Prospects of personalized medicine in cardiovascular diseases.

Cardiovascular diseases remain the dominant cause of death worldwide. In the last decades, the remarkable advances in human genetic and genomic research, plus the now common use of genome-wide association studies, have led to the identification of numerous genetic variants associated with specific cardiovascular traits and diseases. Although the clinical applications are limited because the genetic risk of common cardiovascular disease is still unexplained, and the mechanisms of action of the genetic factor(s) are not known, these research advances have, in turn, widely opened the concept of personalized medicine. In this paper, the status and prospects of personalized medicine for cardiovascular disease will be presented. This will be followed by a discussion of issues regarding the implementation of personalized medicine.

Chest pain of cardiac and noncardiac origin.

Chest pain is one of the most common symptoms driving patients to a physician's office or the hospital's emergency department. In approximately half of the cases, chest pain is of cardiac origin, either ischemic cardiac or nonischemic cardiac disease. The other half is due to noncardiac causes, primarily esophageal disorder. Pain from either origin may occur in the same patient. In addition, psychological and psychiatric factors play a significant role in the perception and severity of the chest pain, irrespective of its cause. Chest pain of ischemic cardiac disease is called angina pectoris. Stable angina may be the prelude of ischemic cardiac disease; and for this reason, it is essential to ensure a correct diagnosis. In most cases, further testing, such as exercise testing and angiography, should be considered. The more severe form of chest pain, unstable angina, also requires a firm diagnosis because it indicates severe coronary disease and is the earliest manifestation of acute myocardial infarction. Once a diagnosis of stable or unstable angina is established, and if a decision is made not to use invasive therapy, such as coronary bypass, percutaneous transluminal coronary angioplasty, or stent insertion, effective medical treatment of associated cardiac risk factors is a must. Acute myocardial infarction occurring after a diagnosis of angina greatly increases the risk of subsequent death. Chest pain in women warrants added attention because women underestimate their likelihood to have coronary heart disease. A factor that complicates the clinical assessment of patients with chest pain (both cardiac and noncardiac in origin) is the relatively common presence of psychological and psychiatric conditions such as depression or panic disorder. These factors have been found to cause or worsen chest pain; but unfortunately, they may not be easily detected. Noncardiac chest pain represents the remaining half of all cases of chest pain. Although there are a number of causes, gastroesophageal disorders are by far the most prevalent, especially gastroesophageal reflux disease. Fortunately, this disease can be diagnosed and treated effectively by proton-pump inhibitors. The other types of non-gastroesophageal reflux disease-related noncardiac chest pain are more difficult to diagnose and treat. In conclusion, the cause of chest pain must be accurately diagnosed; and treatment must be pursued according to the cause, especially if the cause is of cardiac origin.

[Controlling blood pressure: how well are we doing?].

The author analyses global prevalence of arterial pressure and its impact on population mortality and disability, draws attention to insufficient efficacy of this disease treatment, low awareness of the population about this disease and compliance of the patients. To achieve target arterial pressure, cooperation is necessary between the physician and the patient.

Low birth weight and blood pressure.

Evidence supporting the association of normal and pathologically elevated blood pressure with low birth weight is presented and discussed in this article because of the overwhelming global prevalence of hypertension and its impact on individuals and nations. The findings provide strong impetus for the medical and public health communities to consider the concept of the "developmental origins of health and disease" in developing approaches to address the growing burden of hypertension worldwide.

Can prevention of hypertension work?

In this article, the clinical trials that have most effectively demonstrated the effectiveness of hypertension nonpharmacologic prevention interventions are presented and discussed. Thus, data from weight reduction, dietary interventions, and lifestyle modifications are shown and discussed. It is concluded that these interventions lead to control of hypertension either by themselves or in association with pharmacologic interventions. Over the years, many controlled clinical trials have demonstrated the efficacy of pharmacologic treatment of hypertension. However, such treatment has its shortcomings. First, it usually requires a lifelong commitment to therapy because, although this approach can control hypertension and reduce its consequences, it does not cure the condition. Next, the cost of pharmacologic interventions can be very high and, thus, prohibitive for poorer individuals and nations. In addition, many patients experience problems with compliance and adherence, which almost certainly contribute to the low level of hypertension control that is so widely observed. Finally, the pharmacologic approach requires a strong commitment by public health officials for detection and treatment of hypertension if there is to be any hope of limiting this condition's impact. All of these negative considerations are compounded by the fact that the prevalence of hypertension is increasing worldwide. For all these reasons, nonpharmacologic interventions should be implemented to prevent or delay the occurrence of hypertension.

Do sleep disorders have an impact on blood pressure?

In this article, the relationship, perhaps interdependence, between sleep-disordered breathing, hypertension, and obesity is discussed. There is strong evidence that sleep-disordered breathing and hypertension are related. On the one hand, the prevalence of hypertension increases with the number of apnea-hypopnea episodes per hour of sleep, whereas on the other hand, treating sleep-disordered breathing reduces hypertension. It has also been shown that this relationship between sleep-disordered breathing and hypertension is stronger in individuals with a high body mass index. Thus, it is concluded that in individuals presenting with hypertension, sleep-disordered breathing, or increased weight, the two other variables must be investigated and treated if present.

Clinical practice and recent recommendations in hypertension management--reporting a gap in a global survey of 1259 primary care physicians in 17 countries.

OBJECTIVE: High blood pressure (BP) is a leading risk factor for cardiovascular morbidity and mortality. Effective antihypertensive pharmacotherapy is available but recognition and proper management of hypertension and BP goal achievement is still poor. Therefore, it was hypothesized that physicians' attitude towards high BP, as well as patients' perception and knowledge, may influence actual management of hypertension. RESEARCH DESIGN AND METHODS: Telephone interviews were carried out with a random sample of 1259 primary care physicians in 17 countries worldwide from 12 December 2005 to 13 January 2006 using a central computer assisted telephone interview methodology (CATI). RESULTS: (1) Physicians believed that 62 +/- 21% of their patients had their BP controlled. (2) They were mostly in line with guideline recommended BP goals and 96% were aware of the elevated cardiovascular risk of hypertension, but 41% aimed to reduce BP to acceptable levels only. (3) Physicians indicated that in 41% of patients monotherapy controls BP and 71% would escalate to combination therapy after monotherapy failure. (4) 54% regard hypertension management as difficult. (5) Physicians estimated that between 60 and 70% of patients know their BP goal but thought that there was still room for improvement of hypertension management on the patient side. CONCLUSION: Although many effective treatment options for arterial hypertension exist, BP goal achievement worldwide is suboptimal, leaving patients at an unnecessary cardiovascular risk. An increase in patients' awareness and compliance together with an increased adherence of physicians to current guidelines should help in reducing the long term cardiovascular consequences of hypertension.

Reducing the public health burden from elevated blood pressure levels in the United States by lowering intake of dietary sodium.

Elevated blood pressure levels are a major cause of heart disease and stroke. Healthy People 2010 established objectives to reduce mortality from these diseases by 20% and to reduce the major causal factors associated with these elevated levels, such as excess sodium intake. The American public consumes far more sodium than is needed, most of which is added by food manufacturers and restaurants. In November 2002, the American Public Health Association adopted a policy resolution calling for a 50% reduction in sodium in the nation's food supply over the next 10 years. Such a reduction would greatly enhance the chances of attaining the Healthy People 2010 objectives and would save at least 150 000 lives annually. This issue warrants public health intervention.