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 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Up to 80% of diabetic patients die of macrovascular complications, including CAD, stroke, and peripheral vascular disease. Because of the growing numbers of diabetic patients and the increased mortality after their first cardiovascular event, it is critical to identify and treat risk factors early and aggressively in these patients. Numerous studies in patients with type 2 diabetes have shown the benefits of aggressive treatment of blood pressure and lipids to levels that 10 years ago would have seemed abnormally low. The downward changes in "normal" limits can be frustrating to primary care physicians, but advances in treatment are redefining "normal" levels required to avoid complications in this high-risk population.
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PMID:Reducing cardiovascular risk in diabetes. Which factors to modify first? 1131 67

Vascular dementia (VaD) and Alzheimer's disease are sometimes difficult to distinguish due to overlaps in symptomatology, pathophysiology and comorbidity. The issue of differential diagnosis is further complicated by the fact that many patients have concomitant Alzheimer's disease and cerebrovascular disease (CVD) ('mixed' dementia). Each pathology may contribute to varying degrees, giving rise to a continuum of patients in whom pure CVD and pure Alzheimer's disease represent the two extremes. Despite the clear overlap between the conditions, and the prevalence of 'mixed' dementia, a number of criteria for Alzheimer's disease and VaD do not make provision for 'mixed' dementia distinct from the coincidence of any two other dementing illnesses. We will discuss the current diagnostic criteria for VaD, with or without coexisting Alzheimer's disease, in an effort to determine how best to diagnose VaD. These include traditional criteria such as the Diagnostic and Statistical Manual of Mental Disorders or the Hachinski Ischemic Scale, and the more recently developed criteria by the California Alzheimer's Disease Diagnostic and Treatment Centers (CAD-DTC) and the National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) International Workshop. The CAD-DTC and NINDS-AIREN rely on neuroimaging--ideally, every patient suspected of dementia should have brain imaging, but although this is possible in clinical trials (for which these criteria were designed), it is not always feasible in population-based epidemiological studies and clinical practice in some countries.
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PMID:Diagnosis of vascular dementia and Alzheimer's disease. 1140 27

Initial pharmacologic therapy for hypertension is low-dose thiazide diuretics, beta-blockers, and ACE inhibitors. Increasing data have confirmed that ACE inhibitors have specific benefit in patients with diabetes, atherosclerosis, left ventricular dysfunction, and renal insufficiency. CCBs are alternative agents for ISH in the elderly and appear to decrease stroke with perhaps less protection against progression of renal insufficiency and proteinuria, CAD mortality and new onset heart failure versus other initial agents, especially ACE inhibitors. ARBs are well tolerated and effective blood pressure lowering agents but have not been confirmed as effective as ACE inhibitors for reducing renal progression, clinical events, or mortality from heart failure. Effective pharmacologic antihypertensive therapy may avoid disabling and undetected cerebrovascular disease, cognitive dysfunction, and disturbing symptoms of elevated blood pressure. Vasopeptidase inhibitor, such as omapatrilat, and endothelin-1 antagonist, such as bosentan, may become future agents approved for the reduction of morbidity and mortality with hypertension. The ALLHAT trial continues to examine the potential benefits and harms of amlodipine versus chlorthalidone and lisinopril in a diverse high-risk population. Based on ALLHAT data, however, doxazosin is no longer an acceptable initial pharmacological agent. Intensive pharmacologic treatment with blood pressure lowering to less than 130/85 mm Hg is recommended with diabetes, renal insufficiency, and heart failure with additional goal of less than 125/75 mm Hg with renal failure and proteinuria greater than 1 g/24 h, based on multiple outcome studies.
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PMID:Update in pharmacologic treatment of hypertension. 1140 10

Women are underrepresented in clinical trials. Lower doses of beta-blockers are required for Southeast Asians. ACE and ARB's are teratogenic in the second trimester. Torsades de Pointes is more common in women related to a longer QT-interval. Lower dose OCPs decrease the risk of MI, stroke and thrombosis. HRTs are not effective for CAD prevention.
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PMID:Gender, ethnicity, and genes in cardiovascular disease. Part 2: implications for pharmacotherapy. 1278 34

The highly variable clinical course of cervical artery dissections still poses a major challenge to the treating physician. This study was conducted (1) to describe the differences in clinical and angiographic presentation of patients with carotid and vertebral artery dissections (CAD, VAD), (2) to define the circumstances that are related to bilateral arterial dissections, and (3) to determine factors that predict a poor outcome. Retrospectively and by standardised interview, we studied 126 patients with cervical artery dissections. Preceding traumata, vascular risk factors, presenting local and ischemic symptoms, and patient-outcome were evaluated. Patients with CAD presented more often with a partial Horner's syndrome and had a higher prevalence of fibromuscular dysplasia than patients with VAD. Patients with VAD complained more often of neck pain, more frequently reported a preceding chiropractic manipulation and had a higher incidence of bilateral dissections than patients with CAD. Bilateral VAD was significantly related to a preceding chiropractic manipulation. Multivariate analysis showed that the variables stroke and arterial occlusion were the only independent factors associated with a poor outcome. This study emphasises the potential dangers of chiropractic manipulation of the cervical spine. Probably owing to the systematic use of forceful neck-rotation to both sides, this treatment was significantly associated with bilateral VAD. Patients with dissection-related cervical artery occlusion had a significantly increased risk of suffering a disabling stroke.
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PMID:Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. 1565 61

In this study, we developed a new miniature motor-driven pulsatile left ventricular assist device (LVAD) for implantation into a Japanese patient of average build by means of computer-aided design and manufacturing (CAD/CAM) technology. A specially designed miniature ball-screw and a high-performance brushless DC motor were used in an artificial heart actuator to allow miniaturization. A blood pump chamber (stroke volume 55 ml) and an inflow and outflow port were designed by computational fluid dynamics (CFD) analysis. The geometry of the blood pump was evaluated using the value of index of pump geometry (IPG) = (Reynolds shear stress) x (occupied volume) as a quantitative index for optimization. The calculated value of IPG varied from 20.6 Nm to 49.1 Nm, depending on small variations in pump geometry. We determined the optimum pump geometry based on the results of quantitative evaluation using IPG and qualitative evaluation using the flow velocity distribution with blood flow tracking. The geometry of the blood pump that gave lower shear stress had more optimum spiral flow around the diaphragm-housing (D-H) junction. The volume and weight of the new LVAD, made of epoxy resin, is 309 ml and 378 g, but further miniaturization will be possible by improving the geometry of both the blood pump and the back casing. Our results show that our new design method for an implantable LVAD using CAD/CAM promises to improve blood compatibility with greater miniaturization.
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PMID:Design of a miniature implantable left ventricular assist device using CAD/CAM technology. 1459 98

In type 2 diabetic patients with or without nephropathy, we examined relationships between plasma concentrations of total homocysteine (tHcy) and clinical macroangiopathy, as well as endothelial dysfunction indicated by plasma thrombomodulin (TM) concentrations. We studied 103 type 2 diabetic patients including 26 with macroangiopathy (12 patients with coronary artery disease [CAD], 10 with stroke, and 4 with peripheral vascular disease [PVD]). Plasma tHcy was measured by high-performance liquid chromatography. Plasma TM was determined by enzyme immunoassay. As an index of glomerular filtration rate, creatinine clearance (Ccr) also was determined in a 24-hour urine collection. Considering all diabetic patients, plasma tHcy concentrations were significantly higher in those with macroangiopathy than in those without (10.4 +/- 3.7 v 8.5 +/- 2.8 micromol/L, P=.0077). By univariate and multivariate analyses, plasma tHcy was correlated inversely with Ccr. Plasma tHcy concentrations were significantly higher in the patients with overt albuminuria than in those with normoalbuminuria or microalbuminuria. After exclusion of patients with renal insufficiency (Ccr<60 mL/min), differences in plasma tHcy concentrations between patients with and without macroangiopathy were abolished. By multivariate analysis, total cholesterol, urinary albumin, Ccr, C-peptide, and tHcy retained significant influence on the plasma TM. Even in patients with normal renal function (Ccr > or = 80 mL/min), plasma tHcy was correlated positively with plasma TM. In conclusions, diabetic nephropathy is a main determinant of plasma tHcy elevation in type 2 diabetic patients. Since plasma TM is independently associated with plasma tHcy, in diabetic patients with overt nephropathy, elevation of tHcy reflecting reduced clearance is a likely cause of endothelial dysfunction, resulting in the atherosclerosis underlying development of cardiovascular disease.
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PMID:High plasma homocysteine concentrations are associated with plasma concentrations of thrombomodulin in patients with type 2 diabetes and link diabetic nephropathy to macroangiopathy. 1462 17

This paper analyzes the short-term results of 463 consecutive primary reconstructive operations on the carotid bifurcation based on the standards of "quality". In 383 (82.7%) cases, the patients were operated on for stenosis of the internal carotid artery (ICA); 60 (13%) patients had combination of stenosis and kingking of the ICA and 20 (4.3%) presented with isolated kinking of the ICA. Classic open carotid endarterectomy (CEAE) was performed in 240 cases, eversion CEAE in 144, resection with ICA redressment in 45, and ICA grafting in 28 cases. The perioperative lethality accounted for 1.54% (7 cases), per 463 operations, with the standard of "quality" being equal to 2%. Myocardial infarction was the cause of death in 5 cases, one patient developed homolateral stroke which eventuated in lethal outcome, and one more patient developed lethal stroke in the contralateral hemisphere. The incidence of homolateral strokes which did not eventuate in lethal outcome accounted for 1.94% (9 cases). The indicator "stroke plus lethality from stroke" in the general patient group was 2.38% which is even lower versus the standard of "quality" for asymptomatic patients and constitutes 3%. Among asymptomatic patients proper, the indicator "stroke plus lethality from stroke" was equal to 0, among TIA patients to 0 at a 5% standard, and in patients with initial stroke, initial stroke, it amounted to 3.19% at a 7% standard. Perioperative strokes were not recorded in patients with ICA kingking or at ICA grafting. The basic factor of the risk of perioperative neurologic deficit was a history of stroke. Patients with different stages of cerebrovascular insufficiency did not significantly differ as regards age, sex distribution, the presence of CAD, arterial hypertension, diabetes mellitus, the degree of stenosis of the operated ICA and the time of its clamping at operation. Patients with a history of strokes differed significantly from the general group only in the incidence of lesion of the contralateral ICA and in the frequency of the use of internal shunt. Analysis of the risk factors of perioperative stroke in patients with a history of strokes has shown that they were diabetes mellitus and the use of internal shunt. The development of perioperative stroke among patients with a history of stroke was not influenced by the incidence of contralateral ICA lesion, the standing of cerebral circulatory distress or the size of an ischemic focus. The initial character of ICA lesion and the type of reconstruction did not affect the origin of perioperative focal deficits or lethality.
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PMID:What influences the standards of "quality" of carotid endarterectomy? 1465 36

Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality in the western world. These disorders share a common pathophysiology -- atherosclerosis, which affects various arterial beds, leading to protean manifestations (coronary artery disease [CAD], stroke, peripheral arterial disease [PAD]). The platelet plays a pivotal role in the perpetuation and clinical expression of these disorders. The platelet, once believed to have a role confined to modulation of thrombosis and haemostasis, also plays an active role in vascular inflammation. Antiplatelet agents have become first-line therapy for CVD, and their unequivocal benefits are demonstrated in various basic and experimental models and supported by overwhelming evidence from clinical trials. Search is underway for more effective and safer antiplatelet therapy. Novel therapies are emerging to target the redundant pathways of platelet adhesion, activation and aggregation. Efforts are also ongoing to enhance implementation of existent therapy, target therapy selectively to high-risk patients and to those likely to respond (pharmacogenomics), and study the incremental benefits and safety of various antiplatelet combinations and their interaction with other medications in patients with CVD treated with polypharmacy.
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PMID:Advances in antiplatelet therapy. 1466 94

Dyslipidaemia is common in patients with Type 2 diabetes and is held to be responsible for considerable CVD-related morbidity and mortality. Patients with Type 2 diabetes are at high risk from complications associated with atherosclerosis and should therefore receive preventive interventions. At the level of the adipocyte, impaired insulin action leads to increased rates of intracellular hydrolysis of triglycerides with the release of NEFA. The rise in NEFA provides substrate for the liver that, in the presence of impaired insulin action and relative insulin deficiency, is associated with complex alterations in plasma lipids: * Plasma VLDL levels are raised. (i). Increased VLDL levels are associated with post-prandial hyperlipidaemia that is compounded by impaired LPL activity. The latter may be independently associated with CAD. (ii). Remnant particles can deliver more cholesterol to macrophages than LDL-C particles. Thrombogenic alterations in the coagulation system also ensue from hypertriglyceridaemia. * Plasma HDL-C levels are reduced. (i). The reduction in cardioprotective HDL-C means a reduction of cholesterol efflux from the tissues--the first step in reverse cholesterol transport to the liver from peripheral tissues. (ii). The antioxidant and antiatherogenic activities of HDL-C are reduced when circulating levels are low. * LDL-C particles become small and dense. Small, dense LDL-C particles are held to be more atherogenic than their larger, buoyant counterparts because they (a) are more liable to oxidation and (b) may more readily adhere to and subsequently invade the arterial wall. The atherogenicity of LDL-C may also be enhanced by nonenzymatic glycation. Metabolic and lipid abnormalities can often be improved with lifestyle changes, including dietary modification, weight loss, smoking cessation and increased exercise. Although attainment of better glycaemic control may improve diabetic dyslipidaemia, pharmacological intervention is usually required. Several large-scale clinical trials, including 4S and more recently HPS, have clearly demonstrated the benefits of statins in reducing cardiovascular events. By virtue of their high absolute risk of CVD, many patients with Type 2 diabetes may achieve a greater risk reduction than their non-diabetic counterparts. For example, in 4S there was a 43% reduction in total mortality risk among patients with diabetes compared with 29% for non-diabetics and a reduced risk of MI by 55% vs. 32% for diabetic and non-diabetics, respectively. In the diabetic subgroup in HPS, there were reductions of approximately 25-30% in the risk of first major vascular events. More recently, the lipid-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) was halted early because of a significant reduction in cardiovascular events compared with placebo. Surprisingly an analysis of subgroups failed to show significance among the diabetic population, although the sample size, shortened follow-up period and higher drop-in statin use among diabetics on placebo may have affected results. The Collaborative Atorvastatin Diabetes Study (CARDS), involving 2800 patients with Type 2 diabetes, was halted 2 years early in June 2003 because patients allocated atorvastatin had significant reductions in MI, stroke and surgical procedures compared with those receiving placebo. The UKPDS demonstrated that the appearance and progression of certain microvascular complications of Type 2 diabetes could be reduced by treatment directed at hyperglycaemia and hypertension. In addition, correction of dyslipidaemia in patients with diabetes is important in reducing the high toll from macrovascular disease. The subjects in the HPS had similar lipid profiles to the participants in UKPDS, suggesting that additional benefit would accrue from a therapeutic assault on the main cardiovascular risk factors simultaneously. We now have firm evidence that appropriate use of statins in patients with Type 2 diabetes can significantly reduce cardiovascular morbidity and mortality.
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PMID:Lipoprotein abnormalities and their consequences for patients with type 2 diabetes. 1498 18


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