Non-communicable diseases--finally on the global agenda.

After the UN Millennium Development Goals were declared in September 2000 (see Table 1), one of the major short-comings recognized world-wide was the lack of mention of non-communicable diseases (NCDs). While AIDS and malaria were included, none of the leading and universal non-communicable causes of death made the list. There was no mention of cardiovascular diseases, cancer or diabetes, even though these place a far greater burden on global health and economic development than the infectious diseases, and are predicted to continue to increase in epidemic proportions. After much public discussion and intense lobbying, a significant-and uncommon-achievement occurred: on May 13th, 2010, the United Nations General Assembly voted in favour of convening a summit on non-communicable diseases, to take place in September 2011.

Biobehavioral factors in the context of ischemic cardiovascular diseases.

OBJECTIVE: We set out to examine the development of current thinking on the relationship between behavioral factors and ischemic heart disease, with the latter being viewed as an epidemic. METHODS: The present work is a nonsystematic review of the subject. RESULTS: Atherogenic components of the coronary-prone or type A behavior pattern (TABP), including hostility, cynicism, and suppression of anger, as well as stress reactivity, depression, and social isolation, are emerging as particularly significant behavioral characteristics, although their pathophysiology is not yet fully understood. Effective patient management, particularly for lifestyle modification, requires an appreciation of an individual's stage in their readiness to change. CONCLUSION: The control and prevention of cardiovascular diseases depend on a multidisciplinary approach that recognizes the importance and intricacies of lifestyle behaviors.

Managing acute enigmatic chest pain.

The author comments on the report by Dr. Akbar Panju and associates (see pages 541 to 547 of this issue) on patient outcomes associated with a discharge diagnosis of "chest pain not yet diagnosed." Acute chest pain without evidence of cardiac involvement presents a diagnostic challenge for the clinician, particularly in the present climate of cost containment. Esophageal disorders and psychiatric conditions appear to be the most prevalent causes of noncardiac chest pain. Although screening by means of electrocardiography and cardiac enzyme testing may rule out acute ischemia, and other tests may clearly point to a gastrointestinal cause, it is possible for cardiac and gastrointestinal problems to present simultaneously. Understanding and managing persistent chest pain even after a diagnosis has been made continues to challenge clinicians and researchers, and further progress in this area will depend on multidisciplinary collaboration.

Impact of the social environment on blood pressure in women.

A remarkable increase in life expectancy, a decrease in fertility and delayed first birth as well as increased literacy have all contributed to major changes in women's lifestyles and their social environment. Several factors such as level of education, unemployment and low income have been associated in epidemiological studies with elevations in blood pressure. Social support appears to be an important buffer modulating the cardiovascular effects of a variety of stressors. Studies to date suggest that there may be important gender differences in the way socioenvironmental factors affect blood pressure, thus warranting development of intervention strategies directed uniquely at women.

What do we really know about secondary prevention after myocardial infarction?

Secondary prevention following acute myocardial infarction begins at the time of the in initial hospitalization. An aggressive approach should focus on appropriate lifestyle changes as well as pharmacotherapy. Smoking cessation, increased physical activity and lipid lowering are key lifestyle objectives, while beta blockade and aspirin should be routinely prescribed for all patients following acute myocardial infarction, unless there are specific contraindications. Improvement in survivorship, prevention of nonfatal reinfarction, regression of atheromatous disease as well as a better quality of life are all proven benefits of secondary prevention.

Awareness and control of the cardiovascular response to stress among men with and without an acute myocardial infarction.

OBJECTIVE: To compare males who had sustained an acute myocardial infarction with healthy controls in awareness and control of their cardiovascular responses to laboratory stressors as well as their ability to relax. DESIGN: Patients and volunteer controls were recruited to participate in a case control comparative study using a structured protocol. SETTING: Patients were recruited from the Ottawa General Hospital. Controls came from the Ottawa-Carleton region. All participants were studied in the authors' laboratory at the hospital. PATIENTS: Thirty-two men who had sustained an acute myocardial infarction within two years and 39 healthy male controls are reported. Forty-one patients refused participation and 47 were excluded. INTERVENTIONS: All participants completed a self-administered questionnaire and underwent a structured 1 h laboratory session that included exposure to psychological and physical (cold pressor) stress alternating with attempts to relax. During the laboratory session, cardiovascular reactivity was monitored noninvasively. MAIN RESULTS: Compared with controls, patients presented with higher levels of cardiovascular reactivity on exposure to stress, primarily in their vasoconstrictive response. More cases demonstrated an increase in systemic vascular resistance while attempting to relax; they reported feeling relaxed immediately following exposure to stress. CONCLUSION: The discordance between the subjective feeling of relaxation and the actual physiological response indicates, in postinfarction male patients, an impaired ability to monitor and regulate the stress response.

Stroke surveillance: an overview.

Stroke surveillance is the gateway to information about etiology, risk, prognosis, prevention and intervention as well as disease distribution and time trends. While most stroke surveillance has focused on mortality, there is an increasing need to know what the impact is on the community of stroke incidence and prevalence. Available retrospective and prospective surveillance methodologies each have advantages and disadvantages with respect to validity, reliability, precision and cost. Hospital-based stroke surveillance is generally inadequate for population-based incidence estimations. International studies require a large investment in management in order to maintain adequate data quality standards and to ensure subsequent comparability. A major challenge to stroke surveillance is accurate subtyping. Where computerized databases exist, record linkage can provide the means to develop a cost-effective surveillance system. There is a need for strategies to enhance national surveillance systems on the basis of innovations and advances derived from research.

Effects of cardiovascular disease on driving tasks.

Heart disease, even in the elderly individual, need not preclude driving; however, safety for the patient and the public is dependent on close cooperation between the patient and the physician. The patient with ischemic heart disease must be in a stable condition wherein the risk of sudden incapacitation is acceptably low. The physician must take into consideration not only the symptom history, but also the potential impact of concomitant illnesses, devices (e.g., pacemakers), and medications. The patient with congestive heart failure must be assessed for functional ability. Where there is doubt about a subjective report, a practical road test may be advisable. Consideration also should be given to limited driving under preset conditions, such as daytime only, or local roads (excluding highways). Many elderly drivers already limit their driving in such a fashion. Finally, it should be realized that a driving permit is a means to independent mobility. Where heart disease precludes driving and personal transportation is not available, physicians should advise and support their patients to obtain paratransport services where communities offer such services for otherwise immobile citizens.

Assessing adaptive and maladaptive coping in the early phase of acute myocardial infarction.

We assessed retrospectively symptom management behaviors among 45 patients with acute myocardial infarction (AMI). Cluster analysis was conducted on data from the Structured Interview (SI), in order to group patients according to the global TABP, Anger-In, Potential for Hostility, and a newly derived measure of Behavioral Compensation for Stress (BEH-COMP). Two groups were identified. MALADAPT SI-copers (N = 24) had higher scores on Anger-In and Hostility and lower scores on BEH-COMP in comparison to the ADAPT SI-copers (N = 21), while no difference was observed on TABP. The SI groups were next compared on AMI symptom management behaviors. A hierarchical discriminant analysis found that the MALADAPT group reported greater distraction from AMI symptoms, were relief-seeking behavior, and greater perceived vulnerability to reinfarction. AMI coping behaviors correlated meaningfully with delay in seeking medical assistance. Further research is warranted, given the potential for using the ADAPT/MALADAPT SI-profiles to predict adjustment to AMI.

Canadian experience with civilian pilots allowed to fly following an acute myocardial infarction.

Concern has been expressed about allowing pilots to fly following an acute myocardial infarction. From the beginning of 1967 to the end of 1987, 141 Canadian pilots have been licensed following an acute myocardial infarction, 21 of these for the first time. About 200 pilots did not qualify for relicensure. The mean age (+/- SD) of 127 pilots who experienced symptomatic acute myocardial infarction was 46.8 +/- 8.2 years (range 21 to 70). All but one were males. Of 42 commercial pilots who were relicensed, only 11 returned to commercial flying, seven with a restriction. Of 130 private pilots, all but one returned to unrestricted flying. The mean time from acute myocardial infarction to relicensure was 4.3 +/- 2.6 years (range 0.6 to 14.9). During the years 1977-86 inclusive, for which records are available, there has been no aviation fatality in Canada attributed to a cardiac cause involving pilots licensed post acute myocardial infarction. One relicensed pilot crashed shortly after take-off and, with no evidence for cardiac incapacitation, his death was listed as accidental. Therefore, individuals who satisfy strict medical criteria can be licensed to fly post acute myocardial infarction without compromising air safety.

Reasons for patients' delay in response to symptoms of acute myocardial infarction.

Survival in the acute phase of myocardial infarction and the subsequent prognosis are critically dependent on the time between onset of symptoms and medical intervention. Studies have shown that the time that patients take to decide to seek help accounts for most of the delay. We documented the length of time from onset of symptoms to arrival in hospital for 201 patients consecutively admitted to one of four hospitals in the Regional Municipality of Ottawa-Carleton between October 1986 and February 1987 for suspected acute myocardial infarction. Of the 160 survivors 42% waited more than 4 hours (a critical time for effective thrombolytic therapy) before coming to hospital, and nearly a third did not arrive within 6 hours. On the basis of interviews conducted with 42 patients, sociodemographic factors, education, past experience with an acute myocardial infarction, a previous diagnosis of angina and a coronary-prone behaviour pattern did not explain the delay. How patients perceived the seriousness of their symptoms and how they used other illness-related coping strategies explained 46% of the variance in the delay. Interventions aimed at reducing the delay between onset of symptoms and treatment must focus on patients' preadmission behaviour.

Risk factors for myocardial infarction: the importance of relaxation.

Several risk factors for acute myocardial infarction (AMI) were examined, including history of smoking and hypercholesterolemia, income, education, coronary-prone behaviour by Structured Interview (SI) and the type and quality of stress-reducing relaxing activities, in a case-control study. Our sample included 100 AMI patients (80 males and 20 females, with mean ages 57.3 and 64.1 years, respectively), as well as 100 age- and sex-matched controls. Univariate differences between cases and controls were significant for history of smoking, income level, SI-defined hostility, SI-defined suppression of hostility, amount and type of relaxing activities and history of hypercholesterolemia. Multivariable analyses demonstrated that AMI patients reported significantly lower levels of relaxation and income, but higher levels of suppressed hostility and a higher incidence of hypercholesterolemia. Our findings confirm the significance of hostility and particularly suppressed hostility as AMI risk factors; furthermore, inadequate relaxation was identified as an independent risk factor associated with AMI.