RESUMEN
AIMS/HYPOTHESIS: The aim of this work was to investigate whether measurement of the mean common carotid intima-media thickness (CIMT) improves cardiovascular risk prediction in individuals with diabetes. METHODS: We performed a subanalysis among 4,220 individuals with diabetes in a large ongoing individual participant data meta-analysis involving 56,194 subjects from 17 population-based cohorts worldwide. We first refitted the risk factors of the Framingham heart risk score on the individuals without previous cardiovascular disease (baseline model) and then expanded this model with the mean common CIMT (CIMT model). The absolute 10 year risk for developing a myocardial infarction or stroke was estimated from both models. In individuals with diabetes we compared discrimination and calibration of the two models. Reclassification of individuals with diabetes was based on allocation to another cardiovascular risk category when mean common CIMT was added. RESULTS: During a median follow-up of 8.7 years, 684 first-time cardiovascular events occurred among the population with diabetes. The C statistic was 0.67 for the Framingham model and 0.68 for the CIMT model. The absolute 10 year risk for developing a myocardial infarction or stroke was 16% in both models. There was no net reclassification improvement with the addition of mean common CIMT (1.7%; 95% CI -1.8, 3.8). There were no differences in the results between men and women. CONCLUSIONS/INTERPRETATION: There is no improvement in risk prediction in individuals with diabetes when measurement of the mean common CIMT is added to the Framingham risk score. Therefore, this measurement is not recommended for improving individual cardiovascular risk stratification in individuals with diabetes.
Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Grosor Intima-Media Carotídeo , Diabetes Mellitus/epidemiología , Humanos , Infarto del Miocardio/epidemiología , Factores de Riesgo , Accidente Cerebrovascular/epidemiologíaRESUMEN
AIM: To investigate the cardiometabolic risk (CMR) assessment and management patterns for individuals with and without type 2 diabetes mellitus (T2DM) in Canadian primary care practices. METHODS: Between April 2011 and March 2012, physicians from 9 primary care teams and 88 traditional non-team practices completed a practice assessment on the management of 2461 patients >40 years old with no clinical evidence of cardiovascular disease and diagnosed with at least one of the following risk factor-T2DM, dyslipidaemia or hypertension. RESULTS: There were 1304 individuals with T2DM and 1157 without. Pharmacotherapy to manage hyperglycaemia, dyslipidaemia and hypertension was widely prescribed. Fifty-eight percent of individuals with T2DM had a glycated haemoglobin (HbA1c) ≤7.0%. Amongst individuals with dyslipidaemia, median low-density lipoprotein cholesterol (LDL-C) was 1.8 mmol/l for those with T2DM and 2.8 mmol/l for those without. Amongst individuals with hypertension, 30% of those with T2DM achieved the <130/80 mmHg target, whereas 60% of those without met the <140/90 mmHg target. The composite glycaemic, LDL-C and blood pressure (BP) target outcome was achieved by 12% of individuals with T2DM. Only 17% of individuals with T2DM and 11% without were advised to increase their physical activity. Dietary modifications were recommended to 32 and 10% of those with and without T2DM, respectively. CONCLUSIONS: Patients at elevated CMR were suboptimally managed in the primary care practices surveyed. There was low attainment of recommended therapeutic glycaemic, lipid and BP targets. Advice on healthy lifestyle changes was infrequently dispensed, representing a missed opportunity to educate patients on the long-term benefits of lifestyle modification.
Asunto(s)
Diabetes Mellitus Tipo 2/complicaciones , Dislipidemias/tratamiento farmacológico , Hiperglucemia/tratamiento farmacológico , Hipertensión/tratamiento farmacológico , Adulto , Anciano , Antihipertensivos/uso terapéutico , Colombia Británica , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Dislipidemias/complicaciones , Terapia por Ejercicio/estadística & datos numéricos , Femenino , Humanos , Hiperglucemia/complicaciones , Hipertensión/complicaciones , Hipoglucemiantes/uso terapéutico , Hipolipemiantes/uso terapéutico , Masculino , Persona de Mediana Edad , Ontario , Atención Primaria de Salud/estadística & datos numéricos , Quebec , Conducta de Reducción del RiesgoRESUMEN
BACKGROUND: In trials of patients with left ventricular dysfunction or heart failure, ACE inhibitor use was unexpectedly associated with reduced myocardial infarction (MI). Using the Heart Outcomes Prevention Evaluation (HOPE) trial data, we tested prospectively whether ramipril, an ACE inhibitor, could reduce coronary events and revascularization procedures among patients with normal left ventricular function. METHODS AND RESULTS: In the HOPE trial, 9297 high-risk men and women, >/=55 years of age with previous cardiovascular disease or diabetes plus 1 risk factor, were randomly assigned to ramipril (up to 10 mg/d), vitamin E (400 IU/d), their combination, or matching placebos. During the mean follow-up of 4.5 years, there were 482 (10.4%) patients with clinical MI and unexpected cardiovascular death in the ramipril group compared with 604 (12.9%) in the placebo group [relative risk reduction (RRR), 21% (95% CI) (11,30); P<0.0003]. Ramipril was associated with a trend toward less fatal MI and unexpected death [4.0% versus 4.7%; RRR, 16% (-3, 31)] and with a significant reduction in nonfatal MI [5.6% versus 7.2%; RRR, 23% (9,34)]. Risk reductions in MI were documented in participants taking or not taking beta-blockers, lipid lowering, and/or antiplatelet agents. Although ramipril had no impact on hospitalizations for unstable angina [11.9% versus 12.2%; RRR, 3% (-9,14)], it reduced the risk of worsening and new angina [27.2% versus 30.0%; RRR, 12% (5,18); P<0.0014] and coronary revascularizations [12.5% versus 14.8%; RRR, 18%; (8,26) P<0.0005]. CONCLUSIONS: In this high-risk cohort, ramipril reduced the risk of MI, worsening and new angina, and the occurrence of coronary revascularizations.
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Infarto del Miocardio/prevención & control , Ramipril/uso terapéutico , Anciano , Angina Inestable/prevención & control , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/prevención & control , Revascularización Miocárdica/estadística & datos numéricos , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
BACKGROUND: Both hyper- and hypokalemia increase cardiovascular risk. Modest hyperkalemia is common with angiotensin-converting enzyme inhibition. We studied post-hoc the association of an initial, on-treatment serum potassium measurement with subsequent cardiovascular outcomes over 4.5 years in 9297 individuals at high cardiovascular risk, randomized to an ACE inhibitor or to placebo. METHODS: Post-hoc analysis of cardiovascular outcomes, as related to serum potassium levels, in the HOPE (Heart Outcomes and Prevention Evaluation) study which compared ramipril to placebo, and included 692 patients with a serum potassium level >5.0 mM and 137 with a serum potassium level <3.5 mM, defined as hyper- and hypokalemia, respectively. Serum potassium was measured 1 month after start of randomized treatment. RESULTS: With hyperkalemia, the primary event rate was unchanged compared to normokalemia (15.5 vs 15.7%, p > 0.4, respectively), with hypokalemia, the primary event rate was higher (22.6% vs 15.5%, respectively, p = 0.023). The hazard ratio for the primary outcome associated with this initial hypokalemia was 1.44 (1.00-2.06) on multivariate analysis. The combined primary outcome (myocardial infarction, cardiovascular death, stroke) was not different throughout deciles of serum potassium but the lowest and highest deciles included many with normokalemia. Randomized treatment was withheld because of hyperkalemia in 8 and 6 people allocated to ramipril and placebo, respectively. The benefit of ramipril on cardiovascular outcomes was independent of serum potassium, but ramipril reduced hypokalemia in the entire cohort (1.15 vs 1.86% with placebo, p = 0.005), particularly in those participants on diuretics (3.8% vs 6.5%, p = 0.07). CONCLUSIONS: In patients at high cardiovascular risk, modest hypokalemia predicts a less favorable outcome while modest hyperkalemia does not. Ramipril reduces hypokalemia and decreases risk.
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Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Enfermedades Cardiovasculares/etiología , Hiperpotasemia/complicaciones , Hipopotasemia/complicaciones , Ramipril/efectos adversos , Anciano , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/prevención & control , Femenino , Humanos , Hiperpotasemia/inducido químicamente , Hipopotasemia/prevención & control , Masculino , Persona de Mediana Edad , Potasio/sangre , Factores de Riesgo , Resultado del TratamientoRESUMEN
Atherosclerotic cardiovascular disease remains a major cause of mortality and morbidity in most developed countries. Experimental and clinical evidence suggests that angiotensin-converting enzyme inhibitors and vitamin E therapy may retard the atherosclerotic process; however, definitive proof in humans is lacking. The Study to Evaluate Carotid Ultrasound Changes in Patients Treated with Ramipril and Vitamin E (SECURE) is designed to assess the effects of ramipril--an angiotensin-converting enzyme inhibitor, at 2 doses: 2.5 mg daily (which has little effect on lowering blood pressure) and 10 mg daily--and the antioxidant vitamin E, 400 IU daily, on atherosclerosis progression in 732 patients using a factorial 3 x 2 study design. High-risk patients with a documented history of significant cardiovascular disease or with diabetes and additional risk factors were enrolled and will be followed for 4 years. The extent and progression of atherosclerosis are assessed noninvasively by B-mode carotid ultrasonography. The SECURE trial is a substudy of the larger Heart Outcomes Prevention Evaluation (HOPE) study of 9,541 high-risk patients evaluating the effects of ramipril and vitamin E on major cardiovascular events (cardiovascular death, myocardial infarction, and stroke). The 2 studies are complementary. Whereas HOPE is expected to provide information on major clinical outcomes, SECURE will shed light on the mechanisms by which these effects may be mediated.
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Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Arteriosclerosis/tratamiento farmacológico , Enfermedades de las Arterias Carótidas/tratamiento farmacológico , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Arteriosclerosis Intracraneal/tratamiento farmacológico , Ramipril/uso terapéutico , Vitamina E/uso terapéutico , Anciano , Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Progresión de la Enfermedad , Método Doble Ciego , Femenino , Humanos , Arteriosclerosis Intracraneal/diagnóstico por imagen , Masculino , Ramipril/administración & dosificación , Proyectos de Investigación , Factores de Riesgo , UltrasonografíaRESUMEN
OBJECTIVES: To review prospective epidemiological studies and randomized clinical trials regarding the role of antioxidant vitamins (vitamins E and C and beta-carotene) in the prevention of cardiovascular diseases. DATA SOURCES: Computerized (MEDLINE and Science Citation Index) and manual searches on the role of antioxidant vitamins in cardiovascular disease management. STUDY SELECTION: Only prospective epidemiological studies and double-blind, controlled, randomized clinical trials, including at least 100 participants and providing sufficient data to allow quantitative estimation of the effects of vitamin intake were included. Retrospective epidemiological evaluations and other retrospective studies were excluded. Geographic correlation studies of population-based intake of antioxidants and cardiovascular disease rates were also excluded due to the potential large impact of confounders in cross-sectional analyses. DATA SYNTHESIS: Relative risk was evaluated for all prospective epidemiological studies. Relative risk reductions were evaluated for clinical trials. The Mantel-Haenszel method was used to estimate the relative risk reduction in clinical trials when not calculated in the original publication. A formal meta-analysis was not performed because very significant differences among study populations, type (supplemental versus dietary) and dosage of antioxidant vitamins, duration of follow-up and overall study design exist for both epidemiological investigations and clinical trials, and the pooling of study results could be misleading. CONCLUSIONS: Prospective epidemiological investigations suggest a reduction in cardiovascular risk associated with increased intake of antioxidant vitamins, particularly vitamin E. Randomized clinical trials remain inconclusive with regard to the role of vitamin E in cardiovascular protection. The large, randomized clinical trials of beta-carotene in primary prevention show no effect and potential for harm associated with the use of beta-carotene. There are inconclusive and insufficient epidemiological and clinical trial data with regard to the role of vitamin C in cardiovascular protection. Overall, it is recommended that wide-spread use of antioxidant vitamins in cardiovascular protection should not be instituted and should await the results of further ongoing clinical trials.
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Antioxidantes/farmacología , Enfermedades Cardiovasculares/prevención & control , Vitaminas/farmacología , Adulto , Anciano , Ácido Ascórbico/farmacología , Enfermedades Cardiovasculares/epidemiología , Ensayos Clínicos como Asunto , Estudios Epidemiológicos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del Tratamiento , Vitamina E/farmacología , beta Caroteno/farmacologíaRESUMEN
Intracardiac shunts are uncommon cardiac lesions caused by blunt chest trauma. A very unusual case is reported of a young male with an acquired left ventricular to right atrial communication and complete heart block cause by nonpenetrating chest trauma. The left ventricular to right atrial fistula was diagnosed noninvasively by transthoracic and transesophageal echo-Doppler examination and the findings were confirmed by left ventriculography and by the intraoperative findings.
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Bloqueo Cardíaco/etiología , Lesiones Cardíacas/complicaciones , Traumatismos Torácicos/complicaciones , Adolescente , Función del Atrio Derecho , Ecocardiografía/métodos , Electrocardiografía , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/lesiones , Atrios Cardíacos/fisiopatología , Bloqueo Cardíaco/diagnóstico por imagen , Lesiones Cardíacas/diagnóstico por imagen , Humanos , Masculino , Traumatismos Torácicos/diagnóstico por imagen , Ultrasonografía Doppler en Color , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/etiología , Disfunción Ventricular Izquierda/fisiopatología , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico por imagenRESUMEN
This presentation reviews data from epidemiologic and clinical trials on antioxidant vitamins, angiotensin-converting enzyme inhibitors, and homocysteine and their effect on atherosclerotic cardiovascular disease. Each of these areas seems promising, but the results of large, on-going studies must be determined before definitive conclusions can be made as to the effectiveness of these therapies.
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Enfermedad de la Arteria Coronaria/prevención & control , Adulto , Anciano , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Ácido Ascórbico/uso terapéutico , Estudios de Cohortes , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/fisiopatología , Femenino , Homocisteína/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Estrés Oxidativo , Ensayos Clínicos Controlados Aleatorios como Asunto , Vitamina E/uso terapéutico , beta Caroteno/uso terapéuticoAsunto(s)
Enfermedades Cardiovasculares/prevención & control , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antioxidantes/uso terapéutico , Medicina Basada en la Evidencia , Homocisteína/fisiología , Humanos , Estrés Oxidativo , Medición de Riesgo , Factores de Riesgo , Vitamina E/uso terapéuticoRESUMEN
This review summarizes the evidence from five of the larger randomized controlled trials evaluating the effects of angiotensin converting enzyme inhibitors started in the early phase of myocardial infarction on subsequent mortality and major morbidity. Altogether, information on about 98,000 patients is available from these trials. In four studies, trial treatment was started within 24 h, and in one study within 36 h, of the onset of symptoms of acute myocardial infarction, and mortality was assessed after a few weeks or months of treatment. When taken together, these trials show that angiotensin converting enzyme inhibitors produce a significant 7% relative risk reduction in mortality (P < 0.006), which corresponds to an absolute difference of about five fewer deaths per 1,000 patients treated. The benefits may be greater in higher-risk patients (e.g. those with previous myocardial infarction, heart failure or large infarcts). These results demonstrate that for a wide range of patients without clear contraindications, angiotensin converting enzyme inhibitors started early in acute myocardial infarction prevent further deaths in the first few weeks when added to standard therapy (aspirin, thrombolytic therapy and beta-blockers). The early benefits seen with ACE inhibitors seems to persist for at least the first year. The clinical implications of these results are discussed.