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Baraff, L.J., Lee, T.J., Kader, S. and Della Penna, R. (1999), Effect of a practice
guideline on the process of emergency department care of falls in elder patients.
Academic Emergency Medicine, 6 (12), 1216-1223.
Abstract: Objective: To determine the effect of a practice guideline on the process of ED
care in a health maintenance organization. Methods: A pre- post-intervention
comparison with a one-year pre-intervention phase followed by a one-year
post-educational intervention phase was used to study the effect of the guideline
on ED care. Emergency physicians and nurses were provided the details of the
guideline during a two-week interval between the two periods. Results: During
the two years of the study, 1,140 preintervention and 759 post-intervention
patients met study eligibility criteria. More patients were diagnosed as having
had falls due to loss of consciousness, stroke, and seizures during the
post-intervention period (pre- intervention 3.8% vs post-intervention 8.4%, p <
0.001). There was a significant improvement in documentation of six of ten
history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%),
ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%),
prescription medications (79.0% vs 92.2%), and Pneumovax immunization status
(20.8% vs 43.0%); and two of the four physical examination items: visual acuity
(1.5% vs 3.2%) and the "get up and go test" (1.3% vs 11.2%). Prescribing of
calcium and vitamin D increased from 0% to 6.6%. Conclusions: The
educational intervention to the practice guideline for the ED management of falls
in elders led to small but significant improvements in the documentation of
selected history and physical examination items and the prescribing of calcium
and vitamin D, and to a greater consideration of the causes of falls
Keywords: accidental falls-prevention and control/aged/calcium/CLINICAL
GUIDELINES/COMMUNITY/emergency medicine/geriatric
assessment/guideline/health/history/HOME/MANAGEMENT/MEDICINE/PEO
PLE/POLICY/POPULATION/practice guidelines/RANDOMIZED
TRIAL/RISK-FACTORS/status/stroke/vitamin D
Williams, J.E., Rosamond, W.D. and Morris, D.L. (2000), Stroke symptom attribution
and time to emergency department arrival: The delay in accessing stroke
healthcare study. Academic Emergency Medicine, 7 (1), 93-96.
Keywords: cerebral infarction/emergency medicine/HOSPITAL
ADMISSION/KNOWLEDGE/prevention/response
time/RISK-FACTORS/SIGNS/stroke/symptoms
Casebeer, L.L., Klapow, J.C., Centor, R.M., Stafford, M.A., Renkl, L.A., Mallinger, A.P.
and Kristofco, R.E. (1999), An intervention to increase physicians' use of
adherence- enhancing strategies in managing hypercholesterolemic patients.
Academic Medicine, 74 (12), 1334-1339.
Abstract: Purpose. Patients' lack of adherence to medical regimens frustrates many
practicing physicians. This study was conducted to determine the effectiveness of
a combined continuing medical education intervention in increasing physicians'
adherence- enhancing skills and improving hypercholesterolemic patients' health.
Method. A prospective, randomized, controlled trial was designed using a nested
cohort of 28 community physicians throughout Alabama and 222 of their
hypercholesterolemic outpatients, The intervention, carried out in 1998,
consisted of three interactive case audio-conferences plus chart reminders.
Physicians' learning was measured by unannounced standardized patients, and
patients' health by serum cholesterol levels, weight, knowledge of
hypercholesterolemia, self-reported dietary habits, and health status. Results. No
significant difference was found in the numbers of physician
adherence-enhancing strategies, although the number did increase within the
treatment group. There were significant differences in the intervention group's
patients' knowledge of cholesterol management (p =.008) and significant
reductions in their self-reported consumption of dietary fats (p =.002). A
significant difference was found in the serum cholesterol level of men in the
intervention group nine months after the intervention (p =.02), Conclusion.
Combining a series of interactive case audio-conferences with charr reminders
shows promise in increasing physicians' adherence-enhancing strategies. In
chronic disease management, the problem of enhancing adherence remains
complex
Keywords: adherence/cholesterol/chronic
disease/community/disease/education/fats/health/hypercholesterolemia/knowledg
e/men/PREVENTION/randomized/serum/status/STROKE
MORTALITY/treatment/trial/UNITED-STATES/use
Martin, J.B., Murphy, K.J., Gailloud, P., Sugiu, K., Treggiari, M.M., Muster, M.,
Guimaraens, L., Theron, J.G. and Rufenacht, D.A. (2001), In vitro evaluation of
the effectiveness of distal protection in the prevention of cerebral
thromboembolism during carotid stent placement. Academic Radiology, 8 (7),
623-628.
Abstract: Rationale and Objectives. The purpose of this in vitro study was to evaluate
and quantify the benefit of the balloon protection device, to identify the most:
effective sequence of irrigation or flushing, and to determine the most effective
catheter position to remove the maximum number of emboli or debris beneath
the flow-arrest balloon. Materials and Methods. Silicone models of the
neurovasculature were attached to a systodiastolic pump. Stents were placed in
carotid stenoses by using the distal flow protection technique. Embolic material
was released within the stent. The effectiveness of different irrigation techniques
was evaluated. Results. Aspiration under the balloon through the guiding catheter
with a 60-mL syringe followed by one power injection at 40 mL injected at 2
mL/sec will result in removal of about 98% of potential emboli from the inferior
vena cava. Conclusion. In vitro evaluation of the distal flow protection technique
indicates that it should reduce stroke risk during carotid stent placement
Keywords: ARTERY STENOSIS/BALLOON ANGIOPLASTY/carotid/carotid
stent/cerebral/DISEASE/distal
protection/emboli/ENDARTERECTOMY/evaluation/INITIAL
EXPERIENCE/prevention/protection/risk/STROKE/Switzerland/thromboemboli
sm
Verhaeghe, R. (1998), The use of low-molecular-weight heparins in cardiovascular
disease. Acta Cardiologica, 53 (1), 15-21.
Abstract: Unfractionated heparin (UFH) has been used for decades as an effective and
relatively inexpensive agent in the prevention of venous and arterial
thromboembolic events. Low-molecular-weight heparin (LMWH) preparations
are obtained by chemical or enzymatic depolymerization of unfractionated
commercial grade heparin; their mean molecular weights range from below
4,000 to about 6,500 D (Table I). Their mechanism of antithrombotic action is
basically similar to that of UFH - binding to antithrombin to inhibit activated
coagulation factors - but they have a different relative potency (to some extent
also inter-individually) of anti-Xa versus anti-tla activity. Shorter fragments
which contain the essential pentasaccharide to bind to antithrombin but lack the
required chain length to bind at the same time to thrombin, only inhibit activated
Factor X. Fragments above 5,000 D which contain the pentasaccharide maintain
their property to inhibit Factor Xa but with increasing chain length, they become
stranger inhibitors of thrombin. LMWHs have little or no effect on global tests of
blood coagulation such as the activated partial thromboplastin time when used in
prophylactic or therapeutic dosages. A specific assay of anti-Xa activity is
required to monitor biological activity but this is rarely needed. The main
advantage of LMWHs for clinical practice derive from their pharmacokinetic
properties. UFH binds to plasma proteins, endothelial cells and platelets. This
saturable mechanism clears heparin rapidly from the circulation (the plasma half-
life is non-linearly dose-related) and is held responsible for the large variation
from person to person and from moment to moment in biological and clinical
response. LMWHs bind far less to these elements and therefore have a 2 to
4-times longer plasma half-life, a markedly better bioavailability when injected
subcutaneously and a more stable dose response. They also have a lower toxic
effect in terms of heparin-induced thrombocytopenia which may be related to
their lesser interaction with platelets
Keywords: ASPIRIN/cardiovascular disease/coagulation/coronary disease/DEEP-VEIN
THROMBOSIS/DOUBLE-BLIND/ENOXAPARIN/heparin/low-molecular-weig
ht heparin/platelets/PREVENTION/PROPHYLAXIS/stroke/thromboembolic
events/thromboembolism/TOTAL HIP-REPLACEMENT/TRANSLUMINAL
CORONARY ANGIOPLASTY/UNFRACTIONATED HEPARIN/vascular
surgery/VENOUS THROMBOEMBOLISM
Suh, I. (2001), Cardiovascular mortality in Korea: a country experiencing epidemiologic
transition. Acta Cardiologica, 56 (2), 75-81.
Abstract: Background - The pattern of morbidity and mortality of cardiovascular disease
(CVD) changes with epidemiologic transition. An understanding of this pattern
in rapidly developing countries might provide important clues for the
understanding of the epidemiological trends in CVD mortality. The objective of
this paper was to address the changing pattern of CVD mortality in Korea during
the period 1984-1999, and to examine the significant changes in associated major
risk factors for CVD over a similar period. Methods - For the purpose of this
study, three main categories in CVD were reviewed: hypertensive heart disease,
ischaemic heart disease, and cerebrovascular disease (stroke). The analyses of
mortality were based on nationwide mortality data published by the National
Statistical Office from 1984 to 1999. All the mortality rates were adjusted for age
using the direct method. Changes in major CVD risk factors (blood pressure,
cigarette smoking, serum total cholesterol and diet) were also reviewed during
similar periods. Findings - During the 15-year period investigated, the
age-adjusted mortality from CVD decreased markedly. It decreased by 57% in
males (from 172.2 to 73.0/100,000) and 48% in females (from 135.5 to
70.2/100,000). The age-adjusted mortality from stroke decreased while the
proportion of ischaemic strokes among total stroke deaths increased. The
proportion increased about 5.2 times in men and 4.9 times in women,The
age-adjusted mortality from hypertensive heart disease decreased markedly. It
decreased by 92% in men (from 51.6 to 4.1/100,000) and 84% in women (from
34.1 to 5.3/100,000). Also the age-adjusted mortality from ischaemic heart
disease increased significantly. In 1999, the rates for men and women were 11.9
and 7.5/100,000, respectively. These rates were 3.8 and 3.6 times higher than the
rates in 1984 for men and women, respectively. The changes of CVD risk factors
in Korea observed during a similar period were a decrease in hypertension
prevalence, although still present at a high level, an increase in serum total
cholesterol level and intake of total fat along with a high, although decreasing,
prevalence of cigarette smoking. Interpretation - The mortality changes in Korea
are consistent with the change that occurs during the transition from the age of
receding pandemics to the age of degenerative and man-made diseases. This
study has indicated that the change of CVD mortality was closely associated with
the change in CVD risk factors. In order to avert the ongoing epidemic of CVD
in developing countries, prevention and treatment of modifiable risk factors must
become a high health priority
Keywords: age/blood pressure/cardiovascular/cardiovascular disease/cardiovascular
disease mortality/cerebrovascular/cerebrovascular disease/cholesterol/cigarette
smoking/diet/DISEASE/diseases/epidemic/epidemiologic
transition/health/heart/heart disease/hypertension/hypertension
prevalence/ischaemic/ischaemic heart
disease/Korea/men/morbidity/mortality/prevalence/prevention/risk/risk
factors/serum/smoking/stroke/stroke deaths/treatment/trends/women
Finelli, C., Palareti, G., Poggi, M., Torricelli, P., Vianelli, N., Fiacchini, M., Zuffa, E.,
Ricci, P., Gugliotta, L., Coccheri, S. and Tura, S. (1991), Ticlopidine Lowers
Plasma-Fibrinogen in Patients with Polycythemia-Rubra-Vera and Additional
Thrombotic Risk-Factors - A Double-Blind Controlled-Study. Acta
Haematologica, 85 (3), 113-118.
Abstract: Thirty-seven patients affected by polycythaemia rubra vera (PRV) and with at
least one additional thrombotic risk factor (overt vascular disease, diabetes
mellitus, treated hypertension, smoking habit, plasma hyperviscosity,
hyperfibrinogenemia) were enrolled in a double-blind randomized
placebo-controlled study, and 18 were given ticlopidine 250 mg, b.i.d., for 60
days. All the patients had previously been submitted to cytoreduction, and PRV
was under control in all cases at the start of the study. During the study, the
haematological parameters were controlled every 15 days, and venesection was
performed if haematocrit was > 46%. Whole blood viscosity, at low and high
shear rates, plasma viscosity, and fibrinogen were measured on days 0 and 60. In
the ticlopidine group, we recorded a significant 13.14% reduction of the mean
fibrinogen level after treatment (390 +/- 63 vs. 449 +/- 97 mg/dl, p < 0.01). All
the other haemorheological parameters were not significantly modified by
ticlopidine treatment, nor were there significant modifications recorded in the
placebo group. Our study shows that ticlopidine may reduce a probable
thrombotic risk factor (hyperfibrinogenemia) in PRV patients
Keywords: ASPIRIN/COMPLICATIONS/DISEASE/INTERMITTENT
CLAUDICATION/MYELOPROLIFERATIVE DISORDERS/PLASMA
FIBRINOGEN/PLASMA
VISCOSITY/PLATELET-FUNCTION/POLYCYTHEMIA-RUBRA-VERA/PO
LYCYTHEMIA-VERA/PREVENTION/STROKE/TICLOPIDINE/WHOLE
BLOOD VISCOSITY
Lechleitner, M. and Braunsteiner, H. (1991), Cerebrovascular Disorders As A
Manifestation of A Common Disease. Acta Medica Austriaca, 18 (2), 47-&.
Abstract: During the last years several risk factors for cerebrovascular disease (CVI)
could be identified by epidemiologic studies; the incidence of CVI, like that of
coronary artery disease, seems to be closely related to high blood pressure,
hyperlipidaemia, smoking and diabetes mellitus. The diagnostic difficulties in
CVI, especially concerning the localization and size of vascular lesions, explain
controversal results in the evaluation of different clinical studies. A comparison
of these results is often hard to perform also out of the different statistical
methods applied in the various trials. The development of improved diagnostic
methods, especially ultrasonography, which allow a better definition of disease
processes, offers an advantage for controlled screening and intervention trials.
After all further improvements in disease prevention as well as in diagnostic and
therapeutic procedures require an intensive co-operation between internal
medicine and neurology
Keywords: ADULTS/CAROTID-ARTERY
ATHEROSCLEROSIS/CEREBROVASCULAR DISORDERS/CORONARY
HEART-DISEASE/FACTOR INTERVENTION TRIAL/FOLLOW-
UP/MEN/MORTALITY/PREDISPOSITION/RISK FACTOR/RISK
FACTORS/SERUM-CHOLESTEROL/STROKE
Minar, E. (1991), Prevention of Cerebrovascular-Disease. Acta Medica Austriaca, 18 (2),
38-&.
Abstract: The decision for the optimal preventive and therapeutic interventions in
cerebrovascular disease depends on the underlying disease process. Therefore it
is important to identify the different pathomechanisms by modern techniques.
The significantly increased cardiovascular risk of patients with atherosclerotic
extracranial arterial disease - even when neurologically asymptomatic - makes
identification and elimination of all vascular risk factors of crucial importance
for primary and secondary prevention. The low risk of stroke without prior
transient ischemic attacks makes prophylactic carotid surgery not advisable in
asymptomatic patients. Regular controls by sonography are necessary to identify
patients with progression of carotid stenosis, and the patients should be informed
about warning symptoms of threatening stroke. Secondary prevention with
antiplatelet agents (aspirin, ticlopidine) proved effective in patients with
cerebrovascular diseases by significant reduction in mortality and in the
incidence of stroke and myocardial infarction. The optimum dose of aspirin is
not known. Patients with atherosclerotic lesions of the major cerebral arteries
have not been shown convincingly to benefit from long-term anticoagulation,
while the risk of bleeding complications is increased significantly. Major clinical
trials have been initiated to evaluate the benefit of carotid endarterectomy.
Anticoagulation therapy can reduce the risk of cardiogenic emboli. Recently it
was demonstrated that also aspirin seems effective in reducing incidence of
thromboembolic complications in patients with chronic atrial fibrillation. The
start of anticoagulant therapy after cerebral embolism depends mainly on CT
scan findings
Keywords: ANTICOAGULANT-
THERAPY/ANTICOAGULATION/ANTIPLATELET
AGENTS/ANTITHROMBOTIC THERAPY/CARDIOGENIC
EMBOLISM/CAROTID-ARTERY/CEREBRAL-ISCHEMIA/CEREBROVASC
ULAR DISEASE/CHRONIC ATRIAL-FIBRILLATION/CT/LOW- DOSE
ASPIRIN/NATURAL-HISTORY/PREVENTION/RANDOMIZED
TRIAL/SECONDARY PREVENTION/TRANSIENT ISCHEMIC ATTACKS
Polterauer, P., Prager, M., Kretschmer, G. and Huk, I. (1991), Stroke Prevention by
Carotid-Artery Endarterectomy - Technique, Indication, Results. Acta Medica
Austriaca, 18 (2), 51-55.
Abstract: Carotid artery endarterectomy (CAE) is a surgical standard procedure today.
The indication is the symptomatic patient (Stage II) with transient ischemic
attacks (TIA) and stenosis of the internal carotid artery (ACI). Data of several
studies have yielded a highly restrictive policy toward operative procedures in
asymptomatic patients (Stage I) with carotid bruit or ACI-stenosis. Furthermore
there emerged wide consensus, that patients with frank stroke (Stage III) should
not be operated upon. As diagnostic procedures highly advanced non invasive
procedures came up during the last decade, as well as computerized tomography
and digital substraction angiography. The operative procedure is performed in
general anesthesia with controlled hypertension during the clamping period (n =
650). Perioperative results without using a shunt are not different to those with a
shunt. During the last 5 year period our results yielded a 1% perioperative central
permanent neurological deficit rate (CPNDR) and a 1% operative mortality.
During a 51 months median observation period 1.5% presented again with
transient ischemic attacks-with TIA; 0.6% developed a stroke and 2.2%
decreased by cerebral complications yielding at totally 4.3% long term
complication rate. The annual rates are 0.3%, 0.1% respectively 0.5%, totally
0.9%. In conclusion CAE can be offered as a safe surgical stroke preventing
procedure in symptomatic TIA patients with ACI stenoses in our institution.
Perioperative as well as long term results are yielding a high standard and are
clearly better than those without operation
Keywords: CAROTID ARTERY ENDARTERECTOMY/CEREBROVASCULAR
INSUFFICIENCY/DISEASE/RISK/SHUNT/TIA/TRANSIENT ISCHEMIC
ATTACKS
Brainin, M. (1995), Treatment of Hypertension and Stroke - Acute Stroke, Primary and
Secondary Prevention. Acta Medica Austriaca, 22 (3), 54-57.
Abstract: Arterial hypertension represents the single most important treatable risk factor
for stroke, therefore antihypertensive treatment is crucial. Observational studies
have shown that in the acute phase of an ischemic stroke blood pressure is
elevated during the first few days and helps to restore cerebral perfusion,
activates collateral arterial supply and enhances the treatment goal of minimizing
infarct size. Especially for acute ischemic strokes with stable deficits drug
treatment of hypertension therefore is recommended only at systolic pressures of
greater than or equal to 220 mm Hg or with diastolic pressures of greater than or
equal to 120 mm Hg except when heart, lung or renal failure are also present. In
primary prevention of stroke there is a large potential for hypertension treatment
which reduces the relative risk by 42%. Especially elderly people with moderate
hypertension should be treated. One vascular event per year can be avoided in
100 patient treatment years. Only scarce data exist on secondary prevention of
stroke which show that hypertension treatment has a major importance for the
modification of risk factors
Keywords: ADMISSION BLOOD-PRESSURE/antihypertensive treatment/blood
pressure/CEREBRAL INFARCTION/CEREBROVASCULAR
DISEASES/elderly/ELDERLY
HYPERTENSIVES/heart/HYPERTENSION/ischemic
stroke/PREVENTION/primary prevention/RECURRENCE/relative
risk/RISK/risk factors/secondary prevention/stroke/treatment/TRIALS/vascular
Lang, W., Domanovits, H. and Gorzer, H. (1999), Ischemic stroke: New ways of
treatment. Acta Medica Austriaca, 26 (2), 57-69.
Abstract: Recent randomized placebo-controlled studies have introduced new concepts
in the therapy of acute ischemic stroke, such as thrombolysis either with
intraarterial or intravenous administration, lowering of the level of fibrinogen or
administration of aspirin. High dosis of heparin may be useful only in certain
groups of patients. Stroke units proved to be effective in the acute care of stroke
patients. Further advances are achieved by the introduction of new anti-platelet
drugs in secondary stroke prevention and by precise definitions of the criteria for
carotid surgery
Keywords: acute/acute ischemic
stroke/administration/AMERICAN-HEART-ASSOCIATION/antiplatelet/antipla
telet drugs/ANTITHROMBOTIC
THERAPY/aspirin/Austria/carotid/CEREBRAL-
ISCHEMIA/drugs/fibrinogen/GENERAL MEDICAL
WARDS/HEALTH-CARE-PROFESSIONALS/heparin/INFARCTION/INTRA
VENOUS THROMBOLYSIS/ischemic/ischemic stroke/new
concepts/prevention/randomized/RANDOMIZED TRIAL/secondary
prevention/secondary stroke
prevention/SPECIAL-WRITING-GROUP/stroke/stroke prevention/stroke
unit/surgery/therapy/thrombolysis/THROMBOLYTIC THERAPY/treatment
Huber, J., Stollberger, C., Finsterer, J., Schneider, B. and Langer, T. (2003), Quality of
blood pressure control and risk of cerebral bleeding in patients with oral
anticoagulation. Acta Medica Austriaca , 30 (1), 6-9.
Abstract: Background: We assessed how many patients on long-term oral
anticoagulation (OAC) (i) suffer from arterial hypertension (AH), (ii) are aware
of AH, (iii) need improvement of their therapy and (iv) suffer from cerebral
bleeding. Methods: Outpatients on long-term OAC were asked to measure blood
pressure at least 4 times. Blood pressure was classified as normotensive if at least
75 % of all measurements were < 139/89 mm Hg; as mild/moderate AH if > 25
% of all measurements were 140 - 179 mm Hg systolic or 90 - 109 mm Hg
diastolic; and as severe AH if > 25 % of all measurements were > 180 mm Hg
systolic or > 110 mm Hg diastolic. Bleeding complications were registered.
Results: Of the 235 patients (108 female, 67 +/- 12 years), 80 % suffered from
AH. Severe AH was present in 5 %. Only 56 % were aware of suffering from
AH. An improvement of antihypertensive therapy was needed in 64 %. Over 225
days, only one cerebral bleeding occurred. Blood pressure was normotensive in
30 % with known AH. Conclusions: Blood pressure control seems better in OAC
patients than in normals, if the patient is aware of AH. Patients with AH on OAC
are not aware of AH in > 50 %. Repeated blood pressure measurements in OAC
are recommended, even if patients are not aware of AH
Keywords: anticoagulation/antihypertensive therapy/ANTITHROMBOTIC
THERAPY/arterial/arterial hypertension/Austria/AWARENESS/bleeding/blood
pressure/blood pressure control/cerebral/cerebral bleeding/CHRONIC
ATRIAL-FIBRILLATION/COMPLICATIONS/control/HYPERTENSION/oral
anticoagulation/PREVALENCE/PREVENTION/risk/STROKE/therapy/UNIVE
RSITY HOSPITALS/WARFARIN USE
Schick, U., Zimmermann, M. and Stolke, D. (1996), Long-term evaluation of EG-IC
bypass patency. Acta Neurochirurgica, 138 (8), 938-942.
Abstract: The EC-IC Bypass Study Group could not detect any benefit from surgery
compared to medical management in the prevention of strokes in 1985 [15].
During the past years surgical revascularization was re-evaluated and considered
as an appropriate treatment for a small subgroup of patients with recurrent focal
cerebral ischaemia and impaired haemodynamics. This retrospective study
examines the long-term benefit and patency rats of bypass. We present a
follow-up of 5.6 years of 47 patients, all of whom underwent bypass surgery
after 1985. Forty patients suffered recurring transient ischaemic attacks due to
uni- or bilateral internal carotid artery occlusion. Examination included
neurologic status, TCD with CO2 or Diamox challenge, angiography, CT and
SPECT scans. Neurological improvement was seen in 23% of patients with
better results after early surgery, a worsening in 22% suffering further ischaemic
events on a postoperative average of 2.8 years. Patency rate for vein graft
material was 50%, for the STA-MCA procedure 91%. Occlusion of the vein graft
occurred on an average after 1.4 years, other anastomosis after 2.7 years. We
conclude that only few patients derived long-term benefit from EC-IC bypasses.
Functioning of the bypass worsens over time, suggesting a role for surgery
predominantly in the first year of ischaemic events due to insufficient collateral
supply. Actual indications for bypass surgery may be patients with failure of
maximal medical therapy and progressive ischaemia and haemodynamic
compromise
Keywords: ACETAZOLAMIDE/bypass function/bypass grafting/CEREBRAL
BLOOD-FLOW/cerebrovascular reserve capacity/CEREBROVASCULAR
RESERVE CAPACITY/CT/DISEASE/EC-IC bypass/focal/INTERNAL
CAROTID-ARTERY/ischaemia/ISCHEMIA/OCCLUSION/prevention/rats/RE
ACTIVITY/STROKE/SURGERY/treatment
Lowenthal, A. (1988), European Stroke Prevention Study. Acta Neurologica Belgica,
88 (1), 14-18
Lowenthal, A. and Buyse, M. (1994), Secondary Prevention of Stroke - Does
Dipyridamole Add to Aspirin. Acta Neurologica Belgica, 94 (1), 24-34.
Abstract: Background and Purpose : The purpose of this paper is to evaluate, in the light
of all available evidence, the place of aspirin alone and of aspirin combined with
dipyridamole in the secondary prevention of cerebrovascular accidents. Methods :
We performed a meta-analysis of all identified double blind, controlled, studies
in secondary prevention of cerebrovascular accidents for the following
categories : studies comparing aspirin with placebo ; studies comparing aspirin
plus dipyridamole with placebo ; studies comparing aspirin plus dipyridamole
with aspirin alone. An indirect comparison was carried out to compare the results
obtained with aspirin alone and those obtained with aspirin combined with
dipyridamole. Results : The meta-analysis of trials involving aspirin alone
against placebo showed a risk reduction on strokes (17% reduction, p = 0.02),
''important vascular events'', i.e. a combination of vascular deaths, non-fatal
strokes and non-fatal myocardial infarction (18% reduction, p = 0.003). Fatal
vascular events (vascular deaths and fatal strokes) did not seem to be reduced at
all. The overall mortality was reduced by 10%, but this reduction failed to reach
statistical significance (p = 0.23). The meta-analysis of trials involving aspirin
combined with dipyridamole showed more important risk reductions on every
outcome whether fatal or not. Strokes were reduced by 42% (p < 0.001), fatal
strokes by 43% (p = 0.02) and vascular deaths by 24% (p = 0.07, not significant).
The overall mortality was reduced by 30% (p = 0.004). Direct comparisons of
aspirin with aspirin plus dipyridamole did not indicate differences between the
two treatment regimens. However the sample sizes involved in these
comparisons were far too small to be informative. Indirect comparisons yielded
statistically significant results in favour of the combination in terms of
''important vascular events'' (p = 0.007), all strokes (p = 0.007) and fatal strokes
(p = 0.03). The results were also in favour of the combination but not statistically
significant in terms of all deaths (p = 0.10) and vascular deaths (p = 0.08).
Conclusions : Aspirin used alone reduces secondary occurrence of vascular
events in cerebrovascular patients. There is no evidence, however, of a reduction
of fatal events (vascular deaths and fatal strokes). In contrast, aspirin in
combination with dipyridamole reduces non-fatal as well as fatal events. These
results as well as the indirect comparisons of the risk reductions suggest that the
combination of aspirin with dipyridamole may be superior to aspirin alone ; this
hypothesis is presently tested in a large randomized trial
Keywords: ASPIRIN/CEREBRAL-ISCHEMIA/CEREBROVASCULAR
ACCIDENTS/CONTROLLED TRIAL/DIPYRIDAMOLE/DRUG/LOW-DOSE
ASPIRIN/METAANALYSIS/mortality/myocardial
infarction/prevention/risk/SECONDARY
PREVENTION/treatment/trials/vascular
Laloux, P. (2003), Statins and stroke prevention. Acta Neurologica Belgica, 103 (1),
13-18
Keywords: ATHEROSCLEROSIS/cerebrovascular disease/CHOLESTEROL
LEVELS/CORONARY-HEART-DISEASE/hydroxymethylglutaryl-CoA
reductase
inhibitors/MEN/MYOCARDIAL-INFARCTION/PRAVASTATIN/prevention/R
EDUCTION/RISK-FACTORS/SERUM-CHOLESTEROL/statins/stroke/stroke
prevention/TRIALS
Sorensen, P.S., Pedersen, H., Marquardsen, J., Petersson, H., Heltberg, A., Simonsen, N.,
Munck, O. and Andersen, L.A. (1982), Acetylsalicyclic Acid in the Prevention of
Stroke in Patients with Reversible Ischemic Attacks. Acta Neurologica
Scandinavica, 65 176-177
Keywords: COPENHAGEN
Matiasguiu, J., Davalos, A., Pico, M., Monasterio, J., Vilaseca, J. and Codina, A. (1987),
Low-Dose Acetylsalicylic-Acid (Asa) Plus Dipyridamole Versus Dipyridamole
Alone in the Prevention of Stroke in Patients with Reversible Ischemic Attacks.
Acta Neurologica Scandinavica, 76 (6), 413-421
Keywords: COPENHAGEN
Sivenius, J., Riekkinen, P.J., Kilpelainen, H., Laakso, M. and Penttila, I. (1991),
Antiplatelet Therapy Is Effective in the Prevention of Stroke Or Death in Women
- Subgroup Analysis of the European Stroke Prevention Study (Esps). Acta
Neurologica Scandinavica, 84 (4), 286-290.
Abstract: Previous stroke prevention studies have suggested that the efficacy of
antiplatelet therapy may be less in women than in men. This however, could be
due to the small number of women in these trials and the low incidence of cases
among female subjects. The European Stroke Prevention Study was a multicenter
trial comparing the effect of a combination of dipyridamole 75 mg t.i.d and
acetylsalicylic acid 330 mg t.i.d. to placebo in the secondary prevention of stroke
or death after one or more recent attacks of TIA (transient ischemic attack),
RIND (reversible ischemic neurological deficit) or stroke of atherothrombotic
origin. From the 2500 patients recruited, 1307 patients were from a single center,
Kuopio, East Finland. Forty-five percent of the patients were women. The
number of end-point events (stroke or death from any cause) in women was
one-third lower than that in men. End-point reduction in the treatment group was
about 50% in women and about 40% in men, significantly lower than in the
placebo group in both sexes. Thus, in the relatively randomly selected patient
population from one Finnish center, a combination of dipyridamole and
acetylsalicylic acid is as effective in women as in men in the prevention of stroke
or death. It is unclear, however, whether this beneficial effect in both sexes is due
to aspirin only or to the combination therapy of aspirin and dipyridamole
Keywords: ACETYLSALICYLIC ACID/ASPIRIN/CEREBROVASCULAR
DISEASES/DIPYRIDAMOLE/PLATELET-AGGREGATION/PREVENTION/
RISK/SEX-DIFFERENCES/TIA/TRIAL/WHOLE-BLOOD
Gallerani, M., Manfredini, R., Ricci, L., Cocurullo, A., Goldoni, C., Bigoni, M. and
Fersini, C. (1993), Chronobiological Aspects of Acute Cerebrovascular Diseases.
Acta Neurologica Scandinavica, 87 (6), 482-487.
Abstract: The study was aimed at further investigating the circadian and circannual
patterns of stroke onset. Study design and type of participants: 977 strokes (475
in men and 502 in women) concerning 926 subjects (457 men and 469 women)
admitted to Ferrara Hospital in two calendar years (1990-1991), were
prospectively investigated. The strokes were classified as based on cerebral
infarction (CI), transient ischemic attack (TIA) and cerebral hemorrhage (CH:
subarachnoid and intracerebral hemorrhage). Two statistical models of analysis
were used. The assessment of circadian and circannual periodicity was
performed utilizing the single cosinor method. A separate analysis was
performed after distribution of events into 6-hour intervals, and chi-square test
for fit was applied to the number of observed versus expected cases. The
majority of strokes occurred in the morning between 7 a.m. and noon (35% of
cases) and the hypothesis of a uniform distribution of the time onset was rejected
on the basis of the chi-square for all subtypes of stroke. A circadian rhythm was
found for CI and TIA with acrophase at the 11.56 and 12.41 respectively. Also a
circannual periodicity was found for CI with a prevalent peak in October. The
spectral analysis detected a circadian cycle for CH having a period of 4 h, and a
circannual cycle for TIA with a period of 4 months. This study confirms that
stroke is a high-chronorisk disease, with specific circadian and circannual
rhythms. This is very important for a better understanding and control of the
underlying factors and in terms of prevention
Keywords: BLOOD-PRESSURE/CEREBRAL HEMORRHAGE/CEREBRAL
INFARCTION/CIRCADIAN RHYTHM/CIRCADIAN
VARIATION/CIRCANNUAL
RHYTHM/DIURNAL-VARIATION/FIBRINOLYTIC-ACTIVITY/ISCHEMIC
STROKE/MORNING INCREASE/MYOCARDIAL-
INFARCTION/PLATELET
AGGREGABILITY/SEASONAL-VARIATION/SUDDEN CARDIAC
DEATH/TRANSIENT ISCHEMIC ATTACK
Sivenius, J., Riekkinen, P.J., Laakso, M., Smets, P. and Lowenthal, A. (1993), European
Stroke Prevention Study (Esps) - Antithrombotic Therapy Is Also Effective in
the Elderly. Acta Neurologica Scandinavica, 87 (2), 111-114.
Abstract: The ESPS was a multicenter study comparing the effect of the combination of
dipyridamole 75 mg and acetylsalicylic acid 330 mg t.i.d. to placebo in 2500
patients (intention-to-treat analysis) and 1861 patients (explanatory analysis) in
the secondary prevention of stroke or death after one or more attacks of TIA,
RIND or stroke of atherothrombotic origin. End- point reduction was evaluated
in two age groups, those not older than 65 years (1358 patients) and those who
were older than 65 years (1142 patients). End-point reduction was significantly
greater in patients with active therapy than in the placebo group in both age
groups. Subgroup analyses with stroke as an end-point indicated that younger
patients with TIA (less-than-or-equal-to 65 years) had lower risk of stroke than
those > 65 years or patients with stroke. The overall risk reduction was best in
TIA patients > 65 years of age. The risk reduction with study medication was
40-50% in both sexes and in both age groups. Thus, age of the patient does not
influence the efficacy of antithrombotic therapy. However, since these results are
obtained from a secondary analysis of a subgroup of patients, the results may
need confirmation by further studies
Keywords: ASPIRIN/CEREBRAL-ISCHEMIA/CONTROLLED TRIAL/TRANSIENT
ISCHEMIC ATTACKS
Farina, E., Magni, E., Ambrosini, F., Manfredini, R., Binda, A., Sina, C. and Mariani, C.
(1997), Neuropsychological deficits in asymptomatic atrial fibrillation. Acta
Neurologica Scandinavica, 96 (5), 310-316.
Abstract: Objective - To assess the preclinical effects on cognitive functions of
nonrheumatic atrial fibrillation (NRAF) in patients with negative history for
cerebrovascular disease. Materials and methods - The study included 37
consecutive patients with chronic (n=16, mean age 65.3+/-6.6 years) or
paroxysmal (n=21, mean age 58.3+/-9.5 years) NRAF and an equal number of
control subjects in sinus rhythm, who were matched for age, education and
presence of hypertension, A comprehensive neuropsychological battery
including tests of attention, memory, language and visuospatial skills was
administered. Results - Patients with chronic NRAF showed significantly poorer
performances in tasks exploring attention and verbal memory functions, while
the paroxysmal group was significantly impaired in a long-term memory task,
The neuropsychological findings were confirmed excluding from both groups
patients viith CT evidence of cerebrovascular damage. A small subgroup of
patients was also submitted to cerebral MRI. Conclusion - Neurologically
asymptomatic NRAF is related to a subclinical but significant impairment in
attention and memory. These deficits could be produced by minor ischemic
lesions due to microembolization, or by diffuse hypoxic damage due to
hypoperfusion
Keywords: age/asymptomatic/atrial fibrillation/cerebral/CEREBRAL
BLOOD-FLOW/cerebrovascular/cerebrovascular disease/cognitive
impairment/COMPLICATIONS/control/COPENHAGEN/CT/DISEASE/educati
on/EPIDEMIOLOGIC
FEATURES/fibrillation/history/HYPERTENSION/INFARCTION/ischemic/MR
I/neuropsychological tests/PREVENTION/RISK/STROKE/VASCULAR
DEMENTIA
Sivenius, J., Cunha, L., Diener, H.C., Forbes, C., Laakso, M., Lowenthal, A., Smets, P.
and Riekkinen, P. (1999), Second European Stroke Prevention Study: antiplatelet
therapy is effective regardless of age. Acta Neurologica Scandinavica, 99 (1),
54-60.
Abstract: Background - The Second European Stroke Prevention Study (ESPS2) was a
randomized, placebo-controlled trial that investigated the efficacy of low-dose
acetylsalicylic acid (ASA) and modified-release dipyridamole (DP), alone or in
combination, in the secondary prevention of ischemic stroke. The trial
demonstrated that the combination was significantly more effective than either
agent used alone. The aim of the present study was to evaluate the influence of
age on the efficacy of ASA and DP, alone or in combination, in the secondary
prevention of stroke in the ESPS2 population. Methods and results - A total of
6602 patients were recruited to the ESPS2 and there were 4 treatment groups:
ASA (25 mg twice daily), DP (200 mg twice daily), ASA and DP in a combined
formulation, or placebo. Primary endpoints were stroke, death, and stroke or
death together. The endpoints evaluated in the present study were stroke, stroke
and/or death, and vascular events. Stroke was the qualifying event in 76% of the
patients, while 24% had a transient ischaemic attack. Patients were reviewed at
3-month intervals for 2 years. The study population consisted of 2565 (39%)
patients aged less than 65 years, 2240 (34%) patients aged between 65 and 74
years, and 1797 (27%) patients aged 75 years and over, Advancing age was
associated with an increased incidence of endpoints in all 4 treatment groups.
The combination of ASA and DP significantly reduced the incidence of all
endpoints, compared with placebo, in each age group. There was no influence of
age on the efficacy of antiplatelet therapy for any of the evaluated endpoints.
Relative risk reductions of treatment compared with placebo were 11.1-27.6% in
the ASA group, 8.0-18.7% in the DP group, and 20.3-45.2% in patients receiving
combination therapy. Conclusion - This study clearly demonstrates that
combination therapy with DP and ASA is superior to either agent used alone in
the secondary prevention of ischemic stroke, irrespective of the age of the patient
Keywords: acetylsalicylic acid/age/aged/antiplatelet/antiplatelet therapy/cerebrovascular
disease/COPENHAGEN/DENMARK/dipyridamole/Finland/incidence/ischemic/
ischemic stroke/population/prevention/randomized/risk/secondary
prevention/stroke/therapy/transient/treatment/vascular
Arboix, A., Morcillo, C., Garcia-Eroles, L., Oliveres, M., Massons, J. and Targa, C.
(2000), Different vascular risk factor profiles in ischemic stroke subtypes: a
study from the "Sagrat Cor Hospital of Barcelona Stroke Registry". Acta
Neurologica Scandinavica, 102 (4), 264-270.
Abstract: To characterize the vascular risk factor profiles in different subtypes of
ischemic stroke. Material and methods - The study population consisted of 1473
consecutive ischemic stroke patients collected in a prospective stroke registry.
The prevalence of vascular risk factors in each stroke subtype was analyzed
independently and in comparison with other subtypes of stroke pooled together
by means of univariate analysis and logistic regression models. Results
Hypertension was present in 52% of patients followed by atrial fibrillation in
27% and diabetes in 20"/o. The pattern of risk factors associated with
atherothrombotic stroke included chronic obstructive pulmonary disease (COPD)
(odds ratio [OR] = 2.63), hypertension (OR = 2.55), diabetes (OR = 2.26),
transient ischemic attack (OR = 1.61), and age (OR = 1.03). Previous cerebral
hemorrhage (OR =4.72), hypertension (OR =4.29), obesity (OR = 2.45), and
diabetes (OR = 1.73) were strong predictors of lacunar stroke. In the case of
cardioembolic stroke, atrial fibrillation (OR =22.24), valvular heart disease (OR
= 10.97), and female gender (OR = 1.66) occurred more frequently among
patients with this stroke subtype than among the other stroke subtypes combined.
Conclusion - Different potentially modifiable vascular risk factor profiles were
identified for each subtype of ischemic stroke, particularly COPD in the case of
atherothrombotic stroke and previous cerebral hemorrhage and hypertension in
the case of lacunar infarction
Keywords: age/ASSOCIATION/atrial fibrillation/BODY-FAT/cardioembolic
stroke/cerebral/cerebral hemorrhage/CEREBRAL INFARCTION/cerebral
infarction/CEREBROVASCULAR-DISEASE/cigarette
smoking/CIGARETTE-SMOKING/CONSECUTIVE
PATIENTS/COPENHAGEN/DENMARK/diabetes/diabetes
mellitus/fibrillation/heart/heart
disease/hemorrhage/hypertension/infarction/ischemic/ischemic stroke/lacunar
infarction/LACUNAR INFARCTS/lacunar
stroke/lifestyle/MORTALITY/obesity/POPULATION/predictors/prevalence/PR
EVENTION/risk/risk factor/risk factors/Spain/stroke/transient/transient ischemic
attack/vascular/vascular risk factors
Szolnoki, Z., Somogyvari, F., Kondacs, A., Szabo, M. and Fodor, L. (2001), Evaluation
of the roles of common genetic mutations in leukoaraiosis. Acta Neurologica
Scandinavica, 104 (5), 281-287.
Abstract: Objectives - Leukoaraiosis, a relatively frequent neuroimaging entity, is
presumed to be primarily a vascular problem. However, it can be explained only
in part by vascular risk factors. With the assumption of genetic susceptibility, the
roles of common genetic polymorphisms and mutations in leukoaraiosis were
examined in this study. Material and methods - A detailed clinical scrutiny of
843 Hungarian neurological patients with mild cognitive-like complaints
revealed 229 subjects with leukoaraiosis that was probably vascular in origin:
143 with leukoaraiosis alone (group 1), and 86 with leukoaraiosis plus cerebral
infarction (group 2). In all 229 patients, the methylenetetrahydrofolate reductase
C677T (MTHFR C677T) mutation and angiotensin-converting enzyme (ACE
I/D) polymorphism were examined by means of the PCR technique. The
prevalences of the different genotypes for the examined mutations in the 2
groups were analysed in comparison with the data on 362 neuroimaging
alteration-free subjects as controls. Results - The ACE D/D genotype (38.37%, P
< 0.0005; OR 2.46, 95% CI, 1.49-4.08) and ACE D allele (61%,; P < 0.001)
were more frequent in group 2 than in the control group (20.17%; 47%). Neither
the homozygous nor the heterozygous MTHFR C677T mutation alone was found
to be a risk factor for leukoaraiosis. The homozygous MTHFR C677T mutation
combined with the ACE D/D genotype was significantly more frequent in group
1 (11.89%), P < 0.0005; OR 4.75, 95% CI, 2.12-10.65), in group 2 (12.79%, P
<0.0005; OR 5.16, 95% CI, 2.12-12.6) and in combined group 1 + 2 (12.23%, P
<0.0005: OR 4.9, 95% CI, 2.33-10.3) than in the control group (2.76%).
Conclusion - These data indicate that the contributions of the ACE D/D genotype
and the homozygous MTHFR C677T mutation to leukoaraiosis should be taken
into consideration not as major, but as additive factors. These findings draw
attention to the fact that genetic polymorphisms that alone are insignificant can
be risk factors for leukoaraiosis if they cluster in the same subjects
Keywords: ACE I/D polymorphism/ACUTE ISCHEMIC STROKE/AUSTRIAN
STROKE
PREVENTION/BINSWANGER-DISEASE/BLOOD-PRESSURE/cerebral/cereb
ral infarction/control/COPENHAGEN/DELETION
POLYMORPHISM/DENMARK/genetic/genetic interaction/genetic risk
factors/HYPERTENSIVE PATIENTS/infarction/leukoaraiosis/MTHFR C677T
mutation/mutation/NEUROLOGIC FINDINGS/risk/risk factor/risk
factors/SCAN LEUKO-ARAIOSIS/vascular/vascular risk factors/VASCULAR
RISK-FACTORS/WHITE MATTER LUCENCIES
Hillbom, M., Erila, T., Sotaniemi, K., Tatlisumak, T., Sarna, S. and Kaste, M. (2002),
Enoxaparin vs heparin for prevention of deep-vein thrombosis in acute ischaemic
stroke: a randomized, double-blind study. Acta Neurologica Scandinavica, 106
(2), 84-92.
Abstract: Objectives To compare the efficacy, safety, and overall risk benefit pro le of
enoxaparin and unfractionated heparin (UFH) prophylaxis of venous
thromboembolic complications in patients with acute ischaemic stroke. Methods
- Patients with ischaemic stroke resulting in lower-limb paralysis lasting for at
least 24 h and necessitating bedrest, were randomized within 48 h of the onset of
stroke, and treated with enoxaparin ( 40 mg subcutaneously once daily) or UFH
( 5000 IU subcutaneously thrice daily) for 10 2 days. Main outcome measures
were deep- vein thrombosis, pulmonary embolism ( PE), death from any cause,
intracranial haemorrhage including haemorrhagic infarction, or any other major
bleeding. Results Outcome events occurred within 3 months of stroke in 40/106
patients treated with enoxaparin (37.7%) and 52/106 patients treated with UFH
(49.1%, P = 0.127). Fewer patients treated with enoxaparin ( 14, 13.2%) than
with UFH ( 20, 18.9%) had evidence of haemorrhagic transformation of
ischaemic stroke. Conclusions Enoxaparin administered subcutaneously once
daily was as safe and effective as subcutaneous UFH given thrice daily in the
prevention of thromboembolic events in patients with lower limb paralysis
caused by acute ischaemic stroke
Keywords: acute/ACUTE ISCHEMIC
STROKE/bleeding/COMPLICATIONS/COPENHAGEN/death/deep vein
thrombosis/deep-vein
thrombosis/DENMARK/embolism/enoxaparin/Finland/haemorrhage/heparin/inf
arction/intracranial-haemorrhage/ischaemic/ischaemic stroke/LOW-DOSE
HEPARIN/low-molecular-weight heparin/MOLECULAR-WEIGHT
HEPARIN/ORTHOPEDIC- SURGERY/outcome/PLACEBO- CONTROLLED
TRIAL/prevention/PROPHYLAXIS/pulmonary/pulmonary
embolism/randomized/risk/safety/stroke/thromboembolic
complications/thromboembolic events/thromboprophylaxis/thrombosis/TOTAL
HIP-REPLACEMENT/UNFRACTIONATED HEPARIN/VENOUS
THROMBOEMBOLISM
Schmitt, A.B., Buss, A., Breuer, S., Brook, G.A., Pech, K., Martin, D., Schoenen, J.,
Noth, J., Love, S., Schroder, J.M., Kreutzberg, G.W. and Nacimiento, W. (2000),
Major histocompatibility complex class II expression by activated microglia
caudal to lesions of descending tracts in the human spinal cord is not associated
with a T cell response. Acta Neuropathologica, 100 (5), 528-536.
Abstract: Lesion-induced microglial/macrophage responses were investigated in
post-mortem human spinal cord tissue of 20 patients who had died at a range of
survival times after spinal trauma or brain infarction. Caudal to the spinal cord
injury or brain infarction, a strong increase in the number of activated microglial
cells was observed within the denervated intermediate grey matter and ventral
horn of patients who died shortly after the insult (4-14 days). These cells were
positive for the leucocyte common antigen (LCA) and for the major
histocompatibility complex class II antigen (MHC II), with only a small
proportion staining for the CD68 antigen. After longer survival times (1-4
months), MHC II-immunoreactivity (MHC II- IR) was clearly reduced in the
grey matter but abundant in the white matter, specifically within the degenerating
corticospinal tract, co-localising with CD68. In this fibre tract, elevated MHC
II-IR and CD68-IR were still detectable 1 year after trauma or stroke. It is likely
that the subsequent expression of CD68 on MHC II-positive microglia reflects
the conversion to a macrophage phenotype, when cells are phagocytosing
degenerating presynaptic terminals in rey matter target regions at early survival
times and removing axonal and myelin debris in descending tracts at later
survival times. No T or B cell invasion or involvement of co-stimulatory B7
molecules (CD80 and CD86) was observed. It is possible that the up-regulation
of MHC II an microglia that lack the expression of B7 molecules may be
responsible for the prevention of a T cell response, thus protecting the spinal
cord from secondary tissue damage
Keywords: ANTIGEN EXPRESSION/B-CELLS/B7
molecules/brain/CENTRAL-NERVOUS-SYSTEM/CLONAL
ANERGY/Germany/HLA-DR/human/infarction/INFLAMMATORY
BRAIN-LESIONS/INTERFERON-GAMMA/macrophage/MACROPHAGE
RESPONSES/NEUROLOGICAL DISEASE/NEW-YORK/prevention/spinal
cord injury/stroke/WALLERIAN DEGENERATION/white matter
Borstad, E., Urdal, K., Handeland, G. and Abildgaard, U. (1992), Comparison of
Low-Molecular-Weight Heparin Vs Unfractionated Heparin in Gynecological
Surgery .2. Reduced Dose of Low- Molecular-Weight Heparin. Acta Obstetricia
et Gynecologica Scandinavica, 71 (6), 471-475.
Abstract: In a double blind, randomized trial the hemorrhagic complications of a reduced
dose of low molecular weight heparin (LMWH) (Fragmin, KabiPharmacia) were
compared to those of the conventional dose of unfractionated heparin (UH). 2500
anti-XaU of LMWH was given once daily and UH in a dose of 5000 anti-XaU
twice daily. During a one year period 141 patients undergoing gynecological
surgery were included in this study. The patients were examined clinically for
hematomas and for deep venous thrombosis (DVT) on the third and fifth day.
Venography was performed when DVT was suspected. No patients developed
clinical DVT. One woman in the LMWH group had pulmonary embolism 3 days
after the prophylaxis was stopped. Two women in the LMWH group died, one
from a stroke on day 2, one from cancer on day 39. There was no significant
difference in serious bleeding complications between the two regimens, 20% in
the LMWH group and 14% in the UH group. Even with the reduced dose of
LMWH the mean plasma concentration of heparin in the LMWH group was
higher (mean 0.14 anti-XaU/ml) than in the UH group (0.029 anti-XaU/ml) 3
hours after injection on the 2nd postoperative day. A reduced dose of LMWH
(2500 anti XaU once daily) does not cause more bleeding complications than the
conventional heparin regimen to prevent thrombosis, as was the case in our
previous study with 500 anti XaU of LMWH once daily
Keywords: HEMORRHAGE/HEPARIN PROPHYLAXIS/KABI 2165/LOW
MOLECULAR WEIGHT HEPARIN/MULTICENTER
TRIAL/PREVENTION/RABBITS/THROMBOSIS
Skouby, S.O. (2002), Consequenses for HRT following the HERS II and WHI reports:
The primum non nocere is important, but translation into quo vadis is even more
essential. Acta Obstetricia et Gynecologica Scandinavica, 81 (9), 793-798.
Abstract: In the Nordic countries the prevalence of hormonal replacement therapy (HRT)
use in women from 50 to 70 years of age is slightly above 30% evaluated by
sales figures and with some variation between the five countries. The premise for
this commentary is to discuss the best clinical practice when prescribing HRT to
post menopausal women following the publication of the most recent evidence
from two well conducted randomized placebo controlled trials, namely the Heart
and Estrogen/Progestin Replacement Study II (HERS II) and the Women's
Health Initiative study (WHI )
Keywords: age/ATHEROSCLEROSIS/clinical practice/conjugated
estrogens/COPENHAGEN/coronary heart disease/CORONARY
HEART-DISEASE/Denmark/essential/ESTROGEN REPLACEMENT/HERS
II/HORMONE REPLACEMENT/hormone replacement
therapy/HRT/medroxyprogesterone acetate/POSTMENOPAUSAL
WOMEN/prevalence/PREVENTION/primary
prevention/progestins/PROGRESSION/pulmonary embolism/randomised
clinical trial/randomized/stroke/THERAPY/TRIAL/trials/use/venous
thrombosis/WHI study/women
Cruickshank, J.M. and Mcainsh, J. (1992), Patient Compliance on Taking
Cardiovascular Drug-Therapy. Acta Therapeutica, 18 (1), 53-60.
Abstract: The treatment of hypertension which is a very common, generally
asymptomatic condition, leads to a reduction in fatal and non- fatal stroke of the
order of 40-50% and a more modest degree of primary prevention from
myocardial infarction, probably in the region of 10-15 % compared with placebo.
There is thus little doubt that anti-hypertensive therapy is of clinical benefit,
assuming of course that an asymptomatic patient is compliant in taking the
tablets. Patient education by the physician and/or the pharmacist may help to
improve compliance as can an absence of serious drug-induced side effects.
However, simplicity of the dosing schedule is possibly the major factor in
achieving good patient compliance. In particular convenience of once- daily
tablet taking has been shown to improve compliance. To this end some
cardiovascular drugs have pharmacokinetic and pharmacodynamic profiles
which support once-daily dosing, while those that do not can often be
successfully formulated in sustained release preparations to achieve this end
Singh, K. and Chye, G.C. (1998), Adverse effects associated with contraceptive implants:
incidence, prevention and management. Advances in Contraception, 14 (1), 1-13.
Abstract: Contraceptive implants are increasingly being used for fertility regulation all
over the world. Reversible long-term use is their most appealing feature for many
users. They have the practical advantage of overcoming the risks of user failure
and low continuation rates associated with other methods that require continuous
attention or motivation. Disruption of menstruation, complications of insertion
and removal, and infection at implant site, constitute the majority of adverse
effects associated with contraceptive implants. This article reviews these various
common adverse effects associated with contraceptive implants and their
possible management and prevention. In addition, we also discuss very rare
events, like psychiatric disorders, pseudotumor cerebri, thrombotic,
thrombocytopenic purpura and thrombocytopenia, that have been reported by
some researchers. Further surveillance and research is necessary to determine if
these rare adverse events are causally related to contraceptive implants. Until
such a time, providers of contraceptive implants should be more selective in
prescribing the contraceptive implants, especially in women with a history of
and/or risk factors for stroke, cerebral and coronary heart disease,
thrombocytopenia and pseudotumor cerebri
Keywords: adverse events/BLEEDING
PATTERNS/CARBOHYDRATE-METABOLISM/cerebral/CLINICAL-CHEMI
STRY/complications/coronary heart
disease/heart/history/incidence/INTRACRANIAL
HYPERTENSION/LEVONORGESTREL IMPLANTS/NORPLANT(R)
IMPLANTS/prevention/risk/risk factors/stroke/SYSTEM/THROMBOTIC
THROMBOCYTOPENIC PURPURA/USERS/WOMEN
Barnett, H.J.M. (1985), Medical Prevention of Ischemic Stroke. Advances in
Prostaglandin Thromboxane and Leukotriene Research, 13 247-255
Keywords: OSLO
Mccarthy, S.T. and Turner, J. (1986), Low-Dose Subcutaneous Heparin in the
Prevention of Deep-Vein Thrombosis and Pulmonary Emboli Following Acute
Stroke. Age and Ageing, 15 (2), 84-88
Keywords: AGE
Oconnell, J.E., Cassidy, T.P. and Gray, C.S. (1992), Review - Atrial-Fibrillation and
Stroke Prevention. Age and Ageing, 21 (5), 374-380
Keywords: AGE/ANTICOAGULATION/ASYMPTOMATIC CEREBRAL
INFARCTION/ELDERLY PATIENTS/EPIDEMIOLOGIC
FEATURES/FRAMINGHAM/RANDOMIZED
TRIAL/THERAPY/THROMBOEMBOLIC COMPLICATIONS/TRANSIENT
ISCHEMIC ATTACKS/WARFARIN
OConnell, J.E. and Gray, C.S. (1996), Atrial fibrillation and stroke prevention in the
community. Age and Ageing, 25 (4), 307-309.
Abstract: Atrial fibrillation (AF) is an important and independent risk factor for stroke,
particularly in elderly people. The efficacy of treatment with warfarin and aspirin
in primary and secondary stroke prevention in AF has been demonstrated in
randomized clinical trials. In a demographic study, we examined the prevalence
of AF in patients registered with a general practice in the North East of England;
91 patients with known AF were identified, 69 with chronic AF and 22 with
paroxysmal AF. The mean duration of the arrhythmia was 6.43 years and the
prevalence of AF increased with age. There was a high prevalence of
cerebrovascular disease in AF patients. The majority of AF patients were not
receiving therapy with aspirin or warfarin as primary or secondary stroke
prevention. If strategies for stroke prevention in AF are to be applied to the
community, general practitioners will need to play a more active part
Keywords: AGE/aspirin/CARE/cerebrovascular disease/clinical
trials/elderly/ELDERLY PATIENTS/fibrillation/prevention/stroke/stroke
prevention/treatment/trials/warfarin
Sudlow, M., Thomson, R., Rodgers, H., Livingstone, S. and Kenny, R.A. (1998), The
effect of age and quality of life on doctors' decisions to anticoagulate patients
with atrial fibrillation. Age and Ageing , 27 (3), 285-289.
Abstract: Introduction: we report the results of a questionnaire survey into the effect of
patients' age and of medico-social factors on hospital consultants' and general
practitioners' reported use of warfarin anticoagulation to treat patients with non-
valvular atrial fibrillation (NVAF). Methods: half of the general practitioners (n
= 824) and all consultants in specialities likely to be involved in treating such
patients (n = 207) in the former Northern Region were sent questionnaires asking
for their views on the treatment of patients with atrial fibrillation using
anticoagulants. Results: the response rate was 56% (459/824) for general
practitioners and 76% (163/207) for consultants. A patient's age was of
significance to many clinicians. Forty-six percent of consultants and 43% of
general practitioners felt that no patient above the age of 84 years should be
treated. Medico-social factors also had an important effect on whether clinicians
felt patients ought to be treated with anticoagulants. ii patient's quality of life was
the most important medico-social factor, with handicap and place of residence
having much smaller effects. Conclusions: age and medico-social factors have an
important effect on clinicians use of anticoagulants in NVAF and reluctance to
treat elderly subjects is likely to explain much of the apparent under-use of this
treatment
Keywords: age/age factors/anticoagulants/anticoagulation/atrial fibrillation/cerebral
embolism and thrombosis/cerebrovascular
disorders/COMPLICATIONS/elderly/ENGLAND/fibrillation/hospital/physician
s practice patters/PREVENTION/quality of
life/STROKE/treatment/warfarin/WARFARIN
Mead, G.E., Wardlaw, J.M., Lewis, S.C., McDowall, M. and Dennis, M.S. (1999), The
influence of randomized trials on the use of anticoagulants for atrial fibrillation.
Age and Ageing, 28 (5), 441-446.
Abstract: Introduction: anticoagulants and anti-platelet drugs have been shown in
randomized trials to reduce the risk of stroke in patients with atrial fibrillation
(AF). We therefore investigated their use in patients known to be in AF before a
stroke, transient ischaemic attack (either cerebral or ocular) or retinal artery
occlusion to assess the influence of trials on clinical practice. Methods: inpatients
and outpatients with acute stroke, transient ischaemic attack or retinal artery
occlusion were prospectively identified by a stroke physician from 1990 to 1997.
The presence or absence of AF before the vascular event, and prior use of
anticoagulant and anti- platelet drugs were recorded at the time of the assessment
and verified using information from general practitioner and hospital case notes.
Results: of 1934 patients with stroke or retinal artery occlusion, 191 (10%) were
in AF before their ischaemic event. Anticoagulants had been used in 40 (21%) of
these, but only in 32 (2%) of the 1743 patients in sinus rhythm [odds ratio (OR)
14.2, 95% confidence interval (CI) 8.6-23.2]. Anti-platelet drugs had been used
in 62 (32%) of those with AF compared with 500 (30%) of those in sinus rhythm
(OR 1.2, 95% CI 0.9-1.64). Of the 161 patients in AF without contraindications
to anticoagulants, only 36 (22%) were taking them. Although there was a
statistically significant increase in anticoagulant use from 8% in 1990 to 23% in
1996, this could be explained solely by a fall in the age of the patients referred to
our hospital. Conclusion: anticoagulation is probably under-used in AE We
found no conclusive evidence that anticoagulation trials have influenced clinical
practice. This raises issues about the dissemination and implementation of trial
results
Keywords: acute/acute
stroke/AF/AGE/anticoagulant/anticoagulants/anticoagulation/antiplatelet
drugs/atrial fibrillation/cerebral/clinical
practice/COMMUNITY/drugs/ENGLAND/fibrillation/GUIDELINES/hospital/in
patients/MANAGEMENT/PREVENTION/randomized/randomized
trials/risk/sinus rhythm/stroke/STROKE/transient/trials/vascular/WARFARIN
Wensley, S., Keir, S., Caine, S. and Mac Mahon, M. (1999), Additional risk factors in
atrial fibrillation patients not receiving warfarin. Age and Ageing, 28 (4),
355-357.
Abstract: Objective: to study how many elderly inpatients with previously diagnosed
atrial fibrillation were not receiving anticoagulant prophylaxis, and the
prevalence of additional risk factors in these patients. Methods: all new
admissions to a department of medicine for the elderly were screened for atrial
fibrillation. Additional risk factors were analysed in those with established atrial
fibrillation who were not receiving warfarin. Previous hospital admissions,
documentation of why prophylaxis was not being used and use of aspirin as an
alternative agent were also examined. Results: 56 patients had previously
diagnosed atrial fibrillation; 82% were not taking warfarin and 71% of these
were not on aspirin either. ALL patients not taking warfarin had one additional
risk factor for stroke and 95% had two or more. Fifty-two percent had attended
hospital when atrial fibrillation was present within the previous 3 years and there
was nothing documented in their records to explain why anticoagulation had not
been used. Conclusions: most elderly inpatients with. established atrial
fibrillation were not taking warfarin. All had additional risk factors for stroke,
which increase the absolute benefit of anticoagulation
Keywords: AGE/anticoagulant/anticoagulation/aspirin/atrial
fibrillation/ATTITUDES/COMMUNITY/COMPLICATIONS/elderly/ELDERL
Y PATIENTS/England/fibrillation/hospital/inpatients/ORAL
ANTICOAGULANT-THERAPY/prophylaxis/risk/risk factor/risk factors/risk
factors for stroke/stroke/STROKE PREVENTION/warfarin
Scholten, P., Bever, A. and Warburton, L. (2000), Graduated elastic compression
stockings on a stroke unit: a feasibility study. Age and Ageing, 29 (4), 357-359.
Abstract: Background: thrombo-embolic complications are important causes of
morbidity and mortality after acute stroke. Anticoagulant prophylaxis is
contraindicated in intracerebral haemorrhage and not recommended in acute
ischaemic stroke because of increased risk of cerebral haemorrhage. Graduated
elastic compression stockings are a simple alternative but are not widely used in
stroke patients, perhaps because of perceived contraindications and problems
with tolerability. Objectives: to establish the feasibility and tolerability of
graduated compression stockings on a stroke unit. Design: we assessed 112
consecutive stroke patients for contraindications to and tolerability of graduated
compression stockings. Measurements: we used clinical indices and
ankle-brachial Doppler pressure measures to assess suitability. We prospectively
assessed tolerability of the stockings. Results: Ninety-four (84%) of the 112
patients had no contraindications to the use of the stockings. The most common
contraindication was an ankle-brachial index of <0.8. Other contraindications
were marked dependent leg oedema (1/18) and severe venous ulceration.
Eighty-nine (95%) of the 94 patients tolerated the stockings and wore them until
discharge. Skin irritation was the most common reason for intolerance.
Conclusions: contraindications to the use of graduated compression stockings
can be defined using clinical criteria and a Doppler machine to calculate an
ankle-brachial pressure index. If this is done, tolerability is excellent. This
approach may be a useful alternative in preventing venous thrombo-embolism in
stroke patients
Keywords: acute/acute stroke/AGE/cerebral/complications/deep vein
thrombosis/Doppler/Doppler ankle-brachial pressure index/England/graduated
elastic compression stockings/haemorrhage/intracerebral/intracerebral
haemorrhage/ischaemic
stroke/morbidity/mortality/PREVENTION/prophylaxis/risk/stroke/stroke
unit/thromboembolism/THROMBOSIS/use/VASCULAR-DISEASE/VENOUS
THROMBOEMBOLISM
Duggan, S., Eccles, M.P., Steen, N., Jones, S. and Ford, G.A. (2001), Management of
older patients with hypertension in primary care: improvement on the rule of
halves. Age and Ageing, 30 (1), 73-76.
Abstract: Objectives: the benefits of treatment of hypertension in older people are
well-established but implementation of this knowledge may be sub-optimal. We
have determined recent primary care management of older people with
hypertension. Methods: we examined health records (n = 6986) of a 1 in 7
sample of patients aged 65-80 years from a random sample of practices (n = 51)
in the former Northern Region of the UK, stratified by health authority, for the
previous 6 years. We recorded documented risk factors, diagnosis of
hypertension, three most recent blood pressure readings, current drug therapy
and previous blood pressure lowering therapy and presence of coexistent
pathology. Results: blood pressure was defined as hypertensive (greater than or
equal to 160/greater than or equal to 90 mmHg; one or both values above these
limits), normotensive or undetermined using a validated algorithm. In 30% of
patients, blood pressure status was undetermined. Thirty-five percent of subjects
were found to be hypertensive. Of these, 70% were receiving anti-hypertensive
treatment but only 30% of treated patients had controlled (< 150 and 90 mmHg)
and 13% well controlled (< 140 and 85 mmHg) blood pressure. In all, 14% of
older hypertensive patients were detected, treated and had their hypertension
controlled. There were significant differences between practices in the proportion
of hypertensive patients treated (P < 0.001) and in the proportion of hypertensive
patients whose blood pressure was controlled (P < 0.01). Conclusions: treatment
of hypertension in older people in primary care has improved in terms of
detection and treatment but in only one-third of patients is high blood pressure
controlled. There remain important opportunities for prevention of stroke and
myocardial infarction in this age group through achieving improved blood
pressure control
Keywords: AGE/aged/antihypertensive treatment/audit/blood pressure/blood pressure
control/blood pressure measurement/control/detection/diagnosis/drug
therapy/England/GUIDELINES/health/high blood
pressure/hypertension/infarction/knowledge/management/myocardial/myocardial
infarction/older people/pathology/PEOPLE/prevention/primary/primary
care/risk/risk factors/status/stroke/therapy/treatment
Thomson, R. (2002), How can epidemiological studies help us to prevent stroke? The
example of atrial fibrillation. Age and Ageing, 31 9-16
Keywords: AGE/ANTICOAGULANT TREATMENT/atrial/atrial
fibrillation/COMMUNITY/DISEASE/England/epidemiology/fibrillation/FRAMI
NGHAM/GUIDELINES/MORTALITY/PREVALENCE/public health/RISK
PROFILE/stroke/stroke prevention/THERAPY/WARFARIN
Elliott, R.A., Woodward, M.C. and Oborne, C.A. (2002), Antithrombotic prescribing in
atrial fibrillation: application of a prescribing indicator and multidisciplinary
feedback to improve prescribing. Age and Ageing, 31 (5), 391-396.
Abstract: Background: atrial fibrillation is common in older people, and is associated
with an increased risk of ischaemic stroke. Antithrombotic therapy reduces
stroke-risk, but is known to be under-prescribed. Objectives: to use an
evidence-based indicator to audit antithrombotic prescribing for older hospital
inpatients with atrial fibrillation, and to assess whether feedback of audit results
to hospital staff increases antithrombotic use. Design: cross-sectional notes-based
audits, before and after feedback. Setting: six Aged Care and three General
Medicine units at nine Australian public teaching hospitals between September
1998 and May 1999. Subjects: 1416 hospital inpatients aged 65 years and over
(median age 81). Methods: medication charts were reviewed to identify patients
prescribed digoxin or amiodarone. Presence of atrial fibrillation was confirmed
by review of the patients' medical notes. To be considered appropriate, patients
with atrial fibrillation had to be receiving either warfarin or aspirin (or both), or
have documented contraindications to both agents. Feedback of audit results was
provided to medical, pharmacy and nursing staff at multidisciplinary meetings.
Changes in antithrombotic prescribing 4-8 weeks and 6 months after feedback
were assessed. Prescribing 8 weeks prior to feedback was assessed
retrospectively. Results: appropriateness of the decision to prescribe (or not
prescribe) antithrombotic therapy increased from 81/112 (72%) immediately
prior to feedback to 97/105 (92%) 4-8 weeks later (P<0.0001). Six months after
feedback, appropriateness of prescribing declined slightly, to 85% (p=0.36).
Over the 8 weeks prior to feedback, appropriateness of prescribing did not
change (74% versus 77%, p=0.80). Increased aspirin prescribing accounted for
most of the improvement in antithrombotic use after feedback, while warfarin
continued to be under-used. Conclusions: antithrombotics were under-prescribed
for older patients with atrial fibrillation. Audit and multidisciplinary feedback
resulted in increased antithrombotic prescribing. The intervention had a greater
impact on aspirin prescribing compared with warfarin
Keywords: ADDITIONAL
RISK-FACTORS/AGE/aged/ANTICOAGULATION/antithrombotic/antithromb
otic therapy/antithrombotics/aspirin/atrial/atrial
fibrillation/audit/Australia/digoxin/drug/ENGLAND/fibrillation/health
care/hospital/hospitals/IMPLEMENTATION/inpatients/ischaemic/ischaemic
stroke/MANAGEMENT/medical/nursing/older
people/pharmacy/prescriptions/PREVALENCE/quality assurance/RECEIVING
WARFARIN/review/risk/risk of ischaemic stroke/stroke/STROKE
PREVENTION/THERAPY/use/warfarin
Hornig, C.R., Lammers, C., Buttner, T., Hoffmann, O. and Dorndorf, W. (1992),
Long-Term Prognosis After Vertebrobasilar Transient Ischemic Attacks. Aktuelle
Neurologie, 19 (1), 1-5.
Abstract: Clinical, C.A.T, ultrasound, and angiographic findings of 211 consecutive
patients suffering from vertebrobasilar transient ischaemic attacks were recorded
and stored in a data bank. Follow-up was performed by means of questionnaires
sent to the patients and their physicians, and via telephone interviews. Sufficient
information was available from 202 patients. During follow-up of 4 years in
average 11.4% of the patients suffered from a stroke that was disabling or even
fatal in about half of the cases. 4.9% of the patients had a myocardial infarction,
and 13.9% died. The cumulative stroke rate after vertebrobasilar TIA was 3.6%
for the first year and 14.3% for 5 years. The cumulative probability of survival
free of stroke and myocardial infarction was 91% for the first year and 73.6% for
5 years. However, only if the patient was older than 70 years, or suffering from
hypertension the risk of a stroke was significantly increased in a proportional
hazards model. Trend was recognizable to some extent in patients suffering from
hypercholesterolaemia, and from recurrent TIA, in the direction of an enhanced
risk
Keywords: ASPIRIN/CEREBRAL ISCHEMIC
ATTACKS/COMMUNITY/EXTRACRANIAL
ARTERIAL-OCCLUSION/MINNESOTA/PREVENTION/RANDOMIZED
TRIAL/ROCHESTER/STROKE/TIA/VERTEBRAL ARTERY
Spranger, M., Hund, E. and Hacke, W. (1994), Disturbances in Cerebral Blood-Flow.
Aktuelle Neurologie, 21 (1), 32-37.
Abstract: New therapeutic approaches have become possible thanks to progress in
understanding pathophysiological processes. New therapies - which are at
present still in the experimental stage - are due to the discovery of the
neurotoxicity mediated by glutamat and the role of the leucocytes as generators
of free oxygen radicals. Improved diagnostic possibilities allow ever more often
than before the aetiological identification of a cerebral blood flow disturbance.
Topical studies basing on this - taking into consideration the short therapeutic
time window - are promising pointers to the efficacy of old and new therapeutic
methods. Thrombolysis achieved by drugs to enable early recanalisation of
intracranial vascular occlusions and surgical brain pressure therapy in case of
space-occupying infarcts of the mesencephalon and cerebellum are examples of a
highly promising and more aggressive approach in patients suffering from
ischaemic stroke
Keywords: ACUTE ISCHEMIC STROKE/ASPIRIN/cerebral blood flow/EMBOLIC
STROKE/PREVENTION/stroke/TICLOPIDINE/TISSUE
PLASMINOGEN-ACTIVATOR/TRIAL/vascular
Weiller, C. (1994), Ticlopidin. Aktuelle Neurologie, 21 (6), 232-234.
Abstract: Secondary prophylaxis of stroke or TIA with antiplatelet agents is now an
established therapy. Ticlopidine is a new antiplatelet agent that can be used when
there are contraindications or allergic reactions to ASS, or when recurrent strokes
occur despite prophylaxis with ASS. Ticlopidine, given twice daily has a relative
risk reduction of a second stroke of around 33% compared to placebo and about
20% compared to ASS. Common side effects of ticlopidine include diarrhoea
and urticaria. Neutropenia, as a side effect is relatively rare (< 1%) and requires
haematological tests every fortnight during the first three months of treatment
with ticlopidin
Keywords: antiplatelet agents/ASPIRIN/ASS/PREVENTION/prophylaxis/relative
risk/risk/STROKE/TIA/ticlopidine/treatment/TRIAL
Masuhr, F., Back, T. and Einhaupl, K. (1997), Cerebral blood flow disorders. Aktuelle
Neurologie, 24 (1), 2-11.
Abstract: Recently published studies have shown that a variety of substances are
effective in reducing the extension of tissue damage in animal models of focal
cerebral ischemia including glutamate receptor antagonists, free radical
scavangers and inhibitors of nitric oxide synthase. However, clinical studies
demonstrating a therapeutical effect are still lacking. New methods of functional
MR imaging allow an earlier identification of ischemia-related tissue changes.
They provide clear evidence of evolving ischemic lesions during the initial hours
of cerebral ischemia. With special regard to the limited therapeutic time window,
early follow-up investigations will be able to prove the clinical efficacy of yet
experimental therapeutic results. Clinical studies have already shown the
beneficial effect of thrombolysis with recombinant tissue plasminogen activator
in acute ischemic stroke when applied within the initial 3 hours after the onset of
symptoms. However, thrombolysis carries the risk of severe parenchymal
intracranial hemorrhage if patients are included who present with early
space-occupying lesions. Prospective primary and secondary stroke prevention
trials show that coumarins decrease the risk of stroke in patients with atrial
fibrillation and that aspirin and ticlopidine reduce the risk of recurrent
atherothrombotic stroke. While carotid endarterectomy was beneficial in
symptomatic patients, the benefit for patients with asymptomatic carotid lesions
is less convincing. At the moment, carotid endarterectomy in selected
asymptomatic patients can only be recommended if perioperative morbidity and
mortality can be expected to be below 3%
Keywords: acute/ACUTE ISCHEMIC STROKE/animal/ASPIRIN/asymptomatic/atrial
fibrillation/BRAIN/carotid/carotid endarterectomy/cerebral/cerebral
ischemia/DIFFUSION/ENDARTERECTOMY/fibrillation/focal/focal cerebral
ischemia/glutamate/hemorrhage/ischemia/ischemic/ischemic
stroke/morbidity/mortality/MR/NEURONAL DAMAGE/plasminogen
activator/prevention/RATS/recombinant tissue plasminogen
activator/REPERFUSION/risk/stroke/stroke
prevention/THERAPY/thrombolysis/TICLOPIDINE/trials
Weimar, C., Glahn, J., Neumaier, S., Wimmer, M., Busse, O., Haass, A., Haberl, R. and
Diener, H.C. (1999), Pretesting the medical database: Comparison of stroke
treatment in four neurological departments with stroke units. Aktuelle Neurologie,
26 (8), 366-374.
Abstract: We present data of 708 patients with stroke or transient ischemia within one
week prior to admission to compare the management of stroke in four Neurology
Departments with an acute stroke unit. Four months' data on risk factors,
concurrent vascular illnesses, neurological deficits, radiological findings, acute
therapy, course of recovery, complications, secondary prevention, length of stay,
discharge and outcome at 3 and 12 months were prospectively collected in a joint
data base. 70% of all patients were admitted within 24 h, 47% within 6 h. 38% of
all patients were referred by ambulance, 31% by a general practitioner and 23%
by other hospitals or departments within the same hospital. There was a good
correlation between the severity of stroke and the kind of referral. The mean
length of stay of all stroke patients on the acute stroke unit varied between 3.4
and 6.3 days and between 10.4 and 72.7 days in the Neurology department,
depending on the type of care after discharge. 5.4% of all patients with ischemic
stroke and 16.1% of all patients with intracerebral hemorrhage died during the
acute hospital stay. The cumulated lethality of all patients with ischemic stroke
not lost to follow-up at one year was 18.8%. 79% of all surviving patients with
ischemic stroke had a Barthel index of >70. The method of data collection in this
pretest proved to be apt for a multicenter study presently being conducted in 23
Neurology departments with an acute stroke unit
Keywords: acute/acute stroke/acute stroke
unit/COMMUNITY/complications/CONSECUTIVE
PATIENTS/COPENHAGEN- STROKE/data
collection/DATA-BANK/Germany/hemorrhage/hospital/hospitals/intracerebral/i
ntracerebral hemorrhage/ischemia/ischemic/ISCHEMIC STROKE/length of
stay/NEW-YORK/NORTH-CAROLINA/outcome/POPULATION/prevention/P
ROGRAMS/REGISTRY/risk/risk factors/secondary
prevention/severity/stroke/stroke treatment/stroke unit/stroke
units/therapy/transient/treatment/vascular
Diener, H.C. (2001), New publications on stroke. Aktuelle Neurologie, 28 (8), 353-358.
Abstract: This review summarizes the most important publications concerning stroke
from the second half of 1999 until the second half of 2000. The most important
studies were performed in the areas of primary prevention and acute therapy
Keywords: acute/ACUTE ISCHEMIC
STROKE/ALCOHOL-CONSUMPTION/ASPIRIN/CAROTID
ENDARTERECTOMY/CHOLESTEROL/CORONARY
HEART-DISEASE/DOUBLE-BLIND/Germany/PLASMINOGEN-ACTIVATO
R/PREVENTION/primary/primary prevention/RANDOMIZED CONTROLLED
TRIAL/review/stroke/therapy
Endres, M. and Masuhr, F. (2002), Is cholesterol a risk factor for stroke? Aktuelle
Neurologie, 29 (5), 247-253.
Abstract: Surprisingly, the question whether or not cholesterol is a stroke risk factor has
remained controversial and somewhat counterintuitive. In contrast to coronary
heart disease, large trials failed to demonstrate a correlation between elevated
serum cholesterol levels and stroke incidence. There is even evidence for an
inverse relation between cholesterol levels and risk of intracerebral hemorrhage.
Moreover, clinical trials in the pre-statin era failed to demonstrate an effect of
cholesterol-lowering on stroke incidence. On the other hand, in the 1990s large
randomized trials demonstrated unequivocally that HMG-CoA reductase
inhibitors (statins) lower stroke risk in patients with coronary heart disease
(CHD). Hence, lipid- lowering therapy with statins is established for stroke
prophylaxis in patients with CHD. The question, however, whether these
protective effects are cholesterol-dependent or rather mediated by cholesterol -
independent (,,pleiotropic") effects, and whether statins may be beneficial for
secondary prevention of stroke in patients without CHD, remains controversial
Keywords: CARDIOVASCULAR EVENTS/CAROTID
ARTERIES/CHD/cholesterol/cholesterol-lowering/clinical
trials/CONTROLLED TRIALS/coronary heart disease/CORONARY
HEART-DISEASE/DIETARY-FAT/disease/Germany/heart/heart
disease/hemorrhage/HMG-CoA reductase
inhibitors/incidence/intracerebral/intracerebral hemorrhage/JAPANESE
MEN/lipid
lowering/MYOCARDIAL-INFARCTION/prevention/prophylaxis/randomized/ra
ndomized trials/RECURRENT EVENTS CARE/REDUCTASE
INHIBITORS/risk/risk factor/secondary/secondary
prevention/serum/SERUM-CHOLESTEROL/statins/stroke/stroke
incidence/therapy/trials
Bosel, J. and Endres, M. (2002), The use of statins in clinical neurology. Aktuelle
Neurologie, 29 (5), 254-261.
Abstract: HMG-CoA reductase inhibitors (statins) are potent cholesterol- lowering drugs
and are established for the treatment of hypercholesterolemia. Furthermore, large
clinical trials (4S, CARE, LIPID) demonstrated that statins are indicated for
secondary prophylaxis of coronary heart disease (CHD) even in patients with
average cholesterol levels. Although hypercholesterolemia is not an established
risk factor for ischemic stroke, these studies demonstrated that statins also reduce
stroke incidence in patients with CHD. The question whether or not statins are
generally indicated for secondary prevention of stroke is subject of two ongoing
trials (i.e. PROSPER, SPARCL). Clinical as well as experimental evidence
supports the notion that statins exert cholesterol-independent
(so-called,pleiotropic") protective effects. These include anti-inflammatory and
anti-thrombotic effects, improvement of endothelial function and even direct
neuroprotective effects. Furthermore, experimental and preliminary clinical
studies suggest a potential role of statins for the treatment of dementia.
Regarding the use of statins in clinical neurology, current evidence only supports
the use for stroke prophylaxis in patients with a history of CHD
Keywords: 4S/ACUTE CORONARY
SYNDROMES/ALZHEIMERS-DISEASE/antithrombotic/C-REACTIVE
PROTEIN/CARE/CHD/cholesterol/CHOLESTEROL REDUCTION/clinical
studies/clinical trials/COA REDUCTASE INHIBITORS/coronary heart
disease/dementia/disease/drugs/endothelial
function/experimental/Germany/heart/heart disease/history/HMG-CoA reductase
inhibitors/HONOLULU-HEART- PROGRAM/HUMAN
GLIOMA-CELLS/hypercholesterolemia/incidence/INCREASES SERUM
CONCENTRATIONS/ischemic/ischemic
stroke/LIPID/neurology/NITRIC-OXIDE
SYNTHASE/prevention/prophylaxis/risk/risk factor/secondary/secondary
prevention/SMOOTH-MUSCLE/statins/stroke/stroke
incidence/treatment/trials/use
Klatsky, A.L. (1999), Moderate drinking and reduced risk of heart disease. Alcohol
Research & Health, 23 (1), 15-23.
Abstract: Although heavier drinkers are at increased risk for some heart diseases,
moderate drinkers are at lower risk for the most common form of heart disease,
coronary artery disease (CAD) than are either heavier drinkers or abstainers. This
association has been demonstrated in large-scale epidemiological studies from
many countries. Abstainers may share traits potentially related to CAD risk, such
as psychological characteristics, dietary habits, and physical exercise patterns.
However, evidence supports a direct protective effect of alcohol, even after data
have been adjusted for the presence of these factors. The alcohol-CAD
relationship is also independent of the hypothetically increased risk status among
abstainers who stopped drinking for medical reasons. All alcoholic beverages
prefect against CAD, although some additional protection may be attributable to
personal traits or drinking patterns among people who share some beverage
preferences or to nonalcohol ingredients in specific beverages. Alcohol's
protective effect may result from favorable alterations in blood chemistry and the
prevention of clot formation in arteries that deliver blood to the heart muscle.
Because CAD accounts for a large proportion of fetal mortality, the risk of death
from all causes is slightly lower among moderate drinkers than among abstainers,
but heavier drinkers are at considerably higher total mortality risk
Keywords: ALCOHOL/alcoholic beverage/ALCOHOLIC BEVERAGE USE/alcoholic
cardiomyopathy/AOD use frequency/AODR (alcohol and other drug related)
disorder/AODR mortality/BEER/BLOOD- PRESSURE/cardiac
arrhythmia/CARDIOVASCULAR MORTALITY/CONSUMPTION/coronary
artery disease/coronary artery
disorder/diseases/DRINKERS/exercise/formation/HEALTH/heart/heavy AOD
use/HIGH-DENSITY-LIPOPROTEIN/HOSPITALIZATION/hypertensive
disorder/literature review/moderate AOD
use/mortality/muscle/MYOCARDIAL-INFARCTION/prevention/protective
factors/public health/RED WINE/risk/risk factors/stroke
Hillbom, M. (1998), Alcohol consumption and stroke: Benefits and risks.
Alcoholism-Clinical and Experimental Research, 22 (7), 352S-358S.
Abstract: The complex relationship between alcohol consumption and stroke includes
both benefits and risks. Regular light-to-moderate consumption of alcohol seems
to decrease the risk for ischemic stroke by reducing atherothrombotic events, but
the underlying mechanism is still unclear. Recent and current (but not previous)
heavy drinking increases the risk for both hemorrhagic and ischemic strokes.
Young and middle-aged men are stricken more often than women or elderly
persons, probably because they are more often current heavy drinkers. Alcoholic
cardiomyopathy is a cause of cardioembolic brain infarction. Cardiac
arrhythmias caused by regular heavy drinking or binge drinking can precipitate
thrombus formation and propagate already existing thrombi from the heart. The
maintenance of high blood pressure by heavy drinking may promote cerebral
arterial degeneration, but the effect of drinking habits on aneurysm formation is
not known. Acute increases in systolic blood pressure and/or alterations in
cerebral arterial tone could serve as mechanisms triggering hemorrhagic strokes
during alcoholic intoxication. We lack studies to show that prevention of heavy
drinking can efficiently influence the occurrence of strokes
Keywords: ALCOHOL/alcohol drinking/blood pressure/cerebral
hemorrhage/CEREBRAL INFARCTION/cerebral
infarction/CEREBROVASCULAR-DISEASE/CIGARETTE-
SMOKING/CORONARY HEART-DISEASE/drug
abuse/elderly/Finland/formation/heart/high blood pressure/ISCHEMIC
STROKE/LOW-DENSITY-LIPOPROTEIN/NORTHERN MANHATTAN
STROKE/PLATELET-AGGREGATION/prevention/risk/SPONTANEOUS
INTRACEREBRAL HEMORRHAGE/stroke/SUBARACHNOID
HEMORRHAGE/subarachnoid hemorrhage/thrombus/women
Dammann, H.G., Burkhardt, F. and Wolf, N. (1999), Enteric coating of aspirin
significantly decreases gastroduodenal mucosal lesions. Alimentary
Pharmacology & Therapeutics, 13 (8), 1109-1114.
Abstract: Background: Low-dose aspirin (acetylsalicylic acid, ASA) increases the risk of
developing peptic ulceration. Aim: To investigate the gastroduodenal mucosal
tolerability of enteric- coated ASA (EC-ASA) 100 mg/day compared to either
placebo (study 1) or plain ASA 100 mg/day (study 2) in healthy volunteers,
Methods: Study 1: Tn this double-blind study 18 volunteers received randomized
dosing with either EC-ASA 100 mg or placebo for 15 days. Study 2: 41
volunteers underwent randomized 7-day dosing of either EC-ASA 100 mg or
plain ASA 100 mg in this double-blind, parallel-group, comparison study. In
both studies acute gastroduodenal mucosal lesions were assessed endoscopically
before treatment, on the morning of day 1 after the first dose (only in study 2),
and on the morning after the last dose of the test medication, Results: Study 1 did
not reveal any significant differences between the lesion scores of EC-ASA and
placebo, In contrast, in study 2 significantly higher total gastroduodenal mucosal
lesion scores were observed on day 1 after the first dose and after 7 days of
dosing with plain ASA (mean sum of the lesion scores in the gastric fundus,
body, antrum and in the duodenal bulb: day 1: plain ASA 3.95 +/- 3.38 vs.
EC-ASA 1.43 +/- 1.91, P = 0.03; day 7: plain ASA 6.35 +/- 4.10 vs, EC-ASA
2.00 +/- 2.02, P = 0.0004). Tolerance of the test drugs was good, and no other
adverse events were observed, Conclusions: Enteric-coated aspirin 100 mg/day
causes significantly less gastroduodenal damage over 7 days than the same dose
of plain aspirin, when given to healthy subjects, There was little gastric injury
and no significant differences between EC-ASA and placebo in this respect
Keywords: acetylsalicylic acid/acute/adverse events/ANTI-INFLAMMATORY
DRUGS/aspirin/BLEEDING PEPTIC-ULCER/BUFFERED
ASPIRIN/COATED
ASPIRIN/drugs/ENGLAND/GASTRIC-ULCER/INJURY/ISCHEMIC
STROKE/LOW-DOSE ASPIRIN/NONSTEROIDAL ANTIINFLAMMATORY
DRUGS/PREVENTION/randomized/risk/treatment
Okamoto, K., Tanaka, M. and Kondo, S. (2002), Treatment of vascular dementia.
Alzheimer'S Disease: Vascular Etiology and Pathology, 977 507-512.
Abstract: We report positron emission tomography (PET) findings of our patients with
vascular dementia, asymptomatic cerebral infarction, and chronic cerebral
circulatory insufficiency. According to the PET studies, it was suggested that
frontal lobe hypoperfusion and hypometabolism play important roles in dementia
caused by cerebral infarctions. It was also suggested that patients with subjective
complaints associated with asymptomatic strokes and patients with chronic
cerebral circulatory insufficiency already exhibited decreased cerebral circulation.
Since therapeutic approaches to vascular dementia after its development are
limited, active control of risk factors and prevention of recurrent stroke during
the developmental process of vascular dementia are important. We review recent
situations in prevention and treatment of vascular dementia
Keywords: asymptomatic/cerebral/cerebral circulation/cerebral
infarction/chronic/control/dementia/development/DOUBLE-BLIND/infarction/J
apan/MULTI-INFARCT DEMENTIA/MULTICENTER/MULTIINFARCT
DEMENTIA/NEW-YORK/NICERGOLINE/patient/patients/PET/positron
emission tomography/positron emission tomography
(PET)/PREVENTION/recurrent stroke/review/risk/risk
factors/STROKE/stroke/THERAPY/treatment/TRIAL/USA/vascular/vascular
dementia
Meyer, J.S., Chowdhury, M.H., Xu, G.L., Li, Y.S. and Quach, M. (2002), Donepezil
treatment of vascular dementia. Alzheimer'S Disease: Vascular Etiology and
Pathology, 977 482-486.
Abstract: Cholinergic deficits are clinicopathological hallmarks of Alzheimer's disease
(DAT) and during the past decade have been the sole target for clinically
effective treatments. By contrast, vascular dementia subtypes (VaD) are
heterogeneous clinical syndromes, and therapeutic approaches have been
directed toward control of vascular risk factors. Little attention has been paid to
cholinergic deficits as a mechanism contributing to cognitive impairments in
VaD as a potential target for treatment. The purpose of the study was to
determine whether there are therapeutic benefits from long-term treatment with
cholinesterase inhibitors among VaD patients. Ten VaD patients were diagnosed
according to DSM-III-R and NINDS-AIREN criteria and classified into subtypes
by neuroimaging. All were treated with titrated doses of donepezil for a mean
interval of 15 months. At baseline and follow-up clinic visits, patients underwent
medical and neurological examinations, as well as neuropsychological testing
including Mini-Mental Status Examinations (MMSE) and Cognitive Capacity
Screening Examinations (CCSE). Cognitive statuses of 10 treated patients were
then compared before and after treatment. Net changes were expressed as annual
MMSE score changes (DeltaMMSE/year) and annual CCSE score changes
(DeltaCCSE/year). Of the 10 treated VaD patients, cognitive improvements were
found when comparisons were made before and after treatment. Ten treated
patients also showed greater cognitive improvements, while untreated patients
showed continued cognitive decline. This study suggests that cholinergic deficits
in VaD are due to neuronal ischemic damage with loss of acetylcholine and that
treatment of VaD with cholinesterase inhibitors is a rational therapy
Keywords: Alzheimer's disease/ALZHEIMERS-DISEASE/benefits/changes/cholinergic
deficits/cholinesterase inhibitors/CLINICAL DETERMINANTS/cognitive
decline/control/dementia/disease/donepezil/ischemic/medical/MMSE/NEW-YO
RK/NINDS-AIREN/patients/PREVENTION/risk/risk
factors/STROKE/therapy/treatment/USA/vascular/vascular dementia/vascular
dementia (VaD)/vascular risk/vascular risk factors
Wade, J.P.H. (1991), Multiinfarct Dementia - Prevention and Treatment. Alzheimer
Disease & Associated Disorders, 5 (2), 144-148.
Abstract: Multi-infarct dementia (MID) characteristically presents with an acute event
followed by a stepwise and fluctuating downhill course. Progression is generally
considered the consequence of recurrent stroke (Hachinski, 1983): the mainstay
of treatment, therefore, is the prevention of further ischemic events
Keywords:
ALZHEIMERS-DISEASE/DOUBLE-BLIND/MULTICENTER/NALOXONE/P
REPARATION HYDERGINE/RISK-
FACTORS/THERAPY/TRIAL/VASODILATORS
Kuller, L.H. (1996), Potential prevention of Alzheimer disease and dementia. Alzheimer
Disease & Associated Disorders, 10 13-16.
Abstract: The prevention of dementia is of critical importance. The increasing
population of high-risk older individuals will result in an increasing prevalence
of dementia. Primary prevention of dementia and Alzheimer disease can take
either a public health or high-risk preventive medicine approach. At the present
time, there is little evidence to support a specific primary public health approach
such as a specific nutrient. The possible association of vascular disease with
dementia may offer the best preventive high-risk approach. The identification of
individuals with clinical and subclinical vascular disease is possible. There is a
very high prevalence of subclinical cerebral infarction in older individuals.
Specific treatments can prevent clinical disease such as stroke and coronary heart
disease. Whether therapies will prevent some dementia can be determined
Keywords: ALLELE/ASSOCIATION/clinical trials/COGNITIVE
FUNCTION/coronary heart disease/dementia/EDUCATION/ELDERLY
PEOPLE/health/heart/PHENOTYPE/POPULATION/prevention/preventive
medicine/RISK/STROKE/vascular disease/WOMEN
Gorelick, P.B., Erkinjuntti, T., Hofman, A., Rocca, W.A., Skoog, I. and Winblad, B.
(1999), Prevention of vascular dementia. Alzheimer Disease & Associated
Disorders, 13 S131-S139.
Abstract: Stroke is an important public health problem worldwide. Those at high risk of
stroke may be at high risk of cognitive impairment and dementia after stroke.
Modifiable cardiovascular risk factors in midlife including hypertension, alcohol
use, cigarette smoking, and certain dietary factors may be important targets for
prevention of vascular causes of cognitive impairment. These same types of
factors may also be associated with Alzheimer disease. Better control of
cardiovascular disease risk factors might lead to delay or prevention of vascular
dementia and Alzheimer disease
Keywords: alcohol/Alzheimer
disease/ALZHEIMERS-DISEASE/APOLIPOPROTEIN-E
EPSILON-4/BASE-LINE FREQUENCY/BRAIN
INFARCTION/cardiovascular/cardiovascular disease/cardiovascular disease risk
factors/CARDIOVASCULAR HEALTH/cardiovascular risk/cardiovascular risk
factors/cigarette smoking/COGNITIVE FUNCTION/cognitive
impairment/control/dementia/disease/disease risk/health/high
risk/hypertension/MIDLIFE BLOOD-PRESSURE/prevention/public
health/risk/risk factors/RISK- FACTORS/smoking/stroke/STROKE
PREVENTION/use/vascular/vascular dementia/WHITE- MATTER LESIONS
Crisby, M., Carlson, L.A. and Winblad, B. (2002), Statins in the prevention and
treatment of Alzheimer disease. Alzheimer Disease & Associated Disorders, 16
(3), 131-136.
Abstract: Vascular risk factors such as hypertension and hypercholesterolemia during
midlife increase the risk for Alzheimer's disease (AD). Treatment of
hypercholesterolemia and other vascular risk factors may have great implications
in the prevention of AD. Recent findings illustrate that the sterol metabolism in
the brain is an active process, well controlled and regulated by 24-hydroxylase,
an enzyme that is uniquely expressed in the brain. The use of statins in ischemic
heart disease (IHD) has proven to be a phenomenal advance in pharmacological
disease prevention and treatment. A growing body of evidence, suggest that
statins exhibit additional benefits that are independent of their
cholesterol-lowering actions. Statin treatment has also considerable effect in
prevention of ischemic stroke. In animal models of ischemic stroke, statins have
proven to reduce infarct size through up- regulation of endothelial nitric oxide
synthases. Data from recent observational studies have revealed a potential role
for statins in prevention of AD. The following review comments the processes
leading to dementia including the involvement of cholesterol regulation, cerebral
circulation and inflammation in development of dementia. The mechanisms by
which statins may be beneficial in controlling these processes is discussed
Keywords: AD/Alzheimer disease/Alzheimer's disease/AMYLOID PRECURSOR
PROTEIN/animal/APOLIPOPROTEIN-E/BETA-PEPTIDE/brain/cerebral/chole
sterol/CHOLESTEROL/cholesterol-lowering/dementia/development/disease/hea
rt/heart
disease/HEART-DISEASE/HIPPOCAMPAL-NEURONS/hypercholesterolemia/
hypertension/inflammation/ischemic/ischemic heart disease/ischemic
stroke/mechanisms/metabolism/MOUSE MODEL/nitric oxide/NITRIC-OXIDE
SYNTHASE/observational studies/prevention/REDUCTASE
INHIBITORS/review/risk/risk factors/SENILE
PLAQUES/statins/stroke/Sweden/treatment/use/vascular/vascular risk/vascular
risk factors
Sheng, F.C.L. and Busuttil, R.W. (1986), Carotid Surgery in Stroke Prevention.
American Family Physician, 33 (4), 109-124
Keywords: FAMILY/PHYSICIANS
Quest, D.O. (1987), Carotid Endarterectomy for Stroke Prevention. American Family
Physician, 35 (5), 185-191
Keywords: FAMILY/PHYSICIANS
Unwin, D.H. and Greenlee, R.G. (1993), Prophylactic Drug-Therapy in
Cerebrovascular-Disease. American Family Physician, 48 (1), 85-90.
Abstract: Aspirin in doses of 325 mg to 1,300 mg per day is the drug of choice for
prophylactic therapy in cerebrovascular disease. Ticlopidine, a platelet antagonist,
is available for use in patients who cannot tolerate aspirin or who have not had
success with aspirin therapy. Although ticlopidine is more effective than aspirin
in preventing stroke, its use may be somewhat limited due to cost and the
uncommon but serious side effect of neutropenia. Low-dose warfarin remains the
drug of choice for the prevention of cardioembolic stroke. The role of warfarin in
ischemic cerebrovascular disease is unknown
Kerle, K.K. and Nishimura, K.D. (1996), Exertional collapse and sudden death
associated with sickle cell trait. American Family Physician, 54 (1), 237-240.
Abstract: Although rare, exertional collapse and sudden death are the most serious
potential complications of sickle cell trait. Studies suggest that this condition
may occur in susceptible persons when poor physical conditioning, dehydration,
heat stress or hypoxic states precipitate sickling of the abnormal erythrocytes.
Sickling leads to endothelial damage, which can cause vasoconstriction,
disseminated intravascular coagulation and local tissue damage. Cardiac effects
include acute ischemia and arrhythmias. Muscle damage results in acute
compartment syndromes and release of myoglobin into the circulation. Acute
renal failure is possible. Diagnosis is based on a high index of suspicion, and
characteristic presentation and laboratory findings, including myoglobinuria,
hyperkalemia, hypocalcemia, hyperphosphatemia and elevated creatine kinase
levels. The differential diagnosis includes pulmonary embolism, acute cardiac
events, anaphylaxis and heat stroke. Management is based on stabilization,
rehydration, and the treatment and prevention of complications
Keywords:
ACUTE-RENAL-FAILURE/coagulation/COMMUNITY/EXERCISE/FAMILY/
PHYSICIANS/prevention/RHABDOMYOLYSIS/RISK
FACTOR/stroke/treatment
Santilli, J.D., Santilli, S.M. and Rodnick, J.E. (1996), Prevention of stroke caused by
carotid bifurcation stenosis. American Family Physician, 53 (2), 549-556.
Abstract: Prevention of stroke caused by carotid bifurcation stenosis can be achieved by
accurate identification and evaluation of patients at risk. A consensus report from
the National Institute of Neurologic Disorders and Stroke has standardized
diagnostic criteria and symptoms related to this disease. Recent prospective,
randomized trials have identified effective treatment for both asymptomatic and
symptomatic carotid stenosis. The risk factors for carotid stenosis are similar to
those for atherosclerosis-hypertension, diabetes, cigarette smoking and
hyperlipidemia. A carotid bruit is the most common clinical finding, although its
positive predictive value is only about 60 to 70 percent. Recent clinical trials
have identified patient groups that benefit from surgical and medical therapy,
depending on the degree of carotid stenosis and the presence or absence of
symptoms. Symptomatic patients with carotid stenosis greater than 70 percent
benefit from surgical therapy. Asymptomatic patients who have carotid stenosis
greater than 60 percent and are good surgical candidates should be referred for
surgical consultation
Keywords: carotid/carotid stenosis/clinical
trials/consensus/evaluation/FAMILY/FRAMINGHAM/PHYSICIANS/randomiz
ed trials/risk/risk factors/smoking/stroke/treatment/trials
Reddy, M.P. and Reddy, V. (1997), Stroke rehabilitation. American Family Physician,
55 (5), 1742-1748.
Abstract: Stroke is the leading cause of brain damage and resultant disability.
Rehabilitation measures help to restore lost abilities, improve quality of life and
decrease the long-term economic cost of stroke. Proper patient selection, realistic
goal setting, the active participation of both the patient and family, and the use of
an interdisciplinary team approach are important for the success of stroke
rehabilitation. Functional demand and intensive training are believed to trigger
central nervous system reorganization, which is responsible for late functional
recovery after stroke. The outcome following a stroke is most likely to be
positive when patients have bladder and bowel continence, are able to feed
themselves and have a healthy and caring spouse. Stroke rehabilitation must
include the prevention or early diagnosis of medical complications as well as
patient and family education concerning the prevention of recurrent stroke
Keywords:
brain/COMPLICATIONS/cost/diagnosis/education/FAMILY/FOLLOW-UP/LE
NGTH/MORTALITY/PHYSICIAN/PHYSICIANS/PREDICTION/PREVENTI
ON/quality of life/rehabilitation/STAY/stroke/UNIT
Wolf, P.A. and Singer, D.E. (1997), Preventing stroke in atrial fibrillation. American
Family Physician, 56 (9), 2242-2250.
Abstract: Atrial fibrillation, a common cardiac arrhythmia, is now recognized as a
powerful risk factor for stroke. Previously, atrial fibrillation was thought to
predispose persons to stroke only in the presence of rheumatic heart disease with
mitral stenosis. The significant impact of nonvalvular atrial fibrillation on stroke
incidence, recurrence and mortality was not fully appreciated. A series of clinical
trials have confirmed that a five-fold increase in stroke incidence occurs in
patients with atrial fibrillation, and that warfarin anticoagulation is efficacious in
stroke prevention. This anticoagulation benefit was achieved with an acceptably
low risk of serious hemorrhage
Keywords: ANTICOAGULATION/ASPIRIN/atrial fibrillation/clinical
trials/COMPLICATIONS/EMBOLISM/FAMILY/fibrillation/FRAMINGHAM/h
eart/hemorrhage/incidence/mortality/PHYSICIANS/prevention/recurrence/risk/R
ISK-FACTORS/stroke/stroke prevention/trials/WARFARIN
Akhtar, W., Reeves, W.C. and Movahed, A. (1998), Indications for anticoagulation in
atrial fibrillation. American Family Physician, 58 (1), 130-136.
Abstract: Factors associated with an increased risk of thromboembolic events in patients
with atrial fibrillation (AF) include increasing age, rheumatic heart disease poor
left ventricular function, previous myocardial infarction, hypertension and a past
history of a thromboembolic event. Patients with AF should be considered for
anticoagulation or antiplatelet therapy based on the patient's age, the presence of
other risk factors for stroke and the risk of complications from anticoagulation.
In general, Patients with risk factors for stroke should receive warfarin
anticoagulation, regardless of their age. In patients who are tinder age 65 and
have no other risk factors for stroke, either aspirin therapy or no therapy at all is
recommended Aspirin or warfarin is recommended for use in patients between
65 and 75 years of age with no other risk factors, and warfarin is recommended
for use in patients without risk factors who are older than 75 years of age
Keywords: AF/age/anticoagulation/antiplatelet therapy/aspirin/atrial
fibrillation/complications/FAMILY/fibrillation/FOLLOW-UP/FRAMINGHAM/
heart/history/hypertension/MANAGEMENT/myocardial
infarction/PHYSICIANS/PREVENTION/RISK/risk
factors/stroke/therapy/thromboembolic events/WARFARIN
Ryan, M., Combs, G. and Penix, L.P. (1999), Preventing stroke in patients with transient
ischemic attacks. American Family Physician, 60 (8), 2329-2336.
Abstract: Stroke is the third most common overall cause of death and the leading cause
of adult disability in the United States, New therapeutic interventions instituted
in the period immediately after a stroke have revolutionized the approach to
ischemic cerebrovascular disease. Recognition of a transient ischemic attack
provides an opportunity to prevent a subsequent stroke, Specific stroke
prevention treatment depends on the cause of the transient ischemic attack, its
cerebrovascular localization and the presence of associated coexisting medical
problems, Modification of stroke risk factors is the principal therapeutic
approach, Antiplatelet agents and anticoagulants have been shown to be effective
in reducing the occurrence of stroke in certain populations, Several
well-designed studies have recently demonstrated the effectiveness of carotid
endarterectomy in preventing strokes related to extracranial carotid artery disease
Keywords:
AMERICAN-HEART-ASSOCIATION/anticoagulants/ASPIRIN/carotid/carotid
artery/CAROTID ENDARTERECTOMY/cerebrovascular/cerebrovascular
disease/CHOLESTEROL/DISEASE/endarterectomy/FAMILY/ischemic/META
ANALYSIS/PHYSICIAN/PHYSICIANS/PRACTICE
GUIDELINES/prevention/REDUCTASE INHIBITORS/RISK/risk
factors/stroke/stroke prevention/transient/transient ischemic attack/transient
ischemic attacks/treatment/TRIALS/United States
Hart, R.G. and Benavente, O. (1999), Stroke: Part I. A clinical update on prevention.
American Family Physician, 59 (9), 2475-2482.
Abstract: Clinical trials conducted during the past five years have yielded important
results that have allowed us to refine our approach to stroke prevention.
Treatment of isolated systolic hypertension prevents stroke and is generally well
tolerated. New antiplatelet agents (clopidogrel and the combination of aspirin
plus high-dose dipyridamole) have been shown to be effective in reducing
vascular events in survivors of ischemic stroke, although aspirin remains the
mainstay of antiplatelet therapy for stroke prevention. Several clinical trials
support the benefit of lipid-lowering agents ("statins") in reducing stroke.
Warfarin reduces stroke for high-risk patients with atrial fibrillation. Carotid
endarterectomy is highly beneficial in reducing stroke for symptomatic patients
with severe carotid stenosis (greater than 70 percent), but the benefit is less for
symptomatic patients with a moderate degree of stenosis (50 to 69 percent) and
for patients with asymptomatic carotid disease of any severity
Keywords: antiplatelet/antiplatelet agents/antiplatelet
therapy/aspirin/asymptomatic/atrial fibrillation/carotid/CAROTID
ENDARTERECTOMY/carotid stenosis/clinical
trials/clopidogrel/dipyridamole/endarterectomy/FAMILY/fibrillation/hypertensio
n/ischemic/ischemic stroke/isolated systolic
hypertension/METAANALYSIS/PHYSICIAN/PHYSICIANS/prevention/RISK/
severity/STENOSIS/stroke/stroke prevention/therapy/trials/vascular/Warfarin
Pearce, K.A., Boosalis, M.G. and Yeager, B. (2000), Update on vitamin supplements for
the prevention of coronary disease and stroke. American Family Physician, 62
(6), 1359-1366.
Abstract: Dietary antioxidants and folic acid may play a role in the pathophysiology of
coronary disease and stroke. We review patient-oriented evidence on the
effectiveness of supplementation with antioxidants and/or folic acid in the
prevention of myocardial infarction and stroke. Observational data suggest
cardiovascular benefit of vitamin E supplementation, but results of controlled
clinical trials are inconsistent regarding the effect on nonfatal myocardial
infarction. Moreover, studies have not shown a protective effect of vitamin E
against fatal myocardial infarction and have not addressed stroke. For vitamin C
and folic acid supplementation, observational data are inconsistent and controlled
clinical trials are lacking. Thus, the available evidence is insufficient to
recommend the routine use of vitamin E, vitamin C or folate supplements for the
prevention of myocardial infarction or stroke. The evidence argues against the
use of beta carotene supplements for this purpose. The costs and risks associated
with these supplements are low, however, and physicians may choose to
recommend vitamin E. folate and/or vitamin C supplementation pending
conclusive evidence from clinical trials
Keywords: antioxidants/beta carotene/BETA-CAROTENE/C
INTAKE/cardiovascular/CARDIOVASCULAR- DISEASE/clinical
trials/coronary disease/costs/DIETARY ANTIOXIDANT VITAMINS/E
CONSUMPTION/FAMILY/HEART-DISEASE/infarction/myocardial/myocardi
al
infarction/MYOCARDIAL-INFARCTION/PHYSICIAN/PHYSICIANS/POST
MENOPAUSAL WOMEN/prevention/review/RISK FACTOR/stroke/TOTAL
HOMOCYSTEINE/trials/vitamin C/vitamin E
Biller, J. and Thies, W.H. (2000), When to operate in carotid artery disease. American
Family Physician, 61 (2), 400-406.
Abstract: Carotid endarterectomy has proved to be beneficial in the prevention of stroke
in selected patients. The procedure is indicated in symptomatic patients with
carotid-territory transient ischemic attacks or minor strokes who have carotid
artery stenosis of 70 to 99 percent. With a low surgical risk, carotid
endarterectomy provides modest benefit in symptomatic patients with carotid
artery stenosis of 50 to 69 percent. Platelet antiaggregants and risk factor
modification are recommended in symptomatic patients with less than 50 percent
stenosis. In the Asymptomatic Carotid Atherosclerosis Study, carotid
endarterectomy was beneficial in patients who had asymptomatic carotid artery
stenosis of 60 percent or greater and whose general health made them good
candidates for elective surgery, provided that the arteriographic and surgical
complication rates were low. However, in asymptomatic patients, surgery
reduced the absolute risk of stroke by only 1 percent per year
Keywords: absolute risk/asymptomatic/BRUITS/carotid/carotid artery/carotid artery
disease/carotid artery stenosis/carotid
endarterectomy/CLINICAL-SIGNIFICANCE/CONSENSUS/disease/ENDART
ERECTOMY/FAMILY/health/ischemic/MODERATE/PHYSICIAN/PHYSICIA
NS/PLAQUE/PREVENTION/RISK/risk
factor/STENOSIS/STROKE/surgery/transient/transient ischemic attacks
Chatfield, J. (2001), American Heart Association scientific statement on the primary
prevention of ischemic stroke. American Family Physician, 64 (3), 513-514
Keywords: FAMILY/ischemic/ischemic
stroke/PHYSICIAN/PHYSICIANS/prevention/primary/primary
prevention/stroke
Bicket, D.P. (2002), Using ACE inhibitors appropriately. American Family Physician,
66 (3), 461-468.
Abstract: When first introduced in 1981, angiotensin-converting enzyme (ACE)
inhibitors were indicated only for treatment of refractory hypertension. Since
then, they have been shown to reduce morbidity or mortality in congesive heart
failure, myocardial infarction, diabetes mellitus, chronic renal insufficiency, and
atherosclerotic cardiovalcular disease. Pathologies underlying these conditions
are, in part attributable to the renin-angiotensin-aldosterone system.
Angiotension II contributes to endothelial dysfunction, altered renal
hemodynamics, and vascular and cardiac hypertrophy. ACE inhibitors attenuate
these effects. Clinical outcomes of AVE inhibiton include decreases in
myocardial infarction (fatal and nonfatal), reinfarction, angina, stroke, end-stage
renal disease, and morbidity and mortality associated with heart failure. ACE
inhibitors are generally well tolerated and few have few contraindications.
Copyright (C) 2002 American Academy of Family Physicians
Keywords: ACE inhibitors/ACUTE
MYOCARDIAL-INFARCTION/angina/ANTIHYPERTENSIVE
DRUGS/BENEFITS/CAPTOPRIL PREVENTION PROJECT/cardiac/cardiac
hypertrophy/chronic/CONVERTING ENZYME-INHIBITORS/diabetes/diabetes
mellitus/disease/end-stage renal disease/ENDOTHELIAL
DYSFUNCTION/FAMILY/heart/heart
failure/HEART-FAILURE/hemodynamics/hypertension/hypertrophy/infarction/
MORBIDITY/morbidity and mortality/MORTALITY/myocardial/myocardial
infarction/PHYSICIAN/PHYSICIANS/RANDOMIZED TRIAL/renal/renal
disease/stroke/treatment/vascular
King, D.E., Dickerson, L.M. and Sack, J.L. (2002), Acute management of atrial
fibrillation: Part II. Prevention of thromboembolic complications. American
Family Physician, 66 (2), 261-264.
Abstract: Family physicians should be familiar with the acute management of atrial
fibrillation and the initiation of chronic therapy for this common arrhythmia.
Initial management should include hemodynamic stabilization, rate control,
restoration of sinus rhythm, and initiation of antithrombotic therapy. Part 11 of
this two-part article focuses on the prevention of thromboembolic complications
using anticoagulation. Heparin is routinely administered before medical or
electrical cardioversion. Warfarin is used in patients with persistent atrial
fibrillation who are at higher risk for thromboembolic complications because of
advanced age, history of coronary artery disease or stroke, or presence of
left-sided heart failure. Aspirin is preferred in patients at low risk for
thromboembolic complications and patients with a high risk for falls, a history of
noncompliance, active bleeding, or poorly controlled hypertension. The
recommendations provided in this article are consistent with guidelines published
by the American Heart Association and the Agency for Healthcare Research and
Quality
Keywords: acute/age/anticoagulation/antithrombotic/ANTITHROMBOTIC
THERAPY/arrhythmia/atrial/atrial
fibrillation/bleeding/CARDIOVERSION/chronic/complications/control/coronary
artery disease/disease/DRUGS/falls/FAMILY/fibrillation/guidelines/heart/heart
failure/high
risk/history/hypertension/management/medical/METAANALYSIS/PHYSICIAN
/PHYSICIANS/prevention/risk/sinus rhythm/stroke/therapy/thromboembolic
complications/TRANSESOPHAGEAL ECHOCARDIOGRAPHY/Warfarin
Kannel, W.B., Wilson, P.W.F. and Zhang, T.J. (1991), The Epidemiology of Impaired
Glucose-Tolerance and Hypertension. American Heart Journal, 121 (4),
1268-1273.
Abstract: Epidemiologic research indicates that glucose intolerance and hypertension are
interrelated phenomena, each powerfully predisposing to atherosclerotic
cardiovascular disease. Both diabetic and hypertensive patients have greater
amounts of atherogenic risk factors, including dyslipidemia, hyperuricemia,
elevated fibrinogen, and left ventricular hypertrophy. Diabetic persons have an
increased prevalence of hypertension (50%), and glucose intolerance is more
common in hypertension (15% to 18%). Both share a strong relationship to
excess weight, but the excess of hypertension in diabetic persons occurs in both
lean and obese subjects. Diabetes doubles the risk of hypertension associated
with overweight. The risk of coronary disease, stroke, and peripheral arterial
disease increases with increasing blood pressure to the same degree in diabetic
persons as in nondiabetic persons, but at any level of blood pressure, diabetic
persons have a doubled risk of these outcomes. Both diabetic and hypertensive
patients are particularly prone to silent or unrecognized myocardial infarctions.
Greater efforts at primary prevention of both hypertension and diabetes are
clearly needed, including efforts at weight control, exercise, limitation of salt
intake, and control of blood lipid levels. In either diabetic or hypertensive
candidates for cardiovascular disease, optimization of the chances of avoiding
sequelae requires a comprehensive multifactorial approach. Prevention requires
more than normalization of either the blood sugar or blood pressure. Rational
preventive measures must also include weight reduction, a fat-modified diet,
cessation of smoking cigarettes, raising high-density lipoprotein, lowering low-
density lipoprotein, and reduction of fibrinogen. Hypertension, obesity, insulin
resistance, hyperinsulinemia, hypertriglyceridemia, and low high-density
lipoprotein cholesterol tend to coexist. All these factors accelerate atherogenesis
and may be responsible for the increased propensity of either diabetic or
hypertensive patients to develop coronary heart disease. Treatments that worsen
these features in hypertensive or diabetic patients are best avoided
Keywords:
DISEASE/FRAMINGHAM/HEART/MYOCARDIAL-INFARCTION/RISK-FA
CTORS
Singer, D.E., Hughes, R.A., Gress, D.R., Sheehan, M.A., Oertel, L.B., Maraventano,
S.W., Blewett, D.R., Rosner, B. and Kistler, J.P. (1992), The Effect of Aspirin on
the Risk of Stroke in Patients with Nonrheumatic Atrial-Fibrillation - the Baataf
Study. American Heart Journal, 124 (6), 1567-1573.
Abstract: Recent randomized trials have consistently demonstrated the marked efficacy
of warfarin in reducing the risk of stroke caused by nonrheumatic atrial
fibrillation. These trials have provided conflicting evidence on the effect of
aspirin. We report the aspirin analysis from the BAATAF study, a trial in which
control patients could choose to take aspirin. There were two strokes in 446
person-years with warfarin (annual rate of 0.45%); eight strokes in 206
person-years with aspirin, most at 325 mg per day (annual rate of 3.9%); and five
strokes in 271 person-years among patients taking neither aspirin nor warfarin
(annual rate of 1.8%). Simultaneously controlling for the other significant
determinants of stroke in the BAATAF study (age, mitral annular calcification,
and clinical heart disease), the relative rates (95% confidence interval) of stroke
were: (1) warfarin/aspirin = 0.135 (0.029 to 0.64); (2) aspirin/(no aspirin and no
warfarin) = 1.95 (0.64 to 5.97); and (3) warfarin/(no aspirin and no warfarin)
0.263 (0.051 to 1.36). Our "treatment received" analysis argues that warfarin is
strikingly more effective than aspirin in preventing stroke in nonrheumatic atrial
fibrillation
Keywords: FRAMINGHAM/HEART/INTERNAL/PREVENTION/RANDOMIZED
TRIAL/THERAPY/THROMBOEMBOLIC COMPLICATIONS/WARFARIN
Black, I.W., Hopkins, A.P., Lee, L.C.L. and Walsh, W.F. (1993), Evaluation of
Transesophageal Echocardiography Before Cardioversion of Atrial-Fibrillation
and Flutter in Nonanticoagulated Patients. American Heart Journal, 126 (2),
375-381.
Abstract: This study prospectively evaluated the role of transesophageal
echocardiography (TEE) in screening for atrial thrombi before electrical
cardioversion in 40 nonanticoagulated patients with nonvalvular atrial fibrillation
(n = 33) or atrial flutter (n = 7). Transthoracic echocardiography did not detect
atrial thrombus in any patient. TEE detected left atrial appendage thrombi in five
patients (12%, p = 0.03), significantly associated with left ventricular systolic
dysfunction (p = 0.02) and left atrial spontaneous echo contrast (p = 0.04).
Cardioversion was cancelled in the five patients with thrombi and in two patients
with spontaneous reversion before planned cardioversion. Cardioversion was
successful in 25 (76%) of the 33 remaining patients. Cerebral embolism occurred
24 hours after successful cardioversion in one patient with atrial fibrillation and
left ventricular dysfunction, who had left atrial spontaneous echo contrast, but no
thrombus was detected by TEE before cardioversion. Repeat TEE after embolism
showed a fresh left atrial appendage thrombus and increased left atrial
spontaneous echo contrast. These results indicate that TEE improves the
detection of left atrial appendage thrombi in candidates for cardioversion, in
whom the procedure may be deferred. However, the exclusion by TEE of
preexisting atrial thrombi before cardioversion does not eliminate the risk of
embolism after cardioversion because of persistent atrial stasis and de novo
thrombosis
Keywords:
ANTICOAGULATION/HEART/MITRAL-STENOSIS/PREVENTION/RISK/S
TROKE/THERAPY/THROMBUS
Hennekens, C.H. (1994), Platelet Inhibitors and Antioxidant Vitamins in
Cardiovascular- Disease. American Heart Journal, 128 (6), 1333-1336.
Abstract: Considerable research attention has focused on the possible roles of platelet
inhibition, principally using aspirin, and antioxidant vitamins in reducing the
risks of cardiovascular disease. Data from large-scale randomized trials indicate
that aspirin reduces subsequent vascular events among patients with prior
myocardial infarction, stroke, transient ischemic attacks, or unstable angina, as
well as among patients with acute evolving myocardial infarction. In primary
prevention trials, the Physicians' Health Study showed a clear benefit in
decreasing risk of a first myocardial infarction in men; the data on stroke and
total number of deaths from vascular causes are inadequate. The Women's Health
Study, a trial now under way among apparently healthy women, will provide
direct evidence on the balance of risks and benefits of aspirin in primary
prevention. Antioxidant vitamins are hypothesized to decrease cardiovascular
disease risk by several mechanisms, including inhibition of oxidation of
low-density lipoprotein cholesterol and decreasing uptake into the coronary
endothelium. Promising results have emerged from observational studies, which
show that people with high intakes of antioxidant vitamins through diet or
supplements have lowered risks of cardiovascular disease; however, unknown or
unmeasured factors associated with high antioxidant vitamin intake may explain
all or part of the observed associations. Randomized trials to provide reliable
data are now ongoing among apparently healthy men and women, as well as
among survivors of prior cardiovascular disease events
Keywords: angina/ASPIRIN/cardiovascular disease/CHOLESTEROL/diet/disease
risk/E CONSUMPTION/endothelium/HEART/LOW-DENSITY
LIPOPROTEIN/myocardial infarction/observational
studies/prevention/PRIMARY PREVENTION/randomized
trials/RISK/stroke/transient/trials/vascular/WOMEN
Cheng, T.O. (1994), Atrial-Fibrillation, Stroke, and Antithrombotic Treatment.
American Heart Journal, 127 (4), 961-968
Keywords: COMPLICATIONS/FRAMINGHAM/HEART/INTENSITIES/ORAL
ANTICOAGULANT-THERAPY/PREVENTION/RISK/VALVULAR
HEART-DISEASE/WARFARIN
Archer, S.L., James, K.E., Kvernen, L.R., Cohen, I.S., Ezekowitz, M.D. and Gornick,
C.C. (1995), Role of Transesophageal Echocardiography in the Detection of Left
Atrial Thrombus in Patients with Chronic Nonrheumatic Atrial-Fibrillation.
American Heart Journal, 130 (2), 287-295.
Abstract: Transesophageal echocardiography was used to assess cardiac abnormalities
associated with embolization in patients who had completed the Department of
Veterans Affairs Cooperative Study of Stroke Prevention in Nonrheumatic Atrial
Fibrillation at the Minneapolis and West Haven Department of Veterans Affairs
Medical Centers without an embolic event. Patients were men, 71 +/- 7 years old,
with atrial fibrillation of 6.2 +/- 4.3 years' duration who had received warfarin (n
= 32) or placebo (n = 23) for 2 years. Thrombi were found in 5 of 55 patients
(warfarin 4 and placebo 1; p = 0.39); spontaneous echo contrast was seen in 4 of
5 patients. Other abnormalities identified included spontaneous echo contrast
(47%), patent foramen ovale (54%), atrial septal aneurysm (7.3%), and left
ventricular thrombus (3.6%). During 34 months of posttreatment follow-up, 5
patients had a stroke (1 fatal), and 10 died. Potential sources of emboli did not
predict subsequent outcome. Thus warfarin therapy did not preclude the presence
of thrombi. Stroke reduction likely involves the prevention of emboli from
sources in addition to the atrial appendage
Keywords: APPENDAGE THROMBI/atrial fibrillation/atrial septal
aneurysm/DIAGNOSIS/echocardiography/emboli/fibrillation/HEART/LEFT-VE
NTRICULAR THROMBI/patent foramen ovale/PLATELET
SCINTIGRAPHY/PREVALENCE/PREVENTION/SPONTANEOUS ECHO
CONTRAST/STROKE/thrombus/TWO-DIMENSIONAL
ECHOCARDIOGRAPHY/WARFARIN
Nendaz, M.R., Sarasin, F.P., Junod, A.F. and Bogousslavsky, J. (1998), Preventing
stroke recurrence in patients with patent foramen ovale: Antithrombotic therapy,
foramen closure, or therapeutic abstention? A decision analytic perspective.
American Heart Journal, 135 (3), 532-541.
Abstract: Emphasis on the role of patent foramen ovale as a potential risk factor for
ischemic paradoxical stroke has recently increased. Current therapeutic options
for secondary stroke prevention include long-term antithrombotic therapies and
invasive closure of the defect, but selective indications have not been evaluated.
Therefore we developed a Markov-based decision analysis model for a
hypothetical cohort of patients 55 years of age with presumed paradoxical
embolism, measuring for each therapy the risks of stroke recurrence, treatment-
related complications, and death after 5 years and the quality- adjusted life-years.
Over a wide range of stroke risk recurrence (0.8% per year to 7% per year), the
gain provided by closure of the defect exceeded the one obtained by other
therapeutic options. When the risk exceeded 0.8% per year and 1.4% per year,
respectively, this was also verified for anticoagulation and antiplatelet therapies
compared with therapeutic abstention. Therapeutic abstention was the preferred
strategy under 0.8% per year. Sensitivity analyses identified key parameters
influencing the choice of therapy. These included estimates of stroke recurrence,
bleeding rates, surgery-related case fatality rates, and age. Considering the risks
of treatment and the devastating consequences of a recurrent stroke, our model
suggests that if the estimated risk of paradoxical stroke recurrence is >0.8% per
year, therapeutic abstention becomes the worst option. Above this threshold
secondary stroke prevention with anticoagulation therapy or surgical closure of
the defect is the preferred strategy, and assessment of both the risk of stroke
recurrence and the risk related to therapeutic options should guide individual
therapeutic decision making
Keywords: age/anticoagulation/ATRIAL SEPTAL-DEFECT/case
fatality/complications/CRYPTOGENIC STROKE/decision
analysis/decision-making/embolism/FOLLOW-UP/foramen
ovale/HEART/LIFE/NATURAL-HISTORY/PARADOXICAL
EMBOLISM/patent/patent foramen
ovale/prevention/recurrence/RISK/stroke/stroke prevention/SURGICAL
CLOSURE/therapy/TRANSCATHETER CLOSURE/TRANSESOPHAGEAL
ECHOCARDIOGRAPHY/treatment
Sherman, S.E., D'Agostino, R.B., Silbershatz, H. and Kannel, W.B. (1999), Comparison
of past versus recent physical activity in the prevention of premature death and
coronary artery disease. American Heart Journal, 138 (5), 900-907.
Abstract: Background People who are physically active live longer, but it is unclear
whether this is because of physical activity in the distant or more recent post.
Methods We assessed activity levels in 5209 men and women in the Framingham
Heart Study from 1956 to 1958 and again from 1969 to 1973. We included
individuals who were alive and without cardiovascular disease in the period 1969
to 1973. The primary outcome was death from all causes during the 16 years
after the 1969 to 1973 assessment. Secondary outcomes were incidence and
mortality rate of: cardiovascular disease. We used Cox proportional hazards
regression to calculate the relative risk of being sedentary, both unadjusted and
controlling for smoking, weight, systolic blood pressure, cholesterol, glucose
intolerance, left ventricular hypertrophy, chronic obstructive pulmonary disease,
and cancer. Results The overall 16-year mortality rate was 37% for men and 27%
For women. When both distant and recent activity levels were included along
with major cardiovascular disease risk Factors, for recent activity the most active
tertile had lower overall mortality rate than the least active tertile for men (risk
ratio 0.58, 95% confidence interval, 0.43-0.79) and women (risk ratio 0.61, 95%
confidence interval, 0.45-0.82). For distant activity there was no difference in
overall mortality rate between the most and least active tertiles either for men or
for women. Adjusting for major cardiovascular disease risk factors had little
effect on the results. Conclusions The reduction in overall mortality rates is more
associated with recent activity than distant activity. These results suggest that for
sedentary patients, it may never be tao late to begin exercising
Keywords: blood pressure/cardiovascular/cardiovascular disease/cholesterol/coronary
artery disease/DEPRESSION/disease
risk/EXERCISE/glucose/HEALTH/HEART/hypertrophy/incidence/left
ventricular hypertrophy/MEN/MORTALITY/physical
activity/prevention/relative risk/risk/risk factors/smoking/STROKE/systolic
blood pressure/WOMEN
Flaker, G.C., McGowan, D.J., Boechler, M., Fortune, G. and Gage, B. (1999),
Underutilization of antithrombotic therapy in elderly rural patients with atrial
fibrillation. American Heart Journal, 137 (2), 307-312.
Abstract: Background Antithrombotic agents are underutilized in elderly patients with
atrial fibrillation. In a peer-review audit of antithrombotic use in Missouri, rural
patients were given antithrombotic therapy less often than rural patients for
unclear reasons. Methods and Results The charts of 597 hospitalized Medicare
patients discharged between October 1, 1993, and December 31, 1994, from
urban and rural hospitals in Missouri were reviewed. In addition to
antithrombotic therapy prescribed at the time of discharge, patient and physician
information, relative contraindications to antithrombotic therapy, and risk factors
for stroke were identified. Rural and urban patients were similar in terms of age,
sex, and risk factors for stroke. At least one stroke risk factor was noted in 87%
of rural patients and in 84% of urban patients. Urban patients were more likely to
have a relative contraindication to antithrombotic therapy compared with rural
patients (66% vs 54%, P = .04) but received antithrombotic therapy more often
(58% vs 47%, P = .02). Cardiologists prescribed antithrombotic therapy
significantly more often than noncardiologists (69% vs 52%, P = .003).
Conclusions Elderly rural patients with atrial fibrillation receive antithrombotic
therapy less frequently than urban patients despite having a similar high-risk
profile and fewer relative contraindications. Primary care physicians prescribe
antithrombotic therapy less often than cardiologists, which is one of the reasons
for this underutilization
Keywords: ACUTE
MYOCARDIAL-INFARCTION/age/ANTICOAGULATION/antithrombotic/ant
ithrombotic therapy/atrial fibrillation/audit/DRUG-
THERAPY/elderly/EXPERIENCE/fibrillation/HEART/high risk/HOSPITAL
CARDIAC-ARREST/hospitals/PHYSICIANS/PREVENTION/risk/risk
factor/risk factors/risk factors for
stroke/sex/STROKE/therapy/URBAN/WARFARIN
Labovitz, A.J. (1999), Transesophageal echocardiography and unexplained cerebral
ischemia: A multicenter follow-up study. American Heart Journal, 137 (6),
1082-1087.
Abstract: Background Transesophageal echocardiography (TEE) continues to play a
prominent role in the evaluation of patients with unexplained cerebral ischemia.
The STEPS Study Group (Significance of Transesophageal Echocardiography in
the Prevention of Recurrent Stroke) was established to further examine the
clinical significance of TEE findings in patients with suspected cardiac source of
embolus and to assess the impact of these findings with respect to specific
therapy and the prevention of recurrent events. Methods A total of 242 patients
from 15 institutions within the United States underwent TEE study for evaluation
of unexplained cerebral ischemia. Over a 1-year period, detailed follow-vp was
obtained with respect to recurrent stroke, transient ischemia attacks, or
documented embolic events as well as detailed information concerning
nonrandomized antithrombotic therapy. Results Recurrent stroke occurred in 17
of 132 (13%) of the patients in the aspirin group versus 5 of 110 (5%) of the
patients receiving warfarin therapy (P <.02). This decrease in cerebral ischemic
events in the warfarin group was noted, despite the higher prevalence of atrial
fibrillation and impaired ventricular function in the warfarin group. The selection
of antithrombotic therapy appears, at least in part, to have been influenced by the
TEE findings. Among patients receiving aspirin, a higher recurrent stroke rate
was noted in those with left ventricular enlargement and atherosclerotic aortic
plaque, Conclusion Abnormalities are commonly found by TEE in patients with
unexplained cerebral ischemia. Patients with left ventricular enlargement and
demonstrable aortic plaque on TEE study are at increased risk for recurrent
stroke when receiving aspirin therapy alone. Empiric therapy with systemic
anticoagulation may be indicated in patients with stroke unexplained by carotid
atherosclerotic disease
Keywords: anticoagulation/antithrombotic/antithrombotic therapy/aspirin/atrial
fibrillation/ATRIAL SEPTAL ANEURYSM/carotid/cerebral/cerebral
ischemia/COMMUNITY STROKE
PROJECT/CONTRAST/echocardiography/EMBOLISM/embolus/evaluation/EV
ENTS/fibrillation/HEART/ischemia/ischemic/PATENT FORAMEN
OVALE/plaque/POTENTIAL CARDIAC
SOURCE/PREVALENCE/PREVENTION/RECURRENT
STROKE/risk/stroke/therapy/transient/United States/warfarin
Muller, J.E. (1999), Circadian variation and triggering of acute coronary events.
American Heart Journal, 137 (4), S1-S8.
Abstract: The recognition that the onset of cardiovascular events follows a circadian
periodicity and is frequently triggered by physical or mental stresses has created
new possibilities for disease prevention. Morning peaks in occurrence are now
well-documented for acute myocardial infarction, sudden cardiac death, transient
myocardial ischemia, and ischemic stroke. The morning increase in events
begins after subjects assume an upright posture and start the day's activities,
during a time of sympathetic nervous system activation. Additional triggers of
onset include heavy physical exertion, sexual activity, and anger, the risks of
which have been quantified in the Determinants of Myocardial Infarction Onset
Study. A general hypothesis of the triggering of coronary thrombosis has been
proposed. The process begins with the development of a vulnerable
atherosclerotic plaque, which may become disrupted by internal forces or by
external hemodynamic or vasoconstrictive changes. Once disrupted, the plaque
becomes a thrombogenic focus. An occlusive thrombus is more likely to form if
other factors come into play to increase coagulability and vasoconstriction. From
a clinical standpoint these findings provide theoretical support for the use of
long-acting agents to provide adequate anti-ischemic protection during the higher
risk morning hours in patients already taking antiischemic medications. From a
research standpoint this new information on triggering provides clues to a
mechanism of onset that might lead to more effective preventive therapy.
Because most deaths from coronary artery disease occur before any type of acute
therapy can be given, further efforts to explore this new field are warranted
Keywords: activation/acute/acute myocardial infarction/ACUTE
MYOCARDIAL-INFARCTION/cardiovascular/cardiovascular events/coronary
artery
disease/development/FREQUENCY/HEART/infarction/ischemia/ischemic/ische
mic stroke/myocardial/myocardial infarction/ONSET/PHYSICAL
EXERTION/plaque/prevention/RISK/SEXUAL-ACTIVITY/stroke/SUDDEN
CARDIAC DEATH/therapy/thrombosis/thrombus/transient/triggers
Hennekens, C.H. (1999), Update on aspirin in the treatment and prevention of
cardiovascular disease. American Heart Journal, 137 (4), S9-S13.
Abstract: The effects of low-dose aspirin on cardiovascular disease have been tested in
randomized trials in 3 types of populations: (1) patients with a history of
cardiovascular disease; (2) patients with evolving acute myocardial infarction
(MI), and (3) apparently healthy subjects. In a very wide range of patients with
prior occlusive cardiovascular disease, aspirin reduces the risks of nonfatal MI,
nonfatal stroke, and vascular death. Initiating aspirin therapy within 24 hours
after the onset of symptoms of an acute MI also confers conclusive reductions in
the risk of nonfatal reinfarction, nonfatal stroke, and total cardiovascular death.
In primary prevention trials, aspirin has been shown to reduce the risk of a first
MI in men, but the data on stroke and total cardiovascular death are not sufficient
to allow firm conclusions to be drawn; randomized data from studies in women
are not yet available. The Women's Health Study an ongoing large-scale trial in
Female health core professionals, will provide the data necessary to assess the
balance of benefits and risks of aspirin in primary prevention. Until then, the
decision to use aspirin in primary prevention should be based on the clinical
judgment of the physician and considered as an adjunct in the management of
other cardiovascular disease risk factors
Keywords: acute/acute myocardial infarction/aspirin/cardiovascular/cardiovascular
disease/disease
risk/DRUGS/health/HEART/history/infarction/INHIBITION/men/myocardial/m
yocardial infarction/prevention/primary/primary
prevention/randomized/randomized trials/risk/risk
factors/stroke/THERAPEUTIC AGENT/therapy/treatment/trials/vascular/women
Tavazzi, L. (1999), Clinical epidemiology of acute myocardial infarction. American
Heart Journal, 138 (2), S48-S54.
Abstract: In the United States by mid-century, cardiovascular disease accounted for
more than half of all deaths. In the second half of this century, 85% of reduction
in age-adjusted mortality rates from all causes can be ascribed to the decline in
death from cardiovascular disease and stroke. Approximately half of such
dramatic decline in mortality rates from ischemic heart disease (IHD) can be
explained by primary and secondary prevention and half by therapeutic
improvements. Epidemiology of therapeutic regimens in acute myocardial
infarction (AMI) indicates substantial increases in the use of thrombolytic
therapy, aspirin, beta-blockers and, in some countries, coronary angioplasty. The
long-term results of several thrombolytic trials have shown the persistence of
early benefit until 10 years after AMI. However, approximately half of the
patients with AMI are admitted to the hospital too late to fully benefit from
thrombolytic therapy, and one Fourth of eligible patients do not receive any form
of reperfusion. Primary angioplasty is advocated by some as the treatment of
choice in AMI. The present results are not convincing enough to induce the
enormously complex and costly reorganization of the health system, allowing the
immediate access to coronary angiography For all or most patients with AMI.
However, stenting the infarct coronary artery at the site of previous occlusion
appears to improve the immediate and medium-term results of coronary
revascularization procedures. Approximately half of the AMI survivors are
rehospitalized within 1 year after the index event, and postinfarction mortality
rate remains exceedingly high. After AMI, prognostic and therapeutic procedures
have been introduced in the absence of evidence from controlled trials of their
effectiveness profile. Outcome research is needed to standardize effective
post-AMI policies. Moreover, new strategies are needed to reduce the incidence
and mortality rates of acute ischemic events. A number of new candidate risk
Factors for IHD are emerging; they ore associated with endothelial dysfunction,
thrombogenic state, and inflammatory state. It is hoped that advances in
molecular approach to cardiovascular disease, molecular genetics and transgenic
techniques will allow better understanding and more effective therapeutic
strategies to prevent and control IHD
Keywords: acute/acute myocardial
infarction/angioplasty/aspirin/beta-blockers/cardiovascular/cardiovascular
disease/control/coronary angioplasty/CORONARY HEART-DISEASE/coronary
revascularization/epidemiology/FOLLOW-UP/genetics/GLOBAL
BURDEN/health/HEART/hospital/incidence/infarction/INTRAVENOUS
STREPTOKINASE/ischemic/ischemic heart
disease/MORTALITY/myocardial/myocardial
infarction/prevention/primary/PROGNOSIS/reperfusion/REVASCULARIZATI
ON PROCEDURES/risk/RISK-FACTORS/SECONDARY
PREVENTION/stenting/stroke/therapy/THROMBOLYTIC
THERAPY/treatment/trials/United States
Smolensky, M.H. and Portaluppi, F. (1999), Chronopharmacology and chronotherapy of
cardiovascular medications: Relevance to prevention and treatment of coronary
heart disease. American Heart Journal, 137 (4), S14-S24.
Abstract: Biological functions and processes, including cardiovascular ones, exhibit
significant circadian (24-hour) and other period rhythms. Ambulatory blood
pressure assessment reveals marked circadian rhythms in blood pressure both in
normotensive persons and hypertensive patients, whereas Holter monitoring
substantiates day-night patterns in electrocardiographic events of patients with
ischemic heart disease. The concept of homeostasis, that is, constancy of the
milieu interna which has dominated the teaching, research, and practice of
medicine during the 20th century, is now being challenged by emerging concepts
from the field of chronobiology-the science of biological rhythms.
Epidemiologic studies document the heightened morning-time risk of angina,
myocardial infarction, and stroke. Circadian rhythms in coronary tone and
reactivity, plasma volume, blood pressure, heart rate, myocardial oxygen demand,
blood coagulation, and neuroendocrine Function plus day-night patterns in the
nature and strength of environmental triggers all contribute to this morning
vulnerability Homeostatically devised pharmacotherapies, that is, medications
formulated to ensure a near-constant drug concentration, may not be optimal to
adequately control diseases that vary in risk and severity during the 24 hours.
Moreover, circadian rhythms in the physiology of the gastrointestinal tract, vital
organs, and body tissues may give rise to administration-time differences in the
pharmacokinetics and effects of therapies. Thus the same medication consumed
in the same dose under identical conditions in the evening and morning may not
exhibit comparable pharmacokinetics and dynamics. New technology makes
possible chronotherapy, that is, increase of the efficiency and safety of
medications by proportioning their concentrations during the 24 hours in
synchrony with biological rhythm determinants of disease. The chronotherapy of
peptic ulcer disease achieved by the evening dosing of H-2-receptor antagonists
and of asthma by the evening dosing of special drug delivery forms of
theophylline and morning methylprednisolone administration has proven to be
beneficial. Controlled-onset extended-release verapamil constitutes the first
chronotherapy of essential hypertension and ischemic heart disease; once-a- day
bedtime dosing results in a high drug concentration in the morning and afternoon
and a reduced one overnight. Studies demonstrate effective 24-hour control of
blood pressure, including the attenuation of its rapid rise in the morning, without
induction of nighttime hypotension. Moreover, this formulation effectively
controls angina, especially in the morning when the risk of ischemia is greatest.
Determination of the role of verapamil chronotherapy in the primary prevention
of cardiovascular morbidity and mortality awaits the results of the CONVINCE
trial now in progress
Keywords: administration/angina/ANGINA-PECTORIS/BETA-BLOCKER
THERAPY/blood pressure/cardiovascular/cardiovascular morbidity/CHRONIC-
RENAL-FAILURE/CIRCADIAN
VARIATION/coagulation/control/CONTROLLED-ONSET/coronary heart
disease/diseases/DIURNAL-VARIATION/EXTENDED-RELEASE
VERAPAMIL/heart/Holter
monitoring/hypertension/infarction/ischemia/ischemic/ischemic heart
disease/monitoring/morbidity/mortality/myocardial/myocardial
infarction/MYOCARDIAL-ISCHEMIA/NOCTURNAL
BLOOD-PRESSURE/prevention/primary/primary
prevention/risk/safety/severity/STABLE ANGINA/stroke/treatment/triggers
Scardi, S., Mazzone, C., Pandullo, C., Goldstein, D., Poletti, A. and Humar, F. (1999),
Lone atrial fibrillation: Prognostic differences between paroxysmal and chronic
forms after 10 years of follow-up. American Heart Journal, 137 (4), 686-691.
Abstract: Background Lone atrial fibrillation (LAF) is defined by the presence of atrial
fibrillation unassociated with other evidence of organic heart disease. There are
conflicting data concerning the prognostic importance, rate of embolic
complications, and survival in subjects affected by this arrhythmia. Methods and
Results One hundred forty-five patients younger than 50 years at the rime of the
first diagnosis were identified; 96 had paroxysmal and 49 had chronic LAF. They
were followed vp with clinical and echocardiographic controls, and we recorded
every thromboembolic complication and death. During the Follow-up (10 +/- 8
years) among patients with paroxysmal LAF, 1 (1%) had an ischemic stroke, 2 a
transient ischemic attack, and 1 a myocardial infarction. In the group with
chronic LAF, 1 patient had moderate heart failure, 2 myocardial infarction, and 1
transient ischemic attack. In this group, 8 embolic complications in 7 (16.3%)
patients were observed. One patient with intestinal embolism died during surgery;
2 (6.1%) patients died suddenly. Conclusions The prognosis of young patients
with paroxysmal LAF appears to be excellent whereas patients with chronic LAF
are at increased risk of embolic complications and higher mortality rates. Our
results suggest that LAF is not always a benign disorder, as suggested by
previous studies. Subgroups with substantially increased risk for thromboembolic
events caused by LAF should be better identified
Keywords: arrhythmia/atrial
fibrillation/COMPLICATIONS/diagnosis/embolism/EPIDEMIOLOGIC
FEATURES/fibrillation/HEALTH/HEART/heart
failure/infarction/ischemic/ischemic
stroke/MORTALITY/myocardial/myocardial
infarction/POPULATION/PREVENTION/prognosis/risk/STROKE/surgery/THE
RAPY/thromboembolic events/TRANSESOPHAGEAL
ECHOCARDIOGRAPHY/transient/transient ischemic attack/WARFARIN
Connolly, S.J. (2000), Appropriate outcome measures in trials evaluating treatment of
atrial fibrillation. American Heart Journal, 139 (5), 752-760.
Abstract: Background Atrial fibrillation [AF] is a widespread disease chat has only
recently received the focused attention of arrhythmia specialists despite being the
most frequently occurring significant cardiac arrhythmia. Methods and Results
The wide variety of trial designs used to evaluate AF treatment is a reflection of
the diverse outcomes associated with this condition. The best trials assess the
impact of treatment on a clearly measured outcome that is of clinical relevance to
patients. This review discusses the different designs of AF treatment trials and
analyzes the utility of the various outcomes that can be assessed. Conclusions A
sensible goal of AF treatment is to reduce the frequency of recurrences and to
prolong the time between them. The most appropriate trials focus on AF
recurrences that are symptomatic and therefore relevant to the patient. We still do
not know if there is value in AF prevention, beyond preventing symptoms.
However, ongoing and future studies will show whether AF suppression reduces
the longer-term risks of stroke or death and improves patient quality of life. Cost
of care will increasingly be studied in future trials of AF management
Keywords: AF/arrhythmia/ARTERY BYPASS-SURGERY/atrial
fibrillation/ATRIOVENTRICULAR JUNCTION ABLATION/cardiac/cardiac
arrhythmia/CARDIAC-SURGERY/death/disease/DOUBLE-BLIND
CROSSOVER/fibrillation/HEART/III ANTIARRHYTHMIC
AGENT/INTRAVENOUS AMIODARONE/outcome/PLACEBO-
CONTROLLED TRIAL/prevention/quality of
life/QUALITY-OF-LIFE/RANDOMIZED CONTROL TRIALS/review/SINUS
RHYTHM/stroke/treatment/trials
Ibrahim, S.A. and Kwoh, C.K. (2000), Underutilization of oral anticoagulant therapy for
stroke prevention in elderly patients with heart failure. American Heart Journal,
140 (2), 219-220.
Abstract: Background Oral anticoagulant therapy is the most effective prophylaxis
against stroke in atrial fibrillation. Relatively few studies have examined the use
of oral anticoagulant therapy for stroke prevention in a large cohort of elderly
patients with heart failure. To examine the use of stroke prevention therapy, we
studied elderly patients with heart failure admitted to 30 hospitals in northeast
Ohio between 1992 and 1994. Methods and Results The sample consisted of
12,911 Medicare-insured patients greater than or equal to 65 years of age who
were consecutively admitted with a principal diagnosis of heart failure between
1992 and 1994. Baseline demographic and clinical characteristics for patients
with the diagnosis of atrial fibrillation were calculated. Bivariate associations
between receiving anticoagulant therapy and select demographic and clinical
variables were calculated. In our cohort of patients with heart failure, 2093 had
atrial fibrillation (16%). Only 414 (20%) of the patients with atrial fibrillation
received oral anticoagulant therapy. Older age and history of gastrointestinal
bleeding were significantly negatively associated with receiving oral
anticoagulant therapy. History of stroke or transient ischemic attack was
positively associated with receiving oral anticoagulant therapy. Conclusions
Atrial fibrillation is common in older patients with heart failure; oral
anticoagulant therapy for stroke prevention, which has been shown to be
effective, is underutilized in this patient population
Keywords: age/anticoagulant/anticoagulant therapy/atrial
fibrillation/ATRIAL-FIBRILLATION/bleeding/diagnosis/elderly/elderly
patients/fibrillation/heart/heart failure/history/hospitals/ischemic/oral
anticoagulant therapy/population/prevention/prophylaxis/stroke/stroke
prevention/therapy/transient/transient ischemic attack/use/WARFARIN
Strandberg, T.E., Pitkala, K., Berglind, S., Nieminen, M.S. and Tilvis, R.S. (2001),
Multifactorial cardiovascular disease prevention in patients aged 75 years and
older: A randomized controlled trial - Drugs and evidence based medicine in the
elderly (DEBATE) study. American Heart Journal, 142 (6), 945-951.
Abstract: Background The number of patients aged 75+ years with cardiovascular
diseases (CVD) is increasing, but few studies of secondary prevention in this age
group exist. The aim of the Drug and Evidence Based Medicine in the Elderly
(DEBATE) study is to test the applicability and effectiveness of established CVD
treatments in elderly patients. Methods From 1998 to 2000, population-based
postal surveys were performed in Helsinki, Finland, including the age groups 75,
80, 85, 90, and 95 years (n = 4821). Of the 812 individuals reporting any
atherosclerotic disease, 400 patients (66% of those eligible) were included in a
randomized trial. In the intervention group, CVD treatments will be
individualized according to current guidelines. A control group will receive the
usual care. The trial period will last 2 years with a 3-year extension. The primary
end point will be a composite of major CVD. In addition, a number of secondary
end points will be recorded, including permanent institutionalization, decline in
cognitive and physical function, and quality of life. Results During 2000, 400
home-dwelling patients were randomized to the intervention (n = 199) and
control (n = 201) groups. The mean age is 80.2 years and 65.3% are women. Of
the participants, 82% have coronary heart disease (41% with history of
myocardial infarction), 37% history of stroke, 19% non-insulin-dependent
diabetes mellitus, and 45% hypertension, and 6% are current smokers. Before
randomization, 67% used aspirin, 400% beta - blockers, 14%
angiotensin-converting enzyme inhibitors, 36% nitrates, and 20% lipid-lowering
drugs. The groups were well balanced at baseline. Conclusion We have
successfully randomized elderly patients with a high degree of comorbidity into a
multifactorial CVD prevention trial
Keywords: age/aged/angiotensin converting enzyme inhibitors/angiotensin-converting
enzyme inhibitors/aspirin/cardiovascular/cardiovascular disease/cardiovascular
disease prevention/cardiovascular diseases/comorbidity/control/coronary heart
disease/CORONARY-HEART-DISEASE/diabetes/diabetes
mellitus/disease/diseases/drugs/elderly/elderly
patients/EVENTS/Finland/guidelines/HEALTH/HEART/heart
disease/history/hypertension/infarction/lipid lowering/myocardial/myocardial
infarction/non-insulin-dependent diabetes mellitus/physical
function/PLACEBO/population-based/PRAVASTATIN/prevention/primary/qual
ity of life/randomized/randomized controlled trial/randomized
trial/RISK/secondary prevention/stroke/SYSTOLIC
HYPERTENSION/trial/women
Fathi, R. and Marwick, T.H. (2001), Noninvasive tests of vascular function and structure:
Why and how to perform them. American Heart Journal, 141 (5), 694-703.
Abstract: Background Early atherosclerosis involves the endothelium of many arteries.
Information about peripheral arterial anatomy and function derived from vascular
imaging studies such as brachial artery reactivity (BAR) and carotid intima
media thickness (IMT) may be pertinent to the coronary circulation. The
prevention and early treatment of atherosclerosis is gaining more attention, and
these tests might be used as indications or perhaps guides to the effectiveness of
therapy, but their application in clinical practice has been limited. This review
seeks to define the anatomy and pathophysiology underlying these investigations,
their methodology, the significance of their Findings, and the issues that must be
resolved before their application. Methods The literature on BAR and IMT is
extensively reviewed, especially in relation to clinical use. Results Abnormal
flow-mediated dilation is present in atherosclerotic vessels, is associated with
cardiovascular risk factors, and may be a marker of preclinical disease.
Treatment of known atherosclerotic risk Factors has been shown to improve
flow-mediated dilation, and some data suggest that vascular responsiveness is
related to outcome. Carotid IMT is associated with cardiovascular risk factors,
and increased levels can predict myocardial infarction and stroke. Aggressive
risk factor management can decrease IMT. Conclusions BAR and IMT ate
functional and structural markers of the atherosclerotic process. The clinical use
of BAR has been limited by varying reproducibility and the influence by
exogenous factors, but IMT exhibits less variability. A desirable next step in the
development of BAR and IMT as useful clinical tools would be to show an
association of improvement in response to treatment with improvement in
prognosis
Keywords: arterial/arteries/atherosclerosis/Australia/cardiovascular/cardiovascular
risk/cardiovascular risk factors/carotid/CAROTID- ARTERY/clinical
practice/CORONARY-ARTERY DISEASE/DEPENDENT
VASODILATION/development/disease/endothelium/HEART/HEART-DISEAS
E/IMPROVES ENDOTHELIAL FUNCTION/infarction/INTIMA-MEDIA
THICKNESS/management/markers/methodology/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/outcome/pathophysiology/POSITRO
N-EMISSION-TOMOGRAPHY/POSTMENOPAUSAL
WOMEN/prevention/prognosis/review/risk/risk factor/risk
factors/RISK-FACTORS/stroke/therapy/treatment/use/vascular/vessels
Jackson, E.A., Sivasubramian, R., Spencer, F.A., Yarzebski, J., Lessard, D., Gore, J.M.
and Goldberg, R.J. (2002), Changes over time in the use of aspirin in patients
hospitalized with acute myocardial infarction (1975 to 1997): A
population-based perspective. American Heart Journal, 144 (2), 259-268.
Abstract: Objective The purpose of this study was to examine 2 decade- long trends in
the use of aspirin and associated outcomes in patients hospitalized with acute
myocardial infarction. Background Aspirin has been shown to be beneficial in
the seconclary prevention of AML However, little is known about changes over
time in the use of aspirin in patients hospitalized with AMI and associated
outcomes, particularly from a more generalizable population-based perspective.
Methods We examined trends in aspirin use and hospital and long-term outcomes
in 9336 metropolitan Worcester, Mass, residents hospitalized with validated AMI
in all area hospitals between 1975 and 1997. Results Between 1975 and 1986, the
hospital use of aspirin remained stable at approximately 20%. Use of aspirin
increased markedly after this time from 49% in 1988 to 91% in 1997. Younger
age, male sex, and a history of hypertension or stroke were associated with an
increased likelihood of receiving aspirin. Patients with diabetes were less likely
to receive aspirin than were patients without diabetes. Patients who received
aspirin during hospitalization were more likely to receive beta-blockers and
coronary interventions. Patients treated with aspirin were significantly less likely
to have heart failure or cardiogenic shock develop or to die during hospitalization
as compared with patients not treated with aspirin. Patients treated with aspirin
had significantly higher survival rates over a 10-year follow-up period.
Conclusion The results of this community-wide study show that aspirin use in
patients hospitalized with AMI has dramatically increased over time. Despite the
beneficial effects associated with the use of aspirin, this therapy remains
under-used in several high-risk groups
Keywords: acute/acute myocardial infarction/age/AGE-RELATED
TRENDS/aspirin/beta-blockers/CASE-FATALITY
RATES/CLINICAL-TRIALS/COMMUNITY-WIDE
PERSPECTIVE/CONVERTING
ENZYME-INHIBITORS/CORONARY-ARTERY
DISEASE/diabetes/HEART/heart failure/high
risk/history/hospital/hospitalization/hospitals/hypertension/infarction/MEDICAR
E BENEFICIARIES/myocardial/myocardial
infarction/population-based/prevention/sex/stroke/survival/TEMPORAL
TRENDS/therapy/THROMBOLYTIC THERAPY/trends/use/WORCESTER
HEART-ATTACK
Crystal, E., Lamy, A., Connolly, S.J., Kleine, P., Hohnloser, S.H., Semelhago, L.,
Abouzhar, L., Cybulsky, I., Shragge, B., Teoh, K., Lonn, E., Sawchuk, C. and
Oezaslan, F. (2003), Left Atrial Appendage Occlusion Study (LAAOS): A
randomixed clinical trial of left atrial appendage occlusion during routine
coronary artery bypass graft surgery for long-term stroke prevention. American
Heart Journal, 145 (1), 174-178.
Abstract: Background Many patients undergoing coronary artery bypass graft (CABG)
surgery have risk factors for both atrial fibrillation (AF) and stroke. The left
atrial appendage (LAA) is a main source of thrombus coming from the left
atrium. LAA occlusion should be tested as a means to reduce future cerebral
ischemic events in these patients. Methods The Left Atrial Appendage Occlusion
Study (LAAOS) is a randomized clinical trial designed to evaluate the feasibility,
safety, and efficacy of LAA occlusion for prevention of ischemic stroke in
patients undergoing CABG. The target population consists of patients at risk of
AF and stroke who are having routine CABG surgery. The main study will be a
prospective, controlled, unblinded trial. Patients at risk of future development of
AF, or having AF, will be randomly assigned to undergo or not undergo LAA
occlusion. A total of 2500 patients will be randomly assigned and followed for 5
years for the primary outcome of stroke. This study of 2500 patients will have
90% power to detect a relative reduction of 20% in stroke, from a 5-year
incidence of 20% in the control group to 16% in the intervention group.
Currently, a pilot trial is underway that will enroll 100 patients to assess
feasibility, safety, and rates of successful LAA occlusion as assessed by
postoperative transesophageal echocardiography. The most suitable surgical
technique will also be assessed during the pilot trial. In the pilot study, the main
outcomes are safety and rate of successful obliteration of the LAA after surgical
occlusion. Conclusions The clinical trial designed to evaluate LAA occlusion at
the time of routine CABG surgery is currently in the pilot phase
Keywords: AF/APPENDECTOMY/atrial/atrial appendage/atrial
fibrillation/bypass/CABG/CARE/cerebral/clinical trial/control/coronary artery
bypass/development/ECHO/echocardiography/FIBRILLATION/HEART/inciden
ce/ischemic/ischemic stroke/left atrial appendage/left atrium/LIGATION/MAZE
PROCEDURE/outcome/outcomes/population/postoperative/prevention/primary/r
andomized/randomized clinical trial/RELEASE/risk/risk
factors/safety/SODIUM/stroke/stroke
prevention/surgery/thrombus/transesophageal echocardiography/trial/USA
Hague, W., Forder, P., Simes, J., Hunt, D. and Tonkin, A. (2003), Prevention and
rehabilitation - Effect of pravastatin on cardiovascular events and mortality in
1516 women with coronary heart disease: Results from the Long-Term
Intervention with Pravastatin in Ischemic Disease (LIPID) study. American
Heart Journal, 145 (4), 643-651.
Abstract: Background The Long-Term Intervention with Pravastatin in Ischaemic
Disease (LIPID) study showed that cholesterol- lowering therapy prevented
further events in patients with coronary heart disease and average cholesterol
levels. The aim of this subgroup analysis Was to assess the effects of pravastatin
in women. Methods A total of 1516 women (756 assigned to take pravastatin) in
a cohort of 9014 patients with previous myocardial infarction or. unstable angina
and a baseline plasma cholesterol level of 4.0 to 7.0 mmol/L (155-271 mg/dL)
were assigned to receive pravastatin (40 mg/d) or placebo. Major cardiovascular
disease events in 6 years were measured. Results Women were at a lesser risk
than men for death from any cause (10.3% vs 14.8%, P < .01), death from
coronary heart disease (6.6% vs 8.6%, P = .04), and coronary revascularization
(13.6% vs 16.2%, P = .05) and at a similar risk of myocardial infarction (9.2% vs
10.5%, P = .26), stroke (3.6% vs 4.7%, P = .11), and hospitalization for unstable
angina (25.1% vs 24.5%, P = 0.90). Pravastatin significantly reduced the risk of
all prespecified cardiovascular events in all LIPID patients. Relative treatment
effects in women did not differ significantly from those in men (P > .05) for any
events except hospitalization for unstable angina. There were too few events to
demonstrate separately significant effects in women; the estimated relative risk
reduction with pravastatin was 11% (95% Cl -18%-33%) for coronary heart
disease death or nonfatal myocardial infarction, 18% (95% Cl -25%-46%) for
coronary heart disease death, 16% (95% Cl -19%-41%) for myocardial infarction,
and 17% (95% Cl -2%-33%) for coronary heart disease death, myocardial
infarction, or coronary revascularization. Conclusions The study had the largest
secondary-prevention female cohort studied thus far, but was not adequately
powered to show separate effects in women. Nevertheless, the results were
consistent with the main results of this and other trials in showing reduced risks
with cholesterol-lowering treatment
Keywords: angina/Australia/cardiovascular/cardiovascular disease/cardiovascular
events/CHOLESTEROL/cholesterol-lowering/coronary heart disease/coronary
revascularization/death/DESIGN/disease/heart/heart
disease/hospitalization/infarction/LIPID/men/mortality/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/pravastatin/rehabilitation/relative
risk/results/revascularization/risk/risks/secondary
prevention/stroke/therapy/treatment/TRIAL/trials/unstable angina/USA/women
Connolly, S.J. (2003), Preventing stroke in patients with atrial fibrillation: Current
treatments and new concepts. American Heart Journal, 145 (3), 418-423.
Abstract: Atrial fibrillation (AF), is common, and it increases the risk of stroke.
Placebo-controlled trials consistently showed that warfarin reduces the risk of
stroke by two thirds, and a meta- analysis of trials of aspirin show a one-fifth
reduction. Meta- analysis of trials directly comparing warfarin and aspirin shows
that warfarin reduces the risk of stroke compared with aspirin by about one third.
Major advisory bodies recommend risk stratification of patients with AF and
prophylactic therapy with warfarin for patients at higher risk. There are several
problems with warfarin therapy, which have resulted in a widely documented
underuse. These problems include a narrow therapeutic window, marked
variability in pharmacokinetics, and contraindications. There are new promising
approaches to stroke prevention in AF. One of these is combination antiplatelet
therapy. In a large randomized trial, the combination of dipyridamole and aspirin
has been shown to have additive benefits against stroke. The combination of
clopidogrel and aspirin results in additive benefits against vascular events, with
only a modest increase in bleeding. A trial of combined antiplatelet therapy in
AF is warranted. Occlusion of the left atrial appendage, either with a transvenous
device or with surgery, is another strategy that is being explored. A direct
thrombin inhibitor, ximelagatran, has been shown to have an excellent
pharmacokinetic profile and is being developed as an oral agent for stroke
prevention in AF, and it will not need regular monitoring
Keywords: AF/antiplatelet/ANTIPLATELET THERAPY/ANTITHROMBOTIC
THERAPY/ASPIRIN/atrial/atrial appendage/atrial
fibrillation/benefits/bleeding/CARDIOVERSION/clopidogrel/combination/dipyr
idamole/fibrillation/HEART/HIGH-RISK PATIENTS/left atrial
appendage/monitoring/new
concepts/pharmacokinetics/prevention/randomized/randomized
trial/results/risk/risk stratification/SECONDARY PREVENTION/stroke/stroke
prevention/surgery/TERM ANTICOAGULATION/therapy/thrombin/thrombin
inhibitor/THROMBOEMBOLISM/TRIAL/trials/USA/vascular/vascular
events/warfarin/WARFARIN USE/ximelagatran
Malinin, A.I., O'Connor, C.M., Dzhanashvili, A.I., Sane, D.C. and Serebruany, V.L.
(2003), Platelet activation in patients with congestive heart failure: Do we have
enough evidence to consider clopidogrel? American Heart Journal, 145 (3),
397-403.
Abstract: Our understanding of the pathogenesis of congestive heart failure (CHF) has
improved remarkably in recent years. However, despite better knowledge and
novel pharmaceutical strategies, this disease is still one of the most brutal killers
in the Western world. The pathophysiology of CHF is complex, and much of our
comprehension revolves strictly around the neurohormonal and mechanical.
mechanisms involved. It has been suggested that CHF is associated with altered
hemostasis, but whether a prothrombotic state contributes to the pathogenesis
and progression of the disease is still not well known. The purpose of this review
article is to discuss our current knowledge of platelet activation in patients with
CHF and the potential role of antiplatelet agents in preventing these hemostatic
abnormalities. Clopidogrel is an established medication that reduces the
incidence of,stroke, myocardial ischemia, or vascular death. It is currently the
drug of choice in the prophylaxis of subacute stent thrombosis and postischemic
stroke treatment. Promising results of the most resent trials (Clopidogrel versus
Aspirin in Patients at Risk of Ischemic Events [CAPRIE] and Clopidogrel in
Unstable angina to prevent Recurrent Events [CURE]) may expand future
indications of this ADP receptor antagonist for prevention of thrombotic
complications in the CHF population. Currently conducted clinical trials
(Warfarin and Antiplatelet Therapy in Chronic Heart Failure [WATCH] and
Plavix Use for Treatment of Congestive Heart Failure [PLUTO-CHF] should
clarify the, role of clopidogrel in these patients
Keywords: abnormalities/activation/ACUTE
MYOCARDIAL-INFARCTION/ADHESION MOLECULES/ADP/ADP
receptor/ADP receptor antagonist/ADP
RECEPTORS/angina/antiplatelet/antiplatelet agents/clinical
trials/clopidogrel/complications/congestive heart failure/CONVERTING
ENZYME-INHIBITORS/CORONARY-ARTERY DISEASE/death/DILATED
CARDIOMYOPATHY/disease/drug/ESSENTIAL-HYPERTENSION/FLOW
CONDITIONS/heart/heart
failure/hemostasis/incidence/ischemia/knowledge/mechanisms/myocardial/patho
genesis/pathophysiology/platelet/platelet
activation/population/prevention/progression/prophylaxis/results/review/review
article/stent/stroke/stroke
treatment/thrombosis/treatment/trials/UNITED-STATES/USA/vascular/VON-W
ILLEBRAND-FACTOR/Warfarin
Fields, W.S. (1983), Aspirin for Prevention of Stroke - A Review. American Journal of
Medicine, 74 (6A), 61-65
Mcginnis, J.M. (1990), Prevention in 1989 - the State of the Nation. American Journal
of Preventive Medicine, 6 (1), 1-5.
Abstract: Substantial gains have been made in the health of Americans since 1970,
notably the 50% decline in infant mortality; the increase of nearly 4 years in life
expectancy for both men and women; the declines in stroke and coronary heart
disease mortality of 54% and 43%, respectively; the decline of injury deaths by
about 30%; and the decline in deaths from nontobacco related cancers by about
10%. These improvements in the overall national health profile have been
accompanied by enhanced public awareness of the relationship between behavior
and health outcomes as well as sustained behavior change among certain groups.
On the other hand, the research advances of the last two decades have given the
nation an even keener understanding of how short of our full potential we are
falling. International comparisons as well as data on the status of minority and
disadvantaged groups in the United States confirm some of these shortfalls-in
particular with respect ot infant mortality, diabetes, motor vehicle deaths, suicide,
and homicide. The complex etiologies of these problems require the forging of
strong alliances with sectors outside the health arena, such as business and
education, to seek solutions. [Am J Prev Med 1990;6:1-5]
Avis, N.E., Mckinlay, J.B. and Smith, K.W. (1990), Is Cardiovascular Risk Factor
Knowledge Sufficient to Influence Behavior. American Journal of Preventive
Medicine, 6 (3), 137-144.
Abstract: This paper examines the level of cardiovascular risk knowledge in the general
population and the relationship between such knowledge and behavior. The
following questions are addressed: (1) How informed is the general population
about what persons can do to reduce their risk of cardiovascular disease? (2)
How do sociodemographic factors, self-perceptions of health, and cardiovascular
risk factors relate to knowledge? (3) Is there a relationship between knowledge
and behavior? (4) What might explain apparent inconsistencies between
knowledge and behavior? The data used in this paper derive from a random
sample of 732 men and women form the greater Boston area. We assessed
cardiovascular risk factor knowledge by asking respondents what specific steps a
person could take to make a heart attack or stroke less likely. Risk factors
(including physiological measures), sociodemographic factors, and self-
perceptions of health also were measured. Results showed that respondents were
most knowledgeable about the relationships of exercise and cholesterol to heart
disease. Knowledge was related positively to education, being female, and
exercising. When we compared knowledge with behavior, results showed that for
smokers and those who were overweight, risk was related to awareness, thus
suggesting that knowledge does not lead necessarily to risk-reducing behavior.
Implications of these results in terms of education and prevention are discussed
Schoenberger, J.A. (1991), Epidemiology and Evaluation - Steps Toward Hypertension
Treatment in the 1990S. American Journal of Medicine, 90 S3-S7.
Abstract: The percentage of persons in the United States over age 65- especially over
85-is increasing more rapidly than other age groups. Two thirds of people over
age 65 have blood pressure higher than 140 mm Hg systolic or 90 mm Hg
diastolic. Isolated systolic hypertension (systolic blood pressure > 160 mm Hg
with diastolic blood pressure < 90 mm Hg) is also highly prevalent. In a number
of clinical trials, treatment of diastolic hypertension in the elderly has been
shown to be beneficial, although the value of treatment of isolated systolic
hypertension is not yet established. The benefit of antihypertensive therapy on
the incidence of stroke and heart failure has been clearly established, but
prevention of the atherosclerotic complications of high blood pressure (sudden
death or myocardial infarction, for example) has not been convincingly
demonstrated. Since clinical trials designed to investigate this atherosclerotic
complication of hypertension have relied on stepped-care regimens (diuretics and
beta blockers), the question arises whether the use of different drugs might have
a better effect on prevention of myocardial infarction. The basis for this
supposition includes the known adverse effects of diuretics and beta blockers on
electrolytes, lipid metabolism, glucose metabolism, insulin resistance, and
quality of life. Hypertension treatment in the 1990s will focus on the mechanisms
by which blood pressure is lowered by various antihypertensive agents, as well
as individualization of drug therapy based on coexisting diseases and conditions.
Emphasis will be placed on use of monotherapy whenever possible; diuretics in
low doses will probably be used more frequently for second-line therapy. In
recognition of their lack of adverse lipid effects and their tolerability, first- line
therapy with alpha blockers, angiotensin-converting enzyme inhibitors, and
calcium antagonists will become increasingly common. The goal of
antihypertensive therapy will be to extend the life expectancy of hypertensive
patients to that of subjects without high blood pressure; hopefully, these new
treatment approaches will bring us closer to that goal
Keywords: INSULIN RESISTANCE/MILD HYPERTENSION/THERAPY
Hachinski, V.C. (1991), Stroke and Hypertension and Its Prevention. American Journal
of Hypertension, 4 (2), S118-S120.
Abstract: Systolic and diastolic hypertension in both men and women is a
well-established risk factor for the development of ischemic and hemorrhagic
stroke. Antihypertensive treatment decreases the risk, but questions remain as to
the precise level of hypertension to be treated, whether the effects of
antihypertensive treatment are blunted with increasing age, and the best type of
antihypertensive drug or combination of drugs to be used. Further questions
remain concerning the incidence of pseudohypertension and the potentially
harmful effects of its treatment on the brain, and the possibility that fluctuations
in blood pressure may be worse than elevation alone. A pragmatic approach
would be to treat hypertension with vigor in the young, with caution in the
mature, and with reluctance in the old
Keywords: HYPERTENSION/PREVENTION/STROKE
Behar, S., Tanne, D., Abinader, E., Agmon, J., Barzilai, J., Friedman, Y., Kaplinsky, E.,
Kauli, N., Kishon, Y., Palant, A., Peled, B., Reisin, L., Schlesinger, Z., Zahavi, I.,
Zion, M. and Goldbourt, U. (1991), Cerebrovascular Accident Complicating
Acute Myocardial- Infarction - Incidence, Clinical-Significance, and Short-Term
and Long-Term Mortality-Rates. American Journal of Medicine, 91 (1), 45-50.
Abstract: PURPOSE: The purpose of this study was to report the incidence, the
antecedents, and the clinical significance of clinically recognized cerebrovascular
accidents or transient ischemic attacks (CVA-TIA) complicating acute
myocardial infarction. PATIENTS AND METHODS: During 1981 to 1983, a
secondary prevention study with nifedipine (SPRINT) was conducted in 14
hospitals in Israel among 2,276 survivors of acute myocardial infarction. During
the study, demographic, historical, and medical data were collected on special
forms for all patients with diagnosed acute myocardial infarction in 13 of these
14 hospitals (the SPRINT registry, n = 5,839). Mortality follow-up was
completed for 99% of hospital survivors for a mean follow-up of 5.5 years (range:
4.5 to 7 years). RESULTS: The incidence of CVA-TIA was 0.9% (54 of 5,839).
The latter rate increased significantly only with age, from 0.4% among patients
up to 59 years old to 1.6% among those aged greater than or equal to 70 years.
Multivariate analysis identified age, congestive heart failure, and history of
stroke as predictors of CVA-TIA during the acute phase of myocardial infarction.
Patients with CVA-TIA exhibited a complicated hospital course, with a 15-day
mortality rate of 41%. Subsequent mortality rates in survivors at 1 and 5 years
were 34% and 59%, respectively. Rates at the same time points in patients
without CVA-TIA were 16%, 11%, and 29% (p < 0.01). In a multivariate
analysis that included age, gender, congestive heart failure, history of previous
myocardial infarction, and hypertension, CVA-TIA was independently
associated with increased 15-day mortality (covariate-adjusted odds ratio [OR] =
2.62; 90% confidence interval [CI], 1.59 to 4.32), as well as subsequent 1-year
(OR = 3.29; 90% CI, 1.70 to 6.36) and long- term (mean follow-up = 5.5 years)
mortality (OR = 2.46; 90% CI, 1.30 to 4.69). CONCLUSION: In this large
cohort of consecutive patients with myocardial infarction, CVA-TIA was a
relatively infrequent complication of acute myocardial infarction. Factors
independently favoring the occurrence of CVA-TIA were old age, previous CVA,
and congestive heart failure. CVA-TIA occurring during acute myocardial
infarction independently increased the risk of early death threefold as well as the
risk of long-term mortality in early-phase survivors (2.5-fold)
Keywords: CVA/LEFT-VENTRICULAR
THROMBI/NATURAL-HISTORY/STROKE/TWO-DIMENSIONAL
ECHOCARDIOGRAPHY
Sauter, A. and Rudin, M. (1991), Prevention of Stroke and Brain-Damage with
Calcium-Antagonists in Animals. American Journal of Hypertension, 4 (2),
S121-S127.
Abstract: In a rat model of embolic stroke (permanent occlusion of the left middle
cerebral artery [MCAO]), various 1,4- dihydropyridine calcium antagonists have
been shown to attenuate brain damage and the resultant functional impairment
when administered after MCAO. Dose-response curves reveal that isradipine is
one of the most potent and efficacious representatives of this class of compounds,
reducing the infarct size by more than 60%. These results suggest that isradipine,
when administered shortly after stroke onset, may have beneficial effects in
patients suffering from brain ischemia. When isradipine is used to normalize the
high blood pressure in spontaneously hypertensive rats, it will, in addition, also
protect the brain from damage engendered by a subsequent stroke. This is not the
case if blood pressure is controlled with a calcium antagonist which does not
cross the blood-brain barrier, suggesting that the brain protection seen with
isradipine is not due to blood pressure normalization. Isradipine, when used as an
antihypertensive, appears to have an additional beneficial effect within the brain
itself. As high blood pressure is a major risk factor for stroke, such an additional
benefit with isradipine would be particularly valuable in antihypertensive therapy
Keywords: BLOOD PRESSURE/CALCIUM
ANTAGONISTS/CYTOPROTECTION/STROKE
Olsson, G., Tuomilehto, J., Berglund, G., Elmfeldt, D., Warnold, I., Barber, H., Eliasson,
K., Jastrup, B., Karatzas, N., Leer, J., Marchetta, F., Ragnarsson, J., Robitaille,
N.M., Valkova, L., Wesseling, H. and Wikstrand, J. (1991), Primary Prevention
of Sudden Cardiovascular Death in Hypertensive Patients - Mortality Results
from the Maphy Study. American Journal of Hypertension, 4 (2), 151-158.
Abstract: In a randomized primary prevention trial including 3,234 men with mild to
moderate uncomplicated hypertension, the effect of the beta-blocker metoprolol
or a thiazide diuretic as an initial antihypertensive therapy was compared
regarding the risk of sudden cardiovascular death during a follow-up ranging
from 2.3 to 10.8 years (median of 4.2 years). Only men aged 40 to 64 years were
included in the study. The randomization of patients into the metoprolol (n =
1,609) or diuretic group (n = 1,625) was performed after stratification for age,
smoking habits, serum cholesterol, and systolic blood pressure. At baseline the
two treatment groups were well matched. Metoprolol was given in a mean dose
of 174 mg daily and the mean dose of thiazide diuretic was either 46 mg
hydrochlorothiazide daily or 4.4 mg bendroflumethiazide daily. Identical blood
pressure control was achieved using the fixed therapeutic schedule. Total and
cardiovascular mortality were significantly lower for metoprolol than for
diuretics, owing to fewer deaths from coronary heart disease and stroke. Of the
cardiovascular deaths, 78% were classified as sudden cardiovascular deaths
(occurred within 24 h after the onset of symptoms). There were significantly
fewer sudden cardiovascular deaths in the metoprolol group compared to the
diuretic group (32 upsilon 45, P = .017). The present results suggest that initial
antihypertensive therapy with metoprolol is associated with a lesser incidence of
sudden cardiovascular deaths than initial diuretic treatment in uncomplicated
hypertension
Keywords: BETA-BLOCKADE/HYPERTENSION/SUDDEN DEATH
Grines, C.L. (1992), Thrombolytic, Antiplatelet, and Antithrombotic Agents. American
Journal of Cardiology, 70 (21), I18-I26.
Abstract: The relative efficacy and safety of individual thrombolytic agents.
administered alone and with antiplatelet and antitthrombotic drugs, in the
treatment of acute myocardial infarction are presented. The clinical benefits and
risks of treatment choices are discussed in relation to the mechanisms of the
formation a nd prevention of thrombus and thrombolysis. It is concluded that
streptokinase, tissue plasminogen activator (t-PA), and anisoylated
plasminogen-streptokinase activator complex (APSAC) significantly reduce
mortality and improve left ventricular function equally, despite differences in the
rate at which the achieve vascular patency, their durations of action, and the
extent to which their use is associated with adverse events. The questions of how
best to minimize reocclusion/reinfarction, bleeding, and stroke are discussed,
with particular focus on the beneficial use of aspirin and the unresolved issue of
how best to use heparin
Keywords: ACUTE MYOCARDIAL-INFARCTION/CORONARY
THROMBOLYSIS/INTRAVENOUS
STREPTOKINASE/LEFT-VENTRICULAR FUNCTION/LOW-DOSE
ASPIRIN/PLATELET ACTIVATION/RANDOMIZED
TRIAL/REPERFUSION THERAPY/TISSUE
PLASMINOGEN-ACTIVATOR/UNSTABLE ANGINA
Tuomilehto, J., Sarti, C., Narva, E.V., Salmi, K., Sivenius, J., Kaarsalo, E., Salomaa, V.
and Torppa, J. (1992), The Finmonica Stroke Register - Community-Based
Stroke Registration and Analysis of Stroke Incidence in Finland, 1983- 1985.
American Journal of Epidemiology, 135 (11), 1259-1270.
Abstract: In the early 1980s, a standardized community-based stroke register was started
in three geographic areas in Finland: North Karelia and Kuopio in eastern
Finland and Turku/Loimaa in southwestern Finland. The results from the first 3
years, 1983- 1985, confirmed the high incidence of stroke in Finland. The
incidence of stroke was higher in eastern Finland than in the southwestern part of
the country. The age-standardized annual incidence among men aged 25-74 years
varied from 206 per 100,000 population in southwestern Finland to 322 per
100,000 population in the province of Kuopio in eastern Finland. Among women
aged 25-74, incidence was 119 and 187 per 100,000 population in these two
areas, respectively. The age- standardized male:female ratio in incidence was 1.7,
slightly higher than that previously reported in Finland. Out of 3,574 stroke
events registered, 78% were first events without a history of previous stroke.
People aged 65-74 years accounted for 45% of all events among men and 62% of
all events among women. The authors' experience shows that the geographic
variation in stroke incidence and attack rates is difficult to assess even within a
country with a relatively uniform health care system. Rigorous standardization
and quality control is needed for the assessment of long-term trends; this is the
primary goal of the FINMONICA Stroke Register. The findings of this study
suggest that the incidence of stroke is still high in Finland, although mortality
from stroke has steeply declined during the past 15-20 years. The number of
stroke survivors in Finland may actually be increasing. Since the occurrence of
stroke is high in Finland as compared with other countries, intensified primary
and secondary prevention measures are needed to reduce it
Keywords: CEREBROVASCULAR
DISORDERS/CEREBROVASCULAR-DISEASE/CIGARETTE-SMOKING/EP
IDEMIOLOGY/FATALITY
RATES/HEALTH/INCIDENCE/MORTALITY/NORTH-KARELIA/POPULAT
ION/REGISTRIES/RISK/STOMACH-CANCER/TRENDS
Alderman, M.H. (1992), Prevention of Myocardial-Infarction. American Journal of
Cardiology, 70 (12), D21-D26.
Abstract: Despite substantial progress in cardiovascular disease prevention, stroke and
myocardial infarction remain the leading causes of death throughout the
industrialized world. Treatment of high blood pressure, while contributing
importantly to this progress, remains inefficient and less than optimally effective,
particularly in regard to coronary artery disease events. Therapeutic intervention
in the renin angiotensin system offers promise of progress on both these fronts.
Renin- sodium profiles have been shown to permit prognostic stratification of
otherwise indistinguishable hypertensive patients. Indeed, low renin subjects,
without other cardiovascular risk factors, have a particularly favorable prognosis.
Now, the pharmacologic ability to mute the pathologic effects of angiotensin II
also offers the genuine possibility that the cardioprotective value of
antihypertensive therapy may be significantly improved
Keywords: ANGIOTENSIN/BLOOD-PRESSURE/CORONARY
HEART-DISEASE/ESSENTIAL-HYPERTENSION/PROFILE/RENIN/RISK/S
TROKE
Rudberg, M.A., Furner, S.E. and Cassel, C.K. (1992), Measurement Issues in Preventive
Strategies - Past, Present, and Future. American Journal of Clinical Nutrition, 55
(6), S1253-S1256.
Abstract: Prevention of the chronic health conditions of older people can potentially
affect both life expectancy and health. In the past, fatal conditions, namely
coronary heart disease, cancer, and stroke, dominated work on preventive
strategies with the only outcome of concern being mortality. The present
increasing life expectancy of the population has put persons at risk for the
nonfatal and often disabling conditions of old age, such as dementia,
osteoporosis and hip fracture, sensory impairments, and arthritis, to name a few.
These conditions have major effects on, not the quantity, but the quality of life.
In the future, quality of life measured in a variety of ways will be necessary to
evaluate the effects of preventive strategies for nonfatal conditions
Keywords: ESTROGENS/HEALTH/HIP FRACTURE/INTERNAL/MEASUREMENT
ISSUES/POSTMENOPAUSAL WOMEN/PREVENTION/QUALITY OF LIFE
Head, G.A. and Minami, N. (1992), Importance of Cardiac, But Not Vascular,
Hypertrophy in the Cardiac Baroreflex Deficit in Spontaneously Hypertensive
and Stroke-Prone Rats. American Journal of Medicine, 92 S54-S59.
Abstract: In the present study, we examined whether antihypertensive treatment of
young and adult hypertensive rats with the angiotensin-converting enzyme (ACE)
inhibitor perindopril could restore the baroreflex vagal deficit and whether this
was related to prevention of cardiac or vascular hypertrophy. Spontaneously
hypertensive (SHR), stroke-prone spontaneously hypertensive (SHR-SP), and
Wistar-Kyoto (WKY) rats were untreated or treated with perindopril (3
mg/kg/day) in the drinking water from 4-9 and from 14-20 weeks of age. Steady-
state sigmoidal mean arterial pressure (MAP)-heart rate (HR) reflex curves were
obtained in the conscious rats by the injection of pressor and depressor agents
before and after atenolol (vagal component). Increased left ventricle to
bodyweight ratio (LV/BW) indicated cardiac hypertrophy. After ganglion
blockade, the minimum MAP produced by nitroprusside and the maximum
produced by methoxamine were used as indications of vascular hypertrophy.
Perindopril treatment reduced cardiac and vascular hypertrophy to different
extents in SHR and SHR-SP. The 4-9 and 14-20 week treatments reduced MAP
and both minimum and maximum blood pressure of the SHR to the levels of the
untreated WKY. However, only in the older animals was LV/BW restored. In the
SHR-SP, early treatment had a much greater effect on vascular hypertrophy than
on LV/BW. The reverse occurred for the 14-20 week animals. In untreated
hypertensive animals the baroreflex curves were shifted to the right with reduced
vagal HR range. Perindopril treatment shifted the baroreflex curves back towards
the WKY curves. Vagal HR range was strongly correlated with the LV/BW,
whereas vagal HR range was less well related to the level of vascular
hypertrophy or blood pressure. These results suggest that antihypertensive
treatment can restore cardiac baroreflex function and that it is related to the
reduction in cardiac hypertrophy. Although the mechanism of this relationship
remains to be elucidated, these findings suggest that cardiac vagal afferents may
be important
Keywords: 2-KIDNEY/BLOOD-PRESSURE/CONVERTING-ENZYME/HEART
RATE REFLEX/INHIBITION/LONG-TERM/ONE-CLIP
HYPERTENSION/RABBIT/REVERSAL/SENSITIVITY/SHRSP
Pilati, C.F., Bosso, F.J. and Maron, M.B. (1992), Factors Involved in Left-Ventricular
Dysfunction After Massive Sympathetic Activation. American Journal of
Physiology, 263 (3), H784-H791.
Abstract: We sought to determine whether catecholamines are responsible for the
depressed left ventricular (LV) function that follows massive sympathetic
nervous system (SNS) activation and whether the additional myocardial energy
demands of SNS-induced hypertension contribute to this disorder. An
intracisternal injection of veratrine was used to intensely activate the SNS of
anesthetized rabbits, and 150 min later, LV function was evaluated in vitro using
established techniques. To assess catecholamine involvement, rabbits were
pretreated with phentolamine, propranolol, or saline prior to SNS activation.
Control animals received veratrine intravenously. In separate experiments,
angiotensin II (ANG II) was administered to rabbits to produce hemodynamic
and plasma catecholamine profiles comparable to that produced by intense SNS
activity. LV function of hearts after either massive SNS activation or ANG II
administration was significantly diminished compared with control (P < 0.01)
and could be prevented by pretreatment with the catecholamine antagonists. LV
function was also not diminished in another group of animals in which arterial
pressure was maintained near baseline throughout the SNS discharge, thus
suggesting that the increased myocardial energy demand associated with the
development of arterial hypertension contributes to the LV dysfunction. We
conclude that toxic concentrations of catecholamines are responsible for SNS-
induced LV dysfunction and that hypertension, most likely because of its ability
to increase myocardial energy demand, is one of the important events that leads
to depressed cardiac function
Keywords: ANGIOTENSIN-II
CONTRACTILITY/BRAIN-DEATH/CATECHOLAMINE
CARDIOMYOPATHY/CATECHOLAMINES/EPINEPHRINE/FREE-RADICA
LS/INDUCED MYOCARDIAL NECROSIS/INJURY/LEFT VENTRICULAR
PERFORMANCE/PATHOGENESIS/PREVENTION/RABBIT/RABBITS/STR
OKE/SYMPATHETIC NERVOUS SYSTEM/VERATRINE
Verhorst, P.M.J., Kamp, O., Visser, C.A. and Verheugt, F.W.A. (1993), Left Atrial
Appendage Flow Velocity Assessment Using Transesophageal
Echocardiography in Nonrheumatic Atrial- Fibrillation and Systemic Embolism.
American Journal of Cardiology, 71 (2), 192-196.
Abstract: Fifty-four patients with nonrheumatic atrial fibrillation (AF) were studied: 16
patients with (group I) and 38 patients without (group II) documented systemic
embolism. Transesophageal echocardiography (TEE) was performed to evaluate
the presence of left atrial (LA) appendage thrombus and LA spontaneous contrast,
LA size, systolic and diastolic peak velocity of the left pulmonary vein, and
forward and backward peak velocity of the LA appendage. No difference was
observed in the presence of LA thrombus between the 2 groups. The occurrence
of LA spontaneous contrast was significantly (p = 0.01) higher in the group with
embolism. LA size, measured by atria length (4.96 +/- 0.84 vs 4.79 +/- 1.38 cm;
p = NS) and atrial width (4.SO +/- 0.96 vs 4.31 +/- 1.24 cm; p = NS), was the
same for both groups and thus not associated with embolism. There was no
difference in systolic peak velocity (0.39 +/- 0.22 vs 0.44 +/- 0.22 m/s; p = NS),
and a trend toward a higher diastolic peak velocity (0.50 +/- 0.17 vs 0.42 +/- 0.15
m/s; p = 0.08) was seen in the left pulmonary vein in the group with embolism.
Forward (0.25 +/- 0.19 vs 0.39 +/- 0.23 m/s; p <0.05) and backward (0.23 +/-
0.15 vs 0.33 +/- 0.16 m/s; p < 0.05) peak velocities of the LA appendage were
significantly lower in the embolism group. Assessment of LA appendage flow
velocity may potentially identify patients with nonrheumatic AF at high risk for
systemic embolism
Keywords: DOPPLER
ECHOCARDIOGRAPHY/PREVENTION/RISK/STROKE/THERAPY/THRO
MBOEMBOLIC COMPLICATIONS
Chen, A. (1993), Effective Acupuncture Therapy for Stroke and Cerebrovascular
Diseases .2. American Journal of Acupuncture, 21 (3), 205-218.
Abstract: In Part II the author reviews the contemporary therapies of Scalp acupuncture
and Eye (Orbit) acupuncture, their application and supporting research in the
treatment of post- stroke hemiplegia, and illustrates how each therapy is derived
from traditional acupuncture. As such, both share points of the clinically
significant ''Central System of Yang Meridians'' and the ''Eye System of
Collaterals'' (described in Part I) which the author notes are frequently
overlooked in traditional meridian theory. Part Ill will review acupuncture
prescriptions for prevention of transient ischemic attack, hypertension, cerebral
arteriosclerosis, hyperlipidemia, hyperlipoproteinemia and stress, as well as
emergency treatments for coma and shock
Keywords: ACUPUNCTURE/CEREBRAL HEMORRHAGE/CEREBROVASCULAR
ACCIDENT/CLASSIC MERIDIAN THEORY/ENCEPHALOPATHY/EYE
ACUPUNCTURE/HEADACHE/HEMIPLEGIA/MUSCULAR
STRENGTH/SCALP ACUPUNCTURE/STROKE/VERTIGO
Chen, A. (1993), Effective Acupuncture Therapy for Stroke and Cerebrovascular
Diseases .1. American Journal of Acupuncture, 21 (2), 105-122.
Abstract: In Part I of this series the author reviews traditional and contemporary
acupuncture prescriptions for ''Wind-Stroke,'' or cerebrovascular accident (CVA),
and its sequelae, and recent clinical reports on the effectiveness of various
acupuncture prescriptions. Specific emphasis is given to points of the ''Central
System of Yang Meridians' and the ''Eye System of Collaterals'' cited, but
overlooked, in traditional meridian theory. These two subsystems have been
shown to be integral to the most successful methods for treatment of CVA.
Subsequent installments in this series will review Scalp and Eye (Orbit)
acupuncture treatments as derivatives of these subsystems with recommendations
for improved results. Also forthcoming are acupuncture prescriptions for
prevention of transient ischemic attack, hypertension, cerebral arteriosclerosis,
hyperlipidemia, hyperlipoproteinemia and stress, as well as emergency
treatments for coma and shock
Keywords: ACUPUNCTURE/CEREBRAL HEMORRHAGE/CEREBROVASCULAR
ACCIDENT/CLASSIC MERIDIAN THEORY/CVA/EYE
ACUPUNCTURE/SCALP ACUPUNCTURE/STROKE
Tobian, L., Brunner, H.R., Cohn, J.N., Gavras, H., Laragh, J.H., Materson, B.J. and
Weber, M.A. (1994), Modern Strategies to Prevent Coronary Sequelae and
Stroke in Hypertensive Patients Differ from the Jnc-V Consensus Guidelines.
American Journal of Hypertension, 7 (10), 859-872.
Abstract: In recent years, government agencies of many countries have established
consensus guidelines for the evaluation and treatment of hypertension. Once
published, guidelines tend to be perceived as directives by a variety of health
care providers. Unfortunately, these guidelines often do not reflect the practices
of most hypertension experts. This report summarizes the opinions of seven
hypertension experts concerning the impact of ''official'' guidelines on clinical
practice. In addition, the individual therapeutic recommendations of these panel
members are summarized. Their different treatment strategies reflect the
diversity of first rate treatment plans that aim to reduce the cardiovascular
sequelae in individual patients with essential hypertension. Most importantly, not
one of these seven treatment strategies followed the ''preferred'' treatment of the
U.S, guidelines, which recommend diuretics and beta-blockers as first-line
therapy. The present authors approach the treatment of hypertension as a means
to reduce cardiovascular events, Thus, reduction of blood pressure is not the
most important therapeutic endpoint. The panel believes that whereas many
different drugs can produce effective blood pressure reduction, the modern
primary goal of antihypertensive drug therapy is to select a regimen most likely
to prolong the quality and duration of life. In real terms, this means that the
primary goal of treatment is the prevention of the major vascular sequelae of
hypertension (heart attack, ventricular remodeling, hypertrophy, heart failure,
and stroke) that shorten useful life. There are a number of effective hypertensive
treatments, which can be selected based on individual patient requirements.
However, many consensus guidelines do not allow the flexibility required to
optimize individual patient treatment. As a result, health care providers should
not feel compelled to regard the preferences of ''official'' guidelines as the best,
modern, state-of-the-art therapy for an individual patient. All seven experts who
are deeply involved in the daily care of patients preferred drugs other than
beta-blockers and diuretics (the Joint National Committee [JNC] choices) for
first-line therapy of hypertension
Keywords: BETA- BLOCKERS/beta-blockers/blood pressure/cardiovascular
events/consensus/DIURETICS/drug therapy/evaluation/FIRST-LINE
THERAPY/GOVERNMENT
GUIDELINES/health/heart/hypertension/HYPERTENSION
TREATMENT/hypertrophy/JNC
V/NEW-YORK/prevention/stroke/treatment/vascular
Small, J.A. and Sheridan, P.H. (1994), Research on Neuropsychiatric Genetics -
Interests of the National-Institute-Of-Neurological-Disorders-And-Stroke.
American Journal of Medical Genetics, 54 (4), 309-310.
Abstract: The National Institute of Neurological Disorders and Stroke (NINDS) supports
research concerning the determinants of normal and pathological development of
the nervous system, from the genetic to the environmental. NINDS also funds
basic and clinical research concerning the etiology, diagnosis, treatment,
consequences, and prevention of the spectrum of neurodevelopmental disorders
including neurobehavioral and neurodegenerative disorders (National Advisory
Council Neurological Disorders and Stroke, 1989, 1992; Division of Convulsive,
Developmental and Neuromuscular Disorders, NINDS, 1993). (C) 1994
Wiley-Liss, Inc
Keywords: AUTISM/development/diagnosis/etiology/genetic/HUNTINGTON
DISEASE/NEUROLOGICAL DISORDERS/NEUROPSYCHIATRIC
DISORDERS/NEW-YORK/prevention/TOURETTE SYNDROME/treatment
Mahmarian, J.J., Smart, F.W., Moye, L.A., Young, J.B., Francis, M.J., Kingry, C.L.,
Verani, M.S. and Pratt, C.M. (1994), Exploring the Minimal Dose of
Amiodarone with Antiarrhythmic and Hemodynamic Activity. American Journal
of Cardiology, 74 (7), 681-686.
Abstract: Amiodarone in doses of 200 to 400 mg/day has shown promise in secondary
prevention trials for reducing mortality in patients surviving myocardial
infarction who have complex ventricular ectopy or nonsustained ventricular
tachycardia, or both. In an attempt to explore the lowest dose of amiodarone with
antiarrhythmic and hemodynamic activity, we studied 48 patients (mean age 53
+/- 11 years, ejection fraction 23 +/- 9%, clinical heart failure in 85%) with
nonsustained ventricular tachycardia. This was a 3-month, randomized, parallel,
double- blind pilot study comparing placebo (n = 16) with amiodarone 50
mg/day (n = 15) and 100 mg/day (n = 17). Patients randomized to amiodarone
received a mean loading dose of 422 mg/day for the first study week. At the end
of the 12 weeks, amiodarone (100 mg) significantly reduced ventricular
premature complexes (177 +/- 64 to 98 +/- 38/hour), couplets (8 +/- 3 to 4 +/-
2/hour), and runs of nonsustained ventricular tachycardia (13 +/- 7 to 3 +/- 2/day),
all p <0.01 versus baseline. In addition, 10 of 14 patients taking 100 mg/day had
total suppression of non- sustained ventricular tachycardia compared with 4 of 15
taking placebo, p = 0.021. Left ventricular lar ejection fraction improved by
greater than or equal to 7% (absolute) in 11 of 29 patients taking amiodarone as
com pared with only 1 of 15 placebo patients (0 = 0.02). In these 11 patients with
the greatest measurable hemodynamic improvement, amiodarone significantly
increased ejection fraction (21 +/- 7% to 33 +/- 11%, p <0.01), stroke volume
index (28 +/- 9 to 40 +/- 7 ml/m(2), p <0.01) and decreased end-systolic volume
index (116 +/- 48 to 92 +/- 44 ml/m(2), p <0.01). It is concluded that amiodarone,
given at a dose of 100 mg/day, has antiarrhythmic and hemodynamic activity
without toxicity and merits testing in long-term efficacy trials
Keywords: DOUBLE-BLIND/GATED RADIONUCLIDE
ANGIOGRAPHY/heart/HEART-FAILURE/MORTALITY/myocardial
infarction/MYOCARDIAL-INFARCTION/NEW-YORK/PHARMACOKINETI
CS/PHARMACOLOGY/PLACEBO-CONTROLLED
TRIAL/prevention/secondary
prevention/stroke/THERAPY/trials/VENTRICULAR EJECTION FRACTION
Kirby, R.L., Ackroydstolarz, S.A., Brown, M.G., Kirkland, S.A. and Macleod, D.A.
(1994), Wheelchair-Related Accidents Caused by Tips and Falls Among
Noninstitutionalized Users of Manually Propelled Wheelchairs in Nova-Scotia.
American Journal of Physical Medicine & Rehabilitation, 73 (5), 319-330.
Abstract: The purpose of this study was to document what proportion of
noninstitutionalized users of manually propelled wheelchairs are affected by
wheelchair-related accidents caused by tips and falls, determine the nature and
severity of the resulting injuries, and, by comparison with an unaffected group,
identify factors associated with the risk of such accidents. We administered a
postal questionnaire to as many as possible of the estimated 2055 members of the
target population in the province of Nova Scotia. Among the 577 appropriate
respondents, 57.4% reported they had completely tipped over or fallen from their
wheelchairs at least once, and 66.0% reported having partially tipped. Of the falls
and tips that were reported, 46.3% were forward in direction, 29.5% backward
and 24.2% sideways. Many of the accidents occurred outdoors or on ramps. A
total of 292 injuries were reported by 272 (47.1%) respondents. Most of the
injuries (84.3%) were minor (e.g., abrasions, contusions, lacerations and sprains).
Of the 15.8% of injuries that were serious, the most common were fractures
(10.6%) and concussions (2.7%). Factors that appear to be associated with an
increased risk of accidents and injuries included younger age, male gender,
paraplegia or spina bifida as the reason for wheelchair use, having had a
wheelchair prescribed, some wheelchair features (lightweight, camber, adjustable
rear-axle positions, a knapsack), daily use of a wheelchair, propelling the chair
with both hands, use of the wheelchair for recreation, use of a sideways transfer
(without a transfer board) and doing repairs themselves or having them done by
the dealer. Factors associated with a decreased risk include multiple sclerosis,
stroke or arthritis as the reason for wheelchair use, attendant propulsion and the
use of a one- person assist for transfers. The results of this study, that
wheelchair-related accidents caused by tips and falls are very common, that
serious injuries are not unusual and that there is a pattern of risk factors, should
be useful to wheelchair users, clinicians, manufacturers and regulatory bodies
Keywords: EPIDEMIOLOGY/INJURIES/PREVENTION/REHABILITATION/risk/risk
factors/SAFETY/severity/stroke/WHEELCHAIRS
Albers, G.W. (1995), Antithrombotic Agents in Cerebral-Ischemia. American Journal of
Cardiology, 75 (6), B34-B38.
Abstract: The choice of antithrombotic agent in cerebral ischemia depends on the
pathogenesis: thrombo sis, embolism, or hemorrhage, Antiplatelet agents are
considered most beneficial in thrombotic stroke, anticoagulants are most
effective in cardioembolic stroke; antithrombotic agents are generally
contraindicated in hemorrhagic stroke, A meta-analysis of 18 trials documented a
23% reduction in stroke risk with antiplatelet agents; aspirin is typically the
antiplatelet agent of choice for stroke prevention, There are no definitive data
regarding the optimal aspirin dose for stroke prevention and this issue remains
controversial. Ticlopidine is the most effective antiplatelet agent, but its adverse
effect profile restricts its use, Anticoagulants are highly effective for preventing
cardioembolic stroke, but their effectiveness in non-cardioembolic stroke is
uncertain because of lack of trial data. Results of the ongoing Warfarin/Aspirin
Recurrent Stroke Study (warfarin [INR 1.8-2.8] vs aspirin [325 mg/day]) may
clarify this issue, There is renewed interest in thrombolytics because recent data
indicate that reperfusion within a few hours of stroke onset appears to be
effective in preventing in neuronal damage. In addition, when given within 6
hours of stroke onset, thrombolytics appear to be relatively safe, Several direct
thrombin Inhibitors are being evaluated, Experimentally, hirudin, hirulog,
D-Phe-L-Pro-L-Arg-CH2Cl (PPACK), and argatroban are clearly more effective
than heparin In inhibiting platelet deposition and thrombus formation, and also
show promise in preventing reocclusion after thrombolysis for both experimental
thrombotic and embolic stroke, However, the risk of hemorrhage in patients with
cerebrovascular disease is unknown for these agents. New antiplatelet agents,
most of which inhibit the platelet IIb/IIIa receptor, have also shown a significant
reduction in ischemic complications in experimental thrombosis models
Keywords: anticoagulants/antiplatelet
agents/aspirin/ATRIAL-FIBRILLATION/CANINE MODEL/cerebral
ischemia/cerebrovascular
disease/complications/formation/hemorrhage/HEPARIN/ischemia/NEW-YORK/
PREVENTION/RANDOMIZED TRIAL/risk/STROKE/stroke
prevention/THROMBOLYSIS/THROMBOSIS/thrombus/TICLOPIDINE/TISS
UE PLASMINOGEN-ACTIVATOR/trials/warfarin
Serramajem, L., Ribas, L., Tresserras, R., Ngo, J. and Salleras, L. (1995), How Could
Changes in Diet Explain Changes in Coronary Heart- Disease Mortality in Spain
- the Spanish Paradox. American Journal of Clinical Nutrition, 61 (6),
S1351-S1359.
Abstract: We review and compare trends in coronary heart disease (CHD) and stroke
mortality in Spain from 1966 to 1990 and changes in food consumption at
national and regional levels. Since 1976, a decrease in cardiovascular disease
(CVD) mortality in males and females has been observed, and standardized CHD
mortality rates have fallen. Stroke mortality decreased during the same period.
Trends in food consumption show increases in intakes of meat, dairy products,
fish, and fruit, but decreases in consumption of olive oil, sugar, and all foods rich
in carbohydrates. Although fat and saturated fat intakes increased, these changes
were not accompanied by an increase in CHD mortality rates. This paradoxical
situation can be explained by expanded access to clinical care, increased
consumption of fruit and fish, improved control of hypertension, and a reduction
in cigarette smoking. Diet appears to have an important role in this paradox, but
it may not be as critical as other factors. Nevertheless, we suggest dietary
guidelines for prevention of CHD in Spain
Keywords: ANTIOXIDANTS/cardiovascular disease/CARDIOVASCULAR
DISEASES/CARDIOVASCULAR MORTALITY/CATALONIA
SPAIN/control of hypertension/coronary heart disease/CORONARY HEART
DISEASE MORTALITY/EPIDEMIOLOGY/FAT INTAKE/FOOD
CONSUMPTION/heart/HYPERTENSION/MEDITERRANEAN
DIET/mortality/MYOCARDIAL-INFARCTION/NUTRITION/POPULATION/
prevention/RISK
FACTORS/RISK-FACTORS/smoking/SPAIN/stroke/TRENDS
Goodlin, R.C. (1995), Do Concepts of Causes and Prevention of Cerebral-Palsy Require
Revision. American Journal of Obstetrics and Gynecology, 172 (6), 1830-1836.
Abstract: OBJECTIVE: My purpose was to explore the criteria of The American
College of Obstetricians and Gynecologists (Technical Bulletin No. 163) for
perinatal asphyxia to be linked to subsequent cerebral palsy. STUDY DESIGN:
Analysis of four cases of intrapartum fetal insults with subsequent cerebral palsy
and a literature review are presented. RESULTS: All of the four cerebral palsy
cases had sufficient intrapartum causes of cerebral palsy, yet none fulfilled The
American College of Obstetricians and Gynecologists' linkage criteria.
Complications in the cerebral palsy cases were as follows: maternal intrapartum
cardiac arrest, fetal skull fracture with brain infarct, intrapartum fetal stroke, and
a newborn delivered after uterine rupture with only central nervous system
defects. There are no well-done laboratory or clinical studies that unequivocally
support the ''criteria'' that umbilical artery pH must be <7.00 or the requirements
of Apgar score <3, hypoxic-ischemic encephalopathy, and multiple organ
dysfunction. Apparent exceptions to these criteria occur. CONCLUSIONS: The
American College of Obstetricians and Gynecologists Technical Bulletin's
criteria for cerebral palsy linkage and the role of parturition in cerebral palsy
should be reevaluated. A rebirth of obstetric enthusiasm for cerebral palsy
research, teaching, and treatment needs to occur
Keywords: ANTENATAL ORIGIN/APGAR SCORES/BIRTH
ASPHYXIA/CEREBRAL PALSY
LINKAGE/DESIGN/ENCEPHALOPATHY/FETAL/INTRAPARTUM
ASPHYXIA/NEUROLOGIC DAMAGE/NEWBORN-INFANTS/PERINATAL
ASPHYXIA/stroke/treatment
Steiner, M., Glantz, M. and Lekos, A. (1995), Vitamin-e Plus Aspirin Compared with
Aspirin Alone in Patients with Transient Ischemic Attacks. American Journal of
Clinical Nutrition, 62 (6), S1381-S1384.
Abstract: One hundred patients with transient ischemic attacks, minor strokes, or
residual ischemic neurologic deficits were enrolled in a double-blind,
randomized study comparing the effects of aspirin plus vitamin E [0.4 g (400
IU)/d; n = 52] with aspirin alone (325 mg; n = 48). The patients received study
medication for 2 y or until they reached a termination point. Preliminary results
show a significant reduction in the incidence of ischemic events in patients in the
vitamin E plus aspirin group compared with patients taking only aspirin. There
was no significant difference in the incidence of hemorrhagic stroke although
both patients who developed it were taking vitamin E. Platelet adhesion was also
measured in a randomized subgroup of both study populations by using collagen
III as the adhesive surface. There was a highly significant reduction in platelet
adhesiveness in patients who were taking vitamin E plus aspirin compared with
those taking aspirin only. Measurement of a- tocopherol concentrations
confirmed compliance of the patients with the medication schedule, showing a
near doubling of serum concentrations of alpha-tocopherol. We concluded that
the combination of vitamin E and a platelet antiaggregating agent (eg, aspirin)
significantly enhances the efficacy of the preventive treatment regimen in
patients with transient ischemic attacks and other ischemic cerebrovascular
problems
Keywords: ALPHA-TOCOPHEROL/ASPIRIN/DISEASE/E
CONSUMPTION/incidence/INHIBITOR/ISCHEMIC CEREBROVASCULAR
EVENT/NUTRITION/PLATELET
ADHESION/PREVENTION/RISK/STROKE/TIAS/transient/TRANSIENT
ISCHEMIC ATTACKS/treatment/TRIAL/vitamin E/VITAMIN-E
Hsieh, R.L., Lein, I.N., Lee, W.C. and Lee, T.K. (1995), Disability Among the Elderly
of Taiwan. American Journal of Physical Medicine & Rehabilitation, 74 (5),
370-374.
Abstract: A cross-sectional study on the correlates of elderly disability was conducted in
Taiwan. A total of 400 subjects was randomly selected according to Barthel
Index scores from among 2600 subjects, which was a sample of a previous
community-based health survey of elderly aged 65 or over. After comprehensive
interviews and examinations of the subjects, disability dimensions and its
correlates were identified. Results showed elderly with lower Mini-Mental State
Examination scores and chronic diseases (such as stroke, pressure sores,
hypertension, fracture, etc.) were more physical-functionally and socially
disabled. This suggests that prevention and treatment of chronic diseases should
be pursued further and that further assessment of cognitive-mental status in the
elderly is warranted. In addition, males were more disabled than females in a
physical-functional aspect, which may be the consequence of the traditional
Chinese cultural effect
Keywords: ADULTS/aged/ARTHRITIS/BARTHEL
INDEX/COMMUNITY/DEMENTIA/DISABILITY/diseases/ELDERLY/FUNC
TIONAL STATUS/health/hypertension/METHODOLOGICAL
ISSUES/MINI-MENTAL STATE/prevention/RISK/stroke/treatment
Flaker, G.C., Fletcher, K.A., Rothbart, R.M., Halperin, J.L. and Hart, R.G. (1995),
Clinical and Echocardiographic Features of Intermittent Atrial- Fibrillation That
Predict Recurrent Atrial-Fibrillation. American Journal of Cardiology, 76 (5),
355-358.
Abstract: In addition to antithrombotic therapy, 2 treatment strategies for intermittent
atrial fibrillation (AF) are evolving: suppression of AF or control of the
ventricular response during AF. Clinical and echocardiographic features that
predict recurrent AF may influence the choice of management. In this study,
clinical, echocardiographic, and electrocardiographic data from 486 patients with
intermittent AF in the Stroke Prevention in Atrial Fibrillation studies were
analyzed. Patients with intermittent AF were younger (p <0.001), had fewer
incidences of systemic hypertension (p <0.007) and heart failure (p <0.001), and
had more recent-onset AF than patients with constant AF. They also had a
smaller mean left atrial diameter, a lower prevalence of a large (>5 cm) left
atrium, better left ventricular performance by echo, and less mitral regurgitation.
After a mean follow-up of 26 months, 51% of patients remained in sinus rhythm
and 49% of patients developed recurrent AF, including 12% who had AF, as seen
on all follow- up electrocardiograms. Clinical factors predicting recurrent AF
were age, heart failure, and myocardial infarction. An enlarged left atrium was
associated with recurrent intermittent AF; an enlarged left ventricle predicted
conversion to constant AF. Thus, clinical and echocardiographic parameters
predict recurrent AF in patients with intermittent nonvalvular AF
Keywords: atrial
fibrillation/CARDIOVERSION/DISEASE/fibrillation/heart/hypertension/MAIN
TENANCE/MORTALITY/myocardial infarction/SINUS
RHYTHM/THERAPY/treatment
Jacobowitz, G.R., Adelman, M.A., Riles, T.S., Lamparello, P.J. and Imparato, A.M.
(1995), Long-Term Follow-Up of Patients Undergoing Carotid Endarterectomy
in the Presence of A Contralateral Occlusion. American Journal of Surgery, 170
(2), 165-167.
Abstract: BACKGROUND: Patients with stenos4is of one carotid artery and occlusion
of the contralateral carotid artery (stenosis- occlusion) who are treated medically
am at high risk for stroke. We have recently reported that carotid endarterectomy
on the stenotic artery has a low perioperative risk in these patients, We now
present follow-up data to define the long-term effectiveness of this operation.
PATIENTs AND METHODS: From 1985 to 1991, 135 patients with
stenosis-occlusion underwent endarterectomy of the stenotic carotid artery:
Selective intra- arterial shunting was performed based on mental status changes
under regional anesthesia, preoperative neurologic deficit, or evidence of
preoperative cerebral infarction on computed tomography scan. Shunting was
used in 70 patients (52%), Saphenous vein was used for parch closure in 132
patients (98%), and polytetrafluroethylene in 3 (2%). RESULTS: By life- table
analysis, 92% of patients have remained stroke-free at 5 years. Fourteen deaths,
none related to cerebrovascular disease, have occurred during follow-up. The
life-table cumulative Stroke-free survival rate at 5 years is 74%, and the overall
survival rate is 82%. CONCLUSION: Carotid endarterectomy in the presence of
a contralateral occlusion provides long-term benefit to the patient with respect to
prevention of stroke. With lower perioperative stroke rates and proven long-term
benefit, carotid endarterectomy of the stenotic artery should be the treatment of
choice in the patient with stenosis-occlusion
Keywords: ARTERY OCCLUSION/carotid/carotid endarterectomy/cerebrovascular
disease/computed
tomography/endarterectomy/NATURAL-HISTORY/prevention/RISK/STENOSI
S/stroke/treatment
Giles, W.H., Croft, J.B., Keenan, N.L., Lane, M.J. and Wheeler, F.C. (1995), The
Validity of Self-Reported Hypertension and Correlates of Hypertension
Awareness Among Blacks and Whites Within the Stroke Belt. American Journal
of Preventive Medicine, 11 (3), 163-169.
Abstract: Hypertension surveillance activities increasingly are relying on information
obtained by self-report. However, limited information is available concerning the
validity of such data, especially among populations residing within the stroke
belt. We used interview information and blood pressure measurements from the
South Carolina Cardiovascular Disease Prevention Project to determine the
validity of self-reported hypertension and the correlates of hypertension
awareness among 2,210 whites and 704 blacks who participated in the program
in 1987. The sensitivity, specificity, positive predictive value, and negative
predictive value of self-reported hypertension were 79%, 91%, 76%, and 93%
among white women; 82%, 88%, 79%, and 89% among black women; 62%,
91%, 75%, and 85% among white men; and 72%, 89%, 78%, and 85% among
black men, respectively. Groups with highest sensitivity included women,
persons older than age 39 years, and those who had seen a physician for
preventive care within the last year. Correlates of hypertension awareness
included an older age, visit to a physician for preventive care, and a family
history of high blood pressure. Among hypertensive blacks, overweight persons
were substantially more likely than nonoverweight persons to be aware of their
hypertension (odds ratio [OR] = 4.6, 95% confidence intervals [CI] = 1.9, 10.7 in
black women and OR = 4.4, 95% CI = 1.0, 17.9 in black men). The validity of
self- reported hypertension was relatively high in all race-sex groups. There is a
need to increase hypertension awareness among hypertensive blacks who are not
overweight
Keywords: blood pressure/high blood pressure/history/hypertension/stroke/women
Mansour, M.A., Mattos, M.A., Hood, D.B., Hodgson, K.J., Barkmeier, L.D., Ramsey,
D.E. and Sumner, D.S. (1995), Detection of Total Occlusion, String Sign, and
Preocclusive Stenosis of the Internal Carotid-Artery by Color-Flow Duplex
Scanning. American Journal of Surgery, 170 (2), 154-158.
Abstract: BACKGROUND: Stroke prevention depends on the accurate differentiation of
surgically treatable preocclusive lesions from total occlusions of the internal
carotid artery. This prospective study was undertaken to review the accuracy of
color-flow duplex scanning for identifying carotid string signs, focal
preocclusive lesions (95% to 99% stenoses), and total occlusion of the internal
carotid artery. MATERIALS AND METHODS: Over an 18-month period, 4,362
patients underwent color-flow duplex scanning of the carotid arteries.
Angiograms of 596 internal carotid arteries were available for comparison with
the duplex scan findings, Total occlusion was diagnosed by the absence of flow
in internal carotid arteries visualized on B-mode scanning. Preocclusive lesions
were identified by a trickle of flow in the vessel lumen. RESULTS: Of 65
color-flow duplex scans that predicted total occlusion, 64 (98%) were confirmed
by angiography. The negative predictive value for total occlusion was 99%,
Twenty-six (87%) of 30 string signs and focal 95% to 99% stenoses were
correctly identified. Color- flow scanning prediction of preocclusive lesions was
accurate in 84% of 31 cases, Low velocities in the internal carotid artery were
usually associated with a string sign, and high velocities with a focal
preocclusive lesion. CONCLUSIONS: Color-flow duplex scanning accurately
differentiates between stenotic and totally occluded internal carotid arteries.
Identification of preocclusive lesions is not as accurate but the results are
promising, Arteriographic confirmation of duplex scan findings is necessary only
when scans are equivocal
Keywords: ARTERIOGRAPHY/carotid/carotid arteries/DISEASE/DOPPLER
ULTRASOUND/duplex
scanning/ENDARTERECTOMY/focal/prevention/prospective study
Ende, D.J., Chopra, P.S. and Rao, P.S. (1996), Transcatheter closure of atrial septal
defect or patent foramen ovale with the buttoned device for prevention of
recurrence of paradoxic embolism. American Journal of Cardiology, 78 (2),
233-236
Keywords: patent foramen ovale/prevention/STROKE
Graafmans, W.C., Ooms, M.E., Hofstee, H.M.W., Bezemer, P.D., Bouter, L.M. and Lips,
P. (1996), Falls in the elderly: A prospective study of risk factors and risk
profiles. American Journal of Epidemiology , 143 (11), 1129-1136.
Abstract: xIn this prospective study, the authors determined intrinsic risk factors for falls
and recurrent falls and constructed a risk profile that indicated the relative
contribution of each risk factor and also estimated the probabilities of falls and
recurrent falls, In 1992, over a 28-week period, falls were recorded among 354
elderly subjects aged 70 years or over who were living in homes or apartments
for the elderly in Amsterdam and the vicinity, During the study period, 251 falls
were reported by 126 subjects (36%), and recurrent falls (greater than or equal to
2 falls) were reported by 57 subjects (16%). Associations of falls and recurrent
falls with potential risk factors were identified in logistic regression models.
Mobility impairment regarding one or more of the tested items (i.e., impairment
of balance, leg-extension strength, and gait) was associated with falls (adjusted
odds ratio (OR) = 2.6) and was strongly associated with recurrent falls (OR =
5.0). Dizziness upon standing was associated with falls (OR = 2.1) and recurrent
falls (OR = 2.1). However, several risk factors were associated with recurrent
falls only: history of stroke (OR = 3.4), poor mental state (OR = 2.4), and
postural hypotension (OR = 2.0). The authors constructed a risk profile for
recurrent falls that included the five risk factors mentioned above. Inclusion of
all risk factors in the profile implied an 84% probability of recurrent falls over a
period of 28 weeks, compared with 3% when no risk factor was present. The
probability of recurrent falls ranged only from 11% to 29% when predicted by
number of falls occurring in the previous year. Physical activity, use of high-risk
medication, and the use of vitamin D-3, which was randomly allocated to the
participants, were not strongly related to either falls or recurrent falls. In
conclusion, a large range of probabilities of falls, especially of recurrent falls,
was estimated by the risk profiles, in which mobility impairment was the major
risk factor. Recurrent fallers may therefore be especially amenable to prevention
based on mobility improvement
Keywords: accidental
falls/aged/COMMUNITY/elderly/EPIDEMIOLOGY/history/INJURIOUS
FALLS/MUSCLE STRENGTH/prevention/risk factors/stroke/WOMEN
Morley, J., Marinchak, R., Rials, S.J. and Kowey, P. (1996), Atrial fibrillation,
anticoagulation, and stroke. American Journal of Cardiology, 77 (3), A38-A44.
Abstract: There is a demonstrated statistical association between atrial fibrillation,
rheumatic valvular disease, and embolic stroke. This article assesses the results
of 6 major clinical trials (AFASAK, BAATAF, SPINAF, SPAF [parts I and II],
CAFA and EAFTA- see text for trial names). Multivariate analysis revealed 4
independent clinical features that identified patients with atrial fibrillation at an
increased risk for stroke: hypertension, increasing age, previous transient
ischemic attack, and diabetes mellitus. Without anticoagulation therapy, patients
with any of these risk factors had a 4% annual risk of stroke. Patients with
cardiac disorders such as congestive heart failure and coronary artery disease
have a stroke rate 3 times higher than patients without any risk factors; patients
with atrial fibrillation but no concomitant risk factors or structural heart disease
seemed to have little concomitant risk for stroke. Meta-analysis revealed a 64%
reduction of risk for stroke in patients treated with warfarin, as compared with
placebo. The value of warfarin therapy in patients >75 years old is less clear
because of a high risk of hemorrhagic complications
Keywords: anticoagulation/atrial fibrillation/clinical trials/COMPLICATIONS/diabetes
mellitus/fibrillation/heart/hypertension/MANAGEMENT/PREVENTION/risk/ris
k factors/stroke/THERAPY/transient/transient ischemic
attack/trials/WARFARIN
Lonn, E.M., Yusuf, S., Doris, C.I., Sabine, M.J., Dzavik, V., Hutchison, K., Riley, W.A.,
Tucker, J., Pogue, J. and Taylor, W. (1996), Study design and baseline
characteristics of the study to evaluate carotid ultrasound changes in patients
treated with Ramipril and vitamin E: SECURE. American Journal of Cardiology,
78 (8), 914-919.
Abstract: Atherosclerotic cardiovascular disease remains a major cause of mortality and
morbidity in most developed countries. Experimental and clinical evidence
suggests that angiotensin- converting enzyme inhibitors and vitamin E therapy
may retard the atherosclerotic process; however, definitive proof in humans is
lacking. The Study to Evaluate Carotid Ultrasound Changes in Patients Treated
with Ramipril and Vitamin E (SECURE) is designed to assess the effects of
ramipril-an angiotensin-converting enzyme inhibitor, at 2 doses: 2.5 mg daily
(which has little effect on lowering blood pressure) and 10 mg daily-and the
antioxidant vitamin E, 400 IU daily, on atherosclerosis progression in 732
patients using ct factorial 3 x 2 study design. High-risk patients with a
documented history of significant cardiovascular disease or with diabetes and
additional risk factors were enrolled and will be followed for 4 years. The extent
and progression of atherosclerosis are assessed noninvasively by B-mode carotid
ultrasonography. The SECURE trial is a substudy of the larger Heart Outcomes
Prevention Evaluation (HOPE) study of 9,541 high-risk patients evaluating the
effects of ramipril and vitamin E on major cardiovascular events (cardiovascular
death, myocardial infarction, and stroke), The 2 studies are complementary.
Whereas HOPE is expected to provide information on major clinical outcomes,
SECURE will shed light on the mechanisms by which these effects may be
mediated
Keywords: angiotensin converting enzyme
inhibitors/ATHEROSCLEROSIS/cardiovascular
events/CLINICAL-TRIAL/CORONARY-DISEASE/E
CONSUMPTION/EVENTS/HEART-
DISEASE/LIPIDS/morbidity/mortality/MYOCARDIAL-INFARCTION/PRAV
ASTATIN/PROGRESSION/risk factors/stroke
Gold, M.R., Ogara, P.T., Buckley, M.J. and DeSanctis, R.W. (1996), Efficacy and safely
of Procainamide in preventing arrhythmias after coronary artery bypass surgery.
American Journal of Cardiology, 78 (9), 975-979.
Abstract: Arrhythmias are common after cardiac surgery and are associated with
hemodynamic compromise, stroke, and prolonged hospitalization. Beta blockers
prevent atrial fibrillation postoperatively, but there are few data regarding the
prophylactic use of type I antiarrhythmic agents or the prevention of ventricular
arrhythmias, Accordingly, we performed a randomized, double-blind,
placebo-controlled study of the effects of oral procainamide on 100 patients
undergoing elective coronary artery bypass surgery, Procainamide was received
for 4 days; the dosage was adjusted for body weight Patients receiving
procainamide had a significant reduction in atrial fibrillation (16 vs 29
patient-days, p < 0,05) and ventricular tachycardia (2% vs 20%, p < 0.01).
However, the incidence of atrial fibrillation was not significantly reduced (38%
vs 26%), In the group achieving therapeutic serum procainamide levels, there
was a reduction in all measured postoperative arrhythmias. No serious cardiac or
noncardiac adverse events were noted during procainamide therapy, although
there was a significant increase in the incidence of nausea, We conclude that
procainamide reduces arrhythmias in the early postoperative period after
coronary artery bypass surgery, most prominently in patients who achieve
therapeutic serum levels. This was associated with no serious cardiac adverse
reactions. (C) 1996 by Excerpta Medica, Inc
Keywords:
ATRIAL-FIBRILLATION/DIGOXIN/DOUBLE-BLIND/FLECAINIDE/FLUT
TER/OPERATIONS/PROPHYLAXIS/PROPRANOLOL/stroke/SUPRA-VENT
RICULAR TACHYARRHYTHMIAS/SUPRAVENTRICULAR
TACHYARRHYTHMIAS
Gilligan, D.M., Ellenbogen, K.A. and Epstein, A.E. (1996), The management of atrial
fibrillation. American Journal of Medicine, 101 (4), 413-421.
Abstract: Atrial fibrillation affects approximately one million persons in the United
States, making it the most,common cardiac arrhythmia seen in clinical practice.
Its prevalence increases with age, and occurs in up to 10% of the population in
the eighth decade of life. Unlike coronary heart disease, atrial fibrillation affects
men and women approximately equally and, in an increasingly elderly
population, will become an increasing burden to the health care system. The
management of atrial fibrillation has undergone significant change in recent
years. Large randomized controlled trials have shown that anticoagulation
markedly reduces the risk of stroke, and a number of new antiarrhythmic agents
are available for the restoration and maintenance of sinus rhythm. Furthermore,
physicians have become more aware of the potential proarrhythmic side effects
of all antiarrythmic drugs. Finally, new procedures such as radiofrequency
ablation of the atrioventricular junction and permanent pacing are playing
increasing roles in the management of this arrhythmia. In this review, the
identification of underlying causes and/or precipitating factors of atrial
fibrillation, methods to control the ventricular response with atrioventricular
nodal blocking drugs, the questions of whether restoration of sinus rhythm is a
possible or desirable goal and how best to maintain sinus rhythm, should sinus
rhythm be restored, and the importance of long-term anticoagulation with
warfarin or antiplatelet therapy with aspirin are discussed
Keywords:
AMIODARONE/ANTICOAGULATION/aspirin/CARDIOVERSION/elderly/F
LUTTER/MAINTENANCE/PREVENTION/QUINIDINE/SINUS
RHYTHM/stroke/TRIAL/trials/WARFARIN
Luepker, R.V., Rastam, L., Hannan, P.J., Murray, D.M., Gray, C., Baker, W.L., Crow,
R., Jacobs, D.R., Pirie, P.L., Mascioli, S.R., Mittelmark, M.B. and Blackburn, H.
(1996), Community education for cardiovascular disease prevention - Morbidity
and mortality results from the Minnesota Heart Health Program. American
Journal of Epidemiology, 144 (4), 351-362.
Abstract: The Minnesota Heart Health Program was a community trial of cardiovascular
disease prevention methods that was conducted from 1980 to 1990 in three
Upper Midwestern communities with three matched comparison communities. A
5- to 6-year intervention program used community-wide and individual health
education in an attempt to decrease population risk. A major hypothesis was that
the incidence of validated fatal and nonfatal coronary heart disease and stroke in
30- to 74-year- old men and women would decline differentially in the education
communities after the health promotion program was introduced. This hypothesis
was investigated using mixed-model regression. The intervention effect was
modeled as a series of annual departures from a linear secular trend after a 2-year
lag from the start of the intervention program. In the education communities,
2,394 cases of coronary heart disease and 818 cases of stroke occurred, with
2,526 and 739 cases, respectively, being seen in the comparison communities,
The overall decline in coronary heart disease incidence was 1.8 percent per year
in men (p=0.03) and 3.6 percent per year in women (p=0.007). For stroke, there
were no significant secular trends, The authors recently published findings
showing minimal effects of sustained intervention on risk factor levels, In the
current report, there was no evidence of a significant intervention effect on
morbidity or mortality, either for coronary heart disease or for stroke
Keywords: cardiovascular disease/cardiovascular diseases/CHOLESTEROL/coronary
heart disease/DECLINE/DESIGN/education/EPIDEMIOLOGY/health/health
education/health promotion/heart/INTERVENTION
PROGRAM/morbidity/mortality/NORTH-KARELIA
PROJECT/prevention/primary prevention/RISK-FACTORS/STANFORD
5-CITY PROJECT/STRATEGIES/STROKE/WIDE PREVENTION
Iafrati, M.D., Salamipour, H., Young, C., Mackey, W.C. and ODonnell, T.F. (1996),
Who needs surveillance of the contralateral carotid artery? American Journal of
Surgery, 172 (2), 136-139.
Abstract: BACKGROUND: Although the value of carotid endarterectomy has been
proven, postoperative surveillance remains controversial. The purpose of this
study was to determine the natural history of disease progression in the
contralateral carotid artery by duplex surveillance, and to assess the cost of
stroke prevention on this contralateral side. METHODS: Vascular laboratory
records were reviewed to identify carotid endarterectomy patients who had two
or more duplex studies between 1984 and 1995. Critical stenosis was defined as
greater than or equal to 75% area reduction. RESULTS: In all, 324 patients were
followed up with duplex scans for 1 month to 11 years (mean 30.3 months). The
only factors that correlated with progression to critical stenosis were age and
initial stenosis. Overall, 19.5% of patients progressed to critical stenosis within 5
years while the high-risk groups with age >65 years or initial stenosis greater
than or equal to 50% progressed to critical disease in 27% and 39%, respectively
(P less than or equal to 0.05). The cost per stroke prevented ranged from
$143,500 to $418,200 when stratified by initial stenosis. CONCLUSION:
Patients who have undergone a carotid endarterectomy demonstrate a propensity
for progression of carotid stenosis in the unoperated (contralateral) artery, The
cost/benefit ratio may be improved by varying the intensity of duplex
surveillance of the contralateral carotid based on the patient's age and initial
degree of stenosis
Keywords: COST-EFFECTIVENESS/ENDARTERECTOMY/STENOSIS/stroke/stroke
prevention
Johnstone, M.T., Mittleman, M., Tofler, G. and Muller, J.E. (1996), The
pathophysiology of the onset of morning cardiovascular events. American
Journal of Hypertension, 9 (4), S22-S28.
Abstract: Evidence obtained over the past decade indicates that myocardial infarction
(MI) and sudden death are not random events but rather, in many cases, may be
triggered by the daily activities of the subject, The importance of physical or
mental stresses as triggers is suggested by the parallel morning increased onsets
of MI, sudden cardiac death, and stroke. Unstable angina and MI are usually
precipitated by thrombus formation over a disrupted plaque that causes partial or
complete obstruction of coronary artery blood now. This process may be caused
by physiologic factors that lead to rupture of a vulnerable plaque and subsequent
thrombosis. beta-Blockers and aspirin, which can diminish these physiologic
processes, have been shown to blunt or abolish the morning peak of onset of
acute MI. It is hypothesized that occlusive coronary thrombosis occurs when an
atherosclerotic plaque becomes vulnerable to rupture, and mental or physical
stress causes the plaque to rupture. Increases in coagulability or vasoconstriction
triggered by daily activities may also contribute to complete occlusion of the
coronary artery lumen. Recognition of the circadian variation of the onset of
acute cardiovascular disease suggests the need for pharmacologic protection of
patients during the vulnerable periods and provides clues to the mechanism of
disease onset, the investigation of which may lead to improved methods of
prevention
Keywords: acute cardiovascular disease/acute myocardial infarction/ACUTE
MYOCARDIAL-INFARCTION/angina/arterial
thrombosis/aspirin/cardiovascular disease/cardiovascular
events/CASE-CROSSOVER/circadian rhythm/CIRCADIAN
VARIATION/CORONARY-ARTERY
DISEASE/HEART-DISEASE/myocardial infarction/plaque rupture/PLATELET
AGGREGABILITY/POSSIBLE
TRIGGERS/prevention/RESPIRATORY-DISEASE/stroke/SUDDEN
CARDIAC DEATH/thrombosis/thrombus/triggers/UNSTABLE
ANGINA-PECTORIS/vulnerable plaque
Alderman, M.H. (1996), Absolute cardiovascular risk: The basis for deciding to treat.
American Journal of Nephrology, 16 (3), 182-189.
Abstract: It has been convincingly demonstrated that raised blood pressure is a risk
factor for cardiovascular disease and that its reduction saves lives. It seems
logical to suggest that the whole population's blood pressure distribution should
be displaced downwards, since the reduction of blood pressure by only a few
millimeters of mercury, if easily and safely achieved, would produce more
disease prevention than could be attained by any other conceivable clinical
strategy. Physicians already have powerful tools to lower blood pressure in
individual patients, but must make challenging decisions as to when and how to
use them. Blood pressure level is a reflection of relative risk and one of many
risk factors that determine absolute risk. Reduction of blood pressure therefore
does not cure cardiovascular disease, but reduces the risk of developing disease.
The need for hypotensive therapy should be determined by absolute risk and the
opportunity for successful prevention, rather than by a threshold level of blood
pressure. The task of the physician is to assist the patient in assessing the balance
between the potential for benefit and the burden of intervention, and to provide
the best possible care to implement the therapeutic choice that is made
Keywords: absolute risk/blood pressure/BLOOD-PRESSURE
REDUCTION/cardiovascular disease/CORONARY
HEART-DISEASE/EPIDEMIOLOGY/FRAMINGHAM/HYPERTENSION/hyp
otensive therapy/MANAGEMENT/MORTALITY/MYOCARDIAL-
INFARCTION/prevention/PROFILE/relative risk/risk factors/STROKE
Antman, E.M. (1996), Maintaining sinus rhythm with antifibrillatory drugs in atrial
fibrillation. American Journal of Cardiology, 78 67-72.
Abstract: Management of atrial fibrillation is a common and complex clinical problem,
Two major treatment strategies have emerged: suppression of recurrences versus
control of ventricular rate and anticoagulation to reduce the risk of stroke.
Maintaining sinus rhythm offers the hemodynamic benefits of improving
ventricular performance and exercise capacity but may expose the patient to the
risk of proarrhythmia/sudden death and drug- related morbidity, Controlling
ventricular rate helps decrease symptomatic palpitations and improve exercise
capacity but necessitates long-term anticoagulation (which may also be needed
despite the use of antiarrhythmics to suppress recurrences of atrial fibrillation)
with some risk of bleeding, Randomized trials are now needed to define the
relative benefits of these 2 treatment strategies, Such trials should be designed to
provide information on the impact of the 2 approaches on symptoms, exercise
capacity, quality of life, and mortality rate in patients with atrial fibrillation
Keywords: AMIODARONE/anticoagulation/atrial
fibrillation/CARDIOVERSION/control/CONVERSION/drugs/exercise/fibrillati
on/MAINTENANCE/morbidity/mortality/NEW-YORK/PREVENTION/quality
of life/QUINIDINE
THERAPY/risk/SOTALOL/stroke/treatment/trials/WARFARIN/WOMEN
Flam, E., Berry, S., Coyle, A., Dardik, H. and Raab, L. (1996), Blood flow augmentation
of intermittent pneumatic compression systems used for the prevention of deep
vein thrombosis prior to surgery. American Journal of Surgery, 171 (3), 312-315.
Abstract: PURPOSE: TO compare, using Duplex ultrasonography, different intermittent
pneumatic compression (IPC) systems to augment venous blood flow for deep
venous thrombosis (DVT) prevention during and after surgery and during
periods of immobility. METHODS: This cross-over study randomly assigned 26
young, healthy, adult subjects, without history of DVT, hypertension, diabetes,
stroke, vascular or cardiac pathologies, to an order of knee-high, foam,
single-pulse IPC device and thigh-high, vinyl, sequential-pulse pneumatic
compression systems. Prior to making the flow measurement, the girth of the calf
and thigh and length of the leg of each subject were determined. The right leg
was used in this evaluation. RESULTS: The average flow augmentation, which
is a direct measure of the amount of femoral vein blood flow velocity increase
over the base, was 107% +/- 49% with the knee-high system, and 77% +/- 35%
with the thigh-high IPC system (P <0.002). Augmentation was higher for 62% of
the subjects with knee-high IPC, and for 23% of the subjects with the thigh-high
system. Overall, the blood was actively moving through the vein during the
decompression phase. On occasion, the velocity during the decompression phase
would fall to zero for short intervals with both systems, indicating complete
emptying of the vessel. Variation in limb anatomy did not significantly affect
blood-flow augmentation with the knee-high IPC, but augmentation decreased
with increase in girth with the thigh-high IPC. CONCLUSIONS: The study
indicates that the knee-high, foam, single-pulse IPC device produces a
significantly higher venous blood-flow augmentation than the thigh-high, vinyl,
sequential-pulse system
Keywords: CALF
COMPRESSION/DVT/evaluation/FIBRINOLYTIC-ACTIVITY/GRADUATED
STATIC
COMPRESSION/history/hypertension/LEGS/prevention/PROPHYLAXIS/STA
SIS/stroke/surgery/thrombosis/VENOUS THROMBOSIS
Psaty, B.M., Siscovick, D.S., Weiss, N.S., Koepsell, T.D., Rosendaal, F.R., Lin, D.Y.,
Heckbert, S.R., Wagner, E.H. and Furberg, C.D. (1996), Hypertension and
outcomes research - From clinical trials to clinical epidemiology. American
Journal of Hypertension, 9 (2), 178-183.
Abstract: Outcomes research seeks to identify effective evidence-based methods of
providing the best medical care. While randomized clinical trials (RCT) usually
provide the dearest answers, they are often not done or not practicable. More
than a decade after the introduction of calcium channel blockers and angiotensin
converting enzyme (ACE) inhibitors, clinical trial data about their effect on
major disease endpoints in patients with hypertension are still not available. The
primary alternatives are the use of randomized trials that include surrogate
endpoints, such as level of blood pressure or extent of carotid atherosclerosis,
and the use of observational studies that include major disease endpoints. Both
approaches, their strengths and limitations, are discussed in detail. The
possibility of residual confounding limits the strength of inferences that can be
drawn from observational studies. Similarly, the possibility of important drug
effects, other than those involving the surrogate endpoint, limits the inferences
that can be drawn from randomized trials that rely solely on surrogate outcomes
as guides to therapy. In the absence of evidence from large clinical trials that
include major disease endpoints, treatment decisions and guidelines need to
synthesize the best available information from a variety of sources. Consistency
of findings across various study designs, outcomes, and populations is critical to
the practice of evidence-based medicine and the effort to maximize the health
benefits of antihypertensive therapies
Keywords: angiotensin/atherosclerosis/blood
pressure/BLOOD-PRESSURE/carotid/clinical trials/confounding
variables/CORONARY HEART-DISEASE/drug
therapy/epidemiology/evaluation/FAILURE/health/hypertension/inference/MOR
BIDITY/MORTALITY/observational studies/ORAL MILRINONE/PRIMARY
PREVENTION/randomized
trials/SELECTION/STROKE/THERAPY/treatment/trials
Kaplan, N.M. (1997), Beta blockade in the primary prevention of hypertensive
cardiovascular events with focus on sudden cardiac death. American Journal of
Cardiology, 80 (9B), J20-J22.
Abstract: Beta-adrenergic blocking agents are useful drugs in the treatment of
hypertension. In multiple clinical trials, beta blockers have been found to
decrease the incidence of stroke and overall cardiovascular mortality. To provide
maximal benefit, in particular, to blunt the early-morning surge in blood pressure
associated with the increased circadian incidence of sudden cardiac death, the
more cardioselective and longer-acting agents of this drug class are preferred. (C)
1997 by Excerpta Medica, Inc
Keywords: beta-blockers/blood pressure/BLOOD-PRESSURE/cardiovascular
events/cardiovascular mortality/clinical
trials/drugs/FREQUENCY/hypertension/incidence/INTERNAL/mortality/NEW-
YORK/prevention/primary prevention/RISK/stroke/treatment/trials
Leung, D.Y., Davidson, P.M., Cranney, G.B. and Walsh, W.F. (1997), Thromboembolic
risks of left atrial thrombus detected by transesophageal echocardiogram.
American Journal of Cardiology, 79 (5), 626-629.
Abstract: Patients with left atrial thrombus are considered at high risk for
thromboembolic events. The actual prognosis of these patients and the features
most predictive of future events are unclear. We performed transesophageal
echocardiograms in 2,894 patients over a 6 1/2-year period; 94 (age 69 +/- 11
years, 59 men, 83 in atrial fibrillation) were found to have left atrial thrombus.
The thrombi were considered mobile in 45 patients and 33 patients had thrombus
with a maximum dimension greater than or equal to 1.5 cm. Seven of the 94
patients with prosthetic valves were excluded from follow-up analysis. Over a
followup period of 25.3 +/- 19.2 months, 17 patients had suffered a stroke or
embolic event (event rate 10.4% per year) and 27 had died (mortality 15.8% per
year). Cox proportional hazard regression analysis identified a maximum
thrombus dimension greater than or equal to 1.5 cm (RR 19, p = 0.002), history
of thromboembolism (RR 4.2, p = 0.038), and mobile thrombus (RR8 5.3, p =
0.02) as predictors of subsequent rhromboembolism. Moderate or severe left
ventricular dysfunction was the only significant predictor of death (RR 2.9, p =
0.04), Gender, age, warfarin therapy at follow-up, atrial fibrillation, location
(cavity vs appendage) of thrombus, and spontaneous echocardiographic contrast
were not significant, Aggressive antithrombotic therapy may be indicated in
these high-risk patients. (C) 1997 by Excerpta Medica, Inc
Keywords: age/antithrombotic/antithrombotic therapy/atrial
fibrillation/CARDIOVERSION/CEREBRAL-ISCHEMIA/EMBOLISM/FIBRIL
LATION/history/men/mortality/NEW-YORK/predictors/PREVENTION/progno
sis/risk/SPONTANEOUS ECHO
CONTRAST/STROKE/therapy/thromboembolic
events/thromboembolism/thrombus/valves/WARFARIN
Maxwell, J.G., Rutledge, R., Covington, D.L., Churchill, M.P. and Clancy, T.V. (1997),
A statewide, hospital-based analysis of frequency and outcomes in carotid
endarterectomy. American Journal of Surgery , 174 (6), 655-661.
Abstract: BACKGROUND: For more than 40 years carotid endarterectomy (CE) has
been used in the treatment of extracranial carotid disease for the prevention of
stroke, Recent prospective clinical trials have confirmed the benefit of CE for
both symptomatic and asymptomatic patients, Our purpose was to examine
statewide trends in the numbers of CE over a 6-year time period and to evaluate
outcomes, METHODS: Using data from the North Carolina Medical Database
Commission (NCMDC) all CE procedures from 1988 to 1993 were identified,
Numbers of CE were compared with the population and hospital admissions,
Variables of length of stay, hospital charges, discharge disposition, and
occurrence of stroke and death were analyzed. RESULTS: A total of 11,973 CE
were performed in 6 years, Compared by admissions, population, and the
proportion of elderly, the number of CE increased yearly, The stroke rate was
1.7% and the death rate 1.2% for an overall in-hospital stroke plus mortality rate
of only 2.7%. CONCLUSIONS: From a diverse group of hospitals and a large
number of surgeons and patients, this hospital-based study documents the
acceptance and safety of CE in the treatment of extracranial carotid disease. (C)
1997 by Excerpta Medica, Inc
Keywords:
AD-HOC-COMMITTEE/AMERICAN-HEART-ASSOCIATION/AREA/asympt
omatic/carotid/carotid endarterectomy/clinical
trials/elderly/endarterectomy/EXTRACRANIAL
ARTERIES/GUIDELINES/hospital/MANAGEMENT/mortality/NEW-YORK/P
ERFORMANCE/prevention/safety/STATEMENT/STENOSIS/stroke/STROKE-
COUNCIL/SURGERY/treatment/trials
Boninger, M.L., Cooper, R.A., Robertson, R.N. and Shimada, S.D. (1997),
Three-dimensional pushrim forces during two speeds of wheelchair propulsion.
American Journal of Physical Medicine & Rehabilitation, 76 (5), 420-426.
Abstract: Upper limb pain frequently occurs in manual wheelchair users. Analyzing the
pushrim forces and hub moments occurring during wheelchair propulsion is a
first step in gaining insight into the cause of this pain. The objectives of this
study were as follows: to describe the forces and moments occurring during
wheelchair propulsion; to obtain variables that characterize pushrim forces and
are statistically stable; and to determine how these variables change with speed.
Convenience samples (n = 6) of paralympic athletes who use manual wheelchairs
for mobility and have unimpaired arm function were tested. Each subject
propelled a standard wheelchair on a dynamometer at 1.3 and 2.2 m/s.
Biomechanical data were obtained using a force-and moment-sensing pushrim
and a motion analysis system, A number of variables that describe the force and
moment curves were evaluated for stability using Cronbach's alpha. Those
measures found to be stable (alpha > 0.8) at each speed were then examined for
differences associated with speed. The tangential, radial, and medial-lateral
forces were found to comprise approximately 55, 35, and 10% of the resultant
force, respectively. in addition to duration of stroke and propulsion, the
following variables were found to be stable and to differ with speed (1.3 m/s +/-
SD; 2.2 m/s +/- SD): peak force tangential to the pushrim (45.9 +/- 17.9 N; 62.1
+/- 30 N), peak moment radial to the hub (9.8 +/- 4.5 N.m 13.3 +/- 6 N.m),
maximum rate of rise of the tangential force (911.7 +/- 631.7 N/sec; 1262.3 +/-
570.7 N/sec), and maximum rate of rise of the moment about the hub (161.9 +/-
78.3 N.m/s; 255.2 +/- 115.4 N.m/s). This study found stable parameters that
characterize pushrim forces during wheelchair propulsion and varied with speed,
Almost 50% of the forces exerted at the pushrim are not directed toward forward
motion and, therefore, either apply friction to the pushrim or are wasted.
Ultimately this type of investigation may provide insight into the cause and
prevention of upper limb injuries in manual wheelchair users
Keywords: BIOMECHANICS/biomechanics/CARPAL-TUNNEL
SYNDROME/ERGOMETER/kinetics/MODEL/motion/pain/PARAPLEGIA/PO
WER OUTPUT/prevention/RELIABILITY/spinal cord injury/stroke/UPPER
EXTREMITY/wheelchair/wheelchair propulsion
Arnsten, J.H., Gelfand, J.M. and Singer, D.E. (1997), Determinants of compliance with
anticoagulation: A case-control study. American Journal of Medicine, 103 (1),
11-17.
Abstract: BACKGROUND: The number of patients for whom long-term anticoagulation
is indicated has increased dramatically over the past decade. Good patient
compliance is necessary to safely realize the benefits of anticoagulation, yet
barriers to compliance with anticoagulation therapy have not been studied.
METHODS: We conducted a case-control study in the Anticoagulation Therapy
Unit (ATU) at Massachusetts General Hospital. Forty-three patients who had
been discharged from the ATU for noncompliance (cases) and 89 randomly
selected compliant ATU controls were interviewed. Noncompliant cases had
self-discontinued warfarin or were taking warfarin with inadequate monitoring of
international normalized ratio (INR) levels. Telephone interviews assessed
sociodemographic features, indication for anticoagulation, patient satisfaction,
and health beliefs. RESULTS: Noncompliant cases were more likely to be
younger (mean 53.7 years versus 68.7 years, P < 0.0001), male (odds ratio [OR]
3.5, 95% confidence interval [CI] 1.5, 8.2), and nonwhite (OR 6.4, 95% CI 1.9,
21.9), and less likely to have had a stroke or transient ischemic attack (OR 0.2,
95% CI 0.1, 0.7). In open-ended questioning, cases were more likely to report
that they did not know why warfarin had been prescribed (OR 4.4, 95% CI 1.4,
14.2). Noncompliant cases were more likely not to have a regular physician (OR
11.1, 95% CI 3.6, 50.0); among patients with a regular physician, noncompliant
cases were more likely to feel dissatisfied. Examination of health beliefs revealed
that noncompliant cases felt more burdened by taking warfarin, and perceived
fewer health benefits. CONCLUSIONS: Patients who are noncompliant with
warfarin share distinctive clinical characteristics. Notably, younger, male patients
who have not experienced a thromboembolic event are more likely to forego INR
testing or to stop anticoagulation therapy completely. Improved patient education,
physician involvement, and ease of monitoring may improve compliance,
particularly among younger male patients. (C) 1997 by Excerpta Medica, Inc
Keywords:
ADHERENCE/anticoagulation/ATRIAL-FIBRILLATION/education/health/INR
/INTERNAL/ischemic/MEDICAL OUTCOMES/NEW-YORK/patient
education/PREVENTION/RANDOMIZED
TRIAL/RECOMMENDATIONS/stroke/THERAPY/transient/transient ischemic
attack/WARFARIN
Hertog, M.G.L., Sweetman, P.M., Fehily, A.M., Elwood, P.C. and Kromhout, D. (1997),
Antioxidant flavonols and ischemic heart disease in a Welsh population of men:
The Caerphilly Study. American Journal of Clinical Nutrition, 65 (5),
1489-1494.
Abstract: Antioxidant flavonols and their major food source, black tea, have been
associated with a lower risk of ischemic heart disease (IHD) and stroke in Dutch
men. We investigated whether flavonol intake predicted a lower rate of IHD in
1900 Welsh men aged 45-59 y, who were followed up for 14 y. Flavonol intake,
mainly from tea to which milk is customarily added, was not related to IHD
incidence [relative risk (RR), highest compared with lowest quartile: 1.0; 95% CI:
0.6, 1.6; P for trend = 0.996; n = 186] but was weakly positively related to MD
mortality (RR: 1.6; 95% CI: 0.9, 2.9; P = 0.119; n = 131) and cancer mortality
(RR: 1.3; 95% CI: 0.7, 2.3; P = 0.150; n = 104) and strongly related to total
mortality (RR: 1.4; 95% CI: 1.0, 2.0; P = 0.014; n = 334). Men with the highest
consumption of tea (> 1.2 L, or > 8 cups/d) had an RR of 2.4 (95% CI: 1.5, 3.9)
of dying in the follow-up period compared with men consuming < 300 mL/d (< 2
cups/d). We conclude that intake of antioxidant flavonols is not inversely
associated with IHD risk in the United Kingdom. Possibly, flavonols from tea to
which milk is added are not absorbed; experimental evidence suggests that
adding milk to tea abolishes the plasma antioxidant- raising capacity of tea. The
apparent association between tea consumption and increased mortality in this
population merits further investigation
Keywords: aged/antioxidant/antioxidants/Caerphilly
Study/CANCER/CHOLESTEROL/COFFEE/CORONARY/DENSITY-LIPOPR
OTEIN/flavonols/HEALTH/heart/incidence/ischemic/ischemic heart
disease/men/milk/mortality/NUTRITION/POTENTIALLY
ANTICARCINOGENIC
FLAVONOIDS/PREVALENCE/prevention/quercetin/RISK/risk
factor/stroke/tea/TEA CONSUMPTION/United Kingdom
Giardina, E.G.V. (1997), Atrial fibrillation and stroke: Elucidating a newly discovered
risk factor. American Journal of Cardiology, 80 (4C), D11-D18.
Abstract: Atrial fibrillation is the most common sustained arrhythmia reported in the
United States; an estimated 1-2 million Americans have chronic nonvalvular
atrial fibrillation. This disorder is associated with a substantial risk of stroke.
Several recent studies provide evidence that anticoagulation therapy is indicated
for stroke prevention in patients with nonvalvular atrial fibrillation after recovery
from a minor stroke. Clinical and echocardiographic criteria help to identify
those patients who are at especially high risk for thromboembolic stroke and are
candidates for carefully controlled anticoagulation. In an effort to reduce the
possibility of thromboembolic events following either chemical or electrical
cardioversion, the American College of Chest Physicians has recently prepared
guidelines for the use of anticoagulation in the conversion of atrial fibrillation.
The efficacy of antiar-rhythmic drug therapy for cardioversion is often difficult
to assess. Furthermore, it is associated with major risks, including heart failure
and exacerbation of arrhythmia, and minor risks, including systemic intolerance.
A new National Institutes of Health trial, Atrial Fibrillation Follow-up
Investigation of Rhythm Management (AFFIRM), will clarify the true risks and
benefits of antiarrhythmic therapy for conversion of atrial fibrillation to sinus
rhythm. Patients who cannot tolerate drug therapy may benefit from interruption
of conduction in the bundle of His, followed by implantation of a permanent
pacemaker, the use of radiofrequency energy ablation, or the implantation of an
atrial defibrillator. Some patients may benefit from surgical procedures, such as
left atrial isolation, the corridor operation, and the maze operation. (C) 1997 by
Excerpta Medica, Inc
Keywords: ANTICOAGULATION/atrial fibrillation/CARDIOVERSION/drug
therapy/EFFICACY/fibrillation/FLECAINIDE/guidelines/heart/heart
failure/MAINTENANCE/MORTALITY/NEW-YORK/PLACEBO/PREVENTI
ON/QUINIDINE THERAPY/risk/SINUS RHYTHM/stroke/stroke
prevention/therapy/thromboembolic events
Pearson, T.A. and Miettinen, T.A. (1997), Lessons learned from lipid-lowering trials
that have included women. American Journal of Managed Care, 3 S54-S59.
Abstract: While only a handful of primary prevention trials have evaluated the effects of
lipid lowering on coronary heart disease (CHD) risk in women, a growing
number of secondary prevention trials with meaningful numbers of women has
shown that lipid abnormalities are as predictive of CHD in women as they are in
men. In general, these studies have also shown that lipid-lowering drugs affect
men and nomen similarly in modifying lipid abnormalities and in reducing the
risk for CHD and stroke. Tno studies that have evaluated the lipid-lowering
effects of HMG-CoA reductase inhibitors (statins) in postinfarction patients,
including a substantial number of women, are the Cholesterol and Recurrent
Events (CARE) trial and the Scandinavian Simvastatin Survival Study (4S). In
the CARE study, the reduction of CHD risk ntis found to be greater in women
than in men (46% versus 20%, P < 0.05). In the landmark 4S trial, the reduction
in risk for CHD death, nonfatal myocardial infarction, and the need for a
revascularization procedure was virtually identical in men and women. There
was also a significant decrease of 39% in hospital bed days for cardiovascular
disease in women receiving simvastatin compared with placebo, Because there
are so few data regarding primary prevention of CHD in women, however, many
issues remain unresolved
Keywords: cardiovascular disease/CARE/CORONARY
ATHEROSCLEROSIS/coronary heart disease/drugs/heart/hospital/myocardial
infarction/prevention/primary prevention/risk/secondary
prevention/statins/stroke/trials/women
Beyth, R.J., Quinn, L.M. and Landefeld, C.S. (1998), Prospective evaluation of an index
for predicting the risk of major bleeding in outpatients treated with warfarin.
American Journal of Medicine, 105 (2), 91-99.
Abstract: PURPOSE: To evaluate the accuracy and clinical utility of the Outpatient
Bleeding Risk Index for estimating the probability of major breeding in
outpatients treated with warfarin. The index was previously derived in a
retrospective cohort of 556 patients from a different hospital (derivation cohort).
SUBJECTS AND METHODS: We enrolled 264 outpatients starting warfarin
(validation cohort) to validate the index prospectively. All patients were
identified upon hospital discharge, and physician estimates of the probability of
major bleeding were obtained before discharge in the validation cohort.
RESULTS: Major bleeding occurred in 87 of 820 outpatients (6.5%/yr). The
index included four independent risk factors for major bleeding: age 65 years or
greater; history of gastrointestinal bleeding; history of stroke; and one or more of
four specific comorbid conditions. In the validation cohort, the index predicted
major bleeding: the cumulative incidence at 48 months was 3% in 80 low-risk
patients, 12% in 166 intermediate-risk patients, and 53% in 18 high-risk patients
(c index, 0.78). The index performed better than physicians, who estimated the
probability of major bleeding no better than expected by chance. Of the 18
episodes of major bleeding that occurred in high-risk patients, 17 were
potentially preventable. CONCLUSIONS: The Outpatient Bleeding Risk Index
prospectively classified patients according to risk of major breeding and
performed better than physicians. Major bleeding may be preventable in many
high-risk patients by avoidance of over-anticoagulation and nonsteroidal
anti-inflammatory agents. (C) 1998 by Excerpta Medica, Inc
Keywords: age/ATTITUDES/ELDERLY
PATIENTS/evaluation/history/hospital/incidence/MYOCARDIAL-INFARCTIO
N/NEW-YORK/NONRHEUMATIC ATRIAL-FIBRILLATION/ORAL
ANTICOAGULANT-THERAPY/PREVENTION/risk/risk
factors/SEVERITY/STROKE/THROMBOEMBOLIC
COMPLICATIONS/VALIDATION/warfarin
Gonzalez, E.R. and Kannewurf, B.S. (1998), Atherosclerosis: A unifying disorder with
diverse manifestations. American Journal of Health-System Pharmacy, 55 S4-S7.
Abstract: The epidemiology, costs, and comorbidities associated with atherosclerosis
and the role of newer antiplatelet agents are reviewed. Cardiovascular disease is
the leading cause of death in the United States. More than 60 million Americans
have one or more types of cardiovascular disease. The total annual cost of
coronary heart disease has been estimated at $95 billion. Patients with an existing
atherosclerotic disease in one vascular bed are at high risk of having an ischemic
vascular event in the same or another vascular bed. Peripheral arterial disease is a
strong marker for underlying cerebrovascular and cardiovascular disease. The
common link among these diseases is atherosclerosis leading to atherothrombosis.
Platelets play an integral role in atherosclerosis and the formation of arterial
thrombus as well as in subsequent acute events such as ischemic stroke,
myocardial infarction, and vascular death. Arterial thrombosis can be mediated
by shear-stress-induced platelet aggregation. Currently, only one third to one half
of all eligible patients with stroke, myocardial infarction, or peripheral arterial
disease receive antiplatelet therapy. Thienopyridines such as ticlopidine and
clopidogrel are effective inhibitors of shear-stress-induced and endothelial-
injury-induced platelet aggregation. Advances in antiplatelet therapy provide an
opportunity to use newer antiplatelet agents in the prevention of
atherosclerosis-related morbidity and mortality; therapeutic approaches should be
directed toward recognizing atherosclerosis as a generalized disease process and
preventing ischemic events in multiple vascular beds
Keywords: aggregation/antiplatelet agents/antiplatelet
therapy/ASPIRIN/atherosclerosis/cardiovascular disease/cerebrovascular
disorders/clopidogrel/coronary heart disease/CORONARY-ARTERY
DISEASE/costs/diseases/epidemiology/formation/health
care/heart/INFARCTION/ischemic
stroke/MECHANISMS/morbidity/mortality/myocardial infarction/peripheral
vascular diseases/platelet aggregation/platelet aggregation
inhibitors/PLATELET-AGGREGATION/prevention/RISK/stroke/thrombosis/thr
ombus/ticlopidine/vascular
Tisdale, J.E. (1998), Antiplatelet therapy in coronary artery disease: Review and update
of efficacy studies. American Journal of Health-System Pharmacy, 55 S8-S16.
Abstract: The mechanisms of action of currently available and newer antiplatelet agents
and evidence of the efficacy of antiplatelet agents for primary and secondary
prevention of coronary artery disease are reviewed. Available data do not support
the widespread use of aspirin for primary prevention of cardiovascular disease.
Patients over the age of 50 years with at least one additional risk factor for
coronary artery disease may benefit, although possibly at an increased risk of
hemorrhagic stroke. Aspirin is recommended for secondary prevention of
vascular disease in patients with stable or unstable angina, clinical or laboratory
evidence of coronary artery disease, history of myocardial infarction, or history
of stroke or transient ischemic attack. There are no data supporting a role for
dipyridamole for primary or secondary prevention of ischemic heart disease.
Abciximab has been shown to reduce the risk of cardiovascular complications at
30 days after percutaneous transluminal coronary angioplasty in patients with
refractory unstable angina. Studies with other glycoprotein IIb/IIIa-receptor
antagonists, including eptifibatide, tirofiban, and lamifiban, have yielded
promising results. Ticlopidine may be used for secondary prevention of
cardiovascular disease in patients with unstable angina who are allergic to or
intolerant of aspirin. Clopidogrel has been shown to be safe and effective for
secondary prevention of vascular events. Aspirin has a role in secondary
prevention of coronary artery disease; among patients who are allergic to or
intolerant of aspirin, ticlopidine has a role in patients with unstable angina and
clopidogrel has a potential role in patients with ischemic heart or vascular
disease
Keywords: ACUTE MYOCARDIAL-INFARCTION/age/angina/angioplasty/antiplatelet
agents/aspirin/ASPIRIN THERAPY/cardiovascular
disease/CARDIOVASCULAR- DISEASE/clopidogrel/COMBINED
TICLOPIDINE/complications/coronary artery disease/coronary
disease/dipyridamole/glycoprotein antagonists/heart/history/HUMAN
PLATELETS/ischemic heart disease/mechanism of action/myocardial
infarction/PHOSPHODIESTERASE INHIBITORS/platelet aggregation
inhibitors/prevention/PRIMARY PREVENTION/RANDOMIZED
TRIAL/risk/secondary prevention/STENT
IMPLANTATION/stroke/ticlopidine/toxicity/transient/transient ischemic
attack/UNSTABLE ANGINA/vascular/vascular disease
Cooke-Ariel, H. (1998), Circadian variations in cardiovascular function and their
relation to the occurrence and timing of cardiac events. American Journal of
Health-System Pharmacy, 55 S5-S11.
Abstract: Circadian patterns of risk for cardiac events and their implications for
prevention and treatment of cardiovascular conditions are discussed.
Sympathovagal tone, a major biological determinant of circadian variation in
cardiovascular function, is modulated through circadian patterns of sleep-wake
activity. The influence of neurohumoral activity on cardiovascular function is
manifested by 24-hour variability in heart rate, blood pressure, and vasomotor
tone. Platelet aggregation and plasminogen-activator inhibitor-1 activity peak
around the time of awakening. Conversely, endogenous plasminogen activator
exhibits a nadir around the lime of awakening. Studies of patterns of occurrence
of cardiac disorders such as acute myocardial infarction, sudden cardiac death,
stroke, and ventricular arrhythmia show an increased occurrence during the
period surrounding awakening. These patterns are consistent with observed
circadian patterns in cardiovascular function. Diabetes, left ventricular
dysfunction, and congestive heart failure may contribute to alterations in patterns
of occurrence of cardiac events. Factors such as race, sex, and age may lead to
alterations in circadian variation in cardiovascular function. Unusual physical
exertion, stress, and anger may act as triggers of an event at any time of day. The
circadian patterns of cardiac events follow the natural fluctuations in endogenous
physiological processes, with a vulnerable period consistently observed in the
early morning; dynamic assessment of markers of cardiovascular function may
assist in determining the extent of disease progression and in selecting
cardiovascular therapies
Keywords: acute myocardial infarction/ACUTE
MYOCARDIAL-INFARCTION/age/aggregation/blood
pressure/BLOOD-PRESSURE/cardiac drugs/cardiovascular
diseases/chronopharmacology/circadian
rhythm/CONGESTIVE-HEART-FAILURE/CORONARY-ARTERY
DISEASE/DIURNAL-VARIATION/ELDERLY HYPERTENSIVE
PATIENTS/heart/LEFT-VENTRICULAR HYPERTROPHY/MORNING
INCREASE/myocardial
infarction/PLASMINOGEN-ACTIVATOR/PLATELET-AGGREGATION/prev
ention/race/risk/sex/stress/stroke/treatment/triggers
Farnier, M. and Davignon, J. (1998), Current and future treatment of hyperlipidemia:
The role of statins. American Journal of Cardiology, 82 (4B), 3J-10J.
Abstract: Hyperlipidemia is recognized as one of the major risk factors for the
development of coronary artery disease and progression of atherosclerotic lesions.
Dietary therapy together with hypolipidemic drugs are central to the management
of hyperlipidemia, which aims to prevent atherosclerotic plaque progression,
induce regression, and so decrease the risk of acute coronary events in patients
with pre-existing coronary or peripheral vascular disease. In patients at high risk
of coronary artery disease but without evidence of atherosclerosis, treatment is
designed to prevent the premature development of coronary artery disease,
whereas in those with hypertriglyceridemia, treatment aims to prevent the
development of hepatomegaly, splenomegaly, and pancreatitis. The 3-hydroxy-
3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, are
the most potent lipid-lowering agents currently available, and their use in the
treatment of hyperlipidemia provides the focus for this review. Particular
emphasis is given to cerivastatin, a new HMG-CoA reductase inhibitor that
combines potent cholesterol-lowering properties with significant
triglyceride-reducing effects. Recently completed primary and secondary
intervention trials have shown that the significant reductions in low-density
lipoprotein (LDL) cholesterol achieved with statins result in significant
reductions in morbidity and mortality associated with coronary artery disease as
well as reductions in the incidence of stroke and total mortality. Such benefits
occur early in the course of statin therapy and have led to suggestions that these
drugs may possess antiatherogenic effects over and above their capacity to lower
atherogenic lipids and lipoproteins. Experimental studies have also shown
statin-induced improvements in endothelial function, decreased platelet thrombus
formation, improvements in fibrinolytic activity, and reductions in the frequency
of transient myocardial ischemia. (C) 1998 by Excerpta Medica, Inc
Keywords:
atherosclerosis/ATHEROSCLEROSIS-REGRESSION/cholesterol/COA-REDU
CTASE INHIBITORS/coronary artery disease/CORONARY-ARTERY
DISEASE/development/drugs/formation/HEART-
DISEASE/HYPERCHOLESTEROLEMIA/hyperlipidemia/incidence/ischemia/L
DL/lipids/LOWERING
CHOLESTEROL/morbidity/MORTALITY/MYOCARDIAL-INFARCTION/NE
W-YORK/PRIMARY PREVENTION/risk/risk
factors/SERUM-CHOLESTEROL/statins/stroke/thrombus/transient/treatment/tri
als/vascular/vascular disease
Crane, V.S. (1998), Formulary and economic considerations in the selection of
antiplatelet agents. American Journal of Health-System Pharmacy, 55 S28-S31.
Abstract: A pharmacoeconomic model for evaluating antiplatelet therapies is described.
In order to conduct a pharmacoeconomic analysis, it is important to understand
the course of the disease under study and the prevention and treatment options,
identify the associated economic consequences, develop concomitant strategies,
and target high-yield decisions. The steps of a pharmacoeconomics-based
decision are defining the pharmacoeconomic problem, creating a crossfunctional
team, determining the study's perspective, determining the treatment alternatives
and outcomes, selecting the appropriate pharmacoeconomic method, placing a
monetary value on outcomes, identifying resources and data sources, establishing
probabilities of outcomes, using decision analysis, undertaking a cost or
sensitivity analysis, presenting the results, developing and implementing a policy
or clinical intervention based on the results, educating health care professionals
about the new policy or intervention, and documenting the quality of care and
potential cost savings through follow-up. Clopidogrel is given as an example.
The composite endpoint of myocardial infarction, stroke, or vascular death has
been shown to be 8.7% lower with clopidogrel than with aspirin in patients with
recent myocardial infarction, recent ischemic stroke, or symptomatic peripheral
arterial disease. Clopidogrel costs more than aspirin but may be considered as
first-line therapy for high-risk patients, patients who are allergic to aspirin, or
patients who cannot tolerate the gastrointestinal effects of aspirin.
Cost-effectiveness analyses can be used to support formulary decisions about
which antiplatelet agent should be used; the use of a particular agent ultimately
also depends on efficacy, safety, pharmacodynamics, patient-specific factors, and
relative direct and indirect costs
Keywords: administration/antiplatelet agents/aspirin/clopidogrel/costs/decision
analysis/decision-making/formularies/health/health
care/hospital/institutional/ischemic stroke/methodology/myocardial
infarction/pharmacodynamics/pharmacoeconomics/pharmacy/platelet
aggregation inhibitors/prevention/quality of care/safety/stroke/treatment/vascular
Bush, D. and Tayback, M. (1998), Anticoagulation for nonvalvular atrial fibrillation:
Effects of type of practice on physicians' self-reported behavior. American
Journal of Medicine, 104 (2), 148-151.
Abstract: BACKGROUND: This study examines whether social and economic factors
affect physician practice and attitude with regard to warfarin anticoagulation in
patients with nonvalvular atrial fibrillation. METHODS: We identified
physicians in Baltimore City, Baltimore County, and Prince George's County
who (1) had written one or more prescriptions for a digitalis compound during
the preceding year, and (2) were classified as general practitioners, family
practice specialists, internists, or cardiologists. All 358 physicians fulfilling these
criteria were surveyed by questionnaire. RESULTS: The overall response rate
was 43%. Physicians who wrote 15% or more of their digitalis prescriptions for
Medicaid patients said they used warfarin at significantly lower rates for patients
with nonvalvular AF than other (66% versus 79%, P <0.01). The opposite pattern
was seen with regard to aspirin. There were no significant differences in practice
pattern between physicians located in urban vs. suburban counties.
CONCLUSION: In our sample, self-reported anticoagulant practices for patients
with nonvalvular AF were associated with the percentage of digitalis
prescriptions written for Medicaid patients. In this metropolitan area,
anticoagulant therapy was reportedly prescribed for approximately 75% of
patients with nonvalvular atrial fibrillation. (C) 1998 by Excerpta Medica, Inc
Keywords: AF/anticoagulant/anticoagulation/aspirin/atrial
fibrillation/ATTITUDES/behavior/COMPLICATIONS/fibrillation/NEW-YORK
/PREVENTION/RISK-FACTORS/STROKE/therapy/WARFARIN
Schievink, W.I., Atkinson, J.L.D., Bartleson, J.D. and Whisnant, J.P. (1998), Traumatic
internal carotid artery dissections caused by blunt softball injuries. American
Journal of Emergency Medicine, 16 (2), 179-182.
Abstract: This report describes recently treated patients with carotid artery dissection
caused by blunt softball injuries, as well as the results of a study of carotid artery
trauma in a community. Data obtained through the medical records linkage
system used for epidemiologic studies in Olmsted County, MN were used to
identify all cases of traumatic internal carotid artery dissection diagnosed from
1987 through 1994, Four patients with traumatic internal carotid artery
dissections were identified during the 8-year period under study. In two patients
(50%) the carotid dissection was a result of the direct impact of a softball. A
39-year-old man, who developed transient cerebral ischemic symptoms, and a
35-year-old woman, who developed a painful Horner's syndrome, were struck by
a softball on the anterolateral aspect of the neck. Both patients had a low carotid
bifurcation. These data suggest that internal carotid artery dissections may be
underrecognized sequelae of direct softball injuries to the anterolateral neck. A
low carotid bifurcation may be a risk factor for such injuries. Copyright (C) 1998
by Saunders Company
Keywords: aneurysm/arterial dissection/baseball/BASEBALL/carotid/carotid
artery/cerebral/CEREBRAL INFARCTION/cerebrovascular
disease/dissection/linkage/NERVE
PALSIES/PREVENTION/risk/softball/SPORTS/STROKE/transient
Wick, M., Muller, E.J., Ekkernkamp, A. and Muhr, G. (1998), The motorcyclist: Easy
rider or easy victim? An analysis of motorcycle accidents in Germany. American
Journal of Emergency Medicine, 16 (3), 320-323.
Abstract: This report reviews the findings from 86 motorcycle accidents during a I-year
period at the Trauma Center "Bergmannsheil" in Bochum, Germany A study of
the case histories supplemented by telephone conversations yielded the following
results: 90.7% of the patients were men, and the average age was 28.8 years;
most of the accidents occurred in the 25 to 30-year-old age group (27.9%).
Motorcycle accidents happened mostly during recreational rides on weekends in
the summertime, Although there was a high rate of helmet use (98.8%), the head
region was affected in 12 victims. Two patients died because of their severe head
injuries (2.3%), Lower extremity injuries (46%), especially open tibia fractures
(19.7%), were among the most common injuries sustained. Fractures of the distal
radius constituted the largest portion of upper extremity injuries (18.8%), The
average stay in our hospital was 35.4 days; 23.4% of the patients had to change
jobs after the accident. Fifty percent of the crashes happened with motorcycles
between 500 and 750 cc stroke volume. Although 34.5% possessed their driver's
licenses for more than 8 years, they had not had much experience handling a
motorbike. These results underline the fact that motorcycle accidents are
sustained by young men in their working prime; as a result, these accidents pose
a tremendous burden to individuals and society and every attempt should be
made to offer highly qualified surgical and trauma care to minimize the damage
to the motorbiker. A plea is made for more prevention measures like driver
education, better road conditions, or legislative changes to prevent motorcycle
crashes. The wearing of a helmet is strongly advocated, Copyright (C) 1998 by
W.B. Saunders Company
Keywords: age/ALCOHOL/costs/education/HELMET-USE-LAW/hospital/injury
patterns/LEG INJURIES/lower extremity injuries/motorcycle
accident/PREVENTION/stroke
Kannel, W.B., Wolf, P.A., Benjamin, E.J. and Levy, D. (1998), Prevalence, incidence,
prognosis, and predisposing conditions for atrial fibrillation: Population-based
estimates. American Journal of Cardiology, 82 (8A), 2N-8N.
Abstract: Atrial fibrillation (AF) is the most common of the serious cardiac rhythm
disturbances and is responsible for substantial morbidity and mortality in the
general population. Its prevalence doubles with each advancing decade of age,
from 0.5% at age 50-59 years to almost 9% at age 80-89 years. It is also
becoming more prevalent, increasing in men aged 65-84 years From 3.2% in
1968-1970 to 9.1% in 1987-1989. This statistically significant increase in men
was not explained by an increase in age, valve disease, or myocardial infarctions
in the cohort. The incidence of new onset of AF also doubled with each decade
of age, independent of the increasing prevalence of known predisposing
conditions. Based on 38-year follow-up data from the Framingham Study, men
had a 1.5-fold greater risk of developing AF than women after adjustment for age
and predisposing conditions. Of the cardiovascular risk factors, only
hypertension and diabetes were significant independent predictors of AF,
adjusting for age and other predisposing conditions. Cigarette smoking was a
significant risk factor in women adjusting only for age (OR = 1.4), but was just
short of significance on adjustment for of her risk factors. Neither obesity nor
alcohol intake was associated with AF incidence in either sex. For men and
women, respectively, diabetes conferred a 1.4- and 1.6-fold risk, and
hypertension a 1.5- and 1.4-fold risk, after adjusting For other associated
conditions. Because of ifs high prevalence in the population, hypertension was
responsible for more AF in the population (14%) than any other risk factor.
Intrinsic overt cardiac conditions imposed a substantially higher risk. Adjusting
for other relevant conditions, heart failure was associated with a 4.5- and 5.9-
fold risk, and valvular heart disease a 1.8- and 3.4-fold risk for AF in men and
women, respectively. Myocardial infarction significantly increased the risk
factor-adjusted likelihood of AF by 40% in men only. Echocardiographic
predictors of nonrheumatic AF include left atrial enlargement (39% increase in
risk per 5-mm increment), left ventricular fractional shortening (34% per 5%
decrement), and left ventricular wall thickness (28% per 4-mm increment). These
echocardiographic features offer prognostic information for AF beyond the
traditional clinical risk factors. Electrocardiographic left ventricular hypertrophy
increased risk of AF 3-4-fold after adjusting only for age, but this risk ratio is
decreased to 1.4 after adjustment for the of her associated conditions. The chief
hazard of AF is stroke, the risk of which is increased 4- 5-fold. Because of its
high prevalence in advanced age, AF assumes great importance as a risk factor
for stroke and by the ninth decade becomes a dominant factor. The attributable
risk far stroke associated with AF increases steeply from 1.5% at age 50-59 years
to 23.5% at age 80-89 years. AF is associated with a doubling of mortality in
both sexes, which is decreased to 1.5-1.9-fold after adjusting for associated
cardiovascular conditions. Decreased survival associated with AF occurs across a
wide range of ages. (C) 1998 by Excerpta Medica, Inc
Keywords: ACUTE MYOCARDIAL-INFARCTION/ACUTE
STROKE/AF/age/aged/atrial fibrillation/cardiovascular risk
factors/COMPLICATIONS/EPIDEMIOLOGIC
FEATURES/fibrillation/FOLLOW-UP/FRAMINGHAM/heart/HEART-DISEAS
E/hypertension/hypertrophy/incidence/morbidity/MORTALITY/NEW-YORK/pr
edictors/PREVENTION/prognosis/risk/risk
factors/RISK-FACTORS/sex/smoking/stroke/women
Nademanee, K. and Kosar, E.M. (1998), Long-term antithrombotic treatment for atrial
fibrillation. American Journal of Cardiology, 82 (8A), 37N-41N.
Abstract: Nonvalvular atrial fibrillation (AF) is the most common cardiac disorder
causing stroke and systemic emboli, Recent clinical trials have clearly
demonstrated the effects of antithrombotic treatment in preventing these
devastating complications of AF, This review summarizes the salient findings of
the first 5 published studies-the Atrial Fibrillation, Aspirin, Anticoagulation
Study (AFASAK) from Copenhagen, Denmark; the Boston Area Anticoagulation
Trial for Atrial Fibrillation (BATAFF); the Canadian Atrial Fibrillation
Anticoagulation study (CAFA); the Stroke Prevention in Non-rheumatic Atrial
Fibrillation (SPINAF) study; and the Stroke Prevention in Atrial Fibrillation
study (SPAF I) from the United States, These trials emphasize the unequivocal
benefits of warfarin therapy compared with no treatment. SPAF II showed that
aspirin is quite effective in younger patients (<75 years) who have no risk factors.
The European Atrial Fibrillation Trial (EAFT) and SPAF III demonstrated that in
older patients (>75 years) who had associated risk factors, warfarin therapy at the
target international normalized ratio (INR) of 2-3, is the best treatment; however,
a combination of low intensity fixed-dose warfarin and aspirin is ineffective.
Thus, the guidelines recommended by the American College of Chest Physicians
should be followed in treating patients with AF. (C)1998 by Excerpta Medica,
Inc
Keywords: AF/ANTICOAGULATION/aspirin/atrial fibrillation/CAFA/clinical
trials/complications/emboli/fibrillation/NEW-YORK/PREVENTION/risk/risk
factors/STROKE/treatment/trials/WARFARIN
Pengo, V., Zasso, A., Barbero, F., Banzato, A., Nante, G., Parissenti, L., John, N.,
Noventa, F. and Dalla Volta, S. (1998), Effectiveness of fixed minidose warfarin
in the prevention of thromboembolism and vascular death in nonrheumatic atrial
fibrillation. American Journal of Cardiology, 82 (4), 433-437.
Abstract: Adjusted-dose warfarin is effective for stroke prevention in patients with
nonrheumatic atrial fibrillation (AF), but the risk of bleeding is high, especially
among the elderly. Fixed minidose warfarin is effective in preventing venous
thromboembolism with low risk of bleeding and no need for frequent clinical
monitoring. Patients > 60 years with nonrheumatic AF were randomized in an
open-labeled trial to receive fixed minidose warfarin (1.25 mg/day) or standard
adjusted-dose warfarin (International Normalized Patio [INR] between 2.0 and
3.0). Primary outcome events were ischemic stroke, peripheral or visceral
embolism, cerebral or fatal bleeding, and vascular death. Secondary end points
were major bleeding, myocardial infarction, and death. This study was
discontinued before completion in light of publication of the Stroke Prevention in
Atrial Fibrillation III trial, which indicated that low-intensity fixed-dose warfarin
treatment (i.e., INP < 1.5) was insufficient for stroke prevention in high-risk
patients with nonrheumatic AF. From a total of 1,209 considered patients, 303
were randomized to be studied (150 in the minidose group and 153 in the
adjusted-dose group). Mean follow-up was 14.5 months. The rate of cumulative
primary events was 11.1% (95% confidence intervals [CI] 4.0 to 18.2) in the
fixed minidose group and 6.1% (95% CI 1.1 to 11.1) in the adjusted-dose group
(p = 0.29). The rate of ischemic stroke was significantly higher in the minidose
group (3.7% vs 0% per year, p = 0.025). Major bleedings were more frequent in
standard treatment group (2.6% vs 1% per year, p = 0.19). Most thromboembolic
complications occurred at INRs < 1.2, whereas the majority of hemorrhages
occurred at INRs > 3.0. No significant difference in primary outcome events was
observed in the abbreviated study. However, the significantly increased
occurrence of ischemic stroke in the fixed minidose warfarin group suggests that
this regimen does not protect patients with nonrheumatic AF. (C)1998 by
Excerpta Medica, Inc
Keywords: AF/atrial
fibrillation/COMPLICATIONS/elderly/embolism/fibrillation/INTENSITY/ische
mic stroke/LOW-DOSE WARFARIN/myocardial
infarction/NEW-YORK/ORAL ANTICOAGULANT
TREATMENT/prevention/PROPHYLAXIS/RABBITS/RANDOMIZED
TRIAL/risk/stroke/stroke
prevention/THERAPY/thromboembolism/THROMBOPLASTIN/THROMBOSI
S/treatment/vascular/warfarin
Keane, D., Zou, L. and Ruskin, J. (1998), Nonpharmacologic therapies for atrial
fibrillation. American Journal of Cardiology , 81 (5A), 41C-45C.
Abstract: The limited efficacy and proarrhythmic risks of antiarrhythmic drug therapies
for atrial fibrillation have led to the exploration of a wide spectrum of alternative
therapeutic approaches. The diversity of the approaches is warranted by the
current absence of a single procedure that can safety and effectively cure atrial
fibrillation. The interventional therapies that are currently under most active
development include implantable atrial defibrillator therapy, prophylactic atrial
pacing in combination with drug therapy, multisite regional pace-entrainment of
atrial fibrillation by rapid pacing, atrial surgery, and catheter ablation for atrial
fibrillation. The current limitations of these procedures include: (1) for the
implantable atrial defibrillator-patient tolerance of low energy shocks and early
recurrence of atrial fibrillation; (2) for prophylactic pacing-limited efficacy in a
small proportion of the total atrial fibrillation population; (3) for multisite
regional pace-entrainment-lack of proved efficacy and difficulty in the expansion
and merging of the entrained regions; (4) for atrial surgery-highly invasive as a
stand-alone procedure; and (5) for catheter ablation-lack of proved long-term
efficacy, shortcomings of currently available technology, and risk of
thromboembolic stroke. It is evident that more basic and clinical research as well
as technologic innovation are needed. However, it is likely that some of these
new therapies, possibly in combination with antiarrhythmic drug therapy, will
offer considerable clinical benefit to selected patients with symptomatic atrial
fibrillation. (C) 1998 by Excerpta Medica, Inc
Keywords: ARRHYTHMIAS/atrial fibrillation/DEFIBRILLATION/development/drug
therapy/fibrillation/HUMANS/implantable atrial defibrillator/INTERNAL
CARDIOVERSION/NEW-YORK/P-WAVE/PREVENTION/recurrence/risk/saf
ety/SHEEP/SINUS RHYTHM/stroke/surgery/therapy/VENTRICULAR CYCLE
LENGTH/WAVE-FORMS
[Anon]. (1998), Secondary prevention. American Journal of Managed Care, 4 (4),
S201-S208.
Abstract: Landmark trials in secondary prevention-the Scandinavian Simvastatin
Survival Study (4S), the Cholesterol and Recurrent Events (CARE) study, and
the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID)
Study-have consistently demonstrated that lowering low-density lipoprotein
cholesterol (LDL-C) reduces the number of coronary events among patients with
coronary heart disease (CHD). The Pravastatin Atherosclerosis and Myocardial
Infarction (MI) Reduction Analysis, which pooled data from four atherosclerosis
regression trials, revealed that the rate of MI decreased 62% after 3 years and
that all-cause mortality decreased by 46%. The CARE study, the first trial with a
North American population, demonstrated significant reduction in risk for fatal
(CHD) or nonfatal MI (24%), total MI (25%), revascularization procedures
(27%), and stroke (31%). The LIPID, the largest statin trial to date, demonstrated
significant reductions in total mortality (23%), and stroke (20%). The results of
these trials are explored in detail, and a comparison of the populations in the 4S
and CARE trials is provided. The issue of what level of LDL-C reduction
provides maximum benefit is addressed. Although clinical trials have
demonstrated that statins are efficacious, safe, and well tolerated, there is
potential for drug-drug interactions. Pravastatin is metabolized in a different
manner than the other statins and therefore has fewer drug-drug interactions and
serious adverse effects. Pravastatin, with more than 50,000 patient-years of
experience in confirmed clinical trials, is shown to be an optimal therapeutic
choice in secondary prevention for managed care organizations. It reduces the
costs of managing CHD-related events and is cost effective in the treatment of
most CHD patients and compared with other cardiovascular interventions.
Improving physician involvement in secondary prevention is a challenge that
must be met
Keywords: atherosclerosis/CARE/cholesterol/clinical trials/coronary heart
disease/costs/EVENTS/heart/low density
lipoprotein/mortality/PRAVASTATIN/prevention/risk/secondary
prevention/statins/stroke/treatment/trials
Harbison, J.W. (1998), Clinical considerations in selecting antiplatelet therapy in
cerebrovascular disease. American Journal of Health-System Pharmacy, 55
S17-S20.
Abstract: Effective antiplatelet drugs-aspirin, ticlopidine, dipyridamole, and
clopidogrel-are reviewed. Aspirin has remained the pharmacologic foundation of
stroke prevention, primarily because of its low cost. It has been shown to provide
a 22% relative risk reduction of stroke in high-risk patients. Its principal adverse
effect is gastrotoxicity. Ticlopidine has been widely used in patients with a high
risk of stroke who are sensitive to aspirin or in whom aspirin has failed. It has
been associated with a median reduction in adenosine diphosphate- induced
platelet aggregation of 70% in about 8-11 days. Ticlopidine has been shown to
be superior to aspirin at three years in preventing stroke. The principal adverse
effects are diarrhea and rash; there has been a 2.4% occurrence of neutropenia. In
a trial comparing aspirin, dipyridamole, and a combination of the two, the risk of
stroke was 18% lower with aspirin, 16% lower with dipyridamole, and 37%
lower with combination therapy compared with placebo. The adverse-effect
profile of dipyridamole has proven to be less problematic than that of aspirin or
ticlopidine. In a trial comparing clopidogrel with aspirin, patients receiving
clopidogrel had an annual 5.32% risk of ischemic stroke, myocardial infarction,
or vascular death compared with 5.83% for patients receiving aspirin.
Clopidogrel has been associated with a small occurrence of rash and diarrhea,
and gastrointestinal intolerance and hemorrhage were less frequent with
clopidogrel than with aspirin. Both aspirin and clopidogrel are associated with a
low occurrence of neutropenia. Aspirin, ticlopidine,dipyridamole, and
clopidogrel have earned a role in stroke prevention; the different adverse-effect
profiles of the drugs will influence the choice of agent
Keywords: aggregation/antiplatelet therapy/aspirin/ASPIRIN/cerebral
ischemia/cerebrovascular disease/cerebrovascular
disorders/clopidogrel/dipyridamole/DIPYRIDAMOLE/drugs/hemorrhage/ische
mic stroke/mechanism of action/myocardial infarction/platelet
aggregation/platelet aggregation inhibitors/prevention/RANDOMIZED
TRIAL/relative risk/risk/SECONDARY PREVENTION/STROKE/stroke
prevention/TICLOPIDINE/ticlopidine/toxicity/vascular
Hornberger, J. (1998), A cost-benefit analysis of a cardiovascular disease prevention
trial, using folate supplementation as an example. American Journal of Public
Health, 88 (1), 61-67.
Abstract: Objectives. This study illustrates a cost-benefit analysis of clinical trial design,
using as an example a trial of folate supplementation to prevent cardiovascular
disease. Methods. Bayesian statistical and decision-analytic techniques were
used to estimate the cost-benefit and sample size of a placebo- controled trial of
folate targeted to US citizens, aged 35 to 84 years, with elevated serum
homocysteine levels. The main end point is event-free survival (i.e., survival
without new ischemic heart disease or stroke) at 5 years. Results. Because the
screening cost and annual cost and inconvenience of taking folate is small
compared with the consequences of stroke, ischemic heart disease, or death, the
increase in 5-year event- free survival with folate that should compel the use of
folate is just 1.1%. The sample size per group needed to establish this level of
folate's medical effectiveness is estimated to be 17 310. Such a trial would
provide an expected societal cost- benefit savings exceeding $11 billion within
15 years. Conclusions. This study illustrates how Bayesian methods may help in
assessing the societal cost-benefit consequences of proposed disease prevention
trials, deciding which trials are worth sponsoring, and designing cost-effective
trials
Keywords: aged/ATHEROSCLEROSIS/cardiovascular
disease/CLINICAL-TRIALS/cost/cost-benefit
analysis/HEALTH/heart/HOMOCYSTEINE/HYPERHOMOCYSTEINEMIA/is
chemic heart disease/NEURAL-TUBE DEFECTS/prevention/RISK
FACTOR/serum/stroke/trials/VASCULAR-DISEASE
[Anon]. (1998), ASHP therapeutic position statement on antithrombotic therapy in
chronic atrial fibrillation. American Journal of Health-System Pharmacy, 55 (4),
376-381
Keywords: American Society of Health-System
Pharmacists/anticoagulants/ANTICOAGULATION/antithrombotic
therapy/ASPIRIN/aspirin/atrial fibrillation/BLEEDING
COMPLICATIONS/cerebrovascular
disorders/COST-EFFECTIVENESS/fibrillation/organizations/patient
education/pharmacists/platelet aggregation
inhibitors/PREVALENCE/PREVENTION/PROPHYLAXIS/protocols/RISK/ST
ROKE/therapy/warfarin/WARFARIN
Sheps, S.G. (1999), Overview of JNC VI: New directions in the management of
hypertension and cardiovascular risk. American Journal of Hypertension, 12 (8),
65S-72S.
Abstract: Treatment recommendations for hypertension as outlined in the Sixth Report
of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC VI) are constantly evolving and being
refined as new information on the disease becomes evident. Uncontrolled
hypertension is a major antecedent of stroke, heart failure, coronary heart disease,
and end-stage renal disease. The increasing incidences of both cardiovascular
and renal diseases fuel the need for improved control of hypertension. In fact,
according to the National Health and Nutrition Examination Survey (NHANES),
about 69% of Americans whose blood pressure is greater than 140/90 mm Hg are
aware of it, about half are getting treatment for it, and only about one-quarter are
adequately controlled. These observations fuel the need for improved patient
management guidelines. JNC VI makes several changes from the previous JNC
V to assist physicians in the diagnosis, treatment, and improved management of
patients with hypertension. These changes include reporting adult blood pressure
in two new ways, via staging and risk factor classification. A high-normal
classification (systolic: 130 to 139 mm Hg, or diastolic: 85 to 89 mm Hg) is
included in JNC VI because of the clinical importance of such blood pressure
contributing to cardiovascular disease. Additionally, clinicians are advised to
assign a patient to one of three risk categories that, in addition to hypertension
stage, influence the decision to select antihypertensive drug therapy. Lifestyle
modification is an important component at each stage. These and other changes
and highlights of recent studies supporting the need for more intensive blood
pressure control are discussed in this paper. Am J Hypertens 1999; 12:65S-72S
(C) 1999 American Journal of Hypertension, Ltd
Keywords: antihypertensive therapy/AWARENESS/blood pressure/blood pressure
control/cardiovascular/cardiovascular disease/cardiovascular risk/cardiovascular
risk factors/control/control of hypertension/coronary heart
disease/diagnosis/diseases/drug therapy/end-stage renal
disease/guidelines/HEALTH/heart/heart failure/hypertension/incidences/JNC
V/lifestyle
modification/MINNESOTA/NEW-YORK/POPULATION/PREVALENCE/renal
/renal disease/risk/risk factor/STROKE/therapy/treatment/TRENDS
White, R.H., McBurnie, M.A., Manolio, T., Furberg, C.D., Gardin, J.M., Kittner, S.J.,
Bovill, E. and Knepper, L. (1999), Oral anticoagulation in patients with atrial
fibrillation: Adherence with guidelines in an elderly cohort. American Journal of
Medicine, 106 (2), 165-171.
Abstract: PURPOSE: To determine adherence with practice guidelines in a
population-based cohort of elderly persons aged 70 years or older with atrial
fibrillation. SUBJECTS AND METHODS: This was a cross-sectional analysis of
a subgroup of participants in the Cardiovascular Health Study, a prospective
observational study involving four communities in the United States. Subjects
were participants with atrial fibrillation on electrocardiogram at one or more
yearly examinations from 1993 to 1995. The outcome measure was self-reported
use of warfarin in 1995. RESULTS: In 1995, 172 (4.1%) participants had atrial
fibrillation together with information regarding warfarin use and no preexisting
indication for its use, Warfarin was used by 63 (37%) of these participants. Of
the 109 participants not reporting warfarin use, 92 (84%) had at least one of the
clinical risk factors (aside from age) associated with stroke in patients with atrial
fibrillation. Among participants not taking warfarin, 47% were taking aspirin.
Several characteristics were independently associated with warfarin use,
including age [odds ratio (OR) = 0.6 per 5-year increment, 95% CI 0.5-0.9], a
modified mini- mental examination score <85 points [OR = 0.3, 95% confidence
interval (CI) 0.1-0.9], and among patients without prior stroke, female sex (OR =
0.5, 95% CI 0.2-1.0). CONCLUSIONS: Despite widely publicized practice
guidelines to treat patients who have atrial fibrillation with warfarin, most
participants who had atrial fibrillation were at high risk for stroke but were not
treated with warfarin. More studies are needed to determine wily elderly patients
with atrial fibrillation are not being treated with warfarin. Am J Med. 1999;106:
165-171. (C) 1999 by Excerpta Medica, Inc
Keywords: ACUTE
MYOCARDIAL-INFARCTION/age/aged/anticoagulation/aspirin/atrial
fibrillation/CARDIOVASCULAR
HEALTH/elderly/FACTOR-II/FACTOR-VII/FACTOR-X/fibrillation/guidelines
/high
risk/HOSPITALS/MANAGEMENT/NEW-YORK/population-based/risk/risk
factors/sex/stroke/STROKE PREVENTION/THERAPY/United
States/WARFARIN
Gellido, C.L. and Kaufman, D.M. (1999), Carotid endarterectomy: Improved clinical
outcome and reduced length of hospitalization. American Journal of Managed
Care, 5 (8), 1039-1043.
Abstract: Audience This exercise is intended for vascular surgeons, neurologists,
cardiologists, and primary care physicians caring for persons who are at risk for
or who have suffered a stroke. GOAL To present data from a single institution on
the incidence and costs associated with carotid endarterectomy compared with
other techniques to diagnose and prevent stroke. OBJECTIVE 1. Outline the
prevalence of stroke in the United States and the role of carotid endarterectomy
(CEA) in its treatment. 2. Discuss the various preoperative tests that help
determine a patient's suitability for CEA. 3. Discuss the cost implications of
stroke prevention
Keywords: CARE/carotid/carotid
endarterectomy/cost/costs/DISEASE/endarterectomy/exercise/EXTRACRANIA
L
ARTERIES/HEAD/hospitalization/incidence/MR-ANGIOGRAPHY/PERFORM
ANCE/PREOPERATIVE EVALUATION/prevention/primary/primary
care/risk/STENOSIS/stroke/stroke prevention/treatment/ULTRASOUND/United
States/vascular
Jones, D., Basile, J., Cushman, W., Egan, B., Ferrario, C., Hill, M., Lackland, D.,
Mensah, G., Moore, M., Ofili, E., Roccella, E.J., Smith, R. and Taylor, H. (1999),
Managing hypertension in the southeastern United States: Applying the
guidelines from the Sixth Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI).
American Journal of the Medical Sciences, 318 (6), 357-364.
Abstract: The southeastern United States has the highest occurrence of heart disease and
stroke and among the highest rates of congestive heart failure and renal failure in
the country. The Consortium for Southeastern Hypertension Control (COSEHC)
is cooperating with other organizations in implementing initiatives to reduce
morbidity and mortality from hypertension-related conditions in the southeastern
United States. This article outlines for clinicians special consideration for
implementation of the Sixth Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure ONC
VI in the southeastern United States. Clinicians are encouraged to adapt the
recommendations of JNC VI to their own patient groups, paying attention to
these specific areas: (1) Ensure screening for hypertension in your practice and
community. (2) Evaluate all patients for accompanying risk factors and target
organ damage. (3) Promote lifestyle management for individual patients and
populations for prevention and treatment of hypertension. (4) Set a goal blood
pressure for each patient, and monitor progress toward that goal. (5) Recognize
that many patients will be candidates for blood pressure goals of <130/85 mm
Hg. (6) Pay attention to compelling and special indications such as diabetes,
congestive heart failure, and renal dysfunction. (7) Consider combination therapy.
(8) Maximize staff contributions to enhance patient adherence. (9) Encourage
patient, family, and community activities to promote healthy lifestyles and blood
pressure control
Keywords: adherence/blood pressure/blood pressure control/combination/combination
therapy/community/congestive heart
failure/CONGESTIVE-HEART-FAILURE/control/diabetes/DIETARY
POTASSIUM/disease/DISEASE MORTALITY/guidelines/heart/heart
disease/heart
failure/hypertension/lifestyle/METAANALYSIS/MORBIDITY/mortality/OBES
ITY/organizations/prevention/PROGRESSION/RANDOMIZED
TRIAL/REDUCTION/renal/renal failure/risk/risk
factors/screening/southeast/STROKE/stroke belt/therapy/treatment/United States
Piegas, L.S., Flather, M., Pogue, J., Hunt, D., Varigos, J., Avezum, A., Anderson, J.,
Keltai, M., Budaj, A., Fox, K., Ceremuzynski, L. and Yusuf, S. (1999), The
Organization to Assess Strategies for Ischemic Syndromes (OASIS) registry in
patients with unstable angina. American Journal of Cardiology, 84 (5A),
7M-12M.
Abstract: Clinical approaches to the prevention of the potentially catastrophic
consequences of coronary ischemic phenomena such as unstable angina and
suspected non-Q-wave myocardial infarction (MI) differ across the world. in
addition to prevailing physician beliefs in different societies, the level of access
to catheterization laboratories largely determines whether an interventionist or
conservative strategy is adopted. The Organization to Assess Strategies for
Ischemic Syndromes (OASIS)-a prospective registry of approximately 8,000
patients with acute myocardial ischemia with no ST elevation, treated in 95
hospitals across 6 countries-furnished a unique window into regional differences
in clinical management and the frequency and timing of invasive procedures (i.e.,
angiography, percutaneous transluminal coronary angioplasty [PTCA], and
coronary artery bypass graft [CABG] surgery), as well as the outcomes of these
trends. At 6 months after symptom onset, patients in the United States and Brazil,
where the catheterization laboratory facilities are more accessible, underwent
significantly (p <0.001) more angiography (69.4%), PTCA (23.6%), and CABG
(25.2%) than in Canada and Australia, where the corresponding rates were
48.4%, 17.0%, and 16.8% (p <0.001), respectively; and in Hungary and Poland,
where the respective rates were 23.5%, 5.8%, and 10.9% (p <0.001). This
relatively aggressive approach led at 6 months to a more substantial decrease in
refractory angina in the United States and Brazil than in Canada and Australia
(20.4% vs 13.9%; p <0.001), but no improvement in rates of cardiovascular
mortality and MI (10.5% versus 10.5%; p = 0.36). There was a significant (p less
than or equal to 0.012) increase in stroke, (1.9% vs 1.3%; p = 0.010) and major
bleeding (1.9% vs 1.1%; p = 0.009) events. Furthermore, an inverse correlation
emerged between baseline cardiovascular risk status and frequency of
angiography and PTCA interventions preferentially for low-risk compared with
high-risk patients. In concert with findings from other recent randomized trials,
the OASIS Registry data suggest that although there are fewer hospital
readmissions for unstable angina, there is a trend toward increased rates of death,
MI, and stroke. These data urge a cautious approach to the use of invasive
procedures in patients with unstable angina unless future trials demonstrate a
clear benefit with on aggressive approach. (C) 1999 by Excerpta Medico, Inc
Keywords: acute/angina/angioplasty/Australia/CABG/cardiovascular/cardiovascular
mortality/cardiovascular risk/CONSERVATIVE STRATEGIES/coronary
angioplasty/hospital/infarction/ischemia/ischemic/mortality/myocardial/myocard
ial infarction/NEW-YORK/OUTCOMES/prevention/randomized/randomized
trials/risk/stroke/surgery/THERAPY/THROMBOLYSIS/timing/TRIAL/trials/Un
ited States/unstable angina/WAVE MYOCARDIAL-INFARCTION
Achard, J.M., Pruna, A., Fernandez, L.A., Hottelart, C., Mazouz, H., Rosa, A., Andrejak,
M. and Fournier, A. (1999), Prevention of stroke and cancer - Could angiotensin
II type 1 receptor antagonists do better than angiotensin II converting enzyme
inhibitors? American Journal of Hypertension, 12 (10), 1050-1053
Keywords: angiotensin/angiotensin II/AT(2)
RECEPTOR/CAPTOPRIL/EXPRESSION/GERBILS/GROWTH/ISCHEMIA/M
ORTALITY-RATE/NEW-YORK/OUTCOMES/PROTECT/stroke/UNILATER
AL CAROTID LIGATION
Black, H.R. (1999), Optimal blood pressure: How low should we go? American Journal
of Hypertension, 12 (11), 113S-120S.
Abstract: The Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure defines hypertension as systolic blood
pressure greater than or equal to 140 mm Hg or diastolic blood pressure (DBP)
greater than or equal to 90 mm Hg. Evidence shows that even slightly elevated
blood pressure significantly increases the risk of morbidity and mortality and
only aggressive efforts to reduce blood pressure can significantly reduce this risk.
In the recently completed Hypertension Optimal Treatment trial, patients were
assigned to one of three target blood pressure groups, reflecting DBP goals of
less than or equal to 90, less than or equal to 85, and less than or equal to 80 mm
Hg. Aggressive antihypertensive treatment allowed more than 90% of patients to
achieve goal DBP of less than or equal to 90 mm Hg. This study clearly showed
that these defined goals could be safely met and even exceeded. Too few patients
with hypertension receive the level of effective treatment achieved in clinical
trials. Individuals with poorly controlled blood pressure are at significant risk for
cardiovascular and cerebrovascular morbidity and mortality and represent a
potentially substantial burden to the healthcare system. Setting appropriate blood
pressure goals and working to meet them through aggressive antihypertensive
treatment, with multiple agents if necessary, can reduce those risks. Am J
Hypertens 1999;12:113S-120S (C) 1999 American Journal of Hypertension, Ltd
Keywords: aggressive therapy/antihypertensive treatment/AWARENESS/blood
pressure/cerebrovascular/clinical trials/DESIGN/diastolic blood
pressure/DISEASE/DRUG-TREATMENT/HYPERTENSION/hypertension/mor
bidity/mortality/MYOCARDIAL-INFARCTION/NEW-YORK/RATIONALE/R
EDUCTION/risk/STROKE/systolic blood pressure/treatment/TRIAL/trials
McMurray, J. (1999), The health economics of the treatment of hyperlipidemia and
hypertension. American Journal of Hypertension, 12 (10), 99S-104S.
Abstract: In the current economic climate it is important to demonstrate that healthcare
resources are being used efficiently. As a consequence, pharmacoeconomic
analyses are invaluable for assessing the cost-effectiveness of new therapeutic
strategies. A condition with recurrent morbid events that are costly to treat
provides the greatest potential for cost savings. In contrast, there is less
opportunity to redeem original treatment costs when a condition is associated
with infrequent and inexpensive morbidity. Consequently, treatment strategies
that have a rapid onset and substantial impact on disease progression are likely to
be the most highly cost-effective forms of therapy. Elevated blood pressure in the
elderly and established coronary heart disease (CHD) are both associated with
high rates of costly cardiovascular events (eg, stroke, myocardial infarction, and
heart failure). Clinical trials have shown that administration of
blood-pressure-lowering agents to elderly hypertensives and the treatment of
hypercholesterolemia with statins in the secondary prevention of CHD are highly
effective strategies for reducing this morbidity. Pharmacoeconomic analyses of
the data from these clinical trials now provide an additional assessment of their
cost- effectiveness. The results of these analyses suggest that
blood-pressure-lowering therapy for the elderly and the use of statins to control
hypercholesterolemia in patients at high risk of CHD are extremely cost-effective,
compared with many other routine medical interventions. Am J Hypertens
1999;12:99S-104S (C) 1999 American Journal of Hypertension, Ltd
Keywords: administration/AVERAGE CHOLESTEROL LEVELS/blood
pressure/cardiovascular/cardiovascular events/clinical trials/control/coronary
heart disease/CORONARY-HEART-DISEASE/cost/cost
effectiveness/cost-effectiveness/COST-EFFECTIVENESS/costs/elderly/EVENT
S/health/heart/heart
failure/hypercholesterolemia/hyperlipidemia/hypertension/infarction/MEN/morbi
dity/myocardial/myocardial
infarction/NEW-YORK/pharmacoeconomics/PRAVASTATIN/prevention/PRIM
ARY PREVENTION/risk/SCANDINAVIAN SIMVASTATIN
SURVIVAL/secondary prevention/statins/stroke/therapy/treatment/trials
Caro, J.J. and Migliaccio-Walle, K. (1999), Generalizing the results of clinical trials to
actual practice: The example of Clopidogrel therapy for the prevention of
vascular events. American Journal of Medicine, 107 (6), 568-572.
Abstract: PURPOSE: An important element in translating the results obtained in clinical
trials of a new treatment to clinical practice is the estimated event rate in patients
who would be eligible to receive that treatment. We estimated the effect of
clopidogrel, compared with aspirin, in actual practice using the relative risk
reduction observed in the Clopidogrel versus Aspirin in Patients at Risk of
Ischaemic Events (CAPRIE) trial. SUBJECTS AND METHODS: Ischemic
event rates were estimated for 12,931 aspirin users drawn from the Saskatchewan
Health population between 1990 and 1995 who had an index diagnosis of
myocardial infarction, ischemic stroke, or peripheral arterial disease. To estimate
the absolute risk reduction, the 8.7% relative risk reduction from clopidogrel
compared with aspirin that was observed in CAPRIE was applied to these rates.
RESULTS: The rates of ischemic events were greater in actual practice than
among the control patients in the CAPRIE trial. In Saskatchewan population,
patients experienced an outcome event (myocardial infarction, stroke including
intracranial hemorrhage, or death) at a rate of 15.9 per 100 patient-years,
compared with only 6.9 per 100 patient-years in CAPRIE. If the same 8.7%
relative risk reduction seen in the CAPRIE trial is also true for patients seen in
routine clinical practice, the greater absolute risk in actual practice would reduce
the number needed to treat to prevent one event from 200 patients to 70 patients.
CONCLUSION: Absolute risk rates may be substantially greater in clinical
practice than in the selected patients enrolled in randomized trials. As a result,
similar reductions in relative risk, ii true for clinical practice, may yield
substantially more benefit in clinical practice than in randomized trials. Am J
Med. 1999;107:568-572. (C) 1999 by Excerpta Medica, Inc
Keywords: absolute risk/aspirin/CARE/clinical practice/clinical
trials/clopidogrel/CONTEXT/control/diagnosis/DISEASE/hemorrhage/infarction
/ischemic/ischemic stroke/myocardial/myocardial
infarction/NEW-YORK/peripheral arterial
disease/prevention/randomized/randomized trials/relative
risk/risk/stroke/therapy/TREAT/treatment/trials/vascular
Tenenbaum, A., Fisman, E.Z., Boyko, V., Goldbourt, U., Auerbach, I., Shemesh, J.,
Shotan, A., Reicher-Reiss, H., Behar, S. and Motro, M. (1999), Prevalence and
prognostic significance of unrecognized systemic hypertension in patients with
diabetes mellitus and healed myocardial infarction and/or stable angina pectoris.
American Journal of Cardiology, 84 (3), 294-298.
Abstract: Few data are available regarding the prevalence and prognostic significance of
the triple coexistence of undiagnosed systemic hypertension, diabetes mellitus,
and coronary heart disease. This study aimed to evaluate the prevalence and
prognostic significance of unrecognized hypertension in cardiac diabetic patients
previously defined as "normotensives" over a 5-year follow-up period. The study
sample comprised 11,515 patients aged 45 to 74 years with a previous
myocardial infarction and/or anginal syndrome who were screened but not
included in the Bezafibrate Infarction prevention study. Among them, 9,033 were
nondiabetics and 2,482, diabetics. The diabetics were divided into 3 groups: (1)
1,272 normotensives, (2) 152 patients without history of hypertension but with
elevated blood pressure ("unrecognized hypertensives"), and (3) 1,058
hypertensives with established diagnosis. The prevalence of both diagnosed and
unrecognised hypertension in diabetics pooled together increased from 49% to
69% when World Health Organization and new Joint National Committee-VI
criteria were compared. Crude all-cause mortality was lower in nondiabetics than
in diabetics (11.2% vs 22.0%; p <0.001). Among diabetics the lowest all-cause
mortality was documented for normotensives (19.3%), whereas the highest
mortality was observed in unrecognized hypertensives (26.3%, p 0.003). Both
unrecognized and established hypertensives demonstrated a significant
stroke-related mortality excess: about four- and threefold increases in
cerebrovascular accident-related death, respectively, were observed (p = 0.002).
On multivariate analysis, both unrecognized and diagnosed hypertension were
consistent predictors of increased all-cause mortality, with a hazard ratio of 1.28
(95% confidence interval 0.90 to 1.82) and 1.24 (95% confidence interval 1.03 to
1.49), respectively. Our findings demonstrate widespread undiagnosed
hypertension in diabetic coronary patients; their 5-year mortality was
significantly increased compared with normotensives, and tended to be even
higher than in diabetics previously identified as hypertensives. (C) 1999 by
Excerpta Medica, Inc
Keywords: aged/angina/blood pressure/cerebrovascular/coronary heart
disease/diabetes/diabetes
mellitus/diagnosis/heart/HEART-DISEASE/history/HYPERGLYCEMIA/hypert
ension/infarction/Israel/mortality/myocardial/myocardial
infarction/NEW-YORK/predictors/prevention/RANDOMIZED TRIAL/World
Health Organization
Yochum, L., Kushi, L.H., Meyer, K. and Folsom, A.R. (1999), Dietary flavonoid intake
and risk of cardiovascular disease in postmenopausal women. American Journal
of Epidemiology, 149 (10), 943-949.
Abstract: Flavonoids, a group of phenolic compounds found in fruits and vegetables are
known to have antioxidant properties. They prevent low density lipoprotein
oxidation in vitro and thus may play a role in the prevention of coronary heart
disease (CHD). In 1986, in a prospective study of 34,492 postmenopausal
women in Iowa, the authors examined the association of flavonoid intake with
CHD and stroke mortality. Over 10 years of follow- up, 438 deaths from CHD
and 131 deaths from stroke were documented, Total flavonoid intake was
associated with a decreased risk of CHD death after adjusting for age and energy
intake (p for trend = 0.04). This association was attenuated after multivariate
adjustment. However, decreased risk was seen in each category of intake
compared with the lowest. Relative risks and 95% confidence intervals of CHD
death from lowest to highest intake category were 1.0, 0.67 (95% confidence
interval (CI) 0.49-0.92), 0.56 (95% CI 0.39-0.79), 0.86 (95% CI 0.63- 1.18), and
0.62 (95% CI 0.44-0.87). There was no association between total flavonoid
intake and stroke mortality (p for trend = 0.83). Of the foods that contributed the
most to flavonoid intake in this cohort, only broccoli was strongly associated
with reduced risk of CHD death. The data of this study suggest that flavonoid
intake may reduce risk of death from CHD in postmenopausal women
Keywords: ACCURACY/age/antioxidant/ANTIOXIDANT
FLAVONOLS/antioxidants/cardiovascular/cardiovascular disease/coronary heart
disease/CORONARY HEART-DISEASE/diet/flavonoids/HEALTH/heart/low
density lipoprotein/LOW-DENSITY
LIPOPROTEINS/MORTALITY/oxidation/OXIDATIVE
MODIFICATION/postmenopausal women/POTENTIALLY
ANTICARCINOGENIC FLAVONOIDS/prevention/prospective
study/QUESTIONNAIRE/risk/stroke/VITAMINS/women/ZUTPHEN
Yasue, H., Ogawa, H., Tanaka, H., Miyazaki, S., Hattori, R., Saito, M., Ishikawa, K.,
Masuda, Y., Yamaguchi, T., Motomiya, T. and Tamura, Y. (1999), Effects of
aspirin and trapidil on cardiovascular events after acute myocardial infarction.
American Journal of Cardiology, 83 (9), 1308-1313.
Abstract: Aspirin therapy confers conclusive net benefits in the acute phase bf evolving
myocardial infarction, but no clear evidence of benefit from the long-term use of
aspirin after acute myocardial infarction (AMI) has been shown in any single
study. This multicenter study, the Japanese Antiplatelets Myocardial Infarction
Study, was performed to find out whether aspirin or trapidil would improve
clinical outcome compared with no antiplatelets in postinfarction patients, The
study was a multicenter, open-label, randomized controlled trial of aspirin 81
mg/day, trapidil 300 mg/day, and no antiplatelets in patients with AMI admitted
within 1 month from the onset of symptoms, Seven hundred twenty-three
patients were enrolled at 70 hospitals in 18 prefectures of Japan; 250 were
randomly assigned to treatment with 81 mg aspirin (aspirin group), 243 to that
with trapidil (trapidil group), and 230 were not given antiplatelet agents, The
mean follow-vp period was 475 days. This study demonstrated that long-term
use of aspirin at the dose of 81 mg/day reduced the incidence of recurrent AMI
compared with the group receiving no antiplatelets after AMI (p = 0.0045) and
that trapidil also reduced the occurrence of reinfarction compared with the group
receiving no antiplatelets, but the difference was not significant (p = 0.0810),
The incidence of cardiovascular events including cardiovascular death,
reinfarction, uncontrolled unstable angina requiring admission to hospital, and
nonfatal ischemic stroke was reduced in the group receiving 300 mg trapidil
daily compared with the group receiving no antiplatelets (p = 0.0039), The use of
aspirin 81 mg/day provided almost no benefit over no antiplatelets therapy in the
incidence of cardiovascular events, In conclusion, low-dose aspirin (81 mg)
effectively prevented recurrent AMI in postinfarction patients after thrombolysis
or coronary angioplasty when used over a long term, Furthermore, the long-term
use of trapidil resulted in a significant reduction in the incidence of
cardiovascular events, (C) 1999 by Excerpta Medica, Inc
Keywords: ACID/acute/acute myocardial
infarction/angina/angioplasty/antiplatelet/antiplatelet agents/ANTIPLATELET
THERAPY/antiplatelets/aspirin/cardiovascular/cardiovascular events/coronary
angioplasty/GROWTH-FACTOR
ANTAGONIST/HEART-DISEASE/hospital/hospitals/incidence/infarction/ische
mic/ischemic stroke/MORTALITY/myocardial/myocardial
infarction/NEW-YORK/randomized/randomized controlled
trial/RESTENOSIS/SECONDARY
PREVENTION/stroke/therapy/thrombolysis/TRANSLUMINAL CORONARY
ANGIOPLASTY/trapidil/treatment/TRIAL/TRIAZOLOPYRIMIDINE/unstable
angina
Suh, D.C., Sung, K.B., Cho, Y.S., Choi, C.G., Lee, H.K., Lee, J.H., Kim, J.S. and Lee,
M.C. (1999), Transluminal angioplasty for middle cerebral artery stenosis in
patients with acute ischemic stroke. American Journal of Neuroradiology, 20 (4),
553-558.
Abstract: BACKGROUND AND PURPOSE: Precutaneous transluminal angioplasty
(PTA) is currently performed to treat supraaortic atherosclerotic lesions, Our
purpose was to evaluate the safety and efficacy of PTA for middle cerebral artery
(MCA) stenosis in patients with acute ischemic stroke. METHODS: We
performed PTA with the use of a microballoon (2-2.5 mm in diameter and 10-13
nam in length) in 10 consecutive patients (mean age, 48 years) who met the
following criteria: high-grade M1 stenosis (>70%) and mild neurologic deficits
(NIH stroke scale <4) and/or recurrent transient ischemic attacks (TIAs) resistant
to anticoagulation, or a large area of hypoperfusion in the MCA territory on brain
perfusion SPECT scans, During follow-up, we administered antiplatelet agents
and evaluated the status of restenosis by angiography (n = 2), brain perfusion
SPECT (n = 4), and/or transcranial Doppler sonography (TCD) (n = 7),
RESULTS: Stenotic arteries were successfully dilated in nine of 10 patients.
Angioplasty failed in one patient because the balloon could not pass through the
tortuous cavernous internal carotid artery, None of the patients experienced
either peri- or postangioplasty complications. Residual stenosis was less than
50%, and clinical improvement, including elimination of TIAs in four patients
who had suffered resistant TIAs, was observed in all patients; improvement of
the cerebral perfusion was also noted in two patients with a large hypoperfusion
area in the MCA territory, The average follow-up period was 11 months (range,
2 to 36 months). None experienced recurrent stroke during the follow-up period.
TCD revealed decreased flow velocity of the MCA after angioplasty in seven
patients, CONCLUSION: PTA of the proximal portion of the MCA seems to be
a safe and effective therapeutic technique for the prevention of secondary
ischemic stroke
Keywords: acute/acute ischemic
stroke/age/angioplasty/anticoagulation/antiplatelet/antiplatelet
agents/arteries/brain/brain perfusion/carotid/carotid artery/cerebral/cerebral
artery/COMPLICATIONS/Doppler/flow
velocity/FOLLOW-UP/INTRACRANIAL ANGIOPLASTY/ischemic/ischemic
stroke/prevention/recurrent stroke/safety/SPECT/stroke/transcranial
Doppler/transcranial Doppler sonography/transient/transient ischemic attacks
Olney, R.S. (1999), Preventing morbidity and mortality from sickle cell disease - A
public health perspective. American Journal of Preventive Medicine, 16 (2),
116-121.
Abstract: Context: Sickle cell disease is a group of conditions characterized by
production of abnormal hemoglobin, with clinical manifestations that vary by
genotype and age. Objective: To discuss current public health issues associated
with sickle cell disease, and approaches to preventing complications from these
conditions in die United States. Design: Literature review. Results: Most clinical
interventions for people with sickle cell disease discussed in the medical
literature can be classified as tertiary prevention: for example, therapy to
ameliorate anemia, reduce the frequency of pain crises, or prevent stroke I
recurrences. A form of secondary prevention, newborn screening, has emerged as
an important public health approach to identifying affected children before they
develop complications. Newborn screening is the starting point, for simple public
health strategies such as parental education, immunization, and penicillin
prophylaxis. Identification of affected families by newborn or community
screening programs has also been an entry point for genetic counseling, although
utilization of prenatal testing has varied by factors such as geographic location.
Public health agencies have had significant involvement with funding, policy
making, and formulation of laboratory and clinical guidelines for sickle cell
disease. Since the introduction of penicillin prophylaxis policies, newborn
screening, new immunizations, and comprehensive medical care centers, the
survival of young children with sickle cell disease has improved. Conclusions:
Although the efforts of preventive medicine providers in public health programs
are not solely responsible for the improved survival of children with sickle cell
disease, such programs remain an important component in preventing sickle cell
complications
Keywords: age/anemia/ANEMIA/child health
services/CHILDREN/complications/COST-EFFECTIVENESS/education/EXPE
RIENCE/GENE/genetic/guidelines/health/hemoglobin/HEMOGLOBINOPATHI
ES/hemoglobinopathies/HOSPITALIZATIONS/MANAGEMENT/morbidity/mo
rtality/neonatal
screening/NEW-YORK/pain/PRENATAL-DIAGNOSIS/prevention/preventive
medicine/prophylaxis/public health/review/secondary prevention/sickle cell
prevention and control/stroke/therapy/TRIAL/United States
Sato, Y., Kuno, H., Kaji, M., Saruwatari, N. and Oizumi, K. (1999), Effect of ipriflavone
on bone in elderly hemiplegic stroke patients with hypovitaminosis D. American
Journal of Physical Medicine & Rehabilitation, 78 (5), 457-463.
Abstract: A significant reduction in bone mineral density occurs in stroke patients on the
hemiplegic side, correlating with the degree of paralysis and vitamin D
deficiency due to malnutrition, sunlight deprivation, and immobilization-induced
hypercalcemia, and increases the risk of hip fracture. We evaluated the effect of
ipriflavone and 1 alpha-hydroxyvitamin D3 [1 alpha(OH)D3; vitamin D3]
administration on bone mineral density preservation as compared with untreated
controls. In a randomized and prospective study of 103 patients with hemiplegia
after stroke (the mean duration of illness was 4.8 yr), 68 (34 patients in each
group) were given 600 mg ipriflavone or 1 mu g vitamin D3 daily for 12 mo,
whereas the remaining 35 patients received no drug. Bone mineral density on the
hemiplegic side decreased by 1.4% in the ipriflavone group, 3.8% in the vitamin
D3 group, and 5.4% in the control group (P < .0001, ipriflavone v vitamin D3
and control). At baseline, all three groups of patients showed a
25-hydroxyvitamin D insufficiency, increased serum ionized calcium, and low
levels of 1, 25-dihydroxyvitamin D, suggesting immobilization-induced
hypercalcemia and inhibition of renal synthesis of 1, 25- dihydroxyvitamin D.
After treatment, the serum 1, 25- dihydroxyvitamin D level increased by 139.9%
in the ipriflavone group and by 26.9% in the vitamin D3 group. Significant
decreases in the serum ionized calcium and pyridinoline cross- linked
carboxyterminal telopeptide of type I collagen, and increases in parathyroid
hormone and bone Gla protein were observed in the ipriflavone group, whereas
no changes occurred in the other two groups. One patient in the untreated group
suffered a hip fracture, compared with none in the ipriflavone and vitamin D3
groups. These results suggest that ipriflavone is more efficacious than vitamin
D3 in the prevention of decreased bone mineral density in hemiplegic stroke
patients because it decreases serum calcium levels through inhibition of bone
resorption and cause a subsequent increase in 1, 25- dihydroxyvitamin D
concentration
Keywords: 1-ALPHA-HYDROXYVITAMIN
D-3/administration/CALCIUM/collagen/control/D3/elderly/hemiplegia/HIP
FRACTURE/hypercalcemia/ipriflavone/MASS/METACARPAL/OSTEOPENIA
/osteopenia/POSTMENOPAUSAL OSTEOPOROSIS/prevention/prospective
study/randomized/renal/risk/SENILE
OSTEOPOROSIS/serum/stroke/SUPPLEMENTATION/treatment/vitamin
D/WOMEN
Semenza, J.C., McCullough, J.E., Flanders, W.D., McGeehin, M.A. and Lumpkin, J.R.
(1999), Excess hospital admissions during the July 1995 heat wave in Chicago.
American Journal of Preventive Medicine, 16 (4), 269-277.
Abstract: Introduction: This study describes medical conditions treated in all 47 non-VA
hospitals in Cook County, IL during the 1995 heat wave. We characterize the
underlying diseases of the susceptible population, with the goal of tailoring
prevention efforts. Methods: Primary and secondary discharge diagnoses made
during the heat wave and comparison periods were obtained from computerized
inpatient hospital discharge data to determine reasons for hospitalization, and
comorbid conditions, respectively. Results: During the week of the heat wave,
there were 1072 (11%) more hospital admissions than average for comparison
weeks and 838 (35%) more than expected among patients aged 65 years and
older. The majority of this excess (59%) were treatments for dehydration, heat
stroke, and heat exhaustion; with the exception of acute renal failure no other
primary discharge diagnoses were significantly elevated. In contrast, analysis of
comorbid conditions revealed 23% (p = 0.019) excess admissions of underlying
cardiovascular diseases, 30% (p = 0.033) of diabetes, 52% (p = 0.011) of renal
diseases, and 20% (p = 0.027) of nervous system disorders. Patient admissions
for emphysema (p = 0.007) and epilepsy (p 0.009) were also significantly
elevated during the heat wave week. Conclusions: The majority of excess
hospital admissions were due to dehydration, heat stroke, and heat exhaustion,
among people with underlying medical conditions. Short-term public health
interventions to reduce heat-related morbidity should be directed toward these
individuals to assure access to air conditioning and adequate fluid intake.
Long-term prevention efforts should aim to improve the general health condition
of people at risk through, among other things, regular physician- approved
exercise. (C) 1999 American Journal of Preventive Medicine
Keywords: acute/AGE/aged/BLOOD-FLOW/cardiovascular/cardiovascular
diseases/DEATHS/diabetes/diseases/epilepsy/exercise/health/HEALTHY
ELDERLY MEN/heat/heat exhaustion/heat
stroke/hospital/hospitalization/hospitals/INJURY/MORBIDITY/MORTALITY/
NEW-YORK/patient admission/population/prevention/primary/public
health/RECORDS/renal/risk/STRESS/stroke/THIRST/urban
Block, G., Gillespie, C., Rosenbaum, E.H. and Jenson, C. (2000), A rapid food screener
to assess fat and fruit and vegetable intake. American Journal of Preventive
Medicine, 18 (4), 284-288.
Abstract: Background: The U.S. Preventive Services Task Force recommends that
Americans lower dietary fat and cholesterol intake and increase fiber and
fruit/vegetables to reduce prevalence of heart disease, cancer, stroke,
hypertension, obesity, and non- insulin-dependent diabetes mellitus in the United
States. To provide preventive services to all, a rapid, inexpensive, and valid
method of assessing dietary intake is needed. Methods: We used a one-page food
intake screener based on national nutrition data. Respondents can complete and
score the screener in a few minutes and can receive immediate, br ief feedback.
Two hundred adults self-administered the food screener. We compared fat, fiber,
and fruit/vegetable intake estimates derived from the screener with estimates
from a full-length, 100-item validated questionnaire. Results: The screener was
effective in identifying persons with high-fat intake, or low- fruit/ vegetable
intake. We found correlations of 0.6-0.7 (p<0.0001) for total fat, saturated fat,
cholesterol, and fruit/vegetable intake. The screener could identify persons with
high percentages of calories from fat, total fat, saturated fat, or cholesterol, and
persons with low intakes of vitamin C, fiber, or potassium. Conclusions: This
screener is a useful tool fur quickly monitoring patients' diets. The health care
provider can use it as a prelude to brief counseling or as the first stage of triage.
Per sons who score poorly can be referred for more extensive evaluation by
low-cost paper-and- pencil methods. Those who still have poor scores at the
second stage ultimately can be referred for in-person counseling
Keywords: adults/cancer/cholesterol/diabetes/diabetes mellitus/diet/dietary
intake/disease/evaluation/fiber/fruit/health/health care/heart/heart
disease/hypertension/monitoring/NEW-YORK/nutrition/obesity/potassium/preva
lence/primary prevention/RECORDS/screening/stroke/United
States/use/vegetable/vitamin C
Sprecher, D.L. (2000), Raising high-density lipoprotein cholesterol with niacin and
fibrates: A comparative review. American Journal of Cardiology, 86 (12A),
46L-50L.
Abstract: A growing number of trials that used fibrates and niacin alone or in
combination with other lipid-altering agents have shown that both these drugs are
effective for reducing total cholesterol, low-density lipoprotein cholesterol
(LDL-C) and triglycerides, and for increasing high-density lipoprotein
cholesterol (HDL-C) levels. These lipid changes are associated with a reduction
in events such as fatal and nonfatal myocardial infarction, stroke, and transient
ischemic attack. In angiographic trials, they are associated with disease
regression, increased minimal luminal diameter, and protection from risk of new
lesions. In a head-to-head comparison study, niacin 2,000 mg/day increased
HDL-C more than gemfibrozil 1,200 mg/day, and decreased the total
cholesterol-to-HDL-C ratio, lipoprotein (a) (Lp[a]), and fibrinogen levels
significantly more. Combination therapies of niacin plus a resin or statin are
effective, well tolerated, and (C) 2000 by Excerpta Medica, Inc
Keywords: cholesterol/combination/CORONARY
HEART-DISEASE/disease/DOUBLE-BLIND/drugs/FENOFIBRATE/fibrinoge
n/GEMFIBROZIL/HDL CHOLESTEROL/high density lipoprotein/high-density
lipoprotein cholesterol/HYPERLIPIDEMIA/infarction/ischemic/low density
lipoprotein/low-density lipoprotein
cholesterol/MEN/MULTICENTER/myocardial/myocardial
infarction/NEW-YORK/PREVENTION/protection/review/risk/statin/stroke/tran
sient/transient ischemic attack/trials/triglycerides/VEIN-GRAFT
ATHEROSCLEROSIS
Arntz, H.R., Agrawal, R., Wunderlich, W., Schnitzer, L., Stern, R., Fischer, F. and
Schultheiss, H.P. (2000), Beneficial effects of Pravastatin (+/-
colestyramine/niacin) initiated immediately after a coronary event (the
randomized lipid-coronary artery disease [L-CAD] study). American Journal of
Cardiology, 86 (12), 1293-1298.
Abstract: Secondary prevention of coronary heart disease by antilipidemic therapy
beginning at greater than or equal to3 months after an acute coronary syndrome
is well documented. The impact, however, of immediate initiation of
antilipidemic therapy on coronary stenoses and clinical outcome in patients with
acute coronary syndrome is unknown. In our study, patients were randomized, on
average, 6 days after an acute myocardial infarction and/or percutaneous
transluminal coronary angioplasty secondary to unstable angina, to pravastatin
(combined, when necessary, with cholestyramine and/or nicotinic acid) to
achieve low-density lipoprotein cholesterol levels of less than or equal to 130
mg/dl (group A, n = 70). In controls (group B, n = 56), antilipidemic therapy was
determined by family physicians. Quantitative coronary angiography was
performed at inclusion, and at 6- and 24-month followup. The combined clinical
end points were total mortality, cardiovascular death, nonfatal myocardial
infarction, need for coronary intervention, stroke, and new onset of peripheral
vascular disease. Minimal lumen diameter in group A increased by 0.05 +/- 0.20
mm after 6 months and 0.13 +/- 0.29 mm after 24 months, whereas it decreased
by 0.08 +/- 0.20 mm and 0.18 +/- 0.27 mm, respectively, in group B (p = 0.004 at
6 months and p <0.001 at 24 months). After 2 years, 29 patients of 56 patients in
group 8, but only 16 of 70 patients in group A, experienced a clinical end point
(p = 0.005; odds ratio 0.28, confidence intervals 0.13 to 0.6). We conclude that
pravastatin-based therapy initiated immediately after an acute coronary
syndrome is well tolerated and safe, lessens coronary atherosclerosis, and has a
pronounced clinical benefit. (C)2000 by Excerpta Medica, Inc
Keywords: acute/acute myocardial
infarction/angina/ANGIOPLASTY/atherosclerosis/cardiovascular/cholesterol/C
HOLESTEROL LEVELS/coronary angioplasty/coronary heart
disease/DIET/heart/infarction/low density
lipoprotein/MEN/mortality/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/NEW-YORK/peripheral vascular
disease/pravastatin/prevention/PROGRESSION/randomized/REDUCTION/REG
RESSION/RESTENOSIS/stroke/THERAPY/unstable angina/vascular/vascular
disease
McCullough, M.L., Feskanich, D., Rimm, E.B., Giovannucci, E.L., Ascherio, A.,
Variyam, J.N., Spiegelman, D., Stampfer, M.J. and Willett, W.C. (2000),
Adherence to the Dietary Guidelines for Americans and risk of major chronic
disease in men. American Journal of Clinical Nutrition, 72 (5), 1223-1231.
Abstract: Background: The Dietary Guidelines Sor Americans and the food guide
pyramid aim to reduce the risk of major chronic disease in the United States, but
data supporting their overall effectiveness are sparse. The healthy eating index
(HEI) measures the concordance of dietary patterns with these guidelines.
Objective: We tested whether a high HEI score (range: 0-100; 100 is best)
calculated from a validated food- frequency questionnaire (HEI-f) could predict
lower risk of major chronic disease in men. Design: A cohort of US male health
professionals without major disease completed detailed questionnaires on food
intake and other risk factors for heart disease and cancer in 1986 and repeatedly
during the 8-y follow-up. Major chronic disease outcome was defined as incident
major cardiovascular disease (stroke or myocardial infarction, n = 1092), cancer
(n = 1661), or other non-trauma- related deaths (n = 366). Results: The HEI-f
was weakly inversely associated with risk of major chronic disease [comparing
highest with lowest quintile of the HEI-f, relative risk (RR)= 0.89; 95% CI: 0.79,
1.00; P < 0.001 for trend]. The HEI-f was associated with moderately lower risk
of cardiovascular disease (RR = 0.72; 95% CI: 0.60, 0.88; P < 0.001) but was not
associated with lower cancer risk. Conclusions: The HEI-f was only weakly
associated with risk of major chronic disease, suggesting that improvements to
the HEI may be warranted. Further research on the HEI could have implications
for refinements to the Dietary Guidelines for Americans and the food guide
pyramid
Keywords: cancer/cancer prevention/cardiovascular/cardiovascular
disease/cardiovascular disease prevention/chronic disease/chronic disease
prevention/COLON-CANCER/CORONARY HEART-DISEASE/diet/diet
quality/dietary guidelines/Dietary Guidelines for Americans/ESSENTIAL
FATTY-ACIDS/FIBER INTAKE/FOOD FREQUENCY
QUESTIONNAIRE/food guide pyramid/guidelines/health/healthy eating
index/heart/heart disease/infarction/men/myocardial/myocardial
infarction/nutrition/PROSPECTIVE COHORT/PROSTATE-CANCER/relative
risk/REPRODUCIBILITY/risk/risk factors/stroke/United
States/VALIDITY/WOMEN
Record, N.B., Harris, D.E., Record, S.S., Gilbert-Arcari, J., DeSisto, M. and Bunnell, S.
(2000), Mortality impact of an integrated community cardiovascular health
program. American Journal of Preventive Medicine, 19 (1), 30-38.
Abstract: Background: Preventing cardiovascular disease through community
interventions makes theoretical sense but has been difficult to demonstrate. We
set out to determine whether a community cardiovascular health program had an
impact on mortality. Design: Program evaluation plus ecologic observational
analysis of program encounters and mortality rates with external comparisons.
Setting: Franklin County and two comparison counties in rural Maine.
Participants: Program encountered >50% of regional adults, broadly distributed
by site, gender, and age, Interventions: From 1974 to 1994, a community
program, integrated with primary medic;ll care and staffed by professional nurses,
provided education, screening, counseling, referral, tracking, and followup for
cardiovascular risk factors. Main Outcome Measures: Age-adjusted mortality
rates (total, heart, coronary, cerebrovascular, cancer) for three counties and
Maine, plus annual program encounters. Results: Relative to Maine, the Franklin
heart disease death rate was 0.97 at baseline (1960-1969; 95% confidence
interval, 0.91 to 1.03), 0.91 during the program (0.85 to 0.97), 0.83 during the 11
years of program growth (0.78 to 0.88), but 1.0 during the 10 years of decreasing
encounters. Franklin's total death rate was 1.01 at baseline, 0.95 during the
program (0.92 to 0.98), and 0.90 during program growth (0.86 to 0.94). Results
were similar for coronary disease, stroke, and cancer. Relative death rates did not
fall in either comparison county. Nurse- client encounters totaled 120,280 over
21 years. Relative to Maine, heart disease death rates correlated inversely with
program encounters (r = -0.53) but not with unemployment or physician supply.
Conclusions: Integrated with primary medical care, a comprehensive,
nurse-mediated community cardiovascular health program in rural Maine has
been associated with significant time-dependent and dose-dependent reductions
in cardiovascular and total mortality. (C) 2000 American Journal of Preventive
Medicine
Keywords: ACUTE
MYOCARDIAL-INFARCTION/adults/age/cancer/cardiovascular/cardiovascular
disease/cardiovascular diseases/cardiovascular risk/cardiovascular risk
factors/cerebrovascular/community/coronary disease/CORONARY
HEART-DISEASE/COST-EFFECTIVENESS/DEATH/disease/education/EDU
CATION-PROGRAM/evaluation/gender/health/heart/heart
disease/mortality/NEW-YORK/NORTH-KARELIA/nursing/PREVENTION/pri
mary/primary prevention/PROJECT/public health/residence
characteristics/risk/risk factors/RISK- FACTORS/screening/stroke/TRENDS
Li-Saw-Hee, F.L., Blann, A.D. and Lip, G.Y.H. (2000), Effect of degree of blood
pressure on the hypercoagulable slate in chronic atrial fibrillation. American
Journal of Cardiology, 86 (7), 795-+.
Abstract: Both chronic nonvalvular atrial fibrillation (AF) and hypertension are common
cardiovascular conditions that are independently associated with an increased
risk of stroke.(1,2) However, AF and hypertension often coexist, and such
patients have an additive risk of stroke and thromboembolism, thus representing
a "high-risk" population, In the multivariate analysis of pooled data from the 5
initial randomized controlled anticoagulation trials of nonvalvular AF, a history
of hypertension conferred a 1.6-fold increase in risk of stroke over those without
risk factors.(3) The contribution of hypertension was further confirmed by the
Stroke Prevention in Atrial Fibrillation Investigators(4) who found that patients
with AF with a history of hypertension (defined as a systolic blood pressure [BP]
> 160 mm Hg) had a higher rate of primary events (ischemic stroke and systemic
embolism; 3.6%/year) than those with no history of hypertension (1.1%/year; p <
0.001), Hypertension itself is known to be an independent predictor of stroke and
myocardial infarction, both of which usually have an underlying thrombotic basis;
the pulse pressure is a particular risk factor in the elderly.(5,6) Both AF and
hypertension are well recognized to be associated with abnormalities in
hemostatic markers, platelets, and endothelial dysfunction, in keeping with a
prothrombotic or hypercoagulable state.(6-8) For example, the Prospective
Cardiovascular Munster study investigators(9) in their population-based,
cross-sectional study recently reported that levels of various hemostatic markers
of a prothrombotic state were significantly higher in hypertensive than in
normotensive subjects, with significant correlations between these markers and
BP levels. There are no data as to whether BP itself confers an additional
influence on the hypercoagulable state seen in chronic nonvalvular AF. In this
study, we hypothesized that higher levels of BP would further promote the
hypercoagulable state in AF by increasing the degree of hemostatic abnormalities
Keywords: AF/anticoagulation/atrial fibrillation/blood
pressure/cardiovascular/embolism/England/fibrillation/HEMODYNAMIC
ABNORMALITIES/hemostatic
markers/history/HYPERTENSION/infarction/ischemic/ischemic
stroke/markers/myocardial/myocardial
infarction/NEW-YORK/platelets/population/population-based/primary/randomiz
ed/risk/risk factor/STROKE/systolic blood
pressure/thromboembolism/THROMBOGENESIS/trials
Agmon, Y., Khandheria, B.K., Meissner, I., Schwartz, G.L., Petterson, T.M., O'Fallon,
W.M., Gentile, F., Whisnant, J.P., Wiebers, D.O., Covalt, J.L. and Seward, J.B.
(2000), Left atrial appendage flow velocities in subjects with normal left
ventricular function. American Journal of Cardiology, 86 (7), 769-773.
Abstract: The objectives of this study were to establish reference values and define the
determinants of left atrial appendage (LAA) flow velocities in the general
population. LAA flow velocities (contraction and filling velocities) were
assessed by transesophageal echocardiography in 310 subjects aged greater than
or equal to 45 years, sampled from the population-based Stroke Prevention:
Assessment of Risk in a Community study. All subjects were in sinus rhythm,
with preserved left ventricular systolic function (ejection fraction greater than or
equal to 50%), and without valvular disease. Values of LAA contraction and
filling velocities were established for various age groups in the population. Age
was negatively associated with LAA contraction and filling velocities, which
decreased by 4.1 cm/s (p < 0.001) and 2.0 cm/s (p < 0.01) for every 10 years of
age, respectively. Contraction velocities were 5 cm/s higher in men than in
women (p < 0.05). After adjusting for age and sex, heart rate was independently
associated with LAA contraction velocities (p < 0.001; nonlinear association).
Body surface area, left atrial size, left ventricular mass index, and a history of
previous cardiac disease or hypertension showed no significant association with
LAA flow velocities (p > 0.05). Furthermore, detailed analysis of 24-hour
ambulatory blood pressure data (available in 253 subjects) showed no association
between various blood pressure parameters (systolic and diastolic blood pressure,
out-of-bed and in-bed measurements) and LAA flow velocities (all p > 0.05). In
summary, the present study establishes the reference values for LAA flow
velocities in a large sample of the general population. LAA flow velocities
progressively decline with age in subjects with preserved left ventricular systolic
function. (C) 2000 by Excerpta Medica, Inc
Keywords: age/aged/ALTERED LOADING CONDITIONS/ANATOMY/blood
pressure/BLOOD-PRESSURE/diastolic blood
pressure/DISEASE/DOPPLER-ECHOCARDIOGRAPHY/echocardiography/hea
rt/history/hypertension/IMPACT/IN-VIVO/left atrial
appendage/men/NEW-YORK/population/population-based/RISK/sex/sinus
rhythm/STROKE/TRANSESOPHAGEAL ECHOCARDIOGRAPHY/women
Pearce, L.A., Hart, R.G. and Halperin, J.L. (2000), Assessment of three schemes for
stratifying stroke risk in patients with nonvalvular atrial fibrillation. American
Journal of Medicine, 109 (1), 45-51.
Abstract: PURPOSE: The risk of ischemic stroke varies widely among patients with
nonvalvular atrial fibrillation, influencing the choice of prophylactic
antithrombotic therapy. We assessed three schemes for stroke risk stratification
in these patients who were treated with aspirin and who did not have prior
cerebral ischemia. SUBJECTS AND METHODS: Criteria from three schemes of
risk stratification were applied to a longitudinally observed cohort of patients
with atrial fibrillation who did not have prior cerebral ischemia and who were
treated with aspirin alone or aspirin combined with low, ineffective doses of
warfarin in a multicenter clinical trial. The ability of the schemes to identify
patients at high (greater than or equal to 6%), low (less than or equal to 2%), and
intermediate annual risks of ischemic stroke was assessed. RESULTS: During a
mean follow-up of 1.8 years. 48 ischemic strokes occurred among 1,073 patients
with atrial fibrillation who were taking aspirin (rate = 2.5 per 100 person-years).
Each of the three schemes predicted stroke and disabling stroke, and successfully
identified patients at low risk (observed stroke rates of 0.3 to 1.1 per 100
person-years), although the fractions of the cohort that were categorized as low
risk varied from 14% to 45%. The observed rates of ischemic stroke among
patients categorized as high risk ranged from 3.5 to 7.2 per 100 person- years
among the stratification schemes. Two schemes considered all patients >75 years
old as high risk (observed stroke rate 4.2 per 100 person-years), while the
remaining scheme classified one third of patients in this age group as low risk
(observed stroke rate 0.6 per 100 person-years). CONCLUSIONS: When tested
in a large cohort of patients with atrial fibrillation who were treated with aspirin,
available risk- stratification schemes successfully identified patients with low
rates of ischemic stroke, but less consistently identified high-risk patients. Am J
Med. 2000;109:45-51. (C) 2000 by Excerpta Medica, Inc
Keywords: age/antithrombotic/ANTITHROMBOTIC THERAPY/ASPIRIN/atrial
fibrillation/cerebral/cerebral
ischemia/COMMUNITY/fibrillation/GENERAL-PRACTICE/high
risk/ischemia/ischemic/ischemic stroke/NEW-YORK/nonvalvular atrial
fibrillation/POPULATION/PREVALENCE/PREVENTION/PRIMARY-CARE/r
isk/risk stratification/stroke/therapy/THROMBOEMBOLISM/warfarin
De, B.K., Sen, S., Biswas, P.K., Sengupta, D., Biswas, J., Santra, A., Hazra, B. and
Maity, A.K. (2000), Propranolol in primary and secondary prophylaxis of
variceal bleeding among cirrhotics in India: A hemodynamic evaluation.
American Journal of Gastroenterology, 95 (8), 2023-2028.
Abstract: OBJECTIVE: In the present study, we attempted to complete the
hemodynamic assessment of propranolol response in cirrhotics with esophageal
varices at high risk of bleeding, in one sitting, so as to identify nonresponders at
the earliest. Some noninvasive indicators of this response were also evaluated.
METHODS: Hepatic venous pressure gradient (HVPG) was measured in 33 such
cases (18 nonbleeders, 15 bleeders) before and 90 min after an oral dose of 80
mg propranolol, and reduction by greater than or equal to 20% taken as
responder. RESULTS: Twenty-two patients (66.67%) responded (HVPG
reduction greater than or equal to 26%), whereas 11 (33.33%) did not (HVPG
reduction less than or equal to 6%). Postdrug HVPG between responders and
nonresponders showed a significant difference (p < 0.001). Neither baseline
HVPG (p > 0.1), baseline CI (p = 0.665), nor baseline stroke volume index (p >
0.1) could predict responder status. Difference of HVPG reduction (percent)
between bleeders (21.49 +/- 35.53) and nonbleeders (40.58 +/- 23.95)
approached, but did not reach, statistical significance (p = 0.076). However,
logistic regression showed this difference to be significant (p = 0.026). Age of
responders was found to be significantly lower than that of nonresponders (p
approximate to 0.05). During a follow-up of 9- 38 months, only one of 22
responders (on propranolol) had an episode of variceal bleed. None in whom
HVPG fell to less than or equal to 12 mm Hg bled. CONCLUSION: The study
suggests that single-sitting hemodynamic assessment of acute response to
high-dose oral propranolol clearly differentiates between responders and
nonresponders. Moreover, it appears that prior history of variceal bleeding and
old age negatively influences the effect of propranolol. (C) 2000 by Am. Cell. of
Gastroenterology
Keywords: acute/age/bleeding/CIRRHOSIS/evaluation/HEMORRHAGE/high
risk/history/NEW-YORK/PORTAL-
HYPERTENSION/PREVENTION/primary/prophylaxis/PROSPECTIVE
RANDOMIZED
TRIAL/risk/SCLEROTHERAPY/status/stroke/VENOUS-PRESSURE
Prystowsky, E.N. (2000), Management of atrial fibrillation: Therapeutic options and
clinical decisions. American Journal of Cardiology, 85 (10A), 3D-11D.
Abstract: Atrial fibrillation (AF) is the most common, sustained tachyarrhythmia seen in
clinical practice. Although it is not immediately life threatening, AF can cause
troublesome symptoms and poses a risk of stroke. The patient's clinical status is
often complicated by the presence of other cardiovascular or concomitant
diseases. As a result, management of the patient with AF involves many
questions and choices, all of which must be individualized. There ore 3 general
strategies for the management of patients with AF, including (1) restoration and
maintenance of sinus rhythm, (2) control of ventricular rate, and (3) prevention
of stroke. More than 1 strategy may be appropriate in some patients, Furthermore,
either pharmacologic or nonpharmacologic options can be chosen in certain
situations. Although some data from randomized clinical trials are available to
aid in clinical decision-making, only the benefits of anticoagulation are
supported by substantial evidence. This article explores practical approaches to
several management issues and scenarios for which there ore limited relevant
clinical date. These include: (1) patient selection for ventricular rate control and
assessment of treatment, (2) choice of antiarrhythmic drug for maintenance of
sinus rhythm, (3) inpatient versus outpatient initiation of therapy, (4) definition
of antiarrhythmic drug success, (5) methods of transthoracic direct cardioversion,
and (6) prediction and prevention of AF after cardiac surgery. (C) 2000 by
Excerpta Medica, Inc
Keywords: AF/AMIODARONE/anticoagulation/atrial fibrillation/cardiac/cardiac
surgery/CARDIAC-SURGERY/cardiovascular/CARDIOVERSION/clinical
practice/clinical trials/CONGESTIVE-HEART-FAILURE/control/decision
making/decision-making/diseases/EFFICACY/fibrillation/HUMANS/IBUTILID
E/LEFT-VENTRICULAR
DYSFUNCTION/NEW-YORK/prevention/RADIOFREQUENCY
ABLATION/randomized/risk/sinus
rhythm/status/stroke/surgery/therapy/treatment/TRIAL/trials
Fraisse, F., Holzapfel, L., Coulaud, J.M., Simmoneau, G., Bedock, B., Feissel, M.,
Herbecq, P., Pordes, R., Poussel, J.F. and Roux, L. (2000), Nadroparin in the
prevention of deep vein thrombosis in acute decompensated COPD. American
Journal of Respiratory and Critical Care Medicine, 161 (4), 1109-1114.
Abstract: Low molecular weight heparins are as effective as unfractionated heparin in
deep-vein thrombosis (DVT) prophylaxis for major surgery. However, there is
no evidence nor consensus for prophylaxis in medical patients. We compared the
efficacy and safety of nadroparin calcium (nadroparin) with placebo in medical
patients at high risk of DVT. A total of 223 patients mechanically ventilated for
acute, decompensated chronic obstructive pulmonary disease, were randomized
to treatment with subcutaneous nadroparin adjusted for body weight (0.4 ml, i.e.,
3,800 AXa IU, or 0.6 ml, i.e., 5,700 AXa IU) or placebo. The average duration of
treatment was 11 d. The incidence of DVT in patients receiving nadroparin was
significantly lower than that in patients receiving placebo (15.5 versus 28.2%; p
= 0.045). Although the incidence of adverse events was high in both groups,
there were no significant differences between nadroparin and placebo for total
adverse events (46.3 versus 39.8%; p = 0.33), serious adverse events (25.0 versus
19.5%; p = 0.32), or those resulting in early permanent discontinuation of
treatment (12.0 versus 8.8%; p = 0.44). The most common adverse event was
hemorrhage. There was the same number of deaths in both treatment groups.
Subcutaneous nadroparin resulted in 45% decrease in incidence of DVT
compared with placebo
Keywords: acute/ACUTE ISCHEMIC STROKE/adverse
events/calcium/CARE/consensus/deep vein thrombosis/deep-vein
thrombosis/disease/DOUBLE-BLIND/DVT/ENOXAPARIN/hemorrhage/hepari
n/heparins/high risk/HIP-
REPLACEMENT/incidence/INPATIENTS/LUNG/medical
patients/MOLECULAR-WEIGHT
HEPARIN/NEW-YORK/prevention/prophylaxis/randomized/RISK/safety/surger
y/thrombosis/treatment/TRIAL/UNFRACTIONATED HEPARIN/VENOUS
THROMBOEMBOLISM
Johnson, L.N., Stetson, S.W., Krohel, G.B., Cipollo, C.L. and Madsen, R.W. (2000),
Aspirin use and the prevention of acute ischemic cranial nerve palsy. American
Journal of Ophthalmology, 129 (3), 367-371.
Abstract: PURPOSE: To assess the relationship of aspirin use and ischemic cranial
nerve palsies among patients with diabetes mellitus and hypertension,
METHODS: This retrospective case-control study involved 100 patients with
ischemic cranial nerve palsies in association with diabetes, hypertension, or both
(palsy cases) and 163 age-matched and sex-matched patients with diabetes,
hypertension, or both but without ischemic cranial nerve palsies (nonpalsy
control subjects). Comparisons were made with respect to duration of diabetes,
dose and duration of aspirin use, dose and duration of tobacco use, and presence
of cardiac or cerebrovascular disease. RESULTS: There were 20 oculomotor, 33
trochlear, 37 abducens, and 10 facial nerve palsy cases. The median duration of
diabetes was 6 years for cases and 7 years for control subjects. There were 34
cases (34%) who had used aspirin for a mean duration of 5.5 years before the
onset of the cranial nerve palsy and 49 control subjects (30.1%) who had used
aspirin for a mean duration of 4.3 years. There were no significant differences
between cases and control subjects for duration of diabetes (P = .94); aspirin use
(P = .51), duration (P = .50), and dosage (P = .89); tobacco use (P = .73) and
consumption (P = .45); and proportion of cardiac disease (P = .17).
Cerebrovascular disease was significantly less common among palsy cases than
nonpalsy control subjects (P < .001), There was no significant difference in the
odds of a patient having cranial nerve palsy in the aspirin group compared with
the nonaspirin group (odds ratio, 1.12; 95% confidence interval, 0.70-2.04).
CONCLUSION: Aspirin use was not associated with a reduced rate of ischemic
third, fourth, sixth, and seventh nerve palsies among patients with diabetes
mellitus and hypertension. Aspirin appears to be ineffective in preventing
ischemic third, fourth, sixth, and seventh cranial nerve palsies, Patients with
ischemic cranial nerve palsy have a significantly lower rate of strokes and
transient ischemic attacks than patients who have diabetes or hypertension but
who do not have a history of cranial nerve palsy. (C) 2000 by Elsevier Science
Inc. All rights reserved
Keywords: acute/aspirin/BELL PALSY/cardiac/case-control
study/cerebrovascular/cerebrovascular disease/control/diabetes/diabetes
mellitus/DIABETIC OPHTHALMOPLEGIA/disease/HERPES-SIMPLEX
VIRUS/history/hypertension/ischemic/NEW-YORK/OPTIC
NEUROPATHY/PARALYSIS/prevention/PROGNOSIS/RISK-FACTORS/STR
OKE/tobacco/transient/transient ischemic attacks/use
Pullarkat, V.A., Rho, H., Murata-Collins, J.L. and Liebman, H.A. (2000),
Ticlopidine-induced aplastic anemia: Development of chromosomal
abnormalities and response to immunosuppressive therapy. American Journal of
Hematology, 63 (3), 141-144.
Abstract: Severe aplastic anemia is a well-recognized complication of ticlopidine
therapy that carries a high mortality. Therapy with colony-stimulating factors or
corticosteroids has been largely ineffective in this disorder. We report a case of
ticlopidine- induced aplastic anemia that was successfully treated with
cyclosporine and high-dose dexamethasone. The patient rapidly responded to
immunosuppressive therapy and had a normal hemogram after cessation of
immunosuppression, On long-term follow-up, the patient developed a
progressive macrocytic anemia. Repeat bone marrow evaluation demonstrated
myelodysplasia with erythroid hypoplasia. An associated chromosomal
abnormality consisting of a t(3;16) (q21; p13.3) translocation was detected. This
is the first report of a chromosomal abnormality associated with ticlopidine
induced marrow aplastic anemia. Am. J. Hematol. 63:141-144, 2000. (C) 2000
Wiley-Liss, Inc
Keywords: 3Q21/anemia/ANTIPLATELET/aplastic
anemia/cyclosporine/evaluation/GLOBULIN/immunosuppressive
therapy/mortality/NEW-YORK/PREVENTION/RANDOMIZED
TRIAL/STROKE/therapy/ticlopidine
Yochum, L.A., Folsom, A.R. and Kushi, L.H. (2000), Intake of antioxidant vitamins and
risk of death from stroke in postmenopausal women. American Journal of
Clinical Nutrition, 72 (2), 476-483.
Abstract: Background: Antioxidant vitamins may play a role in the prevention of stroke
because they scavenge free radicals and prevent LDL oxidation. Epidemiologic
studies that have examined this relation produced conflicting results. Objective:
We examined the association between antioxidant vitamin intakes and death
from stroke. Design: This was a prospective cohort study of 34492
postmenopausal women. Results: During follow-up, 215 deaths from stroke were
documented. Total vitamin A, carotenoid, and vitamin E intakes were not
associated with death from stroke after multivariate adjustment. Relative risks
(RRs) and 95% CIs of the highest compared with the lowest category were 0.79
(0.45, 1.38; P for trend = 0.33) for vitamin A, 0.88 (0.45, 1.40; P for trend = 0.40)
for carotenoids, and 0.91 (0.55, 1.52; P for trend = 0.86) for vitamin E. The test
for trend for total vitamin C intake was significant, although the association
appeared somewhat U-shaped, not monotonic. An inverse association was seen
between death from stroke and vitamin E intake from food. RRs land 95% CIs)
of death from stroke from the lowest to highest intake categories were 1.0. 0.80
(0.51, 1.26), 0.93 (0.58, 1.49), 0.67 (0.39, 1.14), 0.40 (0.20, 0.80); P for trend =
0.008. The results suggest inverse associations between death from stroke and
intakes of the most concentrated vitamin E food sources consumed by this cohort:
mayonnaise, nuts, and margarine. Conclusions: Our results suggest a protective
effect of vitamin E from foods on death from stroke but do not support a
protective role for supplemental vitamin E or other antioxidant vitamins.
However, given the number of deaths from stroke in the present cohort, a
small-to-moderate association could not be ruled out
Keywords: antioxidant/antioxidant vitamins/BETA-CAROTENE/cardiovascular
disease/CARDIOVASCULAR-DISEASE/cohort study/death/diet/food-
frequency questionnaire/free radicals/HEART-DISEASE/Iowa Women's Health
Study/LDL/LOW-DENSITY-LIPOPROTEIN/MORTALITY/NUTRITION/oxid
ation/OXYGEN/postmenopausal women/prevention/prospective cohort
study/QUESTIONNAIRE/risk/stroke/SUPPLEMENTATION/TRIALS/vitamin
C/vitamin E/vitamins/women
How, C.K., Chern, C.H., Wang, L.M. and Lee, C.H. (2000), Heat stroke in a subtropical
country. American Journal of Emergency Medicine, 18 (4), 474-477.
Abstract: In Taiwan, a subtropical country without any history of heat waves, heat stroke
has been considered a rare disease. However, after seeing several cases of the
classic type of heat stroke at the end of the summer of 1998 (an unusual event)
we began to review and collect cases of suspected heat stroke (hyperthermia
(>40.6 degrees C) in the presence of altered mental status and anhidrosis) and
tried to explore the possible cause of this unusual phenomenon. Through a
emergency department (ED) chart review, case retraction from International
Classification of Diseases (ICD) code, and ED conferences, six patients were
found for the period from June to August (the hottest months in Taiwan) 1998.
We found that the most common comorbid conditions were hypertension (4/6)
and preexisting mental problems (3/6). All patients lived in the inner part of an
urban area, were middle class, and were not socially isolated. Most of our
patients felt unhealthy being exposed to the cold and avoided staying in
air-conditioned rooms. Laboratory abnormalities and clinical presentations,
except for a high fever and conscious change, seemed to be nonspecific. All
cases occurred during two periods of sustained hotter-than average weather and,
to our surprise, we found that three episodes occurred around the day of the
highest weather temperature (38.1 degrees C). However, the higher temperatures
(around 30 degrees to 31 degrees C and 32 degrees to 33 degrees C) did not
reach the criteria of a heat wave. Compared with the other study, our patients
seemed to have initial worse outcomes. Because of special environment and
social factors, classic heat stroke may occur occasion ally in subtropic regions,
without previous history of heat waves and where heat stroke rarely occurs,
during periods of the persistently high temperatures. Prevention of heat stroke in
an area with a low incidence includes early health organizations' issue of
advisories or warnings through the media and reminding at teaching emergency
physicians about heat stroke during sustained hot weather, especially when
record temperatures are set
Keywords: CHICAGO/classic heat stroke/disease/health/heat/heat stroke/heat
wave/HEATSTROKE/history/hypertension/hyperthermia/incidence/organization
s/review/status/stroke/subtropics/urban/WAVE
Rimmer, J.H., Braunschweig, C., Silverman, K., Riley, B., Creviston, T. and Nicola, T.
(2000), Effects of a short-term health promotion intervention for a predominantly
African-American group of stroke survivors. American Journal of Preventive
Medicine, 18 (4), 332-338.
Abstract: The study examined the effects of a 12-week health promotion intervention for
a predominantly urban African-American population of stroke survivors. Design:
A pre-test/post-test lag control group design was employed. Participants/Setting:
Participants were 35 stroke survivors (9 male, 26 female) recruited fi om local
area hospitals and clinics. Main Outcome Measures: Biomedical, fitness,
nutritional, and psychosocial measures were employed to assess program
outcomes. Results: Treatment group made significant gains over lag controls in
the following areas: (1) reduced total cholesterol, (2) reduced weight, (3)
increased cardiovascular fitness, (4) increased strength, (5) increased flexibility,
(6) increased life satisfaction and ability to manege self-care needs, and (7)
decreased social isolation. Conclusions: A short-term health pr-emotion
intervention for predominantly African-American stroke survivors was effective
in improving several physiological and psychological health outcomes
Keywords: cardiovascular/CARE/cerebrovascular
accident/cholesterol/control/design/disabled
persons/exercise/EXERCISE/health/health behavior/health
promotion/hospitals/minorities/NEW-YORK/nutrition/PEOPLE/physical
fitness/PHYSICAL-DISABILITIES/population/PREVENTION/RISK/SERVICE
/stroke/urban/WOMEN
Mcgill, H.C., McMahan, C.A., Herderick, E.E., Malcom, G.T., Tracy, R.E. and Strong,
J.P. (2000), Origin of atherosclerosis in childhood and adolescence. American
Journal of Clinical Nutrition, 72 (5), 1307S-1315S.
Abstract: Atherosclerosis begins in childhood as deposits of cholesterol and its esters,
referred to as fatty streaks, in the intima of large muscular arteries. In some
persons and at certain arterial sites, more lipid accumulates and is covered by a
fibromuscular cap to form a fibrous plaque. Further changes in fibrous plaques
render them vulnerable to rupture, an event that precipitates occlusive thrombosis
and clinically manifest disease (sudden cardiac death, myocardial infarction,
stroke, or peripheral arterial disease). In adults, elevated non-HDL- cholesterol
concentrations, low HDL-cholesterol concentrations, hypertension, smoking,
diabetes, and obesity are associated with advanced atherosclerotic lesions and
increased risk of clinically manifest atherosclerotic disease. Control of these risk
factors is the major strategy for preventing atherosclerotic disease. To determine
whether these risk factors also are associated with early atherosclerosis in young
persons, we examined arteries and tissue from approximate to 3000 autopsied
persons aged 15-34 y who died of accidental injury, homicide, or suicide. The
extent of both fatty streaks and raised lesions (fibrous plaques and other
advanced lesions) in the right coronary artery and in the abdominal aorta was
associated positively with non-HDL-cholesterol concentration, hypertension,
impaired glucose tolerance, and obesity and associated negatively with
HDL-cholesterol concentration. Atherosclerosis of the abdominal aorta also was
associated positively with smoking. These observations indicate that long- range
prevention of atherosclerosis and its sequelae by control of the risk factors for
adult coronary artery disease should begin in adolescence and young adulthood
Keywords:
adolescents/adults/aged/aorta/arteries/atherosclerosis/cholesterol/COMMUNITY
- PATHOLOGY/control/coronary arteries/coronary artery disease/CORONARY
HEART-DISEASE/diabetes/fatty streaks/FATTY STREAKS/glucose/HDL
cholesterol/hypertension/infarction/LOW-DENSITY-LIPOPROTEIN/MACROP
HAGE FOAM CELLS/myocardial/myocardial
infarction/NUTRITION/obesity/peripheral arterial
disease/plaque/POSTMORTEM RENAL INDEX/prevention/risk/risk
factors/RISK-FACTORS/smoking/STATISTICAL-ANALYSIS/stroke/thrombos
is/WHITE MALES/young adults/YOUNG BLACK
Boden, W.E. (2000), High-density lipoprotein cholesterol as an independent risk factor
in cardiovascular disease: Assessing the data from Framingham to the Veterans
Affairs high-density lipoprotein intervention trial. American Journal of
Cardiology, 86 (12A), 19L-22L.
Abstract: The Framingham Heart Study found that high-density lipoprotein cholesterol
(HDL-C) was the most potent lipid predictor of coronary artery disease risk in
men and women >49 years of age. The Air Force/Texas Coronary
Atherosclerosis Prevention Study (AFCAPS/Tex-CAPS), in which subjects were
randomized to treatment with lovastatin or placebo, also reported a striking
benefit of treatment, particularly in patients with HDL-C less than or equal to 35
mg/dL at baseline. Treatment with lovastatin was associated with a remarkable
45% reduction in events for this group. The Veterans Affairs HDL Intervention
Trial (VA-HIT) randomized subjects to gemfibrozil or placebo. A high
proportion of enrolled subjects with low HDL-C also had characteristics of the
dysmetabolic syndrome. HDL-C likewise increased by 6% on treatment, total
cholesterol was reduced by 4% and triglycerides by 31%. There was no change
in low-density lipoprotein cholesterol (LDL-C) levels. These changes in lipid
were associated with a cumulative 22% reduction in the trial primary endpoint of
all-cause mortality and nonfatal myocardial infarction (MI). Additionally,
significant reductions in secondary endpoints including death from coronary
artery disease, nonfatal MI, stroke, transient ischemic attack, and carotid
endarterectomy were associated with the increase in HDL-C. In VA-HIT, for
every 1% increase in HDL-C, there was a 3% reduction in death or MI, a
therapeutic benefit that eclipses the benefit associated with LDL-C reduction. (C)
2000 by Excerpta Medica, Inc
Keywords: age/all-cause mortality/ARTERY DISEASE/cardiovascular/cardiovascular
disease/carotid/carotid endarterectomy/cholesterol/coronary artery
disease/CORONARY HEART-DISEASE/CT/death/disease/disease
risk/endarterectomy/gemfibrozil/HDL/high density lipoprotein/high-density
lipoprotein cholesterol/infarction/ischemic/low density lipoprotein/low-density
lipoprotein cholesterol/MEN/mortality/myocardial/myocardial
infarction/NEW-YORK/PREVENTION/primary/randomized/risk/risk
factor/secondary/stroke/transient/transient ischemic
attack/treatment/trial/triglycerides/women
Waters, D.D. (2001), What do the statin trials tell us? American Journal of Managed
Care, 7 (5), S138-S143.
Abstract: The results of 5 major placebo-controlled trials evaluating the effects of statins
in approximately 31,000 individuals with and without known coronary
disease,have demonstrated the following: statins reduce the incidence of
coronary events, the reduction in relative risk for coronary events increases with
the duration of therapy, the reduction in coronary events is proportional to the
reduction in low-density lipoprotein cholesterol (LDL-C) levels, and lower
LDL-C levels are associated with lower event rates. The studies have also shown
that statins are safe and effective in reducing the incidence of coronary events in
women, individuals with diabetes, and patients older than 65 years of age and in
reducing the risk of stroke and transient ischemic attacks in patients with
coronary disease. Finally studies indicate that statins ameliorate a variety of
pathophysiologic processes that are associated with increased risk for
atherosclerosis
Keywords: 4S/age/atherosclerosis/CARE/cholesterol/coronary disease/CORONARY
HEART-DISEASE/diabetes/disease/EVENTS/HYPERCHOLESTEROLEMIA/i
ncidence/ischemic/low density lipoprotein/low-density lipoprotein
cholesterol/MEN/PREVENTION/relative risk/RISK/SCANDINAVIAN
SIMVASTATIN SURVIVAL/statin/statins/stroke/therapy/transient/transient
ischemic attacks/trials/WOMEN
Tanne, D., Benderly, M., Goldbourt, U., Boyko, V., Brunner, D., Graff, E.,
Reicher-Reiss, H., Shotan, A., Mandelzweig, L. and Behar, S. (2001), A
prospective study of plasma fibrinogen levels and the risk of stroke among
participants in the Bezafibrate Infarction Prevention Study. American Journal of
Medicine, 111 (6), 457-463.
Abstract: PURPOSE: Plasma fibrinogen has emerged as an important predictor of
cardiovascular disease, but few data are available on its association with stroke.
We sought to determine if plasma fibrinogen is a marker of increased risk or a
direct causative risk factor for stroke. SUBJECTS AND METHODS: Patients
from the Bezafibrate Infarction Prevention Study, a placebo-controlled,
randomized clinical trial of secondary prevention of coronary heart disease by
lipid modification with bezafibrate retard (400 mg daily), were studied. Plasma
fibrinogen levels were measured at baseline and yearly thereafter. Stroke, a
prospectively monitored endpoint, was systematically assessed regarding stroke
type, subtype, and functional outcome. RESULTS: Mean baseline fibrinogen
levels were significantly higher in patients subsequently having a
cerebrovascular event (140 strokes, 36 transient ischemic attacks; mean
follow-up, 6.2 years) than in patients who did not (375 vs. 349 mg/dL, P
<0.0001). Fibrinogen levels did not differ significantly by the type, subtype, or
severity of the cerebrovascular event, Risk of ischemic stroke increased from
3.3% in the lowest tertile (baseline fibrinogen <314 mg/dL) to 7.% in the middle
tertile (fibrinogen 314 to 373 mg/dL) to 10% in the upper tertile (fibrinogen
>373 mg/dL, P <0.001). Adjusting for age, blood pressure, and other covariates,
fibrinogen levels in the upper tertile were associated with more than a twofold
increase in risk of ischemic stroke compared with in the lowest tertile (hazard
ratio = 2.6; 95% confidence interval: 1.5 to 4.3). We did not find fibrinogen
change from baseline to be related to subsequent ischemic stroke events,
CONCLUSION: Plasma fibrinogen is a strong predictor of, rather than a direct
causative factor for, subsequent stroke among patients at increased risk owing to
manifest coronary heart disease. (C) 2001 by Excerpta Medica, Inc
Keywords: age/ASSOCIATION/bezafibrate/blood
pressure/cardiovascular/cardiovascular
disease/CARDIOVASCULAR-DISEASE/cerebrovascular/cerebrovascular
event/clinical trial/coronary heart disease/CORONARY
HEART-DISEASE/disease/fibrinogen/heart/heart
disease/INFECTIONS/ischemic/ISCHEMIC
STROKE/Israel/MYOCARDIAL-INFARCTION/NEW-YORK/outcome/POPU
LATION/prevention/prospective study/randomized/randomized clinical
trial/risk/risk factor/secondary/secondary prevention/severity/stroke/stroke
type/transient/transient ischemic attacks/trial/USA
Becker, D.M., Tuggle, M.B. and Prentice, M.F. (2001), Building a gateway to promote
cardiovascular health research in African-American communities: Lessons and
findings from the field. American Journal of the Medical Sciences, 322 (5),
288-293.
Abstract: African American communities traditionally mistrust academic research. This
forms a significant barrier to understanding cardiovascular risk factors in this
population, which bears an excess risk of cardiovascular disease and stroke. A
clergy/academic partnership was established to build a gateway for salient
research and for improving resources for reducing cardiovascular disease risk in
the community. From this partnership emanated the African American Family
Heart Study. People with a family history of premature coronary heart disease
(CHD) have an increased risk for the disease-as high as 12 times that of the
general population, if among siblings. Considerably less is known about the
actual remediable risk factors in African American families with premature CHD.
We initiated the Family Heart Study with a full characterization of 161
apparently healthy, unaffected 30- to 59-year-old African Americans whose
siblings were 85 African American index cases with documented premature
CHD prior to 60 years of age. We compared their risk factor values to population
reference norms obtained in the Third National Health and Nutrition
Examination Survey (NHANES III) and the National Health Interview Survey
(NHIS) for cigarette smoking. Only 13% of African American male siblings and
14% of female siblings from these families were without any major remediable
risk factors. The fact that so many siblings were at extremely high risk calls into
question the current applications by provider systems of national guidelines in
high-risk African American families. This is an easily identifiable population that
would be likely to benefit greatly from targeted screening and culturally sensitive
and appropriate treatment
Keywords: African American/African Americans/age/ATTITUDES/BLOOD
CHOLESTEROL/cardiovascular/cardiovascular disease/cardiovascular
health/cardiovascular risk/cardiovascular risk factors/CHD/cigarette
smoking/community/coronary disease/coronary heart disease/CORONARY
HEART-DISEASE/disease/disease risk/Family Heart
Study/GUIDELINES/health/heart/heart disease/high
risk/HISTORY/MANAGEMENT/MINORITY
POPULATIONS/PHYSICIANS/population/prevention/research/risk/risk
factor/risk factors/screening/SIBLINGS/SMOKING/stroke/treatment
Wiesholzer, M., Harm, F., Tomasec, G., Barbieri, G., Putz, D. and Balcke, P. (2001),
Incidence of stroke among chronic hemodialysis patients with nonrheumatic
atrial fibrillation. American Journal of Nephrology, 21 (1), 35-39.
Abstract: In general, nonrheumatic atrial fibrillation is associated with a high risk of
stroke. However, its impact on stroke in the setting of chronic hemodialysis
treatment is insufficiently addressed in the literature. We assessed the incidence
of stroke among 430 chronic hemodialysis patients and the impact of atrial
fibrillation and various other potential risk factors on stroke in a retrospective
study covering 1,111.16 patient- years. The overall incidence of stroke was
3.78/100 patient- years. Among patients with chronic atrial fibrillation without
any antithrombotic therapy besides regular dialysis anticoagulation, the stroke
incidence was 1.0/100 patient-years and did not differ statistically significantly
from the rate among patients without this arrhythmia, in whom the incidence was
2.8/100 patient-years (p = 0.220). Conversely, the overall rate of stroke incidence
per 100 patient-years was statistically significantly higher in patients with
diabetic nephropathy (6.46, p = 0.0036), age >65 years (5.90, p = 0.0001),
moderate to severe hypertension (6.8, p = 0.0017), weight gain of >2 kg between
dialyses as a marker of poor patient compliance (6.47, p = 0.0433), and
antithrombotic therapy with salicylates or warfarin (8.33, p = 0.0002), as
compared with corresponding groups without these risk factors. Our data suggest
that in contrast to other risk factors nonrheumatic atrial fibrillation in itself is not
associated with an increased risk of stroke in patients on maintenance
hemodialysis treatment. Copyright (C) 2001 S. Karger AG, Basel
Keywords: age/anticoagulation/ANTICOAGULATION/antithrombotic/antithrombotic
therapy/arrhythmia/atrial fibrillation/Austria/chronic atrial
fibrillation/EVENTS/fibrillation/GENERATION/hemodialysis/HEMOSTASIS/h
igh risk/hypertension/incidence/nonrheumatic/patient
compliance/PLATELET-AGGREGATION/PREVALENCE/PREVENTION/RE
NAL-DISEASE/risk/risk factors/risk factors of stroke/stroke/stroke
incidence/therapy/treatment/uremia/WARFARIN/weight
Ikai, T., Uematsu, M., Eun, S.S., Kimura, C., Hasegawa, C. and Miyano, S. (2001),
Prevention of secondary osteoporosis postmenopause in hemiplegia. American
Journal of Physical Medicine & Rehabilitation, 80 (3), 169-174.
Abstract: Objectives: To study secondary osteoporosis postmenopause in women with
hemiplegia and to show the therapeutic effects of etidronate and how
osteoporotic conditions relate to the activities of daily living (ADL). Design:
Eighty-one postmenopausal women with hemiplegia were admitted within 6 mo
of their first cerebrovascular accident. The bone mineral density (BMD) and
biochemical markers of bone turnover were measured at the time of admission.
Forty women (treatment group) received a 2-wk administration of etidronate.
Forty-one women (control group) were not administered etidronate. Results:
After completing a 3-mo rehabilitation program, BMD levels were remeasured.
ADL was evaluated by FIM(TM). The low ADL group had a larger decrease in
BMD than the high ADL group. For the control group, the BMD rate of change
on the paretic side of the femoral neck was -9.6%/3 mo for the low ADL group.
BMD loss was reduced significantly by the administration of etidronate for the
low ADL group. Conclusions: Results indicate that ADL corresponds to the
progression of osteoporosis in postmenopausal women with hemiplegia and that
increasing the level of ADL will reduce the progression of osteoporosis. Use of
etidronate has also been proven to have a suppressive effect on the BMD
decrease in women
Keywords: activities of daily
living/ADL/administration/BISPHOSPHONATES/BONE-MINERAL
DENSITY/cerebrovascular/cerebrovascular
accident/COLLAGEN/control/etidronate/hemiplegia/hemiplegic
women/IMMOBILIZATION/Japan/markers/MASS/osteoporosis/postmenopausa
l women/RADIOIMMUNOASSAY/rehabilitation/secondary/secondary
osteoporosis/STROKE/treatment/women
Aikimbaev, K., Guvenc, B., Canataroglu, A., Canataroglu, H., Baslamisli, F. and Oguz,
M. (2001), Value of duplex and color Doppler ultrasonography in the evaluation
of orbital vascular flow and resistance in sickle cell disease. American Journal of
Hematology, 67 (3), 163-167.
Abstract: The aim of the present study was to assess and to compare the orbital and
retinal vascular flow dynamics and resistance in patients with homozygous sickle
cell disease with controls by means of duplex and color Doppler ultrasonography.
Forty-six patients with homozygous sickle cell disease (SCD) and 20 healthy
subjects were included in the study. None of the patients had objective signs of
ocular involvement. Duplex and color Doppler ultrasonography of the
ophthalmic, short posterior ciliary, and central retinal arterial flows of the both
eyes were performed to assess peak systolic flow velocity (PSFV), end-diastolic
flow velocity (EDFV), and mean flow velocity (MFV) through entire cardiac
cycle with further calculation of resistive indices (RI) and pulsatility indices (PI).
Ophthalmic arterial flow velocities were significantly increased in patients with
SCD than in controls (P < 0.0001). Blood flow velocities of the central retinal
artery were found to be significantly reduced (P < 0.0001) while RI and PI values
were markedly higher (P < 0.02 and P <less than> 0.03) in patients with SCD
compared to controls. Reduction of retinal vascular flow velocities and increase
of retinal vascular resistance were significantly related to the mean hemoglobin
and hematocrit levels, red blood cell count, and mean corpuscular hemoglobin
volume (P < 0.009, P < 0.01, P < 0.02, and P < 0.04, respectively), in conclusion,
Doppler ultrasonography in patients with SCD who had no objective signs of
ocular involvement allowed detection enhancement of ophthalmic flow velocities,
reduced retinal flow velocities, and increased retinal vascular resistance, which
are associated with haematological features. (C) 2001 Wiley-Liss, Inc
Keywords:
ANEMIA/arterial/AUTO-REGULATION/cardiac/CHILDREN/detection/disease
/Doppler/Doppler
ultrasonography/duplex/ENDOTHELIAL-CELLS/ERYTHROCYTES/evaluatio
n/flow velocity/hemoglobin/NEW-YORK/ophthalmic artery/PROLIFERATIVE
RETINOPATHY/retinal artery/RETINAL BLOOD-FLOW/sickle cell
anaemia/sickle cell disease/STROKE PREVENTION
TRIAL/ultrasonography/vascular
Pearson, T.A. (2001), Capacity for research in minority health: The need for
infrastructure plus will. American Journal of the Medical Sciences, 322 (5),
279-283.
Abstract: Cardiovascular mortality has continued to decline, but racial disparities in
cardiovascular diseases (CVD) continue to grow. To build the capacity to
address these racial disparities, two things will be required. First, a research and
policy infrastructure must be in place to provide guidance on what to do and how
to do it. Second, the will to implement and activate this infrastructure must be
present at the community and policymaking levels. The Jackson Heart Study is
an example of a research infrastructure with the economic resources, scientific
expertise, and technical manpower required to monitor, organize, assess, and
follow a cohort of individuals over time to study the burden, natural history,
predictive factors, and level of care for CVD in an African American community.
The creation of will within the community for CVD research may require
additional strategies than in the majority community, such as community
organization and local policy development. These additional efforts at the
community level should create a fertile environment to develop research and,
ultimately, test strategies for reducing national disparities in cardiovascular
health
Keywords: African American/cardiovascular/cardiovascular disease/cardiovascular
diseases/cardiovascular
health/community/DECLINE/development/diseases/health/HEART-DISEASE
MORTALITY/history/manpower/minority
health/mortality/prevention/research/STROKE
MORTALITY/UNITED-STATES
Mosca, L., Barrett-Connor, E., Wenger, N.K., Collins, P., Grady, D., Kornitzer, M.,
Moscarelli, E., Paul, S., Wright, T.J., Helterbrand, J.D. and Anderson, P.W.
(2001), Design and methods of the raloxifene use for the heart (RUTH) study.
American Journal of Cardiology, 88 (4), 392-395.
Abstract: Raloxifene is a selective estrogen receptor modulator that lowers total and
low-density lipoprotein (LDL) cholesterol, reduces the risk of vertebral fracture,
and is associated with a reduced incidence of invasive breast cancer in
postmenopausal women with osteoporosis. The Raloxifene Use for The Heart
(RUTH) trial is designed to determine whether raloxifene 60 mg/day compared
with placebo: (1) lowers the risk of the coronary events (coronary death, nonfatal
myocardial infarction [MI], or hospitalized acute coronary syndromes other than
MI); and (2) reduces the risk of invasive breast cancer in women at risk for a
major coronary event. RUTH is a double-blind, placebo-controlled, randomized
clinical trial of 10,101 postmenopausal women aged greater than or equal to 55
years from 26 countries. Women are eligible for randomization if they are
postmenopausal and have documented coronary heart disease (CHD), peripheral
arterial disease, or multiple risk factors for CHD. Use of estrogen within the
previous 6 months is an exclusion factor. The study will be terminated after a
minimum of 1,670 participants experience a primary coronary end point.
Secondary end points include cardiovascular death, myocardial revascularization,
noncoronary arterial revascularization, stroke, all-cause hospitalization, all-cause
mortality, all breast cancers, clinical fractures, and venous thromboembolic
events, in addition to the individual components of the composite primary
coronary end point. RUTH will provide important information about the
risk-benefit ratio of raloxifene in preventing acute coronary events and invasive
breast cancer, as well as information about the natural history of CHD in women
at risk of major coronary events. (C) 2001 by Excerpta Medica, Inc
Keywords: acute/acute coronary syndromes/aged/all-cause mortality/arterial/breast
cancer/cancer/cardiovascular/CHD/cholesterol/clinical
trial/CLINICAL-TRIALS/coronary heart
disease/death/DISEASE/ESTROGEN/fractures/HEALTHY
POSTMENOPAUSAL WOMEN/heart/heart disease/history/HORMONE
REPLACEMENT THERAPY/hospitalization/incidence/infarction/LDL/low
density lipoprotein/mortality/myocardial/myocardial
infarction/NEW-YORK/osteoporosis/peripheral arterial
disease/PLACEBO/postmenopausal
women/PREVENTION/primary/randomized/randomized clinical
trial/RANDOMIZED TRIAL/revascularization/RISK/risk
factors/stroke/thromboembolic events/trial/use/women
Callahan, A. (2001), Cerebrovascular disease and statins: A potential addition to the
therapeutic armamentarium for stroke prevention. American Journal of
Cardiology, 88 (7B), 33J-37J.
Abstract: Cerebrovascular disease is the leading cause of disability in Western societies.
In the United States, it has been estimated that a stroke occurs every 53 seconds.
Consequently, the societal costs attributable to cerebrovascular disease are
immense and encourage the medical community to seek new therapies that can
reduce stroke's frequency and impact. Although serum lipid levels have not been
shown to act as a surrogate marker for stroke, in landmark lipid-lowering trials,
statin therapy has been associated with reductions in the incidence of ischemic
stroke in patient populations with manifest ischemic heart disease. This
observation is supported by a recently published meta-analysis of statin trials that
reported an average reduction of about 30% in the incidence of cerebrovascular
disease. However, to date, statin studies have only been conducted in patients
with, or at high risk for coronary artery disease, who are not truly representative
of the overall stroke population. The ongoing Stroke Prevention by Aggressive
Reduction of Cholesterol Levels (SPARCL) trial has been designed to
prospectively evaluate the benefits of aggressive lipid-lowering therapy on
cerebrovascular events in patients who have had a previous stroke or transient
ischemic attack, but who have no prior history of coronary artery disease. (C)
2001 by Excerpta Medica, Inc
Keywords: cerebrovascular/cerebrovascular
disease/CHOLESTEROL/community/coronary artery
disease/costs/disability/disease/heart/heart disease/high
risk/history/incidence/ischemic/ischemic heart disease/ischemic stroke/lipid
lowering/medical/meta-analysis/NEW-YORK/population/PRAVASTATIN/prev
ention/REDUCTASE
INHIBITORS/risk/serum/SIMVASTATIN/statin/statins/stroke/stroke
prevention/therapy/transient/transient ischemic attack/trial/trials/United States
O'Connor, C.M., Gattis, W.A., Hellkamp, A.S., Langer, A., Larsen, R.L., Harrington,
R.A., Berkowitz, S.D., O'Gara, P.T., Kopecky, S.L., Gheorghiade, M., Daly, R.,
Califf, R.M. and Fuster, V. (2001), Comparison of two aspirin doses on ischemic
stroke in post- myocardial infarction patients in the warfarin (Coumadin) Aspirin
Reinfarction Study (CARS). American Journal of Cardiology, 88 (5), 541-546.
Abstract: The Coumadin Aspirin Reinfarction Study demonstrated that combination
treatment with fixed dose warfarin (I or 3 mg) + aspirin 80 mg was not superior
to aspirin 160 mg alone after myocardial infarction for reducing nonfatal
reinfarction, nonfatal stroke, and cardiovascular death. In this analysis, we
examined the importance of aspirin dose in the protection against the secondary
end point of ischemic stroke. The comparison arms for this analysis were
warfarin I mg + aspirin 80 mg versus aspirin 160 mg. In the Coumadin Aspirin
Reinfarction Study, 2,028 patients were randomized to aspirin 80 mg plus
warfarin 1 mg, and 3,393 were randomized to aspirin 160 mg alone. A predictive
model for ischemic stroke was developed using the Cox proportional-hazards
model. A reduced Cox proportional-hazards model was developed to test for the
effect of aspirin dose on ischemic stroke in predefined subgroups. The incidence
of ischemic stroke was lower in patients treated with aspirin 160 mg than in
patients treated with aspirin 80 mg + warfarin I mg (0.6% vs 1.1%; p = 0.0534).
Age, previous stroke or transient ischemic attack, and aspirin dose were
independent predictors of ischemic stroke. In addition, the highest risk patients,
those with Q-wave myocardial infarction and male patients, appeared to receive
greater benefit from aspirin It 60 mg than from aspirin 80 mg + warfarin I mg.
The results of this secondary analysis suggest that aspirin 160 mg is more
effective than aspirin 80 mg + warfarin 1 mg in preventing ischemic stroke in
post-myocardial infarction patients. (C) 2001 by Excerpta Medica, Inc
Keywords:
ACID/aspirin/cardiovascular/combination/death/incidence/infarction/ischemic/is
chemic stroke/myocardial/myocardial
infarction/NEW-YORK/predictors/protection/randomized/risk/secondary/SECO
NDARY PREVENTION/stroke/transient/transient ischemic
attack/treatment/TRIAL/warfarin
Rodriguez, C., Calle, E.E., Patel, A.V., Tatham, L.M., Jacobs, E.J. and Thun, M.J.
(2001), Effect of body mass on the association between estrogen replacement
therapy and mortality among elderly US women. American Journal of
Epidemiology, 153 (2), 145-152.
Abstract: In observational studies, estrogen replacement therapy is associated with
decreased cardiovascular disease rates and increased breast cancer rates. Recent
evidence suggests that the impact of estrogen use on disease outcomes may vary
by body mass. In a prospective study of 290,827 postmenopausal US women
with no history of cancer or cardiovascular disease at enrollment in 1982, the
authors examined the association between postmenopausal estrogen use and
all-cause, coronary heart disease, stroke, all-cancer, and breast cancer death rates
and whether these associations differed by body mass. After 12 years of
follow-up, results from Cox proportional hazards models showed that all-cause
death rates were lower among baseline estrogen users than never users (rate ratio
(RR) = 0.82, 95% confidence interval (CI): 0.78, 0.87). The lowest relative risk
was found for coronary heart disease (RR = 0.66, 95% Cl: 0.58, 0.77). The
inverse association between estrogen use and coronary heart disease mortality
was strongest for thin women (body mass index <22 kg/m(2)) (RR = 0.49, p for
interaction = 0.02). Breast cancer mortality did not increase with estrogen use
overall, and no increased risk was observed for thin or heavy women. in this
population, the reduction in coronary heart disease mortality among estrogen
users was greatest for thinner women. Additional studies are needed to confirm
or refute these results
Keywords: body mass index/breast
cancer/BREAST-CANCER/cancer/cardiovascular/cardiovascular
disease/cardiovascular diseases/coronary heart disease/death/DISEASE/disease
mortality/elderly/estrogen/estrogen replacement therapy/FATAL
COLON-CANCER/heart/heart
disease/history/interaction/mortality/observational
studies/population/POSTMENOPAUSAL
WOMEN/PREVENTION/PROSPECTIVE COHORT/prospective study/relative
risk/RISK/stroke/therapy/US/use/USERS/women
Weigner, M.J., Thomas, L.R., Patel, U., Schwartz, J.G., Burger, A.J., Douglas, P.S.,
Silverman, D.I. and Manning, W.J. (2001), Early cardioversion of atrial
fibrillation facilitated by transesophageal echocardiography: Short-term safety
and impact on maintenance of sinus rhythm at 1 year. American Journal of
Medicine, 110 (9), 694-702.
Abstract: BACKGROUND: For patients presenting with atrial fibrillation of only a few
weeks duration, the use of transesophageal echocardiography offers the
opportunity to markedly abbreviate the duration of atrial fibrillation before
cardioversion. We sought to determine if the shorter duration of atrial fibrillation
allowed by a transesophageal echocardiography strategy had an impact on the
recurrence of atrial fibrillation and prevalence of sinus rhythm during the first
year following cardioversion. METHODS: Transesophageal echocardiography
was attempted in 539 patients (292 men, 247 women; 71.6 +/- 13.0 years.) with
atrial fibrillation greater than or equal to2 days (66.1% <3 weeks) or of unknown
duration before elective cardioversion of atrial fibrillation. Therapeutic
anticoagulation at the time of transesophageal echocardiography was present in
94.6% of patients, and 73.4% of subjects were discharged on warfarin.
RESULTS: Atrial thrombi were identified in 70 (13.1%) patients. Successful
cardioversion in 413 patients without evidence of atrial thrombi was associated
with clinical thromboembolism in 1 patient (0.24%, 95% confidence interval:
0.0-0.8%). In patients with atrial fibrillation <3 weeks at the time of
cardioversion (a duration incompatible with conventional therapy of 3 to 4 weeks
of warfarin before cardioversion), the 1-year atrial fibrillation recurrence rate
was lower (41.1% vs. 57.9%, P <0.01), and the prevalence of sinus rhythm at 1
year was increased (65.8% vs. 51.3%, P <0.03). No other clinical or
echocardiographic index was associated with recurrence of atrial fibrillation or
sinus rhythm at 1 year. CONCLUSIONS: Early cardioversion facilitated by
transesophageal echocardiography has a favorable safety profile and provides the
associated benefit of reduced recurrence of atrial fibrillation for patients in whom
the duration of atrial fibrillation is <3 weeks. Am J Med. 2001;110:694-702. (C)
2001 by Excerpta Medica, Inc
Keywords: anticoagulation/atrial
fibrillation/cardioversion/COMPLICATIONS/echocardiography/ELECTRICAL
CARDIOVERSION/fibrillation/FLUTTER/Israel/men/NEW-YORK/PREDICT
ORS/prevalence/PREVENTION/PROLONGED
ANTICOAGULATION/recurrence/safety/sinus
rhythm/STROKE/therapy/THROMBI/thromboembolism/transesophageal
echocardiography/TRIAL/use/WARFARIN/women
White, W.B., Faich, G., Whelton, A., Maurath, C., Ridge, N.J., Verburg, K.M., Geis,
G.S. and Lefkowith, J.B. (2002), Comparison of thromboembolic events in
patients treated with Celecoxib, a cyclooxygenase-1 specific inhibitor, versus
Ibuprofen or Diclofenac. American Journal of Cardiology, 89 (4), 425-430.
Abstract: It has been hypothesized that cyclooxgenase 2 specific inhibitors may increase
the risk of cardiovascular (CV) thromboembolic events because of their
inhibition of vascular prostacyclin synthesis and lack of an effect on platelet
thromboxane A(2) production and aggregation. Thus, we analyzed the data for
celecoxib and nonsteroidal anti-inflammatory drugs (NSAIDs) from the
Celecoxib Long-term Arthritis Safety Study to determine the incidences of
serious CV thromboembolic events. This trial included 3,987 persons
randomized to celecoxib 400 mg twice daily (2,320 person-years of exposure)
and 3,981 persons randomized to either ibuprofen 800 mg 3 times daily or
diclofenac 75 mg twice daily (2,203 person-years). Because acetylsalicylic acid
(ASA) use for CV risk prophylaxis (less than or equal to325 mg/day) was
permitted, separate analyses were performed for all patients and those not taking
ASA. The incidences of serious CV thromboembolic events (myocardial
infarction, stroke, CV deaths, and peripheral events) were similar, and not
significantly different, between celecoxib and NSAID comparators (combined or
individually) for all patients as well as the subgroup of patients not taking ASA.
This observation was true both for all serious CV thromboembolic events, as
well as for individual events. No increase in myocardial infarction was apparent,
even in patients not taking ASA who were candidates for secondary prophylaxis
for myocardial infarction. The relative risks for celecoxib versus NSAIDs for
serious CV thromboembolic events were 1.1 for all patients and 1.1 for the
subgroup of patients not taking ASA (95% confidence interval 0.7 to 1.6 and 0.6
to 1.9, respectively). In addition, the incidences of adverse CV events such as
hypertension, edema, and congestive heart failure were similar to, or
significantly lower than, NSAID comparators regardless of the use of ASA. Thus,
these analyses demonstrate no increased risk of serious CV thromboembolic
events associated with celecoxib compared with conventional NSAIDs and
therefore do not support the hypothesis of a class adverse effect of
cyclooxgenase 2 specific inhibitors on the CV system. (C) 2002 by Excerpta
Medica, Inc
Keywords: acetylsalicylic acid/aggregation/ASPIRIN/cardiovascular/congestive heart
failure/CT/DISEASE/drugs/GASTROINTESTINAL TOXICITY/heart/heart
failure/hypertension/incidences/INDOBUFEN/infarction/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/NEW-YORK/NONSTEROIDAL
ANTIINFLAMMATORY DRUGS/platelet/PRIMARY
PREVENTION/prophylaxis/PROSTACYCLIN/randomized/RANDOMIZED
CONTROLLED
TRIAL/RHEUMATOID-ARTHRITIS/risk/risks/secondary/stroke/thromboembo
lic events/thromboxane/thromboxane A(2)/trial/use/vascular
Okuguchi, T., Osanai, T., Fujiwara, N., Kato, T., Metoki, N., Konta, Y. and Okumura, K.
(2002), Effect of losartan on nocturnal blood pressure in patients with stroke:
Comparison with angiotensin converting enzyme inhibitor. American Journal of
Hypertension, 15 (11), 998-1002.
Abstract: Background: Treatment of nocturnal hypertension has been reported to be
beneficial for primary and secondary prevention of stroke. We compared the
effects of angiotensin 11 antagonist (losartan) and angiotensin converting
enzyme inhibitor (quinapril) on nocturnal blood pressure (BP) and sympathetic
nervous activity in patients with hypertension and stroke. Methods: According to
a prospective, randomized, cross-over design, 30 hypertensive patients with a
previous history of stroke (25 hemorrhage, 5 infarction) were assigned randomly
to receive losartan (50 mg) or quinapril (10 mg) once daily for 4 weeks. The
patients were switched to the alternative regimen for an additional 4-week period.
In the last week of each treatment, 24-h ambulatory BP monitoring was
performed every 30 min, and 24-h urine was collected for the measurement of
catecholamine. Results: Neither systolic nor diastolic BP during daytime differed
between losartan and quinapril treatments, but those during nighttime were lower
with losartan treatment than with quinapril treatment. The nocturnal decreases in
systolic and diastolic BP were both greater with losartan treatment than with
quinapril treatment (systolic BP: 6.1% +/- 5.9% v 2.5% +/- 6.9%, diastolic BP:
6.4% +/- 6.5% v 3.3% +/- 7.8%, both P < .05). The nocturnal decrease in urinary
norepinephrine excretion was greater with losartan treatment than with quinapril
treatment (52.8% +/- 9.7% v 42.8% +/- 17.2%, P < .05). Conclusions: Losartan
enhances the nocturnal decrease in ambulatory BP compared with that of
quinapril in patients with a previous history of stroke presumably by way of the
suppression of nocturnal sympathetic nervous activity. Am J Hypertens
2002;15:998-1002 (C) 2002 American Journal of Hypertension, Ltd
Keywords: angiotensin/angiotensin converting enzyme inhibitor/angiotensin II
antagonist/blood pressure/design/FLOW
AUTOREGULATION/hemorrhage/history/HYPERTENSION/infarction/Japan/l
osartan/monitoring/NEW-YORK/nocturnal/nocturnal blood
pressure/prevention/primary/primary and secondary
prevention/randomized/secondary/secondary prevention/stroke/sympathetic
nervous activity/treatment
Thomas, J., Straus, W.L. and Bloom, B.S. (2002), Over-the-counter nonsteroidal
anti-inflammatory drugs and risk of gastrointestinal symptoms. American
Journal of Gastroenterology, 97 (9), 2215-2219.
Abstract: Objective: Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the
most commonly used medications. Although much is known about prescription
NSAIDs and risk of GI side effects, little is known about over-the-counter (OTC)
NSAIDs and their risk of GI side effects. The aim of this study was to estimate
use of OTC NSAIDs, GI side effects, and professional and self- care for these
side effects. Methods: We conducted a telephone survey of an age-stratified U.S.
random sample of 535 persons at least 40 yr old, who used an OTC NSAID for 4
of the previous 7 days, and a matched comparison population of 1068 persons
who used no NSAID within the previous 30 days. We measured current use of
OTC NSAIDs, GI symptoms, diagnoses and their treatment, and prescription and
OTC GI medications. Results: The most commonly used OTC NSAID was
aspirin (alone or in combination compounds). Prevention of myocardial
infarction or stroke was the most common reason for use (43.2%), followed by
all forms of pain relief (44.2%) and relief of arthritis symptoms (24.5%). NSAID
users were twice as likely as nonusers to report GI side effects (19.6% vs 9.5%,
p=0.0001), and more than twice as likely to use an OTC GI medication when
they had GI symptoms (46.7% vs 20.8%, p=0.001). Conclusions: OTC NSAIDs
are not a benign medication even at low dosages. Physicians may be unaware
that patients self-medicate with OTC NSAIDs and for GI side effects with
additional OTC GI medications. Therefore, physicians should routinely ask
patients about all forms of self-treatment
Keywords: ANTIINFLAMMATORY
DRUGS/aspirin/combination/drugs/infarction/myocardial/myocardial
infarction/NEW-YORK/pain/population/risk/stroke/survey/symptoms/treatment/
use
Sleight, P. (2002), Angiotensin II and trials of cardiovascular outcomes. American
Journal of Cardiology, 89 (2A), 11A-16A.
Abstract: Proven cardiovascular benefit from angiotensin-converting enzyme (ACE)
inhibition is a cornerstone of evidence-based medicine. The first study to show
dramatic benefits from ACE inhibition was the Cooperative North Scandinavian
Enalapril Survival Study (CONSENSUS-I), in which a 31% decrease in the rate
of death was observed in patients with severe heart failure at the end of 1 year of
enalapril treatment (p = 0.001). This result led to large long-term
studies-including Survival and Ventricular Enlargement (SAVE), Acute
Infarction Ramipril Efficacy (AIRE), Trandolapril Cardiac Evaluation (TRACE),
and Study of Left Ventricular Dysfunction (SOLVD)- which verified that ACE
inhibition decreases heart failure, myocardial infarction (MI), and mortality, and
that striking benefit could be observed within 30 days. Short-term studies of
patients in the acute phase of a heart attack verified that ACE inhibition provided
rapid benefits. A meta-analysis of short- term (up to 8 weeks) studies of ACE
inhibition (including CONSENSUS-II, Gruppo Italiano per to Studio della
Sopravvivenza nell'Infarto Miocardico [GISSI]-3, International Study of Infarct
Survival [ISIS]-4, and the Chinese Captopril Study [CCS]-1) demonstrated that
post-MI risk was reduced by 10% within the first day of treatment. The
immediacy of the benefit suggested that ACE inhibition not only improved
cardiovascular function in failing hearts but also affected important mechanisms
in patients without overt heart failure. Effects on more general mechanisms of
heart disease suggested that patients with problems other than hypertension or
heart failure might benefit from ACE inhibitors. The Heart Outcomes Prevention
Evaluation (HOPE) study investigated the hypothesis that ACE inhibition would
confer benefits to patients who were at high risk for cardiovascular events, but
who were without left ventricular dysfunction or heart failure. Long-term
reductions in MI, stroke, cardiac arrest, and heart failure, as well as
improvements in mortality, were observed in this population after treatment with
ACE inhibitors. Substudies of the HOPE study revealed that ACE inhibition
reduced progression of atherosclerosis and improved myocardial remodeling.
Taken together, these studies provide evidence that supports treatment of a broad
population of patients at risk for cardiovascular events with ACE inhibitors. The
next step is to combine ACE inhibition with other treatments to maximize patient
benefit. The Ongoing Telmisartan Alone and in combination with Ramipril
Global Endpoint Trial (ONTARGET) will compare the efficacy of an ACE
inhibitor (ramipril) with an angiotensin receptor blocker (telmisartan), and
determine whether these treatments in combination will further reduce morbidity
and mortality from cardiovascular disease. (C) 2002 by Excerpta Medica, Inc
Keywords: ACE inhibition/ACE inhibitor/ACE inhibitors/acute/angiotensin/angiotensin
receptor
blocker/atherosclerosis/benefits/blocker/cardiac/cardiovascular/cardiovascular
disease/cardiovascular
events/Chinese/combination/death/disease/enalapril/England/heart/heart
disease/heart failure/HEART-FAILURE/high
risk/hypertension/infarction/INHIBITOR/left ventricular/left ventricular
dysfunction/mechanisms/meta-analysis/morbidity/morbidity and
mortality/MORTALITY/myocardial/myocardial
infarction/NEW-YORK/outcomes/population/progression/Ramipril/risk/stroke/T
HERAPY/treatment/trials
Agmon, Y., Khandheria, B.K., Meissner, I., Schwartz, G.L., Petterson, T.M., O'Fallon,
W.M., Whisnant, J.P., Wiebers, D.O. and Seward, J.B. (2002), Relation of
coronary artery disease and cerebrovascular disease with atherosclerosis of the
thoracic aorta in the general population. American Journal of Cardiology, 89 (3),
262-267.
Abstract: The association between clinical coronary artery disease, cerebrovascular
disease, and aortic atherosclerosis has not been examined in the general
population. Transesophageal echocardiography was performed in 581 subjects, a
random sample of the Olmsted County (Minnesota) population aged greater than
or equal to45 years, participating in the Stroke Prevention: Assessment of Risk in
a Community (SPARC) study. The frequency and severity of atherosclerosis of
the thoracic aorta were determined in the population and the association between
clinical coronary artery disease, cerebrovascular disease, and aortic
atherosclerosis was examined. Previous myocardial infarction, angina pectoris,
and coronary artery bypass surgery were significantly associated with aortic
atherosclerosis, adjusting for age and gender (p less than or equal to 0.01).
Among subjects with atherosclerosis, these manifestations were associated with
complex atherosclerosis (plaques >4-mm thick, ulcerated plaques, or mobile
debris), adjusting for age and gender (p <0.05). Age, smoking, pulse pressure,
previous myocardial infarction (odds ratio [OR] 4.67; 95% confidence interval
[CI] 1.42 to 15.40), and coronary artery bypass surgery (OR 5.12; 95% CI 1.01
to 26.01) were independently associated with aortic atherosclerosis. Among
subjects with atherosclerosis, age, smoking, pulse pressure, hypertension
treatment, and coronary artery disease (OR 2.50; 95% CI 1.18 to 5.30) were
independently associated with complex atherosclerosis. Weak associations were
observed between previous ischemic stroke, transient ischemic attack, and aortic
atherosclerosis, associations that were not significant after age- and
gender-adjustment (p >0.2). Thus, coronary artery disease is strongly associated
with aortic atherosclerosis and complex atherosclerosis in the general population.
Cerebrovascular disease is weakly associated with aortic atherosclerosis, thereby
questioning the overall importance of aortic atherosclerosis in the pathogenesis
of cerebrovascular events in the general population. (C) 2002 by Excerpta
Medica, Inc
Keywords: age/aged/angina/angina
pectoris/aorta/ARCH/ATHEROMAS/atherosclerosis/ATRIAL-FIBRILLATION
/bypass/bypass surgery/cerebrovascular/cerebrovascular disease/coronary artery
bypass/coronary artery disease/disease/echocardiography/gender/HIGH
BLOOD-PRESSURE/hypertension/hypertension
treatment/infarction/ischemic/ISCHEMIC STROKE/myocardial/myocardial
infarction/NEW-YORK/pathogenesis/PLAQUE/population/PREVALENCE/puls
e pressure/RISK-
FACTORS/severity/smoking/stroke/surgery/TRANSESOPHAGEAL
ECHOCARDIOGRAPHY/transient/transient ischemic
attack/treatment/VASCULAR EVENTS
Kong, D.F., Hasselblad, V., Kandzari, D.E., Newby, L.K. and Califf, R.M. (2002),
Seeking the optimal aspirin dose in acute coronary syndromes. American Journal
of Cardiology, 90 (6), 622-+.
Abstract: We reexamined the Antiplatelet Trialists' Collaboration data (11 studies) to
evaluate optimal dosing of aspirin for secondary prevention after acute coronary
syndromes, while adjusting for patient population and temporal trends. Although
aspirin reduced the risks of mortality (odds ratio, 0.82; 95% confidence interval,
0.71 to 0.96), death or myocardial infarction, and death, infarction, or stroke,
unadjusted analysis suggested greater benefit in unstable angina versus
myocardial infarction and with higher versus lower aspirin doses, highlighting
the need for larger, randomized comparisons of aspirin dosing in these patients
Keywords: acute/acute coronary
syndromes/ANGINA/aspirin/death/infarction/mortality/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/NEW-YORK/population/prevention/
randomized/secondary/secondary prevention/stroke/trends/TRIAL/unstable
angina
Disler, P., Hansford, A., Skelton, J., Wright, P., Kerr, J., O'Reilly, J., Hepworth, J.,
Middleton, S. and Sullivan, C. (2002), Diagnosis and treatment of obstructive
sleep apnea in a stroke rehabilitation unit - A feasibility study. American Journal
of Physical Medicine & Rehabilitation, 81 (8), 622-625.
Abstract: Obstructive sleep apnea can be diagnosed in approximately 60% of stroke
survivors in the postacute period and has been found to be associated with
increased mortality and a worse functional outcome at 3 and 12 mo after
discharge. In this study, 38 patients undergoing rehabilitation after stroke
underwent sleep studies by using the AutoSet Portable II Plus device; obstructive
sleep apnea was found in 18 of the patients, and five consecutively diagnosed
patients were treated on the ward with nasal continuous positive airway pressure.
The research has shown that it is feasible to routinely implement a diagnostic and
therapeutic approach to sleep apnea on the rehabilitation ward, which is hoped to
have a positive influence on mortality, functional outcome, and secondary
prevention
Keywords: Australia/AUTOSET/BRAIN INFARCTION/continuous positive airway
pressure/diagnostic/DISEASE/hemiplegia/mortality/outcome/POLYSOMNOGR
APHY/prevention/rehabilitation/research/RISK FACTOR/secondary/secondary
prevention/sleep/sleep apnea/stroke/treatment
Stewart, S., Hart, C.L., Hole, D.J. and McMurray, J.J.V. (2002), A population-based
study of the long-term risks associated with atrial fibrillation: 20-year follow-up
of the Renfrew/Paisley study. American Journal of Medicine, 113 (5), 359-364.
Abstract: PURPOSE: To describe the effect of atrial fibrillation on long- term morbidity
and mortality. SUBJECTS AND METHODS: The Renfrew/Paisley Study
surveyed 7052 men and 8354 women aged 45- 64 years between 1972 and 1976.
All hospitalizations and deaths occurring during the subsequent 20 years were
analyzed by the presence or absence of atrial fibrillation at baseline. Lone atrial
fibrillation was defined in the absence of other cardiovascular signs or symptoms.
Cox proportional hazards models were used to adjust for age and cardiovascular
conditions. RESULTS: After 20 years, 42 (89%) of the 47 women with atrial
fibrillation had a cardiovascular event (death or hospitalization), compared with
2276 (27%) of the 8307 women without this arrhythmia. Among men, 35 (66%)
of 53 with atrial fibrillation had an event, compared with 3151 (45%) of 6999
without atrial fibrillation. In women, atrial fibrillation was an independent
predictor of cardiovascular events (rate ratio [RR] = 3.0; 95% confidence interval
[CI]: 2.1-4.2), fatal or nonfatal strokes (RR = 3.2; 95% CI: 1.0-5.0), and heart
failure (RR = 3.4; 95% CI: 1.9-6.2). The rate ratios among men were 1.8 (95%
CI: 1.3-2.5) for cardiovascular events, 2.5 (95% CI: 1.3- 4.8) for strokes, and 3.4
(95% CI: 1.7-6.8) for heart failure. Atrial fibrillation was an independent
predictor of all-cause mortality in women (RR = 2.2; 95% CI: 1.5-3.2) and men
(RR = 1.5; 95% CI: 1.2-2.2). However, lone atrial fibrillation (which occurred in
15 subjects) was not associated with a statistically significant increase in, either
cardiovascular events (RR = 1.5; 95% CI: 0.6-3.6) or mortality (RR = 1.8; 95%
CI: 0.9-3.8). CONCLUSION: Atrial fibrillation is associated with an increased
long-term risk of stroke, heart failure, and all-cause mortality, especially in
women. (C) 2002 by Excerpta Medica, Inc
Keywords: age/aged/all-cause mortality/arrhythmia/atrial
fibrillation/CARDIOMYOPATHY/cardiovascular/cardiovascular
event/cardiovascular events/death/DISEASE/fibrillation/heart/heart
failure/HEART-FAILURE/hospitalization/men/morbidity/MORTALITY/NATU
RAL-HISTORY/NEW-YORK/population-based/PREVALENCE/PREVENTIO
N/PROGNOSIS/risk/SCOTLAND/STROKE/symptoms/women
Yusuf, S. (2002), From the Hope to the Ontarget and the Transcend Studies: Challenges
in Improving Prognosis. American Journal of Cardiology, 89 (2A), 18A-25A.
Abstract: The Heart Outcomes Prevention Evaluation (HOPE) study conclusively
demonstrated that ramipril, an angiotensin- converting enzyme (ACE) inhibitor,
reduces the risk of cardiovascular death, myocardial infarction (MI), and death in
patients at risk for cardiovascular events but without heart failure. The Study to
Evaluate Carotid Ultrasound Changes in Patients Treated with Ramipril and
Vitamin E (SECURE) substudy demonstrated that ramipril also reduced
atherosclerosis. These results suggest that the renin-angiotensin system (RAS)
has a more important role in the development and progression of atherosclerosis
than previously believed, and they indicate the need for further clinical studies to
define the range of benefits available from modifying the RAS. Achieving
maximum benefit may require treatment with both an ACE inhibitor and an
angiotensin II type-1 receptor blocker (ARB). The Randomized Evaluation of
Strategies for Left Ventricular Dysfunction (RESOLVD) study indicated that
combining an ACE inhibitor with an ARB decreased blood pressure and
improved the ejection fraction more than treatment with either drug alone in
patients with congestive heart failure. The Valsartan in Heart Failure Trial
(Val-HeFT) showed that the combination of an ACE inhibitor and an ARB
reduced hospitalization for heart failure in patients with congestive heart failure
by 27.5%, although no decrease in all-cause mortality was observed. The
Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint
Trial (ONTARGET) is a large, long-term study (23,400 patients, 5.5 years). It
will compare the benefits of ACE inhibitor treatment, All treatment, and
treatment with an ACE inhibitor and All together, in a study population with
established coronary artery disease, stroke, peripheral vascular disease, or
diabetes with end-organ damage. Patients with congestive heart failure will be
excluded. In a parallel study, patients unable to tolerate an ACE inhibitor will be
randomized to receive telmisartan or placebo (the Telmisartan Randomized
Assessment Study in ACE-I Intolerant Patients with Cardiovascular Disease
[TRANSCEND]). The primary endpoint for both trials is a composite of
cardiovascular death, MI, stroke, and hospitalization for heart failure. Secondary
endpoints will investigate reductions in the development of diabetes mellitus,
nephropathy, dementia, and atrial fibrillation. These 2 trials are expected to
provide new insights into the optimal treatment of patients at high risk of
complications from atherosclerosis. (C) 2002 by Excerpta Medica, Inc
Keywords: ACE inhibitor/all-cause mortality/angiotensin/angiotensin
II/atherosclerosis/atrial/atrial fibrillation/benefits/blocker/blood
pressure/cardiovascular/cardiovascular events/clinical
studies/combination/complications/congestive heart failure/coronary artery
disease/death/dementia/development/diabetes/diabetes
mellitus/disease/drug/fibrillation/heart/heart failure/high
risk/hospitalization/infarction/mortality/myocardial/myocardial
infarction/nephropathy/NEW-YORK/peripheral vascular
disease/population/primary/progression/ramipril/randomized/renin angiotensin
system/renin-angiotensin system/risk/stroke/treatment/trials/vascular/vascular
disease
Morse, J.M. (2002), Enhancing the safety of hospitalization by reducing patient falls.
American Journal of Infection Control , 30 (6), 376-380.
Abstract: The iatrogenic nature of hospitalization places patients at risk of falling, injury
and death. In this article, the major principles of providing protective and
preventive interventions are outlined. The principles are the establishment of a
multifaceted fall prevention program that targets fall interventions according to
each etiologic factor; the recognition that fall protective and prevention
interventions are distinct and serve a different function; the use of the fall
monitoring system comprehensively; the creation of a clinical nurse specialist
position, responsible for fall intervention; and a conscious and individualized
approach to fall prevention. The process and problems of the varying nature of
providing fall protection and fall prevention are discussed: for example, use of a
side rail as a protective strategy may be successful with one patient but
considered a hazard when used with a different patient
Keywords: death/hospitalization/monitoring/OLDER
ADULTS/prevention/PRONE/protection/RISK/safety/STRENGTH/STROKE
REHABILITATION/use
Ruilope, L.M., Coca, A., Volpe, M. and Waeber, B. (2002), ACE inhibition and
cardiovascular mortality and morbidity in essential hypertension: The end of the
search or a need for further investigations? American Journal of Hypertension,
15 (4), 367-371.
Abstract: Scientific evidence currently available supports the concept that
renin-angiotensin blockade with angiotensin converting enzyme inhibitors as a
first-line treatment exhibits in arterial hypertension beneficial effects in the
prevention of mortality and morbidity comparable to those achieved with
diuretics and beta-blockers. In addition, the renin-angiotensin blockade has also
proved to be beneficial in the secondary prevention of several complications of
hypertensive disease such as after myocardial infarction and congestive heart
failure, as well as in the prevention of the incidence of type 2 diabetes, and the
progression of diabetic and nondiabetic nephropathy. In this later regard, recent
evidence with angiotensin II receptor antagonists in reducing the progression of
nephropathy in type 2 diabetes strongly confirms that antagonism of the
renin-angiotensin system is an effective approach to cardiovascular and renal
disease. Finally, the renin-angiotensin blockade in high-risk patients may reduce
cardiovascular mortality independently of the effect on blood pressure (BP). The
effect of other antihypertensive drugs on cardiovascular risk in patients with
high-normal BP should be investigated to establish whether they exhibit a
comparable effect or whether there is a class-related benefit of drugs blocking
the renin-angiotensin system. Such a strategy could also be encouraged to design
future interventional studies with the newer classes of compounds (angiotensin II
AT(1)-receptor antagonists, vasopeptidase inhibitors. endothelin antagonists),
which would have the additional potential advantage of providing information
more easily transferable to large-scale clinical practice. (C) 2002 American
Journal of Hypertension, Ltd
Keywords: ACE inhibition/angiotensin/angiotensin converting enzyme
inhibitors/angiotensin II/antihypertensive drugs/antihypertensive
therapy/arterial/arterial hypertension/beta-blockers/blood
pressure/BLOOD-PRESSURE/cardiovascular/cardiovascular
mortality/cardiovascular risk/clinical practice/complications/congestive heart
failure/CONVERTING-ENZYME-INHIBITION/design/diabetes/disease/diureti
cs/drugs/essential/heart/heart failure/high
risk/hypertension/incidence/infarction/LEFT-VENTRICULAR
HYPERTROPHY/METAANALYSIS/morbidity/mortality/myocardial/myocardi
al
infarction/MYOCARDIAL-INFARCTION/nephropathy/NEW-YORK/preventio
n/prevention of mortality/RANDOMIZED DOUBLE-BLIND/RATS/renal/renal
disease/renin angiotensin system/renin-angiotensin
system/risk/secondary/secondary
prevention/Spain/STROKE/SURVIVAL/treatment/TRIAL/trials/type 2 diabetes
Sumoza, A., de Bisotti, R., Sumoza, D. and Fairbanks, V. (2002), Hydroxyurea (HU) for
prevention of recurrent stroke in sickle cell anemia (SCA). American Journal of
Hematology, 71 (3), 161-165.
Abstract: Cerebrovascular accident (CVA) is a major cause of morbidity and death in
sickle cell anemia (SCA). Transfusion of packed erythrocytes is widely used to
prevent this complication. However, chronic transfusion may lead to iron
overload, alloimmunization, or infections. Cost and compliance may compromise
transfusion therapy. A possible alternative, the prophylactic use of hydroxyurea
(HU), has not been tried to determine whether it may prevent recurrent stroke.
We used HU in five children with SCA who had suffered stroke, in three of them
after a first episode and in the other two after a second CVA. Four had infarctive
stroke and one a transient ischemic attack (TIA). Four patients took HU at a dose
of 40 mg/kg/d, one patient at 30 mg/kg/d. None of the patients had recurrent
stroke during 42-112 months of observation. None experienced pain crises. In all,
HbF increased significantly. and was maintained above 14.7% during treatment.
The total Hb concentration increased 19.5 g/L (median) above the value before
treatment. HU was well tolerated. None of the five children had leukopenia or
thrombocytopenia during therapy. HU appears to prevent recurrence of stroke in
SCA without risk of major toxicity. (C) 2002 Wiley-Liss, Inc
Keywords: alloimmunization/anemia/cerebrovascular accident
(CVA)/CHILDREN/CVA/death/DISEASE/FETAL
HEMOGLOBIN/hemoglobin S (Hb S)/hydroxyurea (HU)/iron
overload/ischemic/morbidity/MORTALITY/NEW-YORK/pain/prevention/recur
rence/recurrent stroke/risk/RISK-FACTORS/sickle cell anemia/sickle cell
anemia/disease/stroke/THERAPY/TIA/toxicity/transfusion/TRANSFUSIONS/tr
ansient/transient ischemic attack/transient ischemic attack (TIA)/treatment/use
Matchar, D.B., Samsa, G.P., Cohen, S.J., Oddone, E.Z. and Jurgelski, A.E. (2002),
Improving the quality of anticoagulation of patients with atrial fibrillation in
managed care organizations: Results of the Managing Anticoagulation Services
Trial. American Journal of Medicine, 113 (1), 42-51.
Abstract: PURPOSE: Randomized trials have indicated that well-managed
anticoagulation with warfarin could prevent more than half of the strokes related
to atrial fibrillation. However, many patients with atrial fibrillation who are
eligible for this therapy either do not receive it or are not maintained within an
optimal prothrombin time-international normalized ratio (INR) range. We sought
to determine whether an anticoagulation service within a managed care
organization would be a feasible alternative for providing anticoagulation care.
SUBJECTS AND METHODS: We performed a multi-site randomized trial in
six large managed care organizations in the United States. Subjects were aged 65
years or older and had nonvalvular atrial fibrillation. At each site, physician
practices were divided into two geographically defined practice clusters; each
site was randomly assigned to have one intervention and one control cluster. The
intervention cluster received an anti-coagulation service that satisfied
specifications for high-quality anticoagulation care and was coordinated through
the managed care organization. Control clusters continued with their usual
provider-based care. We measured the proportion of time that warfarin-treated
patients in each of the clusters (intervention and control) were in the target range
for the INR at baseline, and again during a follow-up period. RESULTS: Five of
the Six Selected Site, succeeded at developing air anticoagulation service.
Patients in the intervention and control Clusters had Similar demographic
characteristics, contrain-dications to warfarin, and risk factors for stroke. Among
patient, (n = 144 in the intervention clusters; n = 118 in the control clusters) for
whom data were available during the baseline and follow-up periods, the changes
in percentages of time in the target range were similar for those in the
intervention clusters (baseline: 47.7%; follow-up: 55.6%) and in the control
clusters (baseline: 49.1%; follow-up: 52.3%; intervention effect: 5%; 95%
confidence interval: -5% to 14%; P = 0.32). CONCLUSION: Although it was
feasible in a managed care organization to implement anticoagulation services
that were tailored to local circumstances, provision of this service did not
improve anticoagulation care compared With usual care. The effect of the
anticoagulation service was limited by the utilization of the service, the degree to
which the referring physician supports Strict adherence to recommended target
ranges for the INR, and the ability of the anticoagulation service to identify and
to respond to out-of-range Values promptly. (C) 2002 by Excerpta Medica, Inc
Keywords: adherence/aged/anticoagulation/anticoagulation service/atrial/atrial
fibrillation/BLEEDING
COMPLICATIONS/control/fibrillation/INR/INTENSITY/managed care
organization/NEW-YORK/nonvalvular atrial
fibrillation/organizations/OUTCOMES/OUTPATIENTS/PROTHROMBIN
TIME/randomized/randomized trial/risk/risk factors/risk factors for
stroke/RISK-FACTORS/SELF-MANAGEMENT/stroke/STROKE
PREVENTION/THERAPY/trial/trials/United States/warfarin/WARFARIN USE
Wattigney, W.A., Mensah, G.A. and Croft, J.B. (2002), Increased atrial fibrillation
mortality: United States, 1980- 1998. American Journal of Epidemiology, 155 (9),
819-826.
Abstract: The authors used death certificate data to evaluate national trends in the
reporting of atrial fibrillation as an underlying or contributory cause of death for
groups defined by age (45 years or older), sex, and race (Black vs. White) and to
examine comorbidity. The multiple-causes mortality files from 1980 through
1998 were analyzed for decedents, with atrial fibrillation (International
Classification of Diseases, Ninth Revision, code 427.3) listed as one of up to 20
conditions causing death. The number of decedents with atrial fibrillation
increased from 18,947 in 1980 to 61,946 in 1998, and the proportion with atrial
fibrillation reported as the underlying cause of death rose from 8.3% in 1980 to
11.6% in 1998. Age- standardized death rates from 1980 to 1998 were
consistently highest among White men, followed (in descending order) by White
women, Black men, and Black women. Overall, the age- standardized rate (per
100,000) increased from 27.6 in 1980 to 69.8 in 1998 (an average annual
increase of 5.4%, p < 0.0001). Ischemic heart disease was the most frequent
underlying cause of death among decedents with atrial fibrillation (26.8%).
These findings emphasize the need for increased application of proven
prevention and control measures to decrease associated cardiovascular morbidity
and mortality
Keywords: ADULTS/age/atrial/atrial fibrillation/atrial
flutter/cardiovascular/cardiovascular diseases/cardiovascular morbidity/cause of
death/comorbidity/control/death/DEATH/disease/fibrillation/heart/heart
disease/heart diseases/IMPACT/men/morbidity/morbidity and
mortality/mortality/PREVALENCE/PREVENTION/prevention and
control/race/RISK-FACTORS/sex/STATISTICS/STROKE/TRENDS/United
States/women
Hennekens, C.H. (2002), Update on aspirin in the treatment and prevention of
cardiovascular disease. American Journal of Managed Care, 8 (22), S691-S700.
Abstract: Antiplatelet therapy, most notably aspirin, has been well documented to reduce
risks of subsequent cardiovascular disease (CVD) in secondary prevention, acute
myocardial infarction (MI), acute occlusive stroke, as well as in primary
prevention. In secondary prevention, the most recent Antithrombotic Trialists'
Collaboration reviewed 194 published randomized trials of antiplatelet therapy,
mostly aspirin, involving more than 212 000 patients (ie, 135 000 using
antiplatelet therapy or control and 77 000 using different antiplatelet regimens).
In a very wide range of patients who have survived a prior occlusive vascular
event-including MI, transient ischemic attacks, occlusive stroke, unstable and
stable angina, percutaneous coronary interventions, and coronary artery bypass
graft-aspirin prevents about 25% of serious vascular events. Among patients
suffering acute MI or acute occlusive stroke, aspirin begun promptly and
continued long-term reduces risks of subsequent MI, stroke, and vascular death.
In acute coronary syndromes, clopidogrel added to aspirin further reduces the
risk of important vascular events, but not mortality, and causes more side effects,
especially bleeding. For patients undergoing percutaneous coronary interventions,
the addition of a short-term infusion of a glycoprotein IIb/IIIa receptor antagonist
to aspirin prevents additional vascular events during the early in-hospital period
but also increases the risk of major bleeding. Ongoing research is investigating
other combinations of different antiplatelet drugs. In all these high-risk patients,
there is a small excess of major bleeding among those assigned at random to
aspirin, which is far outweighed by the magnitude of benefits on CVD. During
an acute MI, after a loading dose of 160 mg to 325 mg aspirin, daily doses
ranging from 75 to 150 mg daily are as effective as higher doses. For long-term
treatment, the effects of doses <75 mg daily are less certain. Although side
effects are dose- related, especially in doses > 325 mg daily, no antiplatelet
regimen is more effective than aspirin for long-term use. In primary prevention,
5 randomized trials have been published involving more than 60 000 apparently
healthy men and women. Persons randomized to receive aspirin in these trials
had significant reductions in risk of a first MI (32%) and important vascular
events (15%). Since the numbers of strokes and vascular deaths were insufficient
to distinguish between the benefits found in secondary prevention and no effect,
use of aspirin in primary prevention should be weighed in light of the
cardiovascular risk profile, the side effects of the drug, and its clear benefit in
reducing risk of a first MI. Aspirin should be an adjunct, not an alternative, to
managing other cardiovascular risk factors. Recently, the US Preventive Services
Task Force and the American Heart Association recommended aspirin use for all
men and women whose 10-year risks are > 6% and greater than or equal to10%,
respectively. In all these patient categories, including secondary prevention,
acute MI and acute occlusive stroke, as well as primary prevention, increased
and appropriate use of aspirin will prevent large numbers of premature deaths
and MIs
Keywords: acute/acute coronary syndromes/acute myocardial
infarction/angina/antiplatelet/antiplatelet drugs/antiplatelet
therapy/aspirin/benefits/bleeding/BRITISH/bypass/cardiovascular/cardiovascular
disease/cardiovascular risk/cardiovascular risk
factors/CARE/causes/clopidogrel/control/coronary artery
bypass/death/disease/drug/drugs/glycoprotein IIb/IIIa receptor
antagonist/HEALTH/high
risk/infarction/ischemic/men/mortality/myocardial/myocardial
infarction/prevention/primary/primary prevention/randomized/RANDOMIZED
TRIAL/randomized trials/research/risk/risk factors/risks/secondary/secondary
prevention/side effects/stroke/therapy/transient/transient ischemic
attacks/treatment/trials/US/USA/use/vascular/vascular events/women
Iwamoto, J., Takeda, T. and Ichimura, S. (2002), Beneficial effect of etidronate on bone
loss after cessation of exercise in postmenopausal osteoporotic women.
American Journal of Physical Medicine & Rehabilitation, 81 (6), 452-457.
Abstract: Objectives: To determine whether etidronate could prevent or restore bone loss
after cessation of exercise in postmenopausal osteoporotic women. Design:
Thirty-five postmenopausal osteoporotic women were studied. Exercise
consisted of daily brisk walking and gymnastic training. The changes in the
lumbar bone mineral density measured by dual energy x-ray absorptiometry were
assessed. Results: One or two years of exercise increased the bone mineral
density from the baseline. One year of cessation of exercise after 1 yr of exercise
resulted in the loss of the bone mineral density gained through exercise. Two
years of cyclical etidronate treatment from year 2 sustained the bone mineral
density during 2 yr of cessation of exercise in the preventative etidronate
treatment group and completely restored the loss of bone mineral density after 1
yr of cessation of exercise in the therapeutic etidronate treatment group.
Conclusions: Cyclical etidronate treatment, when exercise is discontinued, seems
to be beneficial for the prevention or restoration of bone loss after cessation of
exercise in postmenopausal osteoporotic women. Although the present study has
a small sample size, the results may be interesting, especially because they raise
additional questions that could stimulate further research
Keywords: bone mineral density/CALCITRIOL/CALCIUM/cessation of
exercise/etidronate/exercise/Japan/MASS/MINERAL
DENSITY/osteoporosis/postmenopausal
women/prevention/research/STROKE/THERAPY/treatment/WALKING/women
/xray/YOUNG
Nappi, J. and Talbert, R. (2002), Dual antiplatelet therapy for prevention of recurrent
ischemic events. American Journal of Health-System Pharmacy, 59 (18),
1723-1735.
Abstract: The advantages of dual antiplatelet therapy over monotherapy in preventing
recurrent ischemic events are examined. Atherosclerosis is an insidious systemic
process involving multiple vascular beds, including the cerebral, coronary, and
peripheral arteries. Atherosclerotic plaque rupture is one of the inciting events in
the progression of platelet activation, aggregation, and thrombus formation.
Patients with any clinical manifestation of atherosclerosis are vulnerable to
others in different vascular beds since the disease develops throughout the
vasculature, and different vascular events have common, predisposing risk
factors. Ischemic coronary heart disease and cerebrovascular disease are two of
the three most frequent causes of death in the United States. The efficacy of
aspirin in the secondary prevention of myocardial infarction (MI) and stroke has
been demonstrated in numerous trials. While dipyridamole has not been linked
with a greater odds reduction than aspirin in the development of MI, stroke, and
vascular death, ticlopidine and clopidogrel have been associated with a greater
reduction in the development of acute MI, stroke, and vascular death than aspirin.
Clinical trials evaluating the efficacy and safety of combination antiplatelet
therapy in the prevention,of recurrent ischemic events are ongoing. The rationale
for using a combination of two mechanistically different antiplatelet agents is
supported by ex vivo and clinical studies. Inhibition of platelet aggregation and
thrombus formation is enhanced with dual antiplatelet therapy. Combination
antiplatelet regimens with different mechanisms of action to inhibit multiple sites
in the thrombotic pathway may further improve long-term clinical outcomes.
Dual antiplatelet therapy may have advantages over monotherapy in the
prevention of recurrent ischemic events
Keywords: activation/acute/ACUTE CORONARY
SYNDROMES/aggregation/AMERICAN-HEART-ASSOCIATION/antiplatelet/
antiplatelet agents/antiplatelet therapy/ANTITHROMBOTIC
ACTIVITY/arteries/ARTERY
DISEASE/aspirin/atherosclerosis/ATHEROSCLEROTIC
PLAQUES/causes/cerebral/CEREBRAL-ISCHEMIA/cerebrovascular/cerebrova
scular disease/clinical studies/clopidogrel/combination/COMBINATION
THERAPY/combined therapy/coronary heart
disease/death/development/dipyridamole/disease/formation/heart/heart
disease/infarction/ischemia/ischemic/mechanism of
action/mechanisms/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/plaque/plaque
rupture/platelet/platelet activation/platelet aggregation/platelet aggregation
inhibitors/prevention/RECEPTOR ANTAGONIST/risk/risk
factors/safety/secondary/SECONDARY
PREVENTION/stroke/therapy/thrombus/ticlopidine/trials/United
States/vascular/vasculature
Hu, F.B. and Grodstein, F. (2002), Postmenopausal hormone therapy and the risk of
cardiovascular disease: The epidemiologic evidence. American Journal of
Cardiology, 90 (1), 26F-29F.
Abstract: The relation between hormone use in postmenopausal women and
cardiovascular disease remains controversial. Whereas epidemiologic studies and
clinical studies assessing several intermediate cardiovascular disease endpoints
indicate a clear benefit for the primary prevention of coronary artery disease
(CAD), secondary-prevention trials of relatively short duration do not support a
benefit. More recent epidemiologic studies continue to supply evidence that
long-term postmenopausal hormone therapy may reduce the risk for CAD in
healthy women. Adding progestin to the regimen does not appear to attenuate the
benefit. The Nurses' Health Study and studies from Europe, where estradiol is the
commonly prescribed form of estrogen, suggest that estrogen at lower doses may
confer similar benefit. However, remarkably consistent data from both
epidemiologic studies and a secondary-prevention trial indicate a significantly
increased risk of venous thromboembolism with hormone use. The data on stroke
are inconclusive, but there is little evidence to suggest a benefit of hormone use
on either ischemic or hemorrhagic stroke. Existing evidence indicates that the
various potential benefits and risks should be weighed carefully when
prescribing hormone therapy to a postmenopausal woman. (C) 2002 by Excerpta
Medica, Inc
Keywords: cardiovascular/cardiovascular disease/clinical studies/coronary artery
disease/CORONARY
HEART-DISEASE/DIET/disease/ESTROGEN/Europe/ischemic/LIFE-STYLE/
NEW-YORK/postmenopausal women/prevention/primary/primary
prevention/PROGESTIN/REPLACEMENT THERAPY/risk/SECONDARY
PREVENTION/STROKE/therapy/thromboembolism/trial/trials/use/venous
thromboembolism/WOMEN
Newman, N.J., Scherer, R., Langenberg, P., Kelman, S., Feldon, S., Kaufman, D. and
Dickersin, K. (2002), The fellow eye in NAION: Report from the ischemic optic
neuropathy decompression trial follow-up study. American Journal of
Ophthalmology, 134 (3), 317-328.
Abstract: PURPOSE: To examine the prevalence and incidence of second eye
nonarteritic anterior ischemic optic neuropathy (NAION) and associated patient
characteristics in patients enrolled in the Ischemic Optic Neuropathy
Decompression Trial (IONDT) Follow-up Study. DESIGN: Randomized clinical
trial with observational cohort. METHODS: Patients randomized to optic nerve
sheath decompression surgery or careful follow,up had a diagnosis of acute
unilateral NAION, visual acuity between 20/64 and light perception, and were
aged 50 years or older. Eligible patients who declined randomization or whose
visual acuity was better than 20/64 were not randomized but followed as part of
an observational cohort. Follow-up examinations took place at 3, 6, 12, 18, and
24 months and annually thereafter. RESULTS: Four hundred eighteen patients
were enrolled; 258 randomized and 160 observed. Previous NAION or other
optic neuropathy was present in the fellow eye of 21.1% (88/418) of patients at
baseline. Four patients developed optic neuropathy in the fellow eye at follow up
that could not be conclusively diagnosed as NAION. New NAION in the fellow
eye occurred in 14.7% (48/326) of patients at risk during a median follow up of
5.1 years. Randomized patients experienced a higher incidence (35/201; 17.4%)
than nonrandomized patients (13/125; 10.4%). A history of diabetes and baseline
visual acuity of 20/200 or worse in the study eye, but not age, sex, aspirin use, or
smoking were significantly associated with new NAION in the fellow eye. Final
fellow eye visual acuity was significantly worse in those patients with new
fellow eye NAION whose baseline study eye visual acuity was 20/200 or worse.
CONCLUSIONS: Follow-up data from the IONDT cohort provide evidence that
the incidence of fellow eye NAION is lower than expected: new NAION was
diagnosed in 14.7% of IONDT patients over approximately 5 years. Increased
incidence is associated with poor baseline visual acuity in the study eye and
diabetes, but not age, sex, smoking history, or aspirin use. (C) 2002 by Elsevier
Science Inc. All rights reserved
Keywords: acute/age/aged/ASPIRIN/CLINICAL PROFILE/clinical
trial/DESIGN/diabetes/diagnosis/history/incidence/ischemic/NATURAL-HISTO
RY/NEW-YORK/prevalence/PREVENTION/randomized/risk/RISK-FACTORS
/sex/SMOKING/STROKE/surgery/THERAPY/trial/use
Rubia, M., Marcos, I. and Muennig, P.A. (2002), Increased risk of heart disease and
stroke among foreign-born females residing in the United States. American
Journal of Preventive Medicine, 22 (1), 30-35.
Abstract: Background: Although the number of foreign-born people residing ill the
United States is at its highest point in 80 Nears, a mortality analysis of the
foreign born has not been conducted Since 1989. This article provides all update
Of mortality rates among the foreign burn in the United States and, in particular,
examines mortality rates from heart disease among foreign-born females.
Methods: We calculated mortality rates for U.S.-born and foreign-born people
for all causes ischemic heart disease. stroke, neoplastic disease, hypertensive
diseases, diabetes, accidents, infectious disease, and chronic obstructive
pulmonary disease-for 1997. Death data were obtained from the 1997 Multiple
Cause of Death data file, and population data were obtained from the 1997
Current Population Survey. Results: While all-cause, age-adjusted mortality rates
for foreign-born people are significantly lower than for native-born people,
deaths due to ischemic heart disease and stroke are significantly higher among
foreign-born females than native- born females (161.63) and 58.24 deaths,
espectively, per 100,000 foreign-born females vs 122.01 and 19.39 deaths per
100,000 native-born females). Conclusions: Foreign-born females appear to be at
greater risk of death from ischemic heart disease and stroke than native-born
females. Future research efforts are needed to determine which Foreign-born
groups are most at risk for heart disease and stroke so that targeted prevention
efforts can be initiated
Keywords: ACCULTURATION/BIRTH/causes/chronic/CORONARY-ARTERY
DISEASE/cross-sectional studies/death/diabetes/disease/diseases/emigration and
immigration/HEALTH/heart/heart disease/ischemic/ischemic heart
disease/MORTALITY/mortality/NATIVITY/NEW-YORK/NEW-YORK-CITY/
population/POPULATIONS/prevention/pulmonary/research/risk/stroke/United
States/WOMEN
Lew, H.L., Lee, E.H., Date, E.S. and Melnik, I. (2002), Rehabilitation of a patient with
heat stroke - A case report. American Journal of Physical Medicine &
Rehabilitation, 81 (8), 629-632.
Abstract: The recent death of a famous football player raised public awareness of the
fatal nature of heat stroke, which is actually the third leading cause of death
among American athletes. We present a typical case of heat stroke to illustrate its
clinical manifestation and recovery process; risk factors, treatment options, and
the importance of prevention are also discussed. Although heat stroke is not a
common admission diagnosis for inpatient rehabilitation, physiatrists need to be
aware of its pathophysiology, rehabilitation management, and prevention
Keywords: awareness/case report/cause of death/CLINICAL
CHARACTERISTICS/death/diagnosis/heat/heat
stroke/HEATSTROKE/management/pathophysiology/PILGRIMAGE/prevention
/rehabilitation/risk/risk factors/stroke/treatment
Djousse, L., Folsom, A.R., Province, M.A., Hunt, S.C. and Ellison, R.C. (2003), Dietary
linolenic acid and carotid atherosclerosis: the National Heart, Lung, and Blood
Institute Family Heart Study. American Journal of Clinical Nutrition, 77 (4),
819-825.
Abstract: Background: Dietary intake of linolenic acid is associated with a lower risk of
cardiovascular disease mortality. However, it is unknown whether linolenic acid
is associated with a lower risk of carotid atherosclerosis. Objective: The
objective was to examine the association between dietary linolenic acid and the
presence of atherosclerotic plaques and the intima-media thickness of the carotid
arteries. Design: In a cross-sectional design, we studied 1575 white participants
of the National Heart, Lung, and Blood Institute Family Heart Study who were
free of coronary artery disease, stroke, hypertension, and diabetes mellitus.
High-resolution ultrasound was used to assess intima-media thickness and the
presence of carotid plaques beginning 1 cm below to 1 cm above the carotid bulb.
We used logistic regression and a generalized linear model for the analyses.
Results: From the lowest to the highest quartile of linolenic acid intake, the
prevalence odds ratio (95% CI) of a carotid plaque was 1.0 (reference), 0.47
(0.30, 0.73), 0.38 (0.22, 0.66), and 0.49 (0.26, 0.94), respectively, in a model that
adjusted for age, sex, energy intake, waist-to-hip ratio, education, field center,
smoking, and the consumption of linoleic acid, saturated fat, fish, and vegetables.
Linoleic acid, fish long-chain fatty acids, and fish consumption were not
significantly related to carotid artery disease. Linolenic acid was inversely
related to thickness of the internal and bifurcation segments of the carotid
arteries but not to the common carotid artery. Conclusion: Higher consumption
of total linolenic acid is associated with a lower prevalence odds of carotid
plaques and with lesser thickness of segment-specific carotid intima-media
thickness
Keywords: age/and Blood Institute Family Heart
Study/arteries/atherosclerosis/cardiovascular/cardiovascular
disease/cardiovascular disease mortality/carotid/carotid arteries/carotid
artery/carotid artery disease/carotid atherosclerosis/coronary artery
disease/CORONARY-ARTERY DISEASE/DENSITY-LIPOPROTEIN
CHOLESTEROL/design/diabetes/diabetes mellitus/diet/disease/disease
mortality/education/energy intake/Family Heart Study/fat/fish/FOOD
FREQUENCY QUESTIONNAIRE/hypertension/internal/intima-media
thickness/linolenic acid/Lung/MEN/mortality/n-3 fatty acids/n-6 fatty
acids/National Heart/NUTRITION/plaque/POLYUNSATURATED
FATTY-ACIDS/prevalence/PREVENTION/REPRODUCIBILITY/RISK/sex/sm
oking/stroke/ultrasound/USA/VALIDITY/vegetables/WOMEN
Blake, G.J., Ridker, P.M. and Kuntz, K.M. (2003), Potential cost-effectiveness of
C-reactive protein screening followed by targeted statin therapy for the primary
prevention of cardiovascular disease among patients without overt
hyperlipidemia. American Journal of Medicine, 114 (6), 485-494.
Abstract: BACKGROUND: Evidence suggests that statin therapy reduces the rate of
cardiovascular events among patients with low lipid levels but elevated
C-reactive protein levels. However, no cost-effectiveness analyses have been
performed to assist in determining whether large-scale randomized trials are
merited to test this hypothesis. METHODS: We used a Markov model to
estimate the benefits, costs, and incremental cost- effectiveness of C-reactive
protein screening followed by targeted statin therapy for elevated C-reactive
protein levels, compared with dietary counseling alone, for the primary
prevention of cardiovascular events among patients with low- density lipoprotein
cholesterol levels < 149 mg/ dL. All costs were in 2000 U.S. dollars. RESULTS:
The potential incremental cost-effectiveness ratio for screening followed by
statin therapy compared with no screening and no statin therapy was $48,100 per
quality-adjusted life-year (QALY) for 58-year-old men and $94,400 per QALY
for 58-year-old women. Screening was most cost-effective for 65-year-old men
($42,600 per QALY) and least cost-effective for 35-year-old women ($207,300
per QALY). Our results were most sensitive to the baseline risk of coronary heart
disease, the cost of statin therapy, and the efficacy of statin therapy for
preventing myocardial infarction in patients with high C-reactive protein levels.
If a 58-year- old man who smokes and is hypertensive was considered, screening
for C-reactive protein followed by statin therapy would be cost saving if the cost
of statin therapy was reduced to $500 per year. If the cost of statin therapy was
reduced to $1 per day, the cost-effectiveness of screening would be $4900 per
QALY for 58-year-old men and $19,600 per QALY for women of the same age.
If the costs associated with elective revascularization (percutaneous coronary
intervention or coronary artery bypass surgery) were included in the base case
analyses, the incremental cost-effectiveness ratios for screening would be
$40,100 per QALY for 58-year-old men and $87,300 per QALY for women.
CONCLUSION: A strategy involving C- reactive protein screening to target
statin therapy for the primary prevention of cardiovascular disease among
middle-aged patients without overt hyperlipidemia could be relatively cost-
effective and, in some cases, cost saving. Am J Med. 2003,114:485-494. (C)
2003 by Excerpta Medica Inc
Keywords: ACUTE MYOCARDIAL-INFARCTION/age/AVERAGE CHOLESTEROL
LEVELS/benefits/bypass/bypass surgery/C-reactive
protein/cardiovascular/cardiovascular disease/cardiovascular
events/cholesterol/CONTROLLED TRIALS/coronary artery bypass/coronary
artery bypass surgery/coronary heart disease/CORONARY
HEART-DISEASE/cost/cost
effectiveness/cost-effectiveness/costs/counseling/disease/heart/heart
disease/hyperlipidemia/infarction/INFLAMMATION/low density
lipoprotein/MEN/myocardial/myocardial
infarction/NEW-YORK/old/percutaneous coronary
intervention/PRAVASTATIN/prevention/primary/primary
prevention/randomized/randomized trials/REDUCTASE
INHIBITORS/results/revascularization/RISK/screening/statin/statin
therapy/STROKE/surgery/therapy/trials/USA/women
Vinik, A.I. and Vinik, E. (2003), Prevention of the complications of diabetes. American
Journal of Managed Care, 9 (3), S63-S80.
Abstract: For patients with diabetes mellitus (DM), chronic complications can be
devastating. Cardiovascular illness, the major cause of morbidity and mortality
among these patients, encompasses macrovascular disease, with heart attacks,
strokes, and gangrene; and microvascular disease, with retinopathy, nephropathy,
and neuropathy (somatic and autonomic). Macrovascular events occur earlier in
individuals with DM than in people without DM, and the underlying pathologies
are often more diffuse and severe. Diabetic arteriopathy, which encompasses
endothelial dysfunction, inflammation, hypercoagulability, changes in blood
flow, and platelet abnormalities, contributes to the early evolution of these events.
Efforts are under way to determine interventions that may have the potential to
prevent or halt the complications of DM. Tight glucose and blood pressure (BP)
control is known to improve the vascular status of patients with DM by varying
degrees. Use of anti-inflammatory drugs and lowering low- density lipoprotein
cholesterol (LDLC) levels are also useful. An emerging understanding of the
importance of small, dense LDL-C and the anti-inflammatory effects of statins
has provided new algorithms for primary prevention of macrovascular disease.
Antiplatelet agents have also been shown to be effective in the secondary
prevention of cardiovascular events. In the ideal world every risk factor would be
addressed and each person with DM would have excellent glycemic control, low
to normal BP, and a low LDL level, and would be taking an
angiotensin-converting enzyme (ACE) inhibitor, together with a statin, aspirin,
and clopidogrel. Under these near-perfect conditions, the emerging epidemic of
macrovascular disease could be contained. Microvascular disease, however, is a
consequence of hyperglycemia. For every 1% reduction in glycosylated
hemoglobin it is possible to achieve a 22% to 35% reduction in the
microvascular complications. BP control is vital and the liberal use of ACE
inhibitors and angiotensin receptor blockers to slow the progression of renal
disease should drastically reduce the, incidence of blindness, dialysis, and
amputations. This article provides an overview of prevention of macrovascular
disease such as stroke, myocardial infarction, and peripheral arterial. disease and
microvascular complications such as retinopathy, nephropathy, and neuropathy
in patients with DM
Keywords: abnormalities/ACE
inhibitors/angiotensin/ANTITHROMBIN-III/arterial/ASPIRIN/blindness/blood
flow/blood pressure/cardiovascular/cardiovascular
events/CARE/changes/cholesterol/chronic/CLOPIDOGREL/complications/contr
ol/CORONARY HEART-DISEASE/DENSITY-LIPOPROTEIN
CHOLESTEROL/diabetes/diabetes mellitus/disease/drugs/endothelial
dysfunction/epidemic/EVENTS/glucose/heart/hemoglobin/hyperglycemia/incide
nce/infarction/inflammation/LDL/low density
lipoprotein/MELLITUS/morbidity/morbidity and
mortality/mortality/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/nephropathy/neuropathy/platelet/pre
vention/primary/primary prevention/progression/renal/renal disease/risk/risk
factor/SCANDINAVIAN SIMVASTATIN
SURVIVAL/secondary/SECONDARY
PREVENTION/statin/statins/status/stroke/USA/use/vascular
Liu, S.M., Sesso, H.D., Manson, J.E., Willett, W.C. and Buring, J.E. (2003), Is intake of
breakfast cereals related to total and cause- specific mortality in men? American
Journal of Clinical Nutrition, 77 (3), 594-599.
Abstract: Background: Prospective studies suggested that substituting whole-grain
products for refined-grain products lowers the risks of type 2 diabetes and
cardiovascular disease (CVD) in women. Although breakfast cereals are a major
source of whole and refined grains, little is known about their direct association
with the risk of premature mortality. Objective: We prospectively evaluated the
association between whole- and refined-grain breakfast cereal intakes and total
and CVD- specific mortality in a cohort of US men. Design: We examined 86
190 US male physicians aged 40-84 y in 1982 who were free of known CVD and
cancer at baseline. Results: During 5.5 y, we documented 3114 deaths from all
causes, including 1381 due to CVD (488 myocardial infarctions and 146 strokes).
Whole-grain breakfast cereal intake was inversely associated with total and
CVD-specific mortality, independent of age; body mass index; smoking; alcohol
intake; physical activity; history of diabetes, hypertension, or high cholesterol;
and use of multivitamins. Compared with men who rarely or never consumed
whole-grain cereal, men in the highest category of whole-grain cereal intake
(greater than or equal to 1 serving/d) had multivariate-estimated relative risks of
total and CVD-specific mortality of 0.83 (95% CI: 0.73, 0.94; P for trend < 0.001)
and 0.80 (0.66, 0.97; P for trend < 0.001), respectively. In contrast, total and
refined-grain breakfast cereal intakes were not significantly associated with total
and CVD-specific mortality. These findings persisted in analyses stratified by
history of type 2 diabetes, hypertension, and high cholesterol. Conclusions: Both
total mortality and CVD-specific mortality were inversely associated with
whole-grain but not refined- grain breakfast cereal intake. These prospective data
highlight the importance of distinguishing whole-grain from refined-grain cereals
in the prevention of chronic diseases
Keywords: age/aged/alcohol/body mass index/cancer/cardiovascular/cardiovascular
disease/cardiovascular
diseases/CARDIOVASCULAR-DISEASE/causes/cereal/cholesterol/chronic/CO
RONARY HEART-DISEASE/DEATH/diabetes/DIETARY
FIBER/disease/diseases/history/hypertension/IOWA WOMENS
HEALTH/ISCHEMIC
STROKE/men/mortality/myocardial/NUTRITION/OLDER WOMEN/physical
activity/Physicians' Health Study/prevention/prospective study/refined-grain
cereals/RISK/risks/smoking/type 2 diabetes/US/USA/use/VEGETABLE
INTAKE/whole-grain cereals/WHOLE-GRAIN INTAKE/women
Chalmers, J. (2003), Trials on blood pressure-lowering and secondary stroke prevention.
American Journal of Cardiology, 91 (10), 3G-8G.
Abstract: The risk of stroke is strongly and persistently related to the usual level of both
systolic blood pressure (SBP) and diastolic blood pressure (DBP). This relation
holds for primary and secondary stroke, both ischemic and hemorrhagic. The
Perindopril Protection Against Recurrent Stroke Study (PROGRESS) has now
provided definitive evidence that lowering the blood pressure of patients with
preexisting cerebrovascular disease (prior stroke or transient ischemic attack
[TIA]) also reduces the incidence of secondary stroke. PROGRESS showed that
a flexible blood pressure-lowering regimen involving an angiotensin-converting
enzyme inhibitor (perindopril) and a diuretic (indapamide) reduces the incidence
of stroke, major coronary events, and major vascular events by 28%, 26%, and
26%, respectively. These benefits were associated with an average reduction of
9.0 mm Hg (SBP) and 4.0 mm Hg (DBP). The 28% reduction in stroke incidence
translated into a 24% reduction in ischemic stroke and a 50% reduction in
hemorrhagic stroke. Combination therapy with perindopril and indapamide
decreased blood pressure, more effectively than did perindopril monotherapy
(mean reduction of 12.3 mm Hg [SBP] and 5.0 mm H9 [DBP] vs 4.9 mm Hg
[SBP] and 2.8 mm Hg [DBP], respectively) and was equally effective in
reducing stroke risk in patients with and without hypertension. In conclusion,
blood pressure- lowering therapy is now established as the most important
measure for primary and secondary stroke prevention. Results of PROGRESS
suggest that antihypertensive treatment with a combination of perindopril plus
indapamide should now be routinely considered for all patients with previous
stroke or TIA. (C) 2003 by Excerpta Medica, Inc
Keywords: angiotensin converting enzyme inhibitor/antihypertensive
treatment/Australia/benefits/blood pressure/blood pressure
lowering/cerebrovascular/cerebrovascular disease/combination/diastolic blood
pressure/DISEASE/DRUGS/hemorrhagic/hemorrhagic
stroke/hypertension/incidence/indapamide/ischemic/ischemic stroke/major
coronary
events/NEW-YORK/perindopril/prevention/primary/PROGRESS/RISK/seconda
ry/secondary stroke prevention/stroke/stroke incidence/stroke prevention/systolic
blood/systolic blood pressure/therapy/TIA/transient/transient ischemic
attack/treatment/USA/vascular/vascular events
Sesso, H.D., Gaziano, J.M., Liu, S. and Buring, J.E. (2003), Flavonoid intake and the
risk of cardiovascular disease in women. American Journal of Clinical Nutrition,
77 (6), 1400-1408.
Abstract: Background: Despite emerging evidence of the role of flavonoids in
cardiovascular disease (CVD) prevention, the association remains unclear.
Objective: We examined whether flavonoids and selected flavonols and flavones
or their food sources are associated with CVD risk. Design: Women (n = 38 445)
free of CVD and cancer participated in a prospective study with a mean
follow-up of 6.9 y. On the basis of a food-frequency questionnaire, total
flavonoids and selected flavonols and flavones were categorized into quintiles,
and food sources were categorized into 4 groups. Relative risks were computed
for important vascular events (519 events; excluding revascularizations) and
CVD (729 events),, including myocardial infarction, stroke, revascularization,
and CVD death. Results: The mean flavonoid intake was 24.6 +/- 18.5 mg/d,
primarily as quercetin (70.2%). For both CVD and important vascular events, no
significant linear trend was observed across quintiles of flavonoid intake (P =
0.63 and 0.80, respectively). No individual flavonol or flavone was associated
with CVD. Broccoli and apple consumption were associated with nonsignificant
reductions in CVD risk: 25-30% and 13-22%, respectively. A small proportion of
women (n = 1185) consuming greater than or equal to4 cups (946 ML) tea/d had
a reduction in the risk of important vascular events but with a nonsignificant
linear trend (P = 0.07). Conclusions: Flavonoid intake was not strongly
associated with a reduced risk of CVD. The nonsignificant inverse associations
for broccoli, apples, and tea with CVD were not mediated by flavonoids and
warrant further study
Keywords: ANTIOXIDANT FLAVONOLS/cancer/cardiovascular/cardiovascular
disease/CATECHIN CONTENTS/CORONARY
HEART-DISEASE/death/DENSITY-LIPOPROTEIN/diet/DIETARY
FLAVONOIDS/disease/flavonoids/flavonols/HEALTH/infarction/MALE
SMOKERS/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/nutrition/prevention/primary
prevention/prospective study/quercetin/revascularization/risk/risks/SOY
PROTEIN/stroke/tea/TEA CONSUMPTION/USA/vascular/vascular
events/women
Unger, T. (2003), The ongoing telmisartan alone and in combination with Ramipril
Global Endpoint Trial program. American Journal of Cardiology, 91 (10),
28G-34G.
Abstract: The renin-angiotensin system evolved to maintain volume homeostasis and
blood pressure and to prevent ischemia during acute volume loss. But in the
present age, these mechanisms are redundant, and the clinical significance of
angiotensin II results from its pathologic effects, which are mediated by the
angiotensin II type 1 (AT,) receptor. Activation of AT, receptors has been linked
to pathologic processes that contribute to atherosclerosis and ischemic events,
including oxidative stress, inflammatory processes, low-density lipoprotein
cholesterol trafficking, and prothrombotic states. The Ongoing Telmisartan
Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET)
program will compare the efficacy of the angiotensin II receptor blocker (ARB)
telmisartan, the angiotensin-converting enzyme (ACE) inhibitor ramipril, and
combination therapy with telmisartan plus ramipril for reducing cardiovascular
risk. The ARB telmisartan is distinguished by its long duration of action, which
compares favorably with some other ARBs and conventional antihypertensives.
Ramipril was shown in the Heart Outcomes Prevention Evaluation (HOPE) study
to reduce the risk for myocardial infarction (MI) and other cardiovascular events
in patients at high risk for cardiovascular events but without heart failure or a
low ejection fraction. The ONTARGET program consists of 2 randomized,
double-blind, multicenter international trials: a principal trial, ONTARGET, and
a parallel trial, Telmisartan Randomized Assessment Study in ACE- I Intolerant
Patients with Cardiovascular Disease (TRANSCEND). The treatment arms for
the principal ONTARGET study are telmisartan 80 mg, ramipril 10 mg, and
combination therapy with telmisartan 80 mg plus ramipril 10 mg; for the parallel
study TRANSCEND, the treatment arms are telmisartan 80 mg and placebo.
Both trials will assess cardiovascular outcomes in patients at high risk using the
same criteria as that of the HOPE study, with a single exception: the
TRANSCEND trial will enroll patients who do not tolerate ACE inhibitor
treatment. The primary end points in both ONTARGET and TRANSCEND are
death caused by cardiovascular disease, acute MI, stroke, and hospitalization
because of congestive heart failure. The secondary end points include newly
diagnosed heart failure, revascularization, new-onset type 2 diabetes mellitus,
nephropathy, cognitive decrease and dementia, and newly diagnosed atrial
fibrillation; these will be used for hypothesis generation. (C) 2003 by Excerpta
Medica, Inc
Keywords: ACE inhibitor/acute/ACUTE
MYOCARDIAL-INFARCTION/age/AMBULATORY
BLOOD-PRESSURE/angiotensin/angiotensin II/atherosclerosis/atrial/atrial
fibrillation/blocker/blood pressure/cardiovascular/cardiovascular
disease/cardiovascular events/cardiovascular risk/cholesterol/CIRCADIAN
VARIATION/combination/combination therapy/congestive heart
failure/CONVERTING
ENZYME-INHIBITORS/death/dementia/diabetes/diabetes mellitus/disease/end
points/fibrillation/Germany/heart/heart failure/HEART-FAILURE/high
risk/hospitalization/infarction/ischemia/ischemic/LEFT-VENTRICULAR
DYSFUNCTION/low density lipoprotein/low-density lipoprotein
cholesterol/LOW-DENSITY-LIPOPROTEIN/mechanisms/myocardial/myocardi
al infarction/nephropathy/NEW-YORK/outcomes/oxidative
stress/primary/Ramipril/randomized/RECEPTOR ANTAGONIST
IRBESARTAN/receptors/renin angiotensin system/renin-angiotensin
system/results/revascularization/risk/secondary/stress/stroke/SUDDEN
CARDIAC DEATH/therapy/TO- MODERATE
HYPERTENSION/treatment/trial/trials/type 2 diabetes/USA
Serebruany, V.L., Malinin, A.I. and Sane, D.C. (2003), Rapid platelet inhibition after a
single capsule of Aggrenox (R): Challenging a conventional full-dose aspirin
antiplatelet advantage? American Journal of Hematology, 72 (4), 280-281.
Abstract: Aggrenox(R) is a novel combination of 25 mg of aspirin with 200 mg of
sustained release dipyridamole. In a recent large trial (ESPS-2), Aggrenox(R)
was twice as effective for secondary stroke prevention as either aspirin or
dipyridamole alone, suggesting superior platelet inhibition for combination
therapy. We sought to compare the time course of platelet inhibition with
Aggrenox(R) compared with escalating doses of non-enteric coated aspirin. Data
from 10 healthy volunteers were analyzed. Fasting subjects sequentially ingested
aspirin in the following order: 325 mg, 81 mg, 25 mg, and then one pill of
Aggrenox(R) after a 3-week interval for aspirin washout. Platelet function was
assessed at baseline, 15, 30, 60, and 120 min post-medication with 5 muM
epinephrine and 5 muM ADP using conventional aggregometry. Aspirin
provided significant (P < 0.01) reduction of platelet aggregation at 15 min post
325 mg, 30 min post 81 mg, and unexpectedly within 60 min after taking 25 mg
of aspirin. A single pill of Aggrenox(R) also inhibited platelet aggregation within
1 hr after administration. Aspirin inhibits platelets remarkably fast. Both
Aggrenox(R) and a matching dose of aspirin (25 mg) exhibit significant
antiplatelet properties within 60 min after ingestion. These findings could be
relevant for the optimal balance between the reduction of vascular events via
sufficient and rapid platelet inhibition and low risk of bleeding complications
associated with the Aggrenox(R) therapy. (C) 2003 Wiley-Liss, Inc
Keywords: ACETYLSALICYLIC-ACID/administration/ADP/aggregation/Aggrenox
(R)/antiplatelet/aspirin/bleeding/bleeding
complications/combination/combination
therapy/complications/dipyridamole/DIPYRIDAMOLE/dose of aspirin/healthy
volunteers/NEW-YORK/platelet/platelet
aggregation/platelets/prevention/risk/secondary/secondary stroke
prevention/STROKE/stroke prevention/therapy/trial/USA/vascular/vascular
events
Vaughan, C.J. (2003), Prevention of stroke and dementia with statins: Effects beyond
lipid lowering. American Journal of Cardiology, 91 (4A), 23B-29B.
Abstract: Stroke is a major cause of mortality and morbidity. The epidemiologic
association between elevated serum cholesterol and stroke risk is controversial.
However, recent secondary prevention studies with 3-hydroxy-3-methylglutaryl
coenzyme A reductase inhibitors (statins) have demonstrated a significant
reduction in ischemic stroke without an increase in hemorrhagic stroke. Statins
probably reduce stroke by a variety of mechanisms, including modulation of
precerebral atherothrombosis in the aorta and the carotid artery, thus preventing
plaque disruption and artery-to-artery thromboembolism. Statins also improve
endothelial homeostasis by increasing the bioavailability of nitric oxide, which
orchestrates the paracrine antiatherosclerotic functions of the endothelium.
Studies in experimental models of ischemic stroke show that statin therapy
reduces brain infarct size and improves neurologic outcome by directly
upregulating brain endothelial nitric oxide synthase. Putative anti-inflammatory
actions of statins may also contribute to neuroprotection and stroke prevention.
Although the clinical benefit of statins largely depends on lowering low-density
lipoprotein cholesterol, accumulating data indicate that many of the pleiotropic
effects of statins are attributable to the cellular consequences of depletion of
intermediates in the cholesterol biosynthetic pathway (isoprenoids). These
molecules play fundamental roles in cell growth, signal transduction, and
mitogenesis: In addition to reducing stroke risk, emerging data suggest that
statins may reduce dementia. Further studies are needed to fully address the role
of statins in the prevention of stroke in patients without established vascular
disease and the role of cholesterol modulation in the treatment of dementia. (C)
2003 by Excerpta Medica, Inc
Keywords: ALZHEIMERS-
DISEASE/aorta/APOLIPOPROTEIN-E/atherothrombosis/brain/carotid/carotid
artery/CAROTID
ATHEROSCLEROSIS/CEREBRAL-ISCHEMIA/cholesterol/CHOLESTEROL
REDUCTION/COA REDUCTASE
INHIBITORS/dementia/disease/ENDOTHELIAL-CELLS/endothelium/experim
ental/hemorrhagic/hemorrhagic stroke/INTERVENTION
TRIAL/ischemic/ischemic stroke/lipid lowering/lipid-lowering/low density
lipoprotein/low-density lipoprotein
cholesterol/mechanisms/morbidity/mortality/MYOCARDIAL-INFARCTION/ne
uroprotection/NEW-YORK/nitric oxide/NITRIC-OXIDE
SYNTHASE/outcome/plaque/plaque
disruption/prevention/risk/secondary/secondary prevention/serum/signal
transduction/statin/statin therapy/statins/stroke/stroke
prevention/therapy/thromboembolism/treatment/USA/vascular/vascular disease
Healey, J.S. and Connolly, S.J. (2003), Atrial fibrillation: Hypertension as a causative
agent, risk factor for complications, and potential therapeutic target. American
Journal of Cardiology, 91 (10), 9G-14G.
Abstract: Atrial fibrillation and hypertension are 2 prevalent, and often coexistent,
conditions in the North American population. Their incidence increases with
advancing age, and they are responsible for considerable morbidity and mortality.
Although the relation between the 2 conditions has long been known, the
treatment of hypertension is not currently a focus in the clinical management of
atrial fibrillation. Hypertension is associated with left ventricular hypertrophy,
impaired ventricular filling, left atrial enlargement, and slowing of atrial
conduction velocity.,These changes in cardiac structure and physiology favor the
development of atrial fibrillation, and they increase the risk of thromboembolic
complications. Conventional therapy of atrial fibrillation has focused on
interventions to control heart rate and rhythm and the prevention of stroke
through the use of anticoagulant medications. In patients with atrial fibrillation,
aggressive treatment of hypertension may reverse the structural changes in the
heart, reduce thromboembolic complications, and retard or prevent the
occurrence of atrial fibrillation. Specific pharmocotherapy could potentially play
a major role in the primary and secondary prevention of atrial fibrillation and its
complications. (C) 2003 by Excerpta Medica, Inc
Keywords: age/anticoagulant/ANTIHYPERTENSIVE TREATMENT/atrial/atrial
fibrillation/BLOOD-PRESSURE/cardiac/changes/complications/control/develop
ment/DOUBLE-BLIND/fibrillation/FRAMINGHAM/heart/heart
rate/HEART-FAILURE/hypertension/hypertrophy/incidence/left ventricular/left
ventricular hypertrophy/LEFT-VENTRICULAR
HYPERTROPHY/management/morbidity/morbidity and
mortality/mortality/NEW-YORK/North
American/population/prevention/primary/primary and secondary
prevention/RANDOMIZED TRIAL/risk/risk factor/secondary/secondary
prevention/SINUS RHYTHM/SIZE/stroke/SYSTEMIC
HYPERTENSION/therapy/thromboembolic/thromboembolic
complications/treatment/USA/use
Dankner, R., Goldbourt, U., Boyko, V. and Reicher-Reiss, H. (2003), Predictors of
cardiac and noncardiac mortality among 14,697 patients with coronary heart
disease. American Journal of Cardiology, 91 (2), 121-127.
Abstract: The decrease in mortality from ischemic heart disease during the last 25 years
may partly reflect improvement in diagnosis and treatment of patients with
coronary heart disease. These patients, therefore, are experiencing morbidity and
mortality due to other causes. The aim of our study was to describe the incidence
and causes of cardiac mortality (CM) and noncardiac Mortality (NCM) and to
identify predictive factors. A cohort of 14,697 patients with coronary heart
disease was merged with the Central Population Registry to identify mortality
records from 1990 to 1996. Among the 1,839 deaths, 1,055 (57.4%) were cardiac,
626 (34.0%) were noncardiac, and 158 deaths (8.6%) were due to unknown
causes as classified in the International Classification of Diseases-Ninth Edition
(ICD). The 3 most significant predictors were age for a 10-year increment (odds
ratios 1.75 and 2.25 for CM and NCM, respectively), chronic obstructive
pulmonary disease (odds ratios 1.67 and 1.71), and current smoking (odds ratios
1.29 and 1.66). A history of cancer was a predictor of NCM, but not of CM,
whereas peripheral vascular disease predicted CM but not NCM. As the number
of predictive factors increased from none to greater than or equal to5, the risk of
NCM gradually increased from 1.9% to 15.5%. Similar predictors expose
subjects with coronary disease to CM and NCM, but smoking plays a more
pronounced role in the prediction of NCM, whereas past myocardial infarction,
lower levels of high-density lipoprotein cholesterol, and peripheral vascular
disease are mainly associated with CM. Because of the similarity of antecedent
predictors, treatment of risk factors among patients with coronary heart disease
should prove valuable for the prevention of all-cause mortality. (C) 2003 by
Excerpta Medica, Inc
Keywords: age/all-cause mortality/cancer/cardiac/causes/cholesterol/chronic/coronary
disease/coronary heart disease/diagnosis/disease/FACTOR INTERVENTION
TRIAL/heart/heart disease/high density lipoprotein/high-density lipoprotein
cholesterol/history/incidence/infarction/ischemic/ischemic heart
disease/Israel/LOW SERUM- CHOLESTEROL/LUNG-CANCER
MORTALITY/morbidity/morbidity and
mortality/mortality/MRFIT/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/NEW-YORK/peripheral vascular
disease/prediction/predictors/prevention/pulmonary/RISK/risk
factors/SMOKERS/smoking/SMOKING
CESSATION/STROKE/treatment/USA/vascular/vascular disease/WOMEN
Gregory, P.C. and Kuhlemeier, K.V. (2003), Prevalence of venous thromboembolism in
acute hemorrhagic and thromboembolic stroke. American Journal of Physical
Medicine & Rehabilitation, 82 (5), 364-369.
Abstract: Objective: Deep venous thromboembolism (DVT) is an important health issue
in the hospitalized geriatric population that leads to increased length of stay,
morbidity, and mortality. Patients with hemorrhagic strokes are usually not
placed on prophylactic therapy because of the risk of hemorrhagic extension of
the stroke. The purpose of this study was to evaluate the prevalence of DVTs in
hospitalized patients with hemorrhagic vs. thromboembolic strokes. Design:
Retrospective chart review of data obtained from the Maryland Health Services
Cost Review Commission data base for 1999 to determine the prevalence of
DVTs in both hemorrhagic and thromboembolic stroke patients hospitalized
acutely. Multiple logistic regression was performed to evaluate possible risk
factors. Results: There were 1,926 patients hospitalized with a primary diagnosis
of hemorrhagic stroke and 15,599 with thromboembolic stroke. Women in
general had more strokes than men did. Older patients were more likely to have
strokes as evidenced by the mean ages of 66 and 71 yr for hemorrhagic and
thromboembolic strokes, respectively. A total of 37 patients (1.9%) with
hemorrhagic strokes had DVTs, whereas 74 patients (0.5%) with
thromboembolic strokes had DVTs. Hemorrhagic stroke was an independent risk
factor for DVT (odds ratio, 2.60; 95% confidence interval, 1.49-4.55; P =
0.0008). Conclusions: DVT prevalence and risk was higher among patients with
hemorrhagic strokes in comparison with patients with thromboembolic strokes
Keywords: acute/deep venous thromboembolism/DEEP-VEIN
THROMBOSIS/diagnosis/DVT/health/hemorrhagic/hemorrhagic
stroke/INJURY/intracranial hemorrhage/length of
stay/men/morbidity/mortality/PATTERNS/population/prevalence/PREVENTIO
N/primary/PROPHYLAXIS/PULMONARY-EMBOLISM/REGISTRY/REHAB
ILITATION/review/risk/risk factor/risk factors/stroke/stroke
patients/therapy/thromboembolic/thromboembolism/USA/venous
thromboembolism
Kowey, P.R., Yan, G.X., Winkel, E. and Kao, W. (2003), Pharmacologic and
nonpharmacologic options to maintain sinus rhythm: Guideline-based and new
approaches. American Journal of Cardiology, 91 (6A), 33D-38D.
Abstract: Atrial fibrillation is a common arrhythmia in patients with heart failure and is
responsible for substantial morbidity and mortality. Restoration and preservation
of sinus rhythm, therefore, has a premium. Of the numerous treatment options
available, many must be avoided because of their potential for adverse effects or
because of limited proof of efficacy in defined populations. Published guidelines
provide help by synthesizing clinical trial data into a recommended approach.
This article summarizes current information regarding the best methods
applicable to patients with left ventricular dysfunction for rate control, sinus
rhythm restoration and maintenance, and stroke prevention. New and evolving
therapies and how they might fit into the evolving treatment paradigm are also
briefly reviewed. (C) 2003 by Excerpta Medica, Inc
Keywords: adverse effects/approach/arrhythmia/CATHETER ABLATION/CHRONIC
ATRIAL-FIBRILLATION/clinical
trial/CONGESTIVE-HEART-FAILURE/control/CONVERSION/DOFETILIDE/
DYSFUNCTION/EFFICACY/fibrillation/FLUTTER/guidelines/heart/heart
failure/INTRAVENOUS AMIODARONE/left ventricular/left ventricular
dysfunction/MANAGEMENT/morbidity/morbidity and
mortality/mortality/NEW-YORK/prevention/sinus rhythm/stroke/stroke
prevention/treatment/trial/USA
Shimizu, M., Yamamoto, M., Miyachi, H., Shinohara, Y. and Ando, Y. (2003), Simple,
rapid, and automated method for detection of hyperaggregability of platelets
using a hematology analyzer. American Journal of Hematology, 72 (4), 282-283.
Abstract: Estimation of hyperaggregability of platelets is important for diagnosis and
prevention of vascular events. We have developed and evaluated a simple and
rapid method for detection of a hyperaggregable state of platelets by using An
Abbott CELL- DYN(R) 4000 hematology analyzer. Citrated blood samples were
collected from 62 patients with chronic cerebral infarction (CCI), of whom 19
patients were treated with ticlopidine, and from 9 healthy subjects. Platelet
clumps were detected in the scatter plots for white blood cell populations with
the hematology analyzer. Platelet clumps were positive in 20 of 43 (46.5%) CCI
patients who were not treated with anti-platelet agents but not at all in 9 healthy
subjects and in 19 CCI patients treated with ticlopidine. The detection of platelet
clumps in citrated blood by the hematology analyzer was proved useful in
detecting a platelet hyperaggregability in CCI patients. This method is simple,
rapid, and automated and thus should be suitable for routine clinical use for
monitoring indications and the efficacy of anti-platelet drugs. (C) 2003
Wiley-Liss, Inc
Keywords: AGENTS/AGGREGATION/anti-platelet agents/anti-platelet
therapy/antiplatelet/antiplatelet agents/antiplatelet drugs/CELL/cerebral/cerebral
infarction/chronic/chronic cerebral
infarction/detection/diagnosis/drugs/hematology analyzer/infarction/ISCHEMIC
STROKE/Japan/monitoring/NEW-YORK/platelet/platelet
hyperaggregability/platelets/prevention/ticlopidine/USA/use/vascular/vascular
events
Ball, S.G. and White, W.B. (2003), Debate: Angiotensin-converting enzyme inhibitors
versus angiotensin II receptor blockers - A gap in evidence-based medicine.
American Journal of Cardiology, 91 (10), 15G-21G.
Abstract: In this article, 2 leading physicians debate the strength of outcome data on the
efficacy of angiotensin-converting enzyme (ACE) inhibitors versus angiotensin
II receptor blockers (ARBs) for reducing the incidence of cardiovascular,
cerebrovascular, and renovascular events. Dr. Stephen G. Ball notes that the
efficacy of ACE inhibitors for reducing the risk for myocardial infarction
independent of their effects on blood pressure is controversial. In the Heart
Outcomes Prevention Evaluation (HOPE) study, ramipril treatment in high-risk
patients was associated with a 20% reduction in the risk for myocardial
infarction; mean reduction in blood pressure was 3 mm Hg for systolic blood
pressure and 1 mm Hg for diastolic blood pressure. The HOPE investigators
propose that the 20% reduction was much greater than would be expected based
on the observed blood pressure reduction. However, a meta-regression analysis
of blood pressure reduction in >20 antihypertensive therapy outcome trials found
that the reduction in myocardial infarction risk with ramipril observed in HOPE
was consistent with the modest blood pressure reduction seen with that agent.
Nevertheless, there are convincing data for prevention of myocardial infarction
with ACE inhibitors in patients with heart failure, including those with heart
failure after myocardial infarction, as well as supportive evidence from studies in
patients with diabetes mellitus and cancomitant hypertension. On the other hand,
Dr. William B. White takes the position that ARBs are well-tolerated
antihypertensive agents that specifically antagonize the angiotensin II type 1
(AT(1)) receptor and provide a more complete block of the pathologic effects of
angiotensin II-which are mediated via the AT(1) receptor-than ACE inhibitors.
The Evaluation of Losartan in the Elderly (ELITE) 11 study and the Valsartan
Heart Failure Trial (ValHeFT) suggest that ARBs reduce the risk for mortality in
patients with congestive heart failure. The Losartan Intervention for Endpoint
(LIFE) Reduction in Hypertension trial also demonstrated beneficial effects of
ARBs in the prevention of stroke events. The Irbesartan in Patients with Diabetes
and Microalbuminuria (IRMA) study, the Irbesartan Diabetic Nephropathy Trial
(IDNT), and the Reduction of Endpoints in NIDDM with the Angiotensin II
Antagonist Losartan (RENAAL) study demonstrated significant reductions in the
rate of progression of renal disease in patients receiving ARBs, independent of
effects on blood pressure. These data support the use of ARBs, in addition to the
standard of care, in hypertensive patients with heart failure who are intolerant of
ACE inhibitors, and also provide compelling evidence for their use in patients
with hypertension and type 2 diabetes. (C) 2003 by Excerpta Medica, Inc
Keywords: ACE inhibitors/angiotensin/angiotensin II/ANTAGONISTS/antihypertensive
agents/antihypertensive therapy/blood pressure/BLOOD-PRESSURE
REDUCTION/cardiovascular/CARDIOVASCULAR
MORBIDITY/cerebrovascular/congestive heart failure/CT/diabetes/diabetes
mellitus/DIABETIC NEPHROPATHY/diastolic blood
pressure/disease/ELITE/heart/heart failure/HEART-FAILURE/high
risk/HYPERTENSION/incidence/infarction/INTERVENTION/LIFE/LOSARTA
N/MORTALITY/myocardial/myocardial
infarction/NEW-YORK/NIDDM/outcome/prevention/progression/ramipril/RAN
DOMIZED TRIAL/renal/renal disease/risk/stroke/systolic blood/systolic blood
pressure/therapy/treatment/trial/trials/type 2 diabetes/USA/use
Penado, S., Cano, M., Acha, O., Hernandez, J.L. and Riancho, J.A. (2003), Atrial
fibrillation as a risk factor for stroke recurrence. American Journal of Medicine,
114 (3), 206-210.
Abstract: BACKGROUND: Although atrial fibrillation is a well-known risk, factor for
ischemic stroke, the extent to which it increases the risk of stroke recurrence,
particularly in elderly patients, is less certain. METHODS: We performed a
retrospective cohort study of 915 patients aged 50 to 94 years who were admitted
with an ischemic stroke. The rates of recurrent strokes and recurrent severe
strokes were estimated with the Kaplan-Meier method. The effects of atrial
fibrillation on stroke risk were analyzed with proportional hazards models.
RESULTS: Of the 829 patients who survived the initial hospitalization, 163
(20%) had a stroke during follow- up. Of the 203 patients with-atrial fibrillation
during index hospitalization who were not anticoagulated, 54 (27%) had
recurrent strokes, compared with 18% (19/103) among those with atrial
fibrillation who were anticoagulated and 17% (90/523) among those without
atrial fibrillation. The age-adjusted hazard ratio for recurrent stroke among those
with atrial fibrillation who were not treated with anticoagulants was 2.1 (95%
confidence interval [Cl]: 1.4 to 2.9; P <0.001), whereas the hazard ratio for
recurrent severe stroke was 2.4 (95% CI: 1.6 to 3.6; P <0.001). The increased
risk was observed even inpatients aged greater than or equal to80 years and
persisted during the follow-up for more than 5 years. CONCLUSION: Atrial
fibrillation was an independent risk factor for stroke recurrence over a wide age
range. (C) 2003 by Excerpta Medica Inc
Keywords: age/aged/anticoagulants/ANTICOAGULATION/atrial/atrial
fibrillation/CEREBRAL INFARCTION/COHORT/cohort study/elderly/elderly
patients/fibrillation/hospitalization/inpatients/ischemic/ISCHEMIC
STROKE/MORTALITY/NEW-YORK/PREDICTORS/PREVENTION/PROGN
OSIS/recurrence/recurrent stroke/risk/risk factor/Spain/stroke/stroke
recurrence/USA
Jernigan, W.R. and Hamman, J.L. (1982), The Causes and Prevention of Stroke
Associated with Carotid- Artery Surgery. American Surgeon, 48 (2), 79-84
Edwards, W.H., Jenkins, J.M., Edwards, W.H. and Mulherin, J.L. (1988), Prevention of
Stroke During Carotid Endarterectomy. American Surgeon, 54 (3), 125-128
Steiner, T., Hennes, H.J., Kretz, R. and Hacke, W. (2000), Treatment of acute clinical
stroke. Anaesthesist, 49 (1), 2-8.
Abstract: Stroke is an emergency. Treatment must begin as soon as possible because
significant sustained neurological improvement has been demonstrated when
thrombolytic treatment, mainly with recombined tissue plasminogen activator
(rtPA) is initiated within the first hours of stroke onset. On the other hand in the
acute phase of stroke it is critical that patients get adequate management for the
prevention of early complications. Management of the acute phase of stroke is
the target of this article. Preclinically started treatment must be continued in the
neurological emergency unit. Clinical examination is followed by technical
investigations: cerebral computertomography (CCT) is the most useful
radiological investigation in the acute phase. It allows to distinguish between
ischemia and hemorrhagic lesions and also to rule out nonstroke brain conditions.
Multimodal magnetic resonance imaging (mMRI) may provide data on viable
versus irreversibly damaged tissue. Sufficient stroke treatment is based on well
managed in-hospital infrastructure. Thrombolysis is the only causative treatment
of stroke in selected patients. Complications of acute stroke comprise changes of
blood pressure with hemodynamically relevant effects on cerebral perfusion
pressure,acute postischemic brain edema,and intracerebral bleedings
Keywords: acute/ACUTE ISCHEMIC STROKE/acute stroke/blood
pressure/brain/cerebral/CEREBRAL-ARTERY
INFARCTION/complications/ECASS/Germany/intracerebral/intracranial
pressure/ischemia/magnetic resonance
imaging/NEW-YORK/OCCLUSION/plasminogen
activator/prevention/rtPA/SONOGRAPHY/stroke/stroke treatment/stroke
unit/thrombolysis/THROMBOLYTIC THERAPY/thrombolytic
treatment/treatment/TRIAL/WINDOW
Lagana, A., Bellagamba, G., DAscenzo, G., Gentili, A. and Marino, A. (1997),
Evaluation of ticlopidine in human serum and plaque by liquid chromatography
atmospheric pressure chemical ionization mass spectrometry. Analytica Chimica
Acta, 354 (1-3), 87-95.
Abstract: A method based on liquid chromatography with atmospheric pressure
positive-ion chemical ionization detection in the presence of ammonium acetate
and formic acid for the determination of ticlopidine in human serum and plaque
has been developed. The drug was extracted from the biological matrices using a
single solid-phase C-18 cartridge. The protonated molecule with substantial
fragmentation was obtained by using this ionization technique. The ion signals in
different solvents were evaluated. The chromatographic run time was about 10
min and the method had sufficient sensitivity, precision, accuracy and selectivity
for the analysis of clinical sample containing ticlopidine at concentrations down
to 1 ng ml(-1) for serum samples and 1 ng g(-1) for plaque samples. The limits of
detection (signal: noise=3) were 300 pg ml(-1) and 330 pg g(-1), respectively. (C)
1997 Elsevier Science B.V
Keywords: chemical ionization/detection/human/human serum and
plaque/HYDROCHLORIDE/liquid chromatography/mass
spectrometry/plaque/PREVENTION/serum/STROKE/ticlopidine
Park, G.E., Hauch, M.A., Curlin, F., Datta, S. and Bader, A.M. (1996), The effects of
varying volumes of crystalloid administration before cesarean delivery on
maternal hemodynamics and colloid osmotic pressure. Anesthesia and Analgesia,
83 (2), 299-303.
Abstract: The value of intravenous crystalloid administration in preventing
spinal-induced hypotension in the parturient has recently been questioned. Also,
the association between increasing crystalloid volume and decreasing postpartum
colloid osmotic pressure (COP) raises concern regarding the risk of maternal and
fetal pulmonary edema. To study the dose-response effect of varying amounts of
crystalloid volume prior to spinal anesthesia, we measured maternal
hemodynamic variables and maternal and fetal COP in three groups of healthy
parturients receiving spinal anesthesia for elective cesarean delivery. Fifty-five
parturients were randomized in a double-blind fashion to receive one of 10, 20,
or 30 mL/kg of crystalloid volumes prior to induction of spinal anesthesia.
Measurements included mean arterial blood pressure (MAP), cardiac index (CI),
and systemic vascular resistance index (SVRI) recorded using noninvasive
thoracic impedance monitoring until delivery. Maternal and neonatal COP were
measured. All groups showed declines in MAP and SVRI from baseline at 5 min
after spinal anesthesia, but the amount of decline did not differ among groups.
Total ephedrine and additional intravenous (IV) fluid administered did not differ
among groups. The 20- and 30-mL/kg groups showed a larger decline in
maternal COP than the 10- mL/kg group; no differences in neonatal COP were
seen with varying preload. We conclude that increasing the amount of IV
crystalloid administered to 30 mL/kg in the healthy parturient does not
significantly alter maternal hemodynamics or ephedrine requirements after spinal
anesthesia and has no apparent benefit
Keywords: CARDIAC STROKE VOLUME/IMPEDANCE
CARDIOGRAPHY/INDUCED
HYPOTENSION/PREGNANCY/PRELOAD/PREVENTION/SECTION/SPINA
L-ANESTHESIA/WOMEN
Lang-Lazdunski, L., Heurteaux, C., Dupont, H., Rouelle, D., Widmann, C. and Mantz, J.
(2001), The effects of FK506 on neurologic and histopathologic outcome after
transient spinal cord ischemia induced by aortic cross- clamping in rats.
Anesthesia and Analgesia, 92 (5), 1237-1244.
Abstract: Spinal cord injury is a devastating complication of thoracoabdominal aortic
surgery. We investigated the effect of the immunosuppressant FK506, a
macrolide antibiotic demonstrated to have neuroprotective effects in cerebral
ischemia models, in a rat model of transient spinal cord ischemia. Spinal cord
ischemia was induced in anesthetized rats by using direct aortic arch plus left:
subclavian artery cross- clamping through a limited thoracotomy. Experimental
groups were as follows: sham-operation; control, receiving only vehicle; FK506
A, receiving FK506 (1 mg/kg TV) before clamping; and FK506 B, receiving
FK506 (1 mg/kg IV) at the onset of reperfusion. Neurologic status was assessed
at 24 h and then daily up to 96 h with a 0 to 6 scale (0, normal function; 6, severe
paraplegia). Rats were randomly killed at 24, 48, or 96 h, and spinal cords were
harvested for histopathology. Physiologic variables did not differ significantly
among experimental groups. All control rats suffered severe and definitive
paraplegia. FK506-treated rats had significantly better neurologic outcome
compared with control. Histopathologic analysis disclosed severe injury in the
lumbar gray matter of all control rats, whereas most FK506-treated rats had less
injury. These data suggest that FK506 can improve neurologic recovery and
attenuate spinal cord injury induced by transient thoracic aortic cross-clamping
Keywords: aortic surgery/cerebral/cerebral
ischemia/control/CYCLOSPORINE-A/experimental/GERBIL/IMMUNOSUPPR
ESSANT/INJURY/ischemia/MODEL/NITRIC-OXIDE
PRODUCTION/outcome/PREVENTION/rat/rats/REPERFUSION/RILUZOLE/s
pinal cord/spinal cord injury/status/STROKE/surgery/transient
Greim, C.A., Trautner, H., Kramer, K., Zimmermann, P., Apfel, C.C. and Roewer, N.
(2001), The detection of interatrial flow patency in awake and anesthetized
patients: A comparative study using transnasal transesophageal
echocardiography. Anesthesia and Analgesia, 92 (5), 1111-1116.
Abstract: The Valsalva maneuver in the awake patient and the ventilation maneuver in
the tracheally intubated anesthetized patient are two provocation methods to
detect a patent foramen ovale (PFO) by means of contrast transesophageal
echocardiography. In 60 patients undergoing posterior fossa surgery, a contrast
agent was administered via a peripheral vein during a Valsalva maneuver
immediately before anesthesia induction, followed by central venous
administration during a ventilation maneuver in the same patients when
anesthetized and endotracheally intubated. We evaluated both maneuvers with a
32-element monoplane transnasal transesophageal echocardiography probe to
trace the atrial flow of the contrast agent in a 90 degrees bicaval view. A
maneuver was rated positive when more than four bubbles appeared in the left
atrium during the first three cardiac cycles after intrathoracic pressure release.
The right atrial cross-sectional area before pressure release, and the peak septal
excursion during atrial contrast opacification, were measured. McNemar's test
was used to assess a paired dichotomous response on the two maneuvers for a
significant difference. In 56 patients, the ventilation maneuver was significantly
(P < 0.037) more often positive for PFO (n = 14) than the Valsalva maneuver (n
= 7). Although there was no difference in the methods regarding the peak septal
excursion, the mean right atrial area before pressure release was significantly
smaller during the ventilation maneuver than during the Valsalva maneuver (11.2
<plus/minus> 3.1 cm(2) vs 14.4 +/- 3.3 cm(2), n = 42, P < 0.05). In the patients
with a positive ventilation, but a negative Valsalva maneuver, the discrepancy
was even larger (10.9 <plus/minus> 4.4 cm2 vs 16.3 +/- 4.2 cm(2), n = 7,
P<0.001). We conclude that the ventilation maneuver is superior to the Valsalva
maneuver in detecting PFO. Our data suggest that a peak pressure of 30 cm H2O
during the ventilation maneuver achieves a more pronounced reduction in right
atrial load and allows right atrial pressure to exceed left atrial pressure when
intrathoracic pressure is released
Keywords: administration/AUTOPSY/cardiac/CONTRAST
ECHOCARDIOGRAPHY/detection/DIAGNOSIS/echocardiography/FORAME
N OVALE/Germany/left atrium/NEUROSURGICAL
PATIENTS/PARADOXICAL AIR-EMBOLISM/patent/patent foramen
ovale/PREVENTION/SITTING POSITION/STROKE/surgery/TO-LEFT
SHUNT/transesophageal echocardiography
Scott, N.B., Turfrey, D.J., Ray, D.A.A., Nzewi, O., Sutcliffe, N.P., Lal, A.B., Norrie, J.,
Nagels, W.J.B. and Ramayya, G.P. (2001), A prospective randomized study of
the potential benefits of thoracic epidural anesthesia and analgesia in patients
undergoing coronary artery bypass grafting. Anesthesia and Analgesia, 93 (3),
528-535.
Abstract: We performed an open, prospective, randomized, controlled study of the
incidence of major organ complications in 420 patients undergoing routine
coronary artery bypass. graft surgery with or without thoracic epidural anesthesia
and analgesia (TEA). All patients received a standardized general anesthetic.
Group TEA received TEA for 96 h. Group GA (general anesthesia) received
narcotic analgesia for 72 h. Both groups received supplementary oral analgesia.
Twelve patients were excluded- eight in Group TEA and four in Group
GA-because of incomplete data collection. New supraventricular arrhythmias
occurred in 21 of 206 patients (10.2%) in Group TEA compared with 45 of 202
patients (22.3%) in Group GA (P = 0.0012). Pulmonary function (maximal
inspiratory lung volume) was better in Group TEA in a subset of 93 patients (P <
0.0001). Extubation was achieved earlier (P < 0.0001) and with significantly
fewer lower respiratory tract infections in Group TEA (TEA = 31 of 206, GA =
59 of 202; P = 0.0007). There were significantly fewer patients with acute
confusion (GA = I I of 202, TEA = 3 of 206; P = 0.031) and acute renal failure
(GA = 14 of 202, TEA = 4 of 206; P = 0.016) in the TEA group. The incidence
of stroke was insignificantly less in the TEA group (GA = 6 of 202, TEA = 2 of
206; P = 0.17). There were no neurologic complications associated with the use
of TEA. We conclude that continuous TEA significantly improves the quality of
recovery after coronary artery bypass graft surgery compared with conventional
narcotic analgesia
Keywords: acute/arrhythmias/bypass
grafting/CARDIAC-SURGERY/CLONIDINE/complications/data
collection/HEMODYNAMICS/incidence/METABOLISM/PREVENTION/rando
mized/renal/renal failure/stroke/supraventricular arrhythmias/surgery/use
Neilipovitz, D.T., Bryson, G.L. and Nichol, G. (2001), The effect of perioperative
aspirin therapy in peripheral vascular surgery: A decision analysis. Anesthesia
and Analgesia, 93 (3), 573-580.
Abstract: Patients who undergo infrainguinal revascularization surgery are at increased
risk for perioperative thrombotic complications. Aspirin decreases thrombotic
events in the nonoperative setting; however, aspirin is often discontinued to
avoid perioperative hemorrhagic complications. We used a decision analysis to
determine whether aspirin should be discontinued before infrainguinal
revascularization surgery. Two strategies were compared: aspirin cessation 2 wk
before surgery and aspirin continuation throughout the perioperative period.
Clinical events examined included myocardial infarction, thrombotic
cerebrovascular accident, hemorrhagic cerebrovascular accident, gastrointestinal
hemorrhage, and incisional hemorrhagic complications. Event rates and effect of
aspirin were obtained by using MEDLINE. The outcomes were perioperative
mortality, life expectancy, and quality-adjusted life expectancy. According to the
model, continued aspirin use decreased perioperative mortality rates from 2.78%
to 2.05%. Continued aspirin use increased life expectancy from 14.83 to 14.89 yr
and increased quality-adjusted life expectancy from 14.72 to 14.79 yr. Aspirin
increased the number of hemorrhagic complications by 2.46%, primarily because
of an increased incidence of non-life-threatening complications
Keywords: aspirin/cerebrovascular/cerebrovascular accident/complications/decision
analysis/DISEASE/hemorrhage/HIGH-RISK/incidence/infarction/ISCHEMIA/lif
e expectancy/MORBIDITY/mortality/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/PLATELET-FUNCTION/PREVEN
TION/REGIONAL ANESTHESIA/revascularization/risk/SPINAL
HEMATOMA/STROKE/surgery/therapy/use/vascular/vascular surgery
Stanley, T.O., Mackensen, G.B., Grocott, H.P., White, W.D., Blumenthal, J.A.,
Laskowitz, D.T., Landolfo, K.P., Reves, J.G., Mathew, J.P. and Newman, M.F.
(2002), The impact of postoperative atrial fibrillation on neurocognitive outcome
after coronary artery bypass graft surgery. Anesthesia and Analgesia, 94 (2),
290-295.
Abstract: Neurocognitive decline is a continuing source of morbidity after cardiac
surgery. Atrial fibrillation occurs often after cardiac surgery and has been linked
to adverse neurologic events. We sought to determine whether postoperative
atrial fibrillation was associated with postoperative cognitive dysfunction.
Four-hundred-eleven patients were enrolled to receive a battery of
neurocognitive tests both preoperatively and 6 wk after elective coronary artery
bypass graft surgery. Neurocognitive test scores were separated into four
cognitive domains, with a composite cognitive index (the mean of the four
domain scores) determined for each patient at every testing period. Multivariable
analysis controlling forage, years of education, diabetes, mellitus, left ventricular
ejection fraction, and preoperative atrial fibrillation compared the presence of
postoperative atrial fibrillation with change hi cognitive function.
Three-hundred-eight patients completed both pre- and postoperative cognitive
testing; 69 patients (22% had postoperative atrial fibrillation. Those who
developed atrial fibrillation showed more cognitive decline than those who did
not develop postoperative atrial fibrillation (P = 0.036). Atrial fibrillation was
associated with poorer cognitive function 6 wk after surgery, Although the
mechanism of this association is yet to be determined, prevention of atrial
fibrillation may result in improved neurocognitive function
Keywords: atrial/atrial fibrillation/bypass/cardiac/cardiac
surgery/CARDIOPULMONARY BYPASS/cognitive decline/cognitive
function/coronary artery
bypass/diabetes/DYSFUNCTION/education/fibrillation/HOSPITAL STAY/left
ventricular/morbidity/outcome/postoperative/PREDICTORS/prevention/STROK
E/surgery/TRENDS
Fujiwara, T., Tanohata, K., Hagiwara, Y., Inoue, K. and Fujino, H. (1993),
Vertebrobasilar Insufficiency - Correlation of Clinical and Radiologic Findings.
Angiology, 44 (11), 853-861.
Abstract: Radiological and clinical findings of 20 cases with angiographically proven
stenosis or occlusion of the vertebrobasilar system and with clinical signs and
symptoms attributable to posterior circulation disorder were studied. A
simplified classification of vertebrobasilar arterial disease was presented; type I
refers to stenosis of the vertebrobasilar system or subclavian artery, type II refers
to vertebrobasilar occlusion, and type III refers to vertebrobasilar branch disease.
Type I lesions were further subdivided into types Ia and Ib; type Ia cases showed
no infarction in the posterior territory, whereas type Ib cases showed one or more
infarctions on computed tomography or magnetic resonance imaging. This
angiographic classification is based on treatment options that can be adopted to
specific types of lesion. In type I cases, lesions are usually amenable to surgical
or angiographic intervention. In type II cases, short-term anticoagulation is the
treatment of choice. In type III cases, treatment is primarily aimed at prevention
of complication and further stroke
Keywords: ANGIOGRAPHY/BASILAR ARTERY-OCCLUSION/CEREBELLAR
INFARCTION/CERVICAL SPONDYLOSIS/COMPUTED-
TOMOGRAPHY/DISEASE/SURGICAL TREATMENT/VERTEBRAL
ARTERY
Mortel, K.F., Wood, S., Pavol, M.A., Meyer, J.S. and Rexer, J.L. (1993), Analysis of
Familial and Individual Risk-Factors Among Patients with Ischemic Vascular
Dementia and Alzheimers-Disease. Angiology, 44 (8), 599-605.
Abstract: The purpose of this study was to determine relative contributions of
first-degree familial and individual risk factors to clinical manifestations of two
major age-related dementias. The authors interviewed 183 patients with dementia
of the Alzheimer's type (DAT) and 137 patients with ischemic vascular dementia
(IVD) together with family members and caregivers. Information was also
obtained from medical records and collateral sources as required. Risk factor
data within a predictive model for differentiating the two dementias were
evaluated. There was a greater incidence of family history of degenerative and
dementing neurologic disorders in DAT than in IVD. Both groups were
equivalent for family histories of cerebrovascular disease. Despite familial
equivalence, patients with IVD had a greater individual incidence of risk factors
for cerebrovascular disease. Analysis by gender revealed three observations.
Among DAT patients, family history for degenerative and dementing neurologic
disorders proved to be significantly greater among women than among men. This
risk factor did not, however, predict individual diagnoses for DAT. Women with
IVD were more likely to have a family history of cancer than men. Multiple
regression analyses revealed that reduced educational levels in women predicted
greater liability for IVD than for DAT. Hypertension, heart disease, and diabetes
mellitus were all risk factors for IVD, but not for DAT. Conclusions: Individual
and familial historical data provide useful information concerning identification,
pathogenesis, prevention, and treatments for vascular dementia but little
predictive information for identifying patients with Alzheimer's disease
Keywords: 1ST-DEGREE RELATIVES/ADRDA WORK
GROUP/AGE/CLINICAL-DIAGNOSIS/CRITERIA/DISORDERS/HEART-DI
SEASE/HISTORY/PREVALENCE/STROKE
Maruyama, S., Uchiyama, S., Tohgi, H., Hirai, S., Ikeda, Y., Shinohara, Y., Matsuda, T.,
Fujishima, M. and Kameyama, M. (1995), A Randomized Trial of E5510 Versus
Aspirin in Patients with Transient Ischemic Attacks. Angiology, 46 (11),
999-1008.
Abstract: In a randomized double-blind trial, the Study Group compared the efficacy of
E5510, a novel antiplatelet agent, and aspirin in preventing the recurrence of
transient ischemic attacks (TLA). In total, 227 patients who suffered from TIA in
the twelve weeks prior to the study were enrolled. They were randomly allocated
to three treatment groups, ie, 71 patients in the E5510 4 mg group, 77 patients in
the E5510 2 mg group, and 79 patients in the aspirin 324 mg group, and were
treated for twelve to twenty-four weeks. The incidence of recurrent TLA or
stroke was 21.5% in the aspirin group and was significantly lower in the E5510
groups, being 8.5% in the 4 mg group (P < 0.05) and 11.7% in the 2 mg group (P
< 0.05). Adverse events were observed in 5 cases in the 4 mg group, in 8 cases in
the 2 mg group, and in 10 cases in the aspirin group, but none of them were
serious. Since safety was judged to be comparable among the three groups,
E5510 appears to be an antiplatelet agent for the treatment of TIA with a clinical
benefit over aspirin
Keywords:
aspirin/CEREBRAL-ISCHEMIA/E-5510/HEAD/incidence/safety/SECONDAR
Y PREVENTION/STROKE/TIA/transient/treatment/WOMEN
Hoballah, J.J., Nazzal, M.M., Jacobovicz, C., Sharp, W.J., Kresowik, T.F. and Corson,
J.D. (1998), Entering the ninth decade is not a contraindication for carotid
endarterectomy. Angiology, 49 (4), 275-278.
Abstract: The role of carotid endarterectomy (CEA) in stroke prevention is now better
defined. However, its role in patients older than 79 years of age is controversial.
This group of patients has been excluded in most clinical trials. In this study the
authors reviewed their experience with CEA patients >79 years old. The records
of all patients older than 79 years of age who underwent a CEA in a recent time
period from January 1988 to December 1996 were retrospectively reviewed.
Forty-one patients (31 men, 10 women) were identified by computer search. The
indication for operation included transient ischemic attack in 12 (29.3%),
amaurosis fugax in nine (22%), stroke in two (4.9%), and nonhemispheric
symptoms in three (7.3%). Fifteen patients (36.6%) were asymptomatic. Medical
risk factors included coronary artery disease in 26 (63.4%), hypertension in 22
(53.7%), and smoking in 12 (29.3%). The procedure was performed under EEG
monitoring in all patients. General anesthesia was administered in 37 (90%) and
regional anesthesia in four (10%). Shunts were used in four (10%) patients. The
internal carotid artery was patched in 16 patients (39%). One patient (2.4%)
developed a perioperative stroke and only one patient developed perioperative
myocardial infarction (MI). None of the patients died within 30 days of surgery.
In addition to the one MI case, five patients developed minor complications. The
average length of time for stay after CEA was 3.4 days. Patients were followed
up for an average of 20.7 months. Six patients died during follow-up. Four of
those died from an MI and two from a stroke. The authors conclude that with
proper selection of patients, CEA is safe in the octogenarian. Age alone should
not be a contraindication for CEA
Keywords: age/carotid/carotid endarterectomy/clinical trials/complications/coronary
artery disease/EEG/endarterectomy/HEAD/hypertension/infarction/myocardial
infarction/prevention/RISK/risk factors/smoking/stroke/stroke
prevention/SURGERY/transient/transient ischemic attack/trials/women
Wakita, M., Yasaka, M., Minematsu, K. and Yamaguchi, T. (2002), Effects of
anticoagulation on infarct size and clinical outcome in acute cardioembolic
stroke. Angiology, 53 (5), 551-556.
Abstract: Effects of anticoagulation on infarct size and outcome have not been fully
elucidated in patients with acute cardioembolic stroke, although the
anticoagulation therapy reduces both occurrence and recurrence of ischemic
stroke greatly. The authors retrospectively investigated the relationship of
anticoagulation intensity to infarct size and outcome. In 104 consecutive patients
(mean age 70.8 +/- 10.0 years) who had suffered acute supratentorial
cardioembolic infarction or transient ischemic attacks, they analyzed risk factors
for atherosclerosis, underlying heart diseases, the infarct size (maximal area) on
brain computed tomography, and modified Rankin scale score upon discharge,
They compared these clinical data between patients who had received warfarin
before the ictus and those who had not. In addition, they investigated the effects
of the international normalized ratio (INR) on infarct size and outcome in 19
patients who had been receiving anticoagulant therapy and had measurement of
INR within 24 hours after stroke onset. There were 25 patients who had received
anticoagulation before the stroke (A/C group) and 79 patients who had not
(non-A/C group). The infarct size in the A/C group tended to be smaller than that
in the non-A/C group (p = 0.081, Mann-Whitney U test). In the 19 patients who
had prior anticoagulation and measurement of INR within 24 hours of stroke
onset, large infarcts were seen in 6 of 13 patients with INR < 1.6 and in none of 6
patients with INR; 1.6. Poor clinical outcome was observed in 5 patients with
INR < 1.6, but in none with INR greater than or equal to 1.6. In conclusion,
anticoagulant therapy with INR greater than or equal to 1.6 appears to effectively
prevent a large infarct and poor outcome, even when ischemic stroke dose occurs
in patients with an emboligenic heart disease
Keywords: acute/age/anticoagulant/anticoagulant
therapy/anticoagulation/atherosclerosis/ATRIAL-FIBRILLATION/brain/cardioe
mbolic/cardioembolic stroke/CEREBRAL INFARCTION/computed
tomography/disease/diseases/HEAD/heart/heart disease/heart
diseases/infarction/INR/intensity/international normalized
ratio/ischemic/ischemic
stroke/Japan/outcome/PREVENTION/recurrence/risk/risk
factors/stroke/THERAPY/transient/transient ischemic attacks/warfarin
Mas, J.L. (1996), Patent foramen ovale, aneurysm of the interatrial septum and cerebral
ischaemic accident. Annales de Cardiologie et D Angeiologie, 45 (9), 531-537.
Abstract: Persistence of a patent foramen ovale (PFO) and the presence of an aneurysm
of the interatrial septum (AIAS) are significantly more frequent in patients
examined for cerebral ischaemic accident of unknown cause than in control
subjects. The mechanism of ischaemic accidents associated with these cardiac
abnormalities (frequently associated with each other), particularly the frequency
of paradoxical embolism, remains unclear. In young patients, the risk of
recurrent cerebral ischaemic accident appears to be generally-low (1 to 2% per
year). Secondary prevention remains empirical and controversial. No
comparative studies are available to demonstrate the superiority of platelet
antiaggregants, oral anticoagulants or invasive treatments, such as endovascular
or surgical closure of the foramen ovale. A rational treatment can only be
proposed on the basis of a better understanding of the natural history of
ischaemic recurrences (identification of subgroups of patients at high or low risk
of recurrence) and the therapeutic benefit risk ratio
Keywords: aneurysm of the interatrial
septum/ANTICOAGULANT-THERAPY/cerebral ischaemic
accident/CEREBROVASCULAR EVENTS/CRYPTOGENIC
STROKE/ISCHEMIC STROKE/paradoxical embolism/PARADOXICAL
EMBOLISM/patent foramen ovale/PREVALENCE/RISK
FACTOR/THROMBOSIS/TRANSESOPHAGEAL
ECHOCARDIOGRAPHY/VENOUS THROMBOEMBOLISM
Moreau, P. and Bonnaure, E. (1993), Brain Protection in Carotid Surgery. Annales de
Chirurgie, 47 (8), 742-747.
Abstract: Brain protective measures and monitoring devices in carotid surgery tend
towards absolute prevention of strokes without totally achieving this objective.
When a postoperative stroke occurs, the question is: is it a brain protection
failure, a technical fault or an ill-advised indication? However, apart from
massive stroke, other significant disorders may occur especially affecting higher
functions. We studied a series of 126 patients with a mean age of 68.4 years who
underwent 140 carotid repairs. The average clamping time was 21.8 min. Brain
protection always consisted of: general anesthesia and heparinization,
hyperoxygenation, light hypercapnia without shunting or monitoring. Two deaths
and one hemiplegia (2.1 %) were due to an incorrect indication or technical error.
Three resolving neurological events were related to clamping intolerance (2.1 %).
What appears to be responsible, in case of stroke, is not so much clamping but
technical errors. We also observed disturbances of higher functions in 25 patients
(17,8 %). A study using psychometric tests performed preoperatively and at a
convenient time from the operation is proposed in order to demonstrate carotid
clamping effects on higher functions
Keywords: BRAIN PROTECTION/CAROTID/SURGERY
Finazzi, G. and Barbui, T. (1996), Feasibility of a randomized clinical trial for the
prevention of recurrent thrombosis in the antiphospholipid syndrome: The
WAPS project. Annales de Medecine Interne, 147 38-41
Keywords: ACTIVATED PROTEIN-C/ANTICARDIOLIPIN
ANTIBODIES/antiphospholipid
syndrome/BETA-2-GLYCOPROTEIN-I/ERYTHEMATOSUS/LUPUS
ANTICOAGULANT/MICE/MYOCARDIAL-INFARCTION/PROTHROMBIN
/STROKE/thrombosis/VENOUS THROMBOSIS
Bergmann, J.F. and Mahe, I. (2000), Prevention of venous thrombosis in medical
patients. Annales de Medecine Interne, 151 (3), 207-214.
Abstract: Prophylaxis of deep vein thrombosis with standard heparin and low molecular
weight heparin has been studied in many clinical trials in surgical patients and in
few and various medical conditions in hospitalized subjects. Clinical trials have
been conducted in patients with recent myocardial infarction, heart failure, stroke,
pulmonary sepsis, cancer, or any acute disease with a high risk factors for deep
vein thrombosis (previous thromboembolism, thrombophilia, obesity, recent
bedridden, dehydratation...). The combination of a high risk disease with a high
risk factor related to the history of the patient might reasonably conduct to a
prophylaxis with low molecular weight heparins. The duration of this treatment
has to be short and limited to the period of the acute medical condition inducing
a high risk for deep vein thrombosis. Prophylaxis has to be offered to patients
with ischemic stroke, cardiac failure, recent myocardial infarction, active cancer
or any other acute medical disease in patients with a previous thromboembolism
or thrombophilia history. Bedridden status and age are not, by themselves, an
indication for prophylaxis,vith heparins. A widespread diffusion of these
recommendations is needed to reduce overprescriptions
Keywords: acute/age/cancer/cardiac/clinical trials/deep vein thrombosis/DEEP-VEIN
THROMBOSIS/disease/heart/heart failure/heparin/heparins/high
risk/history/infarction/INPATIENTS/ischemic/ischemic stroke/low molecular
weight heparin/LOW-DOSE HEPARIN/medical patients/myocardial/myocardial
infarction/obesity/prevention/PROPHYLAXIS/risk/risk factor/risk
factors/status/stroke/THROMBOEMBOLISM/thrombosis/treatment/TRIAL/trial
s/venous thrombosis/WARFARIN
Sirol, M., Bouzamondo, A., Sanchez, P. and Lechat, P. (2001), Does statin therapy
reduce incidence of stroke? A meta-analysis. Annales de Medecine Interne, 152
(3), 188-193.
Abstract: Large scale clinical trials have clearly demonstrated that the HMG-CoA
reductase inhibitors (statins) reduce cardiovascular mortality by about 30%. The
specific benefit on stroke prevention remains however to be determined. We
reviewed all controlled clinical trials comparing statins versus placebo in primary
and secondary prevention of cardiovascular disease. We identified 13 studies
including 48, CARE, WOSCOPS and LIPID. More than 32000 patients were
randomized. The mete-analysis was performed using relative risk as treatment
effect parameter. Statin treatment induced a significant relative risk reduction
(RRR) of 24% (95% CI [12%-34%]) for stroke (2.1% vs 2.8%). RRR achieved
25% (95% CI [17%-32%]) for cardiovascular mortality and 34% (95% CI
[30%-38%]) for myocardial infarction, without heterogeneity between trials.
Stroke was reduced by 25% in secondary prevention, and by 15% in primary
prevention, without significant heterogeneity between them. RRR of stroke was
similar with pravastatin (RRR=0.79, p=0.0038) and with simvastatin (RRR=0.71,
p=0.049). The effect model analysis (relationship between annual incidence of
events in treated group versus placebo group in each trial) showed that RRR was
constant whatever the baseline risk. These results are in favor of a preventive
efficacy of statin treatment against stroke in middle aged patients with coronary
heart disease. Complementary information will be needed to clarify the
mechanism of this beneficial effect and to demonstrate statin efficacy in a
population with a higher risk of stroke such as the elderly
Keywords: aged/AVERAGE CHOLESTEROL LEVELS/cardiovascular/cardiovascular
disease/CARDIOVASCULAR EVENTS/cardiovascular
mortality/CARE/CAROTID ATHEROSCLEROSIS/CLINICAL
EVENTS/clinical trials/CONTROLLED TRIALS/coronary heart
disease/disease/elderly/heart/heart disease/HMG-CoA reductase
inhibitors/incidence/infarction/meta-analysis/MORTALITY/myocardial/myocard
ial
infarction/MYOCARDIAL-INFARCTION/population/PRAVASTATIN/prevent
ion/primary/primary prevention/PROGRESSION/randomized/relative
risk/risk/RISK-FACTORS/secondary/secondary
prevention/simvastatin/statin/statines/statins/stroke/stroke
prevention/therapy/treatment/trial/trials
Benkerrou, M., Brahimi, L. and Vilmer, E. (1999), Anemia in pediatric sickle cell
patients. Annales de Pediatrie, 46 (7), 479-485.
Abstract: Chronic hemolytic anemia is a consistent and early manifestation of sickle cell
anemia that arises as a direct consequence of the hemoglobin abnormality.
Genotype is the main determinant of steady-state hemoglobin levels and of the
occurrence of acute anemic events, although considerable interindividual
variability exists for a given genotype. Anemia develops at three months of age
and exhibits a number of specific features in younger children. Thus, massive
sequestration of blood in the spleen is a life-threatening event seen in about 30%
of homozygotes before splenic atrophy occurs around six years of age. Acute
anemia due to hemolysis or erythroblastopenia can occur in response to
infections, some of which are fostered by the functional asplenia. Parvovirus B19
is the leading cause of acute erythroblastopenia in pediatric sickle cell anemia.
The increased nutritional needs due to the conjunction of chronic: hemolysis and
growth can result in rapidly-developing nutritional deficiencies. The
management of anemia in sickle-cell patients requires early diagnosis and
symptomatic therapy. Targeted neonatal screening on a nationwide scale is
associated with a substantial reduction in mortality most marked in children
younger than five years of age. This reduction is due in part to parental education.
Red blood cell transfusions are reserved for severe acute complications and for
the prevention of their recurrence. They are also used before some surgical
procedures. Use of red blood cell transfusions to prevent stroke is controversial.
Simple measures such as education, vitamin supplementation, and
multidisciplinary follow-up have resulted in reductions in mortality and
morbidity due to sickle cell disease. Because it is fairly well tolerated, sickle cell
anemia is not in itself an indication for cumbersome treatments such as long-term
blood transfusion programs, or bone marrow transplantation
Keywords: acute/acute hemolysis/ACUTE SPLENIC SEQUESTRATION/acute splenic
sequestration/age/anemia/COHORT/complications/DEATH/diagnosis/DISEASE
/education/erythroblastopenia/hemoglobin/HYPERSPLENISM/morbidity/mortal
ity/prevention/recurrence/sickle cell anemia/stroke/therapy/transfusion
Oger, E. and Scarabin, P.Y. (1999), Risk of stroke among users of hormone replacement
therapy. Annales D Endocrinologie, 60 (3), 232-241.
Abstract: Background and Purpose Hormone replacement therapy relieves climateric
symptomes and prevents postmenopausal osteoporosis. A protective effect of
estrogen against coronary heart disease remains debatable and inconclusive
results have been reported with respect to the risk of stroke. We have therefore
performed an updated quantitative assessment of the risk for stroke associated
with hormone replacement therapy. Methods MEDLINE database was used
Studies analyzing postmenopausal women and considering any subtypes of
stroke - i.e. fatal or non-fatal; ischaemic or haemorrhagic - as the outcome of
interest were selected. An overall estimate was calculated as a weighted average
of the odds ratios or relative risks, with the weights bring the reciprocal of their
variance Random effects models were used to take into account the heterogeneity
of data. Results Six case-control studies, seventeen cohort studies and one
randomized trial were selected between 1978 and 1998. Seven studies assessed
the risk of ischaemic stroke associated with hormone replacement therapy and
the pealed estimate of the risk was 1.12 (95% confidence interval, 1.01 to 1.25).
The random effects model showed an increased risk of 18% (relative risk 1.18,
95% confidence interval, 0.98 to 1.43). Regarding haemorrhagic stroke, the
analysis based on two case-control studies and cine cohort study showed a
significantly reduced risk of 35%. Lastly, based an five studies, no significant
change in the risk of subarachnoidal hemorrhage was found. Conclusion This
updated analysis suggests an increased risk for ischaemic stroke among
postmenopausal women who nse oral estrogen replacement therapy. No data
regarding transdermal estrogen are available
Keywords: CARDIOVASCULAR-DISEASE/case-control
studies/COAGULATION/COHORT/cohort studies/cohort study/coronary heart
disease/estrogen/ESTROGEN
REPLACEMENT/FIBRINOLYSIS/FOLLOW-UP/heart/hemorrhage/hormone
replacement therapy/ischaemic
stroke/menopause/MORTALITY/osteoporosis/POSTMENOPAUSAL
WOMEN/PREVENTION/randomized/relative risk/risk/stroke/therapy/VENOUS
THROMBOEMBOLISM/women
Papoz, L. (2001), Prevention of cardiovascular disease - A literature review. Annales D
Endocrinologie, 62 (4), 274-279
Keywords: ARTERY DISEASE/ATHEROSCLEROSIS/cardiovascular/cardiovascular
disease/CORONARY HEART-DISEASE/disease/FOLLOW-UP/literature
review/MIDDLE-AGED MEN/MORTALITY/RANDOMIZED CONTROLLED
TRIAL/review/RISK-INTERVENTION/STROKE/VITAMIN-E
Osseby, G.V., Manceau, E., Lemesle-Martin, M., Thomas, V. and Giroud, M. (2001),
Statins and stroke. Annales D Endocrinologie, 62 (2), 113-120.
Abstract: The role of cholesterol in the pathogenesis of stroke, the role of the treatment
of hypercholesterolemia in the prevention of stroke have been controversed. The
explanation was based on the heterogenous characteristics of stroke, on the
relationship between several risk factors, and on the role of the age, in the
evaluation of these 2 questions. The discovery of statins induced major
therapeutic trials whose aim was the impact on coronary events. These trials
demonstrated that statins were accompanied with a major reduction of
cholesterol levels and stroke events similar to the one observed with coronary
events. Even prospective, placebo controlled, randomized specific trials for
stroke are necessary, we can state that cholesterol reduction is the most important
mechanism accounting for a decrease in stroke occurrence with statins
Keywords: 3-YEAR
FOLLOW-UP/age/CEREBROVASCULAR-DISEASE/cholesterol/CHOLESTE
ROL
REDUCTION/CIGARETTE-SMOKING/CORONARY-HEART-DISEASE/CO
RTICAL
INFARCTS/evaluation/HIGH-DENSITY-LIPOPROTEIN/hypercholesterolemia/
prevention/randomized/risk/risk
factors/RISK-FACTORS/SERUM-CHOLESTEROL/statins/stroke/TRANSIEN
T ISCHEMIC ATTACKS/treatment/trials
Melon, E. and Rimaniol, J.M. (1996), Vasospasm in subarachnoid haemorrhage:
Pharmacological treatment. Annales Francaises D Anesthesie et de Reanimation,
15 (3), 366-373.
Abstract: Pharmacological treatment of vasospasm in subarachnoid haemorrhage (SAH)
is founded on prevention and treatment of arterial narrowing and delayed
ischaemic deficits. Safety and efficacy of different agents have been studied and
trials classified according to the level of evidence proposed by the ''Stroke
Council'' of the American Heart Association. Early intracisternal fibrinolysis can
prevent vasospasm (level III to V of evidence, grade C). Pharmacological
treatment is based on few drugs. Nimodipine reduces poor outcome related to
vasospasm, but does not affect angiographic vessel caliber (level of evidence I
and II, grade A). Its use is strongly recommended. Nicardipine decreases
symptomatic and angiographic vasospasm, but does not affect outcome (level of
evidence I to V, grade B). Tirilazad associated with nimodipine prevents delayed
ischaemic deficits due to vasospasm and improves outcome in male patients.
Intra-arterial infusion of papaverine associated with transluminal angioplasty can
improve symptomatic vasospasm, resistant to conventional therapy (level of
evidence IV to V, grade C), Pharmacological treatment of vasospasm associated
with specific management founded on pathophysiology of SAH has improved
patients outcome
Keywords: amino steroids/calcium-channel blocking agents/CEREBRAL
VASOSPASM/COOPERATIVE ANEURYSM/delayed ischaemic
deficits/DOUBLE-BLIND TRIAL/HEMORRHAGE/INTRAVENOUS
NICARDIPINE/MULTICENTER/nicardipine/nimodipine/NIMODIPINE
TREATMENT/PREVENTION/subarachnoid
haemorrhage/SURGERY/THERAPY/treatment/trials/vasospasm
Venketasubramanian, N., Chang, H.M. and Chan, B.P.L. (2002), Update in the
management of stroke. Annals Academy of Medicine Singapore, 31 (6), 717-721.
Abstract: Recent advances have improved the outlook for patients with stroke,
Singapore's fourth leading cause of death. Stroke unit care reduces death,
dependency and institutionalisation, independent of age, gender and stroke
severity. Neuroimaging is essential prior to initiation of specific therapies. While
computed tomography (CT) Head remains the most widely used modality,
magnetic resonance imaging (MRI), particularly diffusion weighted imaging
(DWI) has enhanced the positive diagnosis of ischaemic stroke. General medical
measures include close monitoring, adequate oxygenation, avoidance of
excessive blood pressure lowering, reduction of hyperthermia, control of
hyperglycaemia, adequate nutrition, prevention of complications and early
rehabilitation. Despite the risk of fatal intracranial haemorrhage, thrombolysis
may improve outcomes in appropriately selected patients with ischaemic stroke.
No safe and effective neuroprotectant has been found. While suboccipital
craniectomy is established for large cerebellar infarcts and haemorrhage, surgical
evacuation of supratentorial haemorrhage has not been shown to be beneficial.
Hemicraniectomy reduces mortality after massive hemispheric ischemic stroke.
Early and sustained antiplatelet use after atherothrombotic stroke reduces stroke
recurrence. Stroke recurrence is also reduced by sustained warfarin use for
cardioembolic stroke, carotid endarterectomy for severe symptomatic internal
carotid artery stenosis, blood pressure lowering starting after the acute phase of
stroke and lipid lowering. On-going clinical trails are likely to provide better
treatments in the near future
Keywords: acute/ACUTE ISCHEMIC
STROKE/age/AMERICAN-HEART-ASSOCIATION/antiplatelet/blood
pressure/blood pressure lowering/cardioembolic/cardioembolic
stroke/carotid/carotid artery/carotid artery stenosis/carotid endarterectomy/cause
of death/cerebral infarction/cerebrovascular disease/cerebrovascular
haemorrhage/complications/computed
tomography/control/COUNCIL/CT/death/dependency/diagnosis/endarterectomy/
essential/gender/GUIDELINES/haemorrhage/HEALTH-CARE
PROFESSIONALS/hyperthermia/imaging/internal/internal carotid
artery/INTRACEREBRAL
HEMORRHAGE/intracranial/intracranial-haemorrhage/ischaemic/ischaemic
stroke/ischemic/ischemic stroke/lipid lowering/lipid-lowering/magnetic
resonance
imaging/management/medical/MEDICINE/monitoring/mortality/MRI/nutrition/o
utcomes/prevention/recurrence/rehabilitation/risk/severity/SPECIAL WRITING
GROUP/STATEMENT/stenosis/stroke/stroke
recurrence/thrombolysis/treatment/TRIAL/use/warfarin
Tan, C.C. (2002), National disease management plans for key chronic non-
communicable diseases in Singapore. Annals Academy of Medicine Singapore,
31 (4), 415-418.
Abstract: in Singapore, chronic, non-communicable diseases, namely coronary heart
disease, stroke and cancer, account for more than 60% of all deaths and a high
burden of disability and healthcare expenditure. The burden of these diseases is
likely to rise with our rapidly ageing population and changing lifestyles, and will
present profound challenges to our healthcare delivery and financing systems
over the next 20 to 30 years. The containment and optimal management of these
conditions require a strong emphasis on patient education and the development
of integrated models of healthcare delivery in place of the present uncoordinated,
compartmentalised way of delivering healthcare. To meet these challenges, the
Ministry of Health's major thrusts are disease control measures which focus
mainly on primary prevention; and disease management, which coordinates the
national effort to reduce the incidence of these key diseases and their
predisposing factors and to ameliorate their long-term impact by optimising
control to reduce mortality, morbidity and complications, and improving
functional status through rehabilitation. The key initiatives include restructuring
of the public sector healthcare institutions into two clusters, each comprising a
network of primary health care polyclinics, regional hospitals and tertiary
institutions. The functional integration of these healthcare elements within each
cluster under a common senior administrative and professional management, and
the development of common clinical IT systems will greatly facilitate the
implementation of disease management programmes. Secondly, the Ministry is
establishing National Disease Registries in coronary heart disease, cancer, stroke,
myopia and kidney failure, which will be valuable sources of clinical and
outcomes data. Thirdly, in partnership with expert groups, national committees
and professional agencies, the Ministry will produce clinical practice guidelines
which will assist doctors and healthcare professionals to better manage important
aspects of the key diseases. Finally, the Ministry has committed funds to support
selected National Disease Management programmes, illustrated by the disease
management plan for asthma
Keywords: ageing/ASTHMA/cancer/chronic/clinical practice/clinical practice
guidelines/complications/control/coronary heart
disease/development/disability/disease/disease
control/diseases/education/functional status/guidelines/health/health
care/heart/heart
disease/hospitals/incidence/management/MEDICINE/morbidity/mortality/Nation
al Disease Registries/non-communicable diseases/patient
education/population/practice guidelines/prevention/primary/primary health
care/primary prevention/QUALITY/rehabilitation/status/stroke/TRENDS
Marinella, M.A. (1997), Agranulocytosis associated with ticlopidine: A possible benefit
with filgastrim. Annals of Clinical and Laboratory Science, 27 (6), 418-421.
Abstract: Ticlopidine is an oral antiplatelet agent frequently utilized in the treatment of
cerebrovascular disease and is rarely associated with severe bone marrow
suppression, typically aplastic anemia. Reports in the literature of isolated
agranulocytosis are few, although they may be associated with significant
morbidity and mortality. A case is reported of an elderly woman who developed
febrile agranulocytosis several weeks lifter commencing ticlopidine but who had
a favorable outcome after cessation of that drug and treatment with filgastrim
Keywords: aplastic anemia/cerebrovascular/cerebrovascular
disease/elderly/MECHANISM/morbidity/mortality/PREVENTION/SEVERE
APLASTIC-ANEMIA/STROKE/THERAPY/ticlopidine/treatment
Haan, M.N. and Weldon, M. (1996), The influence of diabetes, hypertension, and stroke
on ethnic differences in physical and cognitive functioning in an ethnically
diverse older population. Annals of Epidemiology, 6 (5), 392-398.
Abstract: Prevention of decline in cognitive and physical functioning In the elderly has
become an important focus in geriatric medicine. Hispanics are among the
fastest-growing group of elderly in the United States, yet few data are available
on functional impairments in this group. We examined the association between
ethnicity (non-Hispanic whites [NHW], English-speaking Hispanics [EH], and
Spanish-speaking Hispanics [SH]) and cognitive status, self-assessed functional
status, and physical performance in a community-dwelling sample of 589 people
aged greater than or equal to 60 years. The purpose of this study was to examine
the association between ethnicity and these measures of functional status and to
evaluate the influence of comorbid stroke, diabetes, and hypertension on this
association. We found that EH and SH had significantly lower scores on the
MiniMental State Exam than NHW, but that this difference was almost entirely
due to educational level. When SH whose educational attainment was grade 8 or
higher were compared to NHWs, there were no differences in cognitive
functioning. Those with diabetes and stroke had poorer cognitive functioning.
Among those with stroke, EH and SH women had more self-assessed functional
limitations (IADLs and ADLs) than NHW. Male SH and EH with diabetes also
had more self- assessed functional limitations than NHW. SH with two or three
of these conditions had more IADL limitations. Our results suggest that elderly
community-dwelling Hispanics experience greater levels of disability and that
this is due, in part, to lower socioeconomic status and higher prevalence of
disabling conditions. (C) 1996 Elsevier Science Inc
Keywords: cognitive function/comorbidity/cross-sectional
study/elderly/Hispanics/hypertension/MEXICAN-AMERICANS/MINI-MENTA
L STATE/physical disability/PREDICTORS/stroke
Haan, M.N., Selby, J.V., Rice, D.P., Quesenberry, C.P., Schofield, K.A., Liu, J. and
Fireman, B.H. (1996), Trends in cardiovascular disease incidence and survival in
the elderly. Annals of Epidemiology, 6 (4), 348-356.
Abstract: This study compared the age-specific incidence, postdiagnostic survival, and
mortality for cardiovascular disease (CVD) in two cohorts of people aged 65
years and older. All subjects were members of a large prepaid health
maintenance organisation. The influence of changes in CVD risk factors on these
rates also was evaluated. Trends in prevalence, incidence, postdiagnostic survival,
and mortality for CVD were examined in both cohorts in 1971 and 1980.
Myocardial infarction (MI), angina pectoris, stroke, and congestive heart failure
(CHF) were included as CVD outcomes in this analysis. Nine-year prospective
data on these diagnoses were abstracted from medical records and computerized
hospitalization records for both cohorts. Age-sex-adjusted cardiovascular
mortality was lower for both sexes by similar to 20% in the 1980 cohort. Overall
survival did not change, whereas cancer mortality increased by 76% in women
and 36% in men. With the exception of stroke, there was no increase in
age-adjusted or age-specific prevalence. In men, the age- adjusted prevalence of
stroke in men was 24% higher in the 1980 cohort. Age-adjusted 9-year incidence
of MI, angina pectoris, stroke, and CHF did not change between cohorts in either
sex. Postdiagnostic, age-adjusted mortality for men with incident stroke was 24%
lower in the 1980 cohort, and Postdiagnostic, age-adjusted mortality for men
with incident angina was 35% lower in the 1980 cohort. Adjustment for risk
factors measured at or before baseline had little influence on cohort differences
in CVD incidence or duration of surgical after CVD diagnosis. This study
confirms other research showing a decline in CVD mortality over the past 20
years. These findings suggest that prevalent angina pectoris is increasing in men,
and that survival with stroke and with angina is improving in men. Later
diagnosis of incident CHF in men suggests that prevention and early detection
may be postponing the development of more serious disease. Ann Epidemiol
1996; 6:348-356
Keywords: aged/angina/cardiovascular disease/cardiovascular diseases/cohort
study/COMMUNITY/elderly/health/health
promotion/heart/HEART-DISEASE/life
expectancy/MINNESOTA/mortality/preventive medicine/risk factors/stroke
Casper, M.L., Barnett, E.B., Armstrong, D.L., Giles, W.H. and Banton, C.J. (1997),
Social class and race disparities in premature stroke mortality among men in
North Carolina. Annals of Epidemiology, 7 (2), 146-153.
Abstract: The purpose of this work was to examine the association between social class
and premature stroke mortality among blacks and whites. For black men and
white men in North Carolina, aged 35- 54 years, mortality data from. vital
statistics files and population data from Census Public Use Microdata Sample
files were matched according to social class for the years 1984-1993. Four
categories of social class were defined based upon a two- dimensional
classification scheme of occupations. For each category of social class,
race-specific age-adjusted stroke mortality rates were calculated, and
race-specific prevalences of income, wealth, education, unemployment, and
disability were estimated. Women were excluded because comparable
information on social class was not available from the mortality and population
data sources. For both black men and white men, the highest rates of premature
stroke mortality were observed among the lowest social classes. The rate ratios
(RR) between the lowest and highest social class were 2.8 for black men and 2.3
for white men. Within each social class, black men had substantially higher rates
of premature stroke mortality than white men (black-to-white RR ranged from
4.0 to 4.9). Among both black men and white mon, the highest social class
consistently had the most favorable levels of income, wealth, education, and
employment. The inverse association between social class and stroke mortality
for both black men and white men supports the need for stroke prevention efforts
that address the structural inequalities in economic and social conditions. (C)
1997 by Elsevier Science Inc
Keywords: aged/AMBULATORY
BLOOD-PRESSURE/CARDIOVASCULAR-DISEASE/cerebrovascular
disease/CORONARY HEART-DISEASE/education/JOB DECISION
LATITUDE/JOHN-
HENRYISM/men/mortality/MYOCARDIAL-INFARCTION/NEW-YORK/OC
CUPATIONAL NOISE EXPOSURE/prevention/race/socioeconomic
status/SOCIOECONOMIC- STATUS/STRAIN/STRESS/stroke/stroke
prevention
Barnett, E., Armstrong, D.L. and Casper, M.L. (1999), Evidence of increasing coronary
heart disease mortality among black men of lower social class. Annals of
Epidemiology, 9 (8), 464-471.
Abstract: PURPOSE: Few data are available to examine coronary heart disease (CHD)
mortality trends by social class in the United States, in contrast to ample data and
well-documented social class disparities in CHD in Europe. In addition, previous
analyses of U.S. national data indicated that the rate of decline in CHD mortality
slowed substantially far blacks in the 1980s. Using a recently published method
for calculating mortality rates by social class, we examined trends in CHD
mortality for black men and white men aged 35-54 in North Carolina from 1984
to 1993. METHODS: Men were assigned to one of four social classes: primary
white collar (I), secondary white collar (II), primary blue collar (III), or
secondary: blue collar (IV), based on usual occupation as recorded on the death
certificate. Population denominators for each social class were constructed. using
data from census Public Use Microdata Sample files. Average annual percent
change in mortality rates for each race-social class group was derived from linear
regression of the log-transformed age-adjusted rates. RESULTS: For black men,
CHD mortality increased by 18% in social class II, by 2% in social class III, and
by 6% in social class IV over the 10-year study period. In contrast, CHD
mortality decreased by 33% for black men in social class I (the highest class).
CHD mortality declined for all white men, with the greatest decline in social
class I and the least decline in social class IV. CONCLUSIONS: These results
suggest that CHD prevention efforts have not benefited black men of lower
social class, and that public health programs need to be targeted to these men.
Ann Epidemiol 1999;9:464-4761. Published by Elsevier Science Inc
Keywords: ACCURACY/aged/blacks/coronary heart
disease/DEATH/DECLINE/health/heart/INDUSTRY
DATA/INEQUALITIES/men/mortality/mortality
trends/NEW-YORK/OCCUPATION/ONSET/prevention/public
health/RACE/social class/socioeconomic status/STROKE MORTALITY/United
States/UNITED-STATES
Giles, W.H., Kittner, S.J., Croft, J.B., Wozniak, M.A., Wityk, R.J., Stern, B.J., Sloan,
M.A., Price, T.R., McCarter, R.J., Macko, R.F., Johnson, C.J., Feeser, B.R.,
Earley, C.J., Buchholz, D.W. and Stolley, P.D. (1999), Distribution and
correlates of elevated total homocyst(e)ine: The Stroke Prevention in Young
Women Study. Annals of Epidemiology, 9 (5), 307-313.
Abstract: PURPOSE: To determine the distribution and correlates of elevated total
homocyst(e)ine (tHcy) concentration in a population of premenopausal black and
white women. METHODS: Data from the Stroke Prevention in Young Women
Study (N = 304), a population-based study of risk factors for stroke in women
aged 15-44 years of age, were used to determine the distribution and correlates of
elevated tHcy in black (N = 103) and white women (N = 201). RESULTS: The
mean tHcy level for the population was 6.58 mu mol/L (range 2.89-26.5 mu
mol/L). Mean tHcy levels increased with age, cholesterol level, alcohol intake,
and number of cigarettes smoked tall: (p < 0.05). There were no race differences
(mean tHcy 6.72 mu mol/L among blacks and 6.51 mu mol/L among whites; p =
0.4346). Regular use of multivitamins and increasing education was associated
with significant reductions in tHcy concentration. Approximately 13% of the
sample had elevated tHcy levels, defined as a tHcy concentration greater than or
equal to 10.0 mu mol/L. Multivariate-adjusted correlates of elevated tHcy
included education > 12 vs. less than or equal to 12 (odds ratio [OR] = 0.4, 95%
confidence interval [CI] = 0.2-0.8); smoking greater than or equal to 20
cigarettes/day vs. nonsmokers (OR = 2.8, 95% CI = 1.1-7.3); and the regular use
of multivitamins (OR = 0.4, 95% CI = 0.2-0.9). CONCLUSIONS: These results
suggest that a substantial proportion of healthy young premenopausal women
have tHcy levels that increase their risk for vascular disease. A number of
potentially modifiable behavioral and environmental factors appear to be
significantly related to elevated tHcy levels in young women
Keywords: age/aged/alcohol/blacks/cholesterol/COMMON
MUTATION/CORONARY-ARTERY
DISEASE/correlates/DETERMINANTS/education/FOLATE/FOLIC-ACID/hom
ocyst(e)ine/homocysteine/HORDALAND
HOMOCYSTEINE/METHYLENETETRAHYDROFOLATE
REDUCTASE/NEW-YORK/PLASMA HOMOCYSTEINE
CONCENTRATIONS/population/population-based/race/risk/RISK
FACTOR/risk factors/risk factors for stroke/smoking/stroke/vascular/vascular
disease/VASCULAR- DISEASE/women
Williams, R.R., Rao, D.C., Ellison, R.C., Arnett, D.K., Heiss, G., Oberman, A., Eckfeldt,
J.H., Leppert, M.F., Province, M.A., Mokrin, S.C. and Hunt, S.C. (2000),
NHLBI Family Blood Pressure Program: Methodology and recruitment in the
HyperGEN network. Annals of Epidemiology, 10 (6), 389-400.
Abstract: PURPOSE: Hypertension is a common precursor of serious disorders
including stroke, myocardial infarction, congestive heart failure, and renal failure
in whites and to a greater extent in African Americans. Large
genetic-epidemiological studies of hypertension are needed to gain information
that will improve future methods for diagnosis, treatment, and prevention of
hypertension, a major contributor to cardiovascular morbidity and mortality.
METHODS: We report successful implementation of a new structure of research
collaboration involving four NHLBI "Networks," coordinated under the Family
Blood Pressure Program. The Hypertension Genetic Epidemiology Network
(HyperGEN) involves scientists from six universities and the NHLBI who seek
to identify and characterize genes promoting hypertension. Blood samples and
clinical data were projected to be collected from a sample of 2244 hypertensive
siblings diagnosed before age 60 from 960 sibships (half African-American) with
two or more affected persons. Nonparametric sibship linkage analysis of over
one million genotype determinations (20 candidate loci and 387 anonymous
marker loci) was projected to have sufficient power for detecting genetic loci
promoting hypertension. For loci showing evidence for linkage in this study and
for loci reported linked or associated with hypertension by other groups,
genotypes are compared in hypertensive cases Versus population-based controls
to identify or confirm genetic variants associated with hypertension. For some of
these genetic variants associated with hypertension, detailed physiological and
biochemical characterization of untreated adult offspring carriers versus
non-carriers may help elucidate the pathophysiological mechanisms that promote
hypertension. RESULTS: The projected sample size of 2244 hypertensive
participants was surpassed, as 2407 hypertensive individuals (1262 African
Americans and 1145 whites) from 917 sibships were examined. Detailed consent
forms were designed to offer participants several options for DNA testing; 94%
of participants gave permission for DNA testing now or in the future for any
confidential medical research, with only 6% requesting restrictions for tests
performed on their DNA. Since this is a family study, participants also are asked
to list all first degree relatives (along with names, addresses, and phone numbers)
and to indicate for each relative whether they were willing to allow study staff to
make a contact. Seventy percent gave permission to contact some relatives; about
30% gave permission to contact all first degree relatives; and less than 1% asked
that no relatives be contacted. Successes after the first four years of this study
include: 1) productive collaboration of eight centers from six different locations;
2) early achievement of recruitment goals for study participants including
African-Americans; 3) an encouraging rate of consent for DNA testing
(including future testing) and relative contacting; 4) completed analyses of
genetic linkage and association for several candidate gene markers and
polymorphisms; 5) completed genotyping of random markers for over half of the
full sample; and 6) early sharing of results among the four Family Blood
Pressure Program networks for candidate and genome search analyses.
CONCLUSIONS: Experience after four years of this five-year program
(1995-2000) suggests that the newly initiated NHLBI Network Program
mechanism is fulfilling many of the expectations for which it was designed. It
may serve as a paradigm for future genetic research that can benefit from large
sample sizes, frequent sharing of ideas among laboratories, and prompt
independent confirmation of early findings, which are required in the search for
common genes with relatively small effects such as those that predispose to
human hypertension. Ann Epidemiol 2000;10:389- 400. Published by Elsevier
Science inc
Keywords: African Americans/age/ANGIOTENSINOGEN/ASSOCIATIONS/blood
pressure/cardiovascular/cardiovascular morbidity/CARDIOVASCULAR
RISK-FACTORS/congestive heart
failure/consent/diagnosis/DNA/DYSLIPIDEMIC
HYPERTENSION/epidemiology/EXTENSIVE
INFORMATION/FRENCH-CANADIAN
POPULATION/GENE/genes/genetic/genetics/heart/heart
failure/human/hypertension/infarction/linkage/linkage
analysis/markers/morbidity/mortality/myocardial/myocardial
infarction/NEW-YORK/pathophysiology/population-based/prevention/recruitme
nt/renal/SODIUM-LITHIUM
COUNTERTRANSPORT/stroke/treatment/TWINS/UTAH PEDIGREES
Du, X.L., McNamee, R. and Cruickshank, K. (2000), Stroke risk from multiple risk
factors combined with hypertension: A primary care based case control study in
a defined population of northwest England. Annals of Epidemiology, 10 (6),
380-388.
Abstract: PURPOSE: To examine how hypertension interacts with ether known risk
factors in affecting the rick of stroke in a primary care based setting. METHODS:
Cases were patients with first-ever stroke identified from the community-based
stroke register in 1994-95 in northwest England. Two controls per case wore
randomly selected from the same primary care site and matched by age and sex.
Information on predefined risk factors was extracted from medical records.
RESULTS: 267 cases and 534 controls were included. Adjusted odds ratio (OR)
for stroke from hypertension was 2.6 (95%, confidence interval: 1.7-3.9). In
hypertensives who were current smokers, risk of stroke was increased 6 fold (OR
= 6.1 (2.7-13.7)) as compared to non- smokers without hypertension.
Hypertensives who had a preexisting history of myocardial infarction or obesity
or diabetes had 3 fold higher risks of stroke. Subjects with hypertension and with
a history of transient ischemic attack or atrial fibrillation had greater than or
equal to 8 fold excess risk of stroke. Among them, the risk was greater in those
with poorly controlled or untreated hypertension (OR = 13.2 (2.6- 67.0)) and in
those with well or moderately controlled (OR = 5.2 (1.6-17.2)) as compared to
subjects without both risk factors. There appeared to be a steady increase in rick
of stroke according to the number of risk factors present, particularly in
hypertensive subjects. CONCLUSIONS: Stroke risks in hypertensives associated
with combinations of other risk factors appeared to follow an additive model.
Subjects with multiple risk factors should he targeted in order to reduce the
overall risk for stroke. Ann Epidemiol 2000;10:380- 388. (C) 2000 Elsevier
Science Inc. All rights reserved
Keywords: age/ALCOHOL/atrial
fibrillation/BLOOD-PRESSURE/CARDIOVASCULAR-DISEASE/case-control
study/CEREBROVASCULAR-
DISEASE/COMMUNITY/control/diabetes/England/fibrillation/FRAMINGHA
M/HEALTH/history/hypertension/infarction/ischemic/MANAGEMENT/myocar
dial/myocardial
infarction/NEW-YORK/obesity/population/PREVENTION/primary/primary
care/risk/risk factors/sex/stroke/transient/transient ischemic attack/WEST
ENGLAND
Schreiner, P.J., Wu, K.K., Malinow, M.R., Stinson, V.L., Szklo, M., Nieto, J. and Heiss,
G. (2002), Hyperhomocyst(e)inemia and hemostatic factors: The atherosclerosis
risk in communities study. Annals of Epidemiology, 12 (4), 228-236.
Abstract: PURPOSE: To determine whether homocyst(e)ine (H(e)) is related to
hemostatic factors in a population-based sample without evidence of
cardiovascular disease. METHODS: A subsample of 660 participants-67
African-American women, 53 African-American men, 201 white women, and
339 white men-was selected from the Atherosclerosis Risk in Communities
Study baseline cohort. This was based on carotid intimal-medial wall thickness
above the 90th percentile or below the 75th percentile of the population
distribution, assessed by B-mode ultrasonography. Unadjusted and
multivariable-adjusted associations between fasting plasma H(e) and the
hemostatic factors fibrinogen, factor VII:c, factor VIII:c, protein C antigen,
hematocrit, platelet count, beta-thromboglobulin ( beta-TG), tissue plasminogen
activator (tPA), PAI-1, D-dimer, and lipoprotein[a] were examined. RESULTS:
Mean age-adjusted H(e) was positively, albeit weakly, correlated with beta-TG,
tPA, hematocrit, D-dimer and PAI-1; inversely cot-related with protein C; and
was higher in smokers, men and African-Americans. In multivariable regression,
beta-TG, tPA, and factor VII:c were positively associated with H(e), as well as
age, black race, male sex, and current cigarette smoking. CONCLUSIONS:
These cross-sectional data for a biracial group of middle-aged individuals
suggest that H(e) levels falling below values consistent with homocyst(e)inemia
are associated with several prothrom boric factors after adjustment for
sociodemographic factors. If H(e) change is antecedent to altered hemostasis,
FDA-mandated fortification of grain products with folic acid for prevention of
fetal neural tube defects may lead to both reduced plasma H(e) levels and
improved hemostatic profiles. (C) 2002 Elsevier Science Inc. All rights reserved
Keywords: African American/African Americans/African-American
women/age/atherosclerosis/cardiovascular/cardiovascular
disease/carotid/cigarette smoking/CORONARY-ARTERY
DISEASE/disease/fibrinogen/folic acid/HEART-
DISEASE/hematocrit/hemostasis/homocyst(e)ine/homocysteine/LIPOPROTEIN
(A)/men/MYOCARDIAL-INFARCTION/NEW-YORK/PLASMA
HOMOCYST(E)INE/plasminogen
activator/platelet/population/population-based/prevention/PROTEIN-C
ACTIVATION/race/risk/SERUM TOTAL
HOMOCYSTEINE/sex/smoking/STROKE/TISSUE-PLASMINOGEN-ACTIV
ATOR/tPA/ultrasonography/VASCULAR-DISEASE/women
Yeh, S.P., Hsueh, E.J., Wu, H. and Wang, Y.C. (1998), Ticlopidine-associated aplastic
anemia - A case report and review of literature. Annals of Hematology, 76 (2),
87-90.
Abstract: Serious hematologic complications associated with ticlopidine have been
reported, including aplastic anemia. We report here an additional case of fatal
aplastic anemia due to ticlopidine. A 66-year-old male patient developed fever
and pancytopenia 2 months after ticlopidine was started. Despite the
administration of granulocyte colony-stimulating factor (G-CSF) and
broad-spectrum antibiotics, as well as aggressive red cell and platelet
transfusions, the patient died 16 days after admission due to septic shock.
Eighteen other cases of ticlopidine-induced aplastic anemia published in the
English literature are also reviewed and presented here. Eight of the total 19
patients (including the one reported here) have died, mostly due to infection. Of
the seven who received supportive treatment only, four had spontaneous
recovery. Nine cases were treated with G-CSF or granulocyte-macrophage
colony-stimulating factor (GM-CSF), and response was observed in only four of
them. Several other cases were treated with high-dose corticosteroids or
androgens; however, it was not possible to evaluate the efficacy of these
treatments because of the limited number of cases. In the absence of satisfactory
treatment for ticlopidine-induced aplastic anemia at present, it may be reasonable
to try antilymphocyte globulin or cyclosporine. Also, great efforts should be
made in the prevention and management of infection accompanying this disease
Keywords: administration/antilymphocyte globulin/aplastic
anemia/complications/corticosteroid/cyclosporine/growth
factor/MECHANISM/NEW-YORK/PATIENT/PREVENTION/STROKE/THER
APY/ticlopidine/treatment
Yasaka, M., Oomura, M., Ikeno, K., Naritomi, H. and Minematsu, K. (2003), Effect of
prothrombin complex concentrate on INR and blood coagulation system in
emergency patients treated with warfarin overdose. Annals of Hematology, 82 (2),
121-123.
Abstract: We investigated the effect of prothrombin complex concentrate (PCC) on the
international normalized ratio (INR) and blood coagulation system in two
emergent patients treated with warfarin for secondary prevention of
cardioembolic stroke due to nonvalvular atrial fibrillation. An 80-year-old
woman developed massive subcutaneous hemorrhage and swelling on her right
upper extremity with weak pulsation of the right radial artery and had an INR
above 10. An 83-year-old man had pleural effusion with an INR value of 6.69
and pleural puncture was immediately required. We administered 500 IU of PCC
to the two patients (17.2 IU/kg and 12.5 IU/kg) with 10 mg of vitamin K. The
INR decreased to 1.12 and 1.85, respectively, with an increase of plasma levels
of protein C and coagulant factors IIa, VIIa, IXa, and Xa 10 min after
administration. The plasma levels of the thrombin-antithrombin III complex
increased (from 4.0 to 12.0 mug/l and from 0.5 to 28.9 mug/l, respectively,
normal value <3.0), but prothrombin fragment 1+2 increased minimally 10 min
after administration (from 0.4 to 1.1 nmol/ml and from 0.4 to 0.7 nmol/ml,
respectively, normal value 0.4-1.4 nmol/ml). Plasma levels of D-dimer remained
unchanged. The massive subcutaneous hemorrhage in the former patient
improved in 14 days. Anticoagulation was restarted in the latter patient after 14
days of PCC administration. There were no embolic episodes during the month
after PCC administration. In conclusion, a small amount of PCC may be
effective in immediately correcting increased INR levels with increased plasma
levels of protein C and coagulant factors IIa, VIIa, IXa, and Xa and may partially
activate the coagulation system without any effects on plasma levels of D-dimer
Keywords: administration/atrial/atrial fibrillation/blood coagulation
system/cardioembolic/cardioembolic
stroke/coagulation/fibrillation/hemorrhage/INR/international normalized
ratio/INTRACRANIAL HEMORRHAGE/Japan/NEW-YORK/nonvalvular atrial
fibrillation/NONVALVULAR ATRIAL-FIBRILLATION/ORAL
ANTICOAGULANT REVERSAL/PREVENTION/prothrombin complex
concentrate/secondary/secondary
prevention/STROKE/USA/vitamin/warfarin/warfarin overdose
Duke, R.J., Bloch, R.F., Turpie, A.G.G., Trebilcock, R. and Bayer, N. (1986),
Intravenous Heparin for the Prevention of Stroke Progression in Acute Partial
Stable Stroke - A Randomized Controlled Trial. Annals of Internal Medicine,
105 (6), 825-828
Keywords: PHYSICIANS
Heidrich, F.E., Stergachis, A. and Gross, K.M. (1991), Diuretic Drug-Use and the Risk
for Hip Fracture. Annals of Internal Medicine, 115 (1), 1-6.
Abstract: Objective: To test the hypothesis that use of thiazide diuretics prevents hip
fracture and to study the risk for hip fracture associated with furosemide use.
Design: A case-control study. Setting: Hospitals owned by a health maintenance
organization in Washington. Patients: Elderly patients (n = 462) hospitalized
because of a hip fracture between 1977 and 1983 and an equal number of age-
and sex-matched population- based control patients. Measurements: Use of
thiazide diuretics and furosemide was ascertained from medical records and
computerized pharmacy records. The relative risk for hip fracture associated with
diuretic use was calculated and adjusted for the potentially confounding effects
of nursing home residence; previous hospitalizations; a history of stroke,
alcoholism, or the organic brain syndrome; body weight; leg paralysis; and use of
phenobarbital, corticosteroids, or other diuretics. Current and former users of
diuretics were analyzed separately. Main Results: The adjusted risk for hip
fracture was 1.6 (95% Cl, 1.0 to 2.5) for current thiazide users. The adjusted risk
for hip fracture for current furosemide use was 3.9 (Cl, 1.5 to 10.4). Conclusions:
According to this study, use of thiazide diuretics did not protect against hip
fracture and cannot be recommended for fracture prevention. Current furosemide
use was also associated with hip fracture
Keywords: BONE-MINERAL CONTENT/DIURETICS/ELDERLY
WOMEN/ESTROGEN/FALLS/FUROSEMIDE/HIP
FRACTURES/OSTEOPOROSIS/PREVENTION/THIAZIDE/THIAZIDE
DIURETICS/THIAZIDES
Ridker, P.M., Manson, J.E., Gaziano, J.M., Buring, J.E. and Hennekens, C.H. (1991),
Low-Dose Aspirin Therapy for Chronic Stable Angina - A Randomized,
Placebo-Controlled Clinical-Trial. Annals of Internal Medicine, 114 (10),
835-839.
Abstract: Objective: To evaluate the efficacy of low-dose aspirin in the primary
prevention of myocardial infarction among patients with chronic stable angina.
Design: A randomized, double-blind, trial. Patients: The study included 333 men
with baseline chronic stable angina but with no previous history of myocardial
infarction, stroke, or transient ischemic attack who were enrolled in the
Physician's Health Study, a trial of aspirin among 22 071 male physicians.
Intervention: Patients were randomly assigned to receive alternate-day aspirin
therapy (325 mg) or placebo and were followed for an average of 60.2 months
for the occurrence of myocardial infarction, stroke, or cardiovascular death.
Results: During follow-up, 27 patients had confirmed myocardial infarction; 7
were among the 178 patients with chronic stable angina who received aspirin
therapy and 20 were among the 155 patients who received placebo (relative risk,
0.30; 95% CI, 0.14 to 0.63; P = 0.003). While simultaneously controlling for
other cardiovascular risk factors in a proportional hazards model, an overall 87%
risk reduction was calculated (relative risk, 0.13; CI, 0.04 to 0.42; P < 0.001).
For the subgroup of patients with chronic stable angina but no previous coronary
bypass surgery or coronary angioplasty, an almost identical reduction in the risk
for myocardial infarction was found (relative risk, 0.14; CI, 0.04 to 0.56; P =
0.006). Of 13 strokes, 11 occurred in the aspirin group and 2 in the placebo
group (relative risk, 5.4; CI, 1.3 to 22.1; P = 0.02). No stroke was fatal, but 4
produced some long-term impairment of function. One stroke, in the aspirin
group, was hemorrhagic. Conclusion: Our data indicated that alternate-day
aspirin therapy greatly reduced the risk for first myocardial infarction among
patients with chronic stable angina, a group of patients at high risk for
cardiovascular death (P < 0.001). Although our results for stroke were based on
small numbers, they suggested an apparent increase in frequency of stroke with
aspirin therapy; this finding requires confirmation in randomized trials of
adequate sample size
Keywords: ACID/ACUTE
MYOCARDIAL-INFARCTION/AGENTS/DISEASE/INHIBITION/MORTALI
TY/PHYSICIANS/PROGNOSIS/SECONDARY PREVENTION/UNSTABLE
ANGINA
Turpie, A.G.G., Gent, M., Cote, R., Levine, M.N., Ginsberg, J.S., Powers, P.J., Leclerc,
J., Geerts, W., Jay, R., Neemeh, J., Klimek, M. and Hirsh, J. (1992), A
Low-Molecular-Weight Heparinoid Compared with Unfractionated Heparin in
the Prevention of Deep-Vein Thrombosis in Patients with Acute Ischemic Stroke
- A Randomized, Double-Blind-Study. Annals of Internal Medicine, 117 (5),
353-357.
Abstract: Objective: To compare the relative safety and efficacy of a
low-molecular-weight heparinoid (ORG 10172) with unfractionated heparin in
the prevention of deep vein thrombosis in patients with acute ischemic stroke.
Design: Double-blind randomized trial. Setting: Seven Canadian
university-affiliated hospitals. Participants: Eighty-seven patients with acute
ischemic stroke resulting in lower-limb paresis. Intervention: Patients received
either low-molecular-weight heparinoid, 750 anti- factor Xa units twice daily, or
unfractionated heparin, 5000 units subcutaneously twice daily. Treatment was
continued for 14 days or until hospital discharge if sooner. Measurements: Deep
vein thrombosis was diagnosed using I-125-labeled fibrinogen leg scanning and
impedance plethysmography. Venography was indicated if either test was
positive. Overt hemorrhage, major or minor, was assessed clinically. Results:
Venous thrombosis occurred in four patients (9%) given low- molecular-weight
heparinoid and in 13 patients (31%) given heparin (relative risk reduction, 71%;
95% CI, 16% to 93%. The corresponding rates for proximal vein thrombosis
were 4% and 12%, respectively (relative risk reduction, 63%; P > 0.2). The
incidence of hemorrhage was 2% in both groups. Conclusion: Low-
molecular-weight heparinoid, given in a fixed dose of 750 anti- factor Xa units
subcutaneously twice daily, is more effective than subcutaneous low-dose
heparin for the prevention of deep vein thrombosis in patients with acute
ischemic stroke
Keywords: CEREBROVASCULAR DISORDERS/CONTROLLED
TRIAL/ENOXAPARIN/HEPARIN/HEPARINOID/HIP-
SURGERY/LEG/LOW-DOSE
HEPARIN/ORG-10172/PROPHYLAXIS/THROMBOEMBOLISM/VENOUS
THROMBOSIS
Anderson, D.C., Asinger, R.W., Newburg, S.M., Farmer, C.C., Wang, K., Bundlie, S.R.,
Koller, R.L., Jagiella, W.M., Kreher, S., Jorgensen, C.R., Sharkey, S.W., Flaker,
G.C., Webel, R., Nolte, B., Stevenson, P., Byer, J., Wright, W., Chesebro, J.H.,
Wiebers, D.O., Holland, A.E., Miller, D.M., Bardsley, W.T., Litin, S.C.,
Meissner, I., Zerbe, D.M., Mcanulty, J.H., Marchant, C., Coull, B.M., Feldman,
G., Hayward, A., Gandara, E., Macmillan, K., Blank, N., Leonard, A.D., Kanter,
M.C., Isensee, L.M., Quiroga, E.S., Presti, C.H., Tegeler, C.H., Logan, W.R.,
Hamilton, W.P., Green, B.J., Bacon, R.S., Redd, R.M., Cadell, D.J., Gomez,
C.R., Janosik, D.L., Labovitz, A.J., Kelley, R.E., Chahine, R., Cristo, L.,
Palermo, M., Perez, O., Feinberg, W.M., Vold, B.K., Kern, K.B., Appleton, C.,
Miller, V.T., Hockersmith, C.J., Cohen, B.A., Martin, G.J., Pawlow, A.J.,
Halperin, J.L., Rothlauf, E.B., Weinberger, J.M., Goldman, M.E., Fuster, V.,
Dittrich, H.C., Rothrock, J.F., Hagenhoff, C., Helgason, C.M., Kondos, G.T.,
Hoff, J., Kaufmann, L., Rabjohns, R.R., Mcrae, R.P., Ghali, J., Adams, H.P.,
Theilen, E.O., Biller, J., Brown, D.D., Marsh, E.E., Sirna, S.J., Mitchell, V.L.,
Rothbart, R.M., Bailey, G.H., Burkhardt, C., Blackshear, J.L., Weaver, L., Lee,
G., Lane, G., Rubino, F., Safford, R., Kronmal, R.A., Mcbride, R., Athearn,
M.W., Pearce, L.A., Nasco, E., Hart, R.G., Sherman, C.P., Sherman, D.G.,
Talbert, R.L., Dacy, T.L. and Heberling, P.A. (1992), Predictors of
Thromboembolism in Atrial-Fibrillation .1. Clinical-Features of Patients at Risk.
Annals of Internal Medicine, 116 (1), 1-5.
Abstract: Objective: To identify those patients with nonrheumatic atrial fibrillation who
are at high risk and those at low risk for arterial thromboembolism. Design:
Cohort study of patients assigned to placebo in a randomized clinical trial.
Setting: Five hundred sixty-eight inpatients and outpatients with nonrheumatic
atrial fibrillation assigned to placebo therapy at 15 U.S. medical centers from
1987 to 1989 in the Stroke Prevention in Atrial Fibrillation study. Patients were
followed for a mean of 1.3 years. Measurements: Clinical variables were
assessed at study entry and correlated with subsequent ischemic stroke and
systemic embolism by multivariate analysis. Main Results: Recent (within 3
months) congestive heart failure, a history of hypertension, and previous arterial
thromboembolism were each significantly and independently associated with a
substantial risk for thromboembolism (> 7% per year; P less- than-or-equal-to
0.05). The presence of these three independent clinical predictors (recent
congestive heart failure, history of hypertension, previous thromboembolism)
defined patients with rates of thromboembolism of 2.5% per year (no risk
factors), 7.2% per year (one risk factor), and 17.6% per year (two or three risk
factors). Nondiabetic patients without these risk factors, comprising 38% of the
cohort, had a low risk for thromboembolism (1.4% per year; 95% Cl, 0.05% to
3.7%). Patients without clinical risk factors who were under 60 years of age had
no thromboembolic events. Conclusion: Patients with atrial fibrillation at high
risk (> 7% per year) and low risk (< 3% per year) for thromboembolism can be
identified by readily available clinical variables
Keywords: ATRIAL FIBRILLATION/CEREBROVASCULAR
DISORDERS/COMPLICATIONS/CONGESTIVE/FRAMINGHAM/HEART
FAILURE/HYPERTENSION/STROKE/SYSTEMIC
EMBOLIZATION/THROMBOEMBOLISM/TRIAL
Anderson, D.C., Asinger, R.W., Newburg, S.M., Farmer, C.C., Wang, K., Bundlie, S.R.,
Koller, R.L., Jagiella, W.M., Kreher, S., Jorgensen, C.R., Sharkey, S.W., Flaker,
G.C., Webel, R., Nolte, B., Stevenson, P., Byer, J., Wright, W., Chesebro, J.H.,
Wiebers, D.O., Holland, A.E., Miller, D.M., Bardsley, W.T., Litin, S.C.,
Meissner, I., Zerbe, D.M., Mcanulty, J.H., Marchant, C., Coull, B.M., Feldman,
G., Hayward, A., Gandara, E., Macmillan, K., Blank, N., Leonard, A.D., Kanter,
M.C., Isensee, L.M., Quiroga, E.S., Presti, C.H., Tegeler, C.H., Logan, W.R.,
Hamilton, W.P., Green, B.J., Bacon, R.S., Redd, R.M., Cadell, D.J., Gomez,
C.R., Janosik, D.L., Labovitz, A.J., Kelley, R.E., Chahine, R., Cristo, L.,
Palermo, M., Perez, O., Feinberg, W.M., Vold, B.K., Kern, K.B., Appleton, C.,
Miller, V.T., Hockersmith, C.J., Cohen, B.A., Martin, G.J., Pawlow, A.J.,
Halperin, J.L., Rothlauf, E.B., Weinberger, J.M., Goldman, M.E., Fuster, V.,
Dittrich, H.C., Rothrock, J.F., Hagenhoff, C., Helgason, C.M., Kondos, G.T.,
Hoff, J., Kaufmann, L., Rabjohns, R.R., Mcrae, R.P., Ghali, J., Adams, H.P.,
Theilen, E.O., Biller, J., Brown, D.D., Marsh, E.E., Sirna, S.J., Mitchell, V.L.,
Rothbart, R.M., Bailey, G.H., Burkhardt, C., Blackshear, J.L., Weaver, L., Lee,
G., Lane, G., Rubino, F., Safford, R., Kronmal, R.A., Mcbride, R., Pearce, L.A.,
Nasco, E., Hart, R.G., Sherman, C.P., Sherman, D.G., Talbert, R.L., Dacy, T.L.
and Heberling, P.A. (1992), Predictors of Thromboembolism in
Atrial-Fibrillation .2. Echocardiographic Features of Patients at Risk. Annals of
Internal Medicine, 116 (1), 6-12.
Abstract: Objective: To identify echocardiographic predictors of arterial
thromboembolism in patients with nonrheumatic atrial fibrillation and to
determine whether these add to clinical variables for risk stratification. Design:
Cohort study of patients assigned to placebo in a randomized clinical trial.
Setting: Five hundred sixty-eight inpatients and outpatients with nonrheumatic
atrial fibrillation assigned to placebo therapy at 15 U.S. medical centers from
1987 to 1989 in the Stroke Prevention in Atrial Fibrillation study. Patients were
followed for a mean of 1.3 years. Measurements: M-mode and two- dimensional
(2-D) echocardiograms performed at study entry and interpreted by local
cardiologists. The predictive value of 14 echocardiographic variables for later
ischemic stroke or systemic embolism was assessed by multivariate analysis.
Main Results: Left ventricular dysfunction from 2-D echocardiograms (P = 0.003)
and the size of the left atrium from M-mode echocardiograms (P = 0.02) were the
strongest independent predictors of later thromboembolism. Multivariate analysis
of these two independent echocardiographic predictors with the three
independent clinical predictors of thromboembolism (history of hypertension,
recent congestive heart failure, previous thromboembolism) identified 26% of
the cohort with a low risk for thromboembolism (1.0% per year; 95% Cl, 0.2% to
4.0%). Compared with risk stratification using clinical variables alone,
echocardiographic results altered thromboembolic risk stratification in 18% of
the entire cohort and in 38% of those without clinical risk factors. Conclusions:
Both left ventricular and left atrial variables are significant predictors of
thromboembolism in patients with nonvalvular atrial fibrillation. Our results
challenge traditional views of the pathogenesis of ischemic stroke in patients
with atrial fibrillation and suggest that standard echocardiography contributes to
risk stratification, differentiating the one third of patients without clinical risk
factors who are at increased risk for stroke from the remainder who may not need
antithrombotic prophylaxis
Keywords: ATRIAL FIBRILLATION/CEREBROVASCULAR
DISORDERS/COMPLICATIONS/CONGESTIVE/HEART
FAILURE/HYPERTENSION/LEFT-VENTRICULAR
MASS/STROKE/SYSTEMIC EMBOLIZATION/THROMBOEMBOLISM
Hylek, E.M. and Singer, D.E. (1994), Risk-Factors Far Intracranial Hemorrhage in
Outpatients Taking Warfarin. Annals of Internal Medicine, 120 (11), 897-902.
Abstract: Objective: To explore the rational use of anticoagulants, especially among the
elderly, balancing antithrombotic efficacy and risk for hemorrhage. Previous
prospective studies have not provided powerful assessments of risk factors for
intracranial hemorrhage, the dominant complication in reversing the
anticoagulant decision. Design: Case-control analysis. Setting: A large general
hospital and its anticoagulant therapy unit. Patients: 121 consecutive adult
patients taking warfarin who were hospitalized with intracranial hemorrhage
were each matched to three contemporaneous controls randomly selected from
among outpatients managed by our hospital anticoagulant therapy unit. Results:
77 patients had intracerebral hemorrhage (46% fatal) and 44 had subdural
hemorrhage (20% fatal). The prothrombin time ratio (PTR) was the dominant
risk factor for intracranial hemorrhage. For each 0.5 increase in PTR over the
entire range, the risk for intracerebral hemorrhage doubled (odds ratio, 2.1; 95%
CI, 1.4 to 2.9). For subdural hemorrhage, the risk was unchanged over the PTR
range from 1.0 to 2.0 but rose dramatically above a PTR of 2.0 (approximate
international normalized ratio, 4.0). Age was the only other significant
independent risk factor for subdural hemorrhage (odds ratio, 2.0 per decade; CI,
1.3 to 3.1). For intracerebral hemorrhage, age was of borderline significance
(odds ratio, 1.3 per decade; CI, 1.0 to 1.6) after controlling for PTR and the two
other independent risk factors: history of cerebrovascular disease (odds ratio, 3.1;
CI, 1.7 to 5.6) and presence of a prosthetic heart valve (odds ratio, 2.8; CI, 1.3 to
5.8). Conclusions: The results emphasize the importance of maintaining the
prothrombin time ratios under 2.0 and the need for especially careful use of
warfarin in the elderly
Keywords: anticoagulants/ATRIAL-FIBRILLATION/CEREBRAL AMYLOID
ANGIOPATHY/cerebrovascular
disease/COMPLICATIONS/elderly/heart/hemorrhage/history/HYPERTENSION
/INTENSITIES/INTERNAL/INTRACEREBRAL HEMATOMAS/intracerebral
hemorrhage/ORAL
ANTICOAGULANT-THERAPY/PHYSICIANS/POPULATION/PREVENTIO
N/prospective studies/prothrombin time/risk/risk factors/STROKE/Warfarin
Jackson, L.A., Hilsdon, R., Farley, M.M., Harrison, L.H., Reingold, A.L., Plikaytis, B.D.,
Wenger, J.D. and Schuchat, A. (1995), Risk-Factors for Group-B Streptococcal
Disease in Adults. Annals of Internal Medicine, 123 (6), 415-420.
Abstract: Objective: To determine risk factors for community-acquired and nosocomial
group B streptococcal disease in adults. Design: Case-control study. Setting: 3
metropolitan areas in the United States with an aggregate population of 6.6
million persons. Patients: 219 nonpregnant adults with invasive group B
streptococcal infection identified by a population-based surveillance in 1991 and
1992 and 645 hospital-matched controls. Results: The following conditions were
associated with a significantly increased risk for community-acquired group B
streptococcal infection after controlling for age in multivariate analysis: cirrhosis
(odds ratio, 9.7 [95% CI, 3.5 to 26.9]; P <0.001), diabetes (odds ratio, 3.0 [CI,
1.9 to 4.7]; P <0.001), stroke (odds ratio, 3.5 [CI, 1.9 to 6.4]; P <0.001), breast
cancer (odds ratio, 4.0 [CI, 1.6 to 9.8]; P =0.002), decubitus ulcer (odds ratio, 4.0
[CI, 1.6 to 9.8]; P =0.002), and neurogenic bladder (odds ratio, 4.6 [CI, 1.4 to
15.1]; P =0.01). Sixty-three percent of community case-patients had at least one
of these conditions. Nosocomial infection (48 cases [22%]) was independently
associated with the placement of a central venous line (odds ratio, 30.9 [CI, 5.2
to 184.1]; P <0.001), diabetes, congestive heart failure, and seizure disorder.
Conclusions: Several chronic conditions were independently associated with
group B streptococcal disease, and most case-patients had at least one of these
conditions. If group B streptococcal vaccines being developed for prevention of
neonatal disease are protective in adults, a vaccination strategy targeting those at
highest risk has the potential to substantially reduce the burden of invasive group
B streptococcal infection in adults
Keywords: adults/ANTIBODY/BACTEREMIA/COMMUNITY-ACQUIRED
INFECTIONS/CROSS INFECTION/heart/III
POLYSACCHARIDE/INFANTS/INFECTION/NONPREGNANT
ADULTS/PHYSICIANS/prevention/risk/RISK FACTORS/STREPTOCOCCAL
INFECTION/STREPTOCOCCUS AGALACTIAE/stroke/TOXOID
CONJUGATE VACCINE/WOMEN
Fihn, S.D., Callahan, C.M., Martin, D.C., McDonell, M.B., Henikoff, J.G. and White,
R.H. (1996), The risk for and severity of bleeding complications in elderly
patients treated with warfarin. Annals of Internal Medicine, 124 (11), 970-&.
Abstract: Objective: To determine whether increasing age is associated with an
increased risk for bleeding during warfarin treatment. Design: Combined
retrospective and prospective cohort studies. Setting: 6 anticoagulation clinics.
Patients: 2376 patients receiving warfarin for various indications. Measurements:
Bleeding events categorized as minor (resulting in no costs or consequences),
serious (requiring testing or treatment), life- threatening, or fatal. Results: 812
first bleeding events (4 fatal, 33 life-threatening, 222 serious, and 553 minor)
occurred during 3702 patient-years. Age was inversely related to the mean
warfarin dose and dose-adjusted prothrombin time ratio. The unadjusted
incidence of minor bleeding complications did not vary according to age group:
18.0 per 100 patient-years for patients younger than 50 years of age, 21.5 for
patients 50 to 59 years of age, 24.0 for patients 60 to 69 years of age; 23.5 for
patients 70 to 79 years of age, and 16.3 for patients 80 years of age and older.
The unadjusted incidence of serious bleeding complications also did not vary
according to age group: 9.3 per 100 patient-years for patients younger than 50
years of age, 7.1 for patients 50 to 59 years of age, 6.6 for patients 60 to 69 years
of age, 5.1 for patients 70 to 79 years of age, and 4.4 for patients 80 years of age
and older. The unadjusted incidence of life-threatening or fatal complications
combined was significantly higher among the oldest patients: 0.75 per 100
patient-years for patients younger than 50 years of age, 0.97 for patients 50 to 59
years of age, 1.10 for patients 60 to 69 years of age, 0.68 for patients 70 to 79
years of age, and 3.38 for patients 80 years of age and older. Patients 80 years of
age and older had a relative risk of 4.5 (95% CI, 1.3 to 15.6) compared with
patients younger than 50 years of age. After adjustment for the intensity of
anticoagulation therapy and the deviation in the prothrombin time ratio using
Cox and Poisson regression, age was not generally associated with the
occurrence of bleeding; relative risk estimates ranged from 0.99 to 1.03 per year
of age (lower- bound 95% CI, 0.97 to 1.01; upper-bound 95% CI, 1.00 to 1.09).
The single exception was life-threatening and fatal complications in patients 80
years of age or older (relative risk, 4.6 [CI, 1.2 to 18.1]). Conclusions: Age did
not appear to be an important determinant of risk for bleeding in patients
receiving warfarin, with the possible exception of age 80 years or older. The
intensity of anticoagulation therapy and the deviation in the prothrombin time
ratio were much stronger predictors of risk for bleeding
Keywords: age factors/anticoagulation/atrial
fibrillation/ATRIAL-FIBRILLATION/cohort
studies/elderly/FOLLOW-UP/HEMORRHAGE/hemorrhage/ORAL
ANTICOAGULANT-THERAPY/OUTPATIENTS/PHYSICIANS/predictors/PR
EVENTION/prothrombin time/severity/STROKE/THROMBOEMBOLIC
COMPLICATIONS/treatment/warfarin
Matchar, D.B., Samsa, G.P., Matthews, J.R., Ancukiewicz, M., Parmigiani, G.,
Hasselblad, V., Wolf, P.A., DAgostino, R.B. and Lipscomb, J. (1997), The
stroke prevention policy model: Linking evidence and clinical decisions. Annals
of Internal Medicine, 127 (8), 704-711.
Abstract: Simulation models that support decision and cost-effectiveness analysis can
further the goals of evidence-based medicine by facilitating the synthesis of
information from several sources into a single comprehensive structure. The
Stroke Prevention Policy Model (SPPM) performs this function for the clinical
and policy questions that surround stroke prevention. This paper first describes
the basic structure and functions of the SPPM, concentrating on the role of large
databases (broadly defined as any database that contains many patients,
regardless of study design) in providing the SPPM inputs. Next, recognizing that
the use of modeling continues to be a source of some controversy in the medical
community, it; discusses the philosophical underpinnings of the SPPM. Finally,
it discusses conclusions in the context of both stroke prevention and other
complex medical decisions. We conclude that despite the difficulties in
developing comprehensive models (for example, the length and complexity of
model development and validation processes, the proprietary nature of data
sources, and the necessity for developing new software), the benefits of such
models exceed the costs of continuing to rely on more conventional methods.
Although they should not replace the clinician in decision making;
comprehensive models based on the best available evidence from large databases
can support decision making in medicine
Keywords: cost effectiveness/COST-EFFECTIVENESS/cost-effectiveness
analysis/costs/decision-making/development/MEDICINE/PHYSICIAN/PHYSIC
IANS/POLICIES/POLICY/prevention/RACE/stroke/stroke prevention
Lee, T.T., Solomon, N.A., Heidenreich, P.A., Oehlert, J. and Garber, A.M. (1997),
Cost-effectiveness of screening for carotid stenosis in asymptomatic persons.
Annals of Internal Medicine, 126 (5), 337-&.
Abstract: Background: The Asymptomatic Carotid Atherosclerosis Study (ACAS)
showed that carotid endarterectomy was beneficial for symptom-free patients
with carotid stenosis of 60% or more. This finding raises the question of whether
widespread screening to identify cases of asymptomatic carotid stenosis should
be implemented. Objective: To determine whether a screening program to
identify cases of asymptomatic carotid stenosis would be a cost-effective strategy
for stroke prevention. Design: Cost-effectiveness analysis using published data
from clinical trials. Setting: General population of asymptomatic 65-year-old
men. Intervention: Patients who were screened for carotid disease with duplex
Doppler ultrasonography were compared with patients who were not screened. If
ultrasonography found significant carotid stenosis (greater than or equal to 60%),
disease was confirmed by angiography before carotid endarterectomy was done.
Measurements: Quality-adjusted life-years, costs, and marginal
cost-effectiveness ratios. Results: When the conditions and results of ACAS were
modeled and it was assumed that the survival advantage produced by
endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness
of screening relative to no screening was $120 000 per quality-adjusted life-year.
Sensitivity analysis showed that marginal cost- effectiveness decreased to $50
000 or less per quality-adjusted life-year only under implausible conditions (for
example, if a free screening instrument with perfect test characteristics was used
or an asymptomatic population with a 40% prevalence of carotid stenosis was
found). Conclusions: Surgery offers a real but modest absolute reduction in the
rate of stroke at a substantial cost. A program to identify candidates for
endarterectomy by screening asymptomatic populations for carotid stenosis costs
more per quality-adjusted life-year than is usually considered acceptable
Keywords: ARTERY DISEASE/asymptomatic/carotid/carotid endarterectomy/carotid
stenosis/clinical trials/cost/cost effectiveness/cost-benefit
analysis/cost-effectiveness/costs/Doppler/duplex/endarterectomy/ENDARTERE
CTOMY/mass
screening/men/MORTALITY/MR-ANGIOGRAPHY/MYOCARDIAL-INFARC
TION/PHYSICIAN/PHYSICIANS/POPULATION/PREVALENCE/prevention/
quality-adjusted life-years/RACE/RISK- FACTORS/STROKE/stroke
prevention/SURVIVAL/trials/ultrasonography
Bucher, H.C., Griffith, L.E. and Guyatt, G.H. (1998), Effect of HMGcoA reductase
inhibitors on stroke - A meta- analysis of randomized, controlled trials. Annals of
Internal Medicine, 128 (2), 89-+.
Abstract: Background: Stroke is a leading cause of death in the industrialized world, and
hypercholesterolemia may be a risk factor for stroke. Objective: To determine
whether reducing cholesterol levels with HMGcoA (3-hydroxy-3-methylglutaryl
coenzyme A) reductase inhibitors or other antilipidemic interventions reduces
risk for nonfatal and fatal stroke. Data Sources: A systematic search in the
MEDLINE and EMBASE databases of the English-language and
non-English-language literature published from 1966 through October 1996.
Study Selection: All randomized, controlled trials of any cholesterol-lowering
intervention that reported data on nonfatal and fatal strokes, on death from
coronary heart disease, and on overall mortality were included. Whether
treatment effects differed according to the type of cholesterol-lowering
intervention used was investigated. Data Extraction: Trials were reviewed for
methods, inclusion and exclusion criteria, and outcomes. Data Synthesis: 28
trials (for a total of 49 477 study participants in the intervention group and 56
636 participants in the control group) were included. The risk ratio for nonfatal
and fatal stroke with HMGcoA reductase inhibitors was 0.76 (95% CI, 0.62 to
0.92; test of heterogeneity, P > 0.2). The risk ratios for nonfatal and fatal stroke
with fibrates, resins, and dietary interventions were all close to 1.0, and the
difference between the HMGcoA reductase inhibitor effect and the pooled
estimate for all other interventions would, under the null hypothesis, be unlikely
to occur by chance (P = 0.01). Trials with HMGcoA reductase inhibitors also
showed reductions in rates of death from coronary heart disease and overall
mortality. Conclusion: This meta-analysis of randomized, controlled trials
suggests that in hyperlipidemic patients who have not previously had stroke,
HMGcoA reductase inhibitors reduce the incidence of stroke
Keywords: ARTERY
DISEASE/cerebrovascular/cholesterol/CHOLESTEROL-LOWERING
TRIALS/control/coronary heart disease/CORONARY
HEART-DISEASE/heart/HMGcoA
inhibitors/hypercholesterolemia/incidence/meta-analysis/MIDDLE-AGED
MEN/MORTALITY/MYOCARDIAL-INFARCTION/PHYSICIANS/PRIMAR
Y- PREVENTION TRIAL/RACE/randomized/RISK/SECONDARY
PREVENTION/SERUM-CHOLESTEROL/stroke/treatment/trials
Lewis, S.J., Moye, L.A., Sacks, F.M., Johnstone, D.E., Timmis, G., Mitchell, J.,
Limacher, M., Kell, S., Glasser, S.P., Grant, J., Davis, B.R., Pfeffer, M.A. and
Braunwald, E. (1998), Effect of pravastatin on cardiovascular events in older
patients with myocardial infarction and cholesterol levels in the average range -
Results of the cholesterol and recurrent events (CARE) trial. Annals of Internal
Medicine, 129 (9), 681-+.
Abstract: Background: A majority of all myocardial infarctions occur in patients who are
65 years of age or older and have average cholesterol levels, but little
information is available on whether cholesterol lowering in such patients reduces
the rate of recurrent cardiovascular disease. Objective: To determine whether
pravastatin reduces the rate of recurrent cardiovascular events in older patients.
Design: Subset analysis of a randomized, controlled trial. Setting: 80 hospitals
and affiliates in the United States and Canada. Patients: 1283 patients aged 65 to
75 years who had had myocardial infarction and had a plasma total cholesterol
level less than 6.2 mmol/L (240 mg/dL) and a low-density lipoprotein cholesterol
level of 3.0 to 4.5 mmol/L (115 to 174 mg/dL). Intervention: Pravastatin, 40
mg/d, or placebo. Measurements: Five-year event rates of major coronary events
(coronary death, nonfatal myocardial infarction, angioplasty, or bypass surgery)
and stroke. Results: Major coronary events occurred in 28.1% of placebo
recipients and 19.7% of pravastatin recipients (difference, 9.0 percentage points
[95% CI, 4 to 13 percentage points]; relative risk reduction, 32%; P < 0.001).
Coronary death occurred in 10.3% of the placebo group and in 5.8% of the
pravastatin group (difference, 4.6 percentage points [CI, 1.9 to 6.5 percentage
points]; relative risk reduction, 45%; P = 0.004). Stroke incidence was 7.3% in
the placebo group and 4.5% in the pravastatin group (absolute reduction, 2.9
percentage points [CI, 0.3 to 4.5 percentage points]; relative reduction, 40%; P =
0.03). The numbers of older patients needed to treat for 5 years were 11 (CI, 8 to
24) to prevent a major coronary event and 22 (CI, 15 to 53) to prevent a coronary
death. For every 1000 older patients treated, 225 cardiovascular hospitalizations
would be prevented compared with 121 hospitalizations in 1000 younger patients.
Conclusions: In older patients with myocardial infarction and cholesterol levels
in the average range, pravastatin is associated with a clinically important
reduction in risk for major coronary events and stroke. Given the high
cardiovascular event rate in older patients, the potential for absolute benefit in
this age group is substantial
Keywords: A-I/age/age factors/aged/angioplasty/ARTERY DISEASE/cardiovascular
disease/cardiovascular events/CARE/cerebrovascular
disorders/cholesterol/coronary disease/CORONARY
HEART-DISEASE/DRUG- TREATMENT/ELDERLY
PATIENTS/FOLLOW-UP/HIGH BLOOD
CHOLESTEROL/incidence/MORTALITY/myocardial
infarction/PHYSICIANS/pravastatin/RACE/relative
risk/risk/RISK-FACTORS/SECONDARY PREVENTION/stroke/surgery
Hart, R.G., Benavente, O., McBride, R. and Pearce, L.A. (1999), Antithrombotic therapy
to prevent stroke in patients with atrial fibrillation: A meta-analysis. Annals of
Internal Medicine, 131 (7), 492-+.
Abstract: Purpose: To characterize the efficacy and safety of anticoagulants and
antiplatelet agents for prevention of stroke in patients with atrial fibrillation. Data
Sources: Randomized trials identified by using the search strategy developed by
the Cochrane Collaboration Stroke Review Group. Study Selection: All
published randomized trials testing antithrombotic agents to prevent stroke in
patients with atrial fibrillation. Data Extraction: Data on interventions, number of
participants, duration of exposure and occurrence of all stroke (ischemic and
hemorrhagic), major extracranial bleeding, and death were extracted
independently by two investigators. Data Synthesis: Sixteen trials included a
total of 9874 participants (mean follow-up, 1.7 years). Adjusted-dose warfarin
(six trials, 2900 participants) reduced stroke by 62% (95% CI, 48% to 72%);
absolute risk reductions were 2.7% per year for primary prevention and 8.4% per
year for secondary prevention. Major extracranial bleeding was increased by
warfarin therapy (absolute risk increase, 0.3% per year). Aspirin (six trials, 3119
participants) reduced stroke by 22% (CI, 2% to 38%); absolute risk reductions
were 1.5% per year for primary prevention and 2.5% per year for secondary
prevention. Adjusted-dose warfarin (five trials, 2837 participants) was more
efficacious than aspirin (relative risk reduction, 36% [CI, 14% to 52%]). Other
randomized comparisons yielded inconclusive results. Conclusions:
Adjusted-dose warfarin and aspirin reduce stroke in patients with atrial
fibrillation, and warfarin is substantially more efficacious than aspirin. The
benefit of antithrombotic therapy was not offset by the occurrence of major
hemorrhage among participants in randomized trials. Judicious use of
antithrombotic therapy, tailored according to the inherent risk for stroke,
importantly reduces stroke in patients with atrial fibrillation
Keywords: absolute risk/anticoagulants/anticoagulants platelet aggregation
inhibitors/ANTICOAGULATION/antiplatelet
agents/antithrombotic/antithrombotic therapy/ASPIRIN/atrial
fibrillation/cerebrovascular
disorders/CLINICAL-TRIALS/EVENTS/fibrillation/FIXED MINIDOSE
WARFARIN/hemorrhage/INDOBUFEN/INTENSITY/ischemic/meta-analysis/P
HYSICIAN/PHYSICIANS/prevention/primary
prevention/RACE/randomized/RANDOMIZED TRIAL/randomized
trials/relative risk/risk/safety/secondary
prevention/stroke/therapy/THROMBOEMBOLIC
COMPLICATIONS/trials/warfarin
Petty, G.W., Brown, R.D., Whisnant, J.P., Sicks, J.D., O'Fallon, W.M. and Wiebers,
D.O. (1999), Frequency of major complications of aspirin, warfarin, and
intravenous heparin for secondary stroke prevention - A population-based study.
Annals of Internal Medicine, 130 (1), 14-22.
Abstract: Background: Complication rates of medical therapy for secondary stroke
prevention derived from clinical trials may or may not be applicable to patients
with cerebrovascular disease in the general population. Objective: To determine
complication rates for aspirin, warfarin, and intravenous heparin administered for
secondary stroke prevention after first episodes of ischemic stroke, transient
ischemic attack, or amaurosis fugax in a community. Design: Population-based
historical cohort study. Setting: Rochester, Minnesota. Patients: All residents of
Rochester who, between 1985 and 1989, received aspirin (n = 339) or warfarin (n
= 145) within 2 years after first ischemic stroke, transient ischemic attack, or
amaurosis fugax or received intravenous heparin (n = 201) within 2 weeks after
first ischemic stroke, transient ischemic attack, or amaurosis fugax.
Measurements: Occurrence of major complications caused by therapy. Results:
Twenty aspirin-associated complications (1 fatal) occurred during an average 1.7
years of treatment, 8 warfarin-associated complications occurred during an
average 0.7 years of treatment, and 3 heparin-associated complications (1 fatal)
occurred during an average 5.1 days of treatment. Complication rates were 3.5
per 100 person-years (95% CI, 2.1 to 5.4) for aspirin, 7.9 per 100 person-years
(CI, 3.4 to 15.6) for warfarin, and 0.30 (CI, 0.06 to 0.86) per 100 person-days for
heparin. Rates of fatal complications were 0.2 per 100 person-years (CI, 0 to 1.0)
for aspirin, 0 per 100 person-years (CI, 0 to 3.6) for warfarin, and 0.10 per 100
person-days (0 to 0.55) for heparin. Conclusions: Complication rates for warfarin
and intravenous heparin given as therapy for secondary stroke prevention in
Rochester, Minnesota, were lower than rates reported from earlier trials and
observational studies. However, complication rates for warfarin were higher than
in more recent referral-based studies and multicenter randomized trials. After
adjustment for duration of therapy, complication rates for heparin were higher
than those for aspirin or warfarin. These rates can be used to judge the
applicability of complication rates derived from ongoing clinical trials
Keywords:
ANTICOAGULATION/aspirin/CEREBRAL-ISCHEMIA/cerebrovascular/cereb
rovascular disease/clinical trials/cohort
study/complications/EPIDEMIOLOGY/GASTROINTESTINAL
HEMORRHAGE/heparin/INFARCTION/ischemic/ischemic
stroke/observational
studies/OUTPATIENTS/PHYSICIAN/PHYSICIANS/population/population-bas
ed/PREDICTION/prevention/RACE/randomized/randomized
trials/RISK-FACTORS/secondary stroke prevention/stroke/stroke
prevention/therapy/transient/transient ischemic attack/TRANSIENT ISCHEMIC
ATTACKS/treatment/TRIAL/trials/warfarin
Go, A.S., Hylek, E.M., Borowsky, L.H., Phillips, K.A., Selby, J.V. and Singer, D.E.
(1999), Warfarin use among ambulatory patients with nonvalvular atrial
fibrillation: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA)
study. Annals of Internal Medicine, 131 (12), 927-+.
Abstract: Background: Warfarin dramatically reduces the risk for ischemic stroke in
nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial
fibrillation has not been widely studied. Objective: To assess the rates and
predictors of warfarin use in ambulatory patients with nonvalvular atrial
fibrillation. Design: Cross-sectional study. Setting: Large health maintenance
organization. Patients: 13428 patients with a confirmed ambulatory diagnosis of
nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and
31 December 1997. Measurements: Data from automated pharmacy, laboratory,
and clinical-administrative databases were used to determine the prevalence and
determinants of warfarin use in the 3 months before or after the identified
diagnosis of atrial fibrillation. Results: Of 11082 patients with nonvalvular atrial
fibrillation and no known contraindications, 55% received warfarin. Warfarin use
was substantially lower in patients who were younger than 55 years of age
(44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of
patients with one or more risk factors for stroke and no contraindications were
receiving warfarin. Among a subset of "ideal" candidates to receive warfarin
(persons 65 to 74 years of age who had no contraindications and had previous
stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our
entire cohort, the strongest predictors of receiving warfarin were previous stroke
(adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63
[CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21
to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous
gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]). Conclusions: In
a large, contemporary cohort of ambulatory patients with atrial fibrillation who
received care within a health maintenance organization, warfarin use was
considerably higher than in other reported studies. Although the reasons why
physicians did not prescribe warfarin could not be elucidated, many apparently
eligible patients with atrial fibrillation and at least one additional risk factor for
stroke, especially hypertension, did not receive anticoagulation. Interventions are
needed to increase the use of warfarin for stroke prevention among appropriate
candidates
Keywords: age/anticoagulation/ASPIRIN/atrial
fibrillation/COMMUNITY/diagnosis/fibrillation/health/heart/heart
failure/hemorrhage/HOSPITALS/hypertension/intracranial
hemorrhage/ischemic/ischemic stroke/NATIONAL PATTERNS/nonvalvular
atrial fibrillation/pharmacy/PHYSICIAN/PHYSICIAN
ATTITUDES/PHYSICIANS/predictors/PREVALENCE/prevention/PROPHYL
AXIS/RACE/risk/risk factor/risk factors/risk factors for
stroke/status/stroke/STROKE PREVENTION/use/Warfarin
Hart, R.G. and Halperin, J.L. (1999), Atrial fibrillation and thromboembolism: A decade
of progress in stroke prevention. Annals of Internal Medicine, 131 (9), 688-695.
Abstract: Atrial fibrillation is associated with a sixfold increased risk for stroke. More
than a dozen published randomized trials of anticoagulants or antiplatelet agents
for stroke prevention provide solid evidence on which to base antithrombotic
prophylaxis. Adjusted-dose warfarin reduces risk for stroke by about 60%
compared with placebo, aspirin reduces this risk (primarily for nondisabling
stroke) by about 20% compared with placebo, and warfarin reduces it by about
40% compared with aspirin. Warfarin provides maximal protection against
stroke at international normalized ratios of 2.0 to 3.0. Risk stratification of
patients with atrial Fibrillation identifier those who potentially benefit most or
least from anticoagulation; this is important because a substantial percentage of
patients with atrial fibrillation have relatively low rates of stroke if they are given
aspirin. Many elderly patients with recurrent intermittent atrial fibrillation
experience high rates of stroke and benefit from anticoagulation. The value of
precordial or trans-esophageal echocardiography in addition to clinical risk
stratifiers for stratifying stroke risk is controversial, Altered hemostasis favoring
thrombosis may contribute to formation of atrial appendage thrombus, but these
conditions remain ill defined. The past decade has brought unprecedented
progress toward understanding thromboembolism in patients with atrial
fibrillation and has changed the clinical perspective of a prevalent cardiac
arrhythmia into an important opportunity for stroke prevention. Making the most
of this promise calls for appreciation of the epidemiology of atrial fibrillation and
the concept of risk specificity in the face of diverse therapeutic options
Keywords: anticoagulants/ANTICOAGULATION/antiplatelet
agents/antithrombotic/aspirin/atrial fibrillation/cardiac
arrhythmia/CARDIOVERSION/DISEASE/echocardiography/elderly/ELDERLY
PATIENTS/EMBOLISM/epidemiology/fibrillation/formation/ISCHEMIC
STROKE/PHYSICIAN/PHYSICIANS/PREVALENCE/prevention/prophylaxis/
RACE/randomized/randomized trials/risk/RISK-FACTORS/stroke/stroke
prevention/thromboembolism/thrombosis/thrombus/TRANSESOPHAGEAL
ECHOCARDIOGRAPHY/trials/WARFARIN
Grodstein, F., Manson, J.E., Colditz, G.A., Willett, W.C., Speizer, F.E. and Stampfer,
M.J. (2000), A prospective, observational study of postmenopausal hormone
therapy and primary prevention of cardiovascular disease. Annals of Internal
Medicine, 133 (12), 933-941.
Abstract: Background: Most primary prevention studies have found that long-term users
of postmenopausal hormone therapy are at lower risk for coronary events, but
numerous questions remain. An adverse influence of hormone therapy on
cardiovascular risk has been suggested during the initial year of use; however,
few data are available on short-term hormone therapy. In addition, the
cardiovascular effects of daily doses of oral conjugated estrogen lower than
0.625 mg are unknown, and few studies have examined estrogen plus progestin
in this regard. Objective: To investigate duration, dose, and type of
postmenopausal hormone therapy and primary prevention of cardiovascular
disease. Design: Prospective, observational cohort study. Setting: Nurses' Health
Study, with follow-up from 1976 to 1996. Patients: 70 533 postmenopausal
women, in whom 1258 major coronary events (nonfatal myocardial infarction or
fatal coronary disease) and 767 strokes were identified. Measurements: Details of
postmenopausal hormone use were ascertained by using biennial questionnaires.
Cardiovascular disease was established by using a questionnaire and was
confirmed by medical record review. Logistic regression models were used to
calculate relative risks and 95% Cls, adjusted for confounders. Results: When all
cardiovascular risk factors were considered, the risk for major coronary events
was lower among current users of hormone therapy, including short-term users,
compared with never-users (relative risk, 0.61 [95% CI, 0.52 to 0.71]). Among
women taking oral conjugated estrogen, the risk for coronary events was
similarly reduced in those currently taking 0.625 mg daily (relative risk, 0.54 [CI,
0.44 to 0.67]) and those taking 0.3 mg daily (relative risk, 0.58 [CI, 0.37 to 0.92])
compared with never-users. However, the risk for stroke was statistically
significantly increased among women taking 0.625 mg or more of oral
conjugated estrogen daily (relative risk, 1.35 [CI, 1.08 to 1.68] for 0.625 mg/d
and 1.63 [CI, 1.18 to 2.26] for greater than or equal to1.25 mg/d) and those
taking estrogen plus progestin (relative risk, 1.45 [CI, 1.10 to 1.92]). Overall,
little relation was observed between combination hormone therapy and risk for
cardiovascular disease (major coronary heart disease plus stroke) (relative risk,
0.91 [CI, 0.75 to 1.11]). Conclusions: Postmenopausal hormone use appears to
decrease risk for major coronary events in women without previous heart disease.
Furthermore, 0.3 mg of oral conjugated estrogen daily is associated with a
reduction similar to that seen with the standard dose of 0.625 mg. However,
estrogen at daily doses of 0.625 mg or greater and in combination with progestin
may increase risk for stroke
Keywords: cardiovascular/cardiovascular disease/cardiovascular risk/cardiovascular risk
factors/cohort study/combination/coronary disease/coronary heart
disease/CORONARY HEART-DISEASE/disease/estrogen/ESTROGEN
REPLACEMENT THERAPY/FOLLOW-UP/heart/heart
disease/infarction/medical/MORTALITY/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/PHYSICIAN/PHYSICIANS/postme
nopausal women/prevention/primary/primary
prevention/PROGESTIN/RACE/relative risk/review/RISK/risk
factors/STROKE/therapy/use/USERS/WOMEN
Ganz, D.A., Kuntz, K.M., Jacobson, G.A. and Avorn, J. (2000), Cost-effectiveness of
3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor therapy in older
patients with myocardial infarction. Annals of Internal Medicine, 132 (10),
780-787.
Abstract: Background: 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitor
(statin) therapy has proven efficacy in reducing the rate of coronary and
cerebrovascular events in patients 75 years of age or younger with a history of
myocardial infarction. However, in patients older than 75 years of age, the
efficacy and potential cost-effectiveness of statins are unknown. Objective: To
estimate the incremental cost- effectiveness of statin therapy compared with
usual care in patients 75 to 84 years of age with previous myocardial infarction.
Design: Cost-effectiveness analysis. Data Sources: Published data from cohort
studies. Target Population: Patients 75 to 84 years of age with a history of
myocardial infarction. Time Horizon: Lifetime. Perspective: Societal.
Intervention: Statin therapy. Outcome Measures: Life expectancy, quality-
adjusted life expectancy, and incremental cost-effectiveness. Results of
Base-Case Analysis: The incremental cost- effectiveness of statin therapy
compared with usual care in patients 75 to 84 years of age with previous
myocardial infarction was $18 800 per quality-adjusted life-year (QALY).
Results of Sensitivity Analysis: On the basis of a probabilistic sensitivity analysis,
there is a 75% chance that statin therapy costs less than $39 800 per QALY
compared with usual care. If the cost of statin therapy and efficacy of statin
therapy at reducing myocardial infarction were set to their most favorable values,
statin therapy cost $5400 per QALY; if cost and efficacy were set to their least
favorable values, statin therapy cost $97 800 per QALY. Conclusions: The
cost-effectiveness ratios of statin therapy in older patients with previous
myocardial infarction are reasonable under a wide variety of assumptions about
drug efficacy, drug cost, and rates of cardiac and cerebrovascular events.
Pending results of randomized, controlled trials of secondary prevention in
patients in this age group, statin therapy seems to be as cost- effective as many
routinely accepted medical interventions in this setting
Keywords: AGE/AVERAGE CHOLESTEROL
LEVELS/cardiac/CARDIOVASCULAR EVENTS/cerebrovascular/cohort
studies/CORONARY HEART-DISEASE/cost/cost
effectiveness/cost-effectiveness/costs/ELDERLY PATIENTS/EVENTS CARE
TRIAL/history/infarction/life expectancy/LONG-TERM
SURVIVAL/myocardial/myocardial
infarction/PHYSICIAN/PHYSICIANS/PRAVASTATIN/prevention/RACE/rand
omized/SECONDARY PREVENTION/statin/statins/STROKE
PROJECT/therapy/trials
Mann, J.F.E., Gerstein, H.C., Pogue, J., Bosch, J. and Yusuf, S. (2001), Renal
insufficiency as a predictor of cardiovascular outcomes and the impact of
ramipril: The HOPE randomized trial. Annals of Internal Medicine, 134 (8),
629-636.
Abstract: Background: The cardiovascular risk associated with early renal insufficiency
is unknown. Clinicians are often reluctant to use angiotensin-converting enzyme
inhibitors in patients with renal insufficiency. Objective: To determine whether
mild renal insufficiency increases cardiovascular risk and whether ramipril
decreases that risk. Design: Post hoc analysis. Setting: The Heart Outcomes and
Prevention Evaluation (HOPE) study, a randomized, double-blind, multinational
trial involving 267 study centers. Patients: 980 patients with mild renal
insufficiency (serum creatinine concentration greater than or equal to 124 mu
mol/L [greater than or equal to 1.4 mg/dL]) and 8307 patients with normal renal
function (serum creatinine concentration < 124 mu mol/L [<1.4 mg/dl]) Patients
with a baseline serum creatinine concentration greater than 200 mu mol/L (2.3
mg/dL) were excluded. Measurements: The primary outcome measure was
incidence of cardiovascular death, myocardial infarction, or stroke. Results:
Cumulative incidence of the primary outcome was higher in patients with renal
insufficiency than in those without (22.2% vs. 15.1%; P < 0.001) and increased
with serum creatinine concentration. Patients with renal insufficiency had a
substantially increased risk for cardiovascular death (11.4% vs. 6.6%) and total
mortality (17.8% vs. 10.6%) (P < 0.001 for both comparisons). The effect of
renal insufficiency on the primary outcome (adjusted hazard ratio, 1.40 [95% Cl,
1.16 to 1.69]) was independent of known cardiovascular risks and treatment.
Ramipril reduced the incidence of the primary outcome in patients with and
those without renal insufficiency (hazard ratio, 0.80 vs. 0.79; P > 0.2 for the
difference). Conclusions: In patients who had preexisting vascular disease or
diabetes combined with an additional cardiovascular risk factor, mild renal
insufficiency significantly increased the risk for subsequent cardiovascular
events. Ramipril reduced cardiovascular risk without increasing adverse effects
Keywords: adverse effects/angiotensin converting enzyme
inhibitors/angiotensin-converting enzyme
inhibitors/cardiovascular/cardiovascular events/cardiovascular
risk/death/diabetes/DISEASE/FAILURE/incidence/infarction/KIDNEY/MILD/
MORTALITY/myocardial/myocardial
infarction/outcome/PHYSICIAN/PHYSICIANS/primary/RACE/ramipril/random
ized/randomized trial/renal/risk/risk factor/serum/SERUM
CREATININE/stroke/treatment/trial/use/vascular/vascular disease
Berg, A.O., Allan, J.D., Frame, P., Homer, C.J., Johnson, M.S., Klein, J.D., Lieu, T.A.,
Orleans, C.T., Peipert, J.F., Pender, N.J., Siu, A.L., Teutsch, S.M. and Woolf,
S.H. (2002), Postmenopausal hormone replacement therapy for primary
prevention of chronic conditions: Recommendations and rationale. Annals of
Internal Medicine, 137 (10), 834-839.
Abstract: This statement summarizes the U.S. Preventive Services Task Force (USPSTF)
recommendations for use of hormone replacement therapy for the primary
prevention of chronic conditions in postmenopausal women and updates the
1996 USPSTF recommendations on this topic. The complete information on
which this statement is based, including evidence tables and references, is
available through the USPSTF Web site (www.preventiveservices.ahrq.gov) and
through the National Guideline Clearinghouse (www.guideline.gov) The
USPSTF reviewed the evidence on the use of postmenopausal hormone
replacement therapy and the following outcomes: cardiovascular disease,
including CHD and stroke; osteoporosis and fractures; thromboembolism;
dementia and cognitive function; breast, colon, ovarian, and endometrial cancer;
and cholecystitis. The USPSTF also reviewed evidence of the effects of hormone
replacement therapy on phytoestrogens and osteoporosis and cardiovascular
disease. The use of hormone replacement therapy for relieving active symptoms
of menopause, such as hot flashes, urogenital symptoms, and mood and sleep
disturbances, among others, is outside the scope of these USPSTF
recommendations, and literature on this topic was not reviewed. Sources for
estimates of benefits and harms cited in this Recommendation statement are
described in the summary of the evidence available from the Agency for
Healthcare Research and Quality
Keywords: BREAST-CANCER/cancer/cardiovascular/cardiovascular
disease/CHD/cognitive function/dementia/DISEASE/ESTROGEN-PROGESTIN
REPLACEMENT/fractures/HEART/hormone replacement
therapy/menopause/METAANALYSIS/MORTALITY/osteoporosis/PHYSICIA
N/PHYSICIANS/postmenopausal hormone replacement/postmenopausal
women/prevention/primary/primary
prevention/RACE/RISK/sleep/STROKE/symptoms/therapy/thromboembolism/U
S/use/WOMEN
Tonelli, M., Moye, L., Sacks, F.M., Kiberd, B. and Curhan, G. (2003), Pravastatin for
secondary prevention of cardiovascular events in persons with mild chronic renal
insufficiency. Annals of Internal Medicine, 138 (2), 98-104.
Abstract: Background: Cardiovascular disease is a common cause of morbidity and
death in persons with renal insufficiency. Although 3-hydroxy-3methylglutaryl
coenzyme A reductase inhibitors (statins) are effective for secondary prevention
of cardiovascular events in the general population, they have not been
specifically studied in chronic renal insufficiency. Objective: To determine
whether pravastatin is effective and safe for secondary prevention of
cardiovascular events in persons with chronic renal insufficiency. Design: Post
hoc subgroup analysis of a randomized, double-blind, placebo- controlled trial.
Setting: The Cholesterol and Recurrent Events (CARE) study, a randomized trial
of pravastatin versus placebo in 4159 participants with previous myocardial
infarction and total plasma cholesterol levels less than 6.21 mmol/L (<240
mg/dL). Participants: 1711 participants with chronic renal insufficiency defined
by creatinine clearance less than or equal to 75 mL/min, using the
Cockcroft-Gault equation. Measurements: The primary outcome was death from
coronary disease or symptomatic nonfatal myocardial infarction. Results: After a
median follow-up of 58.9 months, the incidence of the primary end point was
lower in participants receiving pravastatin than in those receiving placebo
(adjusted hazard ratio, 0.72 [95% Cl, 0.55 to 0.95]; P = 0.02). Pravastatin was
associated with lower adjusted hazard ratios for major coronary events (0.72 [Cl,
0.59 to 0.88]; P = 0.001) and coronary revascularization (0.65 [Cl, 0.50 to 0.83];
P = 0.001), but not total mortality (0.81 [Cl, 0.61 to 1.08]; P = 0.14) or stroke
(0.62 [Cl, 0.39 to 1.00]; P = 0.051). Tests for interaction suggested that the
observed benefit was independent of the presence and severity of renal
insufficiency. Incidence of side effects was similar in persons receiving
pravastatin and those receiving placebo. Conclusions: These data suggest that
pravastatin is effective and appears safe for secondary prevention of
cardiovascular events in persons with mild chronic renal insufficiency. Since
statins may be underused in this setting, physicians should consider prescribing
them for patients with chronic renal insufficiency and known coronary disease
Keywords: cardiovascular/cardiovascular events/CARE/cholesterol/CHOLESTEROL
LEVELS/chronic/coronary disease/coronary
revascularization/death/DISEASE/EPIDEMIOLOGY/IMPACT/incidence/infarct
ion/interaction/major coronary
events/MANAGEMENT/morbidity/mortality/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/outcome/PHYSICIAN/PHYSICIAN
S/population/pravastatin/prescribing/prevention/primary/RACE/randomized/rand
omized trial/renal/renal
insufficiency/revascularization/RISK-FACTORS/secondary/secondary
prevention/SERUM CREATININE/severity/side
effects/statins/stroke/TRIAL/USA
Grundy, S.M. (1991), Recent Nutrition Research - Implications for Foods of the Future.
Annals of Medicine, 23 (2), 187-193.
Abstract: Dietary habits and the foods we ingest influence health. Nutrition is one factor
that can be controlled in such a way as to influence an individual's destiny in
such diseases as coronary heart disease (CHD) hypertension, stroke, cancer,
osteoporosis, diabetes and gall stone disease. The role of nutrition in treatment
and prevention of CHD is one example. It is not only a problem in Western
Europe and in the United States anymore but with "westernization" of Asia and
Africa and in many Eastern European countries, CHD is increasing at an
alarming rate. Led by the American Heart Association, influential groups have
provided dietary recommendations to the general public over the past 30 years.
These recommendations have been based to a large extent on research carried out
to determine the influence of various dietary components, particularly fatty acids
and dietary cholesterol, on the risk factors leading to CHD. The results of these
investigations can now be used by industry to provide foods for the future which
will provide the public with more healthy choices and hopefully aid in the
control of diseases which can be influenced by diet
Keywords: CORONARY HEART DISEASE/DIET/FATTY
ACIDS/LIPIDS/LOW-DENSITY-LIPOPROTEIN/MEN/MONOUNSATURAT
ED FATTY-ACIDS/NUTRITION/PLASMA-
CHOLESTEROL/PREVENTION/WOMEN
Dobson, A.J. (1994), Relationship Between Risk Factor Trends and Disease Trends.
Annals of Medicine, 26 (1), 67-71.
Abstract: To what extent can trends in risk factor levels in populations explain trends in
disease rates? Some methodological difficulties in answering this question
include weaknesses of ecological studies, small sample size, time lags and
multiple sources of variability. Two possible approaches are to apply predictive
equations derived from longitudinal studies of individuals to average data for
populations, or to use results from overviews of randomized, controlled trials and
cohort studies to estimate the magnitude of effects achievable through various
risk factor changes. These methods are illustrated with Australian data on trends
in mortality from ischaemic heart disease and cigarette smoking, blood pressure
and cholesterol during the 1980s. If it is assumed that time lags are short between
reductions in risk factor levels and reductions in risk, then both methods suggest
that about half the mortality decline in men, and less in women, may be related to
changes in these three well-established risk factors. Improvements in population
levels of blood pressure and, for men, reductions in smoking appear to be the
main contributors. It is argued that such ecological analyses can provide valid
results as long as care is taken to avoid various epidemiological pitfalls
Keywords: AUSTRALIA/BIAS/blood pressure/BLOOD-PRESSURE/cholesterol/cohort
studies/CORONARY HEART-DISEASE/DECLINE/ECOLOGICAL
ANALYSIS/ENGLAND/heart/HEART
DISEASE/MORTALITY/MORTALITY-RATES/PREVENTION/risk/RISK
FACTORS/smoking/STROKE/trials/women
Liede, K.E., Haukka, J.K., Saxen, L.M. and Heinonen, O.P. (1998), Increased tendency
towards gingival bleeding caused by joint effect of alpha-tocopherol
supplementation and acetylsalicylic aci. Annals of Medicine, 30 (6), 542-546.
Abstract: alpha-tocopherol (vitamin E) may play a role in the treatment of arterial
thromboembolic disease, possibly by inhibiting platelet aggregation. Thus far, no
clinical evidence exists for this effect. The objective of this study was to assess
the effect of alpha-tocopherol supplementation on gingival bleeding either in
combination with acetylsalicylic acid (ASA) or without it. This study was an
end-point examination of a random sample of male smokers who had
participated in a controlled clinical trial, the Alpha-Tocopherol, Beta-Carotene
Cancer Prevention Study (ATBC Study) for 5-7 years. The study included 409
men aged 55-74 years of whom 191 received alpha-tocopherol supplementation
(50 mg/day); 56 used ASA, 30 received both and 132 received neither. Gingival
bleeding was examined by probing with a WHO probe and reported as a
percentage of bleeding sites adjusted by the logistic regression model. Gingival
bleeding was more common in those who received alpha-tocopherol compared
with nonreceivers among subjects with a high prevalence of dental plaque (P <
0.05). ASA alone increased bleeding only slightly. The highest risk of gingival
bleeding was among those who took both alpha-tocopherol and ASB (33.4% of
probed sites bleeding vs 25.8% among subjects taking neither alpha- tocopherol
nor ASA, P < 0.001). In the ATBC Study, more deaths from haemorrhagic stroke
and fewer from ischaemic heart disease were observed among those participants
who received alpha- tocopherol compared with those who did not. Based on the
results of the present study and the ATBC Study, we conclude that
alpha-tocopherol supplementation may increase the risk of clinically important
bleedings, particularly when combined with ASA
Keywords: acetylsalicylic
acid/aged/AGGREGATION/alpha-tocopherol/ANTIOXIDANT
VITAMINS/ARACHIDONIC-ACID/bleeding/ENGLAND/Finland/heart/ischae
mic heart disease/MEDICINE/men/plaque/platelet
aggregation/PLATELET-FUNCTION/prevalence/risk/SAFETY/stroke/treatment
/vitamin E/VITAMIN-E
Voutilainen, S., Alfthan, G., Nyyssonen, K., Salonen, R. and Salonen, J.T. (1998),
Association between elevated plasma total homocysteine and increased common
carotid artery wall thickness. Annals of Medicine, 30 (3), 300-306.
Abstract: Homocysteine is increasingly recognized as a risk factor for atherothrombotic
arterial diseases. We investigated the relation between plasma concentrations of
total homocysteine (tHcy) and common carotid artery intima-media wall
thickeness, measured by B-mode ultrasonography, in 513 asymptomatic men and
women from eastern Finland aged 45-69 years. The subjects were examined in
1994-95 at the baseline of the Antioxidant Supplementation in Atherosclerosis
Prevention (ASAP) study, a randomized double-blind placebo-controlled two by
two factorial trial on the effect of vitamin E and C supplementation in the
prevention of atherosclerotic progression. The subjects were assigned into two
categories according to the plasma tHcy concentration; concentration over 11.5
mu mol/L (highest quartile) or concentration below 11.5 mu mol/L. In this study
population the mean plasma tHcy concentration was 10.0 mu mol/L, and the
prevalence of plasma tHcy concentration exceeding 11.5 mu mol/L was 33% in
men and 18% in women. The adjusted mean intima-media thickness of the right
and left common carotid arteries was 1.12 mm in men with elevated plasma tHcy
concentration and 1.02 mm in men with a plasma tHcy concentration below 11.5
mu mol/L (P = 0.029). In women there was no significant difference. We
conclude that elevated plasma tHcy concentrations are associated with early
atherosclerosis, as manifested by increased common carotid artery intima-media
wall thickeness, in middle-aged eastern Finnish men
Keywords: aged/ATHEROSCLEROSIS/atherosclerosis/carotid/carotid arteries/carotid
artery wall thickness/CONTAINING
AMINO-ACIDS/diseases/ENGLAND/Finland/HOMOCYST(E)INE/homocyst(e
)ine/INDEPENDENT RISK FACTOR/INTIMA-MEDIA
THICKNESS/LOW-DENSITY-LIPOPROTEIN/MYOCARDIAL-INFARCTIO
N/prevention/risk/SERUM TOTAL
HOMOCYSTEINE/STROKE/VASCULAR-DISEASE/vitamin E/women
Sivenius, J., Riekkinen, P.J., Smets, P., Laakso, M. and Lowenthal, A. (1991), The
European Stroke Prevention Study (Esps) - Results by Arterial Distribution.
Annals of Neurology, 29 (6), 596-600.
Abstract: The European Stroke Prevention Study was a multicenter study comparing the
effect of the combination of dipyridamole, 75 mg, and acetylsalicylic acid, 330
mg, three times a day, to that of placebo in 2,500 patients in the secondary
prevention of stroke or death after one or more transient ischemic attacks,
reversible ischemic neurological deficits, or strokes of atherothrombotic origin.
The patients with vertebrobasilar events at entry comprised one-third of the
whole patient population. The overall total incidence of stroke or death (the end
points) during the 2-year follow-up in the placebo group was lower in the
vertebrobasilar group compared to the carotid group (14% versus 24%,
respectively). The combination therapy of dipyridamole and acetylsalicylic acid
caused a marked reduction in the incidence of stroke or death in patients with
vertebrobasilar (51%) and carotid (30%) events. When only stroke was
considered as the end point, dipyridamole and acetylsalicylic acid seemed to be
more effective in reducing the risk of transient ischemic attacks than stroke, and
more effective in men than in women
Keywords: ASPIRIN/CEREBRAL-ISCHEMIA/CONTROLLED
TRIAL/INFARCTION/MINNESOTA/ROCHESTER/SURVIVAL/TRANSIEN
T ISCHEMIC ATTACKS
Easton, J.D. and Wilterdink, J.L. (1994), Carotid Endarterectomy - Trials and
Tribulations. Annals of Neurology, 35 (1), 5-17.
Abstract: Since its introduction 40 years ago, the value of carotid endarterectomy has
been controversial. In the early 1980s, several clinical trials were initiated to
determine the efficacy of this operation in patients with carotid stenoses who
were either symptomatic or asymptomatic for retinal or hemispheric ischemia In
1991, interim results were published for the North American Symptomatic
Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery
Trial (ECST), both reporting efficacy for surgery in patients with symptomatic
carotid artery stenosis of greater than 70%. Subgroup analyses revealed variable
risk groups. The Veterans Administration (VA) Symptomatic Trial (Cooperative
Studies Program 309 of the Department of Veterans Affairs) terminated early
because of these results and its findings were consistent with the results of the
larger trials. NASCET and ECST continue for symptomatic patients with carotid
stenoses between 30% and 69%. The results of three trials in asymptomatic
patients, the Mayo asymptomatic trial, the Carotid Artery Stenosis with
Asymptomatic Narrowing: Operation Versus Aspirin trial, and the VA
Asymptomatic Trial (Cooperative Studies Protocol 167 of the Department of
Veterans Affairs), have been reported. None showed a statistically significant
benefit for surgery in the prevention of stroke or death. However, none was
sufficiently large to exclude such a benefit. The large Asymptomatic Carotid
Atherosclerosis Study is in progress. Differences in the results and design of
these trials are discussed as are restrictions in the applicability of their results
Keywords: carotid/carotid endarterectomy/clinical
trials/COMMUNITY/COMPLICATIONS/endarterectomy/EXPERIENCE/EXT
RACRANIAL
ARTERIES/ischemia/MORTALITY/OPERATIONS/PERFORMANCE/preventi
on/RISK/STENOSIS/STROKE/surgery/trials
Adams, R.J., Mckie, V.C., Carl, E.M., Nichols, F.T., Perry, R., Brock, K., Mckie, K.,
Figueroa, R., Litaker, M., Weiner, S. and Brambilla, D. (1997), Long-term stroke
risk in children with sickle cell disease screened with transcranial Doppler.
Annals of Neurology, 42 (5), 699-704.
Abstract: Stroke is an important complication of sickle cell disease. Stroke prediction is
clinically important because it offers the possibility of primary prevention. In
1992, transcranial Doppler (TCD) evidence of elevated intracranial internal
carotid or middle cerebral artery velocity was demonstrated to be associated
strongly with an increased risk of ischemic stroke. This study extends the
original study and includes 125 more children, longer follow-up, and intracranial
hemorrhage in the stroke-risk model. Elevated time averaged mean maximum
blood now velocity, especially when velocity is 200 cm/sec or greater by TCD,
was associated strongly with stroke risk. The cases not predicted by TCD point
to the need for more information on the optimal timing of TCD surveillance for
stroke risk
Keywords: ANEMIA/ANGIOGRAPHY/carotid/cerebral/cerebral
artery/CEREBROVASCULAR-DISEASE/CLINICAL
IMPLICATIONS/hemorrhage/ischemic/ischemic
stroke/LIQUID-CHROMATOGRAPHIC SEPARATION/prevention/primary
prevention/QUANTITATION/risk/stroke
Franke, C.L., Koehler, P.J.J., Gorter, J.W., Kappelle, L.J., Rinkel, G.J.E., Tjeerdsma,
H.C., van Gijn, J., Dammers, J.W.H.H., Straatman, H.J.S., ten Houten, R.,
Veering, M.M., Bakker, S.L.M., Dippel, D., Koudstaal, P.J., van Gemert,
H.M.A., van Swieten, J.C., Horn, J., Kwa, I.H., Limburg, M., Stam, J., Boon,
A.M., Lieuwens, W.H.G., Visscher, F., Bouwsma, C., Rutgers, A.W.F., Snoek,
J.W., Brouwers, P.J.A.M., Nihom, J., Solleveld, H., Carbaat, P.A.T., Hertzberger,
L.I., Kleijweg, R.P., Nanninga-van den Neste, V., van Diepen, A.J.H., Linssen,
W.H.J.P., Vanneste, J.A.L., Vos, J., Weinstein, H.C., Schipper, J.P., van der
Meer, W.K., Berntsen, P.J.I.M., Vries-Leenders, E.M., Geervliet, J.P., Tans,
R.J.J., Feikema, W.J., Lohmann, H.J.H.M., van Kasteel, V., Jongebloed, F.A.,
Leyten, Q.H., van Wensen, P.J.M., Jansen, C., Smits, M.G., Driesen, J.J.M., van
Oudenaarden, W.F., Verhey, J.C.B., Bottger, H.R.F., Driessen-Kletter, M.F.,
Zwols, F., van der Gaast, J.B., Wittebol, M.C., Lodder, J., van Oostenbrugge,
R.J., Beintema, K.D., Hilbers, J., van der Weil, H.L., van Lieshout, H.B.M.,
Weststrate, W., Bernsen, P.L.J.A., Frenken, C.W.G.M., Poels, E.F.J., Lindeboom,
S.F., van der Steen, A., Glimmerveen, W.F., Martens, E.I.F., Bulens, C.,
Vries-Bos, L.H.P., Venables, G.S., Koster, J.G., Sinnige, L.G.F., Klaver, M.M.,
Koetsveld-Baart, J.C., Mauser, H.W., Don, J.A., van Geusau, R.B.A., Dijkman,
M.H., Hoppenbrouwers, W.J.J.F., Banford, W.J.J.F., Briet, P.E., Eekhof, J.L.A.,
Witjes, R., Hamburger, H.L., van der Sande, J.J., Bath, P., Hankey, G.J., Koning,
E., Ricci, S., Berendes, J.N., Hooff, L.J.M.A., van Spreeken, A.C.G.A., Wouters,
H.N.A., Kuhler, A.R., Mallo, G.N., van Walbeek, H.K., Gauw, J.C., Vermeij,
A.J., Verheij, J.C.B., Swen, J.W.A., Canhao, P., Keyser, A., Holscher, R.S., de
Jong, G.J., Kraaier, V., Agra, A., Briet, E., deVries-Goldschemdingi, J.,
Eikelboom, B.C., Greebe, P., Hauer, R.N.W., Hermsen, M.G., Loeliger, E.A.,
Pop, G.A.M., Rosendaal, F.R., Schobben, A.F.A.M., Simoons, M.L., Sixma, F.F.,
Slabbers, D.C.V., Tijssen, J.C.P., van Creval, H., van Es, G.A., Verheugt,
F.W.A., Vermeulin, M., Wever, E.F.D. and Wulfsen, E.K.M. (1997), A
randomized trial of anticoagulants versus aspirin after cerebral ischemia of
presumed arterial origin. Annals of Neurology, 42 (6), 857-865.
Abstract: Aspirin is only modestly effective in the secondary prevention after cerebral
ischemia Studies in other vascular disorders suggest that anticoagulant drugs in
patients with cerebral ischemia of presumed arterial (noncardiac) origin might be
more effective. The aim of the Stroke Prevention in Reversible Ischemia Trial
(SPIRIT) therefore was to compare the efficacy and safety of 30 mg aspirin daily
and oral anticoagulation (international normalized ratio [INR] 3.0-4.5), Patients
referred to a neurologist in one of 58 collaborating centers because of a transient
ischemic attack or minor ischemic stroke (Rankin grade less than or equal to 3)
were eligible. Randomization was concealed, treatment assignment was open,
and assessment of outcome events was masked. The primary measure of
outcome was the composite event "death from all vascular causes, nonfatal
stroke, nonfatal myocardial infarction, or nonfatal major bleeding complication."
The trial was stopped at the first interim analysis. A total of 1,316 patients
participated; their mean follow-up was 14 months. There was an excess of the
primary outcome event in the anticoagulated group (81 of 651) versus 36 of 665
in the aspirin group (hazard ratio, 2.3; 95% confidence interval [CI], 1.6-3.5).
This excess could be attributed to 53 major bleeding complications (27
intracranial; 17 fatal) during anticoagulant therapy versus 6 on aspirin (3
intracranial; 1 fatal). The bleeding incidence increased by a factor of 1.43 (95%
CI, 0.96-2.13) for each 0.5 unit increase of the achieved INR. Anticoagulant
therapy with an INR range of 3.0 to 4.5 in patients after cerebral ischemia of
presumed arterial origin is not safe. The efficacy of a lower intensity
anticoagulation regimen remains to be determined
Keywords: ACUTE
MYOCARDIAL-INFARCTION/anticoagulant/anticoagulants/anticoagulation/as
pirin/BLEEDING COMPLICATIONS/cerebral/cerebral
ischemia/complications/DISEASE/drugs/HANDICAP/incidence/infarction/INR/
INTEROBSERVER AGREEMENT/INTRACEREBRAL
HEMORRHAGE/ischemia/ischemic/ischemic stroke/myocardial
infarction/Netherlands/OPTIMAL INTENSITY/oral
anticoagulation/prevention/randomized/safety/secondary
prevention/stroke/STROKE PATIENTS/THERAPY/transient/transient ischemic
attack/treatment/vascular/WARFARIN
van Exel, E., de Craen, A.J.M., Gussekloo, J., Houx, P., Bootsma-van der Wiel, A.,
Macfarlane, P.W., Blauw, G.J. and Westendorp, R.G.J. (2002), Association
between high-density lipoprotein and cognitive impairment in the oldest old.
Annals of Neurology, 51 (6), 716-721.
Abstract: Low high-density lipoprotein cholesterol is associated with an increased risk
for cardiovascular disease and stroke. At the same time, cardiovascular disease
and stroke are important risk factors for dementia. We assessed the association
between total and fractionated cholesterol and cognitive impairment and
explored whether observed associations were dependent on or independent of
atherosclerotic disease. In a population-based study, total cholesterol,
triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein
cholesterol were measured in 561 subjects 85 years old and grouped in three
equal strata representing decreasing serum concentrations. History of
cardiovascular disease and stroke was determined. All subjects completed the
Mini-Mental State Examination (MMSE), and the presence of dementia was
determined. Median MMSE scores were significantly lower in subjects with low
high-density Lipoprotein cholesterol (25 points vs 27 points, p<0.001). No
differences in MMSE scores were found for other lipids and lipoproteins. MMSE
scores in subjects with and without cardiovascular disease were 26 and 27 points
(p=0.007), respectively, and in subjects with and without stroke were 21 and 26
points (p<0.001), respectively. The associations between low MMSE scores and
low high-density lipoprotein cholesterol remained significant after subjects with
cardiovascular disease or stroke were excluded. In a comparison of subjects with
low high-density lipoprotein cholesterol with subjects with high high-density
lipoprotein cholesterol, the odds ratio for dementia was 2.3 (95% confidence
interval, 1.2-4.3), and in subjects without cardiovascular disease or stroke, it was
3.7 (95% confidence interval, 1.3-10.1). All odds ratios were unaffected by
education, low-density lipoprotein cholesterol, triglycerides, and survival. Low
high-density lipoprotein cholesterol is associated with cognitive impairment and
dementia. At least part of the association between high-density lipoprotein
cholesterol and cognitive function is independent of atherosclerotic disease
Keywords:
ALZHEIMERS-DISEASE/APOLIPOPROTEIN/cardiovascular/cardiovascular
disease/CHOLESTEROL/cognitive function/cognitive
impairment/DEMENTIA/disease/education/EXPRESSION/HEART-DISEASE/h
igh density lipoprotein/high-density lipoprotein cholesterol/ISCHEMIC
STROKE/lipids/lipoproteins/low density lipoprotein/low-density lipoprotein
cholesterol/MMSE/Netherlands/NEW-YORK/POPULATION/population-based/
PREVENTION/RISK/risk factors/serum/stroke/survival/triglycerides
Wong, K.S., Gao, S., Chan, Y.L., Hansberg, T., Lam, W.W.M., Droste, D.W., Kay, R.
and Ringelstein, E.B. (2002), Mechanisms of acute cerebral infarctions in
patients with middle cerebral artery stenosis: A diffusion-weighted imaging and
microemboli monitoring study. Annals of Neurology, 52 (1), 74-81.
Abstract: Although most therapeutic efforts and experimental stroke models focus on the
concept of complete occlusion of the middle cerebral artery as a result of
embolism from the carotid artery or cardiac chamber, relatively little is known
about the stroke mechanism of intrinsic middle cerebral artery stenosis.
Differences in stroke pathophysiology may require different strategies for
prevention and treatment. We prospectively studied 30 consecutive acute
ischemic stroke patients with middle cerebral artery stenosis detected by
transcranial Doppler and magnetic resonance angiography. Patients underwent
microembolic signal monitoring by transcranial Doppler and diffusion-weighted
magnetic resonance imaging. Characteristics of acute infarct on
diffusion-weighted magnetic resonance imaging were categorized according to
the number (single or multiple infarcts) and the pattern of cerebral infarcts
(cortical, border zone, or perforating artery territory infarcts). The data of
microembolic signals and diffusion- weighted magnetic resonance imaging were
assessed blindly and independently by separate observers. Diffusion-weighted
magnetic resonance imaging showed that 15 patients (50%) had single acute
cerebral infarcts and 15 patients had multiple acute cerebral infarcts. Among
patients with multiple acute infarcts, unilateral, deep, chainlike border zone
infarcts were the most common pattern (11 patients, 73%), and for single infarcts,
penetrating artery infarcts were the most common (10 patients, 67%).
Microembolic signals were detected in 10 patients (33%). The median number of
microembolic signals per 30 minutes was 15 (range, 3-102). Microembolic
signals were found in 9 patients with multiple infarcts and in 1 patient with a
single infarct (p = 0.002, chi(2)). The number of microembolic signals predicted
the number of acute infarcts on diffusion-weighted magnetic resonance imaging
(linear regression, adjusted R-2 =0.475, p < 0.001). Common stroke mechanisms
in patients with middle cerebral artery stenosis are the occlusion of a single
penetrating artery to produce a small subcortical lacuna-like infarct and an
artery-to-artery embolism with impaired clearance of emboli that produces
multiple small cerebral infarcts, especially along the border zone region
Keywords: acute/acute ischemic stroke/angiography/cardiac/carotid/carotid
artery/CAROTID ENDARTERECTOMY/cerebral/cerebral
artery/China/Doppler/emboli/EMBOLIC
SIGNALS/embolism/EMBOLIZATION PREDICTS
STROKE/experimental/Hong Kong/imaging/ischemic/ischemic stroke/magnetic
resonance angiography/magnetic resonance
imaging/MAGNETIC-RESONANCE
ANGIOGRAPHY/mechanisms/microemboli/middle cerebral
artery/monitoring/NEW-YORK/OCCLUSIVE
DISEASE/pathophysiology/PLAQUE
ULCERATION/prevention/stenosis/stroke/stroke patients/TIA
RISK/transcranial/transcranial Doppler/TRANSCRANIAL DOPPLER
ULTRASOUND/TRANSIENT ISCHEMIC
ATTACKS/treatment/VASCULAR-LESIONS
Mcanally, L.E., Corn, C.R. and Hamilton, S.F. (1992), Aspirin for the Prevention of
Vascular Death in Women. Annals of Pharmacotherapy, 26 (12), 1530-1534.
Abstract: OBJECTIVE: To review current information relevant to the use of aspirin for
preventing vascular death in women, and to provide recommendations based on
this information. DATA SOURCES: References from pertinent articles are
identified throughout the text. DATA SYNTHESIS: Based on current
information, low- dose aspirin is not recommended as primary prevention for
cardiovascular death in women; efforts are better focused at promoting
fisk-factor reduction. Low-dose aspirin is recommended for reducing further
cardiovascular morbidity and mortality in women with known cardiovascular
disease. Women presenting with unstable angina or myocardial infarction should
receive aspirin 325 mg as soon as the diagnosis is confirmed, and this dosage
should be continued on a chronic basis. Women who have experienced transient
ischemic attacks or ischemic stroke should receive aspirin 1 000 mg/d, with a
subsequent dosage reduction to 325 mg/d in patients who do not tolerate the
higher dose. CONCLUSIONS: Current recommendations are based on the
results of studies that involved few women. Further investigation of antiplatelet
agents for primary and secondary prevention of vascular death in women is
needed
Keywords:
ACID/CORONARY/DISEASE/MORTALITY/MYOCARDIAL-INFARCTION/
RANDOMIZED TRIAL/SECONDARY
PREVENTION/TICLOPIDINE/UNSTABLE ANGINA
Floresrunk, P. and Raasch, R.H. (1993), Ticlopidine and Antiplatelet Therapy. Annals of
Pharmacotherapy, 27 (9), 1090-1098.
Abstract: OBJECTIVE: To review the pharmacology, pharmacokinetics, clinical
efficacy, and toxicity of ticlopidine. Comparisons with other antiplatelet agents
are presented, with an emphasis on efficacy, and a recommendation is provided
regarding ticlopidine's place in therapy. DATA SOURCES: A MEDLINE
literature retrieval of English-language journal articles from 1987 to January
1993 and references identified from bibliographies of review articles and clinical
trials. STUDY SELECTION: Randomized, blind, controlled studies of
ticlopidine and other antiplatelet agents were preferentially selected. DATA
EXTRACTION: Clinical trials were reviewed in terms of study design, efficacy
results, and toxicity. DATA SYNTHESIS: Ticlopidine is a new antiplatelet agent
with a distinct mechanism of action. In the largest trial of the drug for the
prevention of stroke, it was found to be more effective than aspirin in reducing
the risk of stroke or death. Clinical trials have also shown ticlopidine to decrease
the rate of vascular death and myocardial infarction in patients with unstable
angina, and to maintain venous graft patency after coronary artery bypass
grafting. The use of ticlopidine in diabetic microangiopathy and peripheral
vascular disease appears promising, but further studies are needed. Adverse
reactions most commonly reported with ticlopidine are gastrointestinal
complaints; the most severe reaction is transient neutropenia, which is seen in
approximately 2.3 percent of patients and is severe in nearly 1 percent.
CONCLUSIONS: Ticlopidine is a reasonable alternative for use in preventing
stroke among patients unable to take aspirin or those who do not benefit from
aspirin therapy. Its use as first-line therapy is limited by its high cost and the
occurrence of hematologic adverse effects
Keywords: ACUTE MYOCARDIAL-INFARCTION/ANTI-THROMBOTIC
THERAPY/ASPIRIN THERAPY/BYPASS GRAFT
OCCLUSION/CEREBRAL-ISCHEMIA/CONTROLLED
TRIAL/INTERMITTENT CLAUDICATION/PLATELET
SURVIVAL/STABLE ANGINA/UNSTABLE ANGINA
Mallet, L. and Mallet, J. (1994), Ticlopidine and Fatal Aplastic-Anemia in An Elderly
Woman. Annals of Pharmacotherapy, 28 (10), 1169-1171.
Abstract: OBJECTIVE: To report a case of aplastic anemia that developed during
ticlopidine treatment. CASE SUMMARY: An 84-year-old woman was started on
ticlopidine for secondary stroke prevention. Within six weeks of initiating
ticlopidine therapy she developed aplastic anemia. She was hospitalized and
received empiric antibiotics, antifungal agents, blood transfusions, platelets, and
granulocyte colony-stimulating factor. The patient died on day 76 after beginning
ticlopidine. DISCUSSION: Hematologic effects such as neutropenia,
thrombocytopenia, agranulocytosis, thrombotic thrombocytopenic purpura, and
pancytopenia have been described with the use of ticlopidine. Previous case
reports have associated ticlopidine with the development of aplastic anemia.
CONCLUSIONS: Ticlopidine can produce fatal hematologic adverse effects, and
its use should be reserved as second-line therapy
Keywords:
ASPIRIN/development/MECHANISM/platelets/PREVENTION/PURPURA/ST
ROKE/stroke prevention/THERAPY/ticlopidine/treatment
Geletko, S.M., Melbourne, K.M. and Mikolich, D.J. (1996), Pseudomonas bacteremia
precipitated by ticlopidine-induced neutropenia. Annals of Pharmacotherapy, 30
(3), 246-248.
Abstract: OBJECTIVE: To report a case of ticlopidine-induced neutropenia resulting in
Pseudomonas bacteremia. CASE SUMMARY: An 83-year- old white man
developed febrile neutropenia 5 days after initiation of ticlopidine therapy. At
presentation, the patient's white blood cell count was 1.1 x 10(9)/L with an
absolute neutrophil count (ANC) of 0. Ticlopidine was discontinued and the
patient was treated empirically with ceftazidime, gentamicin, and filgrastim. The
patient's blood cultures were positive for Pseudomonas aeruginosa. By day 6 of
antibiotic and filgrastim therapy, he was clinically improved and the ANC was
17 040 x 10(6) cells/L. The filgrastim and intravenous antibiotics were
discontinued and oral ciprofloxacin was started. CONCLUSIONS:
Ticlopidine-induced neutropenia can occur suddenly and may result in a serious
infection, such as bacteremia
Keywords: AGRANULOCYTOSIS/ANEMIA/PREVENTION/STROKE/ticlopidine
Chant, C., Fagan, S.C., Aurora, S.K., Gidal, B.E. and Joseph, R. (1997), Effects of
aspirin on platelet aggregation in smokers and nonsmokers. Annals of
Pharmacotherapy, 31 (3), 290-293.
Abstract: OBJECTIVE: TO assess the relative antiaggregatory ability of aspirin on
platelets of smoking and nonsmoking healthy volunteers. DESIGN: Prospective,
randomized, crossover study. SETTING: Tertiary-care teaching institution.
SUBJECTS: Eighteen healthy smoking and nonsmoking male volunteers.
INTERVENTIONS: Each subject received aspirin 325 mg or ticlopidine 250 mg
bid as an active control for 7 days in a crossover manner separated by a 1-month
washout period. Whole blood platelet aggregation was measured on four
occasions, twice at baseline and once after each drug treatment. OUTCOME
MEASUREMENT: Whole blood ex vivo platelet aggregation in terms of
impedance (Omega) and adenosine triphosphate (ATP) release (nmol), as
assessed using Lumi-aggregometry. RESULTS: Aspirin was associated with
significantly less ATP release in both smokers (p = 0.01) and nonsmokers (p =
0.003). No significant differences in platelet aggregation were found between
smokers and nonsmokers at baseline or with any treatment phases. Sixty-seven
percent and 17% of volunteers receiving ticlopidine and aspirin, respectively,
reported adverse effects. CONCLUSIONS: Twice- daily administration of
aspirin for 7 days to healthy volunteers was well tolerated and also reduced
platelet aggregation significantly regardless of smoking status
Keywords:
administration/aggregation/aspirin/CIGARETTE-SMOKING/control/DESIGN/
DISEASE/DRUGS/HABITUAL
SMOKERS/INTERVENTION/MEASUREMENT/OUTCOME/platelet
aggregation/platelets/PREVENTION/randomized/smoking/STROKE/THERAP
Y/TICLOPIDINE/treatment
Howard, P.A. and Duncan, P.W. (1997), Primary stroke prevention in nonvalvular atrial
fibrillation: Implementing the clinical trial findings. Annals of Pharmacotherapy,
31 (10), 1187-1196.
Abstract: OBJECTIVE: To review the clinical trials evaluating warfarin for primary
stroke prophylaxis in nonvalvular atrial fibrillation (NVAF), to discuss the
relative benefits and risks of warfarin versus aspirin therapy, and to review the
clinical practice guidelines and identify potential barriers to their implementation
in clinical practice. DATA SOURCES: A MEDLINE literature search was
performed to identify clinical trials of antithrombotic therapy for NVAF, clinical
practice guidelines, studies evaluating physician practices and attitudes, cost-
effectiveness studies, and pertinent review articles. Key search terms included
atrial fibrillation, stroke, antithrombotic, warfarin, aspirin, and cost-effectiveness.
DATA EXTRACTION: Prospective, randomized clinical trials were selected for
analysis. Clinical practice guidelines from recognized panels of experts were
reviewed. Comprehensive review articles were selected. DATA SYNTHESIS:
NVAF is a common arrhythmia that is associated with a substantial risk for
stroke. Seven prospective, randomized, clinical trials have conclusively
demonstrated the efficacy of warfarin for stroke prevention. The greatest benefits
are achieved in older patients and those with comorbidities that increase their
risk for stroke. The potential benefits of preventing a devastating stroke, however,
must be weighed against the potential for bleeding complications. Warfarin has
been shown to be cost- effective in high-risk patients, provided the rate of
complications is minimized. Nonetheless, many physicians remain hesitant to
implement warfarin therapy in older, high-risk patients. The clinical data on
aspirin are less consistent than those observed with warfarin. Aspirin appears to
be most effective in younger individuals or those considered to be at low risk for
stroke. CONCLUSIONS: In patients with NVAF, the personal, social, and
economic consequences of stroke are often devastating. Clinical trials have
provided definitive proof that the risks of stroke can be significantly reduced
through the use of appropriate antithrombotic therapy. Despite this evidence and
the recommendations of a number of clinical practice guidelines, variations in
care exist that continue to place patients at risk. Additional outcomes research is
needed to evaluate the impact of the clinical trial findings and practice guidelines
on clinical practice and to develop methods for overcoming barriers to
implementation
Keywords: ANTICOAGULATION/ANTITHROMBOTIC
THERAPY/arrhythmias/aspirin/ASPIRIN/atrial
fibrillation/ATTITUDES/clinical trials/complications/cost/cost
effectiveness/COST-EFFECTIVENESS/fibrillation/guidelines/ISCHEMIC
STROKE/prevention/prophylaxis/PROPHYLAXIS/PROTHROMBIN
TIME/randomized/RISK/stroke/stroke
prevention/therapy/trials/warfarin/WARFARIN
Maharaj, S., Bayliff, C.D. and Kovacs, M.J. (1999), Successful anticoagulation with
dalteparin in a patient with mechanical heart valves. Annals of Pharmacotherapy,
33 (11), 1188-1191.
Abstract: BACKGROUND: Standard thromboprophylaxis of patients with mechanical
heart valves is achieved using warfarin. In certain patients this may be very
difficult; thus, alternative pharmacotherapy must be used. OBJECTIVE: To
report a case of a patient who successfully used dalteparin, a low-molecular-
weight heparin, for anticoagulation. CASE SUMMARY: A 58-year- old white
woman with mechanical aortic and mitral heart valves initially received warfarin
for anticoagulation. Thromboprophylaxis was very challenging. Her international
normalized ratios (INRs) were erratic and occasionally responded paradoxically
to changes in dose. Finally, she experienced a left hemispheric stroke when her
INR was extremely subtherapeutic, Subsequently, despite best efforts, her INR
again was subtherapeutic; warfarin was discontinued and dalteparin was initiated
with daily self-administered subcutaneous injections of 16 000 units. No
complications have arisen since initiation of the new pharmacotherapy
approximately 18 months ago. DISCUSSION: The use of low- molecular-weight
heparin for the treatment and prevention of venous thromboembolism is well
described. There are few reports of its use for thromboprophylaxis of patients
with mechanical heart valves. Our patient has been managed successfully with
dalteparin. CONCLUSIONS: Dalteparin was effectively and safely used for the
thromboprophylaxis of a patient with mechanical heart valves whose
anticoagulation was previously difficult to manage with warfarin. Dalteparin
deserves further study in patients who are unable to tolerate warfarin
Keywords: anticoagulation/complications/dalteparin/DEEP VENOUS
THROMBOSIS/FRAGMIN(R)/heart/heparin/INR/low- molecular-weight
heparin/LOW-MOLECULAR-WEIGHT/low-molecular-weight
heparin/mechanical heart
valve/prevention/REPLACEMENT/RESISTANCE/STANDARD
HEPARIN/stroke/THERAPY/THROMBOEMBOLISM/treatment/UNFRACTIO
NATED HEPARIN/valves/venous thromboembolism/warfarin/WARFARIN
Munger, M.A. and Kenney, J.K. (2000), A chronobiologic approach to the
pharmacotherapy of hypertension and angina. Annals of Pharmacotherapy, 34
(11), 1313-1319.
Abstract: OBJECTIVE: To review the chronobiology of hypertension and coronary
artery disease and the application of chronotherapeutics to their treatment and
prevention. DATA SOURCES: Clinical trials and review articles
(English-language) on the topic of chronotherapy and cardiovascular disease
were identified via a MEDLINE search from 1990 to March 2000, using the
search terms chronotherapy, circadian rhythm, cardiovascular disease,
hypertension, and angina. DATA EXTRACTION: Search and evaluation
focused on published clinical trials and review articles of circadian variation
associated with pharmacotherapy for cardiovascular disease. DATA
SYNTHESIS: The existence of circadian:rhythm in cardiovascular disease is
well established. Heart rate and blood pressure peak during the morning hours
and reach a nadir at bedtime. The incidence of myocardial infarction, stroke,
sudden cardiac death, and myocardial ischemia also increases during the early-
morning hours. Based on these relationships, researchers have begun to apply the
science of chronotherapeutics, or timing of drug effect with biologic need, to
improve cardiovascular outcomes. This includes administering traditional agents
at specific times throughout the day and developing new agents -
chronotherapeutic formulations with special release mechanisms - targeted at
inducing the greatest effect during the morning surges. Chronotherapeutic agents
are specifically designed to provide peak plasma concentrations during the
early-morning hours, when effect appears most needed; lowest concentrations
occur at night, when heart rate and blood pressure are lowest and, consequently,
cardiovascular events are least likely to occur. CONCLUSIONS: Whether
chronotherapy of cardiovascular disease offers an advantage in long-term
outcomes over traditional therapy must be studied in clinical trials
Keywords: angina/blood pressure/BLOOD-PRESSURE/cardiovascular/cardiovascular
disease/cardiovascular
events/CARDIOVASCULAR-DISEASE/chronobiology/circadian
rhythm/CIRCADIAN VARIATION/clinical
trials/CONTROLLED-ONSET/coronary artery disease/CORONARY- ARTERY
DISEASE/DIURNAL-VARIATION/evaluation/EXTENDED-RELEASE
VERAPAMIL/heart/hypertension/incidence/infarction/ischemia/myocardial/myo
cardial infarction/MYOCARDIAL-INFARCTION/PLATELET
AGGREGABILITY/prevention/review/stroke/SUDDEN CARDIAC
DEATH/therapy/timing/treatment/trials
Lenz, T.L. and Hilleman, D.E. (2000), Aggrenox: A fixed-dose combination of aspirin
and dipyridamole. Annals of Pharmacotherapy, 34 (11), 1283-1290.
Abstract: OBJECTIVE: To describe the pharmacology, pharmacokinetics, efficacy, and
safety of a fixed-dose combination of aspirin and extended-release (ER)
dipyridamole indicated for the secondary prevention of stroke. DATA
SOURCES: Published articles and abstracts were identified from a MEDLINE
search (1966-December 1999) using the search terms dipyridamole, aspirin,
antiplatelet, antiaggregation, and stroke prevention. Pertinent articles written in
English were considered for review. Additional articles were identified from the
references of retrieved literature. STUDY SELECTION AND DATA
EXTRACTION: Studies including a combination of aspirin/dipyridamole in
human subjects were evaluated. Emphasis was placed on randomized, controlled
trials. DATA SYNTHESIS: Aspirin is a platelet inhibitor that works by
inhibiting platelet cyclooxygenase, which reduces the production of thromboxane
A(2). Dipyridamole is a platelet inhibitor that is thought to work in part by
inhibiting platelet cyclic-3',5'-adenosine monophosphate and
cyclic-3',5'-guanosine monophosphate phosphodiesterase. The active metabolite
of aspirin, salicylic acid, is highly bound to plasma protein and has a plasma
half- life of two to three hours. Dipyridamole is also highly bound to plasma
proteins, and the ER formulation has a plasma half- life of 13 hours. The first
European Stroke Prevention Study (ESPS-1) found the combination of
aspirin/dipyridamole to be superior to placebo in the prevention of stroke and
transient ischemic attack (TIA). The ESPS-1, however, did not include an
aspirin-only treatment arm. Therefore, it was unclear whether the combination of
aspirin/dipyridamole was superior to aspirin alone. As a result, a second trial was
conducted that included treatment arms of aspirin alone, ER dipyridamole alone,
combination therapy, and placebo. The combination of aspirin 25 mg plus ER
dipyridamole 200 mg twice daily was shown in the ESPS-2 to be significantly
better than either agent given individually in preventing stroke and TIAs (p <
0.001). CONCLUSIONS: The American College of Chest Physicians (ACCP)
recommends aspirin 50-325 mg/d to be the initial antiplatelet of choice for the
prevention of atherothrombotic cerebral ischemic events: However, with the
favorable results of the ESPS-2, it may be appropriate to substitute aspirin/ER
dipyridamole for aspirin alone as the drug of choice. This combination appears to
have a favorable adverse effect profile. The relative effectiveness of aspirin/ER
dipyridamole compared with clopidogrel and ticlopidine has yet to be determined.
If alternative antiplatelet therapy is needed, the ACCP recommends clopidogrel
rather than ticlopidine because of its lower incidence of adverse effects. The
ACCP further states that the combination of aspirin plus dipyridamole may be
more effective than clopidogrel; these agents have a similarly favorable adverse
effect profile
Keywords: AMERICAN-HEART-ASSOCIATION/antiplatelet/antiplatelet
therapy/aspirin/cerebral/clopidogrel/combination
therapy/dipyridamole/DISEASE/ESPS-1/human/incidence/ischemic/pharmacolo
gy/prevention/PROSTACYCLIN/randomized/RATES/review/safety/salicylic
acid/SECONDARY PREVENTION/SELECTION/STROKE/stroke
prevention/therapy/thromboxane A(2)/TIA/TICLOPIDINE/transient/transient
ischemic attack/treatment/TRIAL/trials
Rigler, S.K., Webb, M.J., Patel, A.T., Lai, S.M. and Duncan, P.W. (2001), Use of anti
hypertensive and antithrombotic medications after stroke in community-based
care. Annals of Pharmacotherapy, 35 (7-8), 811-816.
Abstract: BACKGROUND: Secondary stroke prevention strategies include
pharmacologic approaches to control hypertension and reduce; thromboembolic
risk. OBJECTIVE: To describe antithrombotic and antihypertensive medication
use, and rates of blood pressure control in the Kansas City Stroke Study, a
prospective stroke cohort receiving community-based care after primarily mild
and moderate stroke.; METHODS: Participants from 12 area hospitals provided
information about medication use prior to stroke. Study personnel measured
blood pressures at enrollment and at one, three, and six months, and collected
medication data at six months during in-home assessment. RESULTS: Complete
data at six months were available for 355 subjects with ischemic stroke, among
whom 13% had atrial fibrillation and 67% had prior hypertension. Prior to stroke,
only 45% of the patients were receiving any antithrombotic (anticoagulant and/or
antiplatelet) therapy; this figure rose to 77% at six months, Antithrombotic
treatment rates among those with atrial fibrillation were 59% before stroke and
83% at six months, including warfarin in 64%. Approximately 70% of subjects
had controlled blood pressures one, three, and six months after stroke, defined as
systolic blood pressure less than or equal to 140 mm Hg and diastolic blood
pressure less than or equal to 90 mm Hg. Use of multiple antihypertensive agents
was common; calcium-channel blockers and angiotensin-converting enzyme
inhibitors were used most frequently, However, 19% of subjects with
uncontrolled blood pressure were untreated at six months. CONCLUSIONS:
Although room for improvement remains, these data suggest improved rates of
antithrombotic and antihypertensive medication use after stroke in
community-based care in a midwestern metropolitan community, compared with
previous reports
Keywords: angiotensin converting enzyme inhibitors/angiotensin-converting enzyme
inhibitors/anticoagulant/anticoagulants/antihypertensive
agents/antiplatelet/antithrombotic/ASSOCIATION/atrial
fibrillation/ATRIAL-FIBRILLATION/blood pressure/blood pressure
control/BLOOD-PRESSURE/calcium channel/calcium channel
blockers/cerebrovascular accident/community/control/diastolic blood
pressure/fibrillation/GUIDELINES/hospitals/hypertension/ischemic/ISCHEMIC
STROKE/OLDER/platelet aggregation
inhibitors/prevention/RISK/STATEMENT/stroke/stroke prevention/systolic
blood/systolic blood pressure/therapy/treatment/use/WARFARIN
Majid, A., Delanty, N. and Kantor, J. (2001), Antiplatelet agents for secondary
prevention of ischemic stroke. Annals of Pharmacotherapy, 35 (10), 1241-1247.
Abstract: OBJECTIVE, To review and summarize the efficacy, mechanisms of action,
and cost of the options available when choosing antiplatelet agents for secondary
stroke prevention. DATA SOURCES: This article is based on a review of the
literature found with MEDLINE, CINAHL, and Cochrane Reviews (1980-June
2000) and abstracts from relevant international scientific meetings. We searched
for the terms aspirin, ticlopidine, dipyridamole, antiplatelet, and clopidogrel.
STUDY SELECTION: English-language articles, both reviews and original
studies, were evaluated, and all information considered relevant was included in
this review. In addition, guidelines from the American Heart Association are
Included. DATA SYNTHESIS; Aspirin is a relatively inexpensive and effective
agent fbr secondary stroke prevention, and lower doses of aspirin appear as
effective as higher doses. Ticlopidine has been used alone or in combination with
aspirin, but serious adverse effects have limited its use. Clopidogrel has emerged
as a safe and effective alternative to ticlopidine and lacks some of the serious
adverse effects associated with ticlopidine, but is not superior to aspirin in
secondary stroke prevention. Unlike previous studies, one recent trial showed
that dipyridamole in combination with aspirin is superior to aspirin alone.
CONCLUSIONS: Antiplatelet therapy is a key component of secondary
prevention strategies in ischemic stroke. While aspirin has been the cornerstone
in the management of stroke, other classes of antiplatelet drugs present new
opportunities to optimize antiplatelet therapy
Keywords: adverse effects/AMERICAN-HEART-
ASSOCIATION/antiplatelet/antiplatelet agents/antiplatelet drugs/antiplatelet
therapy/antiplatelets/aspirin/ASPIRIN/clopidogrel/CLOPIDOGREL/combination
/cost/COST-EFFECTIVENESS
ANALYSIS/DIPYRIDAMOLE/dipyridamole/drugs/guidelines/ischemic/ischemi
c
stroke/MANAGEMENT/prevention/RECURRENCE/review/secondary/secondar
y prevention/secondary stroke prevention/SELECTION/STABLE ANGINA-
PECTORIS/stroke/stroke prevention/therapy/THROMBOTIC
THROMBOCYTOPENIC PURPURA/TICLOPIDINE/ticlopidine/trial/use
Kondo, L.M., Wittkowsky, A.K. and Wiggins, B.S. (2001), Argatroban for prevention
and treatment of thromboembolism in heparin-induced thrombocytopenia.
Annals of Pharmacotherapy, 35 (4), 440-451.
Abstract: OBJECTIVE: TO review the pharmacology, pharmacokinetics, efficacy,
adverse events, and cost of argatroban in the prevention and treatment of
thromboembolism in patients with heparin-induced thrombocytopenia (HIT).
DATA SOURCES: A MEDLINE search (1980 to August 2000) of
English-language literature was conducted using the search term argatroban to
identify pertinent case reports, clinical trials, abstracts, and review articles.
Additional reports were identified from the reference lists compiled in the
literature reviewed, as well as from the manufacturer. DATA SYNTHESIS:
Argatroban is a synthetic direct thrombin inhibitor indicated for parenteral use in
the prevention and treatment of thromboembolism in patients with HIT. Its
elimination half-life is approximately 40-50 minutes, and it is primarily
eliminated by hepatic metabolism and biliary secretion. Compared with historical
controls, argatroban-treated patients with HIT or HIT with thrombosis (HITTS)
experienced lower rates of the composite end point of death, amputation, and
new thrombosis. Dosing is initiated at 2 mug/kg/min and adjusted to maintain the
activated partial thromboplastin time at 1.5-3 times the patient's baseline. In
Japan, argatroban is approved for use in acute ischemic stroke and chronic
peripheral occlusive disease. It has also been used as an alternative to
unfractionated heparin (UFH) in patients with a history of HIT or MITTS
undergoing percutaneous coronary intervention and other procedures.
Additionally, argatroban has been compared with UFH in patients with acute
myocardial infarction who were receiving thrombolytic therapy. Hemorrhage is
the primary adverse event associated with argatroban. Argatroban increases the
prothrombin time, making assessment of the intensity of warfarin therapy during
concurrent administration more complex. CONCLUSIONS: The use of
argatroban in patients with HIT and MITTS is associated with improvement in
clinical outcomes compared with historical controls. Argatroban offers several
practical advantages over other available agents with respect to dosing,
monitoring, reversibility of effect with discontinuation of the drug, and cost
Keywords: acute/acute ischemic stroke/acute myocardial
infarction/administration/adverse
events/ANTICOAGULATION/argatroban/clinical trials/CLINICAL-
APPLICATION/cost/death/disease/heparin/heparin induced
thrombocytopenia/heparin-induced
thrombocytopenia/history/infarction/intensity/ischemic/ischemic
stroke/Japan/metabolism/monitoring/myocardial/myocardial
infarction/PATIENT/PHARMACOLOGY/prevention/primary/prothrombin
time/RECOMBINANT HIRUDIN/review/SMALL-MOLECULE/STENT
IMPLANT/stroke/SYNTHETIC THROMBIN
INHIBITOR/therapy/thrombin/thrombin
inhibitor/thromboembolism/thrombolytic/thrombolytic
therapy/thrombosis/treatment/trials/unfractionated heparin/UNSTABLE
ANGINA/use/warfarin
Klungel, O.H., Heckbert, S.R., de Boer, A., Leufkens, H.G.M., Sullivan, S.D., Fishman,
P.A., Veenstra, D.L. and Psaty, B.M. (2002), Lipid-lowering drug use and
cardiovascular events after myocardial infarction. Annals of Pharmacotherapy,
36 (5), 751-757.
Abstract: BACKGROUND: The benefits of lipid-lowering drug treatment for the
secondary prevention of coronary heart disease have been well established by
randomized, controlled trials. Nonetheless, the risk of events has not been
compared directly for inhibitors of hydroxymethylglutaryl coenzyme A reductase
(statins) and non-statin lipid-lowering drugs. Further, it remains uncertain
whether patients in usual practice who are treated with lipid-lowering drugs after
myocardial infarction (MI) gain a similar benefit with regard to the risk of
cardiovascular events compared with patients in randomized, controlled trials.
OBJECTIVE: To assess the association between lipid-lowering drug therapies in
usual clinical practice and the risk of cardiovascular events in patients with a first
MI who were discharged alive from the hospital. METHODS: An
inception-cohort study was performed among 1956 enrollees of Group Health
Cooperative who sustained an incident MI between July 1986 and December
1996 and survived for at least 6 months after hospitalization. Subjects with
untreated lowdensity- lipoprotein cholesterol concentrations >130 mg/dL or
untreated total cholesterol concentrations >200 mg/dL were included. The
median duration of follow-up after the first MI was 3.3 years. Medical record
review was used to collect information on cardiovascular risk factors.
Computerized pharmacy records were used to assess antihyperlipidemic drug use
during the first 6 months after hospitalization. RESULTS: Compared with 1263
subjects who did not receive lipid-lowering drug treatment, 373 subjects who
received statins had a lower risk of recurrent coronary events (relative risk [RR]
0.59; 95% Cl 0.39 to 0.89), stroke (RR 0.82; 95% Cl 0.35 to 1.95),
atherosclerotic cardiovascular mortality (RR 0.49; 95% Cl 0.21 to 1.13), and any
atherosclerotic cardiovascular event (RR 0.63; 95% Cl 0.40 to 0.98). Among 320
subjects who used non-statin drug therapies, the RRs were 0.66 (95% Cl 0.45 to
0.97) for recurrent coronary events, 0.95 (95% Cl 0.46 to 1.95) for stroke, 0.68
(95% Cl 0.35 to 1.32) for cardiovascular mortality, and 0.77 (95% Cl 0.53 to
1.11) for any atherosclerotic cardiovascular event, compared with untreated
hyperlipidemic patients. CONCLUSIONS: In this study of MI survivors, the use
of lipid-lowering drug therapies after hospitalization was associated with a
reduced risk of cardiovascular events. These results emphasize the importance of
lipid-lowering drug treatment in patients with hyperlipidemia who survive a first
MI
Keywords: cardiovascular/cardiovascular event/cardiovascular events/cardiovascular
mortality/cardiovascular risk/cardiovascular risk factors/cholesterol/clinical
practice/coronary heart disease/DEATH/disease/drug/drugs/heart/heart
disease/hospital/hospitalization/hydroxymethylglutaryl coenzyme
A/hyperlipidemia/infarction/ISCHEMIC-HEART-DISEASE/lipid
lowering/lipid-lowering/METAANALYSIS/MORTALITY/myocardial/myocardi
al
infarction/Netherlands/pharmacy/prevention/randomized/REDUCTION/relative
risk/review/RISK/risk factors/secondary/secondary
prevention/SERUM-CHOLESTEROL/statins/stroke/treatment/TREATMENT
ADHERENCE/TRIALS/use/WOMEN
McKenney, J.M. (2003), Potential nontraditional applications of statins. Annals of
Pharmacotherapy, 37 (7-8), 1063-1071.
Abstract: OBJECTIVE: To review the current evidence for use of
hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) in
nontraditional lipid-related applications, including acute coronary syndromes,
peripheral arterial disease, stroke, and renal disease, and to describe ongoing
trials evaluating the role of statins in these conditions. DATA SOURCES:
Clinical literature was identified by a MEDLINE search (1990-November 2002)
using 1 of the following search terms: acute coronary syndrome(s), angina
pectoris, atherosclerosis, atorvastatin, clinical trials, diabetes mellitus, end-stage
renal disease, fluvastatin, lovastatin, myocardial infarction, peripheral arterial
disease, pravastatin, simvastatin, statins, and stroke. Treatment guidelines issued
by professional and governmental organizations, such as the American Diabetes
Association, American Heart Association, National Cholesterol Education
Program, National Kidney Foundation, and National Stroke Foundation, were
reviewed. STUDY SELECTION AND DATA EXTRACTION: Articles
identified from the data sources were included if they pertained to the conditions
described in the objectives and provided unique information concerning use of
statins. DATA SYNTHESIS: Substantial evidence exists for the use of statins in
acute coronary syndromes. Meta-analyses of data from major clinical trials
indicate that statins prevent first and recurrent stroke, and large-scale trials are
underway to evaluate the efficacy of statins in this setting. Accumulating
evidence suggests that statins may be beneficial in reducing the morbidity and
mortality associated with peripheral arterial disease and end-stage renal disease,
and results from ongoing trials may confirm these benefits. Statins may also have
a future role in amelioration of other conditions associated with atherosclerosis,
such as diabetes mellitus. CONCLUSIONS: A large body of evidence supports
the evaluation of statins in clinical settings beyond primary and secondary
prevention of morbidity and mortality associated with coronary atherosclerosis
Keywords: acute/ACUTE CORONARY SYNDROMES/acute coronary
syndromes/angina/angina pectoris/arterial/arterial
disease/atherosclerosis/ATHEROSCLEROSIS
PROGRESSION/atorvastatin/AVERAGE CHOLESTEROL
LEVELS/benefits/clinical trials/diabetes/diabetes mellitus/disease/end-stage
renal
disease/evaluation/fluvastatin/guidelines/HEART-DISEASE/hydroxymethylglut
aryl coenzyme A/infarction/morbidity/morbidity and
mortality/mortality/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/organizations/peripheral arterial
disease/PERIPHERAL
ARTERIAL-DISEASE/pravastatin/prevention/primary/primary and secondary
prevention/RANDOMIZED CONTROLLED TRIAL/recurrent stroke/renal/renal
disease/RENAL- TRANSPLANT
PATIENTS/results/review/SCANDINAVIAN-SIMVASTATIN-SURVIVAL/sec
ondary/secondary prevention/SELECTION/simvastatin/ST- SEGMENT
ELEVATION/statins/stroke/trials/USA/use
Carroll, C.A., Coen, M.M. and Piepho, R.W. (2003), Economic impact of ramipril on
hospitalization of high-risk cardiovascular patients. Annals of
Pharmacotherapy, 37 (3), 327-331.
Abstract: OBJECTIVE: To estimate differences in direct costs attributable to avoided
hospitalizations. and procedures during the years of the HOPE (Heart Outcomes
Prevention Evaluation). study after the cost of treatment with ramipril or
alternative angiotensin- converting enzyme inhibitor therapy was taken into
account. METHODS: A decision analytical model was developed to estimate the.
economic impact of reductions in hospitalizations and/or procedures both at
annual increments and over the first 4 years of the HOPE study. The analysis
compared the number of cardiovascular events per endpoint per year in the..
intervention and placebo group with hospitalization and procedural costs. Cost
data were derived from the literature and inflated,to the appropriate index year
using the consumer- price index. RESULTS: For approximately 9000 patients
studied, the gross estimated savings in direct costs for 297 events avoided were
more than $5 million over 4 years. After the cost of treatment was,deducted for
both groups, the. net estimated savings were $871000 over 4 years.
CONCLUSIONS: The results demonstrate that the use of ramipril provides
cost-effective treatment for high-risk cardiovascular patients with an ejection
fraction >40%
Keywords: AIRE/angiotensin/angiotensin converting enzyme
inhibitor/cardiovascular/cardiovascular disease/cardiovascular
events/cost/COST-EFFECTIVENESS/costs/EVENTS/HEART-FAILURE/high
risk/hospitalization/INHIBITOR/LEFT-VENTRICULAR
DYSFUNCTION/MYOCARDIAL-
INFARCTION/ramipril/results/STROKE/SURVIVAL/therapy/treatment/USA/u
se
Skurnik, Y.D., Tchemiak, A., Edlan, K. and Sthoeger, Z. (2003), Ticlopidine-induced
cholestatic hepatitis. Annals of Pharmacotherapy, 37 (3), 371-375.
Abstract: OBJECTIVE: To report 2 cases of ticlopidine-induced cholestatic hepatitis,
investigate its mechanism, and compare the observed main characteristics with
those of the published cases. CASE SUMMARIES: Two patients developed
prolonged cholestatic hepatitis after receiving ticlopidine following percutaneous
coronary angioplasty, with complete remission during the follow-up period.
T-cell stimulation by therapeutic concentration of ticlopidine was demonstrated
in vitro in the patients, but not in healthy controls. DISCUSSION: Cholestatic
hepatitis is a rare complication of the antiplatelet agent ticlopidine; several cases
have been reported but few in the English literature. Our patients developed
jaundice following treatment with ticlopidine and showed the clinical and
laboratory characteristics of cholestatic hepatitis, which resolved after
discontinuation of the drug. Hepatitis may develop weeks after discontinuation of
the drug and may run a prolonged course, but complete remission was observed
in all reported cases. An objective causality assessment revealed that the adverse
drug event was probably related to the use of ticlopidine. The mechanisms of this
ticlopidine-induced cholestasis are unclear. Immune mechanisms may be
involved in the drug's hepatotoxicity, as suggested by the T-cell stimulation
study reported here. CONCLUSIONS: Cholestatic hepatitis is a rare adverse
effect of ticlopidine that may be immune mediated. Patients receiving the drug
should be monitored with liver function tests along with complete blood cell
counts. This complication will be observed even less often in the future as
ticlopidine is being replaced by the newer antiplatelet agent clopidogrel
Keywords:
angioplasty/antiplatelet/APLASTIC-ANEMIA/ASPIRIN/cholestasis/cholestatic/
cholestatic hepatitis/CLOPIDOGREL/complication/coronary
angioplasty/drug/hepatitis/HEPATOTOXICITY/IMMUNE-RESPONSE/Israel/ja
undice/mechanisms/PREVENTION/stimulation/STROKE/ticlopidine/treatment/
TRIAL/USA/use
Albunyan, M. (1993), Binswanger-Disease - the King-Khalid-University-Hospital
Experience. Annals of Saudi Medicine, 13 (5), 429-431.
Abstract: Two hundred and twenty-one Saudi patients admitted for stroke in King
Khalid University Hospital between 1982 and 1987 were evaluated clinically and
by laboratory and radiological investigations. Twelve patients were found to
have leukoaraiosis on brain CT and a clinical picture compatible with
Binswanger disease (subcortical arteriosclerotic encephalopathy). Arterial
hypertension was present in all cases, seizure disorders in 25%, and dementia in
83%. The features of these cases are compared with similar cases reported from
other places. The importance of control of hypertension in prevention of
Binswanger disease is emphasized
AlShammari, S.A., Khoja, T.A. and AlMaatouq, M.A. (1996), The prevalence of obesity
among Saudi males in the Riyadh region. Annals of Saudi Medicine, 16 (3),
269-273.
Abstract: Attendees of 15 health centers in urban and rural areas in the Riyadh region
were screened for obesity during May and June 1994. Systemic selection yielded
1580 Saudi males for analysis. The mean age was 33.6 +/- 13.5 years and body
mass index (BMI) was 26.9 +/- 5.7 kg/m(2). Only 36.6% of subjects were their
ideal weight (BMI < 25 kg/m(2)), while 34.5% were overweight (BMI 25-29.9
kg/m(2)), 26.9% were moderately obese (BMI 30-40 kg/m(2) and 1.7% were
morbidly obese (BMI > 40 kg/m(2)). Middle age, lower education and
joblessness predicted a higher risk for obesity. Patients living in rural areas had
greater BMIs than those living in urban areas (P < 0.01). Forty percent of
overweight participants did not think they were so. The high prevalence of
obesity and the lack of awareness among those afflicted emphasizes the need for
community-based programs for preventing and reducing obesity, since weight
control is effective in ameliorating most of the disorders associated with obesity,
such as Type II non-insulin-dependent diabetes mellitus, hypertension, stroke,
heart disease, sleep apnea syndrome and osteoarthritis of the knees. Young
parents who are at risk of developing obesity and who play a central role in
perpetuating it in their offspring should be the target of obesity-prevention
programs
Keywords:
ADULTS/ARABIA/COMMUNITY/education/FAMILY/health/heart/hypertensi
on/stroke
Coyle, K.A., Smith, R.B., Gray, B.C., Salam, A.A., Dodson, T.F., Chaikof, E.L. and
Lumsden, A.B. (1995), Treatment of Recurrent Cerebrovascular-Disease -
Review of A 1O-Year Experience. Annals of Surgery, 221 (5), 517-524.
Abstract: Objective The authors determined whether carotid endarterectomy in patients
with recurrent cerebrovascular disease poses a greater perioperative risk than for
those individuals undergoing first-time carotid endarterectomy. Summary
Background Data A percentage of patients undergoing carotid endarterectomy
for atherosclerosis experience recurrent cerebrovascular disease. Reoperation
may be difficult because of postoperative scarring of the soft tissues of the neck
and the carotid artery itself. Such patients were believed to be at greater risk for
perioperative morbidity than those undergoing first-time carotid endarterectomy.
Methods To address this concern, the authors retrospectively reviewed their
experience with 69 patients who underwent repeat carotid endarterectomies over
a recent 10-year period of time. This subgroup represented 6.4% of 1072 total
carotid endarterectomies performed during the same time period. The average
extent of stenosis on the operated side was 81% and the time elapsed after
previous endarterectomy averaged 83 months. Twelve patients (17.4%) had
contralateral internal carotid occlusion, and 30 patients (43.5%) had undergone
previous endarterectomies on the contralateral side. Results Complications
within 30 days of operation included two deaths (2.9%) and one stroke (1.4%),
for a combined stroke and death rate of 4.3%. Six patients developed cervical
hematomas requiring drainage; one of these had rupture of a saphenous vein
patch. No patient had a significant cranial nerve injury in the reoperative group,
whereas 2.0% of patients undergoing first-time carotid endarterectomy had
cranial nerve injuries. Overall, these results compared favorably with a combined
stroke and death rate of 4.0% among 1003 patients who underwent first-time
carotid endarterectomy during the same period. Conclusions This review
suggests that repeat carotid endarterectomy can be performed safely in
individuals with severe recurrent carotid stenosis, with morbidity and mortality
rates similar to those for patients undergoing first-time carotid endarterectomies.
For this population, reoperative carotid endarterectomy represents a safe and
important mechanism for the prevention of stroke
Keywords: atherosclerosis/carotid/CAROTID ENDARTERECTOMY/carotid
stenosis/cerebrovascular
disease/endarterectomy/morbidity/mortality/OPERATIONS/prevention/RESTE
NOSIS/risk/STENOSIS/STROKE
Ballinger, B.A., Money, S.R., Chatman, D.M., Bowen, J.C. and Ochsner, J.L. (1997),
Sites of recurrence and long-term results of redo surgery. Annals of Surgery, 225
(5), 512-515.
Abstract: Objective The authors determined whether carotid endarterectomy in patients
with recurrent stenosis could provide durable stroke prevention with acceptable
perioperative risk. Summary Background Data Balloon angioplasty and stenting
are being advocated for recurrent stenosis because of the presumption that
reoperation is unsafe with poor results. Methods The authors retrospectively
reviewed their experience with 67 patients undergoing 74 operations for
recurrent stenosis in a recent 11-year period. This represented 8.4% of 883
endarterectomies performed during the same period. Results At original
operation, 55% had primary closure and 45% were patched. Reoperation was
performed for amaurosis fugax and transient ischemic attack (45%), post-stroke
(7%), global ischemia (10%), and asymptomatic severe occlusive disease (35%).
Four patients (6%) undergoing simultaneous cardiac procedures were excluded
from further analysis. Mean duration between primary and first redo operation
was 78 months (range, 1-240 months). The 30-day combined mortality and
stroke morbidity was 2.8%, evenly divided with 1.4% stroke and 1.4% mortality
rates. Recurrent disease occurred predominantly (69%) in the previous
endarterectomy site. Follow-up ranged from 1 to 162 months (mean, 48.2).
Seventeen deaths occurred, of which 10 (59%) were cardiac. Two late ipsilateral
neurologic events and four late contralateral events occurred. Two patients
required third ipsilateral reoperation. Life-table analysis shows the ipsilateral
stroke-free rate at 5 years to be 93.6%. Conclusions Recurrent stenosis occurs
either proximal to or in the previous endarterectomy site in the majority of
patients. Recurrent stenosis can be treated surgically with low morbidity and
mortality and durable long-term stroke prevention. The presumption that results
of redo carotid surgery are poor is disproved
Keywords: angioplasty/asymptomatic/carotid/carotid endarterectomy/CAROTID
STENOSIS/DISEASE/ENDARTERECTOMY/ischemia/ischemic/morbidity/mo
rtality/prevention/recurrence/risk/stenting/STROKE/stroke
prevention/surgery/transient/transient ischemic attack/ULTRASOUND
Almassi, G.H., Schowalter, T., Nicolosi, A.C., Aggarwal, A., Moritz, T.E., Henderson,
W.G., Tarazi, R., Shroyer, A.L., Sethi, G.K., Grover, F.L. and Hammermeister,
K.E. (1997), Atrial fibrillation after cardiac surgery - A major morbid event?
Annals of Surgery, 226 (4), 501-511.
Abstract: Objective The purpose of the study was to investigate the incidence, predictors,
morbidity, and mortality associated with postoperative atrial fibrillation (AF) and
its impact on intensive care unit (ICU) and postoperative hospital stay in patients
undergoing cardiac surgery in the Department of Veterans Affairs (VA).
Summary Background Data Postoperative AF after open cardiac surgery is rather
common. The etiology of this arrhythmia and factors responsible for its genesis
are unclear, and its impact on postoperative surgical outcomes remains
controversial. The purpose of this special substudy was to elucidate the incidence
of postoperative AF and the factors associated with its development, as well as
the impact of AF on surgical outcome. Methods The study population consisted
of 3855 patients who underwent open cardiac surgery between September 1993
and December 1996 at 14 VA Medical Centers. Three hundred twenty-nine
additional patients were excluded because of lack of complete data or presence
of AF before surgery, and 3794 (98.4%) were male with a mean age of 63.7 +/-
9.6 years. Operations included coronary artery bypass grafting (CABG) (3126,
81%), CABG. + AVR (aortic valve replacement) (228, 5.9%), CABG + MVR
(mitral valve replacement) (35, 0.9%), AVR (231, 6%), MVR (41, 1.06%),
CABG + others (95, 2.46%), and others (99, 2.5%). The incidence of
postoperative AF was 29.6%. Multivariate logistic regression analysis of factors
found significant on univariate analysis showed the following predictors of
postoperative AF: preoperative patient risk predictors: advancing age (odds ratio
[OR] 1.61, 95% confidence interval [CI] 1.48-1.75, p < 0.001), chronic
obstructive pulmonary disease (OR 1.37, 95% Cl 1.12-1.66, p < 0.001), use of
digoxin within 2 weeks before surgery (OR 1.37, 95% Cl 1.10- 1.70, p < 0.003),
low resting pulse rate <80 (OR 1.26, 95% Cl 1.06-1.51, p < 0.009), high resting
systolic blood pressure >120 (OR 1.19, 95% Cl 1.02-1.40, p < 0.026),
intraoperative process of care predictors: cardiac venting via right superior
pulmonary vein (OR 1.42, 95% Cl 1.21-1.67, p < 0.0001), mitral valve repair
(OR 2.86, 95% Cl 1.72-4.73, p < 0.0001) and replacement (OR 2.33, 95% Cl
1.55-3.55, p < 0.0001), no use of topical ice slush (OR 1.29, 95% Cl 1.10-1.49, p
< 0.0009), and use of inotropic agents for greater than 30 minutes after
termination of cardiopulmonary bypass (OR 1.36, 95% Cl 1.16- 1.59, p <
0.0001). Postoperative median ICU stay (3.6 days AF vs. 2 days no AF, p <
0.001) and hospital stay (10 days AF vs. 7 days no AF, p < 0.001) were higher in
AF. Morbid events, hospital mortality, and B-month mortality were significantly
higher in AF (p < 0.001): ICU readmission 13% AF vs. 3.9% no AF,
perioperative myocardial infarction 7.41% AF vs. 3.36% no AF, persistent
congestive heart failure 4.57% AF vs. 1.4% no AF, reintubation 10.59% AF vs.
2.47% no AF, stroke 5.26% AF vs. 2.44% no AF, hospital mortality 5.95% AF
vs. 2.95% no AF, 6- month mortality 9.36% AF vs. 4.17% no AF. Conclusions
Atrial fibrillation after cardiac surgery occurs in approximately one third of
patients and is associated with an increase in adverse events in all measurable
outcomes of care and increases the use of hospital resources and, therefore, the
cost of care. Strategies to reduce the incidence of AF after cardiac surgery should
favorably affect surgical outcomes and reduce utilization of resources and thus
lower cost of care
Keywords: adverse events/AF/age/ARRHYTHMIAS/atrial fibrillation/blood
pressure/bypass grafting/CABG/CORONARY-ARTERY
BYPASS/cost/development/etiology/fibrillation/heart/heart
failure/hospital/hospital
mortality/incidence/infarction/morbidity/mortality/myocardial
infarction/OPERATIONS/predictors/PREVENTION/PROPHYLAXIS/PROPRA
NOLOL/RISK/STROKE/SUPRAVENTRICULAR
TACHYARRHYTHMIAS/surgery/VENTRICULAR HYPERTROPHY
Maxwell, J.G., Taylor, A.J., Maxwell, B.G., Brinker, C.C., Covington, D.L. and Tinsley,
E. (2000), Carotid endarterectomy in the community hospital in patients age 80
and older. Annals of Surgery, 231 (6), 781-786.
Abstract: Objective To determine whether the rates of death and complications of
carotid endarterectomy (CE) were different in the octogenarian population than
in patients younger than age 80. Summary Background Data The utility of CE
depends on the ability of the surgeon and hospital to attain low rates of death and
complications, including all subgroups of the patient population. In the past 30
years, the number of people age 85 and older has increased 274%. Methods
Detailed chart review was carried out on all CE procedures done from 1979
through 1998. Descriptive demographic data, risk factors, surgical details, length
of stay, deaths, and complications were recorded. Results A total of 2,398 CEs
were performed in 1,970 patients; 2,180 procedures were performed in 1,783
patients younger than 80, and 218 CEs were performed in 187 patients age 80
and older. Sixty-five percent of the octogenarians and 67% of patients younger
than age 80 had neurologic symptoms. Among asymptomatic patients, 89% had
stenosis of 75% or more. There were 62 strokes in the 2,180 procedures in the
younger group, for a stroke rate of 2.8%, and 7 strokes in the 218 procedures in
the older group, for a stroke rate of 3.2%. The death rates were 0.9% for the
octogenarians and 1.4% for the younger group. Conclusions Carotid
endarterectomy can be safely performed in a community hospital in patients age
80 and cider. Outcomes in octogenarians were not significantly different than
those of younger patients and were within the range required for CE to be
considered beneficial in the prevention of stroke
Keywords: age/asymptomatic/carotid/carotid
endarterectomy/community/complications/death/endarterectomy/hospital/length
of
stay/OCTOGENARIANS/OUTCOMES/population/prevention/review/risk/risk
factors/stenosis/stroke
Nelson, E. (1990), Current Use of Antiplatelet Drugs in Stroke Syndromes in the Usa.
Annals of the New York Academy of Sciences, 598 368-375
Keywords: ASPIRIN/PREVENTION/RANDOMIZED TRIAL/THROMBOEMBOLIC
STROKE/TICLOPIDINE
Yamori, Y. (1993), Hypertensive Cerebrovascular Diseases - Importance of Nutrition in
Pathogenesis and Prevention. Annals of the New York Academy of Sciences, 676
92-104
Keywords: CARDIOVASCULAR-DISEASES/RATS/STROKE-PRONE
Tan, L.C., Perry, M., Sutton, G.L., Fail, T. and Taffinder, N.J. (1996), Audit of 149
consecutive carotid endarterectomies performed by a single surgeon in a district
general hospital over a 12-year period. Annals of the Royal College of Surgeons
of England, 78 (4), 340-344.
Abstract: Carotid endarterectomy has been established by two large randomised
controlled trials (European, Carotid Surgery Trial (ECST) and North American
Symptomatic Carotid Endarterectomy Trial (NASCET)) as an important surgical
procedure for the prevention of ischaemic strokes in patients presenting with
transient cerebral ischaemia or nan-disabling strokes attributable to severe
ipsilateral carotid artery stenosis. care The operation carries significant risk of
death and stroke and it has been advocated by some that carotid endarterectomy
should only be performed in a small number of designated regional centres in
order to achieve good surgical results, It is doubtful that the regional centres
alone can cope with the increasing numbers of patients requiring carotid
endarterectomy and there is therefore a requirement for the procedure to be
carried out by vascular surgeons in district general hospitals. It is important that
surgical results are audited to ensure that comparable outcomes are achieved. We
present an audit of our experience of carotid endarterectomy since 1981. A total
of 149 consecutive carotid endarterectomies were performed by a single surgeon
with a special interest in carotid surgery. The results are comparable to ECST
with a 30-day mortality of 0% and an overall 30-day stroke rate of 5.7% (major
strokes) for patients with severe, ie 70-99%, ipsilateral carotid artery stenoses,
We have shown that carotid endarterectomy is an operation that can be
performed safely and with good results by suitably trained surgeons in district
general hospitals
Keywords: audit/carotid endarterectomy/district general
hospital/endarterectomy/ischaemia/mortality/prevention/stroke/surgery/SYSTE
M/trials
Lewis, D.R., Irvine, C.D., Cole, S.E.A., McGrath, C., Baird, R.N. and Lamont, P.M.
(1997), Computerised audit of carotid endarterectomy: audit loopholes closed?
Annals of the Royal College of Surgeons of England, 79 (6), 455-459.
Abstract: The number of carotid endarterectomies being performed in the UK is
increasing. The role of carotid endarterectomy (CEA) in the prevention of stroke
depends on the procedure being associated with as few operative strokes as
possible. Good clinical practice, with minimum morbidity, depends upon the
integration of recent advances. Continuing audit has been used to examine
changes in surgical practice and in case mix. There was a combined death and
permanent stroke rate of 3.6% after 333 CEAs in a 6-year period (1990-1995)
compared with 4.4% in 203 CEAs in an earlier 5-year audit period (1985-1989).
The impact of an increase in the number of operations performed after recovered
strokes, those performed by trainees and the use of prosthetic patches on the
results of CEA has been assessed. Specific areas to be targeted in future audits
are identified
Keywords: ANGIOGRAPHY/audit/carotid/carotid
endarterectomy/endarterectomy/ENGLAND/morbidity/prevention/stroke
Kumar, S., Osman, I.S., Woollard, C.J. and Cameron, A.E.P. (2000), 'Fast track' carotid
duplex scanning in a district general hospital. Annals of the Royal College of
Surgeons of England, 82 (3), 167-170.
Abstract: 'Fast track' carotid scanning is designed to rapidly identify patients with
significant symptomatic carotid stenosis and, thereby, allow prompt surgery. We
review the outcome of patients referred to our open-access scanning service over
3 years and 6 months. A total of 807 cases (62% males and 38% females with a
mean age of 64 years) were referred. The main presenting symptoms were TIA
in 69%, amaurosis fugax in 11% and minor CVA in 8.3%. The mean time
between referral and scan was 17 days. In 80% of the eases, the scan showed no
significant disease and the patients were not seen in the clinic. Significant
abnormality (stenosis > 70% or occlusion) was found in 20% of the patients. Of
the total, 12% were reviewed in the out-patient clinic following which no action
was taken, 2% had angiography but no surgery, while 5% had angiography and
surgery. 1% were lost to follow-up. The mean delay from scan to operation was
36 days. Conclusion: Fast track scanning has led to early detection of surgically
relevant carotid lesions and avoidance of delay in surgical intervention. It is an
efficient and cost-effective practice
Keywords: age/carotid/carotid duplex scanning/carotid
stenosis/CVA/detection/disease/district general hospital/duplex/duplex
scanning/ENDARTERECTOMY/ENGLAND/hospital/MANAGEMENT/outco
me/review/stenosis/STROKE/stroke prevention/surgery/TIA/transient ischaemic
attack
Qayumi, A.K., Jamieson, W.R.E. and Poostizadeh, A. (1991), Effects of
Platelet-Activating-Factor Antagonist Cv-3988 in Preservation of Heart and
Lung for Transplantation. Annals of Thoracic Surgery, 52 (4), 1026-1032.
Abstract: The preservation of heart and lung for transplantation remains a major concern
in extended ischemic intervals. This experiment evaluated the effect of high
molecular weight deferoxamine and a platelet-activating factor antagonist
(CV-3988) in ischemic reperfused tissue. Heart-lung transplantation was
performed in a swine model after 4 hours 45 minutes of ischemia. Animals were
divided into three groups. Group A was a control without pharmacological
intervention. In group B, high molecular weight deferoxamine, 50 mg/kg, was
used, and in group C, platelet- activating factor antagonist CV-3988, 10 mg/kg,
was used. The results of functional variables (cardiac index, stroke index, lung
water, oxygen and carbon dioxide tensions, alveolar- arterial gradient, and
alveolar-arterial ratio) demonstrated superior heart and lung function for groups
B and C compared with the control group. These alterations of heart and lung
function were significantly less (p < 0.001) in group C, in which the
platelet-activating factor antagonist (CV-3988) was used. The study revealed that
formation of hydroxyl radicals and platelet-activating factor play an important
role in the pathogenesis of ischemia reperfusion injury. Prevention of hydroxyl
radical formation with high molecular weight deferoxamine and inactivation of
platelet-activating factor with CV-3988 reduce the ischemia-reperfusion injury
significantly
Keywords: ALLOPURINOL/DEFEROXAMINE/DESFERRIOXAMINE/FACTOR
PAF/INHIBITION/LIPID-PEROXIDATION/NEUTROPHILS/RADICALS/RE
DUCTION/SUPEROXIDE-DISMUTASE
Yano, O.J., Bielefeld, M.R., Jeevanandam, V., Treat, M.R., Marboe, C.C., Spotnitz,
H.M. and Smith, C.R. (1993), Prevention of Acute Regional Ischemia with
Endocardial Laser Channels. Annals of Thoracic Surgery, 56 (1), 46-53.
Abstract: Laser myocardial revascularization has been shown to reduce mortality and
infarct size after left anterior descending coronary artery (LAD) ligation in dogs.
It has not been shown to improve myocardial contractility in acute ischemia. In
this study a holmium-yttrium-aluminum garnet laser (wavelength, 2.14 mum)
was used to create nontransmural myocardial channels from the endocardial
surface in the ischemic regions of the canine left ventricle. Twelve mongrel dogs
(6 controls, 6 laser myocardial revascularizations) underwent 90 minutes of LAD
ligation followed by 6 hours of reperfusion. The ischemic region was determined
by methylene blue injection during brief LAD occlusion. Laser myocardial
revascularization averaged three channels per square centimeter in the ischemic
region created using 12 J/channel (600 mJ/pulse, 10 Hz) before LAD ligation.
Contractility was assessed from regional preload recruitable stroke work
(RPRSW), using pairs of segment length ultrasonic transducers in the ischemic
and the nonischemic regions. Two-dimensional echocardiography corroborated
with segmental length findings. In control dogs, the ischemic region was
dyskinetic during LAD ligation and reperfusion. Dyskinesis of the ischemic
region during systole produced negative values for regional stroke work, and
RPRSW was considered zero. In 4 of 6 laser-revascularized dogs, RPRSW
remained positive in the ischemic region. Two dogs had intermittent dyskinesis.
The difference between laser-revascularized and control dogs in ischemic region
RPRSW was significant (p < 0.01 by Fischer's exact test). We conclude that laser
myocardial revascularization from the endocardial surface preserves regional
myocardial function during acute ischemia. Because holmium-yttrium-aluminum
garnet laser energy can be transmitted through a flexible fiber, laser myocardial
revascularization could become a percutaneous treatment for prevention of acute
ischemia
Keywords: REVASCULARIZATION
Mills, S.A. (1995), Risk-Factors for Cerebral Injury and Cardiac-Surgery. Annals of
Thoracic Surgery, 59 (5), 1296-1299.
Abstract: Cerebral complications represent the leading cause of morbidity after cardiac
operations. With the growing awareness of their social and economic importance,
increasing attention is being given to their prevention. In the coronary artery
bypass population, advanced age (greater than or equal to 75 years) is associated
with an 8.9% neurologic deficit rate. Mortality is increased ninefold in the
elderly patient with a neurologic deficit. Cardiopulmonary bypass has long been
recognized as a cause of neuropsychologic deficits. Emboli are thought to be the
causal agent. Retinal microvascular lesions during cardiopulmonary bypass as
well as recent demonstration of widespread pathologic subcapillary arteriolar
dilatations in the brain after cardiopulmonary bypass have been documented.
Despite widespread interest in cerebral blood flow and neurologic deficits, there
is no convincing evidence that defines a critically low or dangerously high level
of flow. The ascending aorta represents a leading source of embolic neurologic
injury. The use of intraoperative ultrasound to identify the diseased aorta may
result in alternative operative strategies in an effort to minimize emboli and
improve neurologic outcome. Existing literature offers conflicting views on
optimal management of carotid artery stenosis in the coronary artery surgical
patient. A trend that combined carotid endarterectomy and coronary artery
bypass may often be appropriate will need confirmation through a multicenter
clinical trial. Open cardiac surgical procedures, particularly in the aged
population, carry a significant increased risk of adverse neurologic outcome.
Postoperative arrhythmias may result in embolic neurologic deficit. A further
understanding of risk factors for cerebral injury will be of value in developing
therapeutic approaches to this major clinical problem
Keywords: aged/ASCENDING AORTA/BRAIN/CARDIOPULMONARY
BYPASS/carotid/carotid endarterectomy/cerebral blood
flow/complications/CORONARY-ARTERY
BYPASS/elderly/emboli/endarterectomy/EXTENT/ISCHEMIA/MILD
HYPOTHERMIA/morbidity/NEUROPSYCHIATRIC
COMPLICATIONS/NEW-YORK/OPEN-HEART
SURGERY/prevention/risk/risk factors/STROKE
Bavaria, J.E., Woo, Y.J., Hall, R.A., Carpenter, J.P. and Gardner, T.J. (1995),
Retrograde Cerebral and Distal Aortic Perfusion During Ascending and
Thoracoabdominal Aortic Operations. Annals of Thoracic Surgery, 60 (2),
345-353.
Abstract: Background. Several alternative circulatory management techniques during
thoracic aortic reconstruction have been implemented at this institution. This
study was performed to assess whether retrograde cerebral perfusion during
proximal aortic operations and distal aortic perfusion during thoracoabdominal
aortic operations have improved outcomes. Methods. A retrospective review of
156 patients undergoing elective and emergent operations of the thoracic aorta
over the past 7 years was performed. Seventy-five patients underwent proximal
aortic procedures: 22 with ascending aneurysms, 45 with type A dissections, and
8 with arch reconstructions. Eighty-one patients underwent descending thoracic
or thoracoabdominal procedures: 26 with Crawford type I aneurysms, 18 with
type II, 8 with type III, 8 with type IV, 11 with traumatic transections, and 10
with type B dissections. Outcomes measured were neurologic injury, renal
failure, and mortality. Results. For proximal aortic procedures, the stroke rate
was 12% using cardiopulmonary bypass and 48% using hypothermic circulatory
arrest. The addition of retrograde cerebral perfusion decreased the stroke rate to
0% (p < 0.01) and the mortality rate to 7.1% compared with 37% for
hypothermic circulatory arrest (p < 0.05). For thoracic and thoracoabdominal
aortic operations, straight cross-clamping resulted in a 27% rate of spinal cord
injury and a 24% rate of renal failure, whereas the addition of distal aortic bypass
resulted in a statistically significant reduction (p < 0.01) in neurologic injury to
7% and a notable, but not statistically significant, decrease in renal failure to
13%. Distal aortic bypass also reduced the mortality rate from 22% to 7% (p <
0.05). Conclusions. Retrograde cerebral perfusion decreases the stroke rate and
mortality rate in proximal aortic operations and distal aortic perfusion decreases
the rates of neurologic injury, renal failure, and mortality in thoracoabdominal
aortic operations
Keywords: ARCH ANEURYSM/BRAIN/BYPASS/CIRCULATORY
ARREST/DISSECTION/EXPERIENCE/mortality/PREVENTION/REPLACEM
ENT/stroke/SURGERY/SURGICAL-TREATMENT
McKhann, G.M., Goldsborough, M.A., Borowicz, L.M., Mellits, E.D., Brookmeyer, R.,
Quaskey, S.A., Baumgartner, W.A., Cameron, D.E., Stuart, R.S. and Gardner,
T.J. (1997), Predictors of stroke risk in coronary artery bypass patients. Annals of
Thoracic Surgery, 63 (2), 516-521.
Abstract: Background. Stroke occurs after coronary artery bypass grafting with an
incidence ranging between 0.8% and 5.2%. To identify factors associated with
stroke, we prospectively examined a study cohort and tested findings in an
independent validation sample. Methods. The study cohort comprised 456
patients undergoing coronary artery bypass grafting only and the validation
sample comprised 1,298 patients. Stroke was detected postoperatively by the
study team and confirmed by neurologic consultation and computed tomographic
scanning. Results. Five factors taken together were correlated with stroke:
previous stroke, presence of carotid bruit, history of hypertension, increasing age,
and history of diabetes mellitus. The only significant intraoperative factor was
cardiopulmonary bypass time. probabilities were calculated, and patients were
placed into low, medium, and high stroke-risk groups. In the validation sample,
this model was able to rank the majority of patients with stroke into the high-risk
group. Conclusions. These five factors taken together can identify the risk of
stroke in patients having coronary artery bypass grafting. Recognition of the
high-risk group will aid studies on the mechanism and prevention of stroke by
modification of surgical procedures or pharmacologic intervention. (C) 1997 By
The Society of Thoracic Surgeons
Keywords: age/BRAIN/bypass
grafting/CARDIAC-SURGERY/carotid/diabetes/diabetes
mellitus/GRAFT-SURGERY/history/hypertension/incidence/NERVOUS-SYST
EM COMPLICATIONS/NEW-YORK/prevention/risk/stroke
Caspi, J., Coles, J.G., Benson, L.N. and Wilson, G.J. (1998), Brain damage and
myocardial dysfunction: Protective effects of magnesium in the newborn pig.
Annals of Thoracic Surgery, 65 (6), 1730-1736.
Abstract: Background. Brain damage is associated with myocardial dysfunction
resulting from excessive release of endogenous catecholamines and Ca2+
overload. Magnesium ion, a natural Ca2+ blocker, has recently been recognized
as a myoprotective agent. Methods. Myocardial function was assessed in 3- to
7-day-old piglets from pressure-volume data (obtained by the conductance
catheter/micromanometer technique) before and for 4 hours after ligation of the
aortic arch vessels and was correlated with ultrastructural changes. Group a (n =
6) received MgSO4 immediately after induction of brain damage for 4 hours,
whereas group b tn = 6) did not receive MgSO4 and served as control. Results. In
both groups after induction of brain dam age, there was a significant (p < 0.05)
increase in end- systolic elastance and preload-recruitable stroke work that
persisted for 1 hour. However, after 2 and 4 hours, there was a significant (p <
0.05) reduction in both variables in group b tend-systolic elastance, 74% +/- 5%
and 59% +/- 6%, respectively, and preload-recruitable stroke work, 77% +/- 4%
and 64% +/- 3%, respectively, compared with baseline), and in group a,the
values returned to baseline. The chamber stiffness index rose significantly (p <
0.05) in group b 15 minutes after induction of brain damage and remained
significantly (p < 0.05) higher for 4 hours versus no significant change in group a.
Plasma levels of epinephrine and norepinephrine were similar in the groups
before and after brain damage. Electron microscopic study showed severe
ultrastructural changes in group b and significantly milder changes in group a.
Conclusions. We conclude that MgSO4 may protect the neonatal myocardium
when administered immediately after brain damage. (C) 1998 by The Society of
Thoracic Surgeons
Keywords:
age/BABOON/CATHETER/DEATH/HEART-TRANSPLANTATION/INJURY
/LESIONS/MODEL/NEW-YORK/PRESSURE-VOLUME
RELATIONSHIPS/PREVENTION/stroke
Leyh, R.G., Bartels, C., Notzold, A. and Sievers, H.H. (1999), Management of porcelain
aorta during coronary artery bypass grafting. Annals of Thoracic Surgery, 67 (4),
986-988.
Abstract: Background. Patients with porcelain aorta carry a high risk of systemic
embolism during coronary artery bypass grafting. No currently proposed surgical
approach avoids manipulation of the heavily calcified ascending aorta. A novel
surgical approach avoiding manipulation of the porcelain aorta was evaluated
with regard to its efficacy in prevention of atheroemboli. Methods. The following
surgical protocol was performed in 23 patients with porcelain aorta: (1) arterial
cannulation of the axillary artery, (2) hypothermic fibrillatory arrest for
performance of the distal anastomosis, and (3) construction of the proximal
anastomosis to the inominate artery or to a disease-free area of the ascending
aorta during hypothermic circulatory arrest. Results. The postoperative course
was uneventful in all patients. No patient experienced a cerebrovascular accident
or visceral organ injury as a result of atheroemboli. Conclusions. The proposed
surgical approach is safe and reliable in patients with porcelain aorta and has the
potential to reduce the prevalence of stroke and systemic embolization associated
with coronary artery bypass grafting in patients with porcelain aorta. (Ann
Thorac Surg 1999;67:986-8) (C) 1999 by The Society of Thoracic Surgeons
Keywords: ARCH/ATHEROSCLEROTIC ASCENDING AORTA/bypass
grafting/CARDIAC-SURGERY/cerebrovascular/embolism/NEW-YORK/OPER
ATIONS/prevention/risk/STROKE
Wong, B.I., Mclean, R.F., Fremes, S.E., Deemar, K.A., Harrington, E.M., Christakis,
G.T. and Goldman, B.S. (2000), Aprotinin and tranexamic acid for high
transfusion risk cardiac surgery. Annals of Thoracic Surgery, 69 (3), 808-816.
Abstract: Background. Studies have shown that aprotinin and tranexamic acid can
reduce postoperative blood loss after cardiac operation. However, which drug is
more efficacious in a higher risk surgical group of patients, has yet: to be defined
in a randomized study. Methods. With informed consent, 80 patients undergoing
elective high transfusion risk cardiac procedures (repeat sternotomy, multiple
valve, combined procedures, or aortic arch operation) were randomized in a
double-blind fashion, to receive either high dose aprotinin or tranexamic acid.
Patient and operative characteristics, chest tube drainage and transfusion
requirements were recorded. Results. There was no significant difference
between We 2 treatment groups with respect to age, cardiopulmonary bypass
time, complications (myocardial infarction, stroke, death), chest tube drainage (6,
12, or 24 hours), blood transfusions up to 24 hours postoperatively, total
allogeneic blood transfusions for entire hospital stay, or induction/postoperative
hemoglobin levels. However, multiple regression analysis revealed a positive
relationship between cardiopulmonary bypass time and 24 hour blood loss in We
tranexamic acid group (p = 0.001) unlike the aprotinin group where 24 hour
blood loss is independent of cardiopulmonary bypass time (p = 0.423).
Conclusions. Overall, there was no significant difference in blood loss, or
transfusion requirements, when patients received either aprotinin or tranexamic
acid for high transfusion risk cardiac operation, Aprotinin when given as an
infusion in a high-dose regimen, was able to negate We usual positive effect of
cardiopulmonary bypass time on chest tube blood loss. (C) 2000 by The Society
of Thoracic Surgeons
Keywords: age/aprotinin/ARTERY BYPASS OPERATIONS/cardiac/cardiac
surgery/CARDIOPULMONARY
BYPASS/chest/CLINICAL-TRIAL/complications/consent/COST-BENEFIT/dea
th/DOUBLE-BLIND/EFFICACY/EPSILON-AMINOCAPROIC
ACID/hemoglobin/HIGH-DOSE
APROTININ/hospital/infarction/myocardial/myocardial
infarction/NEW-YORK/POSTOPERATIVE
BLOOD-LOSS/PREVENTION/randomized/risk/stroke/surgery/transfusion/treat
ment
Lee, S.H., Chang, C.M., Lu, M.J., Lee, R.J., Cheng, J.J., Hung, C.R. and Chen, S.A.
(2000), Intravenous amiodarone for prevention of atrial fibrillation after coronary
artery bypass grafting. Annals of Thoracic Surgery, 70 (1), 157-161.
Abstract: Background. Atrial fibrillation occurs in 10% to 40% of patients who undergo
coronary artery bypass grafting. This prospective study assesses the safety and
efficacy of low-dose intravenous amiodarone in the prevention of atrial
fibrillation after coronary artery bypass grafting. Methods. One hundred forty
patients were randomly divided into two groups: an amiodarone group (n = 74)
receiving intravenous amiadarone in a loading dose of 150 mg and maintenance
dose of 0.4 mg . kg(-1) . h(-1) for 3 days before and 5 days after operation and a
control group (n = 76) receiving matching infusions of 5% glucose solution.
Results. Atrial fibrillation occurred in 9 (12%) of the amiodarone group patients
and in 26 (34%) of the control group patients during hospitalization (p < 0.01).
The maximum ventricular rate during atrial fibrillation was significantly slower
in the amiodarone group (107 +/- 21) than in the control group (138 +/- 24 beats
per minute, p < 0.01). The duration of atrial fibrillation in the amiodarone group
(1.1 +/- 1.2 hours) was significantly shorter than that in the control group (3.2 +/-
1.3 hours, p = 0.01). The two groups had no significant differences in incidence
of major morbidity (8 of 74 versus 8 of 76 in amiodarone and control groups,
respectively) or mortality (4 of 74 versus 5 of 76). However, the control group
had significantly longer intensive care unit stays (132 +/- 24 versus 111 +/- 19
hours, p < 0.01). Conclusions. Perioperative low-dose intravenous amiodarone
significantly reduces the incidence, ventricular rate, and duration of atrial
fibrillation after coronary artery bypass grafting. Furthermore, low-dose
intravenous amiodarone is well tolerated and does not increase the risk of
intraoperative or postoperative complications. (Ann Thorac Surg 2000;70:157-61)
(C) 2000 by The Society of Thoracic Surgeons
Keywords: ARRHYTHMIAS/atrial fibrillation/bypass
grafting/complications/control/fibrillation/FLUTTER/glucose/hospitalization/inc
idence/MAINTENANCE/morbidity/mortality/NEW-YORK/PREDICTORS/prev
ention/PROPHYLAXIS/prospective study/risk/safety/SINUS
RHYTHM/STROKE/SURGERY/THERAPY/TRIAL
Salazar, J.D., Wityk, R.J., Grega, M.A., Borowicz, L.M., Doty, J.R., Petrofski, J.A. and
Baumgartner, W.A. (2001), Stroke after cardiac surgery: Short- and long-term
outcomes. Annals of Thoracic Surgery, 72 (4), 1195-1201.
Abstract: Background. Stroke remains a devastating complication of cardiac surgery, but
stroke prevention remains elusive. Evaluation of early and long-term clinical
outcomes and brain- imaging findings may provide insight into stroke prognosis,
etiology, and prevention. Methods. Five thousand nine hundred seventy-one
cardiac surgery patients were prospectively studied for clinical evidence of
stroke. Stroke and nonstroke patients were compared by early outcomes. Data
collected for stroke patients included brain imaging results, long-term functional
status, and survival. Outcome predictors were then determined. Results. Stroke
was diagnosed in 214 (3.6%) patients. Brain imaging demonstrated acute
infarction in 72%; embolic in 83%, and watershed in 24%. Survival for stroke
patients was 67% at 1 year and 47% at 5 years. Independent predictors of
survival were cerebral infarct type, creatinine elevation, cardiopulmonary bypass
time, preoperative intensive care days, postoperative awakening time, and
postoperative intensive care days. Longterm disability was moderate to severe in
69%. Conclusions. Stroke after cardiac surgery has profound repercussions that
are independently related to infarct type and clinical factors. These data are
essential for clinical decision making and prognosis determination. (C) 2001 by
The Society of Thoracic Surgeons
Keywords: acute/ATHEROSCLEROSIS/brain/BRAIN
MICROEMBOLI/cardiac/cardiac surgery/CARDIOPULMONARY
BYPASS/cerebral/CORONARY-ARTERY BYPASS/decision
making/decision-making/DETERMINANTS/disability/essential/etiology/functio
nal status/infarction/intensive care/INTRAOPERATIVE
TRANSESOPHAGEAL
ECHOCARDIOGRAPHY/MORTALITY/NEW-YORK/postoperative/PREDIC
TORS/prevention/prognosis/RISK-FACTORS/ROUTINE/status/stroke/stroke
prevention/surgery
Shiiya, N., Kunihara, T., Kamikubo, Y. and Yasuda, K. (2001), Isolation technique for
stroke prevention in patients with a mobile atheroma. Annals of Thoracic
Surgery, 72 (4), 1401-1402.
Abstract: Mobile atheroma in the proximal aorta is a risk factor for brain complication
after cardiovascular operation. We report a new technique of replacing the
ascending and transverse aorta by establishing selective hypothermic antegrade
cerebral perfusion. After cooling, cerebral vessels are clamped and systemic
perfusion is started. This technique was applied in 5 patients. All patients woke
up normally and recovered without neurologic complication. (C) 2001 by The
Society of Thoracic Surgeons
Keywords: aorta/atheroma/brain/cardiovascular/cerebral/cerebral
vessels/EXPERIENCE/Japan/NEW-YORK/prevention/risk/risk
factor/SELECTIVE CEREBRAL PERFUSION/stroke/stroke prevention
Svensson, L.G. (2002), Progress in ascending and aortic arch surgery: Minimally
invasive surgery, blood conservation, and neurological deficit prevention. Annals
of Thoracic Surgery, 74 (5), S1786-S1788.
Abstract: Background. Herein are described recent developments in aortic surgery
techniques and the improved results. Methods. Of 403 ascending and aortic arch
operations, 68 patients underwent minimally invasive aortic surgery including 23
for aortic dissection, 5 for Marf an syndrome, 29 reoperations, and 39 with
hypothermic arrest. Blood conservation methods were used in 187 of the 403
patients (46.5%). Aortic valve procedures were used in 267 (66.2%), including
51 (12.7%) valve-preserving operations. A protocol for stroke and
neurocognitive deficit prevention was used in an attempt to prevent neurologic
deficits. Data were prospectively collected and included new neurocognitive
events either by formal testing (n = 35) or by informal questioning. Results.
Stroke occurred in 2.0% (8 of 403); clinical gross neurocognitive deficits in 2.5%
(10 of 403) with a 98% 30-day survival. For those patients undergoing the
minimally invasive operation 1 hospital death occurred (98.5% survival).
Homologous operative transfusions were required in only 12% of blood
conservation patients (23 of 187) and their postoperative intubation time,
intensive care unit (ICU) stay, and hospital stay were significantly shorter (p <
0.04). Conclusions. Minimally invasive surgery is particularly useful for
reoperations. The blood conservation methods appear to be beneficial and the
number of neurologic deficits is low with the current protocol. (C) 2002 by The
Society of Thoracic Surgeons
Keywords: aortic surgery/death/dissection/DYSFUNCTION/hospital/HYPOTHERMIC
CIRCULATORY ARREST/intensive care/NEURAL
SUPPORT/NEW-YORK/OPERATIONS/postoperative/prevention/PROTECTIO
N/RETROGRADE CEREBRAL PERFUSION/stroke/surgery/survival
Usui, A., Fujimoto, K., Ishiguchi, T., Yoshikawa, M., Akita, T. and Ueda, Y. (2002),
Cerebrospinal dysfunction after endovascular stent-grafting via a median
sternotomy: The frozen elephant trunk procedure. Annals of Thoracic Surgery,
74 (5), S1821-S1824.
Abstract: Background. Endovascular stent grafting through a median sternotomy for a
distal arch aneurysm (the frozen elephant trunk procedure) is an alternative to
synthetic graft replacement. But spinal cord dysfunction can easily occur as a
complication after surgery. Although its cause is uncertain, some attempts at
prevention have been instituted. We address the mechanism of spinal cord
dysfunction and evaluate the efficacy of our preventive measures. Methods.
There were 22 men and 2 women with an average age of 71 (59 to 83) years.
There were 22 true aneurysms (13 fusiform, nine saccular), one chronic
dissection, and one penetrating aortic ulcer. The following strategies for
prevention of spinal cord dysfunction were utilized: low flow perfusion through
both axillary arteries (n = 10); pigtail catheter guidance (n = 19); use of a shorter
graft with anchoring sutures (n = 12); flooding of the operative field with carbon
dioxide (n = 7); aortic unclamping (n = 7), and use of ultra-thin woven Dacron
grafts (n = 15). Results. There was no operative mortality, but cerebrospinal
dysfunction complicated four cases (17%): one paraplegia, one stroke along the
basilar artery, and two cases of temporary spinal cord dysfunction (paresthesia of
the right leg and urinary disturbance). Cerebrospinal dysfunction tended to occur
in fusiform aneurysms (31%, p = 0.044). Except when low flow antegrade
perfusion through both the axillary arteries was utilized, which resulted in no
cases of paraplegia or paraparesis (p = 0.064), the methods used for prevention of
cerebrospinal dysfunction appeared to have little efficacy. Conclusions.
Cerebrospinal dysfunction is a serious complication of the frozen elephant trunk
procedure. Its cause has not been clarified, but it tends to occur in fusiform-type
aneurysms. Antegrade perfusion through both axillary arteries while the aorta is
open may be helpful in its prevention. (C) 2002 by The Society of Thoracic
Surgeons
Keywords: age/aneurysm/aorta/AORTIC-ARCH ANEURYSM/arteries/basilar
artery/dissection/grafting/Japan/men/mortality/NEW-YORK/prevention/spinal
cord/stent/stroke/surgery/use/women
Svensson, L.G., Nadolny, E.M. and Kimmel, W.A. (2002), Multimodal protocol
influence on stroke and neurocognitive deficit prevention after ascending/arch
aortic operations. Annals of Thoracic Surgery, 74 (6), 2040-2046.
Abstract: Background. Various techniques are used for brain protection during aortic
surgery. Rather than evaluate each factor separately, we evaluated the early
outcome of a multimodal protocol (mannitol, thiopental, MgSO4, lidocaine, CO2
field flooding, Leukoguard filter, head ice packing, electroencephalographic
arrest at 20 degreesC, alpha-stat, increasing right subclavian artery cannulation,
and antegrade/retrograde brain perfusion) for brain protection. Methods.
Prospectively collected data were analyzed on 403 ascending or arch aortic
operations including 199 (49%) arch replacements conducted between July 25,
1991, and September 25, 2001. The mean age was 61.6 years (range 22 to 91
years); 48 (12%) had Marfan syndrome; 141 (35%) had dissection; 134 (33%)
had composite grafts inserted; and 138 (34%) had concurrent coronary bypasses
performed. Results. Stroke occurred in 2.0% (8/403) (3 permanent, 5 transient),
clinical neurocognitive deficits in 2.5% (10/403) either by testing or patient
complaint 2 to 3 weeks after surgery, and 98% (395/403) were 30-day survivors.
Univariate predictors of stroke, neurocognitive decline, or death were the
following: for stroke, aorta symptom severity grade (1 to 4) (p = 0.001), pump
time (p = 0.001), arrest time (p = 0.001), macroscopic atheroma (p = 0.041),
concurrent descending/thoracoabdominal aneurysm (p = 0.036), and highest
blood rewarming temperature (p = 0.043); for neurocognitive decline, degree of
cooling (p = 0.046), pump time (p = 0.001), cooling time (p = 0.001), day
extubated (p = 0.042), and antegrade brain perfusion (p = 0.004); for death,
pump time (p = 0.001) and clamp time (p = 0.011). The multivariable
independent predictors of stroke, neurocognitive decline, or death were the
following: for stroke, aorta symptoms grade (p = 0.025), peripheral vascular
disease (p = 0.043), and pump time (p = 0.015); neurocognitive decline,
preoperative New York Heart Association dyspnea class (p = 0.022), pump time
(p = 0.05), arrest time (p = 0.06), day extubated (p = 0.042), and antegrade
perfusion (p = 0.023); and for death, pump time (p = 0.018). Conclusions. Pump
time continues to be the most important predictor of adverse events. The benefit
of antegrade or retrograde perfusion remains unproven, partly because of the low
event rate (< 2.5%) but may be beneficial for prolonged circulatory arrest.
Embolic material either from macroscopic atheroma, descending or
thoracoabdominal aneurysms, or associated with peripheral vascular disease,
increases the risk of stroke. Preoperative symptoms influence outcome
Keywords: adverse events/age/aneurysm/aorta/aortic surgery/ARCH
ANEURYSM/atheroma/brain/BRAIN PERFUSION/brain
protection/CARDIOPULMONARY
BYPASS/death/disease/dissection/DYSFUNCTION/ELEPHANT TRUNK
TECHNIQUE/HYPOTHERMIC CIRCULATORY ARREST/NEURAL
SUPPORT/NEW-YORK/outcome/perfusion/peripheral vascular
disease/predictors/prevention/PROTECTION/RETROGRADE CEREBRAL
PERFUSION/risk/severity/stroke/SURGERY/symptoms/transient/USA/vascular/
vascular disease
Ascione, R., Reeves, B.C., Chamberlain, M.H., Ghosh, A.K., Lim, K.H.H. and Angelini,
G.D. (2002), Predictors of stroke in the modern era of coronary artery bypass
grafting: A case control study. Annals of Thoracic Surgery, 74 (2), 474-480.
Abstract: Background. Stroke is a rare but devastating complication after coronary artery
bypass grafting (CABG) and its prevention remains elusive. We used a case
control design to investigate the extent to which preoperative and perioperative
factors were associated with occurrence of stroke in a cohort of consecutive
patients undergoing myocardial revascularization. Methods. From April 1996 to
March 2001, data from 4,077 patients undergoing CABG were prospectively
entered into a database. The association of preoperative and perioperative factors
with stroke was investigated by univariate analyses. Factors observed to be
significantly associated with stroke in these analyses were further investigated
using multiple logistic regression to estimate the strength of the associations with
the occurrence of stroke, after taking account of the other factors. Results.
During the study period, 4,077 patients underwent CABG and of these 923
(22.6%) had off-pump surgery. Forty-five patients suffered a perioperative stroke
(1.1%). Overall there were 46 in-hospital deaths (1.1%), of whom 6 also suffered
a stroke. Brain imaging of the stroke patients showed embolic lesions in 58%,
watershed in 28%, and mixed in 14%. Multivariate regression analysis identified
several preoperative factors as independent predictors of stroke, ie, age, unstable
angina, serum creatinine greater than 150 mcg/ml, previous cerebrovascular
accident (CVA), peripheral vascular disease (PVD), and salvage operation.
When operative risk factors were added to the adjusted model, off-pump surgery
was associated with a substantial, but not significant, protective effect against
stroke (odds ratio = 0.56, 95% confidence interval 0.20 to 1.55). Survival for
stroke patients was 93% and 78% at 1 and 5 years, respectively. Conclusions.
Overall incidence of stroke is relatively low in our series. Age, unstable angina,
previous CVA, PVD, serum creatinine greater than 150 mcg/ml, and salvage
operation are independent predictors of stroke. These factors should be taken into
account when informing each individual patient on the possible risk of stroke and
in the decision-making process on the surgical strategy
Keywords: age/angina/ATRIAL-FIBRILLATION/bypass/bypass
grafting/CABG/CARDIOPULMONARY
BYPASS/cerebrovascular/cerebrovascular accident/control/CVA/decision
making/decision-making/design/DISEASE/England/grafting/imaging/incidence/
MARKER/MICROEMBOLI/MORTALITY/multiple logistic
regression/myocardial/NEW-YORK/OPERATIONS/perioperative
stroke/peripheral vascular
disease/predictors/prevention/revascularization/RISK/risk
factors/serum/stroke/SURGERY/unstable angina/vascular/vascular disease
Spielvogel, D., Strauch, J.T., Minanov, O.P., Lansman, S.L. and Griepp, R.B. (2002),
Aortic arch replacement using a trifurcated graft and selective cerebral antegrade
perfusion. Annals of Thoracic Surgery, 74 (5), S1810-S1814.
Abstract: Background. Aortic arch aneurysm repair remains associated with
considerable mortality and risk of cerebral complications. We present results of a
technique utilizing a three-branched graft for arch replacement, deep
hypothermic circulatory arrest (HCA), and selective antegrade cerebral perfusion
(SCP). Methods. Between March 2000 and November 2001, 22 patients (11
female) aged 40 to 77 years (mean 64 +/- 11.2) underwent arch replacement
utilizing the trifurcated-graft technique. Serial anastomosis of the branched graft
to individual cerebral vessels was carried out during HCA, followed by arch
reconstruction during SCP through the graft. All 22 patients had surgery
electively. Eight patients (36%) had undergone previous aortic surgery. In 19
patients, arch replacement was part of an elephant trunk procedure; 2 patients
had Bentall operations and 1 had isolated arch replacement. Concomitant
coronary artery bypass grafting was performed in 6 patients (27%). Mean HCA
duration was 30 6 minutes at a mean temperature of 11.4 +/- 0.8degreesC. Mean
duration of SCP was 52 +/- 18 minutes. Results. Adverse outcome-death before
hospital discharge or permanent stroke or both-occurred in 2 patients (9%). Two
patients experienced transient neurologic dysfunction (9%). Two patients (9%)
developed renal failure requiring short-term hemodialysis and pulmonary
complications occurred in 2 patients. Conclusions. Cerebral protection and
prevention of atheroembolism remain challenges in aortic arch reconstruction.
To reduce neurologic complications we developed an aortic arch reconstruction
technique in which a trifurcated graft is anastomosed to the brachiocephalic
vessels during HCA, reducing the risk of embolization while minimizing cerebral
ischemia by permitting antegrade cerebral perfusion as arch repair is completed.
(C) 2002 by The Society of Thoracic Surgeons
Keywords: aged/ANEURYSM/aortic surgery/bypass/bypass grafting/cerebral/cerebral
ischemia/cerebral vessels/complications/ELEPHANT TRUNK
TECHNIQUE/embolization/grafting/hemodialysis/hospital/HYPOTHERMIC
CIRCULATORY ARREST/ischemia/mortality/neurologic
dysfunction/NEW-YORK/prevention/PROTECTION/pulmonary/renal/renal
failure/risk/stroke/SURGERY/transient/vessels
Srinivasan, A.K., Grayson, A.D., Pullan, D.M., Fabri, B.M. and Dihmis, W.C. (2003),
Effect of preoperative aspirin use in off-pump coronary artery bypass operations.
Annals of Thoracic Surgery, 76 (1), 41-45.
Abstract: Background. The effect of preoperative aspirin use until the day of operation
on mortality rate and bleeding risks in patients who had on-pump coronary artery
bypass operation has been well documented. However, the effect of aspirin use
in patients undergoing off-pump coronary artery bypass operation (OPCAB) with
regard to postoperative blood loss and morbidity has not been studied. We aimed
to determine the effects of continuing aspirin therapy preoperatively. Methods.
We performed a retrospective study of 340 patients who had first- time OPCAB
between January 1998 and September 2001. A propensity score for receiving
aspirin until the day of operation was constructed from core patient
characteristics. All aspirin users (n = 170) were matched with unique 170
nonaspirin users by identical propensity score. The primary outcome measures
were in-hospital mortality rate and hemorrhage-related outcomes (postoperative
blood loss in the intensive care unit, reexploration for bleeding, and blood
product requirements). Secondary outcome measures were stroke, myocardial
infarction, gastrointestinal bleeding, and sternal wound infections. Results. There
were no differences in patient characteristics between aspirin users and
nonaspirin users. The average postoperative blood loss (845 mL versus 775 mL;
P = 0.157) and the rate of reexploration for bleeding (3.5% versus 3.5%; p > 0.99)
were similar in aspirin users and nonaspirin users. We found no significant
difference between blood product requirements for the two groups. Similarly, we
found no significant difference in the incidence of the secondary outcomes.
Conclusions. Preoperative aspirin did not increase bleeding-related
complications, mortality rate, or other morbidities in patients who had off-pump
coronary artery operation. (C) 2003 by The Society of Thoracic Surgeons
Keywords: ANTIPLATELET
THERAPY/aspirin/bleeding/bypass/complications/coronary artery
bypass/DIPYRIDAMOLE/DISEASE/England/IMMEDIATE
POSTOPERATIVE ASPIRIN/in-hospital
mortality/incidence/infarction/intensive care/morbidity/MORTALITY/mortality
rate/myocardial/myocardial infarction/NEW-YORK/outcome/outcome
measures/outcomes/postoperative/PREVENTION/primary/REEXPLORATION/
risks/secondary/stroke/SURGERY/therapy/TRIAL/USA/use/VEIN-GRAFT
PATENCY
Albert, A.A., Beller, C.J., Walter, J.A., Arnrich, B., Rosendahl, U.P., Priss, H. and
Ennker, J. (2003), Preoperative high leukocyte count: A novel risk factor for
stroke after cardiac surgery. Annals of Thoracic Surgery, 75 (5), 1550-1557.
Abstract: Background. Stroke after cardiac surgery is a devastating complication. The
relationship between white blood cell count (WBC) and perioperative
cerebrovascular accident (CVA) has not been investigated. An effort was made
to identify how preoperative WBC may relate to CVA development during or
after cardiac surgery. Methods. Prospective data were collected from 7,483
patients who underwent coronary artery bypass grafting or valvular surgery or
both. WBC was determined preoperatively and postoperatively. Differentiation
of WBC was examined only preoperatively. Results. There were a total of 125
CVAs (10 transient ischemic attacks [TIAs], 115 strokes). WBC was
significantly higher preoperatively and directly postoperatively in patients with
stroke. Qualitative changes in preoperative WBC were also found in these
patients (chi(2); p < 0.001). The predictive power of the stepwise logistic
regression model for CVA was greater when preoperative WBC was included.
The risk for perioperative CVA increased starting at preoperative WBC of 9 x
10(9)/L (p = 0.044) and progressed in higher WBC ranges. WBC had a
significant impact on CVA outcome (analysis of variance, P = 0.001).
Conclusions. Our studies have established the correlation between high
preoperative WBC and stroke during or after cardiac surgery. Furthermore,
elevated preoperative WBC was related to the clinical outcome of CVA.
Preoperative measures aimed at preventing or treating conditions such as
infections that may cause elevated WBC may be beneficial in the prevention of
stroke during or after cardiac surgery. (C) 2003 by The Society of Thoracic
Surgeons
Keywords: ASSOCIATION/bypass/bypass grafting/cardiac/cardiac
surgery/cerebrovascular/cerebrovascular accident/changes/complication/coronary
artery
bypass/CVA/development/DIABETES-MELLITUS/DISEASE/FIBRINOGEN/
Germany/grafting/INFARCTION/INFECTION/ISCHEMIA/ischemic/NEW-YO
RK/outcome/prevention/PROTEIN/risk/risk
factor/stroke/surgery/transient/transient ischemic attacks/USA
Gracey, M. (1998), Australian Aboriginal child health. Annals of Tropical Paediatrics,
18 S53-S59.
Abstract: There have been substantial improvements in the health of Australian
Aboriginal children over the past 2 decades. These include lower infant and
toddler mortality rates and a significant decline in rates of hospitalization for
conditions such as gastro-enteritis and lower respiratory tract infection. In
addition, the degree of illness among these children on presentation is now
generally much less severe than previously. There is evidence also of some
improvement in birthweight, growth and nutritional status over the past 20 years.
Incidence rates of infections among Aboriginal children, however, are still much
higher than among their non-Aboriginal counterparts and much of this is due to
unsatisfactory standards of living and community and personal hygiene. This is
aggravated by widespread inadequate infrastructures for providing better housing,
water supplies, solid and liquid waste disposal and the provision of regular, clean
and nutritious food supplies in Aboriginal communities. These issues and more
effective and culturally acceptable methods of disease prevention and health
promotion are now being accorded high priority. But serious concerns remain
about early Aboriginal "lifestyles" that may have important implications for
health and mortality patterns among Aborigines during young to middle-age
adult life. These include proneness to non-insulin-dependent diabetes mellitus,
hypertension, cardiovascular disease, particularly ischaemic heart disease, and
stroke which are likely to have their origins in childhood. The recent increase in
rates of motor vehicle accidents, sometimes fatal, homicide and suicide, and the
increasing rate of tabacco smoking and the use of addictive drugs, including the
sniffing of petrol, glue and other volatile substances, is cause for serious concern
for the future health and well-being of Aboriginal youth and their families
Keywords: Australia/cardiovascular disease/COMMUNITY/diabetes/diabetes
mellitus/DISEASE/drugs/ENGLAND/GROWTH/health/health
promotion/heart/HOSPITALIZATION/hypertension/INFANTS/INFECTIONS/
MORTALITY/NUTRITION/OXFORDSHIRE/prevention/PROTEIN-CALORIE
MALNUTRITION/smoking/stroke/WESTERN-AUSTRALIA
Barnes, R.W. (1995), Vascular holism: The epidemiology of vascular disease. Annals of
Vascular Surgery, 9 (6), 576-582.
Abstract: This article reviews the distinguishing features of epidemiology and clinical
medicine and their interdependence in clinical epidemiology as applied to
vascular disease. Selected literature is reviewed to emphasize the principles of
clinical epidemiology for five vascular disorders: abdominal aortic aneurysms,
lower extremity peripheral arterial occlusive disease, cerebrovascular disease,
deep vein thrombosis and pulmonary embolism, and varicose veins. These
vascular disorders are prevalent and pose significant risks for death and disability.
Many have risk factors that can be controlled. All can be treated by vascular
surgery, but outcomes including functional health and well-being may fall short
of that which is implied in our traditional surgical literature. Appropriate
allocation of resources to detect and treat vascular disease demands that
clinicians not only assume responsibility for the care of individual patients but
also develop a working knowledge of the clinical epidemiology of vascular
health and disease and its management within populations
Keywords: ABDOMINAL AORTIC-ANEURYSM/CAROTID
ENDARTERECTOMY/cerebrovascular
disease/epidemiology/health/ISCHEMIA/knowledge/PREVENTION/pulmonary
embolism/PULMONARY- EMBOLISM/QUALITY/risk/risk
factors/STENOSIS/STROKE/surgery/thrombosis/vascular/vascular disease
Chiche, L., Bahnini, A., Koskas, F. and Kieffer, E. (1997), Occlusive fibromuscular
disease of arteries supplying the brain: Results of surgical treatment. Annals of
Vascular Surgery, 11 (5), 496-504.
Abstract: Occlusive fibromuscular disease (FMD) of arteries supplying the brain is a
documented cause of neurologic complications. From September 1976 to
December 1994, 70 patients underwent surgery for occlusive FMD involving
arteries supplying the brain, isolated dysplastic aneurysms and ceilings or
kinkings were not included in this series. Twenty-two patients had experienced
previous nonlethal ischemic stroke, 25 patients had experienced transient
ischemic attacks, and 32 patients had vertebrobasilar insufficiency with or
without associated carotid symptoms. Lesions involved one (n = 36) or two (n =
29) internal carotid arteries, and one (n = 18) or two (n = 14) vertebral arteries.
Twenty-seven patients had simultaneous involvement of both carotid and
vertebral arteries, Ten patients had FMD at another site, four had intracranial
aneurysm, and four had an aberrant right subclavian artery. Seventy-seven
carotid procedures including ST graduated intraluminal dilatations were
performed and 18 vertebral arteries were revascularized. One patient (1.4%) died
postoperatively from hemorrhagic stroke and two patients (2.8%) presented
nonlethal stroke, Sixty-two patients were followed postoperatively from 2 to 184
months (mean 86.2 +/- 54.4). Actuarial survival rates at 5 and 10 years were 96.4
+/- 5.0% and 82.1 +/- 14.9%, respectively. Actuarial primary patency rate at 5
and 10 years was 94.3 +/- 5.5%. Actuarial probability of stroke-free survival
rates at 5 and 10 years were 94.2 +/- 5.6% and 88.6% +/- 10.3%, respectively.
We conclude that improvement of symptoms, prevention of stroke, and stable
long-term results justify surgical treatment in symptomatic patients with FMD of
arteries supplying the brain
Keywords: ABERRANT SUBCLAVIAN ARTERY/aneurysm/BALLOON
ANGIOPLASTY/brain/carotid/carotid
arteries/complications/DYSPLASIA/INTERNAL
CAROTID-ARTERY/INTRACRANIAL ANEURYSMS/ischemic/ischemic
stroke/NECK/NEW-YORK/PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY/prevention/stroke/SURGERY/transient/transient ischemic
attacks/treatment/VASCULAR/VERTEBRAL ARTERY
Ballotta, E., Da Giau, G., Baracchini, C. and Manara, R. (2002), Carotid eversion
endarterectomy: Perioperative outcome and restenosis incidence. Annals of
Vascular Surgery, 16 (4), 422-429.
Abstract: Carotid endarterectomy (CEA) for stroke prevention can be performed with
minimal perioperative mortality and morbidity rates. The type of surgical
technique used is important to achieve optimal outcome from CEA. The purpose
of this study was to analyze the perioperative and late results of carotid eversion
endarterectomy (CEE) in more than 400 procedures. From August 1992 to
December 1999, 402 primary CEEs were performed in 388 selected patients for
symptomatic (235/58.4%) and asymptomatic (167/41.6%) carotid lesions.
During the same period, 234 primary CEAs with patch closure (CEAPs) were
performed in 229 selected patients. All CEAs were carried out with continuous
electroencephalographic monitoring for selective shunting, using deep general
anesthesia. All patients underwent postoperative duplex ultrasound study and
clinical follow-up at 1, 6, and 12 months and every year thereafter. The mean
follow-up was 50 months (range 3-88). Main end points were perioperative
stroke and death, and restenosis. Our results showed that use of the CEE
procedure can reduce perioperative mortality and stroke risk rates to around zero
and results in no restenosis
Keywords: ANGIOPLASTY/ARTERY
STENOSIS/asymptomatic/carotid/death/DISEASE/duplex/endarterectomy/eversi
on/incidence/monitoring/morbidity/mortality/NEW-YORK/outcome/perioperativ
e stroke/POLYTETRAFLUOROETHYLENE
PATCH/postoperative/PREVENTION/primary/PRIMARY
CLOSURE/restenosis/risk/SAPHENOUS-VEIN PATCH/stroke/stroke
prevention/SURGERY/TERM
FOLLOW-UP/TRIAL/ultrasound/use/VASCULAR
Middleton, S., Harris, J., Lusby, R. and Ward, J. (2003), Vascular disease risk factor
management 4 years after carotid endarterectomy: are opportunities missed? Anz
Journal of Surgery, 73 (4), 225-231.
Abstract: Background: Because a large percentage of patients surviving carotid
endarterectomy (CEA) subsequently die from a vascular cause, the aim of the
present paper was to determine risk factor management for a cohort of patients 4
years after their CEA. Methods: Surviving patients who had a CEA within the
region administered by the Central Sydney Area Health Service in 1995 were
asked to complete a self-administered questionnaire to determine vascular risk
factors. Results: Of the 181 patients eligible to participate, 162 returned
questionnaires (response rate: 90%). While 106 (65.4%) patients recalled that
they had been diagnosed with high blood pressure either before or after their
CEA, only 79.2% recalled that their latest blood pressure reading was 'about
right for my age'. Nearly one in five (16.7%) who had had their cholesterol level
checked in the last 12 months (n = 120) indicated that the reading was 'too high'.
Only 76.5% reported taking medications to 'thin the blood'. Almost one-fifth of
patients (17.3%) were current smokers. Only 35.2% of patients participated in a
level of physical activity sufficient to confer a health benefit. Further, 30.2% of
patients were overweight and 14.8% were obese. The majority of patients (98.1%)
reported having a regular general practitioner (GP). Of these, 98.7% had visited
their GP at least once within the previous 6 months. Conclusions: Vascular risk
factor management following CEA is suboptimal, inviting the implementation
and evaluation of strategies to improve outcomes
Keywords: age/audit/AUSTRALIA/blood pressure/carotid/carotid
endarterectomy/cholesterol/disease/disease
risk/endarterectomy/England/evaluation/GENERAL-PRACTICE/health/high
blood pressure/LIFE-STYLE FACTORS/management/outcomes/physical
activity/risk/risk factor/risk factors/SECONDARY
PREVENTION/STROKE/stroke risk factors/vascular/vascular risk/vascular risk
factors/vascular surgery
Boissel, J.P. (1991), Antiaggregant Therapy in the Treatment of Peripheral Vascular-
Disease. Archives des Maladies du Coeur et des Vaisseaux, 84 (11), 1721-1724.
Abstract: Intermittent claudication has changed from being only a disabling symptom to
being an indication for secondary prevention of coronary and cerebrovascular
events. Epidemiological studies have shown claudication to be a risk factor of
cardiac and cerebral morbidity and mortality and clinical trials have sought to
show that some antiaggregant agents could reduce the risk and improve the
prognosis. These objectives have practically been attained, in particular with
ticlopidine. The reduction of cardiovascular and cerebral risk observed in the
metaanalysis of clinical trials with aspirin has had a uniting role for the use of
antiaggregant drugs in all spheres of atherosclerotic pathology
Keywords: INTERMITTENT
CLAUDICATION/PREVENTION/RISK/STROKE/TICLOPIDINE
Delahaye, J.P., Pillot, M., Delahaye, F. and Dubost, A. (1991), Management of
Hypertension and Its Cardiovascular Complications. Archives des Maladies du
Coeur et des Vaisseaux, 84 117-121.
Abstract: The three approaches (physiopathological, epidemiological and
pharmacological) to the management of hypertension should converge to provide
a personalised prescription of the most appropriate treatment to prevent and/or
cure the cardiovascular complications of hypertension: - hypertensive left
ventricular hypertrophy and the risks directly related to it (haemodynamic,
arhythmic, ischaemic) may be corrected by certain antihypertensive agents
(methyldopa, ACE inhibitors, some calcium antagonists) although there is no
proof as yet of the benefits of this intervention (which could suppress the
adaptation to the increased wall stress of the left ventricle); - malignant
hypertension and its cardiovascular complications have almost disappeared with
modern antihypertensive therapy. Cardiac failure can be effectively prevented
and cured when exclusively related to hypertension. When diastolic pressures are
lowered by 8-10 mmHg cerebrovascular risk is reduced by a half and coronary
risk by a quarter. Cardiovascular mortality related to hypertension is thus
reduced by 20 % and total mortality is thereby significantly decreased; - the large
scale clinical trials which provided these data were performed in the years
1965-1985 with diuretic therapy relayed by (or compared with) betablockers
from 1980 onwards. These two families remain the drugs of reference in the
prevention and treatment of the cardiovascular complications of hypertension.
Personalised description of antihypertensive therapy should take into account the
degree of risk and previous cardiovascular complications of the hypertensive
patient: betablockers eventually associated with calcium antagonists are to be
preferred in cases of hypertension with coronary artery disease and/or
arrhythmias, severe hypertension and hypertension complicated by cardiac
failure are good indications for ACE inhibitors without prejudicing other
therapeutic options necessary in certain contexts, in particular aspirin therapy in
patients with previous transient ischemic cerebral attacks. It is also important not
to forget dietary advice and treatment aimed at suppressing associated risk
factors which tend to increased cardiovascular morbidity and mortality
Keywords: CORONARY HEART-DISEASE/HIGH
BLOOD-PRESSURE/MORBIDITY/MORTALITY/REGRESSION/STROKE/T
RIALS
Koenig, A., Theolade, R., Chauvin, M. and Brechenmacher, C. (1992), Embolic
Complications of Chronic Atrial-Fibrillation. Archives des Maladies du Coeur et
des Vaisseaux, 85 (3), 315-323.
Abstract: Systemic embolism secondary to chronic atrial fibrillation usually affect the
cerebral circulation. The risk of a cerebrovascular accident in patients with
chronic atrial fibrillation, irrespective of the aetiology, is 1.8 to 7.5 times that of
general population. The embolic risk is 18 times greater in patients with atrial
fibrillation related to the rheumatic heart disease. The risk of patients under 60
years of age with idiopathic atrial fibrillation does not seem to be different to that
of the general population. The risk of early recurrence of embolism in the first 30
days ranges from 8 to 15 %. The risk of late recurrence varies but seems to b
higher than that of the general population. The prognosis of embolic
cerebrovascular accidents is poor with a 20 % mortality rate. The benefits of
preventive therapy of embolism with oral anticoagulants have been clearly
established in rheumatic atrial fibrillation and in other indications. In
non-valvular atrial fibrillation the benefits have to be compared with the risks of
treatment. The incidence of haemorrage due to anticoagulant therapy is between
3 and 5 % per year per patient (about 1 % of severe haemorrhage). Three
randomised studies of primary prevention have shown a significant reduction of
the embolic risk in non-valvular atrial fibrillation treated by warfarin compared
to patients on placebo. Only one study has shown a significant reduction of the
embolic risk in patients under 75 years of age with non-valvular atrial fibrillation
treated with 325 mg/day of aspirin. However, anticoagulant therapy does not
seem necessary in carefully selected patients under 60 years of age with
idiopathic atrial fibrillation (less than 5 % of all patients)
Keywords: BRAIN INFARCTION/CEREBRAL INFARCTION/EPIDEMIOLOGIC
FEATURES/FOLLOW-UP/HEART-DISEASE/LONG-TERM
ANTICOAGULATION/PROGNOSIS/RISK-FACTORS/STROKE/SYSTEMIC
EMBOLISM
Chauvin, M., Koenig, A. and Brechenmacher, C. (1992), Medical-Management of
Atrial-Fibrillation. Archives des Maladies du Coeur et des Vaisseaux, 85 61-68.
Abstract: Atrial fibrillation is a daily cardiological problem which poses three types of
questions, which, though old, are only partially mastered: anticoagulation,
reduction and prevention of recurrence. It is a potent source of embolism. The
risk is the greatest in patients with rheumatic valvular disease when the
fibrillation is recent and when underlying cardiac disease is uncompensated.
Long term anticoagulation is mandatory when the cause is rheumatic heart
disease. In other pathologies, though anticoagulation has not been shown to
reduce mortality, it significantly reduces the number of cerebrovascular accidents,
including in the elderly and with low-dose vitamin K antagonist drugs. The
efficacy of anticoagulation in preventing arterial embolism has not been
established. Reduction of atrial fibrillation is not essential if the arrhythmia is
well tolerated, chronic, especially in elderly patients and when several
recurrences have occurred despite preventive therapy. In other cases, medical
reduction is to be preferred to cardioversion if the fibrillation is recent and well
tolerated. Of the oral and injectable preparations, amiodarone seems to be the
drug with best benefit/risk ratio. Prevention of recurrence of fibrillation is
unnecessary for many after a first episode, especially when idiopathic. In other
cases, there are many available drugs but results are uncertain except in those
observed in atrial fibrillation related to the autonomic nervous system. Strictly
controled and statistically exploitable studies show comparable efficacy of
quinine and other Class I drugs. Beta-blockers are not very useful and the
excellent long term results with amiodarone require confirmation. Finally,
though the number of recurrences is about 55 % at 1 year, the choice of
antiarrhythmic agent is still made according to its tolerance
Keywords:
AMIODARONE/DISOPYRAMIDE/DOUBLE-BLIND/MAINTENANCE/PLA
CEBO/PREVENTION/QUINIDINE THERAPY/SINUS
RHYTHM/STROKE/SUPRA-VENTRICULAR TACHYARRHYTHMIAS
Lekieffre, J., Lacroix, D., Klug, D. and Kacet, S. (1994), Thromboembolic
Complications of Atrial-Fibrillation. Archives des Maladies du Coeur et des
Vaisseaux, 87 17-23.
Abstract: Fifteen per cent of cerebrovascular accidents have a cardiac origin, two thirds
of which are due to atrial fibrillation (AF). The Framingham study showed the
risk of an ischaemic cerebral event to be increased by 5.6 in AF unrelated to
rheumatic heart disease and by 17.5 when AF is associated with valvular heart
disease. The risk of embolism is higher in elderly subjects and in those with
underlying cardiac disease. Other high risk conditions include hypertension,
diabetes, hyperthyroidism and cases with echocardiographic changes : left atrial
dilatation. pre-thrombotic state or intra-atrial thrombus, ateroma of the ascending
aorta. This stratification of risk should be taken into account when deciding on
treatment. Conscious of the importance of the risk of embolism in AF, several
authors have undertaken, over the last few years, randomised studies of the
prevention of thromboembolic complications of AF: the AFASAK, BAATAF,
SPAF and SPINAF trials. All showed the unquestionable efficacy of warfarin,
even at low doses, at the price of a haemorrhagic risk of less than 2 % per year
for severe haemorrhages. A more recent study (SPAF II) confirmed the value of
aspirin at the dosage of 325 mg/day which would seem to be a good alternative
to anticoagulant therapy when this is contraindicated, although aspirin is less
effective. The indications for anticoagulant therapy have become clearer since
the publication of these results. Anticoagulant therapy is essential in permanent
AF whether or not associated with rheumatic heart disease. In cases of
paroxysmal AF. anticoagulants are highly recommended, especially in those at
high risk of thromboembolism; however, the nature of the AF has to be taken
into consideration (the frequency of repetition of AF, its chronicity). Two
indications are much more controversial. The first case is that of subjects over 75
years of age in whom anticoagulant therapy awaits confirmation of the results of
the SPAF II trial. The second case is that of isolated AF in subjects under 60
years of age without any associated risk factors in whom anticoagulant therapy is
not necessary. Finally, in secondary prevention (patients having experienced a
transient ischaemic attack or a mild cerebro-vascular accident), anticoagulants
are necessary. Despite recent advances, some points remain uncertain, such as
the comparative value of the preventive efficacy of anticoagulants versus platelet
anti-aggregant therapy, the interval between the prescription of anticoagulants in
AF and recent cerebro-vascular attack, and the superiority of the association of
low dose aspirin and warfarin versus warfarin alone
Keywords: anticoagulants/aspirin/atrial
fibrillation/complications/elderly/fibrillation/heart/hypertension/PREVENTION/
risk/risk factors/secondary
prevention/STROKE/thromboembolism/thrombus/transient/treatment/trials/WA
RFARIN
Linz, W., Gohlke, P., Unger, T. and Scholkens, B.A. (1995), Experimental-Evidence for
Effects of Ramipril on Cardiac and Vascular Hypertrophy Beyond
Blood-Pressure Reduction. Archives des Maladies du Coeur et des Vaisseaux, 88
31-34.
Abstract: In renal hypertensive rats with pressure overload left ventricular hypertrophy
the angiotensin converting enzyme inhibitor ramipril, given in a high blood
pressure lowering dose as well as in a low non-antihypertensive dose, prevented
and regressed left ventricular hypertrophy. These beneficial effects were
abolished by coadministration of the specific bradykinin receptor antagonist
(HOE 140) in the prevention - but not in the regression studies. Vascular
function of rats with pressure overload left ventricular hypertrophy was impaired,
whereas treated animals showed a reversal to normal. The angiotensin II subtype
AT(1) receptor antagonist, losartan, was barely active in the prevention, however
markedly active in the regression of left ventricular hypertrophy. From these
experimental studies in rats with pressure overload left ventricular hypertrophy
and vascular dysfunction we conclude that inhibition of bradykinin degradation
induced by ramipril may contribute to the antihypertrophic action during the
prevention phase, whereas attenuation of angiotensin II formation may be more
important during the regression period. In another model, the spontaneously
hypertensive rat (SHR and stroke prone SHR) - a non-renal hypertensive model
cardiac left ventricular hypertrophy could be reduced by chronic high-dose
ramipril treatment in prevention and regression studies, whereas the low dose
regimen only reduced left ventricular hypertrophy in the regression experiments.
In addition, both doses improved the myocardial capillary supply to the heart
leading to improved function and metabolism. In comparison, vascular
hypertrophy of the mesenteric artery could only be prevented by early-onset high
dose treatment with the angiotensin converting enzyme inhibitor but not once
hypertrophy has been established. However, the angiotensin converting enzyme
inhibitor improved vascular function under all treatment conditions
independently of its effect on blood pressure or on vascular hypertrophy.
Conclusion: the observed cardiovascular beneficial actions of ramipril
independently of its effect on blood pressure in renal hypertensive rats and SHR
may have been the result of a local accumulation of bradykinin beside the
decrease in the formation of angiotensin II
Keywords: angiotensin/ANGIOTENSIN CONVERTING ENZYME
INHIBITION/angiotensin II/ANGIOTENSIN-CONVERTING
ENZYME/BIOLOGY/blood pressure/formation/GROWTH/heart/high blood
pressure/HYPERTROPHY/INHIBITION/losartan/prevention/PREVENTS/RAM
IPRIL/rat/RATS/SHR/stroke/SYSTEM/treatment/vascular
Rosa, A. and Canaple, S. (1996), Prevention of ischaemic cerebrovascular accidents by
platelet inhibitors. Archives des Maladies du Coeur et des Vaisseaux, 89 (11),
1563-1568.
Abstract: Cohort studies currently available suggest that the most effective platelet
inhibitors for the secondary prevention of ischaemic cerebrovascular accidents
are acetylsalicylic acid and ticlopidine. Aspirin reduces the risk by 20 %. It
seems that moderate doses (100-300 mg/day) are sufficient and better tolerated.
Ticlopidine would seem to be more effective than aspirin as it reduces the risk by
more than 20 % with respect to aspirin therapy. Only aspirin has been evaluated
in the setting of primary prevention and it seems to be ineffective in preventing
cerebral infarction. Nowadays, other anti-platelet molecules are under evaluation,
one of which is Clopidogrel
Keywords: ASPIRIN/CEREBRAL-ISCHEMIA/RANDOMIZED TRIAL/secondary
prevention/STROKE/TICLOPIDINE
Chalon, S. and Lechat, P. (1996), Antithrombotic treatment in atrial fibrillation. Archives
des Maladies du Coeur et des Vaisseaux, 89 (11), 1533-1542.
Abstract: In comparison with the incidence of a cerebrovascular accident in the general
population, atrial fibrillation increases the risk by a factor of five. Although age
is without doubt the main risk factor for cerebrovascular accidents in patients
with permanent or paroxysmal non-valvular atrial fibrillation, other independent
risk factors have been identified : a previous history of hypertension,
cerebrovascular accident, heart failure or diabetes. These factors enable
identification of a population at risk in which oral anticoagulation may be
recommended with an excellent efficacy/risk ratio. Six large scale randomised
controlled multicenter trials of primary prevention have been published with a
total of over 2 800 patients with non-valvular atrial fibrillation. The combined
results of these trials show that treatment with a vitamin K antagonist (INR 2-3)
leads to a significant reduction in the risk of an ischaemic cerebrovascular
accident of 64 % (95 % CI [51-74]; p < 0.001) and in the risk of death from all
causes of 28 % (95 % CI [12-47]; p = 0.038) with a slight increase in the risk of
cerebral haemorrhage (+ 2.7 % NS). Although the benefits of aspirin therapy are
not as impressive (reduction of the risk of an ischaemic cerebrovascular accident
of 22 %; 95 % CI [0-39]; p = 0.053), this alternative may be proposed in patients
under 75 years of age without the previously mentioned risk factors. The value of
combined aspirin-oral anticoagulant therapy, especially in high risk patients, has
not yet been established and is under evaluation
Keywords:
ANTICOAGULATION/ASPIRIN/CARDIOVERSION/PREVALENCE/PREVE
NTION/RISK- FACTORS/SILENT CEREBRAL
INFARCTION/SPONTANEOUS ECHO CONTRAST/STROKE/WARFARIN
Ames, R. (1998), Hyperlipidemia of diuretic therapy. Archives des Maladies du Coeur et
des Vaisseaux, 91 23-27.
Abstract: Hyperlipidemia is a widely acknowledged side effect of thiazide diuretic
therapy, but it is often dismissed as a short-term effect of high-dose therapy.
Large clinical trials usually show no lipid change during late follow-up. These
large trials use intention-to-treat analysis which masks the lipid effect. On-
treatment analysis regularly reveals the persistence of hyperlipidemia during 4-5
years of treatment. Studies of low- dose thiazide therapy give conflicting results.
Metaanalysis of these studies reveals hyperlipidemia of a milder degree than with
high-dose thiazide treatment. However, a trade-off of effects is apparent because
systolic blood pressure is lowered less well with low doses. Thus, thiazide effects
on blood pressure and lipids are dose-dependent. Similar meta-analysis of
indapamide 2.5 mg daily shows no adverse lipid effect and a lowering of blood
pressure equivalent to SO mg of hydrochlorothiazide. Regarding clinical events,
low-dose thiazide treatment exerts primary prevention of coronary heart disease
but provides less benefit against stroke and congestive heart failure than does
high-dose therapy. Thus, an evidence- based therapeutic strategy for further
reducing cardiovascular risk is as follows: initiate antihypertensive therapy with
low- dose diuretics. Add beta-blockers and dihydropyridine-type calcium
channel blockers for further antihypertensive effect, if needed. Hypertension
resistant to a 3-drug regimen should be treated with high-dose thiazides. Lipids
should be monitored at each step and treated with diet and statin drugs to
maintain lipid goals. Risk factor control is an old concept that has yet to be
effectively implemented
Keywords: beta-blockers/blood pressure/calcium channel/CHOLESTEROL/clinical
trials/coronary heart disease/CORONARY
HEART-DISEASE/diet/heart/hypercholesterolemia/hyperlipidemia/hypertension
/HYPERTENSIVE
PATIENTS/indapamide/lipids/LIPOPROTEINS/MEN/PLASMA-LIPIDS/PRES
SURE/PREVENTION/primary prevention/risk/stroke/thiazide
diuretics/treatment/TRENDS/TRIAL/trials
Cambou, J.P., Cothereau, C., Simon, S., Aptel, I. and Conso, F. (1998), High blood
pressure in a representative population of French railway drivers: Environmental
or socio-economic factors? Archives des Maladies du Coeur et des Vaisseaux, 91
(8), 989-993.
Abstract: High blood pressure (HDP) is known as a cardiovascular risk factor depending
both on environmental and socio-economic factors. Methods : From October
1993 to october 1994 a cross sectional study was carried out among 1 855 French
railway drivers (FRD) representative of the 17 432 males FRD, aged 20 to 54
years. Age, weight, height, hip and waist, smoking, living area, type of train they
drove (goods, suburban, MV, inter-city trains), their grade (3 grades) were
recorded. HBP corresponds to systolic blood pressure (BP) 160 mmHg or
diastolic BP greater than or equal to 95 mmHg or to normal BP under
antihypertensive medication. The analysis was carried out according to 2 age
classes : 20-36/37-54 years. Results : In our sample 8.5 % of FRD suffered from
HBP, 3.5 % In the younger class, and 13.5 % in the other one. Using univariate
analysis, among the oldest, subjects with lower grades suffered more often from
HBP (19 %). Paris area was more often related to HBP for the 20-36 years (6,7
%). This was the case for the oldest living in Paris area (19.7 %), and the North
East (15.2 %). Subjects with central obesity (19.9 vs 6 %) and hyperlipidemic
FRD (20.9 vs 10.9 %) were more often related to HBP in the 35- 54 years group
Whatever the type of train they drove no difference was found. In multivariate
analysis, (stepwise logistic regression BMDP LR) independent HBP factors are :
age OR 3.4 IC 1.9-5.9 (20-36 vs 37-54), central obesity OR 1.7 IC 1.1-2.6,
tobacco consumption OR 2.1 IC 1.2-3.5 (smokers vs non smokers), ex-smokers :
OR 2.3 IC 1.3-3.9 (Ex-smokers vs non smokers), living area (all regions vs South
East in the Mediterranean border). Nevertheless, grades and type of train they
drove were not independent factors. Conclusion : These results show the
determining part played by environmental factors : age, central obesity, living
area and tobacco consumption in the determinism of HBP in professional
background : these factors can account for the difference observed in
professional factor (grade)
Keywords: age/aged/blood pressure/DIAGNOSIS/HEALTH-ORGANIZATION
REPORT/obesity/RECOMMENDATIONS/risk/smoking/STROKE
PREVENTION/tobacco
Mas, J.L. (1998), Prevention of cerebral infarction due to atherosclerosis. Archives des
Maladies du Coeur et des Vaisseaux, 91 65-73.
Abstract: Atherosclerosis of the cerebral arteries is the main cause of cerebral infarction
but the frequency with which this cause is implicated is very variable from one
trial to another depending on the criteria used. Primary prevention of this type of
infarction is mostly based on the correction of arterial risk factors and on carotid
artery surgery in selected cases. Aspirin does not appear to be effective in this
indication. The respective indications of heparin and aspirin in the acute phase of
cerebral infarction remain controversial despite the recent publications of large
scale therapeutic trials. The benefits of these treatments is, at best, globally
modest. Thrombolytics could, on the other hand, revolutionise the treatment of
acute cerebral infarction if the encouraging results of a recent trial using rt-PA in
the first 3 hours, are confirmed by other trials. After the acute phase, antiplatelet
agents (aspirin, ticlopidine, clopidogrel or aspirin associated with dipyridamole)
and surgery in patients with symptomatic carotid artery stenosis greater than SO
% or 70-80 % (according to the method of measurement) have been shown to be
effective. Several large scale trials are under way to assess the benefits and risks :
a) of antihypertensive therapy in patients with previous cerebrovascular accidents,
b) of treatment with statins of patients at high risk of infarction due to
atherosclerosis, c) of oral anticoagulants at low dosage (versus antiplatelet agents)
in secondary prevention, d) of thrombolytics in the acute phase of cerebral
infarction, e) of carotid angioplasty (versus surgery) in patients with
symptomatic severe stenosis
Keywords: ACUTE ISCHEMIC STROKE/angioplasty/anticoagulants/antiplatelet
agents/ASPIRIN/atherosclerosis/carotid/CIGARETTE-SMOKING/clopidogrel/d
ipyridamole/DISEASE/heparin/PLACEBO/prevention/RISK/risk
factors/secondary
prevention/statins/STENOSIS/surgery/THERAPY/ticlopidine/treatment/TRIALS
Castaigne, A., Haziza, F. and Lopes-Darmon, M.E. (1998), Heart and brain: Do the risk
factors have the same significance? Are the results of primary and secondary
prevention trials comparable? Archives des Maladies du Coeur et des Vaisseaux,
91 59-63.
Abstract: The aim of this study was to identify the similitudes and the differences in the
epidemiology and prevention of myocardial infarction and cerebrovascular
accidents by analysis of trials of primary and secondary prevention of myocardial
infarction and cerebrovascular accidents. The principal risk factors common to
both pathologies are hypertension, smoking and increased LDL-cholesterol.
However, the statistical significance with respect to causality differs from one
pathology to the other. Similarly, the impact of preventive measures is not the
same : the treatment of hypertension is more important in the prevention of
cerebrovascular accidents than myocardial infarction; the situation is the other
way around with respect to the treatment of hypercholesterolaemia. Of the
therapeutic interventions, aspirin is effective in all stages of coronary artery
disease but does not prevent cerebrovascular accidents in patients without
documented atherosclerosis. Thrombolysis carries a much higher benefit/risk
ratio in the treatment of myocardial infarction than in that of cerebral infarction.
The so-called cardioprotective drugs, such as the betablockers and angiotensin
converting enzyme inhibitors, have only been used to any extent in the secondary
prevention of myocardial infarction. These differences reflect the fact that
cerebrovascular accident covers a range of diseases much more diverse than does
myocardial infarction, and also that the brain is much more exposed to
haemorrhage whereas cardiac haematoma is highly unusual. Finally, cerebral
atherosclerosis is a later event than coronary atherosclerosis and this has
epidemiological implications which are difficult to assess. In conclusion, the
prevention of myocardial infarction and of cerebrovascular accidents may
proceed theoretically by a common pathway but in practice, it is very different
Keywords: angiotensin/angiotensin converting enzyme
inhibitors/aspirin/atherosclerosis/BLOOD-PRESSURE/coronary artery
disease/DISEASE/diseases/epidemiology/hypertension/MORTALITY/myocardi
al infarction/prevention/risk/risk factors/secondary
prevention/smoking/STROKE/treatment/trials
Gueyffier, F., Cornu, C., Bossard, N., Mercier, C., Poncelet, P., Sebaoun, A., Jullien, G.,
Avierinos, C., Fraboulet, J.Y. and Boissel, J.P. (1999), Prognostic value of
ambulatory blood pressure measurement in France. Archives des Maladies du
Coeur et des Vaisseaux, 92 (8), 1151-1157.
Abstract: Rationale : Ambulatory blood pressure measurement (ABPM) is commonly
used in clinical practice, whereas its added value to the management of
hypertension is not definitely documented. Objective : the OCTAVE II study
was launched in 1991 to explore the prognostic value of ABPM, compared to
that of the gold standard, the clinical blood pressure measurement. Methods:
Two hundred and six French cardiologists recruited 3569 participants over 18
years of age, provided they deemed ABPM was useful (mean age of 56 years,
52% of men, 65% already treated by antihypertensive drugs). The prognostic
value of various blood pressure measurements, systolic or diastolic, clinical or
ambulatory (diurnal, nocturnal or during 24 hours), has been assessed in
multivariate models adjusted on the baseline characteristics associated with risk.
The outcome was the occurrence of a major cardiovascular event, including
stroke, myocardial infarction and cardiovascular death. Results : after an average
follow-up of five years, cardiovascular morbidity was known for 85% of the
participants, and their vital status for 91%. On the whole population, the best
prognostic indicators were systolic blood pressure compared with diastolic,
ABPM compared with clinical blood pressure measurement, and nocturnal
ABPM compared with diurnal ABPM. In the untreated participants at baseline,
cardiovascular risk regularly-increased among the four groups : normotensives,
white-coat hypertensives, dippers, non-dippers. Between the extreme categories,
the cardiovascular event rate was multiplied by 6.5. Conclusion : in this French
population, ABPM and most of all its nocturnal component, was better correlated
with cardiovascular prognosis. It remains to assess : 1) the general value of our
findings, 2) the respective values of self blood pressure measurement versus
ABPM, and 3) whether ABPM allows a better risk prevention
Keywords: age/antihypertensive drugs/blood pressure/cardiovascular/cardiovascular
event/cardiovascular morbidity/cardiovascular risk/clinical
practice/drugs/HYPERTENSION/infarction/men/morbidity/myocardial/myocard
ial infarction/nocturnal/prevention/prognosis/risk/stroke/systolic blood pressure
Fournier, A., Achard, J.M., Mazouz, H., Pruna, A., Hottelart, C., Rosa, A., Fernandez, L.
and Andrejak, M. (1999), Could angiotensin II type I receptor antagonists
(ARAT1) better prevent stroke than angiotensin II converting enzyme inhibitors
(ACEI)? Archives des Maladies du Coeur et des Vaisseaux, 92 (8), 997-1000.
Abstract: In contrast with the expected results, the Captopril Prevention Project study
has found that the relative risk of stroke was greater by 25% in patients treated
with ACEI than in patients receiving the conventional diuretics+/-betablockers
regimen (Hanson et al, ISH Amsterdam, June 98). This difference persisted after
adjustment for the initial differences of blood pressure levels between the groups
after randomisation. This does not mean that ACEI would worsen the risk of
stroke when compared to a placebo, since a potent protective effect of diuretics
and betablockers an the relative risk of stroke has long been demonstrated.
Nonetheless, these results suggest that for a similar blood pressure lowering
effect, conventional therapy is more effective than ACEI to prevent stroke. This
finding, in discrepancy with the current prevailing opinion that ACEI have
emerged as the most effective preventive treatment to reduce cardiovascular
morbidity, is regarded as surprising by the investigators. However, a number of
animal experimental data may help to envisage the complete inhibition of
angiotensin II formation as a two-edged sword, because of the multiplicity of its
receptors mediating different, and even opposite effects. In a series of
experimental studies in mammals, the group of Fernandez has provided a bundle
of observations suggesting that angiotensin II contributes to early reperfusion
following acute ischemia by enabling the recruitment of pre-existing collateral
vascularisation, an effect mediated via the stimulation of non-ATI receptors
(possibly AT2). Indeed, the worsening of stroke in the gerbil after incomplete
ligation of the carotid by pre-treatment with ACEI had been demonstrated by
these authors (J Cerebral Blood Flow Metab, 1988; 24:937), and they further
show that pre- administration of losartan significantly reduced the ischemic brain
damage and the mortality induced by the abrupt ligation of one carotid, but that
this preventive effect of losartan was abolished if enalapril was co-administrated
(J Cardiovasc Pharmacol 1994; 24 : 937). The first available clinical data on
stroke risk with ACEI reported in the CPP study, showing a less effective
prevention of stroke with ACEI than diuretics supports the hypothesis that
similar mechanism may also prevail in humans, and lead us to propose to discuss
the rationale for a targe multicentric trial aiming to compare the protective effect
of ARAT1 and ACEI on the risk of recurrence of stroke
Keywords: acute/administration/angiotensin/angiotensin II/animal/blood
pressure/brain/cardiovascular/cardiovascular morbidity/carotid/CAROTID
LIGATION/formation/gerbil/ISCHEMIA/ischemic/losartan/morbidity/mortality/
MORTALITY-RATE/prevention/receptors/recruitment/recurrence/relative
risk/reperfusion/risk/stroke/therapy/treatment
Mallion, J.M., Benkritly, A., Hansson, L. and Zanchetti, A. (1999), Effect of intensive
antihypertensive treatment and acetyl salicylic acid in low dose in hypertensive
patients: HOT Study (Hypertension Optimal Treatment). Archives des Maladies
du Coeur et des Vaisseaux, 92 (8), 1073-1078.
Abstract: The aim of the HOT Study (Hypertension Optimal Treatment) was to
determine the optimal diastolic blood pressure decrease and to assess the effect
of the acetyl salicylic acid as a primary prevention on the cardiovascular
morbidity and mortality in hypertensive patients. The HOT Study is an open,
prospective, randomised, international trial with blinded end points. This study
included 18 790 patients, 50 to 80 years old (mean 61.5 years) in 26 countries (1
574 patients in France) with a primary hyper-tension (100 less than or equal to
PAD less than or equal to 115 mmHg). The patients were randomised in 3 target
diastolic blood pressure: less than or equal to 80 mmHg (n=6 262), less than or
equal to 85 mmHg (n=6 264), less than or equal to 90 mmHg (n=6 264). The
felodipine LP, a long acting dihydropyridine, was selected as a first line therapy,
other hypertension drugs combined if necessary. The lowest incidence of
cardiovascular events was observed at a diastolic blood pressure level of 82.6
mmHg. There was no increased risk below this level even in the hypertensive
patients with medical history of coronary heart disease or stroke, In the diabetic
population, the diastolic blood pressure decrease from 90 to 80 reduced the
incidence of the major cardiovascular events by 51 %. The acetyl salicylic acid
reduced the myocardial infarction risk in the blood pressure well-controlled
population
Keywords: antihypertensive treatment/blood
pressure/BLOOD-PRESSURE/cardiovascular/cardiovascular
events/cardiovascular morbidity/coronary heart disease/diastolic blood
pressure/dihydropyridine/DISEASE/drugs/heart/history/hypertension/incidence/i
nfarction/morbidity/mortality/myocardial/myocardial
infarction/prevention/primary prevention/risk/salicylic
acid/stroke/therapy/treatment/TRIALS
Cohen, A. (2001), The best of echocardiography in 2000. Archives des Maladies du
Coeur et des Vaisseaux, 94 27-39.
Abstract: The advances in Doppler echocardiography, like last year, concern the
technology, the indications and the description of the natural history of
cardiovascular diseases. The year 2000 will be remembered for the development
of portable echocardiographs with two-dimensional and Doppler capabilities but
without M mode, pulsed or continuous Doppler. These instruments weigh less
than 3kg and may be used at the bedside; however, problems of training
personnel, reimbursement and availability of equipment remain. Myocardial
contrast echocardiography has been the subject of many publications which
validate continuous intravenous infusion of different contrast agents, which,
coupled with techniques of image processing, suggest that quantification of
regional myocardial perfusion at rest or during physiological or pharmacological
stress may not be far off. The indications of stress echocardiography have
increased: in addition to diagnostic and prognostic information in coronary artery
disease, the applications of exercise and pharmacological inotropic stress echo
extend to asymptomatic valvular regurgitation to detect infraclinical myocardial
dysfunction before the usual Doppler echocardiographic parameters show
significant changes. The value of Doppler tissue imaging in the assessment of
regional myocardial function has been demonstrated: analysis of diastolic
function with pulsed Doppler at the mitral annulus, quantification of regional
myocardial function in different pathologies such as ischaemic heart disease and
cardiomyopathy, Validation of indices during stress echocardiography with the
hope of a quantitative as well as a qualitative assessment, much improved since
the introduction of harmonic imaging. Finally, Doppler haemodynamic
evaluation has continued to substitute for cardiac catheterisation, now providing
accurate indices of quantification of valvular regurgitation and description of the
natural history of cardiac diseases, especially mitral regurgitation irrespective of
its cause and aortic stenosis including cases with low output states. The
continuing progress of ultrasound technology is therefore confirmed and
provides an outlook into the third millennium: development of portable
equipment, improved probe technology, use of instruments of quantification and
extension of real time three-dimensional reconstruction, systems of image
stocking and transmission and better orientation of its usage with the
recommendations of scientific societies
Keywords: ACUTE MYOCARDIAL-INFARCTION/aortic
stenosis/ARCH/asymptomatic/cardiac/cardiomyopathy/cardiovascular/cardiovas
cular diseases/CONTRACTILE RESERVE/coronary artery
disease/development/diagnostic/disease/diseases/DOBUTAMINE STRESS
ECHOCARDIOGRAPHY/Doppler/echocardiography/evaluation/exercise/heart/
heart disease/history/HYPERTENSIVE PATIENTS/ischaemic/ischaemic heart
disease/mitral regurgitation/MITRAL-VALVE
PROLAPSE/myocardial/NONVALVULAR
ATRIAL-FIBRILLATION/PROGNOSTIC VALUE/stenosis/stress/STROKE
PREVENTION/TRANSESOPHAGEAL
ECHOCARDIOGRAPHY/ultrasound/use/VASCULAR-SURGERY
Milon, H., Lantelme, P., Khettab, F., Mestre-Fernandes, C. and Lasserre-Remy, S.
(2001), Primary prevention of coronary thrombosis with antithrombotics.
Archives des Maladies du Coeur et des Vaisseaux, 94 (11), 1243-1250.
Abstract: At the start of the eighties. in the wake of the good results obtained with
aspirin in secondary prevention, two studies were launched aimed at testing the
effect of aspirin on the primary prevention of myocardial infarctions. The results
published in 1988 and 1989 were divergent: the study conducted by British
doctors showed no benefit with aspirin, that conducted by American doctors
showed a very distinct benefit concerning myocardial infarction but no
advantage for cerebral vascular accidents. Besides, in both studies an additional
risk of haemorrhagic cerebral vascular accident was described. Methodological
reasons were the origin of these facts, but it resulted in a certain confusion as to
the practical conduct to adopt. Ten years later it is much more clear after the
publication of three supplementary trials. The benefits of aspirin in terms of
prevention of myocardial infarction are certain and considerable, at the price of a
haemorrhagic risk equally certain but moderate. On the other hand, questions
remain concerning the preventive effect of aspirin on cerebral vascular accidents
and also on the expected benefits in the female sex. In practice, the prescription
of aspirin with the objective of primary prevention must take into account the
absolute benefit which can be expected. This is a function of the individual
absolute risk before treatment which therefore signifies an evaluation based on
the risk factors. Only subjects exposed to a substantial risk before treatment are
likely to benefit from aspirin. For the others, the risks linked with aspirin could
counterbalance its preventive advantages
Keywords: absolute
risk/antithrombotics/ARCH/aspirin/benefits/CARDIOVASCULAR-DISEASE/c
erebral/CLINICAL-PRACTICE/evaluation/HYPERTENSION OPTIMAL
TREATMENT/infarction/ISCHEMIC-HEART-DISEASE/LOW- DOSE
ASPIRIN/myocardial/myocardial
infarction/MYOCARDIAL-INFARCTION/prevention/primary/primary
prevention/RANDOMIZED TRIAL/results/RISK/risk
factors/risks/secondary/secondary prevention/sex/STROKE/THERAPEUTIC
AGENT/thrombosis/treatment/trials/vascular
Mas, J.L. (2002), Antithrombotic therapy for ischaemic stroke. Archives des Maladies
du Coeur et des Vaisseaux, 95 53-57.
Abstract: Antithrombotic therapy should be considered in the acute phase of an
ischaemic stroke in patients who are not candidates for thrombolysis. The
recommended treatment is aspirin, 160 or 300 mg daily, associated in bed-ridden
patients with prophylactic heparin therapy to avoid venous thromboembolic
complications. Although not founded on scientific proof, high dose
anticoagulants may be used instead of aspirin in special cases presumed to be at
high risk of early recurrence of embolism or of extension of thrombosis.
Secondary prevention in patients who have already suffered a non-embolic
ischaemic stroke is based mainly on antiplatelet drugs. Aspirin, clopidogrel or
the association of aspirin and dipyridamole are possible first line options.
Ticlopidine is not recommended as treatment of first intention because of its
secondary effects and the necessity of monitoring the blood count. Oral
anticoagulants are not recommended after a non-cardio-embolic ischaemic stroke
except in special cases (e.g. deficit in inhibitors of blood clotting). Secondary
prevention in patients at high cardio- embolic risk (e.g. atrial fibrillation) should
be based on oral anticoagulants. Cardiac disease carrying a low or uncertain risk
(e.g. patent foramen ovale without an atrial septal aneurysm) is usually treated
with platelet inhibitors
Keywords: acute/ACUTE ISCHEMIC
STROKE/aneurysm/anticoagulants/antiplatelet/antiplatelet
drugs/ARCH/ASPIRIN/atrial/atrial fibrillation/atrial septal
aneurysm/clopidogrel/complications/dipyridamole/disease/drugs/embolism/fibril
lation/foramen ovale/heparin/high risk/ischaemic/ischaemic
stroke/monitoring/oral anticoagulants/patent/patent foramen
ovale/platelet/PREVENTION/recurrence/risk/secondary/stroke/therapy/thrombo
embolic/thromboembolic
complications/thrombolysis/thrombosis/treatment/TRIAL
Pyke, S.D.M., Wood, D.A., Kinmonth, A.L. and Thompson, S.G. (1997), Change in
coronary risk and coronary risk factor levels in couples following lifestyle
intervention - The British Family Heart Study. Archives of Family Medicine, 6
(4), 354-360.
Abstract: Objectives: To measure the extent to which changes in cardiovascular risk
factors were correlated among married couples following a 1-year primary care,
family-centered, cardiovascular lifestyle intervention program and to identify
couples who benefited most from this prevention program. Design:
Observational study. Setting: Thirteen primary care centers in 13 towns in
Britain. Participants: A total of 1477 men aged 40 to 59 years and their female
partners who attended a family health checkup in 1991 to 1992 from randomly
ordered invitations to registered families. After 1 year, 1204 (82%) partner pairs
were rescreened. Main Outcome Measures: One-year changes in cigarette
smoking, systolic blood pressure, serum cholesterol level, blood glucose level,
and a total coronary risk score. Results: Comparing men and women partners,
baseline values and 1-year changes in overall coronary risk score (Pearson
r=0.27 and r=0.20, respectively), cigarette smoking, body mass index, systolic
blood pressure, cholesterol levels, and glucose levels were all positively
correlated (all P<.001 except smoking cessation, P=.03). Changes in cholesterol
levels and systolic blood pressure were also associated with partner's baseline
measurement (P less than or equal to.01 in both men and women). Conclusions:
Men and women who benefit most from risk factor reductions have partners who
also tend to benefit most. Conversely, men and women who enjoy little or no
benefit have partners who tend to have similarly small benefits. It is likely that
lifestyle intervention targeted at men and women as couples rather than as
individuals may result in a greater reduction in cardiovascular risk factors,
possibly through mutual reinforcement of lifestyle changes
Keywords: aged/AGGREGATION/blood pressure/BLOOD-PRESSURE/body mass
index/cardiovascular risk factors/CHOLESTEROL/coronary
risk/DISEASE/glucose/health/HEART/lifestyle/LUNG/MEN/prevention/primary
care/PRIMARY PREVENTION/risk/risk
factors/serum/SMOKING/STROKE/women
Mosca, L., Jones, W.K., King, K.B., Ouyang, P., Redberg, R.F. and Hill, M.N. (2000),
Awareness, perception, and knowledge of heart disease risk and prevention
among women in the United States. Archives of Family Medicine, 9 (6), 506-515.
Abstract: Context: One of 2 women in the United States dies of heart disease or stroke,
yet women are underdiagnosed and undertreated for these diseases and their risk
factors. Informed decisions to prevent heart disease and stroke depend on
awareness of risk factors and knowledge of behaviors to prevent or detect these
diseases. Objective: Assess (1) knowledge of risks of heart disease and stroke
and (2) perceptions of heart disease and its prevention among women in the
United States. Design and Setting: Telephone survey conducted in 1997 of US
households, including an oversample of African American and Hispanic women.
Participants: One thousand respondents 25 years or older; 65.8% white, 13.0%
African American, and 12.6% Hispanic. Main Outcome Measures: Knowledge
of heart disease and stroke risks, perceptions of heart disease, and knowledge of
symptoms and preventive measures. Results: Only 8% of the respondents
identified heart disease and stroke as their greatest health concerns; less than
33% identified heart disease as the leading cause of death. More women aged 25
to 44 years identified breast cancer as the leading cause of death than women 65
years or older. Women aged 25 to 44 years indicated they were not well
informed about heart disease and stroke. Although 90% of the women reported
that they would like to discuss heart disease or risk reduction with their
physicians, more than 70% reported that they had not. Conclusions: Most women
do not perceive that heart disease is a substantial health concern and report that
they are not well informed about their risk. Age influenced knowledge to a
greater extent than ethnicity. Programs directed at young women that address the
effects of life-style behaviors on long-term health are needed. Better
communication between physicians and patients is also warranted
Keywords: aged/ARCH/awareness/breast
cancer/cancer/CHICAGO/CORONARY-ARTERY
DISEASE/death/disease/disease risk/diseases/ethnicity/HEALTH/heart/heart
disease/knowledge/lifestyle/prevention/risk/risk
factors/stroke/survey/THERAPY/United States/women
Raffaeli, S. and Paciaroni, E. (1995), Stroke and Atrial-Fibrillation - Risks, Prevention
and Therapy in the Elderly. Archives of Gerontology and Geriatrics, 20 (1),
23-28.
Abstract: Atrial fibrillation (AF) represents a high risk of systemic embolism,
particularly of stroke (S). This is true not only when AF is associated with an
organic cardiopathy, but also in the so-called nonvalvular AF (NVAF). Not all
cases of AF are of the same S-risk; such risk is higher for rheumatic AF and
lower for NVAF. Therefore, a risk stratification is important in order to decide
long-term antithrombotic prophylaxis. Five major trials have recently examined
the thromboembolic prophylaxis in this group of patients. These randomised
prospective open studies showed a significant reduction of S and systematic
embolism in patients receiving low dose of warfarin (W), even in the elderly, as
compared to placebo, and the incidence of hemorrhagic complications was also
very low. Significant benefits of aspirin (ASA) were observed only in one trial in
patients, except those older than 75 years. In a double blind, randomised trial
indobufene was found effective resulting in 67% reduction of S and systematic
embolism in patients with various cardiac diseases in AF or sinus rhythm.
Consequently, a reasonable policy would be to treat patients with NVAF (also
old ones) with anticoagulants unless contraindications or lone atrial fibrillations
are present; in the latter cases ASA and indobufene should be considered. In the
secondary prevention of ischemic S, W has given good results, whereas ASA and
indobufene seem to be promising
Keywords:
anticoagulants/aspirin/complications/diseases/elderly/fibrillation/FRAMINGHA
M/incidence/INDOBUFENE/NONVALVULAR ATRIAL
FIBRILLATION/ORAL
ANTICOAGULANTS/prevention/prophylaxis/risk/secondary
prevention/STROKE/THROMBOEMBOLIC
COMPLICATIONS/trials/WARFARIN
Ambrosioni, E. and Bacchelli, S. (1995), Present Perspectives of Therapy in the
Prevention of Stroke - Beta-Blockers. Archives of Gerontology and Geriatrics,
20 (1), 55-61.
Abstract: Stroke represents the third most common cause of death in the developed
world and is also a very significant cause of morbidity. Epidemiological data
clearly show that hypertension is associated with an increased risk of stroke. In
randomized controlled clinical trials, treatment for hypertension has been shown
to reduce stroke events (both fatal and non-fatal) by 40% in all hypertensive
populations. In fact, a reduction in the incidence of stroke has been demonstrated
in middle-aged as well as in older hypertensive patients, and in all grades of
hypertension. Beta blockers are one of the first-line therapeutic alternatives in the
field of hypertension. Their role appears strongly supported also by the results of
some large intervention trials in hypertensive patients. Beta blockers may have,
however, different effects on the prevention of coronary events and sudden death
from those of other antihypertensive drugs (i.e. diuretics), even if the benefit in
terms of stroke prevention seems quite similar. Therefore the choice of the best
mean of optimizing blood pressure control requires additional clinical
considerations, such as the age of the patient, the presence of other risk factors
and the presence of myocardial ischemia
Keywords: BETA BLOCKERS/blood pressure/BLOOD-PRESSURE/clinical
trials/CORONARY
HEART-DISEASE/HYPERTENSION/incidence/ischemia/MORBIDITY/MOR
TALITY/prevention/RECENT TRIALS/risk/risk factors/STROKE/stroke
prevention/treatment/trials
Cao, P.G., Verzini, F., Derango, P., Zannetti, S., Bufalari, A. and Giordano, G. (1995),
Carotid Stenosis and Coronary-Artery Disease in the Elderly - the Vascular
Surgeons Point-Of-View. Archives of Gerontology and Geriatrics, 20 (1), 93-98.
Abstract: Surgical prevention of stroke is justified only when the perioperative morbidity
and mortality rates are very low. Therefore, an accurate cardiac evaluation is
essential for patients with a vascular disease like carotid stenosis, to reduce the
surgical risk and improve prognosis. The aim of our retrospective study was to
characterize subgroups of patients with high cardiac risk. From 1986 to 1993 at
the Vascular Surgery Unit of the Department of Surgery and Surgical
Emergencies at the University of Perugia, 857 carotid endarterectomies were
performed on 739 patients. The stroke/death rate, at 30 days after surgery, was
2.16% per patient and 1.86% per procedure; cardiac mortality was 0. However,
during follow-up 58 patients died: 55% of these deaths could be attributed to
cardiac disease. No statistically significant differences emerged in cardiac
mortality of patients with a positive history of cerebral vascular accident with
respect to asymptomatics, neither among patients with carotid stenosis associated
with complete contralateral occlusion nor among those without. Our group of
patients had a 76% survival rate at 7 years after surgery, which is different from
that reported by other studies. This may be due to some bias associated with the
preoperative selection of the patients and the retrospective nature of our study.
Nevertheless, in patients with carotid stenosis, the most important cause of death
is cardiac ischemia, therefore a rigorous preoperative selection is mandatory
particularly in elderly asymptomatic patients
Keywords: carotid/CAROTID PLAQUE/CAROTID STENOSIS/CORONARY
ARTERY
DISEASE/elderly/evaluation/history/ischemia/morbidity/mortality/prevention/ris
k/stroke/surgery/vascular/vascular disease
Molaschi, M., Ponzetto, M., Ferrario, E., Scarafiotti, C. and Fabris, F. (1995), Health
and Functional Status in Elderly Patients Living in Nursing-Homes. Archives of
Gerontology and Geriatrics, 21 (3), 267-276.
Abstract: Socio-economic background, functional status, multiple pathology and
medical conditions requiring care have been evaluated in 506 elderly subjects
living in nursing homes in Turin (Italy). In the sample 78.8% are women, mean
age 84.2 years, only 21.2% are men, mean age 76.3 years. Particularly in the
oldest age classes women are more represented than men. Most subjects (94.3%)
require help in at least one Activity of Daily Living (ADL). Part of the sample
(21.2%) comes from home, 13.2% from acute wards, 9.1% from long term care
wards, 6.3% from mental hospitals, 26.3% from residential homes. Education
level is rather low. Before retirement, many men were workmen (38.3%), while
many women were housewives (46.6%). Multiple pathology is very common:
23.7% of patients suffer from 4 pathologies, more than 5 diseases are present in
18.8%, while only 4.7% of subjects have less than two pathologies. Half of the
sample (52.6%) is affected by dementia, 37.6% by cardiovascular diseases,
29.1% by chronic obstructive lung disease and 25.5% by stroke. Bone fractures
are present in 22.1% of the subjects. Severe impairments in strength and/or
motility in at least two limbs affect 43.7% of patients, double incontinence
49.2%, severe disturbances in speech and communication 35.4%. The prevalence
of care needs is higher in women compared with men. More females than males
need aid in walking, help in eating, diapers, pressure sores prevention and
bedposts
Keywords: cardiovascular diseases/CARE
NEEDS/COMPRESSION/dementia/DISABILITY/diseases/ELDERLY/FUNCTI
ONAL STATUS/HEALTH STATUS/INSTITUTIONAL CARE/LONG-TERM
CARE/MORBIDITY/MORTALITY/NATURAL DEATH/NEED/NURSING
HOME/PEOPLE/prevention/stroke/women
Elia, G., Carra, R., Santangelo, N., Rosso, D., Culmone, N. and Siciliano, R. (1996),
Prevalence of risk factors in acute ischemic cerebro-vascular disease (CVD) in
elderly patients from eastern Sicily. Archives of Gerontology and Geriatrics,
187-190.
Abstract: Hundred and forty elderly patients (76 males and 64 females, over 65 years of
age) were consecutively admitted to the Institute between November 1989 and
April 1993, in order to (i) verify if the risk factors, reported in other Italian areas
and regions of the world, are prevalent also in our region, and (ii) outline a
secondary prevention strategy against the statistically most important risk factors.
There were 111 cases of ischemic stroke (58 males and 53 females) and 29 cases
of reversible ischemic attack (RIA) (18 males and 11 females). The percental
occurrence of the following risk factors were determined: total cholesterol > 240
mg/dl, HDL cholesterol < 35 mg/dl, triglycerides > 180 mg/dl, fibrinogen > 450
mg/dl, hematocrit > 45 %, hypertension, diabetes mellitus, cigarette smoking,
familial ischemic events, previous ischemic CVD, ischemic cardiac disease,
embolic cardiopathy. In males with ischemic stroke the most frequent risk factors
were: hypertension (43 %), fibrinogen > 450 mg/dl (37.9 %), diabetes mellitus.
cigarette smoking and previous ischemic CVD (25.8 %). in females with
ischemic stroke a clear prevalence of hypertension (69.8 %), ischemic
cardiopathy and previous ischemic CVD (47 %) and diabetes mellitus (41.5 %)
were observed. In males with RIA hypertension (50 %) and cigarette smoking
(38 %). Females with RIA presented a high prevalence of reduced HDL
cholesterol, lower than 35 mg/dl (77.7 %), hypertension (63.6 %) and ischemic
cardiopathy (54.5 %). The results indicate that there are no highly significant
differences between the data reported by other authors on the most important
acute ischemic CVD risk factors in Italy and elsewhere. Arterial hypertension
and diabetes mellitus are the most important risk factors of cerebral ischemic
events in both sexes. The diffusion of cigarette smoking among women in the
last thirty years must be taken into consideration. Although it does not represent
a risk factor for elderly women today, it may do in the future. Therefore,
antismoking campaigns must be more decisive and targeted at both sexes
Keywords: cerebrovascular disease/cholesterol/diabetes
mellitus/elderly/fibrinogen/HIGH-DENSITY-LIPOPROTEIN/hypertension/INT
ERNAL/ischemic stroke/prevention/reversible ischemic attack/risk
factors/secondary prevention/smoking/STROKE/stroke/triglycerides
Cozzolino, D., Salvatore, T. and Torella, R. (1996), Diabetic non ketotic hyperosmolar
state: A special care in aged patients. Archives of Gerontology and Geriatrics,
245-253.
Abstract: The hyperosmolar hyperglycemic nonketotic state (HHNS) is an acute
metabolic complication occurring characteristically in elderly type-2 diabetic
patients. It may account for 10 up to 47 % of cases of severe hyperglycemia with
or without ketoacidosis. Many factors associated with advanced age may explain
the predilection of both elderly subjects in general and older diabetics in
particular to develop hyperosmolar coma, including reduced glomerular filtration
rate and elevated renal threshold for glucose [which fall to correct hyperglycemia
by osmotic diuresis), lack of thirst appropriate to the state of hydratation and
some iatrogenic factors. In HHNS the age of the patients is the best known
prognostic indicator. The increased mortality rate in the elderly diabetics depends
on the severity of precipitating acute diseases (gastrointestinal hemorrhage.
cardiovascular accident, pneumonia, pancreatitis, etc.], but the frequent
compromises of the hemodynamic state and renal function of aged subjects
substantially contributes. However, the role of erroneous management is not
negligible and difficulties may be encountered in conciliating correction of
metabolic disorder with treatment of precipitating illness. Insulin. water and
electrolytes are the most important therapeutical tools for the treatment of
hyperglycemic emergencies. In HHNS, the aggressive fluid replacement with
isotonic or hypotonic NaCl solutions have first priority. Such a type of strategy is
difficult to perform in patients suffering from cerebral stroke (which needs of
anti-edema therapy) or congestive heart failure (necessitating to avoid fluid
excess). According to the literary data, in our experience these two precipitating
factors are frequent causes of death. We outline the validity of prefixed protocols
of management; on the other hand, we think that the pathophysiological
understanding of HHNS in the single patient is essential to decide the proper
corrections and to permit a successful outcome. The primary way aiming at
diminishing mortality by HHNS is its prevention; it is fundamental to warrant an
appropriate fluid intake and to utilize with caution some drugs (thiazides.
steroids, phenytoin, etc.) in aged diabetics, especially when nephropathic or
unable, or living in nursing homes
Keywords: ACUTE STROKE/aged/CEREBRAL EDEMA/COMA/diabetes
mellitus/diseases/elderly/GLUCOSE/heart/HYPERGLYCEMIA/hyperosmolar
hyperglycemic nonketotic
state/INSULIN/KETOACIDOSIS/mortality/PRESSURE/prevention/RABBITS/s
everity/stroke/THERAPY/treatment
Alletto, M., Burgio, A., Fulco, G., Paradiso, R., Piangiamore, M. and Vancheri, F.
(1996), A marked increase of ischemic stroke incidence between 1980 and 1994
in S Caterina, Sicily. Archives of Gerontology and Geriatrics, 167-172.
Abstract: Stroke death rates have been declining for some decades in most of the
industrialized countries. It is not clear, whether this has been associated with a
decrease in stroke incidence. We studied temporal trends in stroke incidence in a
rural community in Sicily, during two periods 1980-84 and 1990-94. There was a
total of 231 patients (120 of them women). The diagnosis of stroke was based on
the clinical evaluation and CT scan since 1982 and onward. There were 109
ischemic strokes (51 women) mean age 72.7 years, in 1980-84 period; 122
ischemic strokes (69 women) mean age 75.1, in 1990-94 period. Cardiovascular
risk factor rates did not change in the two periods considered. The relative annual
stroke incidence rate increased 37.0 %; (2.7 in 1980-84 to 3.7/1000 inhabitants in
1990-94, p = 0.016). In the population older than 65 years, the same parameter
increased by 21.1 % between the two periods; (16.1 in 1980-84 to 19.5/1000
inhabitants in 1990-94, not significant). This increase was due mainly to a 45.3
% significant relative increase in women, from 7.5 to 11.0/1000 inhabitants (p =
0.039). These findings suggest a need of the reconsideration of effective
strategics for the prevention of stroke
Keywords: absolute stroke incidence/CT/DECLINING
INCIDENCE/INTERNAL/ischemic
stroke/MEN/MORTALITY/prevention/relative stroke incidence/stroke/TRENDS
Acanfora, D., Trojano, L., Iannuzzi, G.L., Furgi, G., Picone, C., Rengo, C., Abete, P.
and Rengo, F. (1996), The brain in congestive heart failure. Archives of
Gerontology and Geriatrics, 23 (3), 247-256.
Abstract: In the present paper we discuss two issues about relationships between
congestive heart failure and the brain. First, major acute cerebrovascular events
are very frequent among elderly people, but stroke does not appear io be
frequently associated with congestive heart failure. Second, some cardiovascular
conditions may determine progressive damage of cerebral tissue, with
consequent impairment of cognitive functions. The association of cognitive
impairment and cardiovascular diseases may dramatically increase morbility and
mortality risks in the elderly. Recent studies seem to show that hypotension and
congestive heart failure are risk factors for dementia in elderly people. In view of
this data, an Italian multicentric study on congestive heart failure in hospitalized
elderly patients (CHF Italian Study I) included a brief screening of cognitive
abilities (MMSE)I The presence of congestive heart failure induced a significant
decrease of MMSE scores: mean MMSE score after statistical adjustment for the
other variables was about one point lower in patients with congestive heart
failure respect to elderly patients affected by heart disease but without congestive
heart failure. A novel multicentric study (CHF Italian Study II) has been
performed to identify cognitive functions more specifically impaired during
congestive heart failure in the elderly. Preliminary data relative to 385 patients,
confined that congestive heart failure may induce a generalized impairment of
cognitive functions. These data have relevant implications because they
demonstrate that a multidisciplinary approach is necessary in these patients, both
for prevention and rehabilitation therapy. Copyright (C) 1996 Elsevier Science
Ireland Ltd
Keywords: acute/ALZHEIMERS-DISEASE/brain/cardiovascular
diseases/CARE/cerebral/CEREBRAL
BLOOD-FLOW/cerebrovascular/cognitive function/cognitive
impairment/COGNITIVE PERFORMANCE/congestive heart
failure/dementia/diseases/elderly/heart/heart failure/HYPERTENSIVE
PATIENTS/LEUKO-ARAIOSIS/MINI-MENTAL-STATE/MMSE/mortality/N
ORMS/POPULATION/prevention/rehabilitation/risk/risk factors/SENILE
DEMENTIA/stroke/SURVIVAL/therapy
Vasishta, S., Toor, F., Johansen, A. and Hasan, M. (2001), Stroke prevention in atrial
fibrillation: physicians' attitudes to anticoagulation in older people. Archives of
Gerontology and Geriatrics, 33 (3), 219-226.
Abstract: The increased prevalence of atrial fibrillation (AF) in older people contributes
to an increased risk of stroke. Although clear guidelines exist, there is
considerable variation in physicians' approaches to the selection of patients
appropriate for warfarin treatment as stroke prevention. We compared attitudes
to the anticoagulation of elderly patients with AF, in a postal study of
geriatricians and specialist physicians (general physicians with specialist
interests in Cardiology, Gastroenterology, Diabetes and Endocrinology,
Nephrology and Neurology). A structured questionnaire was mailed to all 108
consultant physicians and geriatricians in South East Wales. This explored their
attitude to their patients' age and comorbidity when considering the benefits and
risks of warfarin prophylaxis for AF. About 25/30 geriatricians (83%) and 43/78
specialist physicians (55%) responded; an overall response rate of 63%. About
94% of the respondents agreed that patients aged over 75 with atrial fibrillation
were at a greater risk of stroke than younger patients. About 68% considered
warfarin related bleeds more likely in this age group, despite which most thought
that the benefits of warfarin outweighed the risks. In people aged above 75, only
13/25 (52%) geriatricians and 17/43 (40%) specialist physicians viewed lone AF
(AF with no underlying risk factor) as an indication for anticoagulation. When
considering the use of warfarin, geriatricians' appeared more likely to be
influenced by coexisting problems such as disability, falls, cerebrovascular
disease and limited life expectancy. Only a history of falls (96% geriatricians vs.
86% specialist physicians) and cerebrovascular disease (79% geriatricians vs.
51% specialist physicians) had a significant influence on prescribing practice (P
< 0.05, chi (2) test). There appears to be widespread uncertainty about the
indications for warfarin as stroke prophylaxis, and ageist attitudes or a lack of
conviction of benefit appear to be disadvantaging older people. Patients aged
below 65 with lone AF who are at the lowest risk of embolic events are often
considered for treatment, whilst the use of warfarin in 75-year-olds with lone AF
who are at a moderately high risk of embolic events remains disappointing. (C)
2001 Elsevier Science Ireland Ltd. All rights reserved
Keywords: AF/age/aged/anticoagulation/ARCH/atrial
fibrillation/cerebrovascular/cerebrovascular
disease/comorbidity/disability/disease/elderly/elderly
patients/fibrillation/FRAMINGHAM/guidelines/high risk/history/life
expectancy/older people/prevalence/prevention/prophylaxis/RISK/risk
factor/stroke/stroke prevention/treatment/use/WARFARIN
Hirsh, J. (1981), Selection and Results of Anti-Platelet Therapy in the Prevention of
Stroke and Myocardial-Infarction. Archives of Internal Medicine, 141 311-315
Lancaster, T.R., Singer, D.E., Sheehan, M.A., Oertel, L.B., Maraventano, S.W., Hughes,
R.A. and Kistler, J.P. (1991), The Impact of Long-Term Warfarin Therapy on
Quality-Of-Life - Evidence from A Randomized Trial. Archives of Internal
Medicine, 151 (10), 1944-1949.
Abstract: To determine the effect of long-term warfarin sodium therapy on quality of life,
we surveyed 333 patients participating in a randomized, controlled trial of
warfarin for the prevention of stroke in nonrheumatic atrial fibrillation. No
significant differences between warfarin-treated and control patients were found
on well-validated measures of functional status, well- being, and health
perceptions. For example, the summary score for health perceptions was 68.8 in
the warfarin-treated vs 66.6 in the control group (scale of 0 to 100; 95%
confidence intervals for the difference, -1.6 to 6.0). In contrast, patients taking
warfarin who had a bleeding episode had a significant decrease in health
perceptions (-11.9; 95% confidence interval, -4.1 to -91.6). Warfarin therapy is
not usually associated with a significant decrease in perceived health, unless a
bleeding episode has occurred. Negative effects of warfarin treatment on health
perceptions may be balanced by confidence in its protective effects
Keywords: ATRIAL-FIBRILLATION/FUNCTIONAL
STATUS/HYPERTENSION/INTERNAL
Kutner, M., Nixon, G. and Silverstone, F. (1991), Physicians Attitudes Toward Oral
Anticoagulants and Antiplatelet Agents for Stroke Prevention in Elderly Patients
with Atrial-Fibrillation. Archives of Internal Medicine, 151 (10), 1950-1953.
Abstract: The use of oral anticoagulants and antiplatelet agents for the prevention of
strokes in elderly patients with atrial fibrillation is controversial. Recent studies
suggest that warfarin and aspirin can be safe and effective in selected patients.
To determine attitudes toward this subject, we sent a questionnaire to 480
attending physicians at two major university-affiliated medical centers. Among
the 251 responses (52.3%), 46 respondents (18.3%) used warfarin in atrial
fibrillation of any cause, 175 (69.7%) used it in atrial fibrillation with transient
ischemic attacks, 161 (64.1%) used it in patients with cerebrovascular accidents,
and 196 (78.0%) used it in patients with mitral valve disease. One hundred
twenty-nine (51.4%) believed that the risk of hemorrhage associated with
warfarin outweighs the benefit, 61 (24.3%) were not convinced that warfarin
prevents strokes in atrial fibrillation, and 42 (16.7%) believed it was difficult to
monitor prothrombin time in elderly because of poor compliance. Aspirin was
used by 91 physicians (36.2%) in atrial fibrillation of any cause, 161 (64.1%) in
patients with transient ischemic attacks, 140 (55.7%) in patients with
cerebrovascular accidents, and 48 (19.1%) when patients were in sinus rhythm.
We concluded that physicians are still hesitant to use oral anticoagulants and
antiplatelet agents for the prevention of strokes in their elderly patients with
atrial fibrillation. These agents are used most frequently after an ischemic
episode (transient ischemic attack or cerebrovascular accident) has occurred or in
patients with mitral valve disease
Keywords: COPENHAGEN/EMBOLIC
COMPLICATIONS/FRAMINGHAM/HEMORRHAGE/LONG/POPULATION/
RISK- FACTORS/THERAPY/THROMBOEMBOLIC
COMPLICATIONS/TRIAL/WARFARIN
Voyce, S.J., Aurigemma, G.P., Dahlberg, S., Orsinelli, D., Pape, L.A., Sweeney, A.,
Cardullo, P. and Recht, L. (1992), A Comparison of 2-Dimensional
Echocardiography Vs Carotid Duplex Scanning in Older Patients with
Cerebral-Ischemia. Archives of Internal Medicine, 152 (10), 2089-2093.
Abstract: Background.-To determine the relative value of two-dimensional (2D)
echocardiography vs carotid duplex scanning and to devise an optimal,
cost-effective diagnostic approach for older patients with cerebral ischemia, 68
consecutive patients in sinus rhythm who suffered focal cerebral ischemia were
studied. All patients underwent 2D echocardiography and carotid duplex
scanning in addition to routine clinical evaluation. Methods.- Twenty-five of 68
patients had Q-wave myocardial infarction by electrocardiography; nine (36%)
of these 25 had left ventricular mural thrombi demonstrated by 2D
echocardiography. In contrast, none of 43 patients without Q-wave myocardial
infarction had clinically unsuspected findings diagnosed by 2D
echocardiography. Duplex scanning, however, identified significant, abnormal
findings in the carotid artery ipsilateral to the involved cerebral hemisphere in 23
patients (34%). Conclusions.-Thus, in older patients in sinus rhythm who suffer a
cerebral ischemic event, carotid duplex scanning has a higher diagnostic yield
than 2D echocardiography and appears to be a more cost-effective initial test.
Our data suggest that in patients with carotid distribution cerebral ischemic
events and no obvious cardiac source for emboli by history and physical
examination, 2D echocardiography should be limited to those with evidence of
Q-wave myocardial infarction by electrocardiography; such management should
optimize diagnostic yield and cost effectiveness
Keywords: ACUTE
MYOCARDIAL-INFARCTION/ATTACKS/CEREBROVASCULAR-DISEAS
E/EMBOLISM/EMBOLIZATION/LEFT-VENTRICULAR
THROMBUS/PREVENTION/STROKE/TWO-DIMENSIONAL
ECHOCARDIOGRAPHY
Bussey, H.I., Force, R.W., Bianco, T.M. and Leonard, A.D. (1992), Reliance on
Prothrombin Time Ratios Causes Significant Errors in Anticoagulation Therapy.
Archives of Internal Medicine, 152 (2), 278-282.
Abstract: Background. - The intensity of warfarin anticoagulation in the United States
may be inappropriate if the international normalized ratio (INR) is not used, or if
the international sensitivity index (ISI) of the thromboplastin is outside the range
of 2.2 to 2.6. Methods. - Fifty-three hospital laboratories provided data on the
sensitivity of their thromboplastin and whether they reported INR values.
Additional data on thromboplastin sensitivity were obtained from 140
laboratories involved in the Stroke Prevention in Atrial Fibrillation study. The
three major manufacturers of thromboplastin confirmed the range of
thromboplastin sensitivity reported by the laboratories. Results. - Of 53
laboratories surveyed, 16 (30%) could not provide ISI data and only 11 (21%)
reported INR results. Unlabeled thromboplastin was being used by 20% to 24%
of laboratories, and only 8% to 20% were using thromboplastins with an ISI of
2.2 to 2.6. At the time the three manufacturers were contacted, they reported
marketing thromboplastins with ISI values from 1.2 to 2.8, but none of the
thromboplastins at that time had ISI values between 2.2 and 2.6. Conclusion. -
Warfarin therapy in the United States is managed inappropriately because most
laboratories do not report INRs and the variability in thromboplastin sensitivity
produces misleading prothrombin time ratio results. Additionally, recent research
may require reexamination if INR or ISI data were not provided
Keywords: INTENSITIES
Stamler, J., Stamler, R. and Neaton, J.D. (1993), Blood-Pressure, Systolic and Diastolic,
and Cardiovascular Risks - United-States Population-Data. Archives of Internal
Medicine, 153 (5), 598-615.
Abstract: The National High Blood Pressure Education Program (NHBPEP) was
launched 20 years ago based on data from population studies and clinical trials
that showed high blood pressure (HBP) was a major unsolved-but soluble-mass
public health problem. The present review summarizes recent data from US
prospective population studies on blood pressure-systolic (SBP), diastolic
(DBP)-and cardiovascular risk. The outcome variables include blood
pressure-related risks, primarily incidence and mortality from coronary heart
disease, stroke, other and all cardiovascular diseases (CVD); also cardiac
abnormalites (roentgenographic, electrocardiographic, echocardiographic); also,
all-cause mortality and life expectancy. Data accrued during the past 20 years
confirm that SBP and DBP have continuous, graded, strong, independent,
etiologically significant relationships to the outcome variables. These
relationships are documented for young, middle-aged, and older men and for
middle-aged and older women of varying socioeconomic backgrounds and
ethnicity. Among persons aged 35 years or more, most have SBP/DBP above
optimal (< 120/<80 mm Hg); hence, they are at increased CVD risk, ie, the blood
pressure problem involves most of the population, not only the substantial
minority with clinical HBP. For middle-aged and older persons, SBP relates even
more strongly to risk than DBP; at every DBP level, higher SBP results in greater
CVD risk and curtailment of life expectancy. A great potential exists for
improved health and increased longevity through control of the blood pressure
problem. its realization requires a strategy combining populationwide and
high-risk approaches, the former to prevent rise of blood pressure with age and to
achieve primary prevention of HBP by nutritional-hygienic means; the latter to
enhance detection, treatment, and control of HBP. The newly expanded goals of
the NHBPEP, aimed at implementing this broader strategy for the solution of the
blood pressure problem, merit active support from physicians and all health
professionals
Keywords: CORONARY HEART-DISEASE/FACTOR INTERVENTION
TRIAL/FOLLOW-UP EXPERIENCE/HYPERTENSIVE
PARTICIPANTS/JAPANESE MEN/LEFT-VENTRICULAR
MASS/MORTALITY/PROGRAM/SERUM-CHOLESTEROL/WESTERN
COLLABORATIVE GROUP
Shorr, R.I., Ray, W.A., Daugherty, J.R. and Griffin, M.R. (1993), Concurrent Use of
Nonsteroidal Antiinflammatory Drugs and Oral Anticoagulants Places Elderly
Persons at High-Risk for Hemorrhagic Peptic-Ulcer Disease. Archives of Internal
Medicine, 153 (14), 1665-1670.
Abstract: Background: Although joint use of nonsteroidal anti- inflammatory drugs
(NSAIDs) and oral anticoagulants may increase the risk of gastrointestinal tract
hemorrhage in elderly persons, no epidemiologic studies have been performed to
quantify this risk. Methods: We performed a retrospective cohort study of
Tennessee Medicaid enrollees aged 65 years or older from 1984 through 1986. A
total of 103 954 individuals contributed 209 066 person-years of follow-up,
including 2203 person-years of current oral anticoagulant use, to the study.
Results: Of the cohort members, 1371 had confirmed hospitalizations for peptic
ulcer disease. Of these, 661 (48%) presented with frank hematemesis or melena
and thus met the definition for hemorrhagic peptic ulcer disease. Among current
users of oral anticoagulants, the adjusted incidence of hospitalization for peptic
ulcer disease was 14.3 per 1000 person-years, and the adjusted incidence of
hospitalization for hemorrhagic peptic ulcer disease was 10.2 per 1000 person-
years. Compared with nonusers, current anticoagulant users were at increased
risk for hospitalization for ulcer disease (relative risk, 2.2; 95% confidence
interval, 1.6 to 3.1), primarily due to the increased risk of hospitalization for
hemorrhagic ulcers (relative risk, 3.3; 95% confidence interval, 2.3 to 4.9).
Compared with nonusers of either drug, the relative risk of hemorrhagic peptic
ulcer disease among current users of both anticoagulants and NSAIDs was 12.7
(95% confidence interval, 6.3 to 25.7). However, the prevalence of NSAID use
among anticoagulant users was 13.5%, the same as in those who were not using
anticoagulants. Conclusions: The nearly 13-fold increase in the risk of
developing hemorrhagic peptic ulcer disease in concurrent users of oral
anticoagulants and NSAIDs suggests that NSAIDs should be prescribed with
extreme caution in patients undergoing anticoagulation therapy
Keywords: ANTIINFLAMMATORY
DRUGS/ATRIAL-FIBRILLATION/COMPLICATIONS/OUTPATIENTS/PRE
VENTION/PROTHROMBIN TIME/RANDOMIZED
TRIAL/STROKE/THERAPY/WARFARIN INTERACTION
Albers, G.W. (1994), Atrial-Fibrillation and Stroke - 3 New Studies, 3 Remaining
Questions. Archives of Internal Medicine, 154 (13), 1443-1448.
Abstract: Three new studies help clarify important clinical issues regarding
antithrombotic therapy for stroke prevention in patients with atrial fibrillation.
The European Atrial Fibrillation Trial compared the efficacy of oral
anticoagulation, aspirin, and placebo for stroke prevention in patients with atrial
fibrillation with a recent stroke or transient ischemic attack. The results of the
Stroke Prevention in Atrial Fibrillation II trial, which compared the efficacy of
warfarin and aspirin, provide new information regarding the risk of intracranial
hemorrhage in elderly patients with atrial fibrillation. Finally, an analysis of
pooled data from the first five randomized trials identified clinical features that
are predictive of stroke risk in individual patients with atrial fibrillation. These
studies address unanswered questions regarding atrial fibrillation and stroke and
have significant implications for patient management
Keywords: ANTICOAGULANT TREATMENT/anticoagulation/aspirin/atrial
fibrillation/elderly/fibrillation/hemorrhage/INTRACEREBRAL
HEMORRHAGE/oral anticoagulation/PREVENTION/randomized
trials/RISK/STROKE/stroke prevention/THERAPY/transient/transient ischemic
attack/trials/WARFARIN
Kanter, M.C., Tegeler, C.H., Pearce, L.A., Weinberger, J., Feinberg, W.M., Anderson,
D.C., Gomez, C.R., Rothrock, J.F., Helgason, C.M. and Hart, R.G. (1994),
Carotid Stenosis in Patients with Atrial-Fibrillation - Prevalence, Risk-Factors,
and Relationship to Stroke in the Stroke Prevention in Atrial-Fibrillation Study.
Archives of Internal Medicine, 154 (12), 1372-1377.
Abstract: Background: Several mechanisms contribute to the increased stroke rate of
patients with atrial fibrillation (AF). We assessed the frequency of carotid artery
stenosis in patients with AF and its relationship to stroke during aspirin or
warfarin therapy. Methods: Carotid ultrasonography was done in 676 patients
with AF enrolled in the Stroke Prevention in Atrial Fibrillation Study to detect
cervical carotid stenosis of 50% or more of the luminal diameter. The presence
of carotid stenosis was correlated with patient features and subsequent stroke
during a mean of 2.6 years of follow-up. Results: In patients with AF who were
older than 70 years, the frequency of carotid stenosis was 12% in men and 11%
in women. Carotid stenosis was independently associated with systolic
hypertension (relative risk, 2.4; P=.002), diabetes (relative risk, 1.8; P=.04), and
tobacco use (relative risk, 1.8; P=.02). Carotid stenosis did not add significantly
to prediction of stroke when analyzed with other clinical risk factors for stroke in
patients with AF (relative risk, 1.3; 95% confidence interval, 0.5 to 3.6; P=.55).
Conclusions: Carotid artery stenosis of 50% or more occurs in about 12% of
elderly patients with AF, reflecting the substantial prevalence of hypertension
and diabetes in these patients. Carotid stenosis was not usefully predictive of
stroke in patients with AF who were given aspirin or warfarin. Routine
ultrasonography to detect carotid stenosis does not appear warranted in patients
with AF without previous symptoms of brain ischemia
Keywords: ADULTS/AF/ARTERY DISEASE/aspirin/ATHEROSCLEROSIS/atrial
fibrillation/CARDIOVASCULAR HEALTH/carotid/carotid
stenosis/DETERMINANTS/elderly/ENDARTERECTOMY/fibrillation/hyperten
sion/ischemia/ISCHEMIC STROKE/ISOLATED SYSTOLIC
HYPERTENSION/OLDER/POPULATION/relative risk/risk/risk
factors/stroke/tobacco/warfarin/women
Gottlieb, L.K. and Salemschatz, S. (1994), Anticoagulation in Atrial-Fibrillation - Does
Efficacy in Clinical-Trials Translate Into Effectiveness in Practice. Archives of
Internal Medicine, 154 (17), 1945-1953.
Abstract: Background: Several recent randomized clinical trials of anticoagulation in
atrial fibrillation have demonstrated significant reduction in stroke rates with a
small incidence of bleeding complications. The objective of this study was to
determine whether the recommendations resulting from these trials have been
implemented into routine practice, and if the anticoagulation control, therapeutic
efficacy, and low complication rates achieved in the trials have been matched in
community practice. Methods: We analyzed the anticoagulation practices and
outcomes obtained for patients in atrial fibrillation at a large staff model health
maintenance organization (HMO). We reviewed the medical records of all
patients in atrial fibrillation as of April 1990. We compared demographic
characteristics and clinical risk factors between HMO patients and those in the
clinical trials. We also compared anticoagulation monitoring, adequacy of
anticoagulation control, and clinical outcomes at the HMO with those achieved
in the clinical trials. Results: Of 238 HMO patients in atrial fibrillation, 198 were
without contraindications and therefore eligible for anticoagulation. Of these,
168 were offered anticoagulation (84.8%) and 156 were receiving
anticoagulation therapy (78.8% of those eligible). The HMO patients had a
greater prevalence of comorbidities than those in the clinical trials. The routine
monitoring interval at the HMO was estimated at between 36.3 and 40.9 days
(compared with 21 to 28 days reported in the clinical trials). The prothrombin
time ratios at the HMO were in the target range on 50% of days compared with
68% of days in the clinical trials. The annual stroke and major bleeding rates in
the HMO patients (1.3% and 0.6%, respectively) were not significantly different
from the rates in the clinical trials (1.3% and 1.1%, respectively). The annual
minor bleeding rate of 13.6% at the HMO was greater than the 7.8% to 8.4%
rates in the two trials with better anticoagulation control (Boston Area
Anticoagulation Trial for Atrial Fibrillation and Stroke Prevention in Atrial
Fibrillation Study) but was not significantly different than the rates of 12.7% and
13.7% Of the two trials with poorer anticoagulation control (Canadian Atrial
Fibrillation Anticoagulation Study and Stroke Prevention in Nonrheumatic Atrial
Fibrillation Study). Conclusions: Anticoagulation practices in this community
setting appear to be good in that a large majority of patients were receiving
anticoagulation therapy, and there were few major adverse outcomes. However,
this study illustrates two common problems in attempting to apply the results of
randomized clinical trials to routine practice: (1) differences between community
patient populations and those on which the conclusions of clinical trials are based,
and (2) less successful application of therapeutic interventions in settings other
than that of a controlled clinical trial. The greater prevalence of comorbidities in
the HMO patient population appears to convey a greater overall risk of
thromboembolism and bleeding complications than in the clinical trials. In
addition, the suboptimal anticoagulation control achieved at the HMO may
increase the risks and decrease the potential benefits compared with those
achieved in the clinical trials. Thus, the efficacy demonstrated in the clinical
trials of anticoagulation in atrial fibrillation may not be directly translated into
effectiveness in practice
Keywords: anticoagulation/ANTITHROMBOTIC THERAPY/atrial fibrillation/clinical
trials/COMMUNITY/complications/DIFFERENT
INTENSITIES/DRUG-THERAPY/fibrillation/health/HEMORRHAGIC
COMPLICATIONS/incidence/ORAL ANTICOAGULANTS/prothrombin
time/RANDOMIZED TRIALS/risk/risk
factors/RISK-FACTORS/stroke/STROKE
PREVENTION/THROMBOEMBOLIC
COMPLICATIONS/thromboembolism/trials/WARFARIN THERAPY
Laupacis, A., Boysen, G., Connolly, S., Ezekowitz, M., Hart, R., James, K., Kistler, P.,
Kronmal, R., Petersen, P., Singer, D., Godtfredsen, J., Andersen, E., Andersen,
B., Hughes, R., Gress, D., Sheehan, M., Oertel, L., Maraventano, S., Blewett, D.,
Rosner, B., Gent, M., Roberts, R., Cairns, J., Joyner, C., Bridgers, S., Colling, C.
and Krausesteinrauf, H. (1994), Risk-Factors for Stroke and Efficacy of
Antithrombotic Therapy in Atrial-Fibrillation - Analysis of Pooled Data from 5
Randomized Controlled Trials. Archives of Internal Medicine, 154 (13),
1449-1457.
Abstract: Background and Methods: Atrial fibrillation is associated with an increased
risk of ischemic stroke. Data on individual patients were pooled from five
recently completed randomized trials comparing warfarin (all studies) or aspirin
(the Atrial Fibrillation, Aspirin, Anticoagulation Study and the Stroke Prevention
in Atrial Fibrillation Study) with control in patients with atrial fibrillation. The
purpose of the analysis was to (1) identify patient features predictive of a high or
low risk of stroke, (2) assess the efficacy of antithrombotic therapy in major
patient subgroups (eg, women), and (3) obtain the most precise estimate of the
efficacy and risks of antithrombotic therapy in atrial fibrillation. For the
warfarin-control comparison there were 1889 patient-years receiving warfarin
and 1802 in the control group. For the aspirin-placebo comparison there were
1132 patient-years receiving aspirin and 1133 receiving placebo. The daily dose
of aspirin was 75 mg in the Atrial Fibrillation, Aspirin, Anticoagulation Study
and 325 mg in the Stroke Prevention in Atrial Fibrillation Study. To monitor
warfarin dosage, three studies used prothrombin time ratios and two used
international normalized ratios. The lowest target intensity was a prothrombin
time ratio of 1.2 to 1.5 and the highest target intensity was an international
normalized ratio of 2.8 to 4.2. The primary end points were ischemic stroke and
major hemorrhage, as assessed by each study. Results: At the time of
randomization the mean age was 69 years and the mean blood pressure was
142/82 mm Hg. Forty-six percent of the patients had a history of hypertension,
6% had a previous transient ischemic attack or stroke, and 14% had diabetes.
Risk factors that predicted stroke on multivariate analyses in control patients
were increasing age, history of hypertension, previous transient ischemic attack
or stroke, and diabetes. Patients younger than 65 years who had none of the other
predictive factors (15% of all patients) had an annual rate of stroke of 1.0%, 95%
confidence interval (CI) 0.3% to 3.0%. The annual rate of stroke was 4.5% for
the control group and 1.4% for the warfarin group (risk reduction, 68%; 95% CI,
50% to 79%). The efficacy of warfarin was consistent across all studies and
subgroups of patients. In women, warfarin decreased the risk of stroke by 84%
(95% CI, 55% to 95%) compared with 60% (95% CI, 35% to 76%) in men. The
efficacy of aspirin was not as consistent. The risk reduction with 75 mg of aspirin
in the Atrial Fibrillation, Aspirin, Anticoagulation Study was 18% (95% CI, 60%
to 58%), and with 325 mg of aspirin in the Stroke Prevention in Atrial
Fibrillation Study the risk reduction was 44% (95% CI, 7% to 66%). When both
studies were combined the risk reduction was 36% (95% CI, 4% to 57%). The
annual rate of major hemorrhage (intracranial bleeding or a bleed requiring
hospitalization or 2 units of blood) was 1.0% for the control group, 1.0% for the
aspirin group, and 1.3% for the warfarin group. Conclusion: In these five
randomized trials warfarin consistently decreased the risk of stroke in patients
with atrial fibrillation (a 68% reduction in risk) with virtually no increase in the
frequency of major bleeding. Patients with atrial fibrillation younger than 65
years without a history of hypertension, previous stroke or transient ischemic
attack, or diabetes were at very low risk of stroke even when not treated. The
efficacy of aspirin was Ibs consistent. Further studies are needed to clarify the
role of aspirin in atrial fibrillation
Keywords: aspirin/atrial fibrillation/blood
pressure/CAFA/CLINICAL-TRIALS/EMBOLIC
COMPLICATIONS/fibrillation/hemorrhage/history/hospitalization/hypertension
/ischemic stroke/PREVENTION/prothrombin time/randomized
trials/REGRESSION-MODELS/risk/stroke/transient/transient ischemic
attack/trials/WARFARIN/WOMEN
Hebert, P.R., Gaziano, J.M. and Hennekens, C.H. (1995), An Overview of Trials of
Cholesterol-Lowering and Risk of Stroke. Archives of Internal Medicine, 155 (1),
50-55.
Abstract: Background: While blood cholesterol level predicts coronary heart disease,
whether there is any association with the risk of stroke is unclear. Some, but not
all, observational studies suggest that cholesterol level predicts risk of stroke,
particularly ischemic stroke. This hypothesis is attractive because ischemic
events constitute the vast majority of all strokes and, like coronary heart disease,
involve atherogenic processes. Methods: To investigate whether lipid lowering
reduces the risk of stroke, we performed an overview of randomized trials that
included more than 36 000 individuals. Results: The mean reduction in
cholesterol level in the treated as compared with the control subjects ranged from
6% to 23%. Those assigned to treatment experienced no significant reduction in
all (fatal plus nonfatal) stroke (relative risk, 1.0; 95% confidence interval, 0.8 to
1.2) or fatal stroke (1.1; 0.8 to 1.6). Conclusions: The confidence interval for
fatal stroke is wide, and alternative hypotheses, including either a small
protective or harmful effect, cannot be excluded; however, the point estimates
are compatible with no benefit of cholesterol lowering on the risk of stroke.
Additional large- scale randomized trials assessing total mortality would more
definitively address any benefits on stroke, as well as any excess nonvascular
causes of mortality, for which risks of cholesterol lowering also remain uncertain
Keywords: CALIFORNIA/cholesterol/coronary heart disease/CORONARY
HEART-DISEASE/HAWAII/heart/ischemic stroke/JAPANESE
MEN/MORTALITY/MYOCARDIAL-INFARCTION/observational
studies/PREVENTION/RANDOMIZED TRIALS/REDUCTION/relative
risk/risk/SERUM- CHOLESTEROL/stroke/treatment/trials/WOMEN
Cook, N.R., Cohen, J., Hebert, P.R., Taylor, J.O. and Hennekens, C.H. (1995),
Implications of Small Reductions in Diastolic Blood-Pressure for Primary
Prevention. Archives of Internal Medicine, 155 (7), 701-709.
Abstract: Objectives: To estimate the impact of small reductions in the population
distribution of diastolic blood pressure (DBP), such as those potentially
achievable by population-wide lifestyle modification, on incidence of coronary
heart disease (CHD) and stroke. Design: Published data from the Framingham
Heart Study, a longitudinal cohort study, and from the National Health and
Nutrition Examination Survey II, a national population survey, were used to
examine the impact of a population-wide strategy aimed at reducing DBP by an
average of 2 mm Hg in a population including normotensive subjects.
Setting/Participants: White men and women aged 35 to 64 years in the United
States. Main Outcome Measures: Incidence of CHD and stroke, including
transient ischemic attacks (TIAs). Results: Data from overviews of observational
studies and randomized trials suggest that a 2-mm Hg reduction in DBP would
result in a 17% decrease in the prevalence of hypertension as well as a 6%
reduction in the risk of CHD and a 15% reduction in risk of stroke and TIAs.
From an application of these results to US white men and women aged 35 to 64
years, it is estimated that a successful population intervention alone could reduce
CHD incidence more than could medical treatment for all those with a DBP of
95 mm Hg or higher. It could prevent 84% of the number prevented by medical
treatment for all those with a DBP of 90 mm Hg or higher. For stroke (including
TIAs), a population-wide 2-mm Hg reduction could prevent 93% of events
prevented by medical treatment for those with a DBP of 95 mm Hg or higher and
69% of events for treatment for those with a DBP of 90 mm Hg or higher. A
combination strategy of both a population reduction in DBP and targeted medical
intervention is most effective and could double or triple the impact of medical
treatment alone. Adding a population-based intervention to existing levels of
hypertension treatment could prevent an estimated additional 67 000 CHD events
(6%) and 34 000 stroke and TIA events (13%) annually among all those aged 35
to 64 years in the United States. Conclusions: A small reduction of 2 mm Hg in
DBP in the mean of the population distribution, in addition to medical treatment,
could have a great public health impact on the number of CHD and stroke events
prevented. Whether such DBP reductions can be achieved in the population
through lifestyle interventions, in particular through sodium reduction, depends
on the results of ongoing primary prevention trials as well as the cooperation of
the food industry, government agencies, and health education professionals
Keywords: aged/blood pressure/CARDIOVASCULAR-DISEASE/cohort
study/coronary heart disease/CORONARY
HEART-DISEASE/education/health/health
education/heart/hypertension/incidence/lifestyle/medical
treatment/MILD/MODERATE HYPERTENSION/OBSERVATIONAL
DATA/observational studies/POPULATIONS/prevention/primary
prevention/randomized trials/RISK/SALT
REDUCTION/STROKE/TIA/transient/treatment/TRIALS/WOMEN
Warner, M.F. and Momah, K.I. (1996), Routine transesophageal echocardiography for
cerebral ischemia - Is it really necessary? Archives of Internal Medicine, 156 (15),
1719-1723.
Abstract: Background: Patients presenting with stroke or transient cerebral ischemic
episodes often undergo transesophageal echocardiography (TEE) as part of their
initial evaluation. Previous studies have demonstrated that TEE is superior to
transthoracic echocardiography for the detection of potential cardiac sources of
embolism. In our institution, this scenario now represents the most frequent
reason for requesting TEE. For the most part, these TEE examinations are
ordered by a neurologist, and transthoracic echocardiography is not performed
beforehand. Patients: Over a 2-year period, TEE was requested for 137 patients
at our institution for the evaluation of a cerebral ischemic event. The complete
hospital chart was available for review in 106 of these patients, and they form the
study group. Methods: All patients underwent TEE using either a biplane or
omniplane transducer, with Doppler color flow imaging and saline contrast
administration performed in every case. Studies were reviewed for the presence
of possible cardiac or aortic sources of cerebral emboli, and hospital charts were
reviewed to collect clinical information. Results: A potential cardiovascular
embolic source was detected in 35% of patients. Abnormalities were discovered
in 53% (16/30) of patients with atrial fibrillation vs 28% (21/76) of patients in
sinus rhythm (P<.001). Both patients who had left atrial thrombus and 12 of 13
with left atrial spontaneous contrast had atrial fibrillation (P<.001). Protruding
aortic atherosclerotic debris was the most frequent abnormality among patients in
sinus rhythm. Conclusions: It may not be cost- effective to perform TEE as a
routine diagnostic procedure in patients presenting with cerebral ischemic events.
Most patients with atrial fibrillation are candidates for empiric warfarin sodium
therapy, and patients in sinus rhythm usually have findings for which there is no
recommended therapy or for which only aspirin is indicated
Keywords: aspirin/atrial fibrillation/CARDIAC SOURCE/cerebral ischemia/CLINICAL
IMPLICATIONS/emboli/EMBOLIZATION/HEART/NONRHEUMATIC
ATRIAL- FIBRILLATION/PREVALENCE/PREVENTION/SPONTANEOUS
ECHO CONTRAST/STROKE/transesophageal
echocardiography/TWO-DIMENSIONAL
ECHOCARDIOGRAPHY/WARFARIN
Stafford, R.S. and Singer, D.E. (1996), National patterns of warfarin use in atrial
fibrillation. Archives of Internal Medicine, 156 (22), 2537-2541.
Abstract: Background: Despite consensus that patients with atrial fibrillation benefit
from warfarin sodium anticoagulation, little is known about national trends and
predictors of anticoagulant use. Methods: We analyzed 1062 visits by patients
with atrial fibrillation to randomly selected office-based physicians included in
the National Ambulatory Medical Care Surveys in 1980, 1981, 1985, and 1989
through 1993. Warfarin and aspirin use in these patients was extrapolated to
national patterns and logistic regression was used to determine independent
predictors. Results: Patients with atrial fibrillation made an estimated 1.3 (1980)
to 3.1 (1992) million annual visits to physicians. Warfarin use in atrial
fibrillation increased from 7% in 1980 and 1981 to 32% in 1992 and 1993
(P<.001 for trend). In 1992 and 1993, patients 80 years or older were
significantly less likely to be taking warfarin (19%) compared with younger
patients (36%), but showed similar rates of increase from 1980 and 1981 to 1992
and 1993. Tn 1992 and 1993, anticoagulation therapy was significantly more
likely to be reported in visits to cardiologists (32%) and general internists (40%)
compared with general and family practitioners (15%), but was similar in women
(34%) and men (30%). Residents of the South (16%) had significantly lower
rates of warfarin use than those in other regions of the United States (36%).
Aspirin use increased from 3% to 10% (P=.001 for trend) and showed little
overlap with warfarin use, Multiple logistic regression indicated that more recent
year, residence outside the South, patient aged 65 to 74 years, and visits to
cardiologists and internists increased the likelihood of warfarin use. Conclusions:
Anticoagulant use for atrial fibrillation has increased dramatically. The
substantial increase from 1989 and 1990 to 1992 and 1993 coincided with the
publication of several randomized clinical trials reporting the benefits of warfarin.
Although it is unrealistic to expect universal warfarin use, the 1992 and 1993 rate
of 32% is probably suboptimal given the benefit of anticoagulation in preventing
embolic strokes. The oldest patients, in whom warfarin may have its greatest
benefit, appear to have the lowest rates of anticoagulant use
Keywords: ACUTE
MYOCARDIAL-INFARCTION/ANTICOAGULATION/ASPIRIN/INTERNAL
/PREVENTION/STROKE/THERAPY
Dustan, H.P., Roccella, E.J. and Garrison, H.H. (1996), Controlling hypertension - A
research success story. Archives of Internal Medicine, 156 (17), 1926-1935.
Abstract: In the past 2 decades, deaths from stroke have decreased by 59% and deaths
from heart attack by 53%. An important component of this dramatic change has
been the increased use of antihypertensive drugs. This remarkable success
resulted from broad-based and diverse research programs supported by the
federal government, pharmaceutical companies, voluntary health agencies, and
private foundations. It included basic research, drug development programs,
epidemiologic studies, health surveys of US citizens, clinical research, and
large-scale drug trials. Four of the categories of antihypertensive drugs in wide
use-diuretics, beta-blockers, calcium antagonists, and angiotensin-converting
ensyme inhibitors-emerged from widely different areas of investigation. In the
beginning, dir major breakthroughs that led to the development of these drugs
were impossible to forecast, and their ultimate applications were impossible to
predict. Although decreases in hypertension- related mortality are impressive,
enthusiasm must be tempered because the mechanisms of hypertension are still
incompletely understood and, prevention is not yet possible. Continued research
is needed to extend these advances
Keywords:
HEALTH/hypertension/mortality/POPULATION/PREVALENCE/stroke/trials
Chesebro, J.H., Wiebers, D.O., Holland, A.E., Bardsley, W.T., Litin, S.C., Meissner, I.,
Zerbe, D.M., Flaker, G.C., Webel, R., Nolte, B., Stevenson, P., Byer, J., Wright,
W., Anderson, D.C., Asinger, R.W., Newburg, S.M., Bundlie, S.R., Farmer, C.C.,
Koller, R.L., Haugland, J.M., Nance, M.A., Tarrel, R.M., Dunbar, D.N.,
Jorgensen, C.R., Sharkey, S.W., Leonard, A.D., Kanter, M.C., Solomon, D.H.,
Zabalgoitia, M., McAnulty, J.H., Marchant, C., Coull, B.M., Kelley, R.E.,
Chahine, R., Palermo, M., Teixeiro, P., Feldman, G., Hayward, A., MacMillan,
K., Gandara, E., Anderson, W., Blank, N., Strauss, R., Feinberg, W.M., Vold,
B.K., Kern, K.B., Appleton, C., Bruck, D., Dorr, S., Dittrich, H.C., Rothrock,
J.F., Hagenhoff, C., Logan, W.R., Hamilton, W.P., Green, B.J., Bacon, R.S.,
Helgason, C.M., Kondos, G.T., Hoff, J., Halperin, J.L., Rothlauf, E.B.,
Weinberger, J.M., Goldman, M.E., Miller, V.T., Hockersmith, C.J., Cohen, B.A.,
Janosik, D.L., Cadell, D.J., Kellerman, L., Gomez, C.R., Labovitz, A.J., Rothbart,
R.M., Bailey, G.H., Burkhardt, C., Horwitz, L., Blackshear, J.L., Weaver, L.,
Baker, V., Lee, G., Lane, G., Rubino, F., Safford, R., Kronmal, R.A., McBride,
R., Pearce, L., Fletcher, K.A., Nasco, E., Hart, R.G., Sherman, D.G., Talbert,
R.L., Heberling, P.A., Colton, T., Levy, D.E., Marsh, J.D., Welch, K.M.A.,
Marler, J.R. and Walker, M.D. (1996), Bleeding during antithrombotic therapy in
patients with atrial fibrillation. Archives of Internal Medicine, 156 (4), 409-416.
Abstract: Background: The Stroke Prevention in Atrial Fibrillation II study compared
warfarin vs aspirin for stroke prevention in atrial fibrillation. Bleeding
complications importantly detracted from warfarin's net effectiveness,
particularly among older patients. Objectives: To analyze bleeding complications
according to assigned therapy. To identify risk factors for bleeding during
anticoagulation. Methods: Eleven hundred patients (mean age, 70 years) were
randomized to 325 mg of aspirin daily (enteric coated) vs warfarin (target
prothrombin time ratio, 1.3 to 1.8; approximate international normalized ratio,
2.0 to 4.5). Major hemorrhages were defined prospectively. Results: The rate of
major bleeding while receiving warfarin was 2.3% per year (95% confidence
interval [CI], 1.7 to 3.2) vs 1.1% per year (95% CI, 0.7 to 1.8) while receiving
aspirin (relative risk, 2.1; 95% CI, 1.1 to 3.1; P=.02). Intracranial hemorrhage
occurred at 0.9% per year (95% CI, 0.5 to 1.5) with warfarin and 0.3% per year
(95% CI, 0.1 to 0.8) with aspirin (relative risk, 2.4; P=.08). Age (P=.006),
increasing number of prescribed medications (P=.007), and intensity of
anticoagulation (P=.02) were independent risks for bleeding at any site during
anticoagulation. The rate of major hemorrhage was 1.7% per year in patients
aged 75 years or younger who received anticoagulation vs 4.2% per year in older
patients (relative risk, 2.6, P=.009); rates by age for intracranial bleeding were
0.6% per year and 1.8% per year, respectively (P=.05). Conclusion: Advancing
age and more intense anticoagulation increase the risk of major hemorrhage in
patients given warfarin for stroke prevention
Keywords: aged/anticoagulation/aspirin/atrial fibrillation/DIFFERENT
INTENSITIES/fibrillation/hemorrhage/INTRACEREBRAL
HEMORRHAGE/ORAL
ANTICOAGULANT-THERAPY/OUTPATIENTS/prevention/PROSTHETIC
HEART-VALVES/prothrombin time/PROTHROMBIN-TIME RATIO/relative
risk/risk/risk factors/RISK- FACTORS/stroke/stroke
prevention/THROMBOEMBOLIC COMPLICATIONS/TRIAL/WARFARIN
Kawachi, I., Willett, W.C., Colditz, G.A., Stampfer, M.J. and Speizer, F.E. (1996), A
prospective study of coffee drinking and suicide in women. Archives of Internal
Medicine, 156 (5), 521-525.
Abstract: Background: Among the many reported central nervous system effects of
long-term caffeine use is improvement in mood. Objective: To examine
prospectively the relationship of coffee and caffeine intake to risk of death from
suicide. Methods: We conducted a 10-year follow-up study (1980 to 1990) in an
ongoing cohort of 86 626 US female registered nurses aged 34 to 59 years in
1980, who were free of diagnosed coronary heart disease, stroke, or cancer.
Information on coffee and caffeine intake was collected by a semiquantitative
food frequency questionnaire in 1980. Deaths from suicide were determined by
physician review of death certificates. Results: Fifty-six cases of suicide occurred
during 832 704 person-years of observation. Compared with nondrinkers of
coffee, the age- adjusted relative risk of suicide in women who consumed two to
three cups per day was 0.34 (95% confidence interval [CI], 0.17 to 0.68) and
0.42 (95% CI, 0.21 to 0.86) in women who consumed four or more cups per day
(P for linear trend=.002). These findings remained essentially unchanged after
adjusting for a broad range of potential confounding factors, including smoking
habit, alcohol intake, medication use (diazepam and phenothiazine), history of
comorbid disease (hypertension, hypercholesterolemia, or diabetes), marital
status, and self- reported stress. A strong inverse relationship was similarly found
for caffeine intake from all sources and risk of suicide. Conclusions: The data
suggest a strong inverse association between coffee intake and risk of suicide.
Whether regular intake of coffee or caffeine has clinically significant effects on
the maintenance of affect or the prevention of depression merits further
investigation in clinical trials and population- based prospective studies
Keywords: aged/CAFFEINE/clinical trials/coronary heart
disease/HEALTH/heart/history/HUMANS/hypertension/prevention/prospective
studies/prospective study/relative risk/risk/SMOKING/stroke/trials/women
Albers, G.W., Yim, J.M., Belew, K.M., Bittar, N., Hattemer, C.R., Phillips, B.G., Kemp,
S., Hall, E.A., Morton, D.J. and Vlasses, P.H. (1996), Status of antithrombotic
therapy for patients with atrial fibrillation in university hospitals. Archives of
Internal Medicine, 156 (20), 2311-2316.
Abstract: Background: The risk of stroke in patients with atrial fibrillation can be
significantly reduced with antithrombotic therapy. Despite this, many physicians
remain hesitant to prescribe warfarin sodium or aspirin therapy for patients with
atrial fibrillation. Objective: To assess the use of antithrombotic therapy in
patients with atrial fibrillation at 6 academic hospitals in the United States.
Methods: Records were reviewed from consecutive hospital admissions of 309
patients with atrial fibrillation at 6 members of the University HealthSystem
Consortium, Oak Brook, Ill, which is a member-driven alliance of 70 academic
health centers in the United States. Risk factors for stroke, contraindications to
anticoagulant therapy, and use of antithrombotic therapy at admission and
discharge were recorded. Results: The mean age of patients was 71.6 years; 54%
had chronic, 22% paroxysmal, and 24% new-onset atrial fibrillation. Eighty-two
percent of the patients had cardiovascular risk factors that have been associated
with increased risk of stroke. At least 1 relative contraindication to anticoagulant
therapy was present in 44%. At the time of admission, 32% of the patients with
previously diagnosed atrial fibrillation (n=235) were receiving warfarin (or
warfarin plus aspirin), 31% were receiving aspirin alone, and 36% were
receiving no antithrombotic therapy. At discharge (n=230), 41% of these patients
were taking warfarin (or warfarin plus aspirin) and 36% were taking aspirin.
Forty-four percent of the patients with risk factors for stroke and no
contraindications to anticoagulation (n=134) were discharged on a regimen of
warfarin (or warfarin plus aspirin), 34% were discharged on a regimen of aspirin,
and 22% received no antithrombotic therapy. Conclusions: About half of the
patients with atrial fibrillation admitted to these academic hospitals had clinical
risk factors that are associated with increased risk of stroke and no
contraindications to anticoagulation. Antithrombotic therapy was underused in
these patients
Keywords: ANTICOAGULATION/ASPIRIN/stroke/STROKE
PREVENTION/WARFARIN
ManSonHing, M., Laupacis, A., OConnor, A., Wells, G., Lemelin, J., Wood, W. and
Dermer, M. (1996), Warfarin for atrial fibrillation - The patient's perspective.
Archives of Internal Medicine, 156 (16), 1841-1848.
Abstract: Objective: To determine the minimal clinically important difference (MCID)
of warfarin therapy for the treatment of nonvalvular atrial fibrillation from the
perspective of patients using 2 different elicitation methods. Design: All patients
completed 2 face-to-face interviews, which were 2 weeks apart. For each
interview, they were randomized to receive 1 of 2 elicitation methods:
ping-ponging or starting at the known efficacy. Setting: The practices of 2
university- affiliated family medicine centers (8 physicians each), 14
community-based family physicians, and 2 cardiologists. Patients: Sixty-four
patients with nonvalvular atrial fibrillation who were initiated with warfarin
therapy at least 3 months before the study. Intervention: During each interview,
the patients' MCIDs were determined by using (1) a pictorial flip chart to
describe atrial fibrillation; the consequences of a minor stroke, a major stroke,
and a major bleeding episode; the chance of stroke if not taking warfarin; the
chance of a major bleeding episode if taking warfarin; examples of the
inconvenience, minor side effects, and costs of warfarin therapy; and then (2) 1
of the 2 elicitation methods to determine their MCIDs (the smallest reduction in
stroke risk at which the patients were willing to take warfarin). Patients'
knowledge of their stroke risk, acceptability of the interview process, and factors
determining their preferences were also assessed. Main Results: Given a baseline
risk of having a stroke in the next 2 years, if not taking warfarin, of 10 of 100,
the mean MCID was 2.01 of 100 (95% confidence interval, 1.60-2.42). Fifty-two
percent of the patients would take warfarin for an absolute decrease in stroke risk
of 1% over 2 years. Before eliciting their MCIDs, patients showed poor
knowledge of their stroke risk, which improved afterward. The interview process
was well accepted by the patients. The MCID using the ping-ponging elicitation
method was 1.015 of 100 smaller compared with use of the starting at the known
efficacy method (P=.01). Conclusions: We were able to determine the MCID of
warfarin therapy for the prevention of stroke from the perspective of patients
with nonvalvular atrial fibrillation. Their MCIDs were much smaller than those
that have been implied by some experts and clinicians. The interview process,
using the flip chart approach, appeared to improve the patients' knowledge of
their disease and its consequences and treatment. The method used to elicit the
patients' MCIDs can have a clinically important effect on patient responses. The
method used in our study can be generalized to other conditions and, thus, could
be helpful in 3 ways: (1) from a clinical decision- malting perspective, it could
facilitate patient-physician communication; (2) it could clarify the patient
perspective when interpreting the results of previously completed trials; and (3) it
could be used to derive more clinically relevant sample sizes for randomized
treatment trials
Keywords: ANTICOAGULATION/atrial
fibrillation/PREFERENCES/PREVENTION/stroke/treatment/TRIALS/Warfarin
Goldstein, S. (1996), beta-Blockers in hypertensive and coronary heart disease. Archives
of Internal Medicine, 156 (12), 1267-1276.
Abstract: beta-Blockers are widely used in cardiovascular medicine. In patients with
hypertension, beta-blockers show beneficial effects on clinical end points of
stroke and coronary heart disease prevention and mortality, beta-Blockers also
are well established in improving exercise tolerance and decreasing the number
and duration of anginal attacks in patients with angina pectoris. Based on
evidence showing reduced mortality and morbidity, beta-blockers are the
cornerstone of therapy after acute myocardial infarction. Unfortunately,
presumption of poor tolerance has left these drugs underutilized in this clinical
setting,despite data that indicate a wide range of tolerability. The use of
beta-blockers in patients with congestive heart failure results in beneficial
hemodynamic effects and symptomatic improvement. Among factors that should
be considered when selecting a beta-blocker for an individual patient are
demonstrated efficacy of the drug in a specific indication, tolerability, product
formulation and duration of action, and the presence or absence of specific
properties such as cardioselectivity
Keywords: acute myocardial infarction/ACUTE
MYOCARDIAL-INFARCTION/angina/ANGINA-PECTORIS/ATTACK
TRIAL/BLOCKING-DRUGS/CONTROLLED TRIALS/coronary heart
disease/DIABETIC-PATIENTS/exercise/heart/hypertension/INTERMITTENT
CLAUDICATION/LEFT-VENTRICULAR
HYPERTROPHY/morbidity/mortality/myocardial
infarction/prevention/SECONDARY PREVENTION/SILENT
ISCHEMIA/stroke
Brodsky, M.A., Chun, J.G., Podrid, P.J., Douban, S., Allen, B.J. and Cygan, R. (1996),
Regional attitudes of generalists, specialists, and subspecialists about
management of atrial fibrillation. Archives of Internal Medicine, 156 (22),
2553-2562.
Abstract: Background: It is unknown whether physicians' attitudes about the
management of atrial fibrillation (AF) reflect the recommendations of published
guidelines. Methods: To obtain information about physicians' attitudes about
management of AF, a questionnaire was returned by 904 (20.1%) of 4500
physicians involved in managing AF (385 cardiologists, 326 internists, and 193
electrophysiologists). The cardiologists and internists were from Massachusetts
or California; the electrophysiologists were from around the United States. The
questionnaire called for 86 separate answers about use of resources and drug
therapy for different types of AF, including recent-onset AF, paroxysmal AF,
and chronic AF of less than 6 months' and more than 3 years' duration. Results:
Transthoracic echocardiography and thyroid function were requested by more
than 90% of physicians; transesophageal echocardiography and catheterization
were requested by 10% of physicians. To control ventricular response, digoxin
was the overwhelming first-line therapy; calcium channel blockers were favored
over beta- blockers for adjunct therapy. To prevent thromboemboli, warfarin
sodium was preferred for chronic AF; warfarin or aspirin were equally
considered for paroxysmal AF. In considering sinus rhythm, respondents agreed
about factors determining whether to revert, the number of drug trials, and the
first-line drug choice (quinidine sulfate) but disagreed about second-line
antiarrhythmic drugs and whether to hospitalize the patient before initiating drug
therapy. Conclusions: Physicians ranging from primary care providers to
subspecialists agree on issues of AF management such as heart rate control and
anticoagulation. Attitudes vary widely about issues such as antiarrhythmic drugs
Keywords: DIGOXIN/DRUG-
THERAPY/HEART-RATE/MAINTENANCE/PHYSICIAN
ATTITUDES/PREVENTION/QUINIDINE THERAPY/SINUS
RHYTHM/STROKE/TRIAL
Blackshear, J.L., Baker, V.S., Holland, A., Litin, S.C., Ahlquist, D.A., Hart, R.G.,
Ellefson, R. and Koehler, J. (1996), Fecal hemoglobin excretion in elderly
patients with atrial fibrillation - Combined aspirin and low-dose warfarin vs
conventional warfarin therapy. Archives of Internal Medicine, 156 (6), 658-660.
Abstract: Background: Antithrombotic prophylaxis using combined aspirin and
low-dose warfarin is under evaluation in several clinical trials. However,
combination therapy may result in increased gastrointestinal blood loss and
clinical bleeding vs conventional single-agent antithrombotic therapy. Methods:
To assess differences in gastrointestinal blood loss, we measured quantitative
fecal hemoglobin equivalents (HemoQuant, Mayo Medical Laboratory,
Rochester, Minn) in 117 patients, mean age 71 years, 1 month after initiation of
assigned therapy in the Stroke Prevention in Atrial Fibrillation III Study.
Sixty-three of these patients who had characteristics for high risk of stroke were
randomly assigned to conventional adjusted-dose warfarin therapy (international
normalized ratio, 2.0 to 3.0) or low-dose combined therapy (warfarin
[international normalized ratio, <1.5] plus 325 mg/d of enteric-coated aspirin).
The remaining 54 patients with low risk of stroke received 325 mg/d of
enteric-coated aspirin. Results: hmong the 63 patients at high risk of stroke,
abnormal values (>2 mg of hemoglobin per gram of stool) were detected in 11%
and values greater than 4 mg of hemoglobin per gram of stool were found in 8%,
Mean (+/-SD) values were more for those randomly assigned to receive
combined therapy (1.7+/-3.3 mg of hemoglobin per gram of stool vs
adjusted-dose warfarin therapy, 1.0+/-1.9 mg/g; P=.003), The 54 nonrandomized
patients with low risk of stroke receiving aspirin alone had a mean (+/-SD)
HemoQuant value of 0.8+/-0.7 mg of hemoglobin per gram of stool 1 month
after entry in the study. Conclusions: Abnormal levels of fecal hemoglobin
excretion were common in elderly patients with high risk of atrial fibrillation 1
month after randomization to prophylactic antithrombotic therapy. Combined
warfarin and aspirin therapy was associated with greater fecal hemoglobin
excretion than standard warfarin therapy, suggesting the potential for increased
gastrointestinal hemorrhage
Keywords: aspirin/atrial fibrillation/clinical
trials/elderly/fibrillation/hemorrhage/PREDICTION/prophylaxis/risk/stroke/trial
s/warfarin
[Anon]. (1997), The efficacy of aspirin in patients with atrial fibrillation - Analysis of
pooled data from 3 randomized trials. Archives of Internal Medicine, 157 (11),
1237-1240.
Abstract: Background: Atrial fibrillation (AF) is associated with an increased risk of
stroke. Six randomized studies of the use of oral anticoagulation therapy have
demonstrated that the relative risk of stroke is decreased by approximately 68%.
Three of these studies also compared aspirin with placebo use in a double-blind
design. We pooled individual patient data from these 3 studies. Objectives: To
determine if there were subgroups of patients who were particularly responsive
to aspirin use and to determine the efficacy of aspirin compared with placebo use
in the broad spectrum of patients with AF. Methods: There were 1985
patient-years assigned to the aspirin and 1867 patient-years assigned to the
placebo groups in the analysis. The daily dose of aspirin was 75 mg in the Atrial
Fibrillation, Aspirin, Anticoagulation Study, 325 mg in the Stroke Prevention in
Atrial Fibrillation 1 Study, and 300 mg in the European Atrial Fibrillation Trial.
The European Atrial Fibrillation Trial was a secondary prevention trial, while the
other 2 were primary prevention studies. The primary end point in this analysis
was ischemic stroke. Results: At the time of randomization, the patients' mean
age was 70 years and the mean blood pressure was 145/83 mm Hg. Sixty-two
percent of patients were male, 46% had a history of hypertension, 35% had a
previous transient ischemic attack or stroke, and 19% had intermittent AF.
Although aspirin use seemed particularly effective in younger patients and in
those with hypertension in the Stroke Prevention in Atrial Fibrillation 1 Study,
this was not the case in the other studies. No other subgroups particularly
responsive to aspirin therapy were identified. When patients from all the studies
were combined, the relative risk reduction with aspirin therapy was 21% (95%
confidence interval, 0%-38%; P=.05). Conclusions: A subgroup of patients with
AF that has a particularly large reduction in stroke incidence from aspirin
therapy was not convincingly identified. The data from the combined analysis of
these 3 randomized trials suggest a small effect of aspirin use in preventing
stroke in patients with AF
Keywords: AF/age/anticoagulation/aspirin/atrial fibrillation/blood
pressure/design/fibrillation/history/hypertension/incidence/ischemic/ischemic
stroke/oral anticoagulation/PREVENTION/primary
prevention/randomized/randomized trials/relative risk/risk/secondary
prevention/STROKE/therapy/transient/transient ischemic
attack/trials/WARFARIN
Crouse, J.R., Byington, R.P., Hoen, H.M. and Furberg, C.D. (1997), Reductase inhibitor
monotherapy and stroke prevention. Archives of Internal Medicine, 157 (12),
1305-1310.
Abstract: Background: Epidemiologic evidence and meta-analyses of data from early
clinical trials suggest that lowering the levels of cholesterol does not reduce the
events of stroke. These analyses have not included more recent clinical trials
using reductase inhibitors. Objective: To conduct a meta-analysis of the effect of
reducing cholesterol levels on stroke in all reported clinical trials of primary (n=4)
and secondary (n=8) prevention of coronary heart disease that used reductase
inhibitor monotherapy and provided information on incident stroke. Results:
Analysis of combined data from primary and secondary prevention trials showed
a highly statistically significant reduction of stroke associated with the use of
reductase inhibitor monotherapy (27% reduction in stroke; P=.001). Analysis of
secondary prevention trials alone disclosed a similar statistically significant
effect (32% reduction in stroke; P=.001). A smaller nonsignificant reduction in
stroke was noted in the primary prevention trials (15% reduction in stroke;
P=.48). Conclusions: Reductase inhibitors now in use for lowering cholesterol
levels are more potent and have fewer side effects than the cholesterol- lowering
agents previously available. They appear to reduce stroke, most notably in
patients with prevalent coronary artery disease, which may be partly due to the
effects of lowering the levels of cholesterol on the progression and plaque
stability of extracranial care tid atherosclerosis or the marked reduction of
incident coronary heart disease associated with treatment
Keywords: ARTERY
DISEASE/atherosclerosis/BLOOD-PRESSURE/CARDIOVASCULAR
EVENTS/CAROTID ATHEROSCLEROSIS/cholesterol/CLINICAL
EVENTS/clinical trials/coronary artery disease/coronary heart
disease/CORONARY HEART-DISEASE/EASTERN
FINLAND/heart/INTERVENTION
TRIAL/meta-analysis/MYOCARDIAL-INFARCTION/plaque/prevention/primar
y prevention/secondary prevention/SERUM-CHOLESTEROL
LEVELS/stroke/stroke prevention/treatment/trials
Whittle, J., Wickenheiser, L. and Venditti, L.N. (1997), Is warfarin underused in the
treatment of elderly persons with atrial fibrillation? Archives of Internal
Medicine, 157 (4), 441-445.
Abstract: Background: Several randomized clinical trials have shown that among
patients with atrial fibrillation, warfarin sodium use protects against stroke.
Recently, experts have voiced concern about possible underuse of warfarin by
practicing physicians. Few studies, however, have quantitated the amount of
warfarin underuse. Methods: We randomly sampled 65 Medicare beneficiaries
discharged alive from each of 5 small Pennsylvania hospitals between July 1,
1993, and June 30, 1994, with a discharge diagnosis code for atrial fibrillation.
Trained abstractors verified that atrial fibrillation was present at some time
during the hospitalization, determined the presence of contraindications to
anticoagulation, and identified warfarin or aspirin use at discharge for each
patient. An internist used implicit criteria to identify the reason for warfarin
nonuse in patients who had none of the explicit contraindications to warfarin and
did not receive it. Results: Of 322 charts reviewed, 48 patients were not in atrial
fibrillation during the hospitalization, 79 had contraindications to warfarin use,
21 either died or were transferred to another hospital, and 2 were admitted with a
complication of warfarin. Of the 172 remaining patients, 76 (44%) underwent
anticoagulation. On implicit review of the 96 patients who did not undergo
anticoagulation, the internist judged that warfarin would not have been
appropriate in 54. After excluding those patient's, 76 (64%) of the remaining 118
patients underwent anticoagulation. Patients not receiving warfarin were slightly
older (81.6 vs 78.3 years old), but this was not statistically significant after
stratifying by hospital. Rates of warfarin use at the 5 hospitals varied widely
(32%, 57%, 79%, 82%, 94%; P<.001, chi(2) with 4 df). Patients with newly
diagnosed atrial fibrillation were not more likely to undergo anticoagulation, nor
were patients treated by internal medicine or cardiology specialists. Conclusions:
There may be significant warfarin underuse in some hospitals. Overall,
approximately one third of patients with atrial fibrillation for whom it appeared
appropriate were not anticoagulated with warfarin. Although the fact that data
were not available to or were missed by our review surely justifies some of the
underuse, one should recall that even a small amount of underuse affect a large
number of people with this common condition
Keywords: ANTICOAGULATION/ANTITHROMBOTIC THERAPY/aspirin/atrial
fibrillation/clinical
trials/COMPLICATIONS/diagnosis/elderly/fibrillation/HEALTH/hospital/hospit
alization/PREVALENCE/PREVENTION/randomized/sodium/stroke/treatment/t
rials/warfarin
Gurwitz, J.H., Monette, J., Rochon, P.A., Eckler, M.A. and Avorn, J. (1997), Atrial
fibrillation and stroke prevention with warfarin in the long-term care setting.
Archives of Internal Medicine, 157 (9), 978-984.
Abstract: Background: While the benefits of warfarin sodium therapy for stroke
prevention in patients with atrial fibrillation (AF) have been extensively
documented, generalizing clinical trial results to the majority of elderly persons
with AF, especially to those who reside in the long-term care setting, remains
challenging. Objectives: To determine the prevalence of AF in the
institutionalized elderly population and the proportion receiving anticoagulation
therapy with warfarin; to identify the clinical and functional characteristics of
institutionalized elderly persons with AF that are associated with the use of
warfarin; and to assess the quality of prescribing and monitoring of warfarin
therapy in institutionalized elderly persons with AF. Methods: This study
involved 30 long-term care facilities (total No. of beds, 6437) located in New
England, Quebec, and Ontario. The proportion of patients with AF who were
receiving treatment with warfarin was determined. The association between
clinical and functional characteristics and the use of warfarin was examined with
crude and multivariable-adjusted analyses. For study subjects with at least 2
weeks of warfarin therapy during the 12-month period preceding the date of
medical record abstraction, we assessed the quality of warfarin prescribing based
on all international normalized ratio or prothrombin time ratio values during this
period. Results: An electrocardiogram indicating AP was present in the records
of 413 of 5500 long-term care residents (7.5%), 32% of such patients were being
treated with warfarin. Only a history of stroke was found to be positively
associated with the use of warfarin in this setting. Patients with a diagnosis of
dementia and those in the oldest age group (greater than or equal to 85 years)
were less likely to receive warfarin therapy. Warfarin was commonly prescribed
to patients with a history of bleeding, substantial comorbidity and functional
impairment, a history of falls, or concomitant potentiating drug therapy. Patients
were maintained above or below the recommended therapeutic range 60% of the
lime. Conclusions: Atrial fibrillation is common in patients residing in long-term
care facilities, but its management with warfarin is highly variable, A more
systematic approach to decision making regarding the use of warfarin for stroke
prevention in these patients is required. Among patients receiving warfarin, the
quality of anticoagulation care warrants improvement
Keywords: AF/age/anticoagulation/atrial
fibrillation/CARE/comorbidity/COMPLICATIONS/decision-making/dementia/d
iagnosis/drug therapy/elderly/fibrillation/history/international normalized
ratio/NURSING-HOME RESIDENTS/ORAL
ANTICOAGULANT-THERAPY/OUTPATIENTS/prevention/PRIMARY-CAR
E/prothrombin time/RISK- FACTORS/sodium/stroke/stroke
prevention/therapy/treatment/TRIALS/warfarin
Grover, S.A., Paquet, S., Levinton, C., Coupal, L. and Zowall, H. (1998), Estimating the
benefits of modifying risk factors of cardiovascular disease - A comparison of
primary vs secondary prevention. Archives of Internal Medicine, 158 (6),
655-662.
Abstract: Objectives: To compare the potential years of life saved (YOLS) associated
with risk factor modification in the primary and secondary prevention of
cardiovascular disease (CVD). Methods: The CVD life expectancy model
estimates the risk of death due to coronary disease, stroke, and other causes
based on the levels of independent risk factors (such as age, blood pressure, and
blood lipid levels) found in the cohort of the Lipid Research Clinics. The model
was validated by comparing its predictions with the observed fatal outcomes of 9
randomized clinical trials. We then estimated the YOLS associated with treating
hyperlipidemia or hypertension among hypothetical patient groups with and
without CVD at baseline. We defined high-risk patients as those with 3 risk
factors (hyperlipidemia, cigarette smoking, and hypertension) and low- risk
patients as those with isolated hypertension or hyperlipidemia. Results: The fatal
events predicted by the model were consistent with the clinical trial results.
Among men and women with hyperlipidemia without CVD, the forecasted
benefits of lipid therapy were substantially greater among high-risk groups vs
low-risk groups (4.74-0.78 YOLS vs 2.50- 0.25 YOLS, respectively). Among
those with CVD, the forecasted benefits of treatment were similar for both
high-risk and low- risk groups (4.65-0.65 YOLS vs 3.84-0.58 YOLS,
respectively). The results for hypertension therapy also demonstrated greater
benefits for high-risk vs low-risk patients undergoing primary prevention therapy
(1.34-0.29 YOLS vs 0.85-0.13 YOLS, respectively), and the forecasted benefits
in secondary prevention were similar (1.26-0.23 YOLS vs 1.00-0.23 YOLS,
respectively). Conclusions: The clinical approach to risk factor modification in
primary prevention should be different from that in secondary prevention. The
forecasted benefits of therapy among patients without CVD are greatest in the
presence of other risk factors. Among those with CVD, the benefits of therapy
are equivalent, thereby obviating the need to target high-risk patients
Keywords: age/blood pressure/cardiovascular disease/CHOLESTEROL
REDUCTION/clinical trials/coronary
disease/CORONARY-HEART-DISEASE/COST-EFFECTIVENESS/HYPERC
HOLESTEROLEMIA/hyperlipidemia/hypertension/LIFE
EXPECTANCY/MEN/MORTALITY/PRAVASTATIN/prevention/primary
prevention/risk/risk factors/secondary
prevention/smoking/STROKE/therapy/treatment/TRIALS/women
Brass, L.M., Krumholz, H.M., Scinto, J.D., Mathur, D. and Radford, M. (1998),
Warfarin use following ischemic stroke among Medicare patients with atrial
fibrillation. Archives of Internal Medicine, 158 (19), 2093-2100.
Abstract: Background: Elderly patients with ischemic stroke and atrial fibrillation are at
especially increased risk for recurrent stroke. Warfarin sodium is highly effective
in reducing this risk. Objective: To determine the use of warfarin among a
population sample of elderly patients with atrial fibrillation hospitalized for
ischemic stroke. Methods: The Connecticut Peer Review Organization conducted
a chart review of Medicare patients, aged 65 years or older, hospitalized in 1994
with a diagnosis of atrial fibrillation. Patients with a principal diagnosis of acute
myocardial infarction or another indication for anticoagulation were excluded.
Results: Among 635 patients (402 women; 585 white; 218 greater than or equal
to 85 years old; 147 with a new diagnosis of atrial fibrillation), 334 had stroke as
a principal diagnosis. Among those discharged alive after a stroke, only 147
(53%) of 278 were prescribed warfarin at discharge. Furthermore, among 130
(47%) of 278 patients not prescribed warfarin at discharge, 81 (62%) of 130 were
also not prescribed aspirin. Increased potential benefit (additional vascular risk
factors) was not associated with a higher rate of warfarin use. Low risk for
anticoagulation (lack of risk factors for bleeding) was associated with a slightly
higher rate of warfarin use. Among those with an increased risk of stroke and a
low risk for bleeding (ideal candidates), 124 (62%) of 278 were discharged on a
regimen of warfarin. Conclusion: Anticoagulation of elderly stroke patients with
atrial fibrillation, even among ideal candidates, is underused. The increased use
of warfarin among these patients represents an excellent opportunity for reducing
the risk of recurrent stroke in this high-risk population
Keywords: acute myocardial infarction/ACUTE
MYOCARDIAL-INFARCTION/aged/AMERICAN-HEART-ASSOCIATION/A
NTICOAGULATION/ASPIRIN/atrial fibrillation/CARE/COPENHAGEN
STROKE/CT/diagnosis/elderly/fibrillation/ischemic stroke/myocardial
infarction/OUTCOMES/PREVENTION/risk/RISK FACTOR/risk
factors/stroke/THROMBOLYTIC THERAPY/vascular/Warfarin/women
Bijnen, F.C.H., Caspersen, C.J., Feskens, E.J.M., Saris, W.H.M., Mosterd, W.L. and
Kromhout, D. (1998), Physical activity and 10-year mortality from
cardiovascular diseases and all causes - The Zutphen Elderly Study. Archives of
Internal Medicine, 158 (14), 1499-1505.
Abstract: Background: Little is known about physical activity and mortality risk in the
elderly. Therefore, we describe the associations between the physical activity
pattern of elderly men and the mortality from cardiovascular diseases (CVDs),
particularly coronary heart disease (CHD) and stroke, and all causes. Methods:
Self-reported physical activity was assessed with a validated questionnaire for
retired men in a population- based sample of 802 Dutch men, aged 64 to 84 years
at baseline. Relative risks were estimated for 10-year mortality from CVD (199
deaths), CHD (90), stroke (47), and all causes (373) for tertiles of time spent on
physical activity (reference, lowest tertile). Adjustments were made for baseline
age, relevant major chronic diseases, cigarette smoking, and alcohol
consumption. Results: Mortality risks from CVD and all causes decreased with
increasing physical activity (P for trend =.04) with adjusted relative risks of 0.70
(95% confidence interval, 0.48-1.01) and 0