Total cardiovascular risk approach to improve efficiency of cardiovascular prevention in resource constrain settings.

OBJECTIVES: To determine the population distribution of cardiovascular risk in eight low- and middle-income countries and compare the cost of drug treatment based on cardiovascular risk (cardiovascular risk thresholds ≥ 30%/≥ 40%) with single risk factor cutoff levels. STUDY DESIGN AND SETTING: Using World Health Organization (WHO) and the International Society of Hypertension risk prediction charts, cardiovascular risk was categorized in a cross-sectional study of 8,625 randomly selected people aged 40-80 years (mean age, 54.6 years) from defined geographic regions of Nigeria, Iran, China, Pakistan, Georgia, Nepal, Cuba, and Sri Lanka. Cost estimates for drug therapy were calculated for three countries. RESULTS: A large fraction (90.0-98.9%) of the study population has a 10-year cardiovascular risk <20%. Only 0.2-4.8% are in the high-risk categories (≥ 30%). Adopting a total risk approach and WHO guidelines recommendations would restrict unnecessary drug treatment and reduce the drug costs significantly. CONCLUSION: Adopting a total cardiovascular risk approach instead of a single risk factor approach reduces health care expenditure by reducing drug costs. Therefore, limited resources can be more efficiently used to target high-risk people who will benefit the most. This strategy needs to be complemented with population-wide measures to shift the cardiovascular risk distribution of the whole population.

Effect on quality of life of different accelerated diagnostic protocols for management of patients presenting to the emergency department with acute chest pain.

This study assessed the effects on quality of life (QoL) of dobutamine-atropine stress echocardiography (DASE) and electrocardiogram exercise testing (EET) accelerated diagnostic protocols for early stratification of low-risk patients with acute chest pain (ACP). A total of 290 patients with ACP, a nondiagnostic electrocardiogram, and negative biomarkers were randomly assigned to an accelerated diagnostic protocol (DASE, n = 110, or EET, n = 89) or usual care (n = 91) and followed up for 2 months. QoL was assessed at discharge and 2-month follow-up using the Nottingham Health Profile questionnaire. Baseline and 2-month follow-up answers to the Nottingham Health Profile questionnaire were available for 207 patients (71%; 55 in the usual-care, 77 in the DASE, and 75 in the ETT arm). At predischarge, patients in the usual-care arm reported higher impairment in the physical mobility and pain dimensions compared with the DASE and EET arms (p = 0.019 and p = 0.023, respectively). At 2-month follow-up, QoL improved in all groups; however, patients in the usual-care arm had significantly worse scores than patients managed using accelerated diagnostic protocols in the physical mobility, pain, social isolation, emotional reactions, and energy level dimensions (p = 0.014, p = 0.002, p = 0.04, p = 0.01, and p = 0.003, respectively). In conclusion, low-risk patients with ACP had non-negligible impairment of QoL in the acute phase. Emergency department ADPs with early DASE and EET reduced QoL impairment at both baseline and 2-month follow-up.

Comparison of early dobutamine stress echocardiography and exercise electrocardiographic testing for management of patients presenting to the emergency department with chest pain.

This study compared the cost-effectiveness of dobutamine-atropine stress echocardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were randomized to DASE (n = 110) or EET (n = 89) <6 hours after emergency department presentation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23 +/- 12 and 31 +/- 23 hours in the DASE and EET arms, respectively (p = 0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p = 0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026 +/- $250 vs $1,329 +/- $1,288, p = 0.03) and 2-month ($1,029 +/- 253 vs $1,684 +/- $2,149, p = 0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET.

Diabetes and associated cardiovascular risk factors in Iran: the Isfahan Healthy Heart Programme.

INTRODUCTION: Diabetes mellitus (DM) is one of the major health problems worldwide. The aim of this study was to detect the prevalence of DM and its associated risk factors in Iran. MATERIALS AND METHODS: This cross-sectional study was performed in 3 cities in the central part of Iran on participants over the age of 19 years. Sampling was conducted by multi-stage randomised cluster method. Initially, a questionnaire consisting of demographic information, drug intake and smoking status was filled out. Later, a physical examination was performed, including the measurement of systolic blood pressure (SBP) and diastolic blood pressure (DBP), body mass index (BMI) and waist-to-hip ratio (WHR). Fasting blood sample was drawn and analysed for sugar, total cholesterol (TC), triglyceride (TG) and 2-hour postprandial glucose. A fasting blood sugar (FBS) of >126 mg/dL or a 2-hour plasma glucose of over 200 mg/dL was considered an indication of diabetes. The impaired glucose tolerance test (IGTT) was defined with 2-hour plasma glucose of 140 to 200 mg/dL and FBS <126 mg/dL. The collected data were analysed with Student's t-test, chi-square test and multiple logistic regression analysis. RESULTS: This study was performed on 12,514 subjects (48.9% males and 51.1% females). The total prevalence of DM was 6.7% and 5.3% in urban and rural areas and 5.4% and 7.1% in males and females, respectively. The mean blood glucose rose with age in both sexes, and blood glucose was higher in females and in urban areas. IGTT, known and new DM heightens as age increased and more than half of the diabetes cases in all age groups were newly diagnosed. The mean blood pressure, age, BMI, waist circumference and serum lipids were higher in people with DM and IGTT especially in females. Obesity, a family history of DM, high blood pressure, high WHR and ageing were associated with a higher probability of DM, but sex had no effect on this probability. DISCUSSION AND CONCLUSION: Considering the high prevalence of DM in the central regions of Iran, providing vast educational programme to prevent this disease is essential and screening FBS tests, especially for obese subjects and those with a family history of DM, should be taken into account.

Fat-modified diets during pregnancy and lactation and serum lipids after birth.

OBJECTIVE: This study investigated the influence of modifying the maternal dietary fat on the serum lipids of infants at birth and at one year of age. METHODS: This single-blind randomized clinical trial was done on 180 4-month-pregnant women. All subjects proved to have a fat-unmodified diet through a 4-day food record dietary questionnaire. They were divided randomly into two groups. The intervention group was kept on a fat-modified diet including saturated fatty acid (SFA) < 10%, monounsaturated fatty acids: (MUFA) 10-5%, polyunsaturated fatty acid (PUFA) upto 10% and cholesterol < 300 mg/day with dietary advice for the pregnancy period. The control group was given only the latter advice. All subjects were followed up monthly. The serum lipids including total cholesterol (T.cho), triglyceride (TG), and HDL cholesterol (HDL-C) were analyzed through enzymatic methods. The level of LDL-cholesterol (LDL-C) was calculated by Friedewald formula. The comparison of mean cord and one-year-old infant serum lipids were done through unpaired T-test in two groups. RESULTS: The mean level of T.cho in the intervention and control group was (70.3+/-15.9, vs 81.4+/-17.2, P< 0.009), TG (85.3 +/- 16.7 vs 97.5 +/- 18.2, P< 0.007), LDL-C (27.8 +/- 15.2 vs 34.8 +/- 17.1, P< 0.04) and non-HDL-C (44.5+/-7.2 vs 54.5 +/- 8.1, P< 0.02) and in one year old infant the comparison of serum lipids were as follows. T.cho (145.7 +/- 51.4 vs 161.4 +/- 56.2, P< 0.003), TG (90.1 +/- 31.8 vs 98.3 +/- 33.1, P< 0.02), LDL-C (85.6 +/- 20.4 vs 92.3 +/- 19.6, P< 0,05) and non-HDL-C (113.6 +/- 30.2 vs 128.8 +/- 34.8, P< 0.04). However, there was no significant difference in HDL-C of both groups. CONCLUSION: There is a significant decrease of T.cho, TG, LDL-C and non-HDL-C levels with no significant increase of HDL-C in the intervention group with the fat-modified diet. Maternal fat-modified diet could be suitable way to prevent cardiovascular disease among infants from the beginning of the life.

Antioxidant activity of three extracts of Morus nigra.

The antioxidant effect of three different extracts of Morus nigra fruit (fruit juice, hydroalcoholic and polyphenolic) on haemoglobin glycosylation, peroxidative damage to human erythrocytes, liver hepatooytes of rats and human low-density lipoprotein (LDL) were studied. The results show that all three extracts inhibited haemoglobin glycosylation induced by glucose to differing degrees. The haemolysis of human erythrocytes induced by hydrogen peroxide was also inhibited. The production of malondialdehyde (MDA) during peroxidative damage to plasma membranes of isolated rat hepatocytes induced by tert-butyl hydroperoxide (tBH) was also inhibited. Inhibition of lipid peroxidation of LDL induced by copper (II) ion was achieved during the study. The results suggest that Morus nigra fruit has a protective action against peroxidative damage to biomembranes and biomolecules.

Tobacco use among Iranian men, women and adolescents.

The aim of this study was to evaluate the self-reported and serum cotinine based prevalence rates of smoking among Iranian men, women and adolescents. The study was carried out on 2626 men and women aged 19 years and above and 836 high school students aged 14-18 years, randomly selected from different clusters and schools in Isfahan. The WHO smoking standard questionnaire was completed for all samples and serum cotinine level was measured using high-performance liquid chromatography in 10% and 20% of the original adult and adolescent samples, respectively. The prevalence of self-reported smoking among Iranian men and women aged 19 years and above was 18.7% and 1.3%, respectively, compared to 21.2% and 6.7% based on serum cotinine level. Nearly 10.6% and 14.6% of claimed nonsmoker girls and boys were classified as current smokers by serum cotinine level. More than 80% of male smokers started the habit before the age of 20 years and the effect of smoker friends was the most important factor for smoking initiation among smokers. Using self-reported prevalence data for smoking among women or adolescents in special populations like Iranians can give invalid measurements, therefore, data based on biochemical tests are suggested.

Effect of some volatile oils on the affinity of intact and oxidized low-density lipoproteins for adrenal cell surface receptors.

Extensive research has shown that a high plasma concentration and oxidation of low-density lipoproteins (LDL) has an important role in atherogenesis. The affinity of LDL to its classic receptor is reduced due to oxidation. Instead, it is taken up by scavenger molecules in macrophages, as a result of which foam cells are formed that have a major role in increasing the subendothelial fat layers of the blood vessels. In the present study the antioxidant effect of eight volatile compounds in plant essences, namely, anethol, eugenol, limonen, linalool, p-cymol, pulegon, thymol, and geraniol, and their effect on the affinities of intact and oxidized (with Cu(+2)) LDL for LDL receptor in sheep adrenal tissue cells in the presence of labeled LDL with fluorescein isothiocynate (FITC) were investigated. The results obtained show that eugenol and thymol have the highest antioxidant effect, on the uptake of LDL (intact and oxidized) by the adrenal cells. The order of the compounds studied with regard to their antioxidant effect on intact and oxidized LDL is as follows: On intact LDL: eugenol > or = thymol > linalool > p-cymol > limonen > geraniol > anethol; on oxidized LDL: thymol > or = eugenol > geraniol > p-cymol > linalool > pulegon. Our findings also show that the compounds, particularly thymol and eugenol, have an antioxidant property and can change the affinity of the LDL particles for the LDL receptor probably due to their lipophylic property. Further research may prove that these compounds can be used clinically, especially in atherosclerotic and hypercholesterolemic cases.

Isfahan Healthy Heart Programme: a comprehensive integrated community-based programme for cardiovascular disease prevention and control. Design, methods and initial experience.

The Isfahan Healthy Heart Programme (IHHP) is a five to six year comprehensive integrated community-based programme for cardiovascular diseases (CVD) prevention and control via reducing CVD risk factors and improvement of cardiovascular healthy behaviour in a target population. IHHP started late in 1999 and will be finished in 2005-2006. A primary survey was done to collect baseline data from interventional (Isfahan and Najaf-Abad) and reference (Arak) communities. In a two-stage sampling method, we randomly selected 5 to 10 percent of households from randomly selected clusters. Then individuals aged > or = 19 years were selected for the survey. This way, data from 12,600 individuals (6300 in interventional counties and 6300 in the reference county) was collected and stratified according to living area (urban vs. rural) and different age and sex groups. The samples underwent a 30-minute interview to complete validated questionnaires containing questions on demography, socioeconomic status, smoking behaviour, physical activity, nutritional habits and other behaviour regarding CVD. Blood pressure and body mass index (BMI) measurements were done and fasting blood samples were taken for two hours post load plasma glucose (2 hpp), serum (total, HDL and LDL) cholesterol and triglyceride levels. A twelve-lead electrocardiogram was recorded in all persons above 35 years of age. Community-wide surveillance of deaths, hospital discharges, myocardial infarction and stroke registry was carried out in the intervention and control areas. Four to five years of interventions based on different categories such as mass media, community partnerships, health system involvement and policy and legislation have started in the intervention area while Arak will be followed without intervention. Considering the results of the baseline surveys, (assessments needed, the objectives, existing resources and the possibility of national implementation) the interventions were planned. They were set based on specific target groups like school children, women, work-site, health personnel, high-risk persons, and community leaders were actively engaged as decision makers. A series of teams was arranged for planning and implementation of the intervention strategies. Monitoring will be done on small samples to assess the effect of different interventions in the intervention area. While four periodic surveys will be conducted on independent samples to assess health behaviours related to CVD risk factors in the intervention and reference areas, the original pre-intervention subjects aged more than 35 years will be followed in both areas to assess the individual effect of interventions and outcomes like sudden death, fatal and nonfatal MI and stroke. The whole baseline survey will be repeated on the original and an independent sample in both communities at the end of the study.

Obesity and associated modifiable environmental factors in Iranian adolescents: Isfahan Healthy Heart Program - Heart Health Promotion from Childhood.

OBJECTIVE: To evaluate the prevalence of overweight and obesity among Iranian adolescents and their relationship with modifiable environmental factors. METHODS: The subjects of the present study were 1000 girls and 1000 boys, aged between 11 and 18 years selected by multistage random sampling, their parents (n = 2000) and their school staff (n = 500 subjects) in urban and rural areas of two provinces in Iran. Data concerning body mass index (BMI), nutrition and the physical activity of the subjects were analyzed by SPSSV10/Win software. RESULTS: The prevalence of 85th percentile 95th percentile in girls was significantly higher than boys (10.7 +/- 1.1 and 2.9 +/- 0.1%vs 7.4 +/- 0.9 and 1.9 +/- 0.1%, respectively; P < 0.05). The mean BMI value was significantly different between urban and rural areas (25.4 +/- 5.2 vs 23.2 +/- 7.1 kg/m2, respectively; P < 0.05). A BMI> 85th percentile was more prevalent in families with an average income than in high-income families (9.3 +/- 1.7 vs 7.2 +/- 1.4%, respectively; P < 0.05) and in those with lower-educated mothers (9.2 +/- 2.1 vs 11.5 +/- 2.4 years of mothers education, respectively). The mean total energy intake was not different between overweight or obese and normal-weight subjects (1825 +/- 90 vs 1815 +/- 85 kCal, respectively; P > 0.05), but the percentage of energy derived from carbo-hydrates was significantly higher in the former group compared with the latter (69.4 vs 63.2%, respectively; P < 0.05). Regular extracurricular sports activities were significantly lower and the time spent watching tele-vision was significantly higher in overweight or obese than non-obese subjects (time spent watching telelvision: 300 +/- 20 vs 240 +/- 30 min/day, P < 0.05). A significant linear association was shown between the frequency of consumption of rice, bread, pasta, fast foods and fat/salty snacks and BMI (beta = 0.05-0.06; P < 0.05). A significant correlation was shown between BMI percentiles and serum triglyceride, high-density lipoprotein-cholesterol and systolic blood pressure (Pearson's r = 0.38, -0.32 and 0.47, respectively). CONCLUSIONS: Enhanced efforts to prevent and control overweight from childhood is a critical national priority, even in developing countries. To be successful, social, cultural and economic influences should be considered.

Anti-oxidant effect of flavonoids on the susceptibility of LDL oxidation.

In vitro studies have demonstrated increased atherogenicity of oxidized low-density lipoprotein (ox-LDL) compared to native LDL. Oxidative modification of LDL alters its structure allowing LDL to be taken up by scavenger receptors on macrophage, endothelial, and smooth muscle cells, leading to the formation of lipid-laden foam cells, the hallmark of early atherosclerotic lesions. The susceptibility of LDL to in vitro oxidation was assessed essentially by the technique described by Esterbauer et al. LDL oxidation were monitored by change in 234-absorbance in the presence and absence of pure flavonoids. Morin, genistein, apigenin and biochanin A, naringin and quercetin were used at different concentration. These flavonoids significantly inhibit in vitro LDL oxidation, genistein, morin and naringin have stronger inhibitory activity against LDL oxidation than biochanin A or apigenin. This study show that flavonoids prevent in vitro LDL oxidation and probably would be important to prevent atherosclerosis.

Vitamin E can reduce blood pressure in mild hypertensives.

This triple-blind placebo-controlled clinical trial was performed to determine the effects of the anti-oxidant vitamin E on blood pressure and heart rate in patients with mild hypertension. A total of 70 new mild hypertensive subjects (systolic blood pressure, SBP: 140-160 mmHg; diastolic blood pressure, DBP: 90-100 mmHg) without secondary hypertension were selected from among people referred to the Hypertension Unit of Isfahan Cardiovascular Research Center and divided randomly into two groups of drug (DG) and placebo (PG). All subjects were aged from 20 to 60 years old, without any other cardiovascular risk factors. The drug group received vitamin E tablets (200 IU/day) and the placebo group received placebo only for 27 weeks. At the beginning and the end of the study, the blood vitamin E level was measured fluorimetrically in all subjects according to the Hansen and Warwick method [14, 15]. Blood pressure and heart rate were measured at the beginning, during, and at the end of the study. Blood pressure was measured by a physician using one random zero mercury sphygmomanometer. Personal information and dietary habits of subjects were collected by separate questionnaire. At the end of the study, it was found that the vitamin E supplement had caused a remarkable decrease in SBP (-24% in DG versus -1.6% in PG) and a less remarkable decrease in DBP (-12.5% in DG versus -6.2% in PG) (p < 0.05). The change in heart rate was -4.3% in DG, and -14.0% in PG (p < 0.05). It is concluded that a vitamin E supplement of 200 IU/day can be effective in mild hypertensive patients in the long term, probably due to nitric oxide, and improve their blood pressure status. Therefore, vitamin E supplement could be recommended to such patients.