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Query: UMLS:C0004153 (atherosclerosis)
 77,401 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Cardiovascular primary prevention may consist of strategies concerning the entire population (population strategy) or individuals at high risk for a cardiovascular event (high risk strategy). Clinicians are mainly involved in the identification and treatment of high risk individuals. Even more so, preventive measures should be focused on patients who are already affected by coronary artery disease (CAD) or other manifestations of atherosclerosis (secondary prevention). According to the beneficial effect anticipated by cardiovascular prevention, there should be a priority list guiding the therapeutic measures: first priority therapy should be reserved for patients with existing CAD, then persons without CAD symptoms at high risk for disease manifestation due to an accumulation of coronary risk factors (hypercholesterolemia, hypertension, smoking, diabetes mellitus, lack of physical activity, adipositas) should be treated. Third priority for preventive therapy for cardiovascular diseases is reserved for asymptomatic 1st degree relatives of CAD patients with an early onset CAD. Fourth priority have persons who are close relatives of high risk individuals, and fifth priority prevention is cardiovascular risk factor assessment in the general population. Estimation of the risk for future cardiovascular events is very important because it provides a rational basis for the necessity and relevance of a treatment strategy. In this review, several therapeutic options for cardiovascular prevention are described and discussed.
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PMID:[Cardiovascular risk patient--how much prevention is necessary and rational?]. 952 31

Lumbar spine stenosis most commonly affects the middle-aged and elderly population. Entrapment of the cauda equina roots by hypertrophy of the osseous and soft tissue structures surrounding the lumbar spinal canal is often associated with incapacitating pain in the back and lower extremities, difficulty ambulating, leg paresthesias and weakness and, in severe cases, bowel or bladder disturbances. The characteristic syndrome associated with lumbar stenosis is termed neurogenic intermittent claudication. This condition must be differentiated from true claudication, which is caused by atherosclerosis of the pelvofemoral vessels. Although many conditions may be associated with lumbar canal stenosis, most cases are idiopathic. Imaging of the lumbar spine performed with computed tomography or magnetic resonance imaging often demonstrates narrowing of the lumbar canal with compression of the cauda equina nerve roots by thickened posterior vertebral elements, facet joints, marginal osteophytes or soft tissue structures such as the ligamentum flavum or herniated discs. Treatment for symptomatic lumbar stenosis is usually surgical decompression. Medical treatment alternatives, such as bed rest, pain management and physical therapy, should be reserved for use in debilitated patients or patients whose surgical risk is prohibitive as a result of concomitant medical conditions.
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PMID:Lumbar spine stenosis: a common cause of back and leg pain. 993 Jan 24

Cardiovascular disease is the leading cause of morbidity and mortality in Westernized populations. Evolving lipoprotein risk factors include LDL oxidation and lipoprotein(a) [lp(a)]. Several lines of evidence support a role for oxidatively modified LDL in atherogenesis and its in vivo existence. There are both direct and indirect measures of oxidative stress. The most relevant direct measure of lipid peroxidation is urinary F2 isoprostanes. The most common indirect measure of LDL oxidation is quantifying the lag phase of copper-catalyzed LDL oxidation by assaying conjugated diene formation. Lp(a) is increased in patients with cardiovascular and cerebrovascular disease. However, not all prospective studies have confirmed a positive relationship between Lp(a) and cardiovascular events. Lp(a) appears to present three major problems: standardization of the assay, establishing its role in atherogenesis, and the lack of an effective therapy that can substantially lower Lp(a) concentrations. Thus, at the present time, Lp(a) concentrations should not be recommended for the general population but be reserved for patients with coronary artery disease without established risk factors, young patients with coronary artery disease or cerebrovascular disease, or a family history of premature atherosclerosis and family members of an index patient with increased concentrations of Lp(a). Although both LDL oxidation and Lp(a) are evolving risk factors for cardiovascular disease, more data are needed before they become part of the established lipoprotein repertoire.
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PMID:Evolving lipoprotein risk factors: lipoprotein(a) and oxidized low-density lipoprotein. 970 92

The importance of glycemic control in reducing the microvascular complications of type 1 diabetes has been clearly demonstrated with a long-term prospective, randomized interventional trial. The data are not as strong with regards to type 2 diabetes. The results of several prospective studies and one interventional study, however, all report benefits of improved glycemic indices on reducing microvascular complications. The available literature evaluating the relationship between glycemic control and macrovascular disease in type 1 and type 2 diabetes demonstrates the importance of glucose control. One could make rational scientific arguments or criticize the design and interpretations of any one individual study. Yet collectively the evidence is powerful. Additionally, there have been no negative studies reported. Lowering the glycosylated hemoglobin to less than 2 percentage points above the upper limit of normal should be the first glycemic goal for most patients with diabetes. Obviously, some patients cannot obtain this degree of control for a variety of reasons. Moreover, the intensity of therapy needs to be individualized and tailored to each patient. In addition, intensive glycemic control does not necessarily mean multiple injections or insulin pumps or home glucose monitoring 10 times a day. Intensive glycemic control means that the glycohemoglobin (hemoglobin and A1C and blood glucose values are in a normal or near-normal range, no matter how simple or how complex the treatment regimen. The most controversial issue is with regards to the relationship between hyperinsulinemia and accelerated atherosclerosis. This association is not consistently found in many of the large prospective studies, and certainly there has never been a direct cause-and-effect relationship proven. Most experts in the field recommend that insulin be reserved for patients with type II diabetes when oral therapy cannot achieve near-normal glycemic control. Weight gain and hypoglycemia are adverse effects of sulfonylurea and insulin therapy. These adverse effects are dwarfed, however, by the acute and chronic complications of poorly controlled diabetes. Lastly, estimates on the economic benefits of reducing long-term microvascular and macrovascular complications in populations are staggering. Based on the available literature, all patients with diabetes should be educated and have access to an appropriate individualized treatment regimen with the goal to normalize or near-normalize glycemic control. This should be the standard of care until proven otherwise.
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PMID:Importance of glucose control. 970 16

The major goal of the evaluation and management of DLP in children is to provide safe and effective therapy with lifestyle modification. There is a strong rationale for the initiation of DLP treatment in childhood to limit the earliest stages of atherosclerosis, to establish lifelong lifestyle changes in diet and activity, and to limit the acquisition of additional CVD risk factors such as smoking and obesity. The NCEP has recommended screening for children with a parent with total cholesterol of 240 mg/dL or greater or a parent or grandparent with onset of CVD before age 55 years. Clinical evaluation and management are based on an LDL-C level of 130 mg/dL or greater. This approach to screening has a low sensitivity to identify children with DLP. Initial therapy is with a step 1 diet followed by the step 2 diet if necessary. Medications are reserved for older children with LDL-C of 190 mg/dL or greater after diet therapy or 160 mg/dL or greater with other CVD risk factors.
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PMID:Evaluation and management of dyslipoproteinemia in children. 978 58

Approximately 150 million people worldwide have diabetes mellitus, of whom 90% are type II diabetics. It is therefore of no surprise that diabetic nephropathy has become the leading cause of end-stage renal disease. Opposite to what has been known previously, kidney disease is at least as common in type II as in type I diabetes. However, because the majority of type II diabetics has hypertension for many years before diabetes mellitus becomes clinically relevant, renal lesions are often heterogeneous with frequent exclusive presence of ischemic changes. For the treatment of hypertension in diabetics without nephropathy (no microalbuminuria), drugs that exert beneficial effects or are at least neutral with respect to lipid and glucose metabolism, such as ACE inhibitors, angiotensin II-receptor antagonists, non-dihydropyridine-calcium channel blockers and the thiazide-like indapamide, are to be preferred. Although metabolically neutral, dihydropyridine calcium channel blockers should be used with caution, since an increase in cardiovascular morbidity and mortality in type II diabetics treated with these compounds has most recently been described. Once that diabetic nephropathy is established, blood pressure should be lowered to 120/80 mmHg (measured in seated position). Antihypertensive treatment should primarily be based on ACE inhibitors; angiotensin II-receptor antagonists are a valuable alternative if ACE inhibitors are not tolerated. Both ACE inhibitors and angiotensin II-receptor antagonists should be used with high caution in elderly patients with severe atherosclerosis in whom acute renal failure could occur due to the presence of bilateral renal artery stenosis. Newer studies indicate that non-dihydropyridine calcium channel blockers such as verapamil and diltiazem may be as effective as ACE inhibitors in preserving renal function in diabetic nephropathy. A fix-dose combination of the ACE inhibitor trandolapril with verapamil is now available; it should be reserved for patients whose blood pressure and/or proteinuria can not be adequately controlled with ACE inhibitors. Finally, indapamide is the only antihypertensive diuretic with nephroprotective properties.
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PMID:[Antihypertensive therapy in diabetes mellitus]. 1006 31

Specific treatment that primarily reduces low density lipoprotein cholesterol (LDLc) levels improves survival of patients with pre-existing vascular disease by 20-30%. Failure to produce a more marked improvement in outcome is most likely explained by: (1) the observation from angiographic studies that established atherosclerotic vascular disease (AVD) is largely irreversible with current therapy and (2) other important factors cause AVD besides LDLc. One such risk factor predicting development of AVD is the atherogenic lipoprotein phenotype (ALP), comprising abnormalities of triglyceride enriched lipoproteins, high density lipoprotein cholesterol (HDLc) and small dense LDL particles. Despite strong links between the ALP and AVD, the mechanism(s) linking these relatively subtle lipoprotein abnormalities to vascular disease is poorly understood. Recent evidence suggests that a procoagulant and proinflammatory state develops within the vasculature, perhaps mediating a link between the ALP and AVD. The purpose of this review is to discuss mechanisms by which the ALP, and specifically, certain triglyceride-rich lipoproteins, may cause AVD by adverse affects on platelet function, coagulation and vascular inflammation. All rights reserved.
Atherosclerosis 1999 Jul
PMID:Triglyceride-rich lipoproteins: are links with atherosclerosis mediated by a procoagulant and proinflammatory phenotype? 1042 91

Renal artery stenosis can present 2 clinical pictures, sometimes associated and potentially treatable, due mainly to atherosclerosis, but also to fibromuscular dysplasia. The first possible presentation is renovascular hypertension which represents 1% of unselected hypertensive populations. The second possible presentation is ischemic renal disease, which represent 10% of the new indications for dialysis therapy and has a 50% mortality rate at 3 years. To explore this disease, arteriography, the gold standard, must be reserved for confirmation and treatment. Hypertension induced by the stenosis is best approached by captopril renal MAG 3 scintigraphy. Measurement of the stenosis severity can be performed either by duplex ultrasonography, magnetic resonance angiography or spinal CT angiography according to patients' characteristics, local experience and facilities. This disease must be searched in the presence of renal insufficiency of unknown cause or refractory hypertension.
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PMID:[How I explore ... a suspicion of renal artery stenosis]. 1054

Intermittent claudication is a symptom complex associated with atherosclerosis of the aorta and lower extremities. It is a clinical marker of systemic atherosclerosis, and therefore, management cannot be considered isolated from treatment of underlying risk factors of atherosclerosis. The focus of the management is twofold. The first is to reduce morbidity and mortality from cardiovascular events, including myocardial infarction and stroke. The second focus is to improve the functional status of patients who have impairment of daily activities secondary to symptoms of claudication through pharmacologic and rehabilitative means, that is, exercise. Exercise is the cornerstone of therapy. A conservative approach is favored in patients who have mild and moderate symptoms of claudication. Intervention with percutaneous techniques or surgery is generally reserved for patients who have severe impairment of lifestyle or threatened tissue.
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PMID:Diagnosis and medical management of patients with intermittent claudication. 1110 62

Intermittent claudication is the most common symptom in patients with peripheral arterial disease (PAD). As such, it is mandatory for clinicians to treat both the PAD-specific symptoms (to decrease functional impairment and thereby improve quality- of-life, as well as to decrease rates of amputation) and the underlying systemic atherosclerosis (and thereby reduce cardiovascular ischemic events, especially myocardial infarction and stroke). Most patients with claudication can successfully decrease their exertional limb symptoms via a combination of exercise (preferably supervised) and pharmacotherapeutic interventions (eg, cilostazol). Endovascular revascularization currently serves as an effective therapy for patients with high-grade stenoses of the proximal limb arterial segments, (eg, the distal aorta, common iliac artery, or external iliac artery, and occasionally the proximal common femoral artery). Surgical revascularization usually is reserved for patients who present with severe aortoiliac disease in whom long-term patency is likely to be achieved (eg, aortobifemoral or femoral-femoral bypass) and who have a low cardiovascular perioperative ischemic risk. Patients who undergo successful revascularization also are likely to benefit from exercise rehabilitation programs. All patients with PAD, of any severity, must successfully normalize atherosclerosis risk factors and use antiplatelet therapies. Such interventions include complete smoking cessation, glycemic control, normalization of blood pressure (less than 130/90 mm Hg), and lowering of low-density lipoprotein (LDL) cholesterol to less than 100 mg/dL. Antiplatelet agents (eg, clopidogrel, aspirin) should be prescribed to decrease rates of cardiovascular ischemic events in all patients with PAD, unless otherwise contraindicated.
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PMID:Intermittent Claudication. 1134 62


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