CVD - Calendar - ProCOR

ProCOR - Home Page: "ProCOR's CVD Calendar compiles events taking place globally that are relevant to the prevention of cardiovascular disease in developing countries.

To submit information about an event to the calendar, email details to info@procor.org."

If you like we, from AMICOR, may intermediate the information to insert your programmed scientific activity into the calendar

How Web 2.0 is changing medicine -- Giustini 333 (7582): 1283 -- BMJ

How Web 2.0 is changing medicine -- Giustini 333 (7582): 1283 -- BMJ: "Few concepts in information technology create more confusion than Web 2.0. The truth is that Web 2.0 is a difficult term to define, even for web experts.1 Nebulous phrases like 'the web as platform' and 'architecture of participation' are often used to describe Web 2.0. Medical librarians suggest that rather than intrinsic benefits of the platform itself, it's the spirit of open sharing and collaboration that is paramount.2 The more we use, share, and exchange information on the web in a continual loop of analysis and refinement, the more open and creative the platform becomes; hence, the more useful it is in our work.

What seems clear is that Web 2.0 brings people together in a more dynamic, interactive space. This new generation of internet services and devices—often referred to as social software—can be leveraged to enrich our web experience, as information is continually requested, consumed, and reinterpreted. The new environment features a highly connected digital network of practitioners (medical or otherwise), where knowledge exchange is not limited or controlled by private interests. For me, the promise of open access in Web 2.0—freed of publishing barriers and multinational interests—is especially compelling.

Web 2.0 is primarily about the benefits of easy to use and free internet software./.../"

Primary Prevention of Cardiovascular Diseases in People With Diabetes Mellitus. A Scientific Statement From the American Heart Association and the Ame

Primary Prevention of Cardiovascular Diseases in People With Diabetes Mellitus. A Scientific Statement From the American Heart Association and the American Diabetes Association -- Buse et al., 10.1161/CIRCULATIONAHA.106.179294 -- Circulation: "bstract--The American Heart Association (AHA) and the American Diabetes Association (ADA) have each published guidelines for cardiovascular disease prevention: The ADA has issued separate recommendations for each of the cardiovascular risk factors in patients with diabetes, and the AHA has shaped primary and secondary guidelines that extend to patients with diabetes. This statement will attempt to harmonize the recommendations of both organizations where possible but will recognize areas in which AHA and ADA recommendations differ."

Triglycerides and the Risk of Coronary Heart Disease. 10 158 Incident Cases Among 262 525 Participants in 29 Western Prospective Studies -- Sarwar et

Triglycerides and the Risk of Coronary Heart Disease. 10 158 Incident Cases Among 262 525 Participants in 29 Western Prospective Studies -- Sarwar et al., 10.1161/CIRCULATIONAHA.106.637793 -- Circulation: "

Background--Many epidemiological studies have reported on associations between serum triglyceride concentrations and the risk of coronary heart disease, but this association has not been reliably quantified. In the present study, we report 2 separate nested case-control comparisons in 2 different prospective, population-based cohorts, plus an updated meta-analysis of 27 additional prospective studies in general Western populations.

Methods and Results--Measurements were made in a total of 3582 incident cases of fatal and nonfatal coronary heart disease and 6175 controls selected from among the 44 237 men and women screened in the Reykjavik and the European Prospective Investigation of Cancer (EPIC)-Norfolk studies. Repeat measurements were obtained an average of 4 years apart in 1933 participants in the EPIC-Norfolk Study and an average of 12 years apart in 379 participants in the Reykjavik study. The long-term stability of log-triglyceride values (within-person correlation coefficients of 0.64 [95% CI, 0.60 to 0.68] over 4 years and 0.63 [95% CI, 0.57 to 0.70] over 12 years) was similar to those of blood pressure and total serum cholesterol. After adjustment for baseline values of several established risk factors, the strength of the association was substantially attenuated, and the adjusted odds ratio for coronary heart disease was 1.76 (95% CI, 1.39 to 2.21) in the Reykjavik study and 1.57 (95% CI, 1.10 to 2.24) in the EPIC-Norfolk study in a comparison of individuals in the top third with those in the bottom third of usual log-triglyceride values. Similar overall findings (adjusted odds ratio, 1.72; 95% CI, 1.56 to 1.90) were observed in an updated meta-analysis involving a total of 10 158 incident coronary heart disease cases from 262 525 participants in 29 studies.

Conclusions--Available prospective studies in Western populations consistently indicate moderate and highly significant associations between triglyceride values and coronary heart disease risk. Because these associations depend considerably on levels of established risk factors, however, further studies are needed to help assess the nature of any independent associations.

"

JAMA -- Theme Issue on Poverty and Human Development: Call for Papers on Interventions to Improve Health Among the Poor, December 27, 2006, Flanagin a

JAMA -- Theme Issue on Poverty and Human Development: Call for Papers on Interventions to Improve Health Among the Poor, December 27, 2006, Flanagin and Winker 296 (24): 2970: "

Poverty is an inveterate consequence and cause of ill health.¹ Without financial resources, people cannot pay for basic human needs: food, water, sanitation, housing, and health care services. In addition, poor people often live in poor countries that have limited or deteriorating health care systems and not enough physicians, nurses, and other trained health care workers. Others live in countries with governments that ignore or are too ineffectual to address the health care needs of the poor. Individuals who are poor also lack adequate education to make appropriate decisions about health and prevention of disease and often lack equity and empowerment to attain education, employment, and skills needed to escape the cycle of poverty.

The first of the United Nation's 8 Millennium Development Goals, determined by 189 countries in 2000, is to eradicate extreme poverty and hunger.² This specific goal is to halve the proportion of people living on less than $1 a day (the World Bank's definition of extreme poverty) and those who suffer from hunger by the year 2015.^2-3 This goal cannot be achieved without improving the level of human development—the opportunity to escape poverty through "the choices that come with a sufficient income, an education, good health, and living in a country that is not governed by tyranny"—among the poor.⁴ Such development requires careful evaluation and study of interventions aimed to address the needs of poor individuals within their unique local conditions and socioeconomic context, with sufficient follow-up to determine whether effects are sustainable.

In 1990, more than 28% of the developing world's population (1.2 billion people) lived in extreme poverty.^2-3 By 2002, this proportion had decreased to 19% but still represented more than 1 billion people.^2-3 While substantial declines in extreme poverty have been reported for Eastern and Southern Asia between 1990 and 2002 (from a rate of 33% to 14% in Eastern Asia and from 39% to 31% in Southern Asia), progress in other regions has been mixed or marginal at best. Limited reductions in poverty rates have been seen in Latin America and the Caribbean (from 11% to 9%), but this region now still has more than 47 million people living in poverty. Rates of poverty in Western Asia and Northern Africa have remained almost unchanged since 1990 (approximately 2%) and have increased in the transition economies of Southeastern Europe and many of the countries of the former Soviet Union (from 0.4% in both regions to 1.8% and 2.5%, respectively). In sub-Saharan Africa, which has the largest regional proportion of extreme poverty in the world, the poverty rate declined only marginally from 1990 to 2002 (from 44.6% to 44.0%), and the number of people living in extreme poverty has increased to 303 million.^2-3

Among all regions of the world other measures demonstrate some progress toward achieving the Millennium Development Goals, including declines in the proportion of people with insufficient food and sanitation, increased enrollments in education, increased proportion of women employed, decreases in child mortality rates, increases in measles vaccination rates, and increased proportion of births attended by skilled health care workers.² Each of these successes will contribute to reducing poverty and promoting human development, but some of this progress has been only marginal and much additional work, aid, funding, and research are needed.^2-3,5

Despite huge increases in wealth and prosperity throughout the world in the last several decades, the gap between the wealthy and the poor has widened, with more than 1 billion people still living in extreme poverty.^{3, 5} The United Nations Human Development Index is a composite of 3 dimensions of human development: living a long and healthy life (measured by life expectancy), being educated (measured by adult literacy and enrollment in primary, secondary, and tertiary schools), and having a decent standard of living (measured by purchasing power parity and income).⁴ According to the most recent report, Norway has the highest level of human development, and Niger the lowest.⁴ Individuals in Norway are nearly 50 times wealthier and live almost twice as long as those in Niger and have nearly universal enrollment in education, compared with 21% in Niger. People in the 31 countries with the lowest levels of human development, which represent 9% of the world's population, have an average life expectancy of 46 years, 32 years less than in countries with high levels of human development. This discrepancy illustrates the connection between income and poverty and human development: poverty prevents people from attaining education and employment, achieving and maintaining health, managing illness or disability, and thus, escaping poverty.⁴

Substantial efforts have been directed at reducing poverty, addressing health needs, and ultimately improving human development during the last few decades.^3-5 However, much of the early work begun in the 1960s and 1970s lost support in the mid-1980s following severe economic downturns in many poor countries, the demise of previously state-run approaches to development and the provision of health care, and overall pessimism about the ability to actually reduce poverty and provide health care for all.⁶ In addition, acts of violence, conflicts, and mass disasters have led to social upheaval and long-term displacement, rendering the most basic health care impossible to deliver. Signs of renewed concern and attention began in the late 1990s with recognition by agencies such as the World Bank of the connection between health, poverty reduction, equity, and economic success as well as increased governmental and private aid and funding of research into poverty and health.⁶ However, most aid still falls far short of promises and what is needed.⁵

A vast literature discusses poverty and its associations and effects. A recent search of MEDLINE using the key term "poverty" resulted in more than 22 000 citations, while results in Google Scholar included about 1.3 million articles. However, the MEDLINE citations represent less than 0.002% of the database's 14 million total citations.⁷ Furthermore, despite the large number of articles, the effectiveness of many interventions to improve health in poor countries remains untested and unproven.⁸ In fact, compared with costly interventions and therapies that are mostly available to those who can pay for them, relatively few health interventions targeted to serve the poor are evidence-based.⁸ A systematic review of 286 randomized controlled trials (RCTs) on topics relevant to 35 leading causes of global burden of disease published in 6 leading general medical journals in 1999 found that 124 (43%) of these trials addressed 1 of the 35 leading causes of global burden of disease. Of these, ischemic heart disease, HIV/AIDS, and cerebrovascular disease were the most commonly studied.⁹ One third of these trials studied 1 of 10 top causes of global burden of disease, but 7 (20%) of the leading causes of global burden of disease were not addressed by any trial.

However, progress is being made in efforts to conduct reliable research on the health needs of the poor and to provide evidence-based solutions. Since 1971, 404 reports of RCTs on interventions related to poverty have been included in MEDLINE, with 57% of these published in the last 6 years. Recent studies have examined a range of interventions, some successful and some not, including strategies to reduce inequalities in access to care; microcredit programs; sustainable health care financing alternatives for the poor; strategies to provide access to essential drugs, vaccines, and therapies; strategies to reduce infant and maternal mortality rates; nutritional interventions; behavioral interventions to improve health and adherence with therapeutic regimens and to prevent disease; educational programs; family planning services; interventions to increase access to clean water and sanitation; and primary care treatments for preventable diseases, chronic diseases, and mental health disorders. The success of microcredit was recognized with this year's award of the Nobel Peace Prize to Muhammad Yunus and Grameen Bank for their "efforts to create economic and social development from below."¹⁰

To help disseminate research into interventions that specifically address the needs of the poor, JAMA will publish a theme issue on poverty and human development in October 2007. JAMA is 1 of more than 140 scientific journals participating in plans to simultaneously publish papers on this topic under the coordination of the Council of Science Editors.¹¹ For this theme issue, JAMA will consider manuscripts that report original research of interventions targeted to address poverty, hunger, access to care, and prevention of disease that are based on careful consideration and analysis of local context, evidence, and environments and that are directly targeted to serve the poor. We are also interested in assessments of interventions that are both scalable and sustainable. We are primarily interested in receiving reports of randomized or cluster controlled trials, but we will also consider cohort studies, case-control studies, and other observational studies as well as systematic reviews, meta-analyses, and commentaries. Manuscripts received by May 1, 2007, will have the best chance of consideration for the issue. Please see JAMA's Instructions for Authors for information on preparing and submitting manuscripts.¹²

Trends in Incidence, Lifetime Risk, Severity, and 30-Day Mortality of Stroke Over the Past 50 Years, December 27, 2006, Carandang et

JAMA -- Abstract: Trends in Incidence, Lifetime Risk, Severity, and 30-Day Mortality of Stroke Over the Past 50 Years, December 27, 2006, Carandang et al. 296 (24): 2939:
" Context Prior estimates of long-term trends in the incidence and severity of stroke have varied; trends in lifetime risk have not been reported.

Objective To determine long-term trends in the incidence, lifetime risk, severity, and 30-day mortality of clinical stroke.

Design, Setting, and Participants Prospective evaluation of the community-based Framingham Study original and offspring cohorts. Participants were 9152 men and women free of prevalent stroke and undergoing follow-up for up to 50 years over 3 consecutive periods (1950-1977, 1978-1989, and 1990-2004), with biennial ascertainment of stroke risk factor data and active surveillance for incident clinical stroke and cause-specific mortality.

Main Outcome Measures Incidence (age-adjusted, sex-specific), severity, 30-day mortality, and mortality-adjusted 10-year and lifetime risk of stroke in each of the specified periods.

Results There were 1030 incident clinical strokes (450 [44%] in men, 629 atherothrombotic brain infarctions [61%]) in 9152 persons 55 years or older over 174 917 person-years of follow-up. The age-adjusted incidence of first stroke per 1000 person-years in each of the 3 periods was 7.6, 6.2, and 5.3, respectively, in men (P = .02 for trend) and 6.2, 5.8, and 5.1 in women (P = .01 for trend). The lifetime risk at age 65 years decreased from 19.5% to 14.5% in men (P = .11) and from 18.0% to 16.1% in women (P = .61). Age-adjusted stroke severity did not vary across periods; however, 30-day mortality decreased significantly in men (from 23% to 14%; P = .01) but not significantly in women (from 21% to 20%; P = .32).

Conclusions In this cohort of men and women free of prevalent clinical stroke at initial examination, incidence of stroke has decreased over the past 50 years but the lifetime risk has not declined to the same degree, perhaps due to improved life expectancy. The results of this study suggest that improved control of risk factors has lowered stroke incidence but emphasize the need for continued primary prevention efforts. "

CVD Surveillance System toward prevention

A Scientific Statement From the American Heart Association Councils on Epidemiology and Prevention, Stroke, and Cardiovascular Nursing and the Interdisciplinary Working Groups on Quality of Care and Outcomes Research and Atherosclerotic Peripheral Vascular Disease

David C. Goff, Jr, MD, PhD; Lawrence Brass, MD†; Lynne T. Braun, PhD, RN, CNP; Janet B. Croft, PhD; Judd D. Flesch; Francis G.R. Fowkes, MD, PhD; Yuling Hong, MD, PhD; Virginia Howard, MSPH; Sara Huston, PhD; Stephen F. Jencks, MD, MPH; Russell Luepker, MD, MS; Teri Manolio, MD, PhD; Christopher O’Donnell, MD, MPH; Rose Marie Robertson, MD; Wayne Rosamond, PhD; John Rumsfeld, MD, PhD; Stephen Sidney, MD, MPH; Zhi Jie Zheng, MD, PhD
A strategic goal of the American Heart Association (AHA) is to reduce heart disease, stroke, and risk for both by 25%,1 and Healthy People 2010 (HP2010) established 4 national goals for heart disease and stroke prevention and management.2 However, the current health tracking systems (surveillance) in the United States cannot track progress toward these goals in a comprehensive
and systematic manner. This article provides a brief overview of these goals, prevention and management strategies, and the role of surveillance in monitoring the impact of prevention and treatment efforts. It also provides a review of the existing surveillance system for monitoring progress toward preventing heart disease and stroke in the United States and recommendations
for filling important gaps in that system. This information will serve as an important basis for advocacy to guide the development of a comprehensive surveillance system to support the current HP2010 and AHA goals and the likely future goal of eliminating the epidemic burden of heart disease and stroke.
Recommendations are categorized as overarching (fundamental recommendations that cut across goal areas) or as goal-specific.
They are further classified according to priority (P) (I for high priority and II for intermediate priority. No low-priority recommendations were made), staging (S) (I for early staging [1–2
years], II for intermediate staging [2–4 years], and III for later staging), and cost (C) ($ for items estimated to cost less than $10 million per year, $$ for estimates of $10 to $100 million, and $$$ for estimates exceeding $100 million). In addition, potential barriers to action are addressed.
Overarching Recommendations
1. A National Heart Disease and Stroke Surveillance unit should be established to produce annual reports on key indicators of progress in the prevention and management of heart disease and stroke. P I, S I, C $.
2. Cardiovascular disease (CVD), including cardiac arrests, acute coronary syndromes (heart attack and unstable angina), stroke, chronic heart failure (CHF), and related interventional procedures, should be classified as reportable conditions. P I, S III (although developmental
work should begin earlier), C $$$.
3. Data collection about patients’ encounters with the healthcare system should be revised to include collection of data on lipoprotein cholesterol concentrations, blood sugar, and glycohemoglobin values. P I, S I, C $.
4. Data elements should be standardized across surveys, and unnecessary duplication in data sources should be avoided. P I, S I, C $ (potentially cost saving).
5. The design and conduct of nationally representative surveillance programs should be revised to facilitate oversampling by states, territories, and tribal organizations and to provide meaningful estimates on ethnic subgroups in the populations. Sampling within states, territories, and tribal organizations should be designed to facilitate oversampling by counties. P I, S
II, C $$ to $$$ (depending on extent of oversampling achieved).
6. Mechanisms should be developed to enable linkage between healthcare data systems, including the national surveillance programs (eg, National Ambulatory Medical Care Survey [NAMCS], National Hospital Discharge Survey [NHDS], and National Death Index), and
electronic health records. P I, S II, C $$$ (startup) and $$ (maintenance).
7. Studies are needed to establish the validity of multiple measures collected by self-report and provider report in national databases. P II, S II, C $$.

More mystery deaths than thought

BBC NEWS | Health | More mystery deaths than thought: "he rate of sudden unexplained deaths in England is around eight times higher than previously thought, warn experts.

Around 500 people may die every year from sudden arrhythmic death syndrome, a study published in Heart shows.

SADS is linked to a genetic heart defect and family members should be screened to prevent more deaths, the researchers said.

The study also found that only one-third of cases had been correctly identified by post-mortem.

The researchers identified 56 cases of SADS from 115 coroners' reports of unascertained causes of death."

'Fat scan' shows up health risk

BBC NEWS Health 'Fat scan' shows up health risk: "Hammersmith Hospital, in west London, is currently the only hospital in Europe using the MRI scan.
Its scientists say 40% of the population have 'bad' fat around the heart, liver or pancreas, even though many appear thin.
They warn it is possible to be slim and yet still be at risk of conditions like diabetes because of 'hidden' fat.
Evidence suggests the precise location of fat has more of a bearing on health than simply being overweight. "

Ischemic Heart Disease Events Triggered by Short-Term Exposure to Fine Particulate Air Pollution -- Pope et al. 114 (23): 2443 -- Circulation

Ischemic Heart Disease Events Triggered by Short-Term Exposure to Fine Particulate Air Pollution -- Pope et al. 114 (23): 2443 -- Circulation: "Background— Recent evidence suggests that long-term exposure to particulate air pollution contributes to pulmonary and systemic oxidative stress, inflammation, progression of atherosclerosis, and risk of ischemic heart disease and death. Short-term exposure may contribute to complications of atherosclerosis, such as plaque vulnerability, thrombosis, and acute ischemic events. These findings are inconclusive and controversial and require further study. This study evaluates the role of short-term particulate exposure in triggering acute ischemic heart disease events.

Methods and Results— A case-crossover study design was used to analyze ischemic events in 12 865 patients who lived on the Wasatch Front in Utah. Patients were drawn from the cardiac catheterization registry of the Intermountain Heart Collaborative Study, a large, ongoing registry of patients who underwent coronary arteriography and were followed up longitudinally. Ambient fine particulate pollution (particles with an aerodynamic diameter ≤2.5 µm; PM2.5) elevated by 10 µg/m3 was associated with increased risk of acute ischemic coronary events (unstable angina and myocardial infarction) equal to 4.5% (95% confidence interval, 1.1 to 8.0). Effects were larger for those with angiographically demonstrated/.../"

Pfizer Ends Studies on Drug for Heart Disease - New York Times

Pfizer Ends Studies on Drug for Heart Disease - New York Times:
By ALEX BERENSON
Published: December 3, 2006
"Pfizer announced last night that it had discontinued research on its most important experimental drug, a treatment for heart disease. The decision is a stunning development that is likely to seriously damage the company’s prospects through the next decades.
Preliminary research found that the drug, torcetrapib, appeared to be linked with deaths and heart problems in the patients who were taking it.
For people with heart disease, Pfizer’s decision to stop the trial represents the failure of a drug that many cardiologists had viewed as a potentially major advance in efforts to reduce heart attacks and strokes.
Torcetrapib is designed to raise levels of so-called good cholesterol. It was to be used in combination with older drugs called statins, like Lipitor and Zocor, which reduce so-called bad cholesterol.
As recently as Thursday, Pfizer executives had hailed the drug at a meeting with investors and analysts at the company’s research center in Groton, Conn.
“This will be one of the most important compounds of our generation,” said Jeffrey B. Kindler, Pfizer’s chief executive.
Pfizer is the world’s biggest drug company, with 106,000 employees and $51 billion in sales in 2005."

Natural History of Atherosclerosis: A Critical Evaluation of the Current Understanding of the Natural History of Human Atherosclerosis

Natural History of Atherosclerosis: A Critical Evaluation of the Current Understanding of the Natural History of Human Atherosclerosis
At a 2004 meeting in Paris, Renu Virmani, MD, FACC, medical director and founder of CVPath Institute, Gaithersburg, Maryland, warned that drug-eluting stents (DESs) could increase the risk of late thrombosis leading to MIs months or even years after the stents were implanted. Despite pathology slides vividly showing the victims’ stents totally occluded by clots, few of her colleagues showed much interest in her warning. Yet subsequent analyses of clinical trial and registry data suggest that late thrombosis is seen more often with DES placement than with older bare-metal stents (BMSs). The data – summarized in an AHA ’06 report featuring Robert S. Schwartz, MD, FACC (click here) – have renewed interest in the natural history of human atherosclerosis and what can be done clinically to reduce the risk of late thrombosis.

Acute rheumatic fever is still a clinical challenge -- 333 (7579): 0 -- BMJ

Acute rheumatic fever is still a clinical challenge -- 333 (7579): 0 -- BMJ: "BMJ 2006;333 (2 December), doi:10.1136/bmj.333.7579.0-b
Related Article
This week in the BMJ
Acute rheumatic fever is still a clinical challenge
Acute rheumatic fever, now rare in high income populations, remains highly prevalent in developing countries where access to health care is poor, says Cilliers (doi: 10.1136/bmj.39031.420637.BE) in her clinical review. Although it is known to be caused by humoral and cell mediated immune responses to group A beta haemolytic streptococcus antigens, the syndrome of carditis, polyarthritis, and skin or neurological changes is still not completely understood. Only 0.3-3% of patients with acute streptococcal pharyngitis develop rheumatic fever and a genetic predisposition is certain.

Related Article
Rheumatic fever and its management
Antoinette M CilliersBMJ 2006 333: 1153-1156. [Extract] [Full Text]

Childhood Poverty Grows into Adult Heart Disease

Childhood Poverty Grows into Adult Heart Disease - CME Teaching Brief® - MedPage Today: ", Nov. 27 -- A poor childhood more than doubles the risk of early heart disease among white male physicians who achieve a high socioeconomic status, found researchers here. Action Points

Explain to patients who ask that this study suggests that relative poverty in childhood has a persistent effect and increases the risk of heart disease as adults among white male physicians who achieve high socioeconomic status.


Point out that this increased risk is not mediated by established coronary heart disease risk factors.
The finding, based on a long-running prospective study of the precursors of heart disease, underlines the persistent effect of relative poverty on children's future health, according to Michelle Kittleson, M.D., Ph.D., of Johns Hopkins.
Interestingly, the effect appears to moderate over time, as other risk factors for coronary heart disease begin to predominate with increasing age, Dr. Kittleson (now at the UCLA) and colleagues reported in the Nov. 27 issue of Archives of Internal Medicine.
Dr. Kittleson and colleagues analyzed data from the John Hopkins Precursors Study, which enrolled graduates of the university's medical school between 1948 and 1964. Median follow-up has reached 40 years.
The cohort was valuable to examine the effects of childhood socioeconomic status, Dr. Kittleson and colleagues said, because it eliminated a key adult confounding effect. All of the participants went on to enjoy the income and professional status of physicians.
For this analysis, the researchers excluded female graduates, those of non-European background, those who did not provide information about parental occupation, and those who were unavailable for follow-up, leaving 1,131 volunteers."

The polypill: at what price would it become cost effective? -- Franco et al. 60 (3): 213 -- Journal of Epidemiology and Community Health

The polypill: at what price would it become cost effective? -- Franco et al. 60 (3): 213 -- Journal of Epidemiology and Community Health: "Introduction: A promising concept in cardiovascular disease prevention (the polypill) was introduced in 2003. Although the polypill may seem as an effective intervention, data on its costs and cost effectiveness remain unknown. The aim of this study was to determine the maximum price of the polypill for it to be a cost effective alternative in the primary prevention of cardiovascular disease.
Methods: Data on the hypothetical effects of the polypill were taken from the literature. Using data from the Framingham heart study and the Framingham offspring study, life tables were built to model the assumed benefits of the polypill. Using a third party payer perspective and a 10 years time horizon, the authors calculated what should be the maximum drug cost of the polypill for it to be cost effective (using a 20 000/year of life saved threshold) in the primary prevention of cardiovascular disease among populations at different levels of absolute risk of coronary heart disease and age.
Results: To be cost effective among populations at levels of 10 year coronary heart disease risk over 20% (high risk), the annual cost of medication for the polypill therapy should be no more than 302 or 410 for men at age 50 and 60 years respectively. For cost effective prevention in populations at levels of coronary heart disease risk between 10% and 20% the costs should be two to three times lower.
Conclusion: Although the polypill could theoretically be a highly effective intervention, the costs of the medication could be its caveat for implementation in the primary prevention of cardiovascular disease. "

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational obs

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE) -- Fox et al. 333 (7578): 1091 -- BMJ: "Objective To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome. Design Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation. Setting Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand. Population 43 810 patients (21 688 in derivation set; 22 122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005. Main outcome measures Death and myocardial infarction. Results 1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries). Conclusions This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome. "

Time course of depression and outcome of myocardial infarction.

De: Marcelo Gustavo Colominas [mailto:mgcolominas@hotmail.com]
Enviada em: quinta-feira, 23 de novembro de 2006 00:50
Arch Intern Med. 2006 Oct 9;166(18):2035-43.
Time course of depression and outcome of myocardial infarction.
Parashar S, Rumsfeld JS, Spertus JA, Reid KJ, Wenger NK, Krumholz HM, Amin A, Weintraub WS, Lichtman J, Dawood N, Vaccarino V.
Divisions of General Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA. smallik@emory.edu
BACKGROUND: Depression predicts worse outcomes after myocardial infarction (MI), but whether its time course in the month following MI has prognostic importance is unknown. Our objective was to evaluate the prognostic importance of transient, new, or persistent depression on outcomes at 6 months after MI. METHODS: In a prospective registry of acute MI (Prospective Registry Evaluating outcomes after Myocardial Infarction: Events and Recovery [PREMIER]), depressive symptoms were measured in 1873 patients with the Patient Health Questionnaire (PHQ) during hospitalization and 1 month after discharge and were classified as transient (only at baseline), new (only at 1 month), or persistent (at both times). Outcomes at 6 months included (1) all-cause rehospitalization or mortality and (2) health status (angina, physical limitation, and quality of life using the Seattle Angina Questionnaire). RESULTS: Compared with nondepressed patients, all categories of depression were associated with higher rehospitalization or mortality rates, more frequent angina, more physical limitations, and worse quality of life. The adjusted hazard ratios for rehospitalization or mortality were 1.34, 1.71, and 1.42 for transient, new, and persistent depression, respectively (all P<.05). Corresponding odds ratios were 1.62, 2.73, and
2.64 (all P<.01) for angina and 1.69, 2.25, and 3.27 (all P<.05) for physical limitation. Depressive symptoms showed a stronger association with health status compared with traditional measures of disease severity.
CONCLUSION: Depressive symptoms after MI, irrespective of whether they persist, subside, or newly develop in the first month after hospitalization, are associated with worse outcomes after MI.
Publication Types:
Multicenter Study
PMID: 17030839 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17030839&dopt=Abstract
_________________
Marcelo G. Colominas
EyP-FAC
SCChaco

Researchers isolate a master heart cell

Researchers isolate a master heart cell - The Boston Globe: "A team of Harvard scientists announced yesterday that it has discovered a single kind of cell that builds the three main types of heart tissue, an advance that boosts the prospects of using cells to treat heart disease, the nation's top killer.
The team identified the heart cell in mice, and proved that it develops into the muscle cells that power the heart, the cells that make up blood vessels, and the smooth muscle cells that allow the vessels to expand and contract.
If the human equivalent of the new cells is found, it could be given to patients to rebuild heart tissue that cannot be repaired today. The work could also give biologists new tools to look for heart drugs.
There has been a rush of work in recent years to develop therapies that inject cells capable of repairing patients' damaged heart muscle. But the field has been hampered because biologists have not known what type of cell to use. Researchers around the world have launched clinical trials, but the trials have used blood cells, not heart cells, and the results have been modest, at best.
The research identifies, for the first time, a kind of master heart cell, similar to a stem cell, with a proven ability to build a wide range of heart tissues. The scientists cautioned that important obstacles remain before cell therapies based on the research can be tested in humans."

Extending the Horizon in Chronic Heart Failure. Effects of Multidisciplinary, Home-Based Intervention Relative to Usual Care -- Inglis et al., 10.1161

Background--The long-term impact of chronic heart failure management programs over the typical life span of affected individuals is unknown.
Methods and Results--The effects of a nurse-led, multidisciplinary, home-based intervention (HBI) in a typically elderly cohort of patients with chronic heart failure initially randomized to either HBI (n=149) or usual postdischarge care (UC) (n=148) after a short-term hospitalization were studied for up to 10 years of follow-up (minimum 7.5 years of follow-up). Study end points were all-cause mortality, event-free survival (event was defined as death or unplanned hospitalization), recurrent hospital stay, and cost per life-year gained. Median survival in the HBI cohort was almost twice that of UC (40 versus 22 months; P<0.001), with fewer deaths overall (HBI, 77% versus 89%; adjusted relative risk, 0.74; 95% CI, 0.53 to 0.80; P<0.001). HBI was associated with prolonged event-free survival (median, 7 versus 4 months; P<0.01). HBI patients had more unplanned readmissions (560 versus 550) but took 7 years to overtake UC; the rates of readmission (2.04±3.23 versus 3.66±7.62 admissions; P<0.05) and related hospital stay (14.8±23.0 versus 28.4±53.4 days per patient per year; P<0.05) were significantly lower in the HBI group. HBI was associated with 120 more life-years per 100 patients treated compared with UC (405 versus 285 years) at a cost of $1729 per additional life-year gained when we accounted for healthcare costs including the HBI.
Conclusions--In altering the natural history of chronic heart failure relative to UC (via prolonged survival and reduced frequency of recurrent hospitalization), HBI is a remarkably cost- and time-effective strategy over the longer term.

Risk Factors Socioeconomic status

Impact of Traditional and Novel Risk Factors on the Relationship Between Socioeconomic Status and Incident Cardiovascular Events -- Albert et al., 10.1161/CIRCULATIONAHA.106.660043 -- Circulation: "Background--Persons of lower socioeconomic status have greater cardiovascular risk than those of higher socioeconomic status. However, the mechanism through which socioeconomic status affects cardiovascular disease (CVD) is uncertain. Virtually no data are available that examine the prospective association between novel inflammatory and hemostatic CVD risk indicators, socioeconomic status, and incident CVD events. Methods and Results--We assessed the relationship between 2 indicators of socioeconomic status (education and income), traditional and novel CVD risk factors (high sensitivity C-reactive protein, soluble intercellular adhesion molecule-1, fibrinogen, and homocysteine), and incident CVD events among 22 688 apparently healthy female health professionals participating in the Women’s Health Study. These women were followed up for 10 years for the development of myocardial infarction, ischemic stroke, coronary revascularization, and cardiovascular death. More educated women were less likely to be smokers; had a lower prevalence of hypertension, diabetes, and obesity; and were more likely to participate in vigorous physical activity than less educated women. At baseline, median total cholesterol, low-density lipoprotein, triglyceride, C-reactive protein, intercellular adhesion molecule-1, fibrinogen, and homocysteine levels for women in 5 categories of education (<2 trend="0.006),">Conclusions--In this prospective analysis, we observed a decrease in incident CVD events with increasing levels of education and income. In contrast to the relationship between income and CVD events, the relationship of CVD events with education was explained only partially by traditional and novel risk factors for CVD."

Alzheimer's heart link explained

BBC NEWS Health Alzheimer's heart link explained: "Both conditions lead to a reduction of oxygen flow to the brain.
A University of British Columbia team, studying mice, found this stimulates increased development of the protein clumps thought to cause Alzheimer's.
The lack of oxygen increases activity in a gene controlling production of the key protein, found the Proceedings of the National Academy of Sciences study. "

cocoa's medicinal potential

The Standard - Mars talks up cocoa's medicinal potential - World Section: "Mars is holding ''serious discussions with large pharmaceutical companies'' about the development of a line of cocoa-based prescription drugs that could help treat diabetes, some forms of dementia and other ailments. "

Novel Drug Effective for Hyponatremia in Heart Failure Patients

AHA: Novel Drug Effective for Hyponatremia in Heart Failure Patients - CME Teaching Brief® - MedPage Today: "CHICAGO, Nov. 15 -- Tolvaptan, an investigational selective oral vasopressin V2-receptor antagonist, restored serum sodium concentrations in heart failure and cirrhosis patients with hyponatremia, researchers reported here.

Compared with placebo patients in randomized, double blind studies of patients with euvolemic or hypervolemic hyponatremia, serum sodium concentrations increased in the tolvaptan arm by day four and the rise was durable at 30 days (P<0.001), said Mihai Gheorghiade, M.D., of Northwestern University. "

High Uric Acid Levels Signal Hypertension in Blacks

High Uric Acid Levels Signal Hypertension in Blacks - CME Teaching Brief® - MedPage Today:
Primary source: HypertensionSource reference: Mellen PB et al. "Serum Uric Acid Predicts Incident Hypertension in a Biethnic Cohort: The Atherosclerosis Risk in Communities Study." Hypertension. 2006;48:1-6. DOI: 10.1161/01.HYP.0000249768.26560.66
"WINSTON-SALEM, N.C., Nov. 6 -- High serum levels of uric acid are strongly associated with risk for hypertension, particularly among blacks, according to researchers here."

How Important Is Diabetes as a Risk Factor for Cardiovascular and Other Diseases in Older Adults?

PLoS Medicine: How Important Is Diabetes as a Risk Factor for Cardiovascular and Other Diseases in Older Adults?: "I is well established that diabetes mellitus is associated with adverse health outcomes. Data from general population cohorts indicate a 2- to 3-fold increase in cardiovascular risks and about a 50 percent increase in the risks of non-cardiovascular mortality associated with this condition [1–3]. These associations appear largely consistent across populations in different regions of the world [3].
There is some evidence that diabetes may be a more important determinant of cardiovascular risk for women than men [4]. However, the relative effects of diabetes on vascular and other diseases among older, compared with younger, individuals is less certain. Heterogeneity by age in the association between diabetes and cardiovascular disease has been reported, with a consistently weaker association observed among older individuals [3,5]. Given this possible age-dependency in the epidemiological associations, and the frequent observation that cardiovascular risk factors are often managed less aggressively in older people than in younger people [6], a better understanding of the relationship between diabetes and disease-specific causes of death among older people is important./.../"

Atividade Física e Saúde CV

Enviado por: Timóteo Leandro de Araújo [timoteo@celafiscs.org.br]

Gostaria de perguntar sobre alguma informação ou tema sobre o impacto da Prática da Atividade na reunião do SBC?
Encaminho a agenda dos programas que estamos colaborando com a TV Cultura em SP nessa sexta-feira será discutido a AF x Infarto.
Um grande abraço.
dia 03/11 – pgm 15 – AF X prevenção do infarto do miocárdio ( Claudia Forjaz / Dr. Nabil Ghaorayeb / Dr. José Aguilar Cortez)
dia 10/11 – pgm 16 – caminhada + promoção saúde ( Timóteo Araújo / Erinaldo Andrade)
dia 17/11 – pgm 17 – atividade física no setor privado (Dr. Márcio Marega)
dia 24/11 – pgm 18 – atividade física e hipertensão (Dr. Celso Amadeo)
dia 01/12 – pgm 19 – atividade física no setor públici de saúde (Dra. Marizete Medeiros)
dia 08/12 – pgm 20 – atividade física nas Ongs (Dr. Mário Albanese)

Prof. Timóteo Araújo

61. Congresso Brasileiro de Cardiologia

Estivemos em Recife participando do 61 Congresso da SBC.
Entre tantas oportunidades de contato e troca de conhecimento e experiências que podem ser visitados no endereço da SBC e no Congresso Virtual, gostaria de registrar com satisfação a premiação de membros da lista AMICOR: Geniberto Paiva Campos, Carisi Polanckzyc, Nadine Clasusell juntamente com o esposo da Dra. Carisi, Dr. Rohde.
Também gostaria de assinalar que entre os candidatos à presidência da SBC constam ilustres AMICOR: Abrahão Afiune Neto, Flávio Danni Fuchs, Jorge Ilha Guimarães e Paulo César B. Jardim.

Juntamente com vários outros membros de nossa lista tive a satisfação de participar de três atividades:

• Abrindo com uma palestra a primeira sessão de temas livres sobre Epidemiologia, abordando "Ultrapassando o Setor Saúde"
• Coordenando e traçando retrato do tabagismo no BR no simpósio sobre "Tabagismo: Doença Negligenciada" com Analice Gigliotti, Jacqueline Issa e José Miguel Chatkin
• Participando de Sessão Especial sobre Tabagismo Passivo, juntamente com Aristóteles Comte de Alencar Fo. Jacqueline Scholz Issa e Silvia Maria Cury Ismael.

ICMJE - Uniform Requirements for Manuscripts Submitted to Biomedical Journals

ICMJE - Uniform Requirements for Manuscripts Submitted to Biomedical Journals:
(Recebido de Fábio Vilas-Boas, Editor dos Arquivos Brasileiros de Cardiologia)
"A small group of editors of general medical journals met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the National Library of Medicine, were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE gradually has broadened its concerns to include ethical principles related to publication in biomedical journals./.../"

How Important Is Diabetes as a Risk Factor for Cardiovascular and Other Diseases in Older Adults?

PLoS Medicine: How Important Is Diabetes as a Risk Factor for Cardiovascular and Other Diseases in Older Adults?: "Clinical Implications
So what are the implications of the results of this study for clinical practice? Primarily, these data confirm that older adults with diabetes are at very high absolute risk of death from cardiovascular causes (four to five percent per year). Thus, strategies aimed at reducing these risks should be aggressively pursued among such individuals, wherever possible.
Fortunately, a range of preventive treatments of proven efficacy are at our disposal, including blood pressure lowering [9] and the use of statins [10]. Intensive glucose lowering in type 2 diabetes has been shown to reduce microvascular (retinal and renal) events. However, the balance of risks and benefits of lowering haemoglobin A1c levels below seven percent (as recommended by many current guidelines), particularly with respect to macrovascular events such as myocardial infarction and stroke, remains uncertain. At least two large-scale randomised clinical trials evaluating this question are ongoing, one of which has no upper age restriction [11] while the other includes participants aged up to 80 years at randomisation [12]. Importantly, to reach such targets for intensive glucose lowering, insulin therapy will be frequently required. Should the trials demonstrate that the benefits of intensive glucose lowering outweigh the risks, these data, rather than observational data suggesting possible harm associated with the use of insulin, should take precedence in guiding clinical practice."

Investigational Drug Converts Afib to Sinus Rhythm

Teaching Brief® - MedPage Today: "NEW ORLEANS Oct. 16 -- For converting atrial fibrillation to sinus rhythm in patients on rate-control or rhythm-control background therapy, an investigational injectable was effective rapidly for most patients, investigators reported here.
In a pooled analysis of two phase 3 clinical trials, vernakalant (RSD1235) converted atrial fibrillation to a sinus rhythm in a median 10 minutes, and nearly all patients who converted had a persistent sinus rhythm over 24 hours, reported Ian Stiell, M.D., from the University of Ottawa, in Ontario, and colleagues.
Vernakalant is a frequency-dependent Na+ and early-activating K+ channel blocker that 'selectively prolongs the atrial refractory period without significantly altering ventricular refractoriness,' the authors said in a poster presentation at the American College of Emergency Physicians meeting.
The randomized, double-blind, placebo controlled ACT (Atrial Arrhythmia Conversion Trials) I and III studies were designed to study the efficacy and safety of vernakalant in patients using concomitant rate- or rhythm-control medications. /.../"

Additional cardiovascular risk factors associated with excess weigth in children and adolescents: the Belo Horizonte heart study

Arquivos Brasileiros de Cardiologia - Additional cardiovascular risk factors associated with excess weigth in children and adolescents: the Belo Horizonte heart study:
"Robespierre Q. C. Ribeiro; Paulo A. Lotufo; Joel A. Lamounier; Reynaldo G. Oliveira; José Francisco Soares; Denise Aparecida Botter
Universidade de São Paulo e Universidade Federal de Minas Gerais - São Paulo, SP - Minas Gerais, MG
Correspondência

RESUMO
OBJETIVO: Examinar a associação de sobrepeso e obesidade com perfis de atividade física, pressão arterial (PA) e lípides séricos. MÉTODOS: Inquérito epidemiológico com 1.450 estudantes – seis a dezoito anos, em Belo Horizonte-MG. Dados: peso, altura, PA, espessura de pregas cutâneas, circunferência das cinturas, atividade física, colesterol total (CT), LDL-c, HDL-c, e hábitos alimentares. RESULTADOS:Prevalências de sobrepeso e obesidade foram 8,4% e 3,1%. Em relação aos estudantes situados no quartil inferior (Q1) da distribuição da prega subescapular, os estudantes do quartil superior (Q4) apresentaram um risco (odds ratio) 3,7 vezes maior de ter um CT aumentado. Os estudantes com sobrepeso e obesos tiveram 3,6 vezes mais risco de apresentar PA sistólica aumentada, e 2,7 vezes para PA diastólica aumentada, em relação aos estudantes com peso normal. Os estudantes menos ativos, no Q1 da distribuição de MET, apresentaram 3,8 vezes mais riscos de terem CT aumentado comparados com os mais ativos (Q4). CONCLUSÃO: Estudantes com sobrepeso ou obesos ou nos quartis superiores para outras variáveis de adiposidade, assim como os estudantes com baixos níveis de atividade física ou sedentários apresentaram níveis mais elevados de PA e perfil lipídico de risco aumentado para o desenvolvimento de aterosclerose"

Walnuts may be heart-healthy nuts

Teaching Brief® - MedPage Today: "
MedPage Today Action Points
Explain to interested patients that walnuts contain alpha-linoleic acid (a plant-based omega-3 fatty acid) and other "cardioprotective constituents" such as L-arginine and antioxidants.
Caution patients that the study looked at the effect of walnuts or olive oil added to a fatty meal in individuals on an otherwise healthy Mediterranean diet, rather than the effect on individuals who repeatedly ate high fat content meals, and did not deal with weight gain.

Review
BARCELONA, Spain, Oct. 10 -- Walnuts may be heart-healthy nuts, suggest Spanish researchers.
While both raw walnuts and olive oil decreased the sudden onset of arterial inflammation and oxidation after an unhealthy meal, the walnuts were better at keeping arteries flexible, they found.
But patients should not take this as an excuse to regularly eat fat-filled meals, followed by a handful of walnuts, said Emilio Ros, M.D., Ph.D., of the Lipid Clinic at Hospital Clínico here, and colleagues, in the Oct. 17 Journal of the American College of Cardiology.
The study, they pointed out, was small, and it looked at the effect of a single meal on individuals whose regular fare was a healthy Mediterranean diet.
Yet study participants had better arterial elasticity after a walnut-containing meal than an olive oil-containing meal. For those with moderately high cholesterol, postprandial flow-mediated dilation of the brachial artery was:
Improved by 24% when they ate walnuts with their high-fat meal (4.1% dilation before meal to 5.1% after), but
Impaired by 36% when they ate olive oil with the meal instead (3.6% dilation before meal to 2.3% after).
For individuals with normal cholesterol levels, the postprandial flow-mediated dilation was:
Unchanged in participants with normal cholesterol levels when they ate walnuts with the meal (4.2% dilation before meal to 4.2% after),
But impaired by 17% after they ate the olive oil-containing meal (4.7% dilation before meal to 3.9% after). /.../"

Psoriasis Increases Risk for Myocardial Infarction

Psoriasis Increases Risk for Myocardial Infarction - CME Teaching Brief® - MedPage Today: "PHILADELPHIA, Oct. 10 -- Psoriasis appears to be an independent risk factor for myocardial infarction, especially for younger patients with severe disease, researchers reported.
Action Points:
Encourage psoriasis patients to aggressively control their modifiable cardiovascular risk factors.
Younger patients, 30 to 40 years old, with severe psoriasis had almost twice the risk of an MI compared with similar patients without psoriasis. By contrast, 60-year-old patients with severe disease had only a 36% increased MI risk, reported Joel Gelfand, M.D., of the University of Pennsylvania here, and colleagues in the Oct. 11 issue of the Journal of the American Medical Association.
These findings came from a prospective, population-based cohort study in the United Kingdom comparing 556,995 controls and 127,139 patients with mild psoriasis and 3,837 with severe disease, in which the researchers controlled for major cardiovascular risk factors. The data have been used widely in epidemiological studies. "

eMJA: Prevention of cardiovascular disease: an evidence-based clinical aid 2004

eMJA: Prevention of cardiovascular disease: an evidence-based clinical aid 2004: "
(Referred by Marcelo Colominas )

Cardiovascular disease is the leading cause of morbidity and mortality in Australia. It is therefore important that all medical practitioners are familiar with the well documented risk factors for cardiovascular disease, as well as the outcome benefits of pharmacological and other interventions.

The large and ever-increasing body of clinical evidence, the range of patient groups at risk and the plethora of recommended interventions all make it increasingly difficult for busy doctors to adopt an integrated approach to prevention of vascular events. While absolute risk calculators, such as the Framingham Heart Study Prediction Score Sheets (www.nhlbi.nih.gov/about/framingham/riskabs.htm) or the New Zealand Cardiovascular Risk Factor Calculator (www.racp.edu.au/bp/resources/EBM_cardio.pdf), enable doctors to assign overall risk, guidelines for management are usually focused on single interventions. Moreover, the continual emergence of new data on vascular risk management redefines risk categories and approaches to risk management.

Prevention of cardiovascular disease: an evidence-based clinical aid was developed by a multidisciplinary group of physicians to address this issue and was first published by the MJA in July 2003. We have revised and updated our evaluation of current best practice based on a rigorous analysis of available published evidence to March 2004, and formulated a concise and up-to-date guide for the prevention of cardiovascular disease. This consensus of opinions is summarised in this document (see Clinical aid, page F12) and provided as a single-page chart for use in clinical practice as a desktop reference.

Patients were classified as being either at high or low risk of cardiovascular events (Box 1). It is widely considered that high-risk patients are those with clinically evident vascular disease, renal disease, diabetes or other risk factors conferring an annual risk of a future event of 2%–3% or greater. Risk can be calculated using an absolute risk-factor calculator (see above).

"

American College of Radiology Clinical Statement on Noninvasive Cardiac Imaging

(Referred by Marcelo Colominas [mgcolominas@gigared.com])
Coronary artery disease (CAD) and other acquired and congenital cardiac diseases are major medical and socioeconomic problems. CAD affects 13.2 million Americans and was responsible for 502 189 deaths in 2001. In 2004, the direct and indirect economic impact of CAD was in excess of $120 billion, which was about one-third of the total costs attributable to cardiovascular diseases (1).
Historically, imaging has had a critical role in the diagnosis and evaluation of acquired and congenital cardiac disease, beginning with chest radiography and fluoroscopy and progressing to coronary angiography and cardiac catheterization, ultrasonography (echocardiography), and nuclear medicine. All of these modalities have a well-established role in patient care. Computed tomography (CT), with multidetector CT and electron-beam technology, and magnetic resonance (MR) imaging, with appropriately equipped imagers, now can image the coronary arteries, cardiac chambers, valves, myocardium, and pericardium and can help assess cardiac function. Thus, CT and MR imaging will have an increasing role in comprehensive cardiac imaging./.../

DIA MUNDIAL DO CORAÇÃO

DIA MUNDIAL DO CORAÇÃO
(Artigo enviado para o jornal ZH mas não publicado)
Como o fazem anualmente desde 1999 a Federação Mundial de Cardiologia, junto com a OMS, a UNESCO e a Organização dos Esportes para o Desenvolvimento e Paz da ONU, designaram o dia 24 de setembro neste ano como o Dia Mundial do Coração.
O tema é: “Quão Jovem está seu Coração?” com o propósito de incentivar hábitos saudáveis de vida para evitar o envelhecimento precoce do sistema cardiovascular.
Em todo o mundo as doenças crônicas – entre as quais se situam as cardiovasculares – se constituem em problema de saúde pública, cada vez mais importante na medida em que as pessoas vivem mais e o coração e o resto do sistema vascular se deterioram prematuramente. Este não é um triste privilégio de países ricos e ditos desenvolvidos. As populações mais pobres e menos desenvolvidas, em toda a parte, terminam adoecendo mais e vivendo menos. A falta de perspectiva na vida, a ignorância e a miséria fazem mal para a saúde em todos os seus aspectos e em qualquer lugar.
Recentemente através de um grupo de trabalho concluímos um estudo para avaliar o impacto econômico das Doenças Cardiovasculares em quatro países: África do Sul, Brasil, China e Índia. O componente brasileiro está situado no Instituto de Educação e Pesquisa do Hospital Moinhos de Vento.
O ano de 2004 contava com dados suficientes para efetuar os cálculos necessários. Naquele ano o Produto Interno Bruto do Brasil foi de mais de um trilhão e setecentos bilhões de Reais. E ficou em torno de 30 bilhões o impacto global estimado destas doenças, (medicamentos, hospitalizações, licenças, aposentadorias e perda de produção). Conta-se uma de cada três mortes; e só de anos de vida saudável perdidos por ano (incapacidade e morte precoce) são cerca de 5 milhões a cada ano.
Outros dois estudos, comparando as regiões do país e comparando os distritos de Porto Alegre, mostraram também nítida correlação negativa com o nível de desenvolvimento da população residente depois de corrigidos possíveis fatores de confusão. Quanto menos educada e mais pobre a população, mais mortes por doenças do coração e mais cedo.
Não basta tratar depois que os sintomas aparecem. É preciso prevenir e não são suficientes os especialistas, consultórios e hospitais. O esforço precisa ser coletivo, na família, na escola, nas empresas, no trabalho, no lazer, nos “shoppings” – onde haja espaço onde as pessoas possam se reunir em busca de melhor qualidade de vida.
Este é um problema também nosso, é mais grave entre os mais pobres, caro de tratar, impacta na produção e pode ser prevenido. Nosso Estado foi pioneiro no Brasil incorporando há 30 anos as doenças cardiovasculares e outras crônicas na agenda da saúde pública. Vamos fazer de Porto Alegre também uma cidade de corações jovens. Investir em saúde é também um investimento econômico.

Aspirin: Primary Prevention

American Journal of Cardiology:
(Recommended by Marcelo Gustavo Colominas [mgcolominas@hotmail.com]
"Until recently, 5 major studies have formed the basis for the use of aspirin (acetylsalicylic acid) in primary prevention of cardiovascular (CV) events. Despite these data, the role of aspirin in primary prevention has not been established firmly. Six randomized trials have evaluated the benefits of aspirin for the primary prevention of CV events: the British Doctors’ Trial, the Physicians’ Health Study, the Thrombosis Prevention Trial, the Hypertension Optimal Treatment study, the Primary Prevention Project, and the Women’s Health Study. The combined sample consists of 47,293 subjects on aspirin and 45,580 not on aspirin or placebo. A meta-analysis of these 6 trials assessed 6 CV end points: total coronary heart disease (CHD), nonfatal myocardial infarction (MI), total CV events, stroke, CV mortality, and all-cause mortality. No covariate adjustment was performed and appropriate tests for treatment effect, heterogeneity, and study size bias were applied. Using odds ratios and confidence intervals, the meta-analysis suggested superiority of aspirin for total CHD, nonfatal MI, and total CV events (p ≤0.001 in each case), with a nonsignificant trend (0.07 <>0.05). Given the study size and cohort, aspirin decreased the risk of CV events in this large patient sample. In conclusion, primary prevention with aspirin decreased the risk of total CHD, nonfatal MI, and total CV events, but there were no significant differences in the incidences of stroke or CV mortality."

Ulcer Risk From Aspirin Use May Outweigh Cardiac Benefits - CME Teaching Brief® - MedPage Today

Ulcer Risk From Aspirin Use May Outweigh Cardiac Benefits - CME Teaching Brief® - MedPage Today: "BOSTON, Sept.20 -- Low-dose aspirin for cardioprotection may cause one extra case per year of gastrointestinal ulcers in every 50 aspirin users, but only in certain high-risk groups, researchers reported.
The study, reported in the Sept. 20 issue of BMC Medicine, is intended as a physician alert, because as the researchers noted, it was not possible to weigh gastrointestinal complications, such as bleeding or perforated ulcers, against actual cardiovascular risks.
For men older than 70 with a history of peptic ulcer, the excess risk was estimated at 20 extra cases per 1,000 aspirin users per year, said Sonia Hernández-Diaz, M.D., of the Harvard School of Public Health here and Luis A.G. Rodriguez of Centro Español de Investigación Farmacoepidemiológica in Madrid. "

Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion

American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion. A Report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. Developed in Collaboration With the Heart Rhythm Society
WRITING COMMITTEE MEMBERS, Cynthia M. Tracy, Masood Akhtar, John P. DiMarco, Douglas L. Packer, Howard H. Weitz, TASK FORCE MEMBERS, Mark A. Creager, David R. Holmes, Jr, Geno Merli, George P. Rodgers, ynthia M. Tracy, and Howard H. Weitz
Circulation published 20 September 2006,
10.1161/CIRCULATIONAHA.106.178893
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.106.178893v1?papetoc

Cardiac Cell Therapy -- Mixed Results from Mixed Cells

NEJM -- Cardiac Cell Therapy -- Mixed Results from Mixed Cells: "Despite substantial advances in treatment, ischemic cardiac injury and the ventricular dysfunction it can provoke remain major causes of morbidity and mortality throughout the world. The endogenous regenerative capacity of the heart appears inadequate to repair injured myocardium, leading to the cumulative loss of cardiomyocytes over the lifetime of a patient. This may contribute to the prevalence of heart failure as a diagnosis at hospital admission — particularly among the elderly.
For these reasons, experiments in animals suggesting that the transfer of cells derived from bone marrow (BMC) could dramatically improve cardiac function after infarction through regeneration of the myocardium1 or neovascularization2 generated tremendous excitement. In addition, they stimulated clinical studies suggesting that this approach is feasible, safe, and potentially effective in humans.3,4 In this issue of the Journal, Schächinger et al.,5 Assmus et al.,6 and Lunde et al.7 — following authors of other recent reports8,9 — provide a realistic perspective on this approach while leaving room for cautious optimism and underscoring the need for further study (Table 1). "

Prostate Cancer Therapy Linked to Diabetes and Heart Disease - CME Teaching Brief® - MedPage Today

Prostate Cancer Therapy Linked to Diabetes and Heart Disease - CME Teaching Brief® - MedPage Today: "BOSTON, Sept. 19 -- Androgen deprivation with a GnRH agonist for local or regional prostate cancer is associated with an increased risk of diabetes, coronary heart disease, heart attack, and sudden cardiac death, according to researchers here.
An observational analysis of more than 73,000 men with local or regional disease showed that treatment with a gonadotropin-releasing hormone (GnRH) agonist increases the risk of diabetes by 44%, with smaller increases in the risks of cardiovascular disease, according to Nancy Keating, M.D., of Harvard Medical School and Brigham and Women's Hospital.
As they make treatment decisions about locoregional disease, 'patients and physicians need to be aware of the elevated risk' of a GnRH agonist, Dr. Keating said. "

Physiological Assessment of Coronary Artery Disease in the Cardiac Catheterization Laboratory:

Physiological Assessment of Coronary Artery Disease in the Cardiac Catheterization Laboratory: A Scientific Statement From the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology -- Kern et al. 114 (12): 1321 -- Circulation: "With advances in technology, the physiological assessment of coronary artery disease in patients in the catheterization laboratory has become increasingly important in both clinical and research applications, but this assessment has evolved without standard nomenclature or techniques of data acquisition and measurement. Some questions regarding the interpretation, application, and outcome related to the results also remain unanswered. Accordingly, this consensus statement was designed to provide the background and evidence about physiological measurements and to describe standard methods for data acquisition and interpretation. The most common uses and support data from numerous clinical studies for the physiological assessment of coronary artery disease in the cardiac catheterization laboratory are reviewed. The goal of this statement is to provide a logical approach to the use of coronary physiological measurements in the catheterization lab to assist both clinicians and investigators in improving patient care."

CT Angiography Warrants Paradigm Shift in Nuclear Cardiology

ASNC: CT Angiography Warrants Paradigm Shift in Nuclear Cardiology - CME Teaching Brief® - MedPage Today: "'The first test in the future of the evaluation of the patient, be it symptomatic or asymptomatic, will be a CTA rather than a stress test because it's more accurate, provides more information, and avoids patients having unnecessary cardiac catheterizations which follows in a substantial number of patients who undergo stress testing because of the high false positive rate,'"

Green Tea Found to Cut All-Cause and Cardiovascular Mortality - CME Teaching Brief® - MedPage Today

Green Tea Found to Cut All-Cause and Cardiovascular Mortality - CME Teaching Brief® - MedPage Today: "SENDAI, Japan, Sept. 12 -- Cup after cup of green tea earned a high grade for reducing all-cause and cardiovascular mortality in a study here, but cancer mortality drew a blank.
Compared with participants who consumed less than one cup of green tea a day, those who drank five or more cups had a risk of all-cause mortality that was 16% lower during 11 years of follow-up and 26% lower for cardiovascular deaths during seven years of follow-up, according to a report in the Sept. 13 issue of JAMA."

Would You Still Recommend Drug-Eluting Stents? -

Survey: Would You Still Recommend Drug-Eluting Stents? - CME Teaching Brief® - MedPage Today: "Drug-eluting stents essentially eliminated short-term restenosis as a complication of coronary angioplasty, but suddenly the coated devices have come under a cloud for possible late-term risks.
Cardiologists attending the European Society of Cardiology/World Congress of Cardiology in Barcelona last week were shocked by meta-analyses data that raised serious questions about the long-term safety of the devices.
This Medpage Today survey asks for your opinion about whether you still have confidence in the elective use of drug-eluting stents. "
Additional Stent Coverage from ESC:
Meta-Analyses Find Increased Death and MI with Cypher Stent
Real World Trial Confirms Drug-Eluting Stents Better in Small Vessels
Investigational Drug-Eluting Stent Superior to Taxus
Drug-Eluting Stent Debate Develops Fever Pitch http://www.medpagetoday.com/2005MeetingCoverage/2005ESCCongress/dh/4075

Promoting Physical Activity in Children and Youth: A Leadership Role for Schools: A Scientific Statement From the American Heart Association Council o

Promoting Physical Activity in Children and Youth: A Leadership Role for Schools: A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism (Physical Activity Committee) in Collaboration With the Councils on Cardiovascular Disease in the Young and Cardiovascular Nursing -- Pate et al. 114 (11): 1214 -- Circulation: "Schools have played a central role in the provision of physical activity to American children and youth for more than a century. Physical education (PE) has been an institution in American schools since the late 1800s,1 and school sports have been a growing component of the educational enterprise since the early 1900s. Traditionally, students have engaged in physical activity during recess breaks in the school day and by walking or riding bicycles to and from school. However, as we move into the 21st century, alarming health trends are emerging, suggesting that schools need to renew and expand their role in providing and promoting physical activity for our nation’s young people.

Over the past 20 years, obesity rates in US children and youth have skyrocketed. Among children ages 6 to 11, 15.8% are overweight (≥95th percentile body mass index [BMI] for age) and 31.2% are overweight or at risk for overweight (≥85th percentile BMI for age).2 Among adolescents ages 12 to 19, 16.1% are overweight (≥95th"

Atrial fibrillation ablation: State of the art

Atrial fibrillation ablation: State of the art: "Atrial fibrillation (AF) is a common and recurrent arrhythmia that can result in significant morbidity and mortality [1]. Pharmacological therapy used to control rate or to achieve and maintain normal sinus rhythm is of limited efficacy, and can result in serious side effects including proarrhythmia and death [2-4]. Although ablation of the AV node and implantation of a permanent pacemaker can provide effective rate control, this loss of atrioventricular synchrony renders the patient dependent on the pacemaker and will require lifelong anticoagulation therapy. "

Framingham Gene Hunt

DATABASE:
(from: http://www.sciencemag.org/content/vol313/issue5792/netwatch.dtl)
The race to find the genes behind common ailments is heating up as many research groups scan patients' entire genomes for markers linked to disease. When it opens later this month, the Genomic Medicine Database (GMED) from Boston University (BU) will showcase such results from 1320 participants in the famed Framingham Heart Study, which has followed the health of a small Massachusetts town for 50 years. You can peruse the chromosomes for possible associations between about 10 traits--such as hypertension and high cholesterol levels--and 100,000 genetic markers, known as SNPs. Click to zoom in on the genes near a SNP. The BU team is posting data before publication so that other researchers can quickly seek to replicate the findings, says GMED co-curator Marc Lenburg. "Our hope is that others will follow our lead" and share unpublished data, he says.
gmed.bu.edu

Treatment of elderly patients with minor ischaemic attacks is inadequate

Treatment of elderly patients with minor ischaemic attacks is inadequate -- 333 (7567): 0 -- BMJ: "Patients aged 80 or older with transient ischaemic attack or minor ischaemic stroke have an increased incidence of symptomatic carotid stenosis but are substantially underinvestigated and undertreated. Fairhead and Rothwell (p 525) compared the management of a total of over 680 000 patients undergoing carotid imaging either in a vascular study (in which all patients were investigated as per published guidelines) or in routine clinical practice in secondary care services. In the group aged 80, rates of carotid imaging, diagnosis of > 50% symptomatic stenosis, and carotid endarterectomy were substantially lower in routine clinical practice. "

Drug-Eluting Stent Debate

ESC/WCC: Drug-Eluting Stent Debate Develops Fever Pitch - CME Teaching Brief® - MedPage Today: "BARCELONA, Spain, Sept 5 -- The long-term safety of drug-eluting stents suddenly eclipsed all other concerns this week at the world's largest gathering of cardiologists.
Many of the more than 25,000 cardiologists meeting here are shaking their heads in disbelief at the meta-analysis data that raised serious questions about the long-term safety of the coated devices.
The two meta-analyses reported Sunday at the Europeans Society of Cardiology/World Congress of Cardiology have highlighted 'the dark side of drug-eluting stents,' as Robert Harrington, M.D., of Duke put it.
Dr. Harrington's 'dark-side' is the finding that first generation drug-eluting stents are associated with an increased risk of late stent thrombosis, an increased cardiac mortality, an increased risk of myocardial infarction, and an increased risk of all cause mortality.
But even as every hallway buzzed with the grim potentialities, should the meta-analyses be borne out by prospective randomized studies, a new positive report emerged about the drug-eluting stents. This was a report of an investigational device showing that that it was superior to one of the two already approved stents.
That device is just one of a handful of second- and third- generation drug-eluting stents wending their way through the approval process.
Weighing the darker and the brighter sides of drug eluting stents has been the focus of heated discussions here, inside and outside the sessions.
An estimated six million of the first generation drug eluting stents-Cypher, a sirolimus-eluting stent, and Taxus, which elutes paclitaxel-have been implanted.
The meta-analyses reported here found that Cypher had significant risks compared with bare metal stents" /.../

BP-lowering effects of aliskiren are additive to amlodipine, persist after withdrawal

BP-lowering effects of aliskiren are additive to amlodipine, persist after withdrawal: ", Spain - A pooled data analysis of antihypertensive treatment with the still-investigational oral renin inhibitor aliskiren (Rasilez, Novartis) in more than 8000 patients suggest that the drug reduces blood pressure (BP) effectively regardless of age or gender, is well tolerated, and appears to be additive to most other antihypertensive agents, with the exception of angiotensin receptor blockers [1].
Dr Matthew R Weir (University of Maryland School of Medicine, Baltimore) presented the pooled analysis of results to date with this new antihypertensive agent.
'Obviously, the hope is that the mechanism of action will provide an incremental opportunity in a sense to tame the renin angiotensin system and better facilitate risk reduction with regard to cardiovascular and kidney disease progression,' he concluded. "

How Sudden Is Sudden Cardiac Death

How Sudden Is Sudden Cardiac Death? -- Müller et al., 10.1161/CIRCULATIONAHA.106.616318 -- Circulation: "Background--Out-of-hospital sudden cardiac death (SCD) is a frequent cause of death. Survival rates remain low despite increasing efforts in medical care. Better understanding of the circumstances of SCD could be helpful in developing preventive measures and facilitating proper reactions to such a pending event.
Methods and Results--Information on cases of out-of-hospital SCD was collected in the Berlin, Germany, emergency medical system via a questionnaire. Bystander interviews were performed by the emergency physician on scene immediately after declaration of death or return of circulation. Of 5831 rescue missions, 406 involved patients with presumed cardiac arrest. Sixty-six percent had a known cardiac disease. In 72%, the arrest occurred at home, and in 67%, it occurred in the presence of an eyewitness. Information on symptoms immediately preceding the arrest was available in 80% (n=323) of all 406 patients and in 274 of those with witnessed arrest. Symptoms were identical in the 2 groups. Typical angina was present for a median of 120 minutes in 25% of the 274 patients with witnessed arrest and in 33% with a symptom duration of less than 1 hour.
Conclusions--SCD occurs most often at home in the presence of relatives and after a longer period of typical warning symptoms. Although the much-hailed use of public access defibrillation is supported by several studies, the present results raise the question of whether educational measures and targeted educational programs tailored for patients at risk and their relatives should have a higher priority.

Key words: death, sudden • resuscitation • myocardial infarction • defibrillation "

EUROACTION: Cardiologists should champion prevention as well as cure

EUROACTION: Cardiologists should champion prevention as well as cure:

"Sep 3, 2006
Lisa Nainggolan
Barcelona, Spain - Results from the largest-ever European-wide preventive cardiology project, EUROACTION, show that a nurse-led multidisciplinary team approach, together with the support and involvement of a patient's family, can generate significant lifestyle improvements and risk-factor reductions in coronary patients and those at risk of developing cardiovascular disease.
The message for cardiologists, says lead investigator Dr David Wood (Imperial College, London, UK), "is that you need to match your PCIs with a preventive program." Wood presented the results of EUROACTION today at the hotline session during the World Congress of Cardiology 2006.
"What we now know is that there has been a collective failure of medical practice to address lifestyle and risk-factor targets. We have clearly demonstrated that this nurse-led program works in a wide range of European countries, in ordinary general hospitals and GP surgeries," he told heartwire. "On the basis of these impressive results, we are going to talk to the national cardiology societies to discuss how we can implement this," he added.
Dr Thomas A Pearson (University of Rochester, NY), who was the discussant for the study, said EUROACTION "will become the benchmark to improve upon. It joins a list of landmark studies of implementation of what we already know from intervention studies."
Eight countries and almost 9000 patients
EUROACTION spanned eight countries—Denmark, France, Italy, the Netherlands, Poland, Spain, Sweden, and the UK—and 24 hospital and general practice centers, in a cluster randomized trial. It addressed the cardiovascular health of more than 8500 patients—half of whom already had coronary heart disease (recruited in hospitals) and half of whom were deemed high risk (from GP practices)—and compared outcomes with "usual-care" patients.
Unusually, partners were also included, something Pearson said was "particularly novel." The EUROACTION nurses performed complete lifestyle and risk-factor assessment of patients and partners and then supported them in making lifestyle changes. Advice was issued according to European preventive cardiology guidelines published in 2003 [1].
In hospitals, this involved regular one-to-one meetings as well as group workshops with members of a multidisciplinary team (including dieticians, physiotherapists, and cardiologists). For the high-risk patients, advice was given by nurses and GPs alone.
Significant improvements were observed after one year, not only in the EUROACTION patients but also in their partners, compared with patients treated by usual care and their partners, across a number of key lifestyle and risk factors.
Significantly more patients in both groups met physical-activity targets, reduced weight, reached blood-pressure goals, and improved use of cardioprotective therapies compared with usual-care patients.
For diet, significant improvements were seen in all three areas—increasing consumption of fruits and vegetables, eating more oily fish, and reducing saturated fat intake—in the coronary patients. For the high-risk patients, only fruit and vegetable intake was significantly improved compared with usual-care patients.
Hospital patients achieved significant reductions in waist circumference, but the GP patients did not, compared with usual care. For LDL-cholesterol levels, the opposite was true—the high-risk GP patients achieved significant reductions but the hospital coronary patients did not, compared with usual-care patients.
Smoking cessation was not significantly improved in either group compared with usual-care patients, but the hospital patients "came quite close with a p-value of 0.06," Wood told heartwire.
Even though significance was not achieved in some key areas, the trends were all in the right direction, he noted, adding that the study was underpowered.
Pearson observed that this "is a difficult kind of research to do. It's a different kettle of fish from efficacy studies."
The partners varied in their abilities to achieve targets but came out significantly better than the partners of the usual-care patients for fruit and vegetable consumption and physical activity.
Cost-effectiveness analysis planned
Wood also revealed that EUROACTION included a cost-effective analysis, with results expected in six months.
"This unique project has shown we can raise standards of preventive cardiology care for coronary and high-risk metabolic patients and their families in everyday care," he commented.
European Society of Cardiology president Dr Michal Tendera said: "It is now up to us to follow the EUROACTION example and work to establish similar prevention programs in every general hospital and GP practice so that patients across Europe can achieve the best possible care."
Source
De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2003; 24 (17): 1601-1610.
Related link
EuroAction Demonstration Project in Preventive Cardiology