Clopidogrel in the treatment of ischaemic heart disease

Clopidogrel is an effective antiplatelet agent that has undergone rigorous assessment in the setting of ischaemic heart disease over the last decade. There is extensive evidence for the use of this drug in patients undergoing percutaneous coronary intervention, in those with stable ischaemic heart disease and also in those with acute coronary syndromes. This article examines the use of clopidogrel in patients with ischaemic heart disease.     

Serum lipids and lipoproteins in ischaemic heart disease following withdrawal of long-term metroprolol treatment

Summary In 39 patients who had been treated with metoprolol 100–200 mg daily or placebo for three years after acute myocardial infarction, serum lipids and lipoproteins were studied while the patients were on treatment as well as after its withdrawal. Withdrawal was performed over 1 week. Treatment had to be reinstituted in 6 patients (1 ex placebo and 5 ex metoprolol) because of aggravated symptoms.During the entire study period total cholesterol was significantly higher in the metoprolol withdrawal group and LDL cholesterol tended to be higher. HDL cholesterol in both groups increased significantly during the initial 28-day period following withdrawal of treatment. In both groups VLDL triglycerides tended to decrease during the first 28 day without treatment. Other lipoprotein fractions in both groups were unchanged.Overall, in patients who tolerated the ending of 3 years of treatment with metoprolol after myocardial infarction, there was no significant effect on lipoprotein fractions as compared to a placebo group.     

Haemodynamic effects and kinetics of concomitant intravenous disopyramide and atenolol in patients with ischaemic heart disease

Summary The haemodynamic effects of concomitant intravenous administration of disopyramide (Norpace) and atenolol (Tenormin) were studied in a cross-over trial in 7 patients with ischaemic heart disease. Following 150 mg disopyramide i.v. the cardiac index (CI) and stroke volume index (SVI) decreased by 14% and 26%, respectively and the heart rate (HR) and preejection period index (PEPI) increased by 13% and 19%, respectively. A decrease in CI of 14% and HR of 21%, respectively were noted after intravenous administration of 7.5 mg atenolol; PEPI increased by 10% whereas SVI remained unchanged. The cardiac Index (CI) fell by 33% following the administration of both drugs. The effect on CI of the two drugs was additive. The effect of disopyramide and atenolol on HR, SVI and PEPI was not significantly modified by coadministration of the other drug. No change in blood pressure was observed after disopyramide or atenolol. A correlation () of 0.540 and 0.387 was observed between the change in PEPI and the log free and total serum concentrations of disopyramide, respectively. Combined intravenous use of the two drugs in patients with incipient or overt heart failure is not recommended, unless it is due to the arrhythmia to be treated.     

Antioxidant effects of simvastatin in primary and secondary prevention of coronary heart disease

Objective The aim of the present study was to determine the effect of simvastatin on the levels of oxidized low-density lipoprotein (ox-LDL) and free radicals in hypercholesterolemic subjects undergoing primary and secondary prevention of coronary heart disease (CHD).Methods Fifteen subjects with hypercholesterolemia and no obvious CHD and 29 subjects with hypercholesterolemia and stable angina received 40 mg of simvastatin daily for 12 weeks. Serum total cholesterol, HDL-cholesterol and triglyceride concentrations were determined by automated enzymatic assays whereas LDL-cholesterol was calculated using the Friedwald formula. The ox-LDL levels were determined by a commercially available ELISA kit. Free radicals were assessed by the Free Radical Analytical System (FRAS).Results Both in primary and secondary prevention, subjects had borderline levels of free radicals but in neither group there was a significant reduction of free radicals after simvastatin treatment. In subjects undergoing primary prevention of CHD, ox-LDL levels were reduced by 31.1±5.0% (P<0.001) whereas in secondary prevention were reduced by 6.5±5.2% (P<0.02) after simvastatin treatment. The reduction of ox-LDL levels did not correlate with the reduction of total cholesterol levels in either group studied. In both groups, ox-LDL levels were not associated with free radical levels either before or after simvastatin treatment.Conclusion This study demonstrates that simvastatin can significantly reduce circulating ox-LDL levels both in subjects undergoing primary and secondary prevention of CHD. These results could partly explain the slowing down of the progression of atherosclerosis caused by HMG-CoA reductase inhibitors.     

Fluctuations in male ischaemic heart disease mortality in Russia 1959–1998: Assessing the importance of alcohol

Introduction and Aims. The decline in cardiovascular mortality in Russia following the Soviet anti‐alcohol campaign of 1985–1988 and the subsequent increase when these extreme alcohol controls were repealed suggested that alcohol consumption is responsible for a substantial number of ischaemic heart disease (IHD) deaths in Russia. To examine whether a similar conclusion can be drawn on the basis of a time‐series analysis covering a longer time period, namely 1959–1998. Design and Methods. Using ARIMA time‐series analysis, the male IHD mortality rates from 1959 to 1998 were analysed in relation to three indicators of alcohol consumption: estimated per capita consumption, mortality from liver cirrhosis and alcohol poisonings. Cigarette sales and lung cancer mortality were used as indicators of smoking. Results. Each indicator of alcohol consumption had positive and statistically significant relationships with male IHD mortality in bivariate autoregressive integrated moving average models. The association was stronger in models predicting changes in premature male IHD mortality (30–54 years). At least one alcohol indicator was significantly related to IHD mortality in multivariate models, and in the case of premature IHD mortality, both mortality indicators were significant. Discussion and Conclusions. The results provide additional empirical evidence supporting alcohol's conceivable negative effects on IHD in Russia and the idea that binge drinking could be the mechanism through which this effect is mediated. There were no signs of any protective effects from alcohol among Russian men.[Ramstedt M. Fluctuations in male ischaemic heart disease mortality in Russia 1959–1998: Assessing the importance of alcohol. Drug Alcohol Rev 2009;28:390–395]     

Comparative effects of alinidine and propranolol in ischaemic heart disease

Summary The effects of single oral doses of alinidine 40 mg, propranolol 40 mg or placebo during a maximal exercise test on a bicycle ergometer in patients with angina pectoris were studied in a randomised, double blind study. 2 and 5 h after drug intake a small fall in resting heart rate and systolic blood pressure was observed both after alinidine and propranolol. At a fixed work load both drugs decreased heart rate, systolic blood pressure, double product and the extent of ST segment depression. Total work performed and time to appearance of angina pectoris were increased 2 h alinidine and propranolol. The same effects were still apparent 5 h after propranolol but not after alinidine. At peak exercise neither drug had any effect on the extent of ischaemic ST segment depression.     

他汀类药物在冠心病二级预防中的作用

目的观察他汀类药物在冠心病二级预防伴或不伴血脂异常中的作用。方法将160例冠心病伴或不伴血脂异常患者随机分成2组：治疗组80例给予辛伐他汀10 mg,并同时接受常规抗缺血治疗,包括β受体阻滞剂,长效硝酸脂类,阿司匹林,及良好的血压控制治疗;对照组80例不给予辛伐他汀治疗,治疗前2组基线年龄、性别、高血压、糖尿病、吸烟及体重指数等均无统计学差异（P〉0.05）。结果治疗组总有效率高于对照组,1年后,心血管事件发生率及不良反应发生率均低于对照组,差异均有统计学意义（P〈0.05）。结论他汀类药物可在已有冠心病伴或不伴血脂异常患者中推广使用。     

Sarcoplasmic reticulum and cardiac oxidative stress: an emerging target for heart disease

The sarcoplasmic reticulum (SR) is a major player in maintaining cardiac function, as it is intimately involved in the regulation of Ca²⁺-movements on a beat-to-beat basis. SR dysfunction due to abnormalities in SR protein content has been reported in different cardiac diseases such as ischaemic heart disease, myocardial infarction, congestive heart failure and various cardiomyopathies; thus the genes expressing the SR Ca²⁺-pump, Ca²⁺-channels, calsequestrin, phospholamban and other regulatory proteins are considered important targets for drug development. In our experience, ischaemic preconditioning (IP) and pharmacological therapies, such as anti-oxidants, β-adrenergic receptor blockers, angiotensin receptor (AT-1) blockers, angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers are effective therapies that improve cardiac performance in the failing heart by improving SR function. Accordingly, this paper is intended to shed light on the knowledge in the field of cardiac therapy targeted to improve and protect SR function.     

Calcium antagonists in the treatment of hypertension in patients with ischaemic heart disease

Are lives saved or heart attacks prevented by antihypertensive therapy, as a result of blood pressure reduction alone, or because of other properties of the antihypertensive medications which are independent of blood pressure lowering? Long-acting calcium antagonists seem to be as effective as thiazide diuretics and angiotensin-converting enzyme (ACE) inhibitors in preventing all-cause mortality and stroke in patients with hypertension, but are probably inferior to ACE inhibitors in preventing coronary artery disease. In patients with symptomatic coronary artery disease, calcium antagonists are generally as effective as β-blockers in relieving angina and improving exercise time-to-onset of angina or ischaemia. Unstable angina or myocardial infarction require treatment with a β-blocker, with an ACE inhibitor added when necessary for blood pressure control or if there is significant left ventricular (LV) dysfunction. If β-blockers are contraindicated and if there is no LV dysfunction, a non-dihydropyridine calcium antagonist can be substituted.     

Serum magnesium,calcium, phosphate and PTH following long-term beta-blockade in ischaemic heart disease

Summary In 40 patients with ischaemic heart disease the serum levels of magnesium, parathyroid hormone (PTH), phosphate, calcium, and ionized calcium remained unchanged and within normal limits following treatment for 12 months with alprenolol (n=20) or placebo (n=20). No changes occurred during a 2 week withdrawal period. The clinical implication is that the non-cardioselective betablocker alprenolol can be given to patients with ischaemic heart disease without the risk of inducing potentially cardiotoxic disturbances in serum magnesium and serum calcium levels. Whether this applies to cardioselective beta-blockers remains to be established.     

Better lipid target achievement for secondary prevention through disease management programs for diabetes mellitus and coronary heart disease in clinical practice in Germany

Aims:

Disease management programs (DMP) for diabetes mellitus (DM) or coronary heart disease (CHD) address the treatment of lipid disorders. The current registry aimed to compare drug utilization, lipid lowering effects and further outcomes of outpatients at high cardiovascular risk in DMP for DM or CHD compared to patients in routine care (no-DMP).

Methods:

This was a prospective non-interventional registry with a 1 year follow-up which enrolled consecutive patients with known DM and/or any vascular disease on simvastatin 40?mg monotherapy, to document lipid target achievement in clinical practice in Germany according to existing guidelines. Drug use (maintenance, add-on, switch, discontinuation) and other components of care were upon the discretion of the treating physician.

Results:

Of a total of 12,154 patients (mean age 65.8 years, 61.2% males), 3273 were in DMP CHD, 3265 in DMP DM and 1760 in DMP CHD?+?DM. In DMP patients compared to no-DMP patients, comorbidities/risk factors were more frequent. More patients in the DMP groups attained the target level of low density lipoprotein (LDL-C) <70?mg/dl (1.8?mmol/l) at baseline (8.5% DMP vs. 5.7% no-DMP), at 6 month (10.3% vs. 7.4%) and 12 month follow-up (10.1% vs. 7.1%). Cholesterol absorption inhibitors were added in 16% of the patients at the end of the baseline or at the follow-up visits, while statin treatment (including mean dose) remained largely unchanged. Target achievement rates were highest for all time points in the DMP CHD?+?DM group. With respect to limitations, this study was restricted to lipid disorders as qualifying diagnosis and simvastatin as qualifying treatment, which is a potential cause of selection bias. Information on non-pharmacological measures was not collected, and the 12-month follow-up period was relatively short.

Conclusion:

Patients in DMP compared to those not in DMP achieved better LDL-C lowering and higher control rates, but overall lipid target achievement rates need to be improved. Longer-term observations are needed to corroborate these findings.     

两种氯吡格雷片在冠心病二级预防中的效价比观察

目的 比较两种氯吡格雷片（波立维和泰嘉）在冠心病二级预防中的疗效、安全性及经济性.方法 89例患者随机分为A组（45例）和B组（44例）.A组患者在基础治疗上每日口服75 mg波立维片,B组患者在基础治疗上每日口服75 mg泰嘉,随访2年,比较两组患者随访期间心血管事件发生率、药物不良反应发生率及药物支出情况.结果 两组患者随访期间均没有心源性猝死发生.A组发生4例主要心血管事件,发生率为8.9％.B组3例,发生率为6.8％.两组患者间主要心血管事件发生率的比较,差异无统计学意义（x2=0.132,P=1.000）.患者服药期间没有明显的肝肾功能损伤.A组9例发生不良反应,发生率为20.0％.B组10例,发生率为22.7％.两组患者间不良反应发生率的比较,差异无统计学意义（x2=0.099,P=0.800）.A组患者服用波立维2年的药品支出为（14 600±2726）元,B组患者服用泰嘉2年的药品支出为（7450±1525）元.两组患者间氯吡格雷片的药品支出比较,差异有统计学意义（t=2.355,P=0.021）.结论 两种氯吡格雷片发挥了相似的冠心病二级预防作用,药物不良反应发生率相似,泰嘉的费用明显低于波立维,有利于提高患者二级预防的持续性.     

Coronary heart disease prevention in menopausal women

During the last 20 years, cardiovascular mortality has steadily declined in men. Concurrently, cardiovascular death rates have remained stable in women. Prior to the availability of randomised, controlled trial results, postmenopausal hormonal therapy was believed to confer cardiac protection. Now that these trials have been completed, it is clear that oestrogen is not effective for coronary prevention; consequently, other pharmacological and non-pharmacologic interventions must be invoked to reduce coronary risk. This paper discusses the impact of menopause on conventional risk factors and reviews gender-specific primordial, primary and secondary prevention strategies.     

The need for pharmaceutical care in the prevention of coronary heart disease: an exploratory study in acute myocardial infarction patients

AIM: To determine guideline-related pharmaceutical care issues for the prevention of coronary heart disease in hospitalised patients admitted for myocardial infarction (MI). METHODS: Consecutive patients admitted with a diagnosis of Q-wave MI to two large teaching hospitals were studied. Relevant patient medical and drug histories, co-morbidities and total cholesterol concentrations were recorded. Primary or secondary prevention treatment prior to admission was assessed using a data collection tool of 16 criteria developed from the Scottish Intercollegiate Guidelines Network (SIGN) guidelines. MAIN OUTCOME MEASURES: Frequency of adherence to defined clinical guideline criteria. RESULTS: There were 167 patients reviewed (mean age 65 years, 111 males), representing possible candidates for primary prevention (n = 98) or secondary prevention (n = 69) based on absence or presence of past history of coronary heart disease (CHD), respectively. Possible primary prevention candidates: eight guideline-based criteria were developed from the SIGN guideline. There were 85 (87%) patients with a total cholesterol concentration available on admission of whom 56 (66%) had a predicted CHD risk > or = 15% and 10 (12%) had CHD risk > or = 30%. Of those with CHD risk > or = 15% 6 (11%) had been receiving an anti-platelet agent and of those with CHD risk > or = 30% only 1 (10%) was recorded as taking a statin. Of known hypertensives with CHD risk > or = 15%, 21% (5/24) were not recorded as having received treatment. Secondary prevention candidates: a further eight guideline-based criteria were developed from the SIGN guidelines. There were 42/65 (65%) candidates for aspirin documented as receiving it. There were 22/47 (47%) of those who had a total cholesterol > or = 5 mmol/l and/or known history of hypercholesterolaemia receiving a statin (representing 76% of the known hypercholesterolaemic patients identified in the community). Of statin-treated patients with a cholesterol measured on admission, 44% (7/16) had cholesterol remaining > or = 5 mmol/l. Beta-blocker use was 27/62 (44%) and ACE inhibitors use was 11/31 (36%) of those eligible. Sublingual GTN was recorded in 36/69 (52%). CONCLUSION: The study has identified opportunities for improved pharmaceutical care in primary and secondary CHD prevention among those destined to suffer an MI. Candidates for secondary prevention are potentially identifiable from community pharmacy patient medication records from which the contribution of pharmacists in primary care might be targeted. The findings were obtained during a period of evolution of the evidence-base and so they establish a baseline for future work.     

护士在冠心病二级预防中的作用

目的：探讨护士在冠心病二级预防中的作用。方法：对冠心病及高危人群进行为期6个月的危险因素评估、系统治疗、健康教育和追踪随访。结果：生命网可以提高患者对于冠心病相关知识认知态度,使患者自觉改变生活习惯,使生存质量明显提高。生命网患者6个月后治疗的依从性由38％上升到95％。结论：在冠心病二级预防中,护士发挥重要的作用。     

The clinical and economic impact of a secondary heart disease prevention clinic jointly implemented by a practice nurse and pharmacist

BACKGROUND: A primary care practice in the West of Scotland used clinical governance funding to develop a heart disease prevention clinic to target patients with existing heart disease. The practice nurse enlisted the help of the practice pharmacist and the protocol for the clinic was subsequently developed with the involvement of both practitioners. OBJECTIVE: The aim of this project was to identify and offer health screening and appropriate disease modifying treatment to patients of a primary care (or general medical) practice suffering from cardiovascular heart disease in a clinic run jointly by a practice nurse and pharmacist. METHOD: Patients identified by the practice pharmacist were offered a full health screen. Their clinical parameters were assessed and appropriate disease modifying drug therapy and lifestyle advice was offered in a review clinic with the practice nurse and pharmacist. RESULTS: The practice pharmacist identified over 212 patients over a 30-month period. A majority demonstrated hypertension (91%) and angina (89%), while over half (57%) had suffered a heart attack. Statin therapy was modified in a large number of patients (47%) and the number of patients with satisfactory total cholesterol levels has increased from 30% to 57% (P < 0.001). Aspirin and beta-blocker therapy has been initiated in a significant number of patients (53% and 26% respectively). Twelve patients (6%) stopped smoking; however, many 42% continued to smoke. The general medical doctors (GPs) who demonstrated a change in their own practice readily accepted changes to therapy recommended by the practice nurse and pharmacist. The practice pharmacist offset the additional cost of drug spend on statin therapy by making savings in other therapeutic areas. CONCLUSION: A secondary heart disease clinic can benefit patients by optimising drug and lifestyle therapy. While the inclusion of a pharmacist confers clinical and economic benefits.     

高尿酸血症与冠心病患者性别关系的研究

目的 探讨高尿酸血症与冠心病患者性别的关系.方法 选取2012年3-9月于安贞医院急诊综合病房住院患者75例.将40例冠心病患者按性别分为男性冠心病组和女性冠心病组,各20例;同期入组的对照组为经冠状动脉造影证实冠状动脉正常的疑似冠心病患者,男20例,女15例,回顾性收集入选受试者的资料,比较2组患者的年龄、血尿酸、空腹血糖、血肌酐、血脂的情况.结果 男、女冠心病组的平均血尿酸水平未达到高尿酸血症的标准[(351±67)μmol/L、(310 ±74) μmol/L],男性冠心病组尿酸水平高于女性冠心病组(P＜0.05).男性冠心病组尿酸水平与男性对照组[(327±82)μmol/L]比较差异无统计学意义(P＞0.05).女性冠心病组尿酸水平显著高于女性对照组[(216 ±52) μmol/L],差异有统计学意义(P＜0.01).女性冠心病组的HDL-C[(1.09±0.19) mmol/L]低于女性对照组[(1.27±0.23) mmol/L](P＜0.05),而TG[(1.6±0.6)mmol/L]高于女性对照组[(1.1 ±0.4)mmol/L](P＜0.05).结论 高尿酸血症可能是女性冠心病患者的一个危险因素.