Practical aspects of preventing and managing atherosclerotic disease in post-menopausal women

Size: px
Start display at page:

Download "Practical aspects of preventing and managing atherosclerotic disease in post-menopausal women"

Transcription

1 European Heart Journal (1996) 17 {Supplement D), Practical aspects of preventing and managing atherosclerotic disease in post-menopausal women J. M. Sullivan University of Tennessee, Memphis, TN, U.S.A. Factors that exacerbate the risk of atherosclerotic plaque formation include cigarette smoking, hypertension, hypercholesterolaemia, sedentary lifestyle, and oestrogen deficiency. The potentially important role of oestrogen deficiency in this process is evidenced by the significant increase in cardiovascular risk observed in women after menopause, and in the marked reduction in cardiovascular events observed in women who take hormone replacement therapy. Oestrogen replacement therapy, through an effect on the blood vessel wall and on serum lipids, also appears Introduction The atherosclerotic process begins with injury to the endothelium, which allows white blood cells to adhere, travel beneath the endothelium, imbibe lipids, and become collections of lipid-laden macrophages that are eventually covered by a thin fibrous cap. With the release of growth factors, vascular smooth muscle cells migrate into the area of atheroma formation and proliferate. Platelets adhere to the surface, initiating thrombus formation that becomes incorporated into the growing atheroma. Eventually, the surface of the plaque becomes unstable and starts fissuring, usually at the shoulders of the fibrous cap. This process causes formation of a larger thrombus that can occlude the vessel and lead to ischaemic damage and infarction. Quantitative angiographic studies have demonstrated that it is possible to stop the growth of most atherosclerotic plaques and, in certain cases, promote regression of the atherosclerotic lesion 1 ' 1. Although the shrinkage is relatively small, several studies have shown that it is still enough to reduce the incidence of cardiac events by about 50%. These observations are the basis for the important concept of atherosclerotic plaque stabilization. Attaining this goal requires meticulous control of cardiovascular risk factors. Several factors increase a person's risk of accelerated atherosclerosis. These include: cigarette Correspondence: Jay M. Sullivan, MD, Department of Medicine, University of Tennessee, 951 Court Avenue, Room 353D, Memphis, Tennessee, 38163, U.S.A X/96/0D $18.00/0 to stabilize existing atherosclerotic plaques. The combination of oestrogen and progesterone reduces risk of endometrial cancer while possibly delivering the same benefits as oestrogen alone. Other measures, such as antithrombotic therapy, exercise, and smoking cessation, also contribute to reduced risk of cardiovascular disease in older women. (Eur Heart J 1996; 17 (Suppl D): 32-37) Key Words: Thrombus, atherosclerosis, hormone replacement therapy, cardiovascular disease, menopause. smoking, hypertension, hypercholesterolaemia, diabetes mellitus, low levels of high-density lipoprotein (HDL) cholesterol, male gender, and sedentary lifestyle. In women, oestrogen deficiency is a consideration. Epidemiological studies have shown how dramatically cardiovascular risk increases after menopause, quadrupling after surgical menopause and doubling after natural menopause' 21. Oestrogen replacement and risk of coronary events More than 30 observational studies have examined the use of oestrogen replacement therapy to prevent cardiovascular disease in post-menopausal women 131. Ten of 13 case-control studies found that women who received oestrogen replacement had a lower cardiovascular event rate than those who did not. Only one study, however, reached statistical significance 141. These uncontrolled studies have been criticized for selection bias: women who opt for oestrogen replacement therapy might also be those who change their lifestyles in other ways that prevent cardiovascular disease. Seventeen cohort studies involving prospective evaluation of post-menopausal women examined the incidence of cardiovascular events and total mortality relative to oestrogen use. Only one study linked oestrogen use with an increased cardiovascular event rate. Possible explanations for these conflicting results could have been differences in patient composition, selection biases, or misdiagnosed trial end-points. For example, 1996 The European Society of Cardiology

2 Atherosclerotic disease in post-menopausal women 33 certain trials used chest pain to indicate the presence of coronary artery disease. It is now accepted that the anginal syndrome can occur in persons who have no coronary atherosclerosis. Inclusion of such patients would bias the results of a study of atherosclerosis end-points. Four laboratories have used coronary arteriography for cross-sectional studies of oestrogen replacement therapy in post-menopausal patients' 5 " 8 '. All have found less extensive coronary atherosclerosis in women who took oestrogen. Because there were differences other than oestrogen use between patients with and without coronary disease, all studies used logistic regression analysis to identify oestrogen replacement therapy as the variable significantly associated with the absence of coronary disease. There are few studies of oestrogen replacement for the secondary prevention of cardiovascular disease. The first was the Coronary Drug Project' 91, which randomized male survivors of acute myocardial infarction (MI) into several groups, two of which involved administration of conjugated equine oestrogen in daily doses of 2-5 or 50 mg. The men receiving 5 mg per day experienced more cardiovascular events than those who received placebo; definite non-fatal MI occurred in 6-2% of oestrogen-treated men, compared with 3-2% of those receiving placebo. Similarly, there was a statistically significant increase (3-5% vs 13%) in the rate at which oestrogen-treated men had definite pulmonary embolism or thrombophlebitis. Although the men receiving 2-5 mg per day of oestrogen lacked a statistically significant increase in heart attacks, this arm of the study was stopped when malignancy was found more often in the oestrogen-supplemented men than in those receiving placebo" 01. Because of the increased incidence of MI observed in older women who smoked cigarettes and used oral contraceptive preparations containing high doses of oestrogens and progestins, many physicians were reluctant to prescribe these agents for women who had or were at increased risk for cardiovascular disease. We now appreciate that large doses of oestrogen stimulate hepatic production of clotting factors, thus inducing a hypercoagulable state. Effects of oestrogen in women with previous cardiovascular disease Two large, long-term observational studies' 1 IT ' 2 ' have included women with cardiovascular disease at baseline. Both have found that oestrogen replacement conveys a greater survival benefit in this group than in women who initially lacked clinical evidence of cardiovascular disease. The Lipid Research Clinics Program'" 1 included a cohort of 2270 women who were followed for an average of 8-5 years. In women free of cardiovascular disease, the mortality rate was 12-8/ in oestrogen users and 30-2/ in nonusers. In women with cardiovascular disease, the cardiovascular death rate was 13-8/ in oestrogen users and 66-3/ in non-users. The Leisure World Study" 2 ' included 8881 postmenopausal women who were followed for 7-5 years. In women with no history of angina or MI, all-cause mortality was 21-8/1000 in oestrogen users and 26-7/ 1000 in non-users. In women with a positive history, all-cause mortality was 27-5/1000 in oestrogen users and 41-7/1000 in nonusers. The effect of oestrogen replacement on survival in patients with angiographicauy-documented coronary artery disease has been studied in 2268 women undergoing cardiac catheterization' 13 '. Actuarial methods were used to examine survival over 10 years. Patients who were free of coronary artery disease at baseline had good survival rates (10-year survival >90%) whether or not they took oestrogen. In patients with mild to moderate coronary lesions at baseline, 10-year survival was significantly better among oestrogen users than in nonusers. Among those who never took oestrogen, 85% were still alive, compared with 96% of those who were taking oestrogen (P=0021). The difference in survival was greatest in patients with severely stenotic lesions: 60% of those who never used oestrogen were alive at 10 years, compared with 98% of those who had ever taken oestrogen (P=0-007). The Cox stepwise proportional hazards analysis was used to determine which factors had a statistically significant independent effect on total mortality. The most powerful determinants were the number of coronary arteries involved, the severity of cardiac function impairment, age, and disease of the left main coronary artery. The only significant factor predicting survival was oestrogen use. Relative risk equaled 016 with 95% confidence intervals of 0-04 to 0-66 (^=0-011). The relationship between post-menopausal oestrogen use and survival has also been studied in women who underwent coronary artery bypass surgery 1 ' 4 '. Life-table analysis was used to compare postsurgical survival in women who received oestrogen replacement therapy with those who did not. The 10-year survival was 81-4% in the oestrogen users and 65-1% in the non-users (/ > =00001). A Cox proportional hazards model selected number of vessels diseased, oestrogen use, left main coronary stenosis, and diabetes mellitus as significant independent predictors of survival. Mechanisms of cardioprotection by oestrogen Epidemiological and experimental studies suggest that the effect of oestrogen replacement therapy on serum lipids accounts for about 25% of its cardioprotective effect' 151. Before menopause, women have higher HDL levels than men. After menopause, low-density lipoprotein (LDL) levels rise while HDL levels decline

3 34 J. M. Sullivan slightly or remain unchanged. Oestrogen decreases LDL and total cholesterol levels and increases levels of HDL cholesterol and triglycerides [16]. Oestrogen replacement is usually given in combination with a progestin. However, there are relatively few available data regarding possible cardioprotective effects of combined hormone replacement therapy. The PEPI Trial' 171 found that conjugated oestrogens, with or without progestins, lowered LDL by mg. dl~'. Oestrogen alone raised HDL by 5-6mg.dl~'. The addition of a progestin attenuated the HDL rise to 1-2 to l-5mg.dl~', and micronized progesterone raised HDL by 4-2 mg. dl~ '. In a study involving surgically menopausal nonhuman primates, both oestrogen and oestrogen with progestin reduced the extent of aortic atherosclerosis, even though combination therapy reduced HDL levels' 181. Combination therapy reduced LDL cholesterol uptake by arterial walls to the same extent as oestrogen. In long-term human cohort studies, HDL levels did not differ significantly between those taking oestrogen or combination hormone replacement therapy 1 ' 91. The Uppsala Study 1 ' 51 showed that oestrogen or combination replacement therapy equivalently reduced the risk of first MI or stroke. Nachtigall and colleagues' 201, in the only randomized trial of oestrogen/progestin therapy, showed a reduction in the rate of MI in 84 pairs of hospitalized women. Their results, however, did not achieve statistical significance. Oestrogen's effect on coronary arteries In addition to their effect on lipids, oestrogens have a direct effect on vascular reactivity that may influence the balance of myocardial oxygen supply and demand. The endothelium plays an important role in the modulation of blood vessel tone. Furchgott and co-workers' 2 ' 1 demonstrated that removing the endothelium altered the way in which arterial strips responded to acetylcholine. Intact strips responded by vasodilatation. After removal of the endothelium, acetylcholine caused arterial constriction. Further research led to the discovery that acetylcholine stimulates the release of endothelial-derived relaxing factor, a vasodilating compound' 221. The relaxing factor was subsequently identified as nitric oxide, formed from L-arginine. Release of nitric oxide activates guanylate cyclase. This triggers synthesis of cyclic GMP, which in turn alters calcium binding, causing vasodilatation. Ludmer and co-workers' 231 found that infusion of acetylcholine into normal human coronary arteries caused vasodilatation. Infusion of the same dose in an artery with an atherosclerotic lesion produced vasoconstriction of the stenotic and adjacent areas. This suggested that atherosclerotic involvement of the vessel wall impairs endothelial function. Williams and his colleagues' 241 demonstrated that acetylcholine causes constriction when infused into coronary vessels of oophorectomized monkeys fed a high-lipid diet, suggesting loss of endothelial function. When the monkeys received oestrogen replacement therapy, acetylcholine produced a more normal response. Four recent studies have made similar observations in women with coronary disease, but the same results were not seen in men' 25 " 281. The other evidence that oestrogen replacement therapy alters blood vessel function includes studies showing the presence of oestrogen receptors in blood vessel walls, the ability of oestrogen to act as a vasodilator, and the calcium channel blocking properties of oestrogen, which stimulates the production of prostacyclin' 291. In addition to being actively involved in regulating vascular tone through the production of vasorelaxing and vasoconstricting factors, endothelial cells prevent white blood cells from adhering to blood vessel walls (an early event in the formation of atherosclerotic plaques). The endothelium also performs the following roles: regulates the growth of vascular smooth muscle, an important component in the growth of atherosclerotic plaques; limits the passage of LDL cholesterol into the blood vessel wall, which in turn retards the growth of the atherosclerotic plaque; and helps the metabolism of triglycerides through the action of cell membrane lipoprotein lipase 130 ' 3 ' 1. Management of other coronary risk factors A National Center for Health Statistics survey 1321 has found that 29% of adult American women regularly smoke cigarettes. Eighty-four percent of women under age 50 with a history of acute MI are also regular cigarette smokers' 331. Epidemiological studies suggest that cigarette smoking and oral contraceptives act synergistically as coronary risk factors in women over age 35' 341. Twenty-three percent of American women are hypertensive' 351. With ageing, the prevalence of hypertension rises to 35% in white women and 55% in black women. These figures continue to increase with each decade of age. However, the recent NHANES III [3S] Survey indicates a definite decline in the prevalence of hypertension in the general population over the past decade. The importance of hypertension as a coronary risk factor in women has been debated' 371. The prognosis appears more benign in women than in men, which may explain the apparent lack of benefit from antihypertensive therapy in three clinical trials. The Hypertension Detection and Follow-Up Program' 381 found that effective treatment of mild hypertension reduced cardiovascular mortality. Analysis of the outcome in younger white women in this trial suggested no benefit. The relatively small number of white women in this trial, their low event rate, and the trial's duration (5 years) may have made it impossible to demonstrate any benefit from therapy.

4 Atherosclerotic disease in post-menopansal women 35 The British Medical Research Council Trial' 391 included 8000 women, aged years. Antihypertensive treatment reduced cardiovascular events by 25% and strokes by 48%. The Systolic Hypertension in the Elderly Program' 401 observed a 36% reduction in strokes and a decline in coronary heart disease. A meta-analysis of randomized drug treatment trials, in which 47% of participants were women, showed a 42% decrease in stroke and a 14% decline in coronary disease. Based on these trials, women with systolic blood pressure over 160 mmhg and diastolic pressure over 90 mmhg should change lifestyle to reduce weight, lower sodium and alcohol intake, and increase exercise. If blood pressure remains elevated, pharmacological treatment should be added A relationship between hyperlipidaemia and coronary heart disease is present in both sexes, although epidemiological studies have found that the various lipid subfractions affect age groups differently. The Lipid Research Clinics Program Follow-Up Study 1421 followed 2270 women for an average of 8-5 years and found no association between total or LDL cholesterol and cardiovascular death. Triglycerides were found to be a significant risk factor for cardiovascular death in women and, as in men, HDL cholesterol was protective. According to the Framingham Study 1431, total and LDL cholesterol are definite risk factors for coronary disease in women in their fifth, sixth, and seventh decades of life. The Framingham Study 1441 also found that, although the relative risk of coronary events for each increment in serum cholesterol was as high in women as in men, the absolute risk was half as great. Furthermore, each 1% increase in total cholesterol was accompanied by a 2% increase in coronary disease in women. For each lomg.dl"' change in HDL, there was a 40-50% change in coronary risk. Two randomized trials' 45 ' 461 on the effects of dietary and drug intervention on atherosclerosis involved cohorts containing 52% women. These studies showed that lowering LDL and increasing HDL slowed the progression of atherosclerosis in men and women. However, data were insufficient to identify real reduction of coronary events. The results of one primary prevention trial and six secondary prevention trials' 471 suggested that women and men both benefit from lipid lowering. However, the small number of women (4%) present in these trials prevent a definitive conclusion. While it is reasonable to propose that lowering cholesterol is beneficial for women based on the limited available data, this hypothesis has not been proved by any adequately sized, randomized, controlled trials. Evidence that diabetes mellitus is a very powerful predictor of cardiovascular risk for women is compelling. Several studies, including autopsy series, death certificate reviews, and one prospective investigation have shown a stronger association between glucose intolerance and risk of coronary heart disease in women than in men' Regular aerobic exercise is frequently recommended for prevention and management of coronary heart disease. One possible mechanism of cardioprotection is through an effect on lipoproteins, particularly an elevation of HDL. Such a beneficial effect of exercise on HDL cholesterol has not been convincingly demonstrated in women, except for those who participate in endurance training 151 " 521. Daily low-dose aspirin therapy has been shown to significantly reduce the incidence of heart attack and stroke in studies with predominantly male cohorts. The U.S. Nurses' Health Study 1531 found as well that women who took 1-6 aspirin tablets a week had 32% fewer first episodes of MI. Women who took the most vitamin E for over 2 years had a 44% lower rate of coronary artery disease compared with others. Intake of beta-carotene did not have a cardioprotective effect. Conclusion Aggressive treatment of cardiovascular risk factors particularly serum lipid levels can stop the growth of atherosclerotic plaque in most patients and can reduce the size of lesions in a few. Although the change in the dimensions of atherosclerotic lesions is relatively small, the reduction in subsequent cardiovascular events is quite large. It thus appears that an atherosclerotic plaque can be stabilized, reducing the likelihood, that its surface will deteriorate and stimulate formation of an occlusive thrombus. Oestrogen replacement therapy, through an effect on serum lipids and on the blood vessel wall, appears to play an important role in this process. However, it is not the only player. Other important interventions include: the use of antithxombotic therapy (aspirin) to reduce platelet adhesion; reduction of blood pressure to prevent endothelial damage; smoking cessation; and precise control of diabetes mellitus to prevent vascular damage. Antioxidants help by preventing the oxidation of LDL cholesterol, thereby reducing its uptake into the blood vessel wall and into atherosclerotic plaques. Women looking to reduce their risk of coronary disease should also exercise, which enlarges the size of coronary vessels and stimulates collateral formation. References [1] Brown E, Albers JJ, Fisher LD et al. Regression of coronary artery disease as a result of intensive lipid lowering therapy in men with high levels of apolipoprotein B. N Engl J Med 1990; 323: [2] Kannel WB, Hjortland MC, McNamara PM et al. Menopause and the risk of cardiovascular disease. The Framingham Study. Ann Intern Med 1976; 85: [3] Stampfer MJ, Graham AC. Oestrogen replacement therapy and coronary heart disease: a quantitative assessment of the epidemiologic evidence. Prev Med 1991; 20: [4] Ross RK, Paganini-Hill A, Mack TM et al. Menopausal oestrogen therapy and protection from death from ischaemic heart disease. Lancet 1981; 1: [5] Sullivan JM, Vander Zwaag R, Lemp GF el al. Postmenopausal oestrogen use and coronary atherosclerosis. Ann Intern Med 1988; 108:

5 36 J. M. Sullivan [6] Gruchow HW, Anderson AJ, Barboriak JJ et al. Postmenopausal use of oestrogen and occlusion of coronary arteries. Am Heart J 1988; 115: [7] McFarland KF, Boniface ME, Hornung CA et al. Risk factors and noncontraceptive oestrogen use in women with and without coronary disease. Am Heart J 1989; 117: [8] Hong MK, Romm PA, Reagan K et al. Effects of oestrogen replacement therapy on serum lipid values and angiographically defined coronary artery disease in postmenopausal women. Am J Cardiol 1992; 69: [9] The Coronary Drug Project Research Group. The coronary drug project. Initial findings leading to modifications of its research protocol. JAMA 1970; 214: [10] The Coronary Drug Project Research Group. The coronary drug project. Findings leading to discontinuation of the 2-5 mg/day oestrogen group. JAMA 1973; 226: [11] Bush TL, Barrett-Connor E, Cowan LD et al. Cardiovascular mortality and noncontraceptive use of oestrogen in women: results from the Lipid Research Clinics Program Follow-up Study. Circulation 1987; 75: [12] Henderson BE, Paganini-Hill A, Ross RK. Decreased mortality in users of oestrogen replacement therapy. Arch Intern Med 1991; 151: [13] Sullivan JM, Vander Zwaag R, Hughes JP et al. Oestrogen replacement and coronary artery disease: effect on survival in postmenopausal women. Arch Intern Med 1990; 150: [14] Sullivan JM, El-Zeky F, Vander Zwaag R, Ramanathan KB. Oestrogen replacement therapy after coronary artery bypass surgery: effect on survival. J Am Coll Cardiol 1994; 23: 49A. [15] Falkeborn M, Persson I, Adami HO et al. The risk of acute myocardial infarction after oestrogen and oestrogenprogestogen replacement. Br J Obstet Gynaecol 1992; 99: [16] Walsh BW, Schiff I et al. Effects of postmenopausal oestrogen replacement on the concentrations and metabolism of plasma lipoproteins. N Engl J Med 1991; 325: [17] The Writing Group for the PEPI Trial. Effects of oestrogen or oestrogen/progestin regimens on heart disease risk factors in postmenopausal women. The Postmenopausal Oestrogen/ Progesterone Interventions (PEPI) Trial. JAMA 1995; 273: [18] Clarkson TB, Shively CA, Morgan T et al. Oral contraceptives and coronary artery atherosclerosis of cynomolgus monkeys. Obstet Gynaecol 1990; 75: [19] Nabulsi AA, Folsom AR, White A et al. Association of hormone replacement therapy with various cardiovascular risk factors in postmenopausal women. N Engl J Med 1993; 328: [20] Nachtigall LE, Nachtigall RH, Nachtigall RD et al. Oestrogen replacement therapy: II A prospective study m the relationship to carcinoma and cardiovascular and metabolic problems. Obstet Gynaecol 1979; 54: [21] Furchgott RF, Zawadzk JV. The obligatory role of endothelial cells in the relaxation of arterial smooth muscle by acetylcholine. Nature 1980; 288: [22] Ignarro LJ, Byrns RE, Buga GM et al. Endothelium-derived relaxing factor (EDRF) released from artery and vein appears to be nitric oxide (NO) or a closely related radical species. Fed Proc 1987; 46: 644. [23] Ludmer PL, Selwyn AP, Shook TL et al. Paradoxical vasoconstriction induced by acetylcholine in atherosclerotic coronary arteries. N Engl J Med 1986; 315: [24] Williams JK. Adams MR. Klopfenstein HS. Oestrogen modulates responses of atherosclerotic coronary arteries. Circulation 1990; 81: [25] Herrington DM, Braden GA, Williams JK, Morgan TM. Endothelial-dependent coronary vasomotor responsiveness in postmenopausal women with and without oestrogen replacement therapy. Am J Cardiol 1994; 73: [26] Reis SE, Gloth ST, Blumenthal RS et al. Ethinyl oestradiol acutely attenuates abnormal coronary vasomotor responses to acetylcholine in postmenopausal women. Circulation 1994; 89: [27] Gilligan DM, Quyyumi AA, Cannon RO III et al. Effects of physiological levels of oestrogen on coronary vasomotor function in postmenopausal women. Circulation 1994; 89: [28] Collins P, Rosano GMC, Sarrel PM et al. 17 ^-oestradiol attenuates acetylcholine-induced coronary arterial constriction in women but not men with coronary heart disease. Circulation 1995; 92: [29] Fogelberg M, Vesterquist O, Dicfalusy U et al. Experimental atherosclerosis: effects of oestrogen and atherosclerosis on thromboxane and prostacyclin formation. Eur J Clin Invest 1990; 20: [30] Dzau VJ. Atherosclerosis and hypertension: mechanisms and interrelationships. J Cardiovasc Pharmacol 1990; 15 (Suppl 5): S59-S84. [31] Newman KP, Sullivan JM. Coronary heart disease in women: epidemiology, clinical syndromes and management. Menopause 1996; 3: [32] U.S. Department of Health and Human Services, National Center for Health Statistics. U.S. mortality data tapes, 1968 to [33] Rosenberg L, Miller DR, Kaufman DW et al. Myocardial infarction in women under 50 years of age. JAMA 1983; 250: [34] Russell-Bnefel R, Ezzati T, Fulwood R et al. Cardiovascular risk status and oral contraceptive use: United States, Prev Med 1986; 15: [35] Drizd T, Dannenberg AL, Engel A. Blood pressure levels in persons years of age in , and trends in blood pressure from 1960 to 1980 in the United States. Washington DC: National Center for Health Statistics; 1986 July PHS Publication No [36] Burt VL, Whelton P, Roccella EJ et al. Prevalence of hypertension in the U.S. adult population. Results from the Third National Health and Nutrition Exammation Survey, Hypertension 1995; 25: [37] Kaplan N. Primary hypertension natural history, special populations and evaluations. In: W. W. Neal, ed. Clinical Hypertension, 6th edn. Baltimore: Williams and Wilkins, 1994: [38] HDFP Cooperative Group. Five-year findings of the Hypertension Detection and Follow-Up Program: 11 Mortality by race, sex, and age. JAMA 1979; 242: [39] MRC Working Party. MRC trial of treatment of mild hypertension: principal results. Br Med J 1985; 29: [40] SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991; 265: [41] Dannenberg AL, Drizd T, Horan MJ et al. Progress in the battle against hypertension: changes in blood pressure levels in the United States from Hypertension 1987; 10: [42] Bush TL, Barrett-Connor E, Cowan LD et al. Cardiovascular mortality and noncontraceptive use of oestrogen in women: results from the Lipid Research Clinics Program Follow-up Study. Circulation 1987; 75: [43] Kannel WB, Castelli WP, Gordon T. Serum cholesterol, lipoproteins, and the risk of coronary heart disease. Ann Intern Med 1971; 74: [44] Kannel WB, Wilson PWF. Risk factors that attenuate the female coronary disease advantage. Arch Intern Med 1995; 155: [45] Kane JP, Malloy MJ, Ports TA et al. Regression of coronary atherosclerosis during treatment of familial hypercholesterolaemia with combined drug regimens. JAMA 1990; 264:

6 Atherosclerotic disease in post-menopausal women 37 [46] Levy RI, Brensike JF, Epstein SE et al. The influence of changes in lipid values induced by cholestyramine and diet on progression of coronary artery disease: results of the NHLBI Type II Coronary Intervention Study. Circulation 1984; 69: [47] Rich-Edwards JW, Manson JE, Hennekens CH, Bunng JE. The primary prevention of coronary heart disease in women. N Engl J Med 1995; 332: [48] Clawson BJ, Bell ET. Incidence of fatal coronary disease in nondiabetic and in diabetic patients. Arch Pathol 1949; 48: [49] Kessler II. Mortality experience of diabetic patients. A twenty-six year follow-up study. JAMA 1971; 51: [50] Kannel WB, Mcgee DL. Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham Study. Diabetes Care 1979; 2: [51] Frey MAB, Doerr BM, Laubach LL et al. Exercise does not change high-density lipoprotein cholesterol levels in women after ten weeks of training. Metabolism 1982; 31: [52] Rotkis TC, Boyden TW, Stanforth PR et al. Increased high-density lipoprotein cholesterol and lean weight in endurance-trained women runners. J Cardiac Rehabil 1984; 4: [53] Manson JE, Stampfer MJ, Colditz GA et al. A prospective study of aspirin use and primary prevention of cardiovascular disease in women. JAMA 1991; 266:

Menopausal hormone therapy currently has no evidence-based role for

Menopausal hormone therapy currently has no evidence-based role for IN PERSPECTIVE HT and CVD Prevention: From Myth to Reality Nanette K. Wenger, M.D. What the studies show, in a nutshell The impact on coronary prevention Alternative solutions Professor of Medicine (Cardiology),

More information

Editorial. Smoking, Estrogen, and Prevention of Heart Disease in Women

Editorial. Smoking, Estrogen, and Prevention of Heart Disease in Women Editorial Smoking, Estrogen, and Prevention of Heart Disease in Women Despite the remarkable decline in mortality rates from coronary heart disease (CHD) in the United States (and many other Western nations),

More information

American Medical Women s Association Position Paper on Principals of Women & Coronary Heart Disease

American Medical Women s Association Position Paper on Principals of Women & Coronary Heart Disease American Medical Women s Association Position Paper on Principals of Women & Coronary Heart Disease AMWA is a leader in its dedication to educating all physicians and their patients about heart disease,

More information

How would you manage Ms. Gold

How would you manage Ms. Gold How would you manage Ms. Gold 32 yo Asian woman with dyslipidemia Current medications: Simvastatin 20mg QD Most recent lipid profile: TC = 246, TG = 100, LDL = 176, HDL = 50 What about Mr. Williams? 56

More information

Postmenopausal hormones and coronary artery disease: potential benefits and risks

Postmenopausal hormones and coronary artery disease: potential benefits and risks CLIMACTERIC 2007;10(Suppl 2):21 26 Postmenopausal hormones and coronary artery disease: potential benefits and risks R. A. Department of Obstetrics and Gynecology, Columbia University, New York, New York,

More information

Evidence for primary and secondary prevention of coronary artery disease in women taking oestrogen replacement therapy

Evidence for primary and secondary prevention of coronary artery disease in women taking oestrogen replacement therapy European Heart Journal (1996) 17 {Supplement D), 9-14 Evidence for primary and secondary prevention of coronary artery disease in women taking oestrogen replacement therapy T. L. Bush The increasing use

More information

Kathryn M. Rexrode, MD, MPH. Assistant Professor. Division of Preventive Medicine Brigham and Women s s Hospital Harvard Medical School

Kathryn M. Rexrode, MD, MPH. Assistant Professor. Division of Preventive Medicine Brigham and Women s s Hospital Harvard Medical School Update: Hormones and Cardiovascular Disease in Women Kathryn M. Rexrode, MD, MPH Assistant Professor Division of Preventive Medicine Brigham and Women s s Hospital Harvard Medical School Overview Review

More information

Risk Factors and Primary and Secondary Prevention of Coronary Heart Disease

Risk Factors and Primary and Secondary Prevention of Coronary Heart Disease Special Issue Risk Factors and Primary and Secondary Prevention of Coronary Heart Disease Shung Chull Chae, M.D. Department of Internal Medicine / Division of Cardiology Kyungpook National University College

More information

Cardiovascular Disease Risk Factors:

Cardiovascular Disease Risk Factors: Cardiovascular Disease Risk Factors: Risk factors are traits or habits that increase a person's chances of having cardiovascular disease. Some risk factors can be changed. These risk factors are high blood

More information

Statistical Fact Sheet Populations

Statistical Fact Sheet Populations Statistical Fact Sheet Populations At-a-Glance Summary Tables Men and Cardiovascular Diseases Mexican- American Males Diseases and Risk Factors Total Population Total Males White Males Black Males Total

More information

Angina Pectoris. Edward JN Ishac, Ph.D. Smith Building, Room

Angina Pectoris. Edward JN Ishac, Ph.D. Smith Building, Room Angina Pectoris Edward JN Ishac, Ph.D. Smith Building, Room 742 eishac@vcu.edu 828-2127 Department of Pharmacology and Toxicology Medical College of Virginia Campus of Virginia Commonwealth University

More information

Complications of Diabetes mellitus. Dr Bill Young 16 March 2015

Complications of Diabetes mellitus. Dr Bill Young 16 March 2015 Complications of Diabetes mellitus Dr Bill Young 16 March 2015 Complications of diabetes Multi-organ involvement 2 The extent of diabetes complications At diagnosis as many as 50% of patients may have

More information

Chapter 18. Diet and Health

Chapter 18. Diet and Health Chapter 18 Diet and Health Risk Factors and Chronic Diseases Interrelationships among Chronic Diseases Chronic Disease Heart Disease and Stroke Hypertension Cancer Diabetes The Formation of Plaques in

More information

The inhibition of CETP: From simply raising HDL-c to promoting cholesterol efflux and lowering of atherogenic lipoproteins Prof Dr J Wouter Jukema

The inhibition of CETP: From simply raising HDL-c to promoting cholesterol efflux and lowering of atherogenic lipoproteins Prof Dr J Wouter Jukema The inhibition of CETP: From simply raising HDL-c to promoting cholesterol efflux and lowering of atherogenic lipoproteins Prof Dr J Wouter Jukema Dept Cardiology, Leiden University Medical Center, Leiden,

More information

Andrew Cohen, MD and Neil S. Skolnik, MD INTRODUCTION

Andrew Cohen, MD and Neil S. Skolnik, MD INTRODUCTION 2 Hyperlipidemia Andrew Cohen, MD and Neil S. Skolnik, MD CONTENTS INTRODUCTION RISK CATEGORIES AND TARGET LDL-CHOLESTEROL TREATMENT OF LDL-CHOLESTEROL SPECIAL CONSIDERATIONS OLDER AND YOUNGER ADULTS ADDITIONAL

More information

Cardiovascular System and Health. Chapter 15

Cardiovascular System and Health. Chapter 15 Cardiovascular System and Health Chapter 15 Cardiovascular Disease Leading cause of death in U.S. Claims 1 life every 43 seconds Often, the first sign is a fatal heart attack Death Rates #1 CVD #2 Cancer

More information

Optimizing risk assessment of total cardiovascular risk What are the tools? Lars Rydén Professor Karolinska Institutet Stockholm, Sweden

Optimizing risk assessment of total cardiovascular risk What are the tools? Lars Rydén Professor Karolinska Institutet Stockholm, Sweden Optimizing risk assessment of total cardiovascular risk What are the tools? Lars Rydén Professor Karolinska Institutet Stockholm, Sweden Cardiovascular Disease Prevention (CVD) Three Strategies for CVD

More information

PCTH 400. Endothelial dysfunction and cardiovascular diseases. Blood vessel LAST LECTURE. Endothelium. High blood pressure

PCTH 400. Endothelial dysfunction and cardiovascular diseases. Blood vessel LAST LECTURE. Endothelium. High blood pressure PCTH 400 LAST LECTURE Endothelial dysfunction and cardiovascular diseases. Classic Vascular pharmacology -chronic -systemic Local Vascular pharmacology -acute -targeted High blood pressure Blood pressure

More information

Understanding Cholesterol and Triglycerides

Understanding Cholesterol and Triglycerides MINTO PREVENTION & REHABILITATION CENTRE CENTRE DE PREVENTION ET DE READAPTATION MINTO Understanding Cholesterol and Triglycerides About This Kit Along with cigarette smoking, high blood pressure, physical

More information

Dyslipidemia Endothelial dysfunction Free radicals Immunologic

Dyslipidemia Endothelial dysfunction Free radicals Immunologic ATHEROSCLEROSIS Hossein Mehrani Professor of Clinical Biochemistry Definition Atherosclerosis: Is a chronic inflammatory process characterized by plaque formation within the vessel wall of arteries and

More information

Term-End Examination December, 2009 MCC-006 : CARDIOVASCULAR EPIDEMIOLOGY

Term-End Examination December, 2009 MCC-006 : CARDIOVASCULAR EPIDEMIOLOGY MCC-006 POST GRADUATE DIPLOMA IN CLINICAL CARDIOLOGY (PGDCC) 00269 Term-End Examination December, 2009 MCC-006 : CARDIOVASCULAR EPIDEMIOLOGY Time : 2 hours Maximum Marks : 60 Note : There will be multiple

More information

Women and Heart Disease

Women and Heart Disease Women and Heart Disease The Very Latest in Cardiovascular Medicine and Surgery Gretchen L. Wells, MD, PhD, FACC Thomas Whayne Endowed Professor in Women s Heart Health Gill Heart Institute University of

More information

Intermediate Methods in Epidemiology Exercise No. 4 - Passive smoking and atherosclerosis

Intermediate Methods in Epidemiology Exercise No. 4 - Passive smoking and atherosclerosis Intermediate Methods in Epidemiology 2008 Exercise No. 4 - Passive smoking and atherosclerosis The purpose of this exercise is to allow students to recapitulate issues discussed throughout the course which

More information

Risk Factors for Heart Disease

Risk Factors for Heart Disease Risk Factors for Heart Disease Risk Factors we cannot change (Age, Gender, Family History) Risk Factors we can change (modifiable) Smoking Blood pressure Cholesterol Diabetes Inactivity Overweight Stress

More information

Hormone therapy. Dr. med. Frank Luzuy

Hormone therapy. Dr. med. Frank Luzuy Hormone therapy Dr. med. Frank Luzuy Reasons for Initiating/Continuing HT* Menopause-Related Symptoms Osteoporosis, Bone Loss, Fracture Prevention Doctor Prescribed It, Told Me to Take It Cardiovascular

More information

Wellness: Concepts and Applications 8 th Edition Anspaugh, Hamrick, Rosato

Wellness: Concepts and Applications 8 th Edition Anspaugh, Hamrick, Rosato Wellness: Concepts and Applications 8 th Edition Anspaugh, Hamrick, Rosato Preventing Cardiovascular Disease Chapter 2 Cardiovascular Disease the leading cause of death in the U.S. 35.3% of all deaths

More information

Ezetimibe and SimvastatiN in Hypercholesterolemia EnhANces AtherosClerosis REgression (ENHANCE)

Ezetimibe and SimvastatiN in Hypercholesterolemia EnhANces AtherosClerosis REgression (ENHANCE) Ezetimibe and SimvastatiN in Hypercholesterolemia EnhANces AtherosClerosis REgression (ENHANCE) Thomas Dayspring, MD, FACP Clinical Assistant Professor of Medicine University of Medicine and Dentistry

More information

Endothelium. A typical endothelial cell is about 30mm long, Accounts for 1% or less of the arterial weight

Endothelium. A typical endothelial cell is about 30mm long, Accounts for 1% or less of the arterial weight Endothelium Discovered in 1845 A typical endothelial cell is about 30mm long, 10mm wide, and 0.2 3 mm thick Accounts for 1% or less of the arterial weight As recently as the late 1960s it was thought of

More information

Title for Paragraph Format Slide

Title for Paragraph Format Slide Title for Paragraph Format Slide Presentation Title: Month Date, Year Atherosclerosis A Spectrum of Disease: February 12, 2015 Richard Cameron Padgett, MD Executive Medical Director, OHVI Pt RB Age 38

More information

Eugene Barrett M.D., Ph.D. University of Virginia 6/18/2007. Diagnosis and what is it Glucose Tolerance Categories FPG

Eugene Barrett M.D., Ph.D. University of Virginia 6/18/2007. Diagnosis and what is it Glucose Tolerance Categories FPG Diabetes Mellitus: Update 7 What is the unifying basis of this vascular disease? Eugene J. Barrett, MD, PhD Professor of Internal Medicine and Pediatrics Director, Diabetes Center and GCRC Health System

More information

The Gender Divide Women, Men and Heart Disease February 2017

The Gender Divide Women, Men and Heart Disease February 2017 The Gender Divide Women, Men and Heart Disease February 2017 Nandita S. Scott, MD FACC Co-Director MGH Heart Center Corrigan Women s Heart Health Program Massachusetts General Hospital Heart Disease For

More information

Vascular disease. Structural evaluation of vascular disease. Goo-Yeong Cho, MD, PhD Seoul National University Bundang Hospital

Vascular disease. Structural evaluation of vascular disease. Goo-Yeong Cho, MD, PhD Seoul National University Bundang Hospital Vascular disease. Structural evaluation of vascular disease Goo-Yeong Cho, MD, PhD Seoul National University Bundang Hospital resistance vessels : arteries

More information

Understanding Risk Factors for Stroke

Understanding Risk Factors for Stroke MINTO PREVENTION & REHABILITATION CENTRE CENTRE DE PREVENTION ET DE READAPTATION MINTO Understanding Risk Factors for Stroke About This Kit Risk factors have been identified that can predict who is most

More information

Estrogen replacement therapy and coronary heart disease: a quantitative assessment of the epidemiologic evidence 1,2

Estrogen replacement therapy and coronary heart disease: a quantitative assessment of the epidemiologic evidence 1,2 IJE vol.33 no.3 International Epidemiological Association 2004; all rights reserved. International Journal of Epidemiology 2004;33:445 453 Advance Access publication 27 May 2004 DOI: 10.1093/ije/dyh125

More information

Dyslipedemia New Guidelines

Dyslipedemia New Guidelines Dyslipedemia New Guidelines New ACC/AHA Prevention Guidelines on Blood Cholesterol November 12, 2013 Mohammed M Abd El Ghany Professor of Cardiology Cairo Universlty 1 1 0 Cholesterol Management Pharmacotherapy

More information

The Framingham Coronary Heart Disease Risk Score

The Framingham Coronary Heart Disease Risk Score Plasma Concentration of C-Reactive Protein and the Calculated Framingham Coronary Heart Disease Risk Score Michelle A. Albert, MD, MPH; Robert J. Glynn, PhD; Paul M Ridker, MD, MPH Background Although

More information

Cardiac Pathophysiology

Cardiac Pathophysiology Cardiac Pathophysiology Evaluation Components Medical history Physical examination Routine laboratory tests Optional tests Medical History Duration and classification of hypertension. Patient history of

More information

Estrogens vs Testosterone for cardiovascular health and longevity

Estrogens vs Testosterone for cardiovascular health and longevity Estrogens vs Testosterone for cardiovascular health and longevity Panagiota Pietri, MD, PhD, FESC Director of Hypertension Unit Athens Medical Center Athens, Greece Women vs Men Is there a difference in

More information

Module 2. Global Cardiovascular Risk Assessment and Reduction in Women with Hypertension

Module 2. Global Cardiovascular Risk Assessment and Reduction in Women with Hypertension Module 2 Global Cardiovascular Risk Assessment and Reduction in Women with Hypertension 1 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored,

More information

HIGH LDL CHOLESTEROL IS NOT AN INDEPENDENT RISK FACTOR FOR HEART ATTACKS AND STROKES

HIGH LDL CHOLESTEROL IS NOT AN INDEPENDENT RISK FACTOR FOR HEART ATTACKS AND STROKES HIGH LDL CHOLESTEROL IS NOT AN INDEPENDENT RISK FACTOR FOR HEART ATTACKS AND STROKES A study published in the British Medical Journal shows that not only is high LDL cholesterol not a risk factor for all-caused

More information

Results of Ischemic Heart Disease

Results of Ischemic Heart Disease Ischemic Heart Disease: Angina and Myocardial Infarction Ischemic heart disease; syndromes causing an imbalance between myocardial oxygen demand and supply (inadequate myocardial blood flow) related to

More information

Marshall Tulloch-Reid, MD, MPhil, DSc, FACE Epidemiology Research Unit Tropical Medicine Research Institute The University of the West Indies, Mona,

Marshall Tulloch-Reid, MD, MPhil, DSc, FACE Epidemiology Research Unit Tropical Medicine Research Institute The University of the West Indies, Mona, Marshall Tulloch-Reid, MD, MPhil, DSc, FACE Epidemiology Research Unit Tropical Medicine Research Institute The University of the West Indies, Mona, Jamaica At the end of this presentation the participant

More information

Structure and organization of blood vessels

Structure and organization of blood vessels The cardiovascular system Structure of the heart The cardiac cycle Structure and organization of blood vessels What is the cardiovascular system? The heart is a double pump heart arteries arterioles veins

More information

Hospital and 1-year outcome after acute myocardial infarction in patients with diabetes mellitus and hypertension

Hospital and 1-year outcome after acute myocardial infarction in patients with diabetes mellitus and hypertension (2003) 17, 665 670 & 2003 Nature Publishing Group All rights reserved 0950-9240/03 $25.00 www.nature.com/jhh ORIGINAL ARTICLE Hospital and 1-year outcome after acute myocardial infarction in patients with

More information

Financial Conflicts of Interest

Financial Conflicts of Interest Hormone Treatment of Menopausal Women: What Are the Data Telling Us (and Not Telling Us)? S. Mitchell Harman, M.D., Ph.D. Chief, Endocrine Division Phoenix VA Health Care System Clinical Professor, Medicine

More information

9/29/2015. Primary Prevention of Heart Disease: Objectives. Objectives. What works? What doesn t?

9/29/2015. Primary Prevention of Heart Disease: Objectives. Objectives. What works? What doesn t? Primary Prevention of Heart Disease: What works? What doesn t? Samia Mora, MD, MHS Associate Professor, Harvard Medical School Associate Physician, Brigham and Women s Hospital October 2, 2015 Financial

More information

Pathology of Coronary Artery Disease

Pathology of Coronary Artery Disease Pathology of Coronary Artery Disease Seth J. Kligerman, MD Pathology of Coronary Artery Disease Seth Kligerman, MD Assistant Professor Medical Director of MRI University of Maryland Department of Radiology

More information

Part 1 Risk Factors and Atherosclerosis. LO1. Define the Different Forms of CVD

Part 1 Risk Factors and Atherosclerosis. LO1. Define the Different Forms of CVD Week 3: Cardiovascular Disease Learning Outcomes: 1. Define the difference forms of CVD 2. Describe the various risk factors of CVD 3. Describe atherosclerosis and its stages 4. Describe the role of oxidation,

More information

Younger adults with a family history of premature artherosclerotic disease should have their cardiovascular risk factors measured.

Younger adults with a family history of premature artherosclerotic disease should have their cardiovascular risk factors measured. Appendix 2A - Guidance on Management of Hypertension Measurement of blood pressure All adults from 40 years should have blood pressure measured as part of opportunistic cardiovascular risk assessment.

More information

Five chapters 1. What is CVD prevention 2. Why is CVD prevention needed 3. Who needs CVD prevention 4. How is CVD prevention applied 5. Where should CVD prevention be offered Shorter, more adapted to clinical

More information

Diabetes Mellitus: A Cardiovascular Disease

Diabetes Mellitus: A Cardiovascular Disease Diabetes Mellitus: A Cardiovascular Disease Nestoras Mathioudakis, M.D. Assistant Professor of Medicine Division of Endocrinology, Diabetes, & Metabolism September 30, 2013 1 The ABCs of cardiovascular

More information

Appendix This appendix was part of the submitted manuscript and has been peer reviewed. It is posted as supplied by the authors.

Appendix This appendix was part of the submitted manuscript and has been peer reviewed. It is posted as supplied by the authors. Appendix This appendix was part of the submitted manuscript and has been peer reviewed. It is posted as supplied by the authors. Appendix to: Banks E, Crouch SR, Korda RJ, et al. Absolute risk of cardiovascular

More information

Declaration of conflict of interest. None to declare

Declaration of conflict of interest. None to declare Declaration of conflict of interest None to declare Risk management of coronary artery disease Arrhythmias and diabetes Hercules Mavrakis Cardiology Department Heraklion University Hospital Crete, Greece

More information

CETP inhibition: pros and cons. Philip Barter The Heart Research Institute Sydney, Australia

CETP inhibition: pros and cons. Philip Barter The Heart Research Institute Sydney, Australia CETP inhibition: pros and cons Philip Barter The Heart Research Institute Sydney, Australia Philip Barter Disclosures Received honorariums for lectures, consultancies or membership of advisory boards from:

More information

Total risk management of Cardiovascular diseases Nobuhiro Yamada

Total risk management of Cardiovascular diseases Nobuhiro Yamada Nobuhiro Yamada The worldwide burden of cardiovascular diseases (WHO) To prevent cardiovascular diseases Beyond LDL Multiple risk factors With common molecular basis The Current Burden of CVD CVD is responsible

More information

By Graham C. Wong, MD; and Christian Constance, MD. therapy in reducing long-term cardiovascular

By Graham C. Wong, MD; and Christian Constance, MD. therapy in reducing long-term cardiovascular Lipid-Lowering Therapy For Acute Coronary Syndromes There is a large amount of evidence that supports the early use of statins in the treatment of acute coronary syndromes. The anti-inflammatory, anti-thrombotic

More information

Case Study: Chris Arden. Peripheral Arterial Disease

Case Study: Chris Arden. Peripheral Arterial Disease Case Study: Chris Arden Peripheral Arterial Disease Patient Presentation Diane is a 65-year-old retired school teacher She complains of left calf pain when walking 50 metres; the pain goes away after she

More information

http://noodlemaz.wordpress.com/category/science/cancer/ Outline Introduction Serious nature of Cardiovascular Disease (CVD) How to prevent CVD? The disease process Damage and plaque development Current

More information

The investigation of serum lipids and prevalence of dyslipidemia in urban adult population of Warangal district, Andhra Pradesh, India

The investigation of serum lipids and prevalence of dyslipidemia in urban adult population of Warangal district, Andhra Pradesh, India eissn: 09748369, www.biolmedonline.com The investigation of serum lipids and prevalence of dyslipidemia in urban adult population of Warangal district, Andhra Pradesh, India M Estari, AS Reddy, T Bikshapathi,

More information

Cho et al., 2009 Journal of Cardiology (2009), 54:

Cho et al., 2009 Journal of Cardiology (2009), 54: Endothelial Dysfunction, Increased Carotid Artery Intima-media Thickness and Pulse Wave Velocity, and Increased Level of Inflammatory Markers are Associated with Variant Angina Cho et al., 2009 Journal

More information

Ischaemic Heart Disease

Ischaemic Heart Disease Ischaemic Heart Disease Katherine Rothwell Case 1 65 yr old female PMHx : Eczema, is a smoker 20/day Comes to see you complaining of central chest pain Present past few months. Comes on when gardening

More information

Cardiovascular Disorders Lecture 3 Coronar Artery Diseases

Cardiovascular Disorders Lecture 3 Coronar Artery Diseases Cardiovascular Disorders Lecture 3 Coronar Artery Diseases By Prof. El Sayed Abdel Fattah Eid Lecturer of Internal Medicine Delta University Coronary Heart Diseases It is the leading cause of death in

More information

Cardiovascular Complications of Diabetes

Cardiovascular Complications of Diabetes VBWG Cardiovascular Complications of Diabetes Nicola Abate, M.D., F.N.L.A. Professor and Chief Division of Endocrinology and Metabolism The University of Texas Medical Branch Galveston, Texas Coronary

More information

American Osteopathic College of Occupational and Preventive Medicine 2012 Mid-Year Educational Conference St. Petersburg, Florida

American Osteopathic College of Occupational and Preventive Medicine 2012 Mid-Year Educational Conference St. Petersburg, Florida The 21 st Century Paradigm Shift: Prevention Rather Than Intervention for the Treatment of Stable CHD The Economic Burden of Cardiovascular Diseases Basil Margolis MD, FACC, FRCP Director, Preventive Cardiology

More information

Current Cholesterol Guidelines and Treatment of Residual Risk COPYRIGHT. J. Peter Oettgen, MD

Current Cholesterol Guidelines and Treatment of Residual Risk COPYRIGHT. J. Peter Oettgen, MD Current Cholesterol Guidelines and Treatment of Residual Risk J. Peter Oettgen, MD Associate Professor of Medicine Harvard Medical School Director, Preventive Cardiology Beth Israel Deaconess Medical Center

More information

Cardiovascular disease, studies at the cellular and molecular level. Linda Lowe Krentz Bioscience in the 21 st Century September 23, 2009

Cardiovascular disease, studies at the cellular and molecular level. Linda Lowe Krentz Bioscience in the 21 st Century September 23, 2009 Cardiovascular disease, studies at the cellular and molecular level Linda Lowe Krentz Bioscience in the 21 st Century September 23, 2009 Content Introduction The number 1 killer in America Some statistics

More information

THE SAME EFFECT WAS NOT FOUND WITH SPIRITS 3-5 DRINKS OF SPIRITS PER DAY WAS ASSOCIATED WITH INCREASED MORTALITY

THE SAME EFFECT WAS NOT FOUND WITH SPIRITS 3-5 DRINKS OF SPIRITS PER DAY WAS ASSOCIATED WITH INCREASED MORTALITY ALCOHOL NEGATIVE CORRELATION BETWEEN 1-2 DRINKS PER DAY AND THE INCIDENCE OF CARDIOVASCULAR DISEASE SOME HAVE SHOWN THAT EVEN 3-4 DRINKS PER DAY CAN BE BENEFICIAL - WHILE OTHERS HAVE FOUND IT TO BE HARMFUL

More information

Update on Lipid Management in Cardiovascular Disease: How to Understand and Implement the New ACC/AHA Guidelines

Update on Lipid Management in Cardiovascular Disease: How to Understand and Implement the New ACC/AHA Guidelines Update on Lipid Management in Cardiovascular Disease: How to Understand and Implement the New ACC/AHA Guidelines Paul Mahoney, MD Sentara Cardiology Specialists Lipid Management in Cardiovascular Disease

More information

Data Alert #2... Bi o l o g y Work i n g Gro u p. Subject: HOPE: New validation for the importance of tissue ACE inhibition

Data Alert #2... Bi o l o g y Work i n g Gro u p. Subject: HOPE: New validation for the importance of tissue ACE inhibition Vascular Bi o l o g y Work i n g Gro u p c/o Medical Education Consultants, In c. 25 Sy l van Road South, We s t p o rt, CT 06880 Chairman: Carl J. Pepine, MD Professor and Chief Division of Cardiovascular

More information

ORIGINAL INVESTIGATION. Hormone Replacement Therapy and Associated Risk of Stroke in Postmenopausal Women

ORIGINAL INVESTIGATION. Hormone Replacement Therapy and Associated Risk of Stroke in Postmenopausal Women ORIGINAL INVESTIGATION Hormone Replacement Therapy and Associated Risk of Stroke in Postmenopausal Women Rozenn N. Lemaitre, PhD, MPH; Susan R. Heckbert, MD, PhD; Bruce M. Psaty, MD, PhD; Nicholas L. Smith,

More information

Cardiovascular Health Practice Guideline Outpatient Management of Coronary Artery Disease 2003

Cardiovascular Health Practice Guideline Outpatient Management of Coronary Artery Disease 2003 Authorized By: Medical Management Guideline Committee Approval Date: 12/13/01 Revision Date: 12/11/03 Beta-Blockers Nitrates Calcium Channel Blockers MEDICATIONS Indicated in post-mi, unstable angina,

More information

All medications are a double-edged sword with risks

All medications are a double-edged sword with risks Menopause: The Journal of The North American Menopause Society Vol. 14, No. 5, pp. 1/14 DOI: 10.1097/gme.0b013e31802e8508 * 2007 by The North American Menopause Society REVIEW ARTICLE Postmenopausal hormone

More information

Ischemic Heart and Cerebrovascular Disease. Harold E. Lebovitz, MD, FACE Kathmandu November 2010

Ischemic Heart and Cerebrovascular Disease. Harold E. Lebovitz, MD, FACE Kathmandu November 2010 Ischemic Heart and Cerebrovascular Disease Harold E. Lebovitz, MD, FACE Kathmandu November 2010 Relationships Between Diabetes and Ischemic Heart Disease Risk of Cardiovascular Disease in Different Categories

More information

Arteriosclerosis & Atherosclerosis

Arteriosclerosis & Atherosclerosis Arteriosclerosis & Atherosclerosis Arteriosclerosis = hardening of arteries = arterial wall thickening + loss of elasticity 3 types: -Arteriolosclerosis -Monckeberg medial sclerosis -Atherosclerosis Arteriosclerosis,

More information

EFFECT OF NICARDIPINE ON FASTING PLASMA LIPIDS AND APOLIPOPROTEINS IN MALE NEW ZEALAND WHITE RABBITS. Kamsiah Jaarin, Nafeeza MI*

EFFECT OF NICARDIPINE ON FASTING PLASMA LIPIDS AND APOLIPOPROTEINS IN MALE NEW ZEALAND WHITE RABBITS. Kamsiah Jaarin, Nafeeza MI* REVIEW ARTICLE Malaysian Journal of Medical Sciences, Vol. 6, No. 2, July 1999 (5-11) EFFECT OF NICARDIPINE ON FASTING PLASMA LIPIDS AND APOLIPOPROTEINS IN MALE NEW ZEALAND WHITE RABBITS Kamsiah Jaarin,

More information

CVD risk assessment using risk scores in primary and secondary prevention

CVD risk assessment using risk scores in primary and secondary prevention CVD risk assessment using risk scores in primary and secondary prevention Raul D. Santos MD, PhD Heart Institute-InCor University of Sao Paulo Brazil Disclosure Honoraria for consulting and speaker activities

More information

JUPITER NEJM Poll. Panel Discussion: Literature that Should Have an Impact on our Practice: The JUPITER Study

JUPITER NEJM Poll. Panel Discussion: Literature that Should Have an Impact on our Practice: The JUPITER Study Panel Discussion: Literature that Should Have an Impact on our Practice: The Study Kaiser COAST 11 th Annual Conference Maui, August 2009 Robert Blumberg, MD, FACC Ralph Brindis, MD, MPH, FACC Primary

More information

Figure 13-1: Antiplatelet Action of Aspirin (Modified After Taneja et.al 2004) ASPIRIN RESISTANCE

Figure 13-1: Antiplatelet Action of Aspirin (Modified After Taneja et.al 2004) ASPIRIN RESISTANCE CHAPTER 13 ASPIRIN Action Aspirin Resistance Aspirin Dose Therapeutic Efficacy - Secondary prevention - Acute coronary syndromes - Primary prevention Limitations and Side Effects Aspirin Aspirin should

More information

SUPPLEMENTAL MATERIAL

SUPPLEMENTAL MATERIAL SUPPLEMENTAL MATERIAL A Meta-analysis of LDL-C, non-hdl-c, and apob as markers of cardiovascular risk. Slide # Contents 2 Table A1. List of candidate reports 8 Table A2. List of covariates/model adjustments

More information

YOUR GUIDE TO. Understanding Your Angina Diagnosis and Treatment

YOUR GUIDE TO. Understanding Your Angina Diagnosis and Treatment YOUR GUIDE TO Understanding Your Angina Diagnosis and Treatment Our goal at the Mercy Health Heart Institute is to help you be well. Our experienced team includes cardiologists, cardiovascular surgeons,

More information

HYPERTENSION GUIDELINES WHERE ARE WE IN 2014

HYPERTENSION GUIDELINES WHERE ARE WE IN 2014 HYPERTENSION GUIDELINES WHERE ARE WE IN 2014 Donald J. DiPette MD FACP Special Assistant to the Provost for Health Affairs Distinguished Health Sciences Professor University of South Carolina University

More information

Acute Vascular Effects of Estrogen

Acute Vascular Effects of Estrogen 786 Acute Vascular Effects of Estrogen in Postmenopausal Women David M. Gilligan, MD; Diane M. Badar, RN; Julio A. Panza, MD; Arshed A. Quyyumi, MD; Richard. Cannon III, MD Downloaded from http://ahajournals.org

More information

Dyslipidemia in the light of Current Guidelines - Do we change our Practice?

Dyslipidemia in the light of Current Guidelines - Do we change our Practice? Dyslipidemia in the light of Current Guidelines - Do we change our Practice? Dato Dr. David Chew Soon Ping Senior Consultant Cardiologist Institut Jantung Negara Atherosclerotic Cardiovascular Disease

More information

Clinical Recommendations: Patients with Periodontitis

Clinical Recommendations: Patients with Periodontitis The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease. Friedewald VE, Kornman KS, Beck JD, et al. J Periodontol 2009;

More information

The JUPITER trial: What does it tell us? Alice Y.Y. Cheng, MD, FRCPC January 24, 2009

The JUPITER trial: What does it tell us? Alice Y.Y. Cheng, MD, FRCPC January 24, 2009 The JUPITER trial: What does it tell us? Alice Y.Y. Cheng, MD, FRCPC January 24, 2009 Learning Objectives 1. Understand the role of statin therapy in the primary and secondary prevention of stroke 2. Explain

More information

C-Reactive Protein and Your Heart

C-Reactive Protein and Your Heart C-Reactive Protein and Your Heart By: James L. Holly, MD Inflammation is the process by which the body responds to injury. Laboratory evidence and findings at autopsy studies suggest that the inflammatory

More information

coronary heart disease (CHD) is the leading

coronary heart disease (CHD) is the leading Appendix I: Evidence on HRT and Coronary Heart Disease I coronary heart disease (CHD) is the leading cause of death among U.S. women, surpassing the rates from cancer and other diseases (13). Any change

More information

Effects of Statins on Endothelial Function in Patients with Coronary Artery Disease

Effects of Statins on Endothelial Function in Patients with Coronary Artery Disease Effects of Statins on Endothelial Function in Patients with Coronary Artery Disease Iana I. Simova, MD; Stefan V. Denchev, PhD; Simeon I. Dimitrov, PhD Clinic of Cardiology, University Hospital Alexandrovska,

More information

Ira S. Ockene, M.D. David and Barbara Milliken Professor of Preventive Cardiology University of Massachusetts Medical School

Ira S. Ockene, M.D. David and Barbara Milliken Professor of Preventive Cardiology University of Massachusetts Medical School Cardiovascular Disease: how did it become such a problem, what are the risk factors with particular emphasis on diabetes and obesity, and how public policy work can to improve the health of all Ira S.

More information

Treatment to reduce cardiovascular risk: multifactorial management

Treatment to reduce cardiovascular risk: multifactorial management Treatment to reduce cardiovascular risk: multifactorial management Matteo Anselmino, MD PhD Assistant Professor San Giovanni Battista Hospital Division of Cardiology, Department of Internal Medicine University

More information

Serum Creatinine and Blood Urea Nitrogen Levels in Patients with Coronary Artery Disease

Serum Creatinine and Blood Urea Nitrogen Levels in Patients with Coronary Artery Disease Serum Creatinine and Blood Urea Nitrogen Levels in Patients with Coronary Artery Disease MAK Akanda 1, KN Choudhury 2, MZ Ali 1, MK Kabir 3, LN Begum 4, LA Sayami 1 1 National Institute of Cardiovascular

More information

Preventive Cardiology Scientific evidence

Preventive Cardiology Scientific evidence Preventive Cardiology Scientific evidence Professor David A Wood Garfield Weston Professor of Cardiovascular Medicine International Centre for Circulatory Health Imperial College London Primary prevention

More information

Elevated Risk of Cardiovascular Disease Prior to Clinical Diagnosis of Type 2 Diabetes

Elevated Risk of Cardiovascular Disease Prior to Clinical Diagnosis of Type 2 Diabetes Epidemiology/Health Services/Psychosocial Research O R I G I N A L A R T I C L E Elevated Risk of Cardiovascular Disease Prior to Clinical Diagnosis of Type 2 Diabetes FRANK B. HU, MD 1,2,3 MEIR J. STAMPFER,

More information

CARING FOR A LOVED ONE AFTER A HEART ATTACK OR STROKE

CARING FOR A LOVED ONE AFTER A HEART ATTACK OR STROKE CARING FOR A LOVED ONE AFTER A HEART ATTACK OR STROKE AFTER YOUR LOVED ONE HAS HAD A HEART ATTACK OR STROKE Heart attack and stroke affects the whole family. If your loved one has had a heart attack or

More information

Misperceptions still exist that cardiovascular disease is not a real problem for women.

Misperceptions still exist that cardiovascular disease is not a real problem for women. Management of Cardiovascular Risk Factors in the Cynthia A., MD University of California, San Diego ARHP 9/19/08 Disclosures Research support Wyeth, Lilly, Organon, Novo Nordisk, Pfizer Consultant fees

More information

CLINICIAN INTERVIEW CARDIOVASCULAR DISEASE IN POSTMENOPAUSAL WOMEN

CLINICIAN INTERVIEW CARDIOVASCULAR DISEASE IN POSTMENOPAUSAL WOMEN CARDIOVASCULAR DISEASE IN POSTMENOPAUSAL WOMEN Nanette K. Wenger, MD, is a recognized authority on women and coronary heart disease. She chaired the US National Heart, Lung, and Blood Institute conference

More information

On May 2001, the Third Adult

On May 2001, the Third Adult THE RISK OF DIABETES: CAN WE IMPACT CHD THROUGH THE ATP III CHOLESTEROL GUIDELINES? * Based on a presentation given by Steven M. Haffner, MD, MPH ABSTRACT Diabetes has been recognized among diabetologists

More information

KEY COMPONENTS. Metabolic Risk Cardiovascular Risk Vascular Inflammation Markers

KEY COMPONENTS. Metabolic Risk Cardiovascular Risk Vascular Inflammation Markers CardioMetabolic Risk Poor blood sugar regulation and unhealthy triglyceride and lipoprotein levels often present long before the diagnosis of type 2 Diabetes. SpectraCell s CardioMetabolic and Pre-Diabetes

More information

Heart Disease in Women: Is it Really Different?

Heart Disease in Women: Is it Really Different? Heart Disease in Women: Is it Really Different? Jennifer Jarbeau, MD Southcoast Physicians Group Cardiovascular Associates of RI Disclosures I have no financial interests to disclose I wish I did! Are

More information

Risk Factors for Ischemic Stroke: Electrocardiographic Findings

Risk Factors for Ischemic Stroke: Electrocardiographic Findings Original Articles 232 Risk Factors for Ischemic Stroke: Electrocardiographic Findings Elley H.H. Chiu 1,2, Teng-Yeow Tan 1,3, Ku-Chou Chang 1,3, and Chia-Wei Liou 1,3 Abstract- Background: Standard 12-lead

More information