Primary prevention of cardiovascular disease: implications of lipid-lowering trials

AVAILABLE LIPID-LOWERING TREATMENT: Aggressive cholesterol-lowering with 3-hydroxy-3-methylglutaryl (HMG)-coenzyme A reductase inhibitors has proved to be more effective than drugs available in the past. This treatment is safe and reduces morbidity and mortality from coronary heart disease substantially in all categories of patients at risk. The effect of treatment on clinical events is proportional to the reduction in low-density-lipoprotein cholesterol. FUTURE PROSPECTS: In the future, even more effective drugs will become available that may yield even greater benefit than has been observed in trials until now. At present, this therapy is too expensive for use in mass strategy to prevent coronary heart disease. Therefore, it should be limited to patients with a high risk. When further development brings newer drugs with a lower cost, drug treatment for cholesterol-lowering may become as widespread as antihypertensive treatment is today in order to prevent cardiovascular disease.     

Primary prevention of cardiovascular disease: Communitywide strategies for youth.

National interest in health promotion and disease prevention has led naturally to a concern with primary prevention and with youth. This attention to youth has been particularly notable in efforts to prevent injuries and chronic diseases. Specific behavior patterns that are learned in childhood and adolescence are implicated in the development of chronic diseases. These behavior patterns logically become the targets for early intervention. Over the past two decades, studies on the prevention of cardiovascular disease (CVD), the primary cause of mortality in the Western world, have become numerous and comprehensive and have included substantial work with youth. This article provides a rationale for that focus. We review promising communitywide strategies for youth and argue that communitywide strategies ought to be most efficient and efficacious for primary prevention. Both interest in and research on communitywide strategies are relatively recent; consequently, few strategies can be recommended unequivocally. The need for future research in this area by multidisciplinary teams is identified. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Compliance with cardiovascular disease prevention strategies: a review of the research

The efficacy of cardiovascular risk-reduction programs has been established. However, the extent to which risk-reduction interventions are effective may depend on adherence. Non-compliance, or non-adherence, may occur with any of the recommended or prescribed regimens and may vary across the treatment course. Compliance problems, whether occurring early or late in the treatment course, are clinically significant, as adherence is one mediator of the clinical outcome. This article, which is based on a review of the empirical literature of the past 20 years, addresses compliance across four regimens of cardiovascular risk reduction: pharmacological therapy, exercise, nutrition, and smoking cessation. The criteria for inclusion of a study in this review were: (a) focus on cardiovascular disease risk reduction; (b) report of a quantitative measure of compliance behavior; and (c) use of a randomized controlled design. Forty-six studies meeting these criteria were identified. A variety of self-report, objective, and electronic measurement methods were used across these studies. The interventions employed diverse combinations of cognitive, educational, and behavioral strategies to improve compliance in an array of settings. The strategies demonstrated to be successful in improving compliance included behavioral skill training, self-monitoring, telephone/mail contact, self-efficacy enhancement, and external cognitive aids. A series of tables summarize the intervention strategies, compliance measures, and findings, as well as the interventions demonstrated to be successful. This review reflects the progress made over two decades in compliance measurement and research and, further, advances made in the application of behavioral strategies to the promotion of cardiovascular risk reduction.     

The gynecologist and cardiovascular disease: a window of opportunity for prevention

OBJECTIVE: We present current concepts and assess the quality of information available for the prevention of cardiovascular disease in women. METHODS: This article reviews research bearing on the prevention of cardiovascular disease in women, with particular attention to modifiable risk factors. We describe the magnitude of the problem and assess the quality of the data with respect to the classic risk factors. The concept is emphasized that changes at menopause, states of endocrine aberration, and benefits and risks of hormone substitution and oral contraception must be understood in conjunction with all other potentially modifiable and nonmodifiable risk factors. CONCLUSIONS: Primary care physicians, especially obstetrician/gynecologists, have a pivotal role to play in the reduction of this disease. Behavior modification is the key to integrating prevention into the regular annual visit.     

Predisposing factors for individuals' Lyme disease prevention practices: Connecticut, Maine, and Montana

OBJECTIVES: This study examined factors that predispose individuals to protect against Lyme disease. METHODS: Knowledge, attitude, and practice questions concerning Lyme disease prevention were included in the Behavioral Risk Factor Surveillance surveys in Connecticut, Maine, and Montana. A total of 4246 persons were interviewed. RESULTS: Perceived risk of acquiring Lyme disease, knowing anyone with Lyme disease, knowledge about Lyme disease, and believing Lyme disease to be a common problem were significantly associated with prevention practices. CONCLUSIONS: Predisposing factors differ substantially between states and appear related to disease incidence. Personal risk, knowing someone with Lyme disease, and cognizance about Lyme disease and acting on this information are consistent with social learning theories.     

Primary prevention of cardiovascular disease risk factors: review and implications for population-based practice

This review analyzed the results of population-based intervention studies targeting primary prevention of cardiovascular disease risk factors among children and adolescents in the United States. In general, the findings indicate that cardiovascular disease risk factors may be amenable to interventions in school-based programs. Although the interventions have small effects on risk factor outcomes, they should be interpreted within the context of population-based approaches that ultimately may have a greater impact on disease prevention than much larger effects among the small proportion of individuals at the highest levels of risk.     

Plasma leptin concentrations: gender differences and associations with metabolic risk factors for cardiovascular disease

The cloning of the obese gene and the characterization of its protein product, leptin, has permitted the study of a new hormone potentially involved in the regulation of adipose tissue mass. The present study examined the gender differences in fasting plasma leptin concentration and its relationship to body fatness, adipose tissue distribution and the metabolic profile in samples of 91 men (mean age +/- SD: 37.3 +/- 4.8 years) and 48 women (38.5 +/- 6.8 years). Plasma leptin concentrations were strongly associated with body fat mass measured by underwater weighing [men: r = 0.80, p < 0.0001; women: r = 0.85, p < 0.0001]. In both genders, plasma leptin levels were also strongly correlated with waist girth as well as cross-sectional areas of abdominal subcutaneous and visceral adipose tissue measured by computed tomography. Women had, on average, plasma leptin concentrations that were three times higher than men. Furthermore, this gender difference remained significant when comparing men and women matched for similar levels of body fat mass. The associations between plasma leptin and lipoprotein concentrations were dependent of adiposity. In both men and women, elevated fasting plasma leptin levels were associated with higher plasma insulin concentrations, but only in women was the association maintained after correction for fat mass. Thus, results of the present study show that women have higher plasma leptin levels compared to men, independent of the concomitant variation in total body fat mass. Furthermore, our results also suggest that, in women, the association between plasma leptin and insulin concentrations is independent of adiposity, a finding which provides further support to the observation that adipose tissue leptin secretion may be upregulated by insulin.     

Secondary prevention of cardiovascular diseases in the elderly

Secondary prevention in cardiovascular diseases has its meaning also in elderly people. It is specific in some factors. The currently known facts gradually include measures which are not associated with old age of individuals. They include: influencing of the deteriorated adaptation of old organism to internal and external effects, decreased physical activity, restricted self-sufficiency, social isolation, incorrect life style, polymorbidity and subsequent polypragmatic therapy, etc.. Prolongation of life span of man, the struggle against CVD and the improvement of the quality of life of patients can be secured only by means of a complex of rational preventive measures. (Ref. 22.)     

Endothelial dysfunction in cardiovascular disease

A 34-year-old man presented with acute hemolytic anemia secondary to acute viral hepatitis A and a coexisting acute cytomegalovirus infection. This association has not been described previously in patients with glucose-6-phosphate dehydrogenase deficiency and is the subject of this report.     

Trends in cardiovascular disease in Minnesota

Nurses have long recognized the importance of self-care. In the current Information Age, nurses can use the Internet to locate computer- and non-computer-based programs and tools that encourage people to become active consumers who control decisions and actions related to their health. The Internet can support self-care in two main ways: by supplying information and by providing a medium for interactive social support. But there are pros and cons to such use of the Internet.     

Importance of increased physical activity in ambulatory cardiovascular prevention

Current trends in public health provided potential arguments to, first, intensify the recommendations of a physically active lifestyle in the primary prevention of atherosclerosis and, second, to prescribe a supervised outpatient exercise training program for secondary prevention of cardiovascular diseases. Regular physical exercise may positively influence cardiovascular risk factors (overweight, hypertension, hyperlipoproteinaemia, insulin resistance, hemostatic markers). Physical conditioning modifies the body composition in favor of an increased skeletal muscle mass, changes the eating habits, and other life style characteristics. The dietary modifications characterized by a low-fat, more vegetarian food supports the weight control and the adjustment of the other metabolic risk factors. All these changes are suitable to reduce the manifestation of atherosclerosis and to minimize the risk of an acute thromboembolic arterial occlusion. Physical conditioning on one's own initiative in primary prevention or an exercise training program supervised by health professionals in secondary prevention of atherosclerosis should predominantly include a low intensive aerobic endurance exercise training. Lactate concentration in capillary blood can be measured to objectify and regulate exercise intensity. The additional energy turnover should amount to a minimum of 1,000 kcal and a maximum of 3,500 kcal weekly. This energy expenditure could be realized either with an increased physical activity level in daily routine (e.g., stair climbing, go for a walk, gardening) or by a regular leisure-time physical exercise. A turnover of 300 kcal per session should be prescribed. In long-term clinical trials investigating the benefit of primary and secondary cardiovascular prevention a reduction of the cardiovascular mortality of about 20-30% has been demonstrated.     

Aspirin for primary prevention of cardiovascular events

OBJECTIVE: The use of aspirin for primary prevention of cardiovascular events in the general population is controversial. The purpose of this study was to create a versatile model to evaluate the effects of aspirin in the primary prevention of cardiovascular events in patients with different risk profiles. DESIGN: A Markov decision-analytic model evaluated the expected length and quality of life for the cohort's next 10 years as measured by quality-adjusted survival for the options of taking or not taking aspirin. SETTING: Hypothetical model of patients in a primary care setting. PATIENTS: Several cohorts of patients with a range of risk profiles typically seen in a primary care setting were considered. Risk factors considered included gender, age, cholesterol levels, systolic blood pressure, smoking status, diabetes, and presence of left ventricular hypertrophy. The cohorts were followed for 10 years. Outcomes were myocardial infarction, stroke, gastrointestinal bleed, ulcer, and death. MAIN RESULTS: For the cases considered, the effects of aspirin varied according to the cohort's risk profile. By taking aspirin, the lowest-risk cohort would be the most harmed with a loss of 1.8 quality-adjusted life days by taking aspirin; the highest risk cohort would achieve the most benefit with a gain of 11.3 quality-adjusted life days. Results without quality adjustment favored taking aspirin in all the cohorts, with a gain of 0.73 to 8.04 days. The decision was extremely sensitive to variations in the utility of taking aspirin and to aspirin's effects on cardiovascular mortality. The model was robust to other probability and utility changes within reasonable parameters. CONCLUSIONS: The decision of whether to take aspirin as primary prevention for cardiovascular events depends on patient risk. It is a harmful intervention for patients with no risk factors, and it is beneficial in moderate and high-risk patients. The benefits of aspirin in this population are comparable to those of other widely accepted preventive strategies. It is especially dependent on the patient's risk profile, patient preferences for the adverse effects of aspirin, and on the level of beneficial effects of aspirin on cardiovascular-related mortality.     

Thrombosis and cardiovascular disease

The use of combinatorial chemistry for the generation of new lead molecules is now a well established strategy in the drug discovery process. Central to the use of combinatorial chemistry is the design and availability of high quality building blocks which are likely to afford hits from the libraries that they generate. Herein we describe "RECAP" (Retrosynthetic Combinatorial Analysis Procedure), a new computational technique designed to address this building block issue. RECAP electronically fragments molecules based on chemical knowledge. When applied to databases of biologically active molecules this allows the identification of building block fragments rich in biologically recognized elements and privileged motifs and structures. This allows the design of building blocks and the synthesis of libraries rich in biological motifs. Application of RECAP to the Derwent World Drug Index (WDI) and the molecular fragments/ building blocks that this generates are discussed. We also describe a WDI fragment knowledge base which we have built which stores the drug motifs and mention its potential application in structure based drug design programs.