Epidemiology of coronary heart disease: the Puerto Rico heart health program revisted.

Coronary heart disease (CHD) remains as the main cause of death in most countries of the world including Puerto Rico. Due to the importance of gathering knowledge regarding the harmful effects and risk factors associated with the development of CHD some basic information is reviewed to stimulate the institution of measures for reduction of the prevalence of clinical CHD and its ultimate consequences. Special attention is given in the manuscript of the Puerto Rico Heart Health Program conducted in men aged 45-64 residing in four rural and three urban areas. The Puerto Rico and the Honolulu Study confirmed the initial publication on the epidemiology of coronary heart disease by the Framingham study. The presentation of some data collected among the three studies strengthen the message of avoiding the development of CHD by installing preventive measures for control and reduction of the risk factors. Concurrent data obtained in the three studies is presented. Although the degree of the involvement of the populations is higher in Framingham than in Puerto Rico and Honolulu, the deleterious effects of specific risk factors are harmful in all the three populations. Difference in the prevalence of risk factors among the urban and rural males in Puerto Rico is also illustrated. It is our hope that more intense measures be instituted in Puerto Rico at all levels in order to control risk factors and reduce the incidence of coronary disease in Puerto Rico.

Gender disparities in Puerto Ricans hospitalized with an initial acute myocardial infarction: A population-based perspective.

OBJECTIVE: The published literature suggests differences in presenting symptoms for acute myocardial infarction (AMI), management, and outcomes according to gender and age. However, limited information exists on this topic among Hispanics. METHODS: In Puerto Rican patients hospitalized with an initial AMI, we examined differences in presenting symptoms, effective cardiac therapies, and in-hospital mortality as a function of gender and age groups. We reviewed the medical records of patients hospitalized with a validated AMI in 12 greater San Juan, Puerto Rico hospitals during 2007. RESULTS: The average age of 1,415 patients hospitalized with a first AMI was 66 years and 45 % were women. Chest pain (81%) was the most prevalent acute presenting symptom with significant differences in its frequency between women (77%) and men (85%)(p<0.001). Right arm pain, shortness-of-breath/dyspnea, and sweating/ diaphoresis were most prevalent in patients 55-64 years old (45%), compared with patients 75 years and older (29%)(p<0.005). Relative to men and patients < 55 years old, coronary angiography/thrombolytic therapy and percutaneous coronary interventions were used less frequently in women and older patients (>75 years old). During hospitalization for AMI the in-hospital death rate was higher in women (8.6%) than men (6.0%), and increased with advancing age (p<0.05). CONCLUSION: These findings suggest significant gender and age differences in presenting symptoms, management, and early mortality in Puerto Ricans hospitalized with an initial AMI. It remains of considerable importance that health care personnel become aware of these gender and age differences to improve the management and outcomes of these patients.

A peripheral artery disease screening study in Puerto Rico.

UNLABELLED: Peripheral artery disease (PAD) of the lower extremities is frequently underdiagnosed and undertreated. The results of screening for PAD in adults attending outpatient clinics at different sites in Puerto Rico from 2007 to 2010 are presented. METHODS: A total of 33 outpatients screening clinics were conducted at different sites throughout the Island. Following the ACC/AHA Guideline recommendations, asymptomatic patients who qualified were screened for PAD using the ankle-brachial index (ABI). An ABI < 0.9 was considered positive for PAD. We estimated the prevalence of PAD in the study population and used logistic regression models to assess factors associated with a positive screening test for PAD. RESULTS: A total of 933 patients were screened for PAD. Out of the 933 patients, the ABI was < 0.9 in 390 (41.8%) of them. Bivariate analysis showed a significant difference in PAD screening results by gender (P = 0.004) and history of arterial hypertension (P = 0.004). Regarding clinical characteristics, leg edema 44.7% (P = 0.001), intermittent claudication 40.3% (P = 0.002), distal extremity coldness 29.0% (P = 0.012), and weak lower extremity pulses 67.5% (P < 0.001) were more prevalent on patients with an ABI < 0.9. In the multivariate analysis, male gender (OR = 1.92, 95% CI: 1.18, 3.11) and arterial hypertension (OR = 2.16, 95% CI: 1.28, 3.65) were significantly associated with PAD after adjusting for specific confounders. CONCLUSIONS: Arterial hypertension, cigarette smoking, diabetes mellitus, and dyslipidemia are known key factors in development of PAD. Practicing physicians must be aware of the importance of an early diagnosis of PAD, particularly in the asymptomatic patient, so as to institute preventive and management measures.

Cardiovascular services and human resources in Puerto Rico - 2008.

Available information (2004-2008) concerning population statistics, the occurrence of cardiovascular disease, cardiovascular services and human resources in Puerto Rico is presented. Relevant information concerning life expectancy at birth, death by specific causes in a recent four years period, the commonest causes of death, and the related cardiovascular risk factors prevalence data available is included. The surgical and medical interventional services rendered to cardiovascular patients in different institutions and their locations in Puerto Rico in the year 2008 is presented. Some remarks concerning the productivity of physicians by our Schools of Medicine is included. Information about ACGME accredited postgraduate cardiovascular training programs conducted in Puerto Rico is presented. Data concerning the prevalence of hypertension, diabetes mellitus, overweight and obesity obtained by BRFSS in presented.

Physical activity and prostate cancer mortality in Puerto Rican men.

Studies on the association between physical activity and fatal prostate cancer have produced inconclusive results. The Puerto Rico Heart Health Program was a cohort study of a randomly selected sample of 9824 men age 35 to 79 years at baseline who were followed for mortality until 2002. Multiple examinations collected information on lifestyle, diet, body composition, exercise, urban-rural residence, and smoking habits. Physical activity status was measured using the Framingham Physical Activity Index, an assessment of occupational, leisure-time, and other physical activities measured as usual activity over the course of a 24-hour day. Physical activity was stratified into quartiles. Multivariate logistic regression analysis was used to assess the association of physical activity with prostate cancer mortality. Other covariates included age, education, urban-rural residence, smoking, and body mass index. Compared with the lowest level of physical activity (Q1), the risk of prostate cancer mortality was OR = 0.99 (95% CI = 0.64-1.55) for Q2, OR = 1.34 (95% CI = 0.88-2.05) for Q3, and OR = 1.19 (95% CI = 0.75-1.90) for Q4. Further analyses by age group, overweight status, or vigorous physical activity also did not show a significant association between physical activity and prostate cancer mortality. Physical activity did not predict prostate cancer mortality in this group of Puerto Rican men.

Protein and legume intake and prostate cancer mortality in Puerto Rican men.

Prostate cancer is the number 1 cancer killer among Puerto Rican (PR) men. Plant foods have been inversely associated with prostate cancer. Legumes play a significant role in the PR diet; consumption of legumes in PR (14 lb/capita) was double that of the United States (7 lb/capita). We examined dietary protein consumption (from baseline 24-h dietary recalls) and prostate cancer mortality in the PR Heart Health Program, a cohort study of 9,824 men aged 35-79 years at baseline (1964) with follow-up until 2005. Total protein intake in the cohort was 85 g/day, and sources of protein were 30% vegetable, 30% dairy, 31% animal, and 8% seafood protein. Legume intake was 2.3 servings/day (1/4 cup each). Legume intake was not associated with prostate cancer mortality [comparing highest quartile to lowest quartile-odds ratio (OR) 1.40 [95% confidence interval (CI) 0.91-2.18], P trend 0.17]-nor were total protein, animal, seafood, dairy, or vegetable protein intakes. Consuming 1-2 servings of fruit was inversely associated (OR 0.50, 95% CI 0.32-0.77), whereas consuming more than 2 servings of fruit was not associated with prostate cancer mortality. Thus, we find no association between legumes or protein intake and prostate cancer mortality in this longitudinal cohort study of PR men.

Skin color and mortality risk among men: the Puerto Rico Heart Health Program.

PURPOSE: To examine the association between skin color and all-cause and cardiovascular disease (CVD)-related mortality risk before and after adjusting for selected characteristics and risk factors, we used data on 5,304 men with information on skin color at Exam 3 of the Puerto Rico Heart Health program (PRHHP), a longitudinal study of the incidence of coronary heart disease in Puerto Rican men. METHODS: Mortality was ascertained using hospital and physician records, postmortem records, death certificates, and information from the next of kin. RESULTS: Dark-skinned men exhibited higher age-adjusted mortality rates than light skinned men (10.1 vs. 8.8/10,000 population). There was no association between skin color and all-cause and CVD-related mortality. However, the association between skin color and all-cause mortality varied with area of residence (p for interaction = 0.05). Among men living in urban areas, the risk of all-cause mortality was 28% (95% confidence interval, 1.02-1.61) greater among dark-skinned men than their light-skinned counterparts after adjusting for age, education, BMI, physical activity, and the presence of diabetes. There was no association between skin color and CVD mortality in urban men. Neither all-cause nor CVD mortality was associated with skin color among rural men. CONCLUSION: Our results suggest that skin color may be capturing environmental dynamics that may influence mortality risk among Puerto Rican men.

Update on cardiovascular disease in Puerto Rico in 2007.

Recent information (2004-2007) concerning population statistics and the occurrence of cardiovascular disease in Puerto Rico is presented. Complemen-tary relevant information concerning life expectancy at birth, death by specific causes in a recent five years period, the commonest causes of death, and the related prevalence data available is included. The statistics about invasive surgical and medical services rendered to cardiovascular patients in different institutions in Puerto Rico in the year 2006 is presented. A summary of the status concerning the ACGME accredited Postgraduate Cardiovascular Training programs in Puerto Rico is also included.

Heart failure in rupture of a sinus of valsalva aneurysm.

We report a 22-year-old man who developed shortness of breath after lifting weights and then developed acute heart failure due to rupture of an aneurysm of the right sinus of Valsalva into the right ventricle. The patient developed dyspnea, and clinical findings included tachycardia, wide pulse pressure, bounding carotid and peripheral pulses, pulmonary crackles, and prominent continuous precordial murmur with thrill. Transesophageal echocardiogram with Doppler examination confirmed the diagnosis. The patient underwent surgery with cardioplegia directly infused into the coronary arteries with excision of redundant tissue and closure of the defect with a Dacron patch. He has been asymptomatic since surgery. This condition must to be included in the differential diagnosis for young patients with heart failure.

Evidence based secondary prevention of coronary artery disease in the elderly--2006.

Eighty percent of coronary deaths occur in people above 65 years of age. Fifty percent of deaths in persons above 85 years of age is due to coronary artery disease. The overall aging of the population and the improvement in survival of patients with coronary artery disease has been creating a growing large population of elderly adults who are elegible for secondary prevention. Multiple clinical trials and research trials have revealed evidence based information confirming the usefulness and effectiveness of secondary prevention of coronary artery disease in the elderly patient. The secondary prevention beneficial results have been obtained by addressing and controlling the predisposing items recognized a coronary risk factors. Secondary preventive measures, including lifestyle modifications and pharmacotherapy, modifying risk factors in elderly patients, have been shown to reduce morbidity and mortality from coronary artery disease. Evidence based data on prevention in elderly patients with coronary artery disease concerning smoking cessation, treatment of hypertension, control of hyperlipidemia, improved dietary patterns, physical activity, moderation in alcohol intake, management of diabetes, weight management, use of antiplatelet agents, beta blockers and renin-angiotensin-andosterone blockers is summarized. Emphasis has been given to AHA/ACC consensus statements on the prevention of coronary artery disease.

Cardiovascular disease in HIV infection.

Cardiovascular disease has been well documented in patients with Human Immunodeficiency Virus infection, especially after the introduction of highly active antiretroviral therapy. At present, HIV infection is one of the leading causes of acquired cardiovascular disease including heart failure. Some of the changes observed in these patients include left ventricular systolic dysfunction, dilated cardiomyopathy, congestive heart failure, myocarditis, lipodystrophy, dyslipidemia, insulin resistance, accelerated atherosclerosis including myocardial infarction, prothrombotic state, pericardial effusion, pulmonary hypertension, autonomic dysfunction, and malignancy. This article summarizes the main findings in the principal HIV-associated cardiovascular manifestations in order to stimulate its early recognition so helping in early intervention and therapy.

Wide pulse pressure is an independent predictor of cardiovascular mortality in Puerto Rican men.

BACKGROUND AND AIM: Emerging evidence suggests that pulse pressure is an independent predictor of risk for cardiovascular mortality. New studies in diverse populations are needed to further establish the applicability of this finding. Thus, the purpose of this study is to examine the relationship between pulse pressure and cardiovascular mortality in a cohort of Puerto Rican men after 12 years of follow-up. METHODS AND RESULTS: The Puerto Rico Heart Health Program is a study of coronary disease risk factors in men aged 35-79 years at baseline who had an initial examination during the years 1962-1965. It was attended by 9824 subjects representing 80% of the total age-specific male residents in 4 rural and 3 urban areas of Puerto Rico. Cardiovascular risk factors including systolic and diastolic blood pressures were monitored prospectively. This study includes 9106 men free of overt CHD at baseline who were stratified by quartiles of pulse pressure in mmHg: quartile 1, or=57. The odds ratio of cardiovascular mortality was calculated using logistic regression analysis. After adjusting for age, education, smoking status, hypercholesterolemic status, physical activity, diabetic status and mean arterial pressure, we found that those in the highest quartile of pulse pressure (pulse pressure>=57) had significantly higher cardiovascular mortality than those in the lowest quartile (reference group) (OR=1.38 95% CI=1.01-1.88). CONCLUSION: Our findings showed that a wide pulse pressure is independently associated with cardiovascular mortality in this group of Puerto Rican men.

Prevalence of cardiovascular conditions and health services utilization in Puerto Rico, 2001.

OBJECTIVE To study the prevalence of cardiovascular conditions and health services utilization in Puerto Rico, 2001. METHODS All medical claims for coronary heart disease (ICD-9 410-414), hypertension (ICD-9 401-405), congestive heart failure (ICD-9 428) and cerebrovascular accidents and transient ischemia (ICD-9:430-438.9) submitted for reimbursement purposes to an insurance company (private and public sector) in Puerto Rico in 2001 were identified. Prevalence and medical care utilization concerning cardiovascular conditions was estimated with 95% confidence. RESULTS Overall prevalence of cardiovascular conditions was 13.5% (95% CI: 11.68%-15.44%), being larger in the private sector (16.0%; 95% CI: 15.98%-16.08% vs. 11.7%; 95% CI: 11.62%-11.77%). Although in both sectors prevalence increased with age, at same age groups was two times higher in the private sector. Hypertension was the most prevalent condition (9.7; 95% CI: 8.14%-11.41%) being higher in females (10.4; 95% CI: 10.37%-10.51%) than in males (8.9; 95% CI: 8.81%-8.96%). The health service utilization (physician's office visits, emergency room visits, and hospital admissions) was higher in males. However, it varies by sectors. CONCLUSIONS Significant difference exists in the prevalence of cardiovascular conditions and health services utilization among private and public sectors in Puerto Rico. The observed differences among the private and public populations imply that there are factors such as socioeconomic status, education, lifestyles, environmental hazards in neighborhoods, and health habits that could be involved in the differences.

Status of cardiovascular disease in Puerto Rico.

For the last 40 years diseases of the heart has ranked as the primary cause of death in Puerto Rico, being cancer the second. In the National Vital Statistics of the Department of Health of Puerto Rico for the year 2002, cancer is listed as the main cause of death and diseases of the heart ranks as the second most frequent. This unexpected change is mainly due a new classification by ICD-10, that now substitutes ICD-9, in association to a change introduced by using the 2000 population census rather than the 1990 census used until 1999. Additional relevant information concerning life expectancy at birth, death by specific causes in the last 5 years and statistics about invasive surgical and medical services rendered to cardiovascular patients in the year 2003 are included. A summary of the situation concerning postgraduate training programs in Puerto Rico in different cardiovascular subspecialties is also included.