0.001). This result was replicated using plasma measurements after one-year. No interactions were detected with the nutritional intervention.ConclusionPlasma 2-hydroxyglutarate, fumarate and malate levels were prospectively associated with increased cardiovascular risk.Clinical trial numberISRCTN35739639     

Hormone therapy and mortality during a 14-year follow-up of 14 324 Norwegian women

OBJECTIVES: We evaluated mortality from cardiovascular disease (CVD), coronary heart disease (CHD) and all causes in relation to use of any hormone therapy (HT) and HT with oestradiol and norethisterone or levonorgestrel. DESIGN: Population-based cohort study. SETTING AND SUBJECTS: Women in three Norwegian counties were invited to a health survey in 1985-88 and 82.8% participated. In all 14 324 post- or perimenopausal women aged 35-62 years, including 702 HT users with a mean age of 48.8 years, were followed for 14 years. RESULTS: Women using HT had mortality from all causes and CVD comparable with that of nonusers. The relative risk (RRs) for CVD mortality amongst all women were 0.69 (95% CI: 0.35-1.33) for users of HT, and 0.96 (95% CI: 0.43-2.17) for users of HT with norethisterone or levonorgestrel. Amongst women free of self-reported cardiovascular health problems at baseline all-cause, CVD and CHD mortality tended to be lower amongst users of HT whilst HT use was linked with increased mortality amongst women with cardiovascular health problems. CONCLUSIONS: In this cohort of women around the usual age of menopause all-cause or CVD mortality amongst users of HT, most often oestradiol combined with norethisterone or levonorgestrel, was not markedly different from that of nonusers. Early CHD events amongst HT users prior to the baseline survey, together with selective inclusion of healthy subjects, may in part explain protective effects of HT on CHD reported from previous observational studies.     

Multifactorial Intervention to Reduce Cardiovascular Events in Type 2 Diabetes

Type 2 diabetes is associated with a significantly increased risk of cardiovascular disease (CVD) morbidity and mortality. Although several clinical trials have evaluated the effects of interventions to reduce CVD risk in people with diabetes, such studies are primarily conducted to target individual risk factors such as hypertension, hyperglycemia, and dyslipidemia rather than using a multifactorial interventional approach. Existing clinical trial data suggest that intensive multifactorial interventions that target several important risk factors simultaneously result in a significantly greater risk reduction in CVD risk compared with single risk factor interventions. However, few studies have evaluated the efficacy and effectiveness of such interventions on CVD hard end points. A multidisciplinary team management of diabetes should focus on weight control, diet, physical activity, diabetes education, and adherence to pharmacotherapy. An individually tailored aggressive management program to reduce multiple CVD risk factors simultaneously has great potential to prevent CVD morbidity and mortality among patients with type 2 diabetes.     

Sex-specific cardiovascular morbidity and mortality in a cohort treated for hypertension

OBJECTIVE: Incidence of cardiovascular disease (CVD) is higher in men than in women. The aim of this study was to investigate whether the gender differential can be modified by pharmacological intervention in a population-based setting. DESIGN AND METHOD: In a prospective population-based cohort--the Malm? Diet and Cancer study--a total of 3608 hypertensives (1559 men, 2049 women), 45-73 years old, with a mean of 10 years' treatment at baseline examination, participated in the study. Information on blood pressure-lowering medication was collected in a questionnaire. Incidences of first-ever cardiac event, stroke or CVD death were followed. The mean period of follow-up was 7.4 years. RESULTS: During follow-up, 341 first-ever CVD events and 128 CVD deaths occurred. The risk of CVD morbidity or mortality was significantly higher in hypertensive men than in hypertensive women: cardiac event [relative risk (RR) = 3.11; 95% confidence interval (CI): 2.13-4.54], stroke (RR = 1.50; 95% CI: 1.01-2.22) and CVD death (RR = 2.96; 95% CI: 1.86-4.20). However, the gender gap in CVD risks was reduced with advancing age. Two background factors--single household and concomitant diabetes--are apt to have an independent sex-specific impact on CVD risk. CONCLUSIONS: Gender remains a strong independent predictor for CVD morbidity and mortality, irrespective of antihypertensive intervention or other risk factors. Increased clinical attention should be given to hypertensive men living alone and hypertensive women with diabetes.     

Physical activity interventions in Hispanic American girls and women

The purpose of this article was to review physical activity interventions done with Hispanic American girls and women that were published between 1994 and 2007, and suggest ways of enhancing these interventions. A total of 12 such interventions were found. Majority of the interventions focused on both physical activity and nutrition behaviours. Only half of the interventions were based on a behavioural theory. Social cognitive theory was the most popular theory, which was operationalized by four interventions. The interventions ranged from 3 weeks to 2 years in duration. The impact was not necessarily linked to the length of the intervention. The most popular physical activity that was promoted was walking, which was utilized by four interventions. Most of the interventions utilized a classroom format for imparting instruction in being physically active. All the interventions utilized individual‐level behaviour change as an approach, and none tried to address broader policy and environmental‐level changes. Process evaluation was done by very few interventions and must be done more systematically. In terms of the impact, half of the interventions were successful in influencing the outcomes. Recommendations for enhancing the effectiveness of physical activity interventions in Hispanic American girls and women are presented.     

11省市队列人群心血管病发病前瞻性研究Ⅱ.个体危险因素聚集与心血管病发病的关系

目的     

Appropriate Use of Intravascular Ultrasound During Arterial and Venous Lower Extremity Interventions

BackgroundThere has been growing use of intravascular ultrasound (IVUS) during lower extremity arterial and venous revascularization. Observational data suggest that the use of IVUS can improve periprocedural and long-term outcomes, but largescale prospective data remain limited. Consensus opinion regarding the appropriate use of IVUS during peripheral intervention is needed.ObjectivesThe purpose of this consensus document is to provide guidance on the appropriate use of IVUS in various phases of peripheral arterial and venous interventions.MethodsA 12-member writing committee was convened to derive consensus regarding the appropriate clinical scenarios for use of peripheral IVUS. The group iteratively created a 72-question survey representing 12 lower extremity arterial interventional scenarios. Separately, a 40-question survey representing 8 iliofemoral venous interventional scenarios was constructed. Clinical scenarios were categorized by interventional phases: preintervention, intraprocedure, and postintervention optimization. Thirty international vascular experts (15 for each survey) anonymously completed the survey instrument. Results were categorized by appropriateness using the median value and disseminated to the voting panel to reevaluate for any disagreement.ResultsConsensus opinion concluded that IVUS use may be appropriate during the preintervention phase for evaluating the etiology of vessel occlusion and plaque morphology in the iliac and femoropopliteal arteries. IVUS was otherwise rated as appropriate during iliac and femoropopliteal revascularization in most other preintervention scenarios, as well as intraprocedural and postprocedural optimization phases. IVUS was rated appropriate in all interventional phases for the tibial arteries. For iliofemoral venous interventions, IVUS was rated as appropriate in all interventional phases.ConclusionsExpert consensus can help define clinical procedural scenarios in which peripheral IVUS may have value during lower extremity arterial and venous intervention while additional prospective data are collected.