Secondary prevention in coronary heart disease

After myocardial infarction, beta-blockers, aspirin and (in selected patients) ACE inhibitors all reduce substantially the risk of further myocardial infarction or coronary death. With regard to life-style changes, giving up cigarette smoking reduces coronary risk by about 50%. Weight reduction and regular exercise are advised, although the effect of these measures on prognosis is uncertain. Recently, two major trials, the Scandinavian Simvastatin and West of Scotland Pravastatin studies, have radically changed ordinary medical practice. In these trials HMG CoA reductase inhibitor (statin) treatment reduced coronary events by 30–40%, reduced all-cause mortality, and proved safe and well-tolerated. The accepted policy now is to treat all patients with coronary heart disease, who have a cholesterol concentration 5.5 mmol/l or higher, with a statin. Where does this leave cholesterol-lowering dietary advice in secondary prevention? The benefits of statin treatment were attained by reducing serum cholesterol by an average of 25%. Diet change rarely attains such a fall in cholesterol and should therefore be used only as an adjunct to drug therapy. When recommending a lipid-lowering diet there is a danger that patients may be denied highly-effective drug treatment because of the «threshold» effect. A decision on the need for cholesterol reduction should be made before diet change is advised. Once the decision is made the target is a 25% cholesterol reduction, which will require drug therapy in addition to diet changes.     

A long-term nutrition intervention experience: lipid responses and dietary adherence patterns in the Multiple Risk Factor Intervention Trial

Nutrition counselors in the Multiple Risk Factor Intervention Trial (MRFIT) were able to help middle-aged men who were at high risk for coronary heart disease change their dietary habits, maintain those changes over time, and decrease their serum cholesterol levels. Most of a 7.5% mean serum cholesterol reduction achieved after 6 years of nutrition intervention occurred during the first year of the trial and was thereafter sustained. Total cholesterol and low-density lipoprotein cholesterol fraction decreases indicated improvement in terms of coronary heart disease risk. The food record rating, a numerical, semi-objective adherence technique that assesses a 3-day food record with respect to lipid-lowering potential, was used throughout the trial to measure adherence to recommended food patterns. Participants with lower food record rating scores, which indicate better adherence, demonstrated greater reductions in serum total cholesterol, plasma total cholesterol, and low-density lipoprotein fraction cholesterol determinations on a group basis. Subjective evaluations of the suitability of home and working environments, evidence of deviation from the MRFIT food patterns, and overall nutrition program motivation also showed that as ratings in each category became more favorable, lower food record rating scores and greater blood lipid reductions were consistently observed. The subgroup of participants who were non-smokers and not hypertensive demonstrated greater lipid responses and better dietary adherence. Continued smoking and antihypertensive medications appeared to adversely influence dietary adherence and/or lipid reductions. The MRFIT experience, however, demonstrated for the first time that dietary changes and blood lipid reductions can be achieved after the initial intervention effect, despite a continued emphasis on high blood pressure management and smoking cessation.     

Physician practice for cardiovascular disease risk-factor reduction in six upper Midwestern communities

Preventive practice for coronary heart disease risk is increasingly accepted in the medical community. To determine the extent and characteristics of treatment advice for high blood pressure, blood cholesterol, and cigarette smoking, 274 randomly selected primary care physicians were interviewed by telephone in six Midwestern cities. Participation in the survey was 90%. Reported care for high blood pressure was consistent with national guidelines. Management of high blood cholesterol varied significantly among physicians and frequently differed from national recommendations. Although consensus existed on the importance of advising cigarette smoking cessation, reported approaches differed. The results observed indicate improved preventive practice compared with earlier surveys and recent national reports. Continued improvement, however, is needed in cholesterol and smoking-cessation management.     

冠心病合并高血压患者86例血浆BNP浓度与发病危险相关性的临床研究

目的通过分析某院86例冠心病合并高血压患者血浆中心房钠尿肽(BNP)的高低研究其与冠心病、高血压发病的相关性,为临床诊断、治疗提高相关性依据。方法选择该院2011年5月～2011年10月收治的86例冠心病(和或)高血压患者做为观察对象,其中患高血压不患冠心病的患者35例,仅患冠心病的患者22例,冠心病合并高血压患者29例,将所有患者出入院的资料录入Excel,分为3组进行讨论,使用SPSS18.0对不同疾病患者进行体内BNP水平与血压、血浆低密度脂蛋白、甘油三酯、总胆固醇、血糖、体重、吸烟按照逐步分析原则进行Logistics回归性统计分析。结果血糖超标、总胆固醇、甘油三酯水平超标是单纯高血压组BNP水平升高的危险因素(OR=2.21,2.22,1.84,P﹤0.01);单纯冠心病组BNP升高的危险因素分别为:低密度脂蛋白异常、高密度脂蛋白异常、总胆固醇偏高、吸烟、血压升高(OR=1.11,0.91,0.24,1.37,1.32,P﹤0.01);冠心病合并高血压组的BNP水平偏高的危险因素包括:血压、血糖、体重、吸烟、低密度脂蛋白,高血压合并冠心病组BNP浓度(109.2±87.2)均高于其他两组(F=1.241,P﹤0.01)。结论冠心病、高血压病患者某些因素是其致病的重要原因,而BNP的高低又与这些致病危险的高低存在显著相关性,BNP可以做为预测冠心病、高血压病患者疾病严重程度,同时可以做为临床治疗水平高低的有效指标。     

Coronary heart disease risk factors and attributable risks in African-American women and men: NHANES I epidemiologic follow-up study.

OBJECTIVES: This study assessed associations of risk factors with coronary heart disease incidence in African Americans. METHODS: The participants in the NHANES I Epidemiologic Follow-Up Study included in this analysis were 1641 Black and 9660 White persons who were aged 25 to 74 years when examined and who did not have a history of coronary heart disease. Average follow-up for survivors was 19 years. RESULTS: Significant, independent risk factors for coronary heart disease were age, systolic blood pressure, and smoking in Black women and age, systolic blood pressure, serum cholesterol, low education, and low family income in Black men. In this cohort, 19% of incident coronary heart disease in Black women and 34% in Black men might be prevented if systolic blood pressure were below 140 mm Hg. In Black men, attributable risk for low education (46%) was even higher than that for elevated blood pressure. CONCLUSIONS: Elevated systolic blood pressure and smoking were predictive of coronary heart disease incidence in African Americans. Estimates of population attributable risk were highest for elevated systolic blood pressure in women and education less than high school in men. Further studies of serum lipids, education, and coronary heart disease in Black women are needed.     

Coronary heart disease mortality in the Western Collaborative Group Study. Follow-up experience of 22 years

In 1960-1961, 3,154 healthy, middle-aged men were entered into the Western Collaborative Group Study, a long-term study of coronary heart disease. A 22-year mortality follow-up of this cohort in 1982-1983 accounted for almost 99% of the cohort, and determined that 214 of the men had died of coronary heart disease. The risk of coronary heart disease mortality was studied for several variables measured at baseline, i.e., Type A/B behavior, systolic blood pressure, serum cholesterol level, cigarette smoking status, and age. Using a proportional hazards regression model, systolic blood pressure, serum cholesterol level, cigarette smoking status, and age were highly significant predictors (p less than 0.001) of 22-year coronary heart disease mortality. Type A/B behavior showed no association with 22-year coronary heart disease mortality (standardized relative hazard (SRH) = 0.98, 95% confidence interval (CI) = 0.85-1.12). Systolic blood pressure, serum cholesterol, and age showed relatively consistent positive associations with coronary heart disease mortality over four successive time intervals after the baseline examination. Cigarette smoking showed a significant positive association in the first and second intervals and a nonsignificant positive association in the third and fourth intervals. Type A/B behavior was positively but not significantly associated with coronary heart disease in the first and third intervals, significantly negatively associated (SRH = 0.70, 95% CI = 0.53-0.93) in the second interval and not associated in the fourth interval. The results confirm the importance of the traditional coronary heart disease risk factors, and raise a substantial question about the importance of Type A/B behavior as a risk factor for coronary heart disease mortality.     

Public health burden of coronary heart disease risk factors among middle-aged and elderly men

BACKGROUND: An epidemiological evidence shows that smoking, high total cholesterol, hypertension, overweight, and a low level of physical activity are significant risk factors for coronary heart disease mortality. Therefore, by turning these risk factors in a healthier direction, presumably a substantial proportion of the deaths would be preventable. METHODS: The avoidable proportion of coronary heart disease deaths associated with smoking, a high level of total cholesterol, systolic hypertension, overweight, and a low level of leisure-time physical activity was assessed with the use of the population attributable risks for initially 30- to 63-year-old Finnish men (six studies with 1,340-7,928 subjects) who were followed up from 7 to 30 years. RESULTS: The theoretical estimates of population at tributable risks derived from published studies were as follows: smoking 10 to 33%; high total cholesterol 9 to 21%; hypertension 6 to 15%; overweight 3 to 6%; and low level of leisure-time physical activity 22 to 39%. CONCLUSIONS: These estimations, based on observed mortality rates and risk factor prevalences, suggest that, even if modest estimates are used, the burden from coronary heart disease deaths can be substantially reduced by converting the risk factors to more healthful levels. The results also suggest that efforts to increase physical activity deserve as much consideration as those aimed at influencing more traditional risk factors.     

Preventing heart disease: is treating the high risk sufficient?

Monte Carlo simulation was used to assess the effects of several intervention strategies on coronary heart disease mortality rates in a Finnish and a North American cohort. Lowering total serum cholesterol by 4%, smoking by 15%, and diastolic blood pressure by 3% for the whole cohort would be expected to reduce the incidence of non-fatal myocardial infarction by at least 13% and coronary heart disease deaths by at least 18%. Lowering serum cholesterol by 34%, diastolic blood pressure to 90 mmHg, and reducing smoking by 20% in the subset of the population with all three risk factors in the highest quartile would result in a 6-8% reduction in non-fatal myocardial infarction and a 2-9% reduction in deaths from coronary heart disease in these cohorts. These data demonstrate that in populations with a relatively high incidence of heart disease, treating the entire population will produce larger effects than focusing only on high-risk populations.     

Cholesterolemia control in Spain, 2000. A tool for cardiovascular disease prevention. Ministry of Health and Consumption, Spanish Society of Cardiology and Spanish Society of Arteriosclerosis

The report "Cholesterolemia Control In Spain, 2000. A tool for Cardiovascular Disease Prevention" reviews current evidence on cardiovascular prevention and therapeutical advances occurred in the last years, in order to help overall risk-based clinical decision-making. Cardiovascular disease ranks as the first cause of death in Spain, accounting for almost 40% of total mortality. During the last years age-adjusted cardiovascular death rates have been declining, but the absolute number of deaths by coronary heart disease is ascending due mainly to the population aging. Coronary heart disease is the first cause of hospital consultation due both to the lesser coronary heart disease mortality and to the increase in coronary heart disease incidence. The demographic, health and social impact of cardiovascular disease is increasing and it is likely to go on in the next decades. Appropriate treatment of high blood cholesterol and of other major modifiable risk factors is crucial for preventing cardiovascular disease. Specific actions to carry out depend on the risk to get ill. Individual risk stratification is essential as it determines the follow up periodicity and treatment intensity. Priorities of control of cholesterolemia and its consequent risk are based on risk stratification. The groups for intervention are ordered in a descendent priority hierarchy as follows: 1. Secondary prevention: Patients with established coronary heart disease or other atherosclerotic disease. 2. Primary prevention: Healthy individuals who are at high risk of developing coronary heart disease or other atherosclerotic disease, because of a combination of risk factors--including lipids (raised total cholesterol, and LDL-cholesterol, low HDL-cholesterol and raised triglycerides), smoking, raised blood pressure, raised blood glucose, family history of premature coronary disease--or who have severe hypercholesterolaemia, or other forms of dyslipidaemia, hypertension or diabetes. 3. Close relatives of patients with early onset coronary heart disease or other atherosclerotic disease. 4. Others individuals met in connection with ordinary clinical practice. In primary prevention, the therapeutic objective in high risk patients (risk (3)20%--upon the risk chart of the European Societies of Cardiology, Atherosclerosis, Hypertension--or individuals with 2 or more risk factors--National Cholesterol Education Program II-) is set up at LDL-cholesterol < 130 mg/dl. In secondary prevention, the drug treatment will be indicated when LDL-cholesterol (3)130 mg/dl and the therapeutic objective will be LDL-cholesterol < 100 mg/dl. Statins are first line drugs for treatment of high blood cholesterol. Where moderate-severe hypertrigliceridemia or low HDL-cholesterol fibrates are preferred. In acute coronary syndrome hypolipemiant treatment, where indicated, should be used as soon as possible. Coronary heart disease patients should be offered secondary prevention programmes which provide, in a continuous manner, a good clinical and risk factor control, with appropriate cost-effectiveness drugs.     

Physical inactivity as a risk factor for coronary heart disease: a WHO and International Society and Federation of Cardiology position statement.

Coronary heart disease is responsible for a considerable amount of the morbidity and mortality from chronic diseases in industrialized countries. Many countries have therefore adopted prevention policies designed to reduce the prevalence of three of the major risk factors for coronary heart disease--high serum cholesterol, smoking, and high blood pressure. Physical inactivity is, however, also an important risk factor for developing coronary heart disease. This article presents a position statement by WHO and the International Society and Federation of Cardiology on physical inactivity and coronary heart disease.     

老年急性脑梗死合并冠心病的危险因素分析

目的分析老年急性脑梗死合并冠心病的危险因素,为防治老年急性脑梗死合并冠心病提供参考。方法选取2013年1月—2014年3月我院治疗的93例老年急性脑梗死合并冠心病患者作为临床研究对象,另选取同期治疗的90例单纯老年急性脑梗死患者作为对照组,比较两组高血压、糖尿病、血脂及血糖等生化检查的差异性,应用Logistic回归方程分析老年急性脑梗死合并冠心病的临床危险因素。结果观察组患者BMI为（28.7±4.6）kg/m2,SBP为（170.6±17.5）mmHg,TG为（2.9±0.6）mmol/L,LDL-C为（4.3±0.5）mmol/L,TC为（5.8±1.9）mmol/L,FBG为（8.4±2.5）mmol/L,2hPG为（14.3±2.9）mmol/L,年龄为（71.86±7.96）岁,吸烟共68例,高血压共74例,糖尿病共,46例,血脂异常共39例,显著高于对照组患者,对照组BMI 22.6±4.3kg/m2,SBP为（142.3±12.9）mmHg,TG为（1.7±0.7）mmol/L,LDL-C为（3.1±0.6）mmol/L,TC为（4.6±1.4）mmol/L,FBG为（5.7±2.8）mmol/L,2hPG为（10.6±2.2）mmol/L,年龄为（65.29±7.58）岁,吸烟共51例,高血压共55例,糖尿病共24例,血脂异常共26例（P〈0.05）;Logistic回归方程分析显示年龄、吸烟、肥胖、高血压、高血糖以及高血脂均为老年急性脑梗死合并冠心病的危险因素,糖尿病及高LDL-C血症为独立危险因素。结论老年急性脑梗死合并冠心病的独立危险因为糖尿病及高LDL-C血症,早期干预危险因素,有利于防治心脑血管事件。     

A randomized primary preventive trial in coronary heart disease: The oslo study

One thousand, two hundred thirty-two healthy, normotensive, but coronary high-risk men were selected for a 5-year randomized trial to assess if dietary control of hypercholesterolemia and cessation of cigarette smoking are effective in the primary prevention of coronary heart disease. The men included in the trial had serum cholesterol levels between 7.5 mmol/l (290 mg/dl) and 9.8 mmol/l (380 mg/dl), coronary risk score (based on cholesterol, smoking, and blood pressure) in the upper quartile of the distribution, and systolic blood pressure <150 mm Hg. The men in the intervention group were advised to stop smoking and to lower their blood lipids by dietary changes. On average, mean serum cholesterol concentration was 13% lower in the intervention group compared with the controls during the 5 years of the trial. Mean fasting serum triglycerides decreased by 20% in the intervention group compared with the control group. On the average, tobacco consumption was reduced about 45% in the intervention group compared to controls during the study. (Eighty percent of the men in both groups were daily cigarette smokers at the start of the study.) Diagnoses of events of cardiovascular disease during the 5 years were made blindly according to predefined criteria, by a diagnostic board not involved in the study. At the end of the observation time the incidence of myocardial infarction (fatal and nonfatal) and sudden death was 47% lower in the intervention group than in the controls (P = 0.028, 2-sided test). It is concluded that in healthy, coronary high-risk, middle-aged men, advice to change eating habits and to stop smoking significantly reduces the incidence of first events of myocardial infarction and sudden death.     

Hypertriglyceridemia: management of atherogenic dyslipidemia

Elevated triglycerides are now considered an independent risk factor for coronary heart disease and continue to be a major risk for acute pancreatitis, especially when levels exceed 1000 mg/dL (SOR: B). Elevated triglycerides are a component of atherogenic dyslipidemia and often signal the presence of other conditions (eg, metabolic syndrome, type 2 diabetes mellitus) associated with an increased cardiovascular risk (SOR: A). When evaluating a patient with elevated triglycerides, it is important to be cognizant of all atherogenic lipoproteins to more accurately determine the risk of coronary heart disease (SOR: C). Patients with hypertriglyceridemia should first achieve their low-density lipoprotein cholesterol goal, followed by their non-high-density lipoprotein cholesterol goal (SOR: C). Fibrates, niacin, and omega-3 acid ethyl esters are highly effective at reducing triglycerides, while statins are considered moderately efficacious (SOR: A).     

Risk factors for coronary heart disease in African American women.

There have been few studies of risk factors for coronary heart disease in African American women. The authors investigated factors associated with prevalent coronary heart disease in data provided by participants in the Black Women's Health Study. In 1995, 64,530 US Black women aged 21-69 years completed postal health questionnaires. The 352 women who reported having had a heart attack (cases) were frequency matched 5:1 on age with 1,760 women who had not (controls); medical record review for 35 cases indicated that two-thirds had had a heart attack and the remainder had other coronary heart disease. Odds ratios, obtained from multiple logistic regression analyses, were significantly elevated for cigarette smoking, drug-treated hypertension, drug-treated diabetes mellitus, elevated cholesterol level, and history of heart attack in a parent. High body mass index (kg/m2) was associated with coronary heart disease in the absence of control for hypertension, diabetes mellitus, and elevated cholesterol but not when they were controlled, suggesting that obesity may influence risk as a result of its effects on blood pressure, glucose tolerance, and cholesterol levels. Odds ratios increased with increasing parity and with decreasing age at first birth. These data suggest that important risk factors for coronary heart disease are similar in Black women and White women.     

Serum cholesterol--risk factor for coronary disease mortality in younger and older blacks and whites. The Charleston Heart Study, 1960-1988.

Serum total cholesterol (> or = 6.7 mmol/L) measured in 1960 in the Charleston Heart Study cohort was found to be a risk for mortality from coronary heart disease during the period of 1960 to 1988 in white men (relative risk [RR] 1.5; 95% confidence interval [CI]: 1.1, 2.2), white women (RR 1.7; 95% CI: 1.1, 2.7), and black women (RR 1.6; 95% CI: .9, 2.9) after age, systolic blood pressure, smoking status, education level, obesity, and diabetes were considered. For black men, the relative risk was .96 (95% CI, .39, 2.39). Only among white women was the relative risk (RR 2.4; 95% CI, 1.2, 4.5) increased among those in the older ages (55 to 74) in 1960. The evidence for cholesterol as a risk factor for coronary disease mortality in black men is inconclusive and requires further study.     

The change of attitude of Hungarian physicians towards the importance of risk factors of coronary heart disease over the period 1985–1996

Cardiovascular mortality in Hungary is still increasing, while it shows a continual decrease in the developed Western world. The authors examined, by means of a questionnaire, the attitude of physicians, in a large county hospital, to prevention of cardiovascular diseases and promotion of a healthy way of life. The questionnaire was answered by 170 physicians, 107 (63%) males and 63 (37%) females. Eighty-six percent of them believed coronary heart disease to be preventable. Twenty-six percent of the physicians currently smoked, and 53% did not know their own cholesterol level. As a cardiovascular mortality risk factor smoking was considered the most important risk factor, with sedentary life-style the second, high cholesterol level the third, and hypertension being only the fourth. Hungarian hospital physicians' rating of the effect of reducing the risk factors for coronary heart disease was similar to those results published in 1986 of American doctors, there being no significant difference in the importance attributed to smoking and elevated blood cholesterol. American doctors believed that hypertension had a more important effect on coronary heart disease than did Hungarian physicians, whilst the Hungarians attributed greater importance to a diet high in fat, being overweight, having a sedentary life-style, stress, elevated triglyceride level and type A behaviour. The results of this present study which related to the doctors attitudes towards health education for their patients were compared to results obtained from a study relating to physicians in the same hospital in 1985. Only in two aspects was a significant change observed. According to the authors' opinion greater efforts should be made regarding physician education on the subject of disease prevention. Additionally the employment of well educated nurses with specific training in preventive medicine could improve the effectiveness of the prevention of coronary heart disease.     

冠心病与血脂异常的相关危险因素分析探讨及策略

目的 探讨血脂异常对冠心病相关危险因素的影响,以及它们之间的危险度.方法 从笔者所在医院门诊就诊患者及干部年度健康体检者中随机抽取430例各型高脂血症患者,并在正常对照组中随机抽取160例,分别检测它们的血脂水平,以及分析它们发生冠心病的危险度,并以吸烟、肥胖（体重指数）为辅助因素计算其调整危险度.结果 Ⅰ型、Ⅱ型、Ⅲ型和Ⅳ型高脂血症的冠心病患病率分别为52.10%、55.20%、56.60%和63.44%;对照组的冠心病患病率分别为28.33%和20.00%,与对照组比较,均有显著性差异（P〈0.01）.Ⅰ型、Ⅱ型、Ⅲ型、Ⅳ型高脂血症患者与冠心病的调整相对危险度分别是对照组的4、5、6、7倍.结论 血清甘油三酯、胆固醇、高密度脂蛋白异常时冠心病发生的危险度均会升高,高脂血症是冠心病发病最强的预告信号,是重要的可调性间接危险因素之一,控制血脂、戒烟、合理饮食、降低超重和肥胖是预防冠心病的有力措施.     

The Good Heart,Good Life survey: self-reported cardiovascular disease risk factors,health knowledge and attitudes among Greek-Australians in Sydney

Abstract: This survey aimed to assess the prevalence and knowledge of coronary risk factors and self-perceived coronary heart disease risk among Greek-Australians in the Marrickville area of inner Sydney. A random sample of 834 household addresses was selected from the 2 403 households having Greek-Australian surnames on the electoral roll. In each household, one individual aged 18 years or over was selected using a Kish grid, and a questionnaire was administered by a bilingual interviewer. Questions concerned knowledge of and self-reported risk factors for coronary heart disease, and ratings of perceived stress, social support and networks. There was a response rate of 81 per cent of actual Greek-Australian households, a total of 541 interviews (61 per cent women). Most of the sample (86 per cent) were born in Greece and 77 per cent of interviews were administered in Greek. The age-adjusted male prevalences of self-reported smoking, high blood pressure, high blood cholesterol and body mass index over 26 kg/m² were 44 per cent, 5 per cent, 14 per cent and 58 per cent, respectively. The age-adjusted female prevalences of self-reported smoking, high blood pressure, high blood cholesterol and body mass index over 26 kg/m² were 19 per cent, 8 per cent, 15 per cent and 40 per cent, respectively. Compared to the National Heart Foundation risk-factor prevalence survey, the prevalence of self-reported high blood pressure was lower, but obesity and, among males, smoking, were higher. Low levels of education and poor English-language skills among older Greek-Australians may be contributing to the problem. There is a need for linguistically and culturally appropriate health promotion programs for communities of non-English-speaking background.     

Risk factors in arteriosclerosis and cardiovascular disease with special emphasis on cigarette smoking.

Large international differences in mortality from the atherothrombotic diseases, notably coronary heart disease, suggest that differences in environment and lifestyle may be important. Cholesterol is the lipid characteristically found in the atheromatous plaque. Serum cholesterol concentration is invariably higher in populations with high rates of coronary heart disease than in populations where the prevalence is low. The serum cholesterol level is probably determined by the amount of fat habitually consumed and only infrequently by genetic factors. Arterial hypertension and heavy cigarette smoking powerfully increase the risk of coronary heart disease in the presence of hypercholesterolemia. The mechanism whereby cigarette smoking aggravates and accelerates atheropoiesis is unknown, but carbon monoxide and mobilization of catecholamines are probably implicated. The prevalence of the atherothrombotic diseases and of their ischemic complications can, in theory, be reduced by controlling hypercholesterolemia and hypertension and eliminating cigarette smoking.