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Although large-scale heart failure (HF) studies in Hispanic Americans are lacking, some compelling data indicate that they are a particularly vulnerable population and underscore the need for further research. Hispanics comprise the largest and fastest-growing ethnic group in the U.S., in whom the impact of this burgeoning public health problem may be magnified. Current data show that Hispanics with HF are more likely to be younger and underinsured than non-Hispanic whites. They have higher rates of readmissions but have lower in-hospital and short-term mortality rates. Epidemiologic studies demonstrate that Hispanics have excessive rates of diabetes, obesity, dyslipidemia, and metabolic syndrome. Although hypertension and ischemic heart disease are established risk factors in this ethnic group, it may be considered that insulin resistance plays a significant role in the pathogenesis of HF in Hispanics, accounting for their inordinate cardiometabolic risk burden and the growing evidence of novel metabolic risk factors for HF. Hispanics encounter multiple barriers to health care influenced by socioeconomic, linguistic, and cultural factors that, in turn, have an adverse impact on disease prognosis. Recognition of predominant risk factors and health care disparities in this population is crucial to tailoring appropriate management strategies. This review summarizes epidemiologic and clinical data on Hispanics with HF, details risk factors and health care impediments, and presents an agenda for future investigation.
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PMID:Heart failure in Hispanics. 1934 56

Combination of drugs from different classes of antihypertensives provides an additional antihypertensive effect thus minimising the probability of adverse effects related to the dose of antihypertensive. Combination therapy is indicated for the following groups of hypertensive patients: (a) all hypertensive patients whose systolic blood pressure exceeds the target systolic blood pressure value by > 20 mm Hg, or whose diastolic blood pressure exceeds the target diastolic blood pressure value by > 10 mm Hg; (b) in patients with diabetes mellitus (because the target values are < 130/80 mm Hg); (c) patients with target organ damage; (d) patients with a kidney or cardiovascular disease (patients with IHD, patients after a cerebrovascular accident); (e) patients with overall cardiovascular risk according the SCORE > or = 5%. The advantage of fixed combinations resides in the fact that they increase compliance with treatment by reducing the number of pills taken by the patients. A fixed combination of the ACE inhibitor perindopril and the calcium channel blocker amlodipine proves optimal as has been shown by the results of the ASCOT-BPLA study. The launch of the above combination on this market should therefore be welcome. The fixed combination of perindopril and amlodipine will be indicated for hypertensive patients with uncontrolled hypertension or cardiovascular risk factors. This fixed combination will also be ideal for patients with a higher risk of diabetes mellitus, i.e. patients with a higher fasting glycaemia, in patients with impaired glucose tolerance and in patients with the metabolic syndrome. We strongly believe that it will improve the control of hypertension in our hypertensive patients, and improve the cardioprotective and nephroprotective effect of hypertension therapy.
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PMID:[The combination of an ACE inhibitor and a calcium channel blocker is an optimal combination for the treatment of hypertension]. 1934 94

Morbid obesity and diabetes cause diastolic dysfunction that can be detected by Doppler echocardiography. Patients with the metabolic syndrome could demonstrate early diastolic dysfunction that may influence effort tolerance. A total of 32 patients (17 men) who fulfilled >/=2 of the 5 metabolic syndrome criteria were studied. The average age of patients was 37+/-2 years. All patients were overweight/obese (mean body mass index of 34.4+/-0.7 kg/m(2)), 15 had blood pressure >130/85 mm Hg, 19 had elevated triglyceride levels (>150 mg/dL), and 17 had low high-density lipoprotein cholesterol levels (men <40 mg/dL, women <50 mg/dL). Maximal exercise was performed using Bruce treadmill protocol with standard stress echocardiography and tissue Doppler. Maximal oxygen consumption (VO(2max)) was measured using indirect calorimetry. Left ventricular filling pressure was indirectly derived from dividing pulse Doppler early mitral inflow velocity (E) by tissue Doppler early diastolic mitral annular motion (E') or E/E'. The group's average treadmill time was 8.06+/-0.28 minutes, VO(2max) was 28.6+/-1.1 mL/kg/min, and 8.2+/-0.3 metabolic equivalents. None had evidence of myocardial ischemia or systolic or diastolic dysfunction with exercise. Mean "resting" E/E' and "post-exercise" E/E' were 7.01+/-0.04 and 7.41+/-0.41, respectively. There was no significant correlation between resting E/E' and VO(2max) (r=-0.266; P=.14). The post-exercise E/E' significantly correlated with VO(2max) (r=-0.483; P=.005) and metabolic equivalents (r=-0.487; P=.005). Diastolic function is preserved in early metabolic syndrome. Even in the normal diastolic function range, exercise E/E' is inversely related to VO(2max). Further longitudinal studies are needed to determine whether they develop diastolic dysfunction and related heart failure.
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PMID:Correlation of Normal Diastolic Cardiac Function With VO in the Metabolic Syndrome. 1952 60

We provide an overview of the current views on the association between metabolic syndrome and cardiovascular disease. Insulin resistance, frequently onsetting from obesity and associated hypercholesterolemia, hypertension and diabetes mellitus, is the common denominator. We also highlight another risk factor - heart rate, closely related to the prognosis of healthy individuals, patients with hypertension and patients following myocardial infarction. Finally, we present the results of the CRUSADE study that has clearly described the association between obesity and age and the first manifestation of the ischemic heart disease.
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PMID:[Metabolic syndrome and cardiovascular disease]. 1973 71

The rapid growth transformation of China from a rural agrarian society to an industrial society with increased wealth has impacted the cardiovascular health of the entire population. The increasing prevalence of cardiovascular disease (CVD) and CVD risk factors mirror in some regards the disease prevalence in western industrialized countries and in other areas present unique public health issues. This article reviewed recent population surveys, reports, and clinical trials conducted in China. It was found that the prevalence of CVD and many of the risk factors such as hypertension, obesity, and diabetes contributing to disease mortality are increasing in China. However, compared with the United States, disease mortality is lower. Also, cerebrovascular disease is far more common than ischemic heart disease in China. The low prevalence of disease may suggest a reduced role of diagnostic imaging studies as compared with the US, while the increased percentage of strokes may point to the need for widely available emergent computed tomography (CT) imaging in hospitals in China. This article also discusses the occurrence of metabolic syndrome, obesity, glucose intolerance, diabetes, and their unique features in the Chinese population. Of interest, compared with the Caucasian cohort of the same body mass index (BMI), the Chinese had a higher percentage of body fat. Metabolic syndrome was found to be associated with increased cardiovascular mortality rate. With one fifth of the world's population, China can anticipate a dramatic rise, in absolute numbers, of CVD. It is imperative that national and regional programs are initiated to detect and treat the disease.
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PMID:Evolving cardiovascular disease prevalence, mortality, risk factors, and the metabolic syndrome in China. 1974 93

The incidence of isolated systolic hypertension increases with age since 50 years. Systolic pressure appears to have higher prognostic importance than diastolic pressure in patients older than 50 years. Treatment of isolated systolic hypertension importantly decreases cerebrovascular events, coronary events as well as overall mortality. Studies providing the relevant evidence have mostly been conducted at the beginning of 1990s. The baseline systolic pressure in all these studies was 160 mmHg and higher. This is because the isolated systolic hypertension then was defined as systolic pressure of 160 mmHg or higher and diastolic hypertension as pressure of 95 mmHg or higher. No study confirming that systolic pressure lowering to the range of 140-159 mmHg in older patients would positively affect morbidity and mortality, with a further aim to achieve systolic pressure levels of less than 140 mmHg, have been conducted so far. The recommendation to aim, even in older patients, for the target values of less than 140 mmHg is based mainly on observational studies. Possible existence of the diastolic pressure J-curve in patients with ischemic heart disease represents another unresolved issue. There is a lack of randomised studies on this subject comparing reduction of the diastolic pressure to below 80, below 70 mmHg and below 60 mm Hg. The joint guidelines of the European Society of Hypertension and European Society of Cardiology recommend the target value of <140/90 mmHg for the treatment of isolated systolic hypertension, and systolic pressure of less than 130 mmHg in patients with diabetes, cardiovascular or renal diseases (following myocardial infarction, cerebrovascular event or renal dysfunction), in patients with metabolic syndrome and in patients with the overall cardiovascular SCORE-based risk of > or = 5%. There are no data available confirming that lowering blood pressure to these target values is justified. The 'lower the blood pressure is better' rule applies to cerebrovascular events only. The data from the large ONTARGET study show that lowering of the systolic blood pressure to less than 130 mmHg does not bring any benefit to hypertonics with high cardiovascular risk, except from cerebrovascular events. The J-curve exists for cardiovascular mortality, myocardial infarction and probably also for diabetics, with the turning point at about 130 mmHg. Further reduction of blood pressure increases cardiovascular mortality and myocardial infarctions. We believe that, in the current atmosphere of contradictory data on the diastolic pressure and coronary events relationship J-curve, caution is needed in older patients with isolated systolic hypertension and IHD in cases when the on-treatment diastolic pressure falls below 70 mmHg. In such a situation we would not insist on reaching the systolic pressure target value. We believe that this should apply to older patients with ischemic heart disease in particular. In summary, it is possible to conclude that hypertension treatment target blood pressure values of less than 140/90 mmHg are justified. However, target values of less than 130/80 mmHg in diabetics, in patients with a cardiovascular disease and in other patient groups (metabolic syndrome, overall cardiovascular risk of 5% or higher) are challenged by the results of a range of large studies, and verification in prospective studies is of utmost importance.
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PMID:[Target values in hypertension treatment. Will they apply in older patients with hypertension, diabetics and in patients with IHD?]. 2007 36

Diabetic men have benefited in the last 30 years from a significant improvement in total and cardiovascular mortality, whereas diabetic women have had no improvement at all. Moreover, recent research focused on the role of sex hormones in glucose homeostasis, and might account for different pathophysiologic mechanisms in the development of diabetes-related complications. Thus, care of diabetic women is a challenge that requires particular attention. The available data regarding gender-specific care of diabetes mellitus are uneven, rich in some domains but very poor in others. The large prospective trials performed in the last 20 years have assumed that the natural history of diabetes mellitus in men and women, as well as the efficiency of glucose-lowering therapies and management of hyperglycemic-related complications, could be attributable without distinction to men and women. We propose in this paper to analyze the published medical literature according to the specific management of diabetes mellitus in women, and to try to distinguish some particular features. We found important distinctions between diabetic men and women regarding the patterns of abnormalities of glucose regulation, epidemiology, development of diabetes-related complications, ischemic heart disease, morbidity and mortality, impact of cardiovascular risk factors, development of the metabolic syndrome, depression and osteoporosis, as well as the impact of lifestyle modifications or primary and secondary preventions on cardiovascular risk factors, and finally medical therapeutics. Moreover, special considerations were given to some particular aspects of the medical life in diabetic women, such as the features of gestational diabetes mellitus and the management of pregnancy in pregestational diabetic women, use of contraception, hormone-replacement therapy and polycystic ovary syndrome.
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PMID:Gender-specific care of diabetes. 1980 83

Although psoriasis has been associated with components of the metabolic syndrome, its association with myocardial infarction is less clear. A cohort study was conducted using hospital and pharmacy records of 2.5 million Dutch residents between 1997 and 2008. The risk of ischemic heart disease (IHD) hospitalizations was compared between psoriasis patients and a matched reference cohort. Additional adjustments were made for healthcare consumption and use of cardiovascular drugs. A total of 15,820 psoriasis patients and 27,577 reference subjects were included, showing an incidence rate of 611 and 559 IHD per 100,000 person-years, respectively (P=0.066). The age- and gender-adjusted risk of IHD was comparable between both cohorts (hazard ratio (HR)=1.10, 95% confidence interval 0.99-1.23). Before cohort entry, psoriasis patients used more antihypertensive, antidiabetic, and lipid-lowering drugs and were more often hospitalized. Adjusting for these confounders decreased the HR for IHD, but it remained comparable between both populations. There was no different risk of IHD between the subgroup of patients who only used topicals versus those who received systemic therapies or inpatient care for their psoriasis. This study, therefore, suggests that psoriasis is not a clinically relevant risk factor for IHD hospitalizations on the population level.
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PMID:Psoriasis may not be an independent risk factor for acute ischemic heart disease hospitalizations: results of a large population-based Dutch cohort. 2023 29

Coronary Heart Disease (CHD) risk factor assessment and management is no insignificant undertaking. In 2009, 785,000 Americans will experience their first coronary event, 470,000 will have a recurrent event, and an additional 195,000 will suffer a silent myocardial infarction (MI). As family physicians, we see many patients who have angina or MI, and we work aggressively with them to prevent myocardial ischemia and acute coronary syndromes. However, many of our otherwise healthy patients have subclinical atherosclerosis and are at increased risk for a first coronary event. Subclinical atherosclerosis is common, occurring in 39% of men and 36% of women aged > or =65 years in the Cardiovascular Health Study. The presence of subclinical cardiovascular disease roughly doubles the rate of development of clinically apparent disease over an 8-year period in healthy individuals, as well as in those with metabolic syndrome or diabetes mellitus. Unfortunately, for most patients, CHD is not diagnosed during routine screening. Rather, the diagnosis of CHD often is made only after symptoms occur, or when the patient is evaluated incidentally for another health problem.
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PMID:An urgent matter-identifying your patients' cardiovascular risk and improving their outcomes. Commentary. 1989 47

Overweight and obesity potentiate the development of cardiovascular risk factors but many doubts have arisen recently regarding their role in coronary events. We evaluated the predictive value of a surrogate maker of insulin resistance, the ratio of triglyceride (TG) to high-density lipoprotein (HDL), for the incidence of a first coronary event in men workers according to body mass index (BMI). We designed a case-control study of active subjects collected from a single factory through their annual health examination and medical reports. Case subjects included those with myocardial infarction, unstable angina pectoris, or subclinical myocardial ischemia detected through electrocardiographic abnormalities. The sample was constituted by 208 case and 2,080 control subjects (mean age 49.9 years, 49.6 to 50.2). General characteristics of case and control subjects were well matched. The TG/HDL ratio was significantly higher in case subjects compared to controls. Stratification of the sample revealed an increasing prevalence of case subjects and mean TG/HDL in each category of BMI. Multivariable analysis, adjusted by smoking, demonstrated that TG/HDL increased 50% the risk of a first coronary event (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.26 to 1.71), whereas low-density lipoprotein cholesterol values indicated a more moderate increased risk (OR 1.01, 95% CI 1.005 to 1.012); metabolic syndrome (OR 1.76, 95% CI 0.94 to 3.30) and hypertension (OR 1.50, 95% CI 0.81 to 2.79) did not reach statistical significance. The TG/HDL ratio was associated with a first coronary event in all categories of BMI. In conclusion, the TG/HDL ratio has a high predictive value of a first coronary event regardless of BMI.
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PMID:Usefulness of triglycerides-to-high-density lipoprotein cholesterol ratio for predicting the first coronary event in men. 1989 56


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