Family history of hypertension, personality patterns, and cardiovascular reactivity to stress

The study was conducted to assess whether certain personality characteristics in combination with a positive family history for essential hypertension (EH) are associated with excessive cardiovascular reactivity. Subgroups who differed in the patterns of their personality characteristics were identified within normotensives with a positive family history (FH+) of EH and within normotensives with a negative family history (FH-) of EH via cluster analytic techniques. A subgroup of FH+ subjects who were characterized by denial and unwilling to admit to neurotic feelings or aggressiveness exhibited exaggerated blood pressure reactivity to two experimental tasks. Moreover, relative to their level of heightened physiologic arousal, subjects in this subgroup reported little negative affect in response to the tasks, which further suggests that they deny or suppress their feelings. The similarity of the personality pattern of these cardiovascularly reactive FH+ individuals to that sometimes found among individuals with EH is discussed.     

Model-based patterns of cardiovascular risk factors in Mozambique

Background: Risk factors for cardiovascular diseases tend to cluster, although evidence from settings under epidemiological transition is scarce.

Aim: To identify patterns of clustering of cardiovascular risk factors and to quantify their association with sociodemographic characteristics, in Mozambique.

Subjects and methods: A national representative sample (n?=?3323) of subjects aged 25–64 years was evaluated in 2005, using the World Health Organization Stepwise Approach to Chronic Disease Risk Factor Surveillance (STEPS). Patterns of joint exposure to high blood pressure, high fasting blood glucose, high body mass index, smoking, excessive alcohol consumption, low fruit/vegetables intake and insufficient physical activity were identified through latent class analysis.

Results: Three patterns were identified among women: (1) “healthier”, lower frequency of most risk factors (53.0%); (2) “hypertension-overweight” (21.1%), more frequent among older and urban subjects; and (3) “hypertension-smoking-alcohol” (25.9%), whose frequency increased with age and decreased with education. In men, two clusters were identified: (1) “hypertension-overweight” (30.1%); and (2) “smoking” (69.9%). The frequency of the latter pattern was higher in urban areas and increased with age and education.

Conclusion: Hypertension, overweight/obesity, smoking and excessive alcohol intake defined the main clusters of cardiovascular risk factors. This should be considered when planning prevention and control strategies for cardiovascular diseases in Mozambique.     

Managing cardiovascular risk in patients with HIV infection

Highly active antiretroviral therapy (HAART) improves the survival of patients with HIV infection; however, several observational studies have described associations between HIV infection, HAART, and cardiovascular disease. Important limitations of these studies included a low incidence of cardiovascular events, short duration of HAART exposure, and retrospective design. Nevertheless, the weight of evidence from observational and surrogate end point studies suggests that the dyslipidemia and other metabolic changes that are common in patients with HIV infection and those using HAART may be associated with increased cardiovascular risk. The Infectious Disease Society of America/Adults AIDS Clinical Trials Group guidelines for the evaluation and management of dyslipidemia recommend target lipid levels and treatment of dyslipidemia in patients with HIV infection. Although practitioners should consider dyslipidemia and cardiovascular risk when making plans for initiating or altering HAART therapy, maintaining viremic control should be the overriding factor, because short-term absolute rates of cardiovascular disease are significantly lower than death rates from AIDS in inadequately suppressed patients. This article reviews the cardiovascular risks in patients receiving HAART and discusses the implementation of the new guidelines.     

The community-acquired pneumonia: appropriateness of the admissions, risk factors and therapy

In a clinical and epidemiological study used Fine's Pneumonia Severity Index to determine the appropriateness of the hospitalisation of patients with community acquired pneumonia in the Internal Medicine Department of a hospital in Northern Italy. Risk factors and antibiotic treatment were checked against recent international guidelines. The study shows that 20% of the admissions were to be not appropriate. The principal risk factors were old age and such the co-morbidities heart failure, chronic cerebral diseases and COPD. In the home setting macrolides are less used than the new fluoroquinolones respirators. In the hospitals arrangements, b-lactams are still highly used, perhaps because of the high percentage of elderly patients. The data currently available suggest that some new fluoroquinolones such as levofloxacin are quite effective, presenting a broad spectrum of action, high bioavailability and good tolerability. Sequential therapy with this antibiotic leads to shorter hospitalisation times.     

HIV and antiretroviral therapy: lipid abnormalities and associated cardiovascular risk in HIV-infected patients

It has been demonstrated that patients on highly active antiretroviral therapy are at increased risk for developing metabolic abnormalities that include elevated levels of serum triglycerides and low-density lipoprotein cholesterol and reduced levels of high-density lipoprotein cholesterol. This dyslipidemia is similar to that seen in the metabolic syndrome, raising the concern that highly active antiretroviral therapy also potentially increases the risk for cardiovascular complications. This paper reviews the contribution of both HIV infection and the different components of highly active antiretroviral therapy to dyslipidemia and the role of these abnormalities toward increasing the risk of cardiovascular disease in HIV-infected patients; therapeutic strategies to manage these risks are also considered.     

Adherence to nicotine replacement patch therapy in cardiovascular patients

Nicotine Replacement Therapy (NRT) is the most frequently used pharmacological intervention for smoking cessation. Research on the effect of NRT showed serious nonadherence among users. We investigated adherence to NRT in cardiovascular patients. A number of 174 outpatients (N = 174), who smoked > 5 cigarettes a day, received free patches and intensive instructions from nurses. Questionnaires were sent to patients assessing patient characteristics, adherence to a 7–8 weeks time frame and appliance instructions, side effects/withdrawal symptoms, and reasons for non-adherence. Only 38% of the patients was adherent to the time frame. Appliance instructions were followed in 76–96% of the cases, except for smoking; 50% continued to smoke during NRT. In conclusion, despite considerable attention to appliance instructions, access to free patches and additional behavioral support, adherence to NRT in these patients is rather low.     

Hyperphosphatemia and cardiovascular risk in patients on dialysis

Cardiovascular diseases are the leading causes of mortality among patients with end-stage renal disease (ESRD), with arterial disease and left ventricular hypertrophy being the two principal factors of the high mortality rate in this population. In addition to traditional risk factors (age, gender, diabetes, hypertension, lifestyle, hyperlipidemia, smoking, hyperhomocystinemia), inflammation, oxidative stress and disorders of mineral metabolism may contribute to cardiovascular risk in patients with uremic syndrome. High serum phosphate may influence vascular calcifications directly and indirectly, by worsening secondary hyperparathyroidism. Several treatment options are available for the treatment of hyperphosphatemia and secondary hyperparathyroidism in patients with ESRD. The treatment approach includes a diet low in phosphorus, with less than 1 g/kg/day of protein. Vitamin D supplementation is an important part of treatment. Phosphate binding agents are in most of the patients necessary in addition to diet. Aluminum hydroxide has been widely used for many years. It is very potent, but also very toxic, with severe encephalopathy as the most dangerous side effect. Calcium salts are less potent, and were considered safe for use in patients on dialysis. However, improvement in the understanding of vascular calcifications has demonstrated that calcium overload significantly contributes to widespread atherosclerosis in patients with ESRD. Sevelamer-hydrochloride is a novel non-aluminum, non-calcium containing phosphate binder, which is capable of reducing the levels of phosphorus as well as of low-density lipoprotein cholesterol, and increasing high-density lipoprotein cholesterol.     

Predictors and barriers to timely medical follow-up after cardiovascular disease risk factor screening according to race/ethnicity

BACKGROUND: The purpose of this study was to assess followup practices among individuals found to have elevated cardiovascular disease (CVD) risk factors in a screening and educational outreach. METHODS: Participants in the National Heart, Lung and Blood Institute Family Intervention Trial for Heart Health (FIT Heart) who were found to have hypertension, prehypertension, suboptimal lipids and/or abnormal blood glucose were included in this study (N = 214, mean age 49 +/- 13, 64% female, 33% nonwhite). Contact was made at two weeks, six weeks and three months to determine if medical follow-up was initiated. Barriers to nonadherence were assessed. RESULTS: After two weeks, significantly more whites had medical follow up compared to nonwhites (34% vs. 20%, p = 0.04). Racial/ethnic minorities were more likely to report that not having a doctor was a barrier (30% vs. 11%, p = 0.02). Non-whites were more likely to return to the study staff for followup rather than an outside physician (32% vs. 15%, p = 0.001). CONCLUSION: Racial/ethnic minorities with elevated CVD risk factors may have delayed medical follow-up compared to whites, and this may be attributable to lack of access to a doctor. These data suggest that improving access to care may reduce racial/ethnic disparities in risk factor management and CVD outcomes.     

Effects of severity of degeneration on gait patterns in patients with medial knee osteoarthritis

This study tested the hypothesis that patients with mild and severe medial knee osteoarthritis (OA) adopt different compensatory gait patterns to unload the deseased knee, in not only the frontal plane but also the sagittal plane. Fifteen patients with mild and 15 with severe bilateral medial knee OA, and 15 normal controls walked while the kinematic and kinetic data were measured. Compared to the normal group, both OA groups had significantly greater pelvic anterior tilt, swing-pelvis list, smaller standing knee abduction, as well as smaller standing hip flexor and knee extensor moments during stance. The severe group also had greater hip abduction, knee extension and ankle plantarflexion. The mild group successfully reduced the extensor moment and maintained normal abductor moment at the diseased knee mainly through listing and anterior tilting the pelvis. With extra compensatory changes at other joints and increased hip abductor moment, the severe group successfully reduced the knee extensor moment but failed to reduce the abductor moment. These results suggest that, apart from training of the knee muscles, training of the hip muscles and pelvic control are essential in the rehabilitative intervention of patients with knee OA, especially for more severe patients.     

Therapeutic drug and cardiovascular disease risk monitoring in patients with bipolar disorder

OBJECTIVES: We assessed whether patients with bipolar disorder received serum drug level and toxicity monitoring for mood stabilizers and assessment of cardiovascular disease (CVD)-related risk factors attributed to atypical antipsychotic medications. METHODS: A population-based study of individuals with bipolar disorder was conducted between July 2004 and July 2006. Based on American Psychiatric and American Diabetes Association guidelines, we assessed whether patients received recommended drug level and toxicity monitoring tests on or within 6 months for mood stabilizers, and lipid and glucose tests for atypical antipsychotics. Multivariable regression was used to determine the patient factors associated with receipt of lab tests. RESULTS: Of the 435 patients (mean age=49 years, 14.3% female, 22.8% nonwhite), 60.3% were currently prescribed mood stabilizers and 65.5% were prescribed atypical antipsychotics. Overall, 39.7% received a serum drug level for mood stabilizers, 38.8% received a thyroid function test for lithium, and the majority (71.4%-75.9%) received complete blood counts and hepatic function tests for valproate or carbamazepine. About half of patients prescribed atypical antipsychotics received cholesterol counts (49.6%), and 68.7% received serum glucose levels. After adjusting for patient factors, women prescribed atypical antipsychotics were less likely than men to receive cholesterol counts (OR=0.43; p<0.05). LIMITATIONS: Single-site retrospective study and a relatively short observation period. CONCLUSIONS: About half of patients received recommended lab tests for mood stabilizers and atypical antipsychotics. Additional research regarding whether the receipt of these lab tests is associated with improved outcomes will inform efforts to improve quality of care related to drug toxicities and CVD risk factors in patients with bipolar disorder.     

Perceptions of cardiovascular risk among patients with hypertension or diabetes

We aimed to examine risk perceptions among patients at moderate to high cardiovascular risk. A questionnaire about perceived absolute risk of myocardial infarction and stroke was sent to 2424 patients with hypertension or diabetes. Response rate was 86.3% and 1557 patients without atherosclerotic disease were included. Actual cardiovascular risk was calculated by using Framingham risk functions. A total of 363 (23.3%) of the 1557 patients did not provide any risk estimates and these were particularly older patients, patients with a lower educational level, and patients reporting no alcohol consumption. The remaining 1194 patients tended to overestimate their risk. In 42.3% (497/1174) and 46.8% (541/1155) of the cases, patients overestimated their actual 10-year risk for myocardial infarction and stroke, respectively, by more than 20%. Older age, smoking, familial history of cardiovascular disease (CVD), and actual absolute risk predicted higher levels of perceived absolute risk. Male sex, higher scores for an internal health locus of control, lower scores for a physician locus of control, and self-rated excellent or (very) good health were positively related to higher accuracy. In conclusion, patients showed inadequate perceptions of their absolute risk of cardiovascular events and physicians should thus provide greater information about absolute risk when offering preventive therapy.     

Inter-laboratory comparison of knee biomechanics and muscle activation patterns during gait in patients with knee osteoarthritis

BackgroundGait analysis has been used for decades to quantify knee function in patients with knee osteoarthritis; however, it is unknown whether and to what extent inter-laboratory differences affect the comparison of gait data between studies. Therefore, the aim of this study was to perform an inter-laboratory comparison of knee biomechanics and muscle activation patterns during gait of patients with knee osteoarthritis.MethodsKnee biomechanics and muscle activation patterns from patients with knee osteoarthritis were analyzed, previously collected at Dalhousie University (DAL: n = 55) and Amsterdam UMC, VU medical center (VUmc: n = 39), using their in-house protocols. Additionally, one healthy male was measured at both locations. Both direct comparisons and after harmonization of components of the protocols were made. Inter-laboratory comparisons were quantified using statistical parametric mapping analysis and discrete gait parameters.ResultsThe inter-laboratory comparison showed offsets in the sagittal plane angles, moments and frontal plane angles, and phase shifts in the muscle activation patterns. Filter characteristics, initial contact identification and thigh anatomical frame definitions were harmonized between the laboratories. After this first step in protocol harmonization, the offsets in knee angles and sagittal plane moments remained, but the inter-laboratory comparison of the muscle activation patterns improved.ConclusionsInter-laboratory differences obstruct valid comparisons of gait datasets from patients with knee osteoarthritis between gait laboratories. A first step in harmonization of gait analysis protocols improved the inter-laboratory comparison. Further protocol harmonization is recommended to enable valid comparisons between labs, data-sharing and multicenter trials to investigate knee function in patients with knee osteoarthritis.     

The pulmonary CO diffusing capacity according to Bates and according to Filley in patients with unequal ventilation

The pulmonary CO diffusing capacity (d l, co) was determined according to Filley et al., by these authors' method and according to Bates et al. in 24 patients with unequal ventilation without severe diffusion disturbances. Under the influence of the unequal ventilation, the Filley method yielded too high D values, while the values according to Bates were too low. The D values obtained by the authors' method were in between the above two extremes.In patients with unequal ventilation, the d value calculated by one of these methods affords little information as to the presence or absence of a diffusion disturbance, and no information on the extent of this diffusion disturbance. Only if D(F) is much too low is there a possibility of a disturbance in diffusion. A normal D(B) or D(K) indicates the probability of absence of a diffusion disturbance.     

Management of metabolic complications and cardiovascular risk in HIV-infected patients

As result of the great benefit of HAART, AIDS-related deaths have dramatically declined during the last decade in HIV-infected individuals. However, mortality due to non-AIDS conditions and particularly cardiovascular events seems to be on the rise in this population. Metabolic complications and other conditions responsible for increased cardiovascular risk are common in HIV persons. Moreover, antiretroviral medications and HIV itself might play a role in further increasing cardiovascular risk. As the HIV population is aging, a growing impact of cardiovascular events on survival can be expected. Therefore, early diagnosis and treatment of predisposing cardiovascular risk factors is warranted in this population. In this way, all HIV-infected individuals should be evaluated regularly for lipid abnormalities, hyperglycemia, arterial hypertension, overweight, renal disease, and smoking. The individual′s absolute risk for coronary heart disease must be defined, and comprehensive therapeutic measures should be undertaken in order to minimize future complications in subjects with significant cardiovascular risk. Lifestyle habits must be encouraged, including healthy diet and exercise. Switches in antiretroviral regimens using metabolic-friendly agents should also be considered for managing mild metabolic abnormalities in lipids and glucose, as long as suppression of viral replication is not compromised. The management of overt lipid disorders, diabetes, and hypertension basically must follow the guidelines applied to the general population and specific drugs administered, taking into account the potential for drug interactions with antiretroviral agents. In summary, efforts for reducing the increased cardiovascular risk characteristically seen in HIV-infected individuals are warranted, and preventable factors, including adequate management of metabolic abnormalities and hypertension, along with promotion of lifestyle habits and smoke cessation, should no longer be neglected.