Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery:

1.1. Purpose of the Expedited Update
Since the publication of the previous guidelines on perioperative cardiovascular evaluation for noncardiac surgery in 2002, the issue of perioperative beta blockade for non-cardiac surgery has taken on increased importance. Specifically, the Physicians Consortium for Performance Improvement and the Surgical
Care Improvement Project have both identified perioperative beta blockade as a quality measure. Given the importance of these quality measures for both public reporting and eventual pay-for-performance, and the recent series of publications on the subject, it became imperative to update the recommendations
related to beta blockade. Therefore, we have chosen to expedite the review of the literature on perioperative beta blockade in order to produce recommendations that can be used in these national quality initiatives. In general, ACC/AHA Class I and III indications for therapy identify potential
dimensions of care and processes for performance measurement; however, not all Class I and III guidelines recommendations should be selected for performance measurement (1).

Patient Behavior Immediately After Transient Ischemic Attack According to Clinical Characteristics, Perception of the Event, and Predicted Risk of Stroke

Patient Behavior Immediately After Transient Ischemic Attack According to Clinical Characteristics, Perception of the Event, and Predicted Risk of Stroke -- Giles et al., 10.1161/01.STR.0000217388.57851.62 -- Stroke: "Background and Purpose--Little research has been done on patients� behavior after transient ischemic attack (TIA). Recent data on the high early risk of stroke after TIA mean that emergency action after TIA is essential for effective secondary prevention. We therefore studied patients� behavior immediately after TIA according to their perceptions, clinical characteristics, and predicted stroke risk.
Methods--Consecutive patients with TIA participating in the Oxford Vascular Study or attending dedicated hospital clinics in Oxfordshire, UK, were interviewed. Predicted stroke risk was calculated using 2 validated scores.
Results--Of 241 patients, 107 (44.4%) sought medical attention within hours of the event, although only 24 of these attended the emergency department. A total of 107 (44.4%) delayed seeking medical attention for 1 day. Correct recognition of symptoms (42.2% of patients) was not associated with less delay. However, patients with motor symptoms or duration of symptoms 1 hour were more likely to seek emergency attention (hazard ratio, 2.1; 95% CI, 1.4 to 3.2; P=0.00005), as were those at higher predicted stroke risk (P=0.001). The other main correlate with delay was the day of the week on which the TIA occurred (P<0.001), with greater delays at the weekend. Delay was unrelated to age, sex, or other vascular risk factors.
Conclusions--Many patients delay seeking medical attention after a TIA irrespective of correct recognition of symptoms, although patients at higher predicted risk of stroke do act more quickly. Public education about both the urgency and"

Randomized Trials Versus the Real World

Randomized Trials Versus the Real World - CME Teaching Brief - MedPage Today:
"this study, the mean number of chronic conditions of patients in a primary care practice eligible for randomized clinical trials in the area of hypertension ranged from 5.5 - 3.3 to 11.7 - 5.3.
Explain to interested patients that the randomized controlled trials for a common condition they read about, hypertension for instance, tend to exclude or omit data on patients with co-morbid conditions. Such exclusions may make it difficult for primary care practitioners, who care for many patients with multiple conditions, to determine for whom the guidelines are relevant.
Review
SHERBROOKE, Quebec, March 28 - Randomized controlled trials are used to support clinical practice guidelines, but their results may have limited relevance to physicians in the trenches.
That's the issue studied by investigators here, who evaluated whether randomized controlled trials that may have excluded patients with co-morbidities provide useful information for clinical practice. They described their research in the March/April issue of the Annals of Family Medicine.
'With our study, we wanted to call attention to an issue of increasing relevance -- comorbidity,' wrote Martin Fortin, M.D., M.Sc., of the department of family medicine at Sherbrooke University, and colleagues.
'Results from our study suggest that randomized controlled trials targeting a chronic medical condition such as hypertension would most likely find a great many patients with co-morbid conditions during the screening process,' they wrote./.../ "

Loneliness Weighs Heavily on the Heart

Loneliness Weighs Heavily on the Heart - CME Teaching Brief - MedPage Today: "Explain to patients that this study suggests that increasing social connectedness may reduce elevated blood pressure to a similar degree as losing weight and exercising.
Point out however that the study design prevents any inferences concerning causality.
Review
CHICAGO - Loneliness may be as bad for the heart as being overweight or inactive, researchers here suggested.
Middle-age and older adults reporting the greatest degree of loneliness had blood pressure levels 10 mm Hg to 30 mm/Hg higher on average than those who were least lonely, found psychologist Louise C. Hawkley, Ph.D., of the University of Chicago, and colleagues.
The magnitude of the effect of loneliness on blood pressure is comparable to the magnitude of reduction that can be achieved through weight loss and exercise, said Dr. Hawkley and Jarett D. Berry, M.D., a cardiology fellow at Northwestern, in the March issue of Psychology and Aging. "

Recommendation to Develop Strategies to Increase the Number of ST-Segment-Elevation Myocardial Infarction Patients With Timely Access to Primary Percu

Recommendation to Develop Strategies to Increase the Number of ST-Segment-Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention. The American Heart Association's Acute Myocardial Infarction (AMI) Advisory Working Group -- Jacobs et al., 10.1161/CIRCULATIONAHA.106.174477 -- Circulation: "Abstract-- Although evidence suggests that primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in the majority of patients with ST-segment-elevation myocardial infarction (STEMI), only a minority of patients with STEMI are treated with primary PCI, and of those, only a minority receive the treatment within the recommended 90 minutes after entry into the medical system. Market research conducted by the American Heart Association revealed that those involved in the care of patients with STEMI recognize the multiple barriers that prevent the prompt delivery of primary PCI and agree that it is necessary to develop systems or centers of care that will allow STEMI patients to benefit from primary PCI. The American Heart Association will convene a group of stakeholders (representing the interests of patients, physicians, emergency medical systems, community hospitals, tertiary hospitals, and payers) and quality-of-care and outcomes experts to identify the gaps between the existing and ideal delivery of care for STEMI patients, as well as the requisite policy implications. Wor"

Oily fish and omega 3 fat supplements -- Brunner, 10.1136/bmj.38798.680185.47 -- BMJ

Oily fish and omega 3 fat supplements -- Brunner, 10.1136/bmj.38798.680185.47 -- BMJ
(recomendado por Marcelo Gustavo Colominas [mgcolominas@hotmail.com])
Seventy five years ago, long chain omega 3 fatty acids were added to the list of essential nutrients. Later in the 20th century, the properties of marine polyunsaturated oils were linked with several health benefits, including protection from cardiovascular disease. However, a high quality systematic review draws attention to uncertainties about some of the health enefits attributed to omega 3 fats.
The review shows that the evidence for a reduction in cardiovascular vents and mortality is less conclusive than we believed.
A previous meta-analysis indicates that mortality is reduced wing to fewer fatal coronary events among people ingesting mega 3 fatty acids, but the current review found no strong evidence f a reduction in combined cardiovascular events. The laim that omega 3 fats reduce the risk of cancer is not upported here or by another recent systematic review. For each ealth outcome there are too few trials with adequate allocation oncealment, and too few cohort studies in which the intake of
omega 3 fat rather than total fish intake was measured.
..............................................................

We are faced with a paradox. Health recommendations dvise increased consumption of oily fish and fish oils, within imits,9 on the grounds that intake is generally low. However, ndustrial fishing has depleted the world’s fish stocks by some 0% since 1950,11 and rising fish prices reduce affordability particularly or people with low incomes. Global production trends figure) suggest that, although fish farming is expanding rapidly, e probably do not have a sustainable supply of long chain mega 3 fats.

Nonsteroidal Antiinflammatory Drugs, Acetaminophen, and the Risk of Cardiovascular Events -- Chan et al. 113 (12): 1578 -- Circulation

Nonsteroidal Antiinflammatory Drugs, Acetaminophen, and the Risk of Cardiovascular Events -- Chan et al. 113 (12): 1578 -- Circulation:
"Background - Although randomized trials of cyclooxygenase-2 (COX-2) inhibitors have shown increased cardiovascular risk, studies of nonselective, nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen have been inconsistent.
Methods and Results - We examined the influence of NSAIDs and acetaminophen on the risk of major cardiovascular events (nonfatal myocardial infarction, fatal coronary heart disease, nonfatal and fatal stroke) in a prospective cohort of 70 971 women, aged 44 to 69 years at baseline, free of known cardiovascular disease or cancer, who provided medication data biennially since 1990. During 12 years of follow-up, we confirmed 2041 major cardiovascular events. Women who reported occasional (1 to 21 d/mo) use of NSAIDs or acetaminophen did not experience a significant increase in the risk of cardiovascular events. However, after adjustment for cardiovascular risk factors, women who frequently (22 d/mo) used NSAIDs had a relative risk (RR) for a cardiovascular event of 1.44 (95% CI, 1.27 to 1.65) compared with nonusers, whereas those who frequently consumed acetaminophen had a RR of 1.35 (95% CI, 1.14 to 1.59). The elevated risk associated with frequent NSAID use was particularly evident among current smokers (RR=1.82; 95% CI, 1.38 to 2.42) and was absent among never smokers (Pinteraction=0.02). Moreover, we observed significant dose-response relations: Compared with nonusers, the RRs for a cardiovascular event among women who used 15 tablets per week were 1.86 (95% CI, 1.27 to 2.73) for NSAIDs and 1.68 (95% CI, 1.10 to 2.58) for acetaminophen.
Conclusions— Use of NSAIDs or acetaminophen at high frequency or dose is associated with a significantly increased risk for major cardiovascular events, although more moderate use did not confer substantial risk. "

Grapefruit juice -

Grapefruit juice - encyclopedia article about Grapefruit juice.: "Grapefruit juice is the fruit juice coming from grapefruits. It is rich with Vitamin C. It is slightly sour. Variations include pink grapefruit juice. Pharmacological EffectsGrapefruit juice has been found to interact with some medicines. It is believed that flavonoids in the juice affect the activity of certain intestinal enzymes like CYP3A4 and CYP1A2. The flavonoid existing in highest concentration in grapefruit juice is naringin, which in humans is metabolized to naringenin. Other flavonoids exist in grapefruit juice in lower concentrations as well. [1]

These cytochrome P450 enzymes, ordinarily responsible for limiting drug metabolites from entering the bloodstream, are inhibited. As a result, more medicine reaches the bloodstream. This may result in a harmful overdose. This is particularly dangerous when the drug in question has a low therapeutic index, so that a small increase in blood concentration can be the difference between therapeutic success and toxicity.

Drugs that may be affected include midazolam (Versed), cyclosporin (Sandimmune, Neoral), lovastatin (Mevacor), simvastatin (Zocor), pravastatin (Pravachol), and caffeine, as well as a number of antihistamines including astemizole (Hismanal) and terfenadine (Seldane, Seldane-D). [2]

An easy way to tell if a medication may affected by grapefruit juice is by researching whether another known CYP3A4 inhibtor drug is already contraindicated with the drug in question. Examples of such known CYP3A4 inhibitors include cisapride (Propulsid), erythromycin, itraconazole (Sporanox), ketoconazole (Nizoral), and mibefradil (Posicor).

Orange juice does not contain naringin in as high a concentration, instead containing hesperetin. It is recommended as a substitute.
References
USDA Database of Flavonoid content of food
Pharmacological Effects

Seattle Heart Failure Model

Seattle Heart Failure Model: "The Seattle Heart Failure Model (SHFM) is a calculator of projected survival at baseline and after interventions for patients with heart failure. SHFM is designed for use by health care providers knowledgeable in cardiac medicine. Patients should only use SHFM when their healthcare providers are present, such as at a doctor�s office. Please click the option below that applies to you:"

Revisiting Rose: strategies for reducing coronary heart disease -- Manuel et al. 332 (7542): 659 -- BMJ

Revisiting Rose: strategies for reducing coronary heart disease -- Manuel et al. 332 (7542): 659 -- BMJ: "The way we assess risk of coronary heart disease has become more accurate in recent years. How does this affect the efficacy of primary and secondary prevention strategies?
Twenty years ago Geoffrey Rose used the examples of blood pressure and cholesterol to show that shifting the distribution curve of a single risk factor by a small amount in an entire population has a greater effect on death rates than does treating only people with high levels of that risk factor.1 2 Rose did not entirely discount screening and treatment, but he cautioned that it should target people at high risk of developing an adverse health outcome rather than people with a single raised risk factor such as cholesterol concentration. In the case of coronary heart disease, medical practice has evolved to include assessment of the baseline risk of disease when recommending drug treatment. Rose's argument that a population based strategy reduces more deaths from coronary heart disease than drug treatment should be re-evaluated now that the medical treatment has incorporated the high baseline risk strategy. "

Preventing coronary heart disease -- Jackson et al. 332 (7542): 617 -- BMJ

Preventing coronary heart disease -- Jackson et al. 332 (7542): 617 -- BMJ: "In this issue (p 659) Manuel and colleagues report how they estimated the effectiveness of three strategies to lower blood cholesterol concentrations in Canadians adults.1 A 'population' strategy assumed that blood cholesterol could be lowered by 2% in the whole population and deaths from coronary heart disease by 2.7%. The two other strategies were patient based, assuming that prescribing statins to subgroups of people at high risk of coronary heart disease would reduce their risk by 27%. A 'single risk factor' strategy targeted patients with blood cholesterol levels greater than 6.2 mmol/l and a 'baseline risk' strategy targeted those with a baseline risk of cardiovascular disease greater than 15% over five years, irrespective of their blood cholesterol levels. "

ACC: Salt Substitute Cuts Systolic Blood Pressure - CME Teaching Brief - MedPage Today

ACC: Salt Substitute Cuts Systolic Blood Pressure - CME Teaching Brief - MedPage Today: "# Explain to interested patients that a salt substitute consisting of sodium chloride, potassium chloride, and magnesium sulfate in a roughly 3:2:1 ratio can lower systolic blood pressure by 5.4 mm Hg without affecting diastolic pressure in a population with a very high-sodium diet.

# Be aware that most sodium in the typical American diet comes from processed foods, and cannot easily be substituted with healthier alternatives.

# This study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication."

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the A

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. -- Sacco et al. 113 (10): e409 -- Circulation: "The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations."

Cobertura ACC - 2006

Cobertura ACC - 2006:
(Apud Cardioclick)
"ACC 2006: “A atenção agora deve ser direcionada ao HDL”, afirma o Dr. Eugene Braunwald.

Atlanta, 11 de Março de 2006.

No simpósio satélite especialmente dedicado ao papel do HDL no processo aterosclerótico, o Dr. Eugene Braunwald, professor de Medicina da Harvard Medical School, realizou as considerações iniciais do evento.

Segundo Dr. Braunwald, após 12 anos de vários estudos randomizados com mais de 90.000 indivíduos com doença cardiovascular e controles saudáveis, verificou-se que a redução do LDL-colesterol impacta diretamente em redução de risco cardiovascular1. Segundo o professor, os estudos mostraram que em média a redução de 1 mg/dL de LDL-colesterol reduz 1% do risco para eventos cardiovasculares.

A partir destes protocolos, mais quatro estudos (PROVE-IT TIMI 22, A to Z, TNT e o IDEAL) randomizaram mais 27.548 pacientes para comparar uma terapêutica “padrão” (pravastatina 40mg diárias, simvastatina 20 mg diárias e atorvastatina 10 mg diárias) com uma terapia “agressiva” (simvastatina 80 mg diárias e atorvastatina 80 mg diárias) para redução dos níveis de LDL.

Todos esses trials demonstraram benefícios clínicos da terapia agressiva e conseqüentemente, estabeleceu-se o consenso de que para/.../"

Community Lay Rescuer Automated External Defibrillation Programs: Key State Legislative Components and Implementation Strategies: A Summary of a Decad

Community Lay Rescuer Automated External Defibrillation Programs: Key State Legislative Components and Implementation Strategies: A Summary of a Decade of Experience for Healthcare Providers, Policymakers, Legislators, Employers, and Community Leaders From the American Heart Association Emergency Cardiovascular Care Committee, Council on Clinical Cardiology, and Office of State Advocacy -- Aufderheide et al. 113 (9): 1260 -- Circulation: "Cardiovascular disease is a leading cause of death for adults ≥40 years of age. The American Heart Association (AHA) estimates that sudden cardiac arrest is responsible for about 250 000 out-of-hospital deaths annually in the United States. Since the early 1990s, the AHA has called for innovative approaches to reduce time to cardiopulmonary resuscitation (CPR) and defibrillation and improve survival from sudden cardiac arrest. In the mid-1990s, the AHA launched a public health initiative to promote early CPR and early use of automated external defibrillators (AEDs) by trained lay responders in community (lay rescuer) AED programs. Between 1995 and 2000, all 50 states passed laws and regulations concerning lay rescuer AED programs. In addition, the Cardiac Arrest Survival Act (CASA, Public Law 106-505) was passed and signed into federal law in 2000. The variations in state and federal legislation and regulations have complicated efforts to promote lay rescuer AED programs and in some cases have/.../"

Coronary Heart Disease Risk Equivalence in Diabetes Depends on Concomitant Risk Factors -- Howard et al. 29 (2): 391 -- Diabetes Care

Coronary Heart Disease Risk Equivalence in Diabetes Depends on Concomitant Risk Factors -- Howard et al. 29 (2): 391 -- Diabetes Care: "OBJECTIVE—Diabetes has been defined as a coronary heart disease (CHD) risk equivalent, and more aggressive treatment goals have been proposed for diabetic patients.

RESEARCH DESIGN AND METHODS—We studied the influence of single and multiple risk factors on the 10-year cumulative incidence of fatal and nonfatal CHD and cardiovascular disease (CVD) in diabetic and nondiabetic men and women, with and without baseline CHD or CVD, in a population (n = 4,549) with a high prevalence of diabetes.

RESULTS—In both sexes, diabetes increased the risk for CHD (hazard ratio 1.99 and 2.93 for men and women, respectively). Diabetic men and women had a 10-year cumulative incidence of CHD of 25.9 and 19.1%, respectively, compared with 57.4 and 58.4% for nondiabetic men and women with previous CHD. The pattern was similar when only fatal events were considered. Diabetic individuals with one or two risk factors had a 10-year cumulative incidence of CHD that was only 1.4 times higher than that of nondiabetic individuals (14%). However, the 10-year incidence of CHD in diabetic subjects with multiple risk factors was >40%, and the incidence of fatal CHD was higher in these subjects than in nondiabetic subjects with previous CHD. Data for CVD showed /.../"

HeartBeat December 2005

(Lembrado por Mário Maranhão)
Please find below links to the December 2005 issue of Heartbeat, Newsletter of the World Heart Federation. In this issue, Valentin Fuster and Sidney Smith co-sign the editorial on the World Congress of Cardiology 2006, stressing the fact that this will be a special opportunity to exchange knowledge and ideas as well as to extend the hand of friendship to all who suffer from cardiovascular disease. There is a lack of global recognition of the burden linked with chronic disease and its impact. In his article “Preventing chronic disease - a vital investment”, Robert Beaglehole presents the WHO report launched in response to this situation, calling for urgent global action. For the same reason, Valentin Fuster and Janet Voûte called for the importance of including chronic diseases in the Millennium Development Goals in an article reprinted with permission from the Lancet : "MDGs: chronic diseases are not on the agenda". Articles on awareness building projects of the World Heart Federation such as World Heart Day ( "World Heart Day 2005: a resounding success" and "World Heart day wins again" ) and Go Red for Women ( "A Go Red for Women campaign for every WHF member") are also included in this issue. As usual, you will also find our list of Forthcoming Congresses & Events as well as the list of National congresses of Societies of Cardiology for 2006. Enjoy your reading! Best regards, Danielle Grizeau-Clemens Science Information Officer World Heart Federation

Immunization for Atherosclerosis: Cardiosource Cholesterol Management enews

Immunization for Atherosclerosis: Cardiosource Cholesterol Management enews: "
(Lembrado por Mário Maranhão)
• Immunization for Atherosclerosis - Interview with Prediman Shah CME CME
• Is Hypertriglyceridemia a Risk Factor in Patients With Normal Cholesterol Levels? ACCEL Online with W. Virgil Brown CME
• Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese (MEGA)
• Relationship Between C-Reactive Protein and Subclinical Atherosclerosis. The Dallas Heart Study (Circulation)
• Reduction in Ventricular Tachyarrhythmias with Statins in MADIT-II (J Am Coll Cardiol)
• Myocardial blood flow and flow reserve are inversely related to Framingham risk score in adults with no clinical coronary heart disease. (J Am Coll Cardiol)
• Targeting Cholesteryl Ester Transfer Protein for the Prevention and Management of Cardiovascular Disease (J Am Coll Cardiol)
• Patients with cardiovascular disease who take a statin have a lower incidence of sepsis. (Lancet)"