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Mineralocorticoid receptor (MR) blockade is effective in reducing total mortality and the incidence of heart failure in patients with systolic left ventricular dysfunction (SLVD) associated with chronic heart failure or post myocardial infarction. Pre-clinical and clinical studies in SLVD have shown that MR blockade reduces sudden cardiac death, left ventricular remodelling, left ventricular hypertrophy, endothelial dysfunction, autonomic imbalance, renal dysfunction and improves fibrinolysis. While MR blockade promotes sodium excretion and the combination of an angiotensin-converting enzyme inhibitor and a MR blocker have been shown to be more effective than either alone in causing natriuresis, it is unlikely that their beneficial effects can be explained solely on this basis. Aldosterone has been shown to have a number of adverse effects, including activation of other neurohumeral mediators, stimulation of active reactive oxygen species (ROS), activation of the NF-Greek small letter kappa kappabeta and AP-1 signalling pathways, vascular inflammation and fibrosis, myocardial hypertrophy, autonomic imbalance, and a decrease in fibrinolysis. MR blockade is, however, effective both in situations with and without an increase in serum aldosterone level, since the MR can be occupied and activated by cortisol as well as by aldosterone. In view of these mechanisms, MR blockade may play an important role not only on SLVD, but also in essential hypertension with normal systolic function, diastolic heart failure, valvular heart disease, vascular stiffening with ageing, progression of renal disease, and diabetes mellitus. This hypothesis will, however, require further prospective evaluation.
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PMID:Mineralocorticoid receptor blockade: new insights into the mechanism of action in patients with cardiovascular disease. 1460 20

Atrial fibrillation (AF) is a major risk factor for stroke. Although acute alcohol intake has been associated with AF, it is not known whether long-term alcohol consumption in moderation is associated with an increased risk of AF. We used a risk set method to assess the relation of long-term alcohol consumption to the risk of AF among participants in the Framingham Study. For each case, up to 5 controls were selected and matched for age, age at baseline examination, sex, cohort, baseline history of hypertension, congestive heart failure, and myocardial infarction. Within each risk set, alcohol consumption was averaged from baseline until the examination preceding the index case of AF. Of the 1,055 cases of AF occurring during a follow-up of >50 years, 544 were men and 511 were women. In a conditional logistic regression with additional adjustment for systolic blood pressure, age at baseline examination, education, and cumulative history of myocardial infarction, congestive heart failure, diabetes mellitus, left ventricular hypertrophy, and valvular heart disease, the relative risks were 1.0 (reference), 0.97 (95% confidence interval [CI] 0.78 to 1.22), 1.06 (95% CI 0.80 to 1.38), 1.12 (95% CI 0.80 to 1.55), and 1.34 (95% CI 1.01 to 1.78) for alcohol categories of 0, 0.1 to 12, 12.1 to 24, 24.1 to 36, and >36 g/day, respectively. In conclusion, our data indicate little association between long-term moderate alcohol consumption and the risk of AF, but a significantly increased risk of AF among subjects consuming >36 g/day (approximatively >3 drinks/day).
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PMID:Long-term alcohol consumption and the risk of atrial fibrillation in the Framingham Study. 1501 74

The most disabling consequence of atrial fibrillation (AF) is stroke. In the elderly, AF is the single most important cause of stroke. The risk of stroke is increased at least 6-fold in subjects with AF. Strokes in patients with AF are in general severe, associated with higher risk of fatality and prone to early and long-term recurrence. The cardiac origin of stroke can be strongly suspected by anamnesis, clinical examination and findings on neuroimaging. Paroxysmal AF is an important cause of brain embolism, that is often difficult to document. Risk factors for stroke in AF include: previous embolism (including previous transient ischaemic attack (TIA), or ischaemic stroke), age >65 years, structural cardiac disease, rheumatic or other significant valvular heart disease, valvular artificial prosthesis, hypertension, heart failure and significant left ventricular systolic dysfunction, diabetes and coronary disease. All AF patients with TIA or stroke have a formal indication for long-term anticoagulation. Only patients without risk factors or with contraindications to warfarin should be put on aspirin. Treating 1 000 patients with AF for 1 year with oral anticoagulants rather than aspirin would prevent 23 ischaemic strokes while causing 9 major bleedings. Despite its enormous preventive potential, oral anticoagulants are underused in AF, because treating physicians often have lack of knowledge about trials and guidelines, underestimate the benefits and overestimate the risks associated with continuous oral anticoagulation. The introduction of anticoagulants that do not need frequent control tests, such as ximelagatran, will increase the proportion of AF patients with risk factors for stroke who are anticoagulated. There is no evidence to support routine immediate anticoagulation in acute ischeamic stroke associated with AF.
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PMID:Atrial fibrillation and cardioembolic stroke. 1519 93

Heart failure (HF) is very common in the elderly but there are not sufficient data about the clinical characteristics and prognostic factors of HF among the Asian elderly patients. The aim of the study was to find out the clinical characteristics, survival, and prognostic factors of HF in Korean elderly patients. Among elderly patients admitted from February 1995 to February 1998, the patients with a discharge diagnosis of HF were enrolled. Through the medical record review, the diagnosis was confirmed and clinical parameters to affect survival were identified. Total number of the subjects was 104 [age: 77+/-7 years (65-96), male:female=36:68, follow-up duration: 20+/-14 months, LVEF: 46+/-16%]. Ischemic heart disease (IHD) was the most common cause of HF (42%) followed by valvular heart disease (28%), and hypertension (20%). The 1-year survival rate was 71.3%. Advanced age [risk ratio (RR): 1.41 per 5 years of age; 95% CI: 1.11-1.80] and reduced left ventricular ejection fraction (0.69 per 10%, 0.52-0.93), poor initial functional class (2.40, 1.15-5.00), diabetes (2.79, 1.30-5.97) and past history of HF (2.37, 1.10-5.10) badly affected the survival rates. When the Cox proportional hazard model was applied for multivariate analysis, only aging (1.64 per 5 years of age, 1.19-2.28) and diabetes (4.92, 1.83-13.23) predicted poor prognosis. Twenty-seven percent of the patients had diastolic HF (LVEF>45%, LVEDD<55 mm) who had higher survival rates with marginal significance (0.35, 0.10-1.17, P=0.09).
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PMID:Heart failure in Korean elderly patients - clinical features, prognosis and prognostic factors. 1537 71

Epidemiologic data from the Framingham Study provide insights into the population burden of heart failure (CHF), its prognosis and modifiable risk factors that promote it. In the general population CHF is chiefly the end stage of hypertensive, coronary and valvular cardiovascular disease. It is a major and growing problem in most affluent countries because of aging populations of increased size, and the prolongation of the lives of cardiac patients by modern therapy. Once clinically manifest, CHF, despite recent innovations in therapy, carries an unacceptably high mortality rate. In the Framingham Study, median survival is only 1.7 y for men and 3.2 y for women, with only 25% of men and 38% of women surviving 5 y. This is a mortality rate 4-8 times that of the general population of the same age. This poor outlook is observed for all etiologies of CHF and sudden death is a prominent feature of the mortality. Based on population attributable risks, hypertension has the greatest impact, accounting for 39% of CHF events in men and 59% in women. Despite its much lower prevalence in the population (3-10%) myocardial infarction also has a high attributable risk in men (34%) and women (13%). Valvular heart disease only accounted for 7-8% of CHF. Hypertension increased the age and risk factor adjusted hazard of CHF 2-fold in men and 3-fold in women, with a greater impact of the systolic than diastolic blood pressure. Diabetes increased CHF risk 2-8 fold with risk ratios twice as large in women as men. About 19% of CHF cases have diabetes. It accounted for 6-12% of the CHF in the Framingham Study cohort. Dyslipidemia characterized by a high total/HDL cholesterol ratio, but not the total cholesterol alone was a risk factor for CHF. An enlarged heart on X-Ray, ECG-LVH, a reduced vital capacity and rapid heart rate usually signified deteriorating cardiac function. CHF risk associated with ECG-LVH was independent of X-Ray cardiomegaly but risk was further augmented when both coexist. Echocardiographic left ventricular hypertrophy signifies a high risk of CHF proportional to the degree of increase in left ventricular mass without a critical value that delineates compensatory from pathological hypertrophy. Risk of CHF in persons predisposed by hypertension, diabetes or cardiac conditions varies over a 10-fold range depending on the aforementioned modifiable risk factors and indicators of deteriorating left ventricular function. Using multivariate risk formulations it is possible to identify 20% of the population from which 70% of the CHF will evolve. Those in the upper quintile of multivariate risk are good candidates for echocardiographic testing to delineate those needing aggressive preventive measures to delay the onset of CHF. Therapy of CHF must begin with treatment of presymptomatic left ventricular dysfunction to reverse the dysfunctional maladaptive changes.
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PMID:Incidence and epidemiology of heart failure. 1622 42

The aging of a population replete with risk factors for heart failure(HF) (coronary heart disease, diabetes, and hypertension) coupled with a declining age-adjusted mortality rate for coronary artery and hypertensive heart diseases has created, and will continue to create, a literal explosion in the prevalence of HF in the United States. Despite advances in maximal medical therapy, however, most patients who have symptomatic HF can expect functional impairment, interludes of worsening symptomatology, and a shortened lifespan. This article updates the use of interventional therapies for the treatment of elderly patients who have HF caused by coronary artery disease, valvular heart disease, congenital heart disease, myocardial disease, and renal vascular disease.
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PMID:Interventional therapies for heart failure in the elderly. 1790 83

The coronary flow velocity reserve (CFVR), a measure of endothelial function in coronary circulation, can be measured semi-invasively in the left anterior descending coronary artery by using stress transesophageal echocardiography (TEE). During the same stress TEE, aortic distensibility indices (elastic modulus [E(p)] and Young's circumferential static elastic modulus [E(s)]) can be assessed. The purpose of the present study was to examine whether stress TEE is valuable method for parallel evaluation of CFVR, E(p), and E(s) in patients with hypertension. A total of 38 patients with chest pain but with a negative coronary angiogram were enrolled into the present study, which included examination of the presence or absence of hypertension. Significant coronary stenosis was considered present in the event of a luminal diameter reduction of >50% on use of the "worst view method." Patients with significant coronary or valvular heart disease, atrial fibrillation, heart failure, unstable angina pectoris, acute myocardial infarction, or diabetes mellitus were excluded from the study. Stress TEE was performed in each case to evaluate CFVR, E(p), and E(s). Coronary flow velocity reserve and diastolic coronary flow velocities measured at peak stress were decreased in hypertensive patients as compared with normotensive subjects. E(p) and E(s) were significantly increased in hypertensive patients. In conclusion, it can be stated that Stress TEE is a useful tool for the simultaneous evaluation of the CFVR, E(p), and E(s) in hypertension. The CFVR and aortic distensibility are decreased in hypertension.
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PMID:Simultaneous echocardiographic evaluation of coronary flow velocity reserve and aortic distensibility indices in hypertension. 1739 Feb

We investigated the pro-apoptotic potential of pericardial fluids from patients with different clinical conditions on cultured neonatal rat cardiomyocytes. Pericardial fluids were obtained during open heart surgery from 88 patients with ischemic heart disease (n=44), valvular heart disease (n=32), or aortic disease (n=12). The terminal deoxynucleotidyl transfer-mediated end labeling fragmented nuclei assay was performed on primary cardiac myocytes from neonatal rats in the presence of 1% pericardial fluid from each patient. We evaluated relations between these patients' clinical characteristics and the extent of myocardial cell apoptosis. Induction of myocardial cell apoptosis by pericardial fluids was observed in 29 of the 88 patients (33.0%). The prevalence of myocardial cell apoptosis was significantly influenced by diabetes mellitus (DM) (53.6% with vs. 23.3% without, P<0.005), acute coronary syndrome (ACS) (64.7% with vs. 25.4% without, P<0.005), and poor left ventricular systolic function (60.0% with vs. 25.0% without, P<0.005). Multivariate stepwise logistic regression analysis revealed that the presence of DM, ACS, and poor left systolic function were significant predictors of myocardial cell apoptosis. DM, ACS and left ventricular dysfunction may play important roles in the pathogenesis of myocardial cell apoptosis in the clinical setting.
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PMID:Clinical characteristics relevant to myocardial cell apoptosis: analysis of pericardial fluid. 1767 Feb 60

The aim of this study was to evaluate the frequency of cardiovascular disease and risk factors associated in patients hospitalised in coronary care units at Military Hospital, Tunis, over the period 1994-1998. The clinical features of 3513 patients (2389 men and 1124 women) on hospital admission were analysed. 47.3% of patients were hospitalised for coronary disease, 12.5% for valvular heart disease, 5.2% for cardiomyopathy, 16.2% for arrhythmia and conduction disturbance, 6.4% for hypertension and 12.2% for other pathologies. With this risk factor profile Tunisia has to implement a national strategy of primary prevention and heart heath promotion in addition to the efforts recently made in secondary prevention of some chronic disease such as hypertension and diabetes.
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PMID:[Epidemiological features of patients hospitalized in coronary care units at the military hospital, Tunisia, for 1994-1998: preliminary results]. 1772 93

During 2002 and 2003, 1438 patients underwent a complete medical history and physical by the same hospital-based prescreening program before elective total joint arthroplasty to determine the benefits of this preoperative examination. Sixty percent of patients were female. Mean age was 67.5 years. New diagnoses established as a result of this prescreening program included coronary artery disease (0.12%), congestive heart failure (0.6%), valvular heart disease (3.2%), cardiac dysrhythmia (4.4%), chronic obstructive pulmonary disease (7.2%), cancer (9.6%), hypertension (55.8%), gastrointestinal disorder (37.1%), diabetes mellitus (12.1%), and urinary tract infection (2.2%). Forty-five (2.5%) patients were deemed unacceptable surgical candidates. Patients identified with an increased risk of perioperative cardiac problems were those with a preoperative diagnosis of valvular heart disease (P = .0077), congestive heart failure (P = .0093), or diabetes mellitus (P = .0187).
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PMID:The prescreening history and physical in elective total joint arthroplasty. 1782 9


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