小剂量阿司匹林对心血管病一级预防效果及安全性的系统评价

目的 系统评价小剂量阿司匹林在高危人群中一级预防心血管病的有效性和安全性.方法 计算机检索MEDLINE、EMbase、Cochrane图书馆(2008年第3期)、中国生物医学文献数据库、中国学术期刊全文数据库,同时筛检了纳入文献的参考文献.收集小剂量阿司匹林(75～150 mg)一级预防心血管病的随机对照试验(RCT),2名评价员独立评价文献质量和提取资料,并采用RevMan4.2软件对资料进行荟萃分析.结果 共纳入6个研究(TPT,HOT,PPP,WHS,POPADAD,JPAD),72 466例患者.(1)小剂量阿司匹林总的心血管事件的发生率(RR=0.85,95% CI:0.80～0.92)、卒中发生率(RR=0.87,95% CI:0.77～0.98)、非致死性卒中发生率(RR=0.81,95%CI:0.70～0.95)、短暂脑缺血发作发生率(RR=0.76,95%CI:0.64～0.90)均低于安慰剂(均P＜0.05).(2)小剂量阿司匹林非致死性心肌梗死(RR=0.89,95%CI:0.77～1.02)、心血管性死亡(RR=0.98,95% CI:0.86～1.13)、全因死亡发生率(RR=0.95,95%CI:0.88～1.02)与安慰剂比较,差异无统计学意义(P＞0.05).(3)在老年人群中分析显示,小剂量阿司匹林冠心病的发生率低于安慰剂(RR=0.81,95%CI:0.70～0.94,P＜0.01).(4)在安全性方面,与安慰剂比较,小剂量阿司匹林有出血并发症的风险(RR=1.15,95%CI:1.12～1.18,P＜0.01),而在过敏反应方面差异无统计学意义(P＞0.05).结论 小剂最阿司匹林能降低总的心血管事件、短暂脑缺血发作、卒中、非致死性卒中的发生率;对降低非致死性心肌梗死、心血管性死亡、全因死亡方面效果不明显;在老年人群中小剂量阿司匹林能降低冠心病的发牛率;长期应用无明显过敏反应,但存在出血并发症的风险.     

Behavioral strategies in diabetes prevention programs: A systematic review of randomized controlled trials

The worldwide epidemic of type 2 diabetes (T2D) emphasizes the need for guidelines regarding community implementation of lifestyle modification prevention programs. An understanding of effective behavioral strategies is needed if evidence translation is to be realized. The aim of this paper is to systematically review the behavioral change strategies for lifestyle T2D prevention programs.

Methods

Randomized controlled trials (RCTs) of lifestyle interventions for the prevention of T2D were reviewed with a systematic literature search. Data relating to the behavioral strategies and trial outcomes were extracted.

Results

Overall, lifestyle interventions were successful in reducing the incidence of T2D. The behavioral strategies utilized in these interventions were drawn from a variety of theoretical backgrounds. All RCTs utilized intensive modes of delivery and were associated with low dropout rates of 5.5-13.4%.

Conclusions

The available evidence shows that a robust behavioral change strategy is an essential part of an effective lifestyle modification program, as the absence of intensive individualized advice or “information only” more closely resembles the control group interventions used in these RCTs.     

The dietary and lifestyle indices of insulin resistance are associated with increased risk of cardiovascular diseases: A prospective study among an Iranian adult population

Background and aimsPrevious studies have introduced insulin resistance (IR) as a major risk factor for poor cardiovascular diseases (CVDs) outcomes. Diet, body weight, and physical activity are three key pillars of lifestyle that can significantly impact the IR status. We aimed to assess the possible link between the empirical dietary index for IR (EDIR) and the empirical lifestyle index for IR (ELIR) with the risk of chronic heart disease (CHD) and CVDs.Methods and resultsThis study was conducted on 4980 participants aged ≥30 years (follow-up rate: 99.85%). Dietary intake data was collected using a validated food frequency questionnaire. Cox proportional hazard regression was used to estimate the hazard ratio and 95% confidence intervals (HRs and 95% CIs) of CVDs and CHD across tertiles of EDIR and ELIR scores. In the final model, after adjusting for all potential confounding variables, participants in the highest tertile of EDIR had a higher risk of CVD (HR:1.36, 95%CI:1.03–1.80, P-trend = 0.016) and CHD (HR:1.36, 95% CI:1.01–1.83, P-trend = 0.023) compared to the lowest tertile. Also, participants with a higher score of ELIR had a higher risk of CVD (HR: 1.64, 95%CI:1.24–2.16, P-trend=<0.001) and CHD (HR: 1.72, 95%CI:1.28–2.32, P-trend=<0.001).ConclusionA greater adherence to the lifestyle and diet with a higher EDIR and ELIR may be associated with an increased risk of CVD and CHD outcomes in the adult population.     

Physical activity in primary and secondary prevention of cardiovascular disease: Overview updated

Although the observed progress in the cardiovascular disease treatment, the incidence of new and recurrent coronary artery disease remains elevated and constitutes the leading cause of death in the developed countries. Three-quarters of deaths due to cardiovascular diseases could be prevented with adequate changes in lifestyle, including increased daily physical activity. New evidence confirms that there is an inverse dose-response relationship between physical activity and cardiovascular disease and mortality risk. However, participation in moderate to vigorous physical activity may not fully attenuate the independent effect of sedentary activities on increased risk for cardiovascular diseases. Physical activity also plays an important role in secondary prevention of cardiovascular diseases by reducing the impact of the disease, slowing its progress and preventing recurrence. Nonetheless, most of eligible cardiovascular patients still do not benefit from secondary prevention/cardiac rehabilitation programs. The present review draws attention to the importance of physical activity in the primary and secondary prevention of cardiovascular diseases. It also addresses the mechanisms by which physical activity and regular exercise can improve cardiovascular health and reduce the burden of the disease.     

Lipid-lowering therapy with statins for the primary and secondary prevention of cardiovascular disease

Cardiovascular disease (CVD) still ranks as the top cause of mortality worldwide. Lipid-modifying therapy has revolutionized the treatment of the disease and is partly responsible for the recent decline in deaths due to CVD. Treatment strategies have evolved since the introduction of the earlier lipid-lowering agents (fibrates, niacin, bile acid resins) to the advent of statins, which have become the standard drugs in cholesterol therapy. The strategy of using high-intensity statin therapy as the initial treatment approach in high-risk individuals, rather than focusing on specific cholesterol levels alone, remains a subject of debate.     

Prevention of cardiovascular diseases: Role of exercise, dietary interventions, obesity and smoking cessation

Hypertension, myocardial infarction, atherosclerosis, arrhythmias and valvular heart disease, coagulopathies and stroke, collectively known as cardiovascular diseases (CVDs), contribute greatly to the mortality, morbidity and economic burden of illness in Canada and in other countries. It has been estimated that over four million Canadians have high blood pressure, a comorbid condition that doubles or triples the risk of CVD. According to the Heart and Stroke Foundation of Canada, CVDs caused 36% of deaths in 2001 and were responsible for 18% of the total hospital costs in Canada. The majority of Canadians exhibit at least one CVD-related risk factor, such as tobacco smoking, physical inactivity, diabetes, obesity, hypertension, a lack of daily fruit and vegetable consumption, and psychosocial factors, making these people more prone to developing a serious CVD-related illness in the future. It is therefore important that CVD-related causes and concerns be addressed. Given the scope and prevalence of CVDs, it is obvious that a population health approach – ‘prevention is better than cure’ – would be the most appropriate model to adopt to deal with this ubiquitous health problem and to reduce the costs of hospitalization, long-term medication and rehabilitation. The focus of the present review is to evaluate and compare the results of epidemiological, experimental and clinical studies, reporting on the influence of physical activity, dietary intervention, obesity and cigarette smoking on cardiovascular health and the prevention of CVDs. The prophylactic measures must be dealt with collectively because there is overwhelming evidence that the occurrence of CVDs can be reduced by approximately 80% by making lifestyle modifications. The preventive strategies against CVDs must be targeted at a primary health promotion level before some of the important underlying causes of CVD seriously afflict a person or a population at large. Such preventive approaches would help in reducing not only employee absenteeism but also the hospital and drug costs burdening the health care systems of both developed and developing countries.     

Aspirin in the primary prevention of cardiovascular disease on diabetic patients: Systematic review and meta-analysis

AimsThe publication of new trials brought additional data to the controversial topic of aspirin use in diabetic patients for primary prevention. Therefore, we aimed to systematically review all randomized controlled trials evaluating the clinical impact of aspirin in this setting.MethodsWe searched for randomized controlled trials (RCTs) evaluating the impact of aspirin in patients with diabetes in primary prevention, in MEDLINE, EMBASE, CENTRAL (November/2018). The primary outcomes were all-cause mortality and the composite outcome of major adverse cardiovascular events (MACE). A meta-analysis was performed deriving risk ratios (RR) and 95% confidence intervals (CI).ResultsAll-cause mortality was not significantly reduced with RR 0.96 (95% CI 0.90–1.03; 7RCT; 27,595 patients). Regarding MACE, there was an 8% risk reduction (RR 0.92, 95% CI 0.84-0.999; I² = 0%; 8RCT; 29,814 patients). The risks of major bleeding (RR 1.30, 95% CI 1.10–1.53; 2RCTs, 18,019 patients), and major GI bleeding (RR 1.39, 95% CI 1.08–1.80; 2RCTs, 18,019 patients) were significantly increased.The risks of cardiovascular mortality, myocardial infarction, stroke and amputation were not significantly different from control arm.ConclusionsAspirin use among diabetic patients in primary prevention appears was associated with increased risk of major bleeding, a modest decrease of MACE and lack of mortality benefit.     

Walking for prevention of cardiovascular disease in men and women: a systematic review of observational studies

In this systematic review, walking (a generally accessible activity for a largely sedentary population) was assessed as a preventive risk factor for development of fatal and non-fatal cardiovascular disease (CVD). PubMed, CINHAL and reference list searches identified 21 peer-reviewed publications examining walking in relation to CVD; studies assessing active transportation were excluded. Generally, there were dose-dependent reductions in CVD risk with higher walking duration, distance, energy expenditure and pace. Associations appeared to be stronger for ischaemic stroke than other CVD outcomes such as coronary heart disease or haemorrhagic stroke. Adjustment for clinical CVD risk factors, obesity or other types of physical activity generally attenuated but did not eliminate associations. Because functional status may be an important determinant of walking behaviour in adults, potential bias due to pre-existing illness is of concern in all studies reviewed, particularly in case–control studies which ascertain walking retrospectively and yielded the strongest associations. Study findings were consistent with current physical activity recommendations, but there is a need for improvements in measurement of walking and other CVD risk factors, more thorough control for pre-existing illness, examination of mediating or moderating conditions such as obesity and other analytical issues.     

Statins for primary cardiovascular prevention in the elderly

The elderly population is increasing worldwide, with subjects > 65 years of age constituting the fastest-growing age group. Furthermore, the elderly face the greatest risk and burden of cardiovascular disease mortality and morbidity. Although elderly patients, particularly those older > 75, have not been well represented in randomized clinical trials evaluating lipid-lowering therapy, the available evidence supporting the use of statin therapy in primary prevention in older individuals is derived mainly from subgroup analyses and post-hoc data. On the other hand, elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of statin therapy. The aim of this review was to present the relevant literature regarding statin use in the elderly for their primary cardiovascular disease, with the associated risks and benefits of treatment.     

Epidemiologic studies targeting primary cardiovascular disease prevention in South Asia

South Asia has experienced a 73% increase in healthy life years lost due to ischemic heart disease between 1990 and 2010. There is a lack of quality data relating to cardiovascular risk factors and disease from this region.Several observational and prospective cohorts in South Asia have been established in recent times to evaluate the burden of cardiovascular disease and their risk factors. The Prospective Rural Urban Epidemiology (PURE) study is the largest of these studies that has provided data on social, environmental, behavioral and biologic risk factors that influence heart disease and diabetes. Some studies have also borrowed data from large datasets to provide meaningful insights. These studies have allowed a better understanding of cardiovascular disease risk factors indigenous to the South Asian population along with conventional risk factors. Culturally sensitive interventions geared towards treating risk factors identified in these studies are needed to fully realize the true potential of these epidemiologic studies.     

Effectiveness of exercise in hepatic fat mobilization in nonalcoholic fatty liver disease: Systematic review

AIM: To investigate the efficacy of exercise interventions on hepatic fat mobilization in non-alcoholic fatty liver disease(NAFLD) patients.METHODS: Ovid-Medline, Pub Med, EMBASE and Cochrane database were searched for randomized trials and prospective cohort studies in adults aged ≥ 18 which investigated the effects of at least 8 wk of exercise only or combination with diet on NAFLD from 2010 to 2016. The search terms used to identify articles, in which exercise was clearly described by type, duration, intensity and frequency were: "NASH", "NAFLD", "nonalcoholic steatohepatitis", "non-alcoholic fatty liver disease", "fat", "steatosis", "diet", "exercise", "MR spectroscopy" and "liver biopsy". NAFLD diagnosis, as well as the outcome measures, was confirmed by either hydrogen-magnetic resonance spectroscopy(H-MRS) or biopsy. Trials that included dietary interventions along with exercise were accepted if they met all criteria. RESULTS: Eight studies met selection criteria(6 with exercise only, 2 with diet and exercise with a total of 433 adult participants). Training interventions ranged between 8 and 48 wk in duration with a prescribed exercise frequency of 3 to 7 d per week, at intensities between 45% and 75% of VO2 peak. The most commonly used imaging modality was H-MRS and one study utilized biopsy. The effect of intervention on fat mobilization was 30.2% in the exercise only group and 49.8% in diet and exercise group. There was no difference between aerobic and resistance exercise intervention, although only one study compared thetwo interventions. The beneficial effects of exercise on intrahepatic triglyceride(IHTG) were seen even in the absence of significant weight loss. Although combining an exercise program with dietary interventions augmented the reduction in IHTG, as well as improved measures of glucose control and/or insulin sensitivity, exercise only significantly decreased hepatic lipid contents.CONCLUSION: Prescribed exercise in subjects with NAFLD reduces IHTG independent of dietary intervention. Diet and exercise was more effective than exercise alone in reducing IHTG.     

Comparison of primary versus secondary prevention of cardiovascular disease in patients with type2 diabetes: Focus on achievement of ABC goals

BackgroundPrimary and secondary prevention of cardiovascular disease is of utmost importance in the management of patients with diabetes.ObjectivesWe studied a group of Iranian patients with type2 diabetes to provide an overview of the current status of secondary prevention of cardiovascular disease in the Middle East.MethodsThis is a cross-sectional study of 2029 Patients with type2 diabetes including 323 patients with coronary artery disease (CAD) were recruited. Achievement of goals in HbA1c (A), blood pressure (B) and LDL-cholesterol(C) was assessed.ResultsThe study showed 25.3% of CAD positive patients achieved HbA1c <7% compared to 30% in CAD negative patients. The achievement of blood pressure ≤140/90 mmHg was 53.2% and 52.8% in CAD positive and CAD negative patients respectively. There was no difference in the achievement of all three ABC goals between the two groups (p = 0.733). After logistic regression analysis, history of hypertension had the highest odds ratio for CAD.ConclusionAlthough ABC control has an important impact on the prevention of cardiovascular outcomes, the ideal goal needs further efforts to be achieved.     

中国四省市阿司匹林预防心血管疾病用药现状调查

目的 调查阿司匹林在我国部分地区心血管疾病一级预防和二级预防中的应用现状.方法 入选来自2007年6月至2008年5月糖尿病和代谢综合征患病率变迁调查研究中湖南、广东、四川、辽宁四省的9000例受试者,进行问卷调查,内容包括是否服用阿司匹林、服用频率及剂量.总体人群心血管一级预防治疗标准依据美国心脏病协会心血管及脑卒中一级预防指南（2002）10年心血管风险＞10%的推荐,计算阿司匹林实际使用率;糖尿病和高血压亚组则分别将美国糖尿病协会（2010）指南和欧洲心脏病学会/欧洲高血压协会高血压指南（2007）的相关推荐作为治疗标准.结果 共收回7186份有效问卷,其中233例有明确的心血管疾病.总人群中符合一级预防人群实际阿司匹林使用率为14.09%,二级预防人群使用率为26.61%;糖尿病亚组无心血管疾病患者实际阿司匹林使用率为32.47%,糖尿病心血管疾病二级预防阿司匹林使用率为51.16%.高血压亚组心血管疾病一级预防阿司匹林使用率为19.93%,二级预防人群使用率为29.52%.所有服用阿司匹林的人群中,87.67%为每日1次,10.35%为不规律服用,1.98%为隔日1次,半数受试者（50.25%）服用剂量低于指南推荐的最小剂量.结论 我国心血管疾病一级预防和二级预防人群阿司匹林使用率过低,在使用阿司匹林预防的人群中,使用剂量也不规范,半数每日应用少于75 mg.应进一步提高心血管疾病中高危患者及已有心血管疾病患者阿司匹林的使用率并规范其应用.     

Dyslipidemia management in primary prevention of cardiovascular disease:Current guidelines and strategies

Cardiovascular disease is the leading cause of death in the United States. In 2010, the Centers for Disease Control and Prevention estimated that $444 billion was spent on cardiovascular diseases alone, about $1 of every $6 spent on health care. As life expectancy continues to increase, this annual cost will also increase, making costeffective primary prevention of cardiovascular disease highly desirable. Because of its role in development of atherosclerosis and clinical events, dyslipidemia management is a high priority in cardiovascular prevention. Multiple major dyslipidemia guidelines have been published around the world recently, four of them by independent organizations in the United States alone. They share the goal of providing clinical guidance on optimal dyslipidemia management, but guidelines differ in their emphasis on pharmacotherapy, stratification of groups, emphasis on lifestyle modification, and use of a fixed target or percentage reduction in low density lipoprotein cholesterol. This review summarizes eight major guidelines for dyslipidemia management and considers the basis for their recommendations. Our primary aim is to enhance understanding of dyslipidemia management guidelines in patient care for primary prevention of future cardiovascular risk.     

Primary and secondary prevention strategy for cardiovascular disease in diabetes mellitus

The majority of individuals with diabetes die from cardiovascular disease (CVD) and related complications. The risk of CVD is 2 to 4 fold greater in diabetes and largely magnified by co-morbidities that aggregate along with it. Sufficient evidence-based data now exist to support multifactorial risk intervention with specific targets for goal-directed therapy for both primary and secondary prevention. These interventions have shown survival benefit in addition to prevention of vascular complications. Prevention of diabetes and delaying its onset should also be an important aspect in future health care strategy and research to confront the oncoming tsunami of CVD related to diabetes.     

Risk assessment in the prevention of cardiovascular disease in low-resource settings

IntroductionCardiovascular disease (CVD) prevalence is increasing in low- and middle-income countries. Total risk assessment is key to prevention.MethodsStudies and guidelines published between 1990 and 2013 were sought using Medline database, PubMed, and World Health Organization report sheets. Search terms included ‘risk assessment’ and ‘cardiovascular disease prevention’. Observational studies and randomized controlled trials were reviewed.ResultsThe ideal risk prediction tool is one that is derived from the population in which it is to be applied. Without national population-based cohort studies in sub-Saharan African countries like Nigeria, there is no tool that is used consistently. Regardless of which one is adopted by national guidelines, routine consistent use is advocated by various CVD prevention guidelines.ConclusionsIn low-resource settings, the consistent use of simple tools like the WHO charts is recommended, as the benefit of a standard approach to screening outweighs the risk of missing an opportunity to prevent CVD.     

Effect of aspirin on mortality in the primary prevention of cardiovascular disease

Objective

The lack of a mortality benefit of aspirin in prior meta-analyses of primary prevention trials of cardiovascular disease has contributed to uncertainty about the balance of benefits and risks of aspirin in primary prevention. We performed an updated meta-analysis of randomized controlled trials of aspirin to obtain best estimates of the effect of aspirin on mortality in primary prevention.

Methods

Eligible articles were identified by searches of electronic databases and reference lists. Outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, and bleeding. Data were pooled from individual trials using the DerSimonian-Laird random-effects model, and results are presented as relative risk (RR) and 95% confidence intervals (CIs).

Results

Nine randomized controlled trials enrolling 100,076 participants were included. Aspirin reduced all-cause mortality (RR 0.94; 95% CI, 0.88-1.00), myocardial infarction (RR 0.83; 95% CI, 0.69-1.00), ischemic stroke (RR 0.86; 95% CI, 0.75-0.98), and the composite of myocardial infarction, stroke, or cardiovascular death (RR 0.88; 95% CI, 0.83-0.94), but did not reduce cardiovascular mortality (RR 0.96; 95% CI, 0.84-1.09). Aspirin increased the risk of hemorrhagic stroke (RR 1.36; 95% CI, 1.01-1.82), major bleeding (RR 1.66; 95% CI, 1.41-1.95), and gastrointestinal bleeding (RR 1.37; 95% CI, 1.15-1.62). A lack of availability of patient-level data precluded exploration of benefits and risks of aspirin in key subgroups.

Conclusion

Aspirin prevents deaths, myocardial infarction, and ischemic stroke, and increases hemorrhagic stroke and major bleeding when used in the primary prevention of cardiovascular disease.     

Dynamics of cardiovascular and all-cause mortality in Western and Eastern Europe between 1970 and 2000

Aims Important changes in cardiovascular and all-cause mortalityrates are occurring in Western and Eastern Europe, each withtheir own dynamics. Differences in trends will be analysed andpossible causes are discussed. Methods and results Mortality data for cardiovascular and all-causemortality rates from different countries were obtained fromWHO and were analysed for the period 1970–2000. The annualchanges in cause-specific mortality rates were calculated usinglinear and polynomial regression models. Mortality rates declinedalmost linearly for ischaemic heart disease, stroke, and totalcardiovascular diseases between 1970 and 2000 in Western Europe.In both men and women, the decline for these diseases variedbetween 50 and 65% or 2%/year in this period. In contrast, inEastern Europe cardiovascular mortality rates reached a maximumin the period 1990–94, followed by a decline of 3%/yearin Poland, 2%/year in Hungary, and 5%/year in the Baltic states.The changes in cardiovascular mortality rates were reflectedin all-cause mortality rates in both Western and Eastern Europe. Conclusion Over the past 30 years, mortality rates in cardiovasculardiseases increased or decreased very rapidly. The causes arecomplex but changes in diet appear to play a major role. Themore recent declines in Western Europe also reflect improvementsin modern cardiovascular treatment.     

Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease.

AIMS: To estimate the potential effectiveness of different "high-risk" and "population" approaches to the primary prevention of cardiovascular disease (CVD) in middle-aged British men, after correction for regression dilution bias. METHODS AND RESULTS: We used a combination of cohort and randomised controlled trial evidence to estimate the effectiveness of high-risk strategies, based on the identification of high-risk factors or high absolute risk, and strategies based on population-wide reductions in cholesterol and blood pressure. High-risk strategies were potentially effective but would need to be used widely to have a substantial effect on CVD in the population. Aggressive pharmacological treatment (using statins, beta-blockers, ACE-inhibitors and aspirin) in individuals with a 10-year Framingham event risk of >or=30% (6% of population) would have reduced major CVD by at most 11%. This figure increased to 34% at a >or=20% treatment threshold (26% of population). In contrast, modest downwards shifts in the population distributions of serum total cholesterol and systolic blood pressure led to marked expected reductions in major CVD. Taking regression dilution bias into account, 10% reductions in long-term mean blood cholesterol and blood pressure could have reduced major CVD by 45%. CONCLUSIONS: If high-risk strategies are to have a major impact on CVD in the population, they need to be more widely used than previously envisaged. Population-wide reduction of major risk factors is needed if CVD is to be substantially reduced.