Cardiovascular Disease Reversed

Your Heart and Nutrition

Your Heart and Nutrition

Prevention is better than a cure. Learn how to cherish your heart by taking the necessary means to keep it pumping healthily and steadily through your life.

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Natural Secrets For Healing Your Heart

This eBook is devoted to exposing the secrets that cardiologists and surgeons don't want you to know, and how to take control of your own heart and heal yourself. Eight out of every ten coronary bypasses will not actually help the patient. So why risk being in the 80% that will get no benefit from a bypass? Learn to heal your own heart and keep yourself healthy with this eBook guide. Bob Livingston has poured years of research into his findings, and is now sharing the methods that he has developed from careful, methodical research that the medical industry would never allow. It would make them go bankrupt! You will learn what supernutrient doctors don't want you to know about, and how to make an all-natural, chemical and drug-free blood thinner And even more information that doctors don't want revealed to the public. You don't have to be one of the 70% of Americans diagnosed with heart disease. You can heal your heart!

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The Atlas of Heart Disease and Stroke

The Atlas of Heart Disease and Stroke World Health Organization 2004 The atlas of heart disease and stroke Judith Mackay and George Mensah with Shanthi Mendis and Kurt Greenlund. l.Heart diseases epidemiology 2.Cerebrovascular accident epidemiology 3.Risk factors 4.Atlases I.Mensah, George. II.Mendis, Shanthi. III.Greenlund, Kurt. IV.Title.

Outcomes measurement basic principles and applications in stroke rehabilitation

The objective of this chapter is to give an overview of basic principles guiding the development and application of outcome measures. This chapter starts by introducing basic concepts related to the development of outcome measures, and demonstrates their applications in stroke rehabilitation. Specifically, the first section includes a theoretical discussion of reliability, validity and responsiveness, and how to approach interpretation. This discussion is based on classical test theory. For each property the theory is applied to development of a measure of participation. Future trends related to computer-adapted testing (CAT) are also briefly described. In the second section, the evaluation of walking competency after stroke is used to illustrate the selection of appropriate outcome measures for this population, as well as their relation to participation. These measures include self-reported scales, performance-based ratings and laboratory assessments. This chapter concludes with...

Rheumatic fever and rheumatic heart disease

Rheumatic fever usually follows an untreated beta-haemolytic streptococcal throat infection in children. It can affect many parts of the body, and may result in rheumatic heart disease, in which the heart valves are permanently damaged, and which may progress to heart failure, atrial fibrillation, and embolic stroke. Of 12 million people currently affected by rheumatic fever and rheumatic heart disease, two-thirds are children between 5 and 15 years of age. There are around 300 000 deaths each year, with two million people requiring repeated hospitalization and one million likely to require surgery in the next 5 to 20 years. Early treatment of streptococcal sore throat can preclude the development of rheumatic fever. Regular long-term penicillin treatment can prevent rheumatic fever becoming rheumatic heart disease, and can halt disease progression in people whose heart valves are already damaged by the disease. In many developing countries, lack of awareness of these measures,...

Ischemic Heart Disease

The most common cause of death in Western culture is ischemic heart disease, which results from insufficient coronary blood flow. About 35 per cent of people in the United States die of this cause. Some deaths occur suddenly as a result of acute coronary occlusion or fibrillation of the heart, whereas other deaths occur slowly over a period of weeks to years as a result of progressive weakening of the heart pumping process. In this chapter, we discuss acute coronary ischemia caused by acute coronary occlusion and myocardial infarction. In Chapter 22, we discuss congestive heart failure, the most frequent cause of which is slowly increasing coronary ischemia and weakening of the cardiac muscle.

Risks for Heart Disease

The racing heart that is characteristic of thyrotoxicosis can complicate preexisting heart disease, or worsen risk factors that predispose you to heart disease, even in the absence of Graves' disease. If you have any of these conditions while thyrotoxic, you need to take steps to lower some of these other risk factors as soon as possible. In addition, heart rhythm problems can be induced by thyrotoxicosis in Graves' disease. While most young people with otherwise normal hearts have rapid regular heartbeats (called sinus tachycardia), older people or those with some heart problems may have an irregular rapid heart rhythm called atrial fibrillation. Atrial fibrillation requires the intervention of a cardiologist, particularly since it can cause blood clots that result in strokes. Thy-

Function of the Heart After Recovery from Myocardial Infarction

Occasionally, a heart that has recovered from a large myocardial infarction returns almost to full functional capability, but more frequently its pumping capability is permanently decreased below that of a healthy heart. This does not mean that the person is necessarily a cardiac invalid or that the resting cardiac output is depressed below normal, because the normal heart is capable of pumping 300 to 400 per cent more blood per minute than the body requires during rest that is, a normal person has a cardiac reserve of 300 to 400 per cent. Even when the cardiac reserve is reduced to as little as 100 per cent, the person can still perform normal activity of a quiet, restful type but not strenuous exercise that would overload the heart.

Nutrition for a Healthy Heart

Many healthy-heart diets and foods have a reduced fat content but, in most instances, have replaced fat with sugar and, even worse, refined sugar. As fat intake has decreased, refined sugar and processed grain intake has skyrocketed. The average American consumes more than 150 pounds of added refined sugar every year.

Hypertrophy of the Heart in Valvular and Congenital Heart Disease

Brickner ME, Hillis LD, Lange RA Congenital heart disease in adults second of two parts. N Engl J Med 342 334,2000. Guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines. Circulation 98 1949, 1998. Hoffman JI, Kaplan S The incidence of congenital heart disease. J Am Coll Cardiol 39 1890, 2002. Reimold SC, Rutherford JD Clinical practice valvular heart disease in pregnancy. N Engl J Med 349 52, 2003.

The evolution of cerebral reorganisation after stroke

Tasks after stroke is likely to engage such a mechanism, but the degree to which this is successful will depend on the degree of overall damage to the motor network. The role of error signal generation in a damaged motor system is clearly of interest, particularly as it may diminish with chronicity of impairment (Ward et al., in press Ward et al 2004). These important issues remain to be explored, and may have significant implications for rehabilitative interventions. downregulation of the a1-gamma-aminobutyric acid (GABA) receptor subunit and a decrease in GABAergic inhibition (Neumann-Haefelin et al., 1998) (see Chapter 14 of Volume I, pp. 18-21 for further discussion of these phenomena). This would be of particular interest to clinicians as it is easier to induce long-term potentiation (LTP) in hyperex-citable cortex, that is the cortex is more responsive to afferent input. In humans, acute limb deaf-ferentation leads to reduced levels of GABA within minutes (Levy et al., 2002). It...

How Does Alcohol Reduce the Risk of Heart Disease

We have identified many of the biologic and physiologic effects of wine and alcohol that relate to protection against CAD. Alcohol affects blood lipids it increases HDL-cholesterol, the good cholesterol that lowers the risk of heart disease. Alcohol also tends to slightly decrease LDL-cholesterol, the bad cholesterol that increases atherosclerosis. Thus, individuals who have consumed moderate amounts of alcohol for most of their adult years tend to have less atherosclerosis. The progress in heart surgery and treatment of general heart disease has been remarkable over the last fifty years. Many conditions that doctors in the 1950s considered fatal are now routinely treatable with a variety of options including drugs (for hypertension, for example), surgery, and less invasive techniques. At the same time these surgical techniques have become accepted, our knowledge of cardiac disease prevention has made incredible leaps forward. New studies are beginning to show that moderate to light...

Serum cholesterol concentration and risk of ischaemic heart disease

An extreme example of heterogeneity was evident in a 1994 review14 of the 10 largest prospective cohort studies of serum cholesterol concentration and the risk of ischaemic heart disease in men, which included data on 19 000 myocardial infarctions or deaths from ischaemic heart disease. The purpose was to summarise the magnitude of the relation between serum cholesterol and risk of ischaemic heart disease in order to estimate the long term benefit that might be expected to accrue from reduction in serum cholesterol concentrations. The results from the 10 prospective studies are shown in Figure 9.2. These are expressed as proportionate reductions in risk associated with a reduction in serum cholesterol of 0-6 mmol l (about 10 of average levels in Western countries), having been derived from the apparently log-linear associations of risk of ischaemic heart disease with serum cholesterol concentration in individual studies. They also take into account the underestimation that results...

Coronary Artery Disease and Mortality from All Cardiac Causes

Numerous studies demonstrate that Hodgkin's disease (HD) survivors treated with mediastinal irradiation have an increased risk of fatal CVD 68-71 . Relative risk estimates for all survivors range from 2.2-7.2, compared with age and gender-matched controls from the general population 68-70 . The absolute excess risk of fatal cardiovascular disease is 11.9-48.9 per 10,000 patient years, depending upon patient characteristics 70 . This increased risk becomes statistically significant 5-10 years after radiotherapy 71, 72 , and is largely due to fatal myocardial infarctions 70 . Myocardial infarction (MI) may be the most important cardiac concern for survivors treated with radiotherapy since the 1970s. While risk of death from cardiac causes other than myocardial infarction has decreased with the use of subcarinal blocking, the incidence of fatal MI has not changed significantly. This was demonstrated by a study of 2,232 HD patients treated at Stanford during 1960-1991. The study showed...

Of Coronary Artery Disease Risk Factors

All childhood cancer survivors should be screened regularly for coronary artery disease (CAD) risk factors. While those treated with mantle radiation are probably most at risk for CAD, survivors treated with anthracyclines and high-dose cyclophosphamide are also likely to have damaged hearts that can ill afford further damage from a myocardial infarction. Patients who received brain irradiation, especially those with proven growth hormone deficiency or other hypothalamic-pituitary axis dysfunction,may also be at higher risk, compared with other survivors. Risk factors for CAD, such as family history, hypertension, smoking, hyperlipidemia, obesity, diabetes mellitus and a sedentary life-style, should be evaluated at each long-term visit. Counseling to reduce such risk factors is not only appropriate, it is extremely important. Signs and symptoms of pericarditis (fever, dyspnea, pleuritic chest pain, friction rub, ST and T wave changes, decreased QRS voltage), cardiomyopathy, valvular...

Post Myocardial Infarction Ventricular Septal Defect

Another complication of coronary artery disease that requires heart surgery is called post-myocardial infarction ventricular septal defect. This happens when the common wall between the right and the left ventricle (the ventricular septum) ruptures after a heart attack. Another complication of a heart attack is that one of the papillary muscles, which is inside the left ventricle and helps control the mitral valve, may be involved in the heart attack. The entire muscle may Unfortunately, because this condition is associated with heart attacks, we may be doing several operations at once. We might be placing coronary artery bypass grafts and, in some cases, may even have to remove a left ventricular aneurysm. The chance of surviving emergency mitral valve replacement for papillary muscle rupture is about 70 percent, and most of the survivors do well providing the left ventricle has not been too badly damaged by the heart attack.

Suicidal thoughts after acute stroke

Our first investigation of patients with suicidal thoughts evaluated 301 patients with acute stroke in whom we had systematically asked them about the existence of suicidal thoughts or plans (Kishi et al. 1996a). Using the present state examination (PSE), a total of 20 patients (6.6 ) reported that they had deliberately considered suicide and that these death wishes were not simply passive death wishes or fleeting thoughts (Fig. 19.1). Background comparisons of the 20 patients who had suicidal intentions and the 281 patients without suicidal intentions are shown in Table 19.1. The suicidal patients were significantly younger than non-suicidal patients (p 0.03). In addition, the patients with suicidal thoughts had a greater frequency of alcohol abuse than non-suicidal patients (p 0.03). The suicidal patients also had a Figure 19.1 The frequency of depression among 301 patients with acute stroke. Note that suicidal patients have a significantly higher prevalence of major depression but...

Example 101 Pravastatin in preventing cardiovascular disease

Figure 10.1 is taken from Nakamura et al. (2006) who reported a large placebo-controlled randomised trial evaluating the effect of pravastatin in preventing cardiovascular disease. The overall treatment effect was positive, with a hazard ratio of 0.67 (p 0.01). We will cover hazard ratios and their use in survival analysis in Chapter 13 for the moment simply note that, like the odds ratio and the relative risk, a value of one corresponds to equal treatments. The homogeneity of the treatment effect was assessed by looking at the p-value for the treatment-by-covariate interaction and also by calculating the hazard ratio separately in various subgroups defined by baseline factors of interest as seen in Figure 10.1.

Staying Alert About Heart Disease

If you are past menopause, you must educate yourself about the signs and symptoms of heart disease, since you are at higher risk. Other risk factors, such as smoking, obesity, high blood pressure, and high cholesterol, can be reduced with lifestyle changes. For example, women who are physically active have a 60 to 75 percent lower risk of heart disease than inactive women. Heart disease is currently the number-one cause of death in postmenopausal women more women die of heart disease than lung cancer or breast cancer. Half of all North Americans who die from heart attacks each year are women. One of the reasons for such high death rates from heart attacks among women is medical ignorance. Most studies examining heart disease excluded women, which led to a myth that more men than women die of heart disease. In reality, more men die of heart attacks before age fifty, while more women die of heart attacks after age fifty. It remains unclear whether estrogen loss increases the risk, or...

Benefit of Alcohol in Cardiovascular Disease

In an early study on alcohol and coronary artery disease, Marmot et al. (3) screened 1422 middle-aged, male civil servants in and around London between 1967 and 1969 using a 3-day dietary recall format. Ten years later the investigators compared mortality rates of those who used various amounts of alcohol. Even correcting for smoking, systolic blood pressure, and serum cholesterol, the authors found the now-famous U-shaped curve. They grouped the men according to consumption of no alcohol per day, up to 9 g (approximately one alcoholic beverage) per day, 34 g (three to four beverages) per day, and over 34 g per day. Of note, the U-shaped curve was seen for all-cause mortality, with the cardiovascular death curve assigned a relative risk of 1.0 for the 0.1-9 g day group. They found a relative risk of 1.5 for the 9.1-34-g day group, and 0.9 for the over-34-g day group. The abstainer group had a relative risk of death due to coronary artery disease of 2.1. The London group, however, was...

Example 2 intravenous magnesium in acute myocardial infarction

The following table gives data from 16 randomised controlled trials of intravenous magnesium in the prevention of death following myocardial infarction. These trials are a well-known example where the results of a meta-analysis8 were contradicted by a single large trial (ISIS-4)9-11 (see also Chapters 3 and 11).

Global burden of coronary heart disease

Map Healthy years of life lost to coronary heart disease Ounpuu S, Anand S, Yusuf S. The global burden of cardiovascular disease. Medscape cardiology, 24 January 2002 Nayha S. Cold and the risk of cardiovascular diseases. A review. International journal of circumpolar health,

Deaths from coronary heart disease

Map Deaths from coronary heart disease Deaths from coronary heart disease compared with other causes Ounpuu S, Anand S, Yusuf S. The global burden of cardiovascular disease. Medscape cardiology, 24 January 2002 Khot UN, Khot MB, Bajzer CT et al. Prevalence of conventional risk factors in patients with coronary heart disease. Journal of the American Medical Association, 2003, 290 898-904. Chambless L, Keil U, Dobson A, Mahonen M, Kuulasmaa K, Rajakangas AM, Lowel H, Tunstall-Pedoe H. Population versus clinical view of case fatality from acute coronary heart disease results from the WHO MONICA Project 1985-1990. Multinational MONItoring of Trends and Determinants in CArdiovascular Disease. Circulation, 1997, 96(11) 3849-59.

Example 142 ESTAT trial in acute stroke

This was a multi-centre, pan-European, randomised double-blind placebo-controlled clinical trial in acute stroke to evaluate the effect of ancrod, a natural defribrinogenating agent (Hennerici et al. (2006)). The primary endpoint was based on the Barthel Index a favourable score of 95 or 100 or a return to the pre-stroke level at three months was viewed as a success. The primary method of statistical analysis was based on a logistic model including terms for treatment, age category, baseline Scandinavian Stroke Scale and centre.

Example 154 Meta Analysis of trials of magnesium and streptokinase in acute myocardial infarction

In the upper part of Figure 15.2 we see a funnel plot of trials evaluating the effect of intravenous magnesium in the treatment of myocardial infarction. Note the absence of small trials with odds ratios greater than one (which would indicate a lack of benefit for intravenous magnesium) this

Angina and myocardial infarction

Cardiac ischaemia is common in sleep, particularly during the second half of the night 7 . It is more often silent (asymptomatic) in sleep than during exercise. During sleep, cardiac output falls as a result of a slower heart rate rather than any change in stroke volume. In NREM sleep, blood pressure also falls and the drop in perfusing pressure reduces the coronary artery blood flow. An exaggeration of this hypotension (over-dipping), especially in stages 3 and 4 NREM sleep, may cause clinically significant cardiac ischaemia, especially in the presence of coronary artery disease. The peak time for myocardial infarction during NREM sleep is between 12.00 and 2.00 am when stages 3 and 4 are most likely. Despite this, NREM sleep is largely cardioprotective because of the low metabolic rate and the constant, but low, cardiac output. The process of awakening is probably even more of a risk for cardiac ischaemia than REM sleep. The chance of a myocardial infarction rises between 4.00 and...

Myocardial infarction See heart attack or

Nitroglycerin A drug used to dilate coronary arteries so more oxygenated blood can reach the heart muscle. This drug is generally used by patients with atherosclerotic coronary artery disease. open heart surgery Heart operations in which the heart-lung machine is used and the heart is opened so various structures can be repaired or replaced. However, many people also use the term to refer to any heart operation in which the heart-lung machine is used, including coronary bypass surgery, in which only the surface of the heart is worked on. palliative A treatment that improves a condition but does not cure it. A palliative heart procedure would be one that would improve the patient's condition but not cure the heart disease.

Stages of Recovery from Acute Myocardial Infarction

Top, Small and large areas of coronary ischemia. Bottom, Stages of recovery from myocardial infarction. Top, Small and large areas of coronary ischemia. Bottom, Stages of recovery from myocardial infarction. Replacement of Dead Muscle by Scar Tissue. In the lower part of Figure 21-8, the various stages of recovery after a large myocardial infarction are shown. Shortly after the occlusion, the muscle fibers in the center of the ischemic area die. Then, during the ensuing days, this area of dead fibers becomes bigger because many of the marginal fibers finally succumb to the prolonged ischemia. At the same time, because of enlargement of collateral arterial channels supplying the outer rim of the infarcted area, much of the nonfunctional muscle recovers. After a few days to three weeks, most of the nonfunctional muscle becomes functional again or dies one or the other. In the meantime, fibrous tissue begins developing among the dead fibers because ischemia can stimulate growth of...

Strategies Using Cell Therapy to Induce Cardiomyocyte Regeneration in Adults with Heart Disease

Congestive heart failure remains a major public health problem and is frequently the end result of cardiomyocyte apoptosis and fibrous replacement after myocardial infarction (MI), a process referred to as left ventricular remodeling. Cardiomyocytes undergo terminal differentiation soon after birth and are generally considered to withdraw irreversibly from the cell cycle. In response to ischemic insult, adult cardiomyocytes undergo cellular hypertrophy, nuclear ploidy, and a high degree of apoptosis. A small number of human cardiomyocytes retain the capacity to proliferate and regenerate in response to ischemic injury. However, whether these cells are derived from a resident pool of cardiomyocyte stem cells or from a renewable source of circulating bone marrow-derived stem cells that home to the damaged myocardium is at present not known. Replacement and regeneration of functional cardiac muscle after an ischemic insult to the heart could be achieved either by stimulating...

Types of cardiovascular disease

Types Cardiovascular Diseases

Deaths from cardiovascular diseases (CVD) coronary heart disease stroke other cardiovascular diseases hypertensive heart disease inflammatory heart disease rheumatic heart disease coronary heart disease stroke inflammatory heart disease 0.4m rheumatic heart disease 0.3m other forms of heart disease 2.4m inflammatory heart disease 0.4m rheumatic heart disease 0.3m other forms of heart disease 2.4m Coronary heart disease Rheumatic heart disease Congenital heart disease Other cardiovascular diseases Risk factors As for coronary heart disease.

Atherosclerosis as a Cause of Ischemic Heart Disease

Acute occlusion of a coronary artery most frequently occurs in a person who already has underlying atherosclerotic coronary heart disease but almost never in a person with a normal coronary circulation. Acute occlusion can result from any one of several effects, two of which are the following 1. The atherosclerotic plaque can cause a local blood clot called a thrombus, which in turn occludes the artery. The thrombus usually occurs where the arteriosclerotic plaque has broken through the endothelium, thus coming in direct contact with

Treatment of Decompensated Heart Disease with Digitalis

Treatment of decompensated heart disease showing the effect of digitalis in elevating the cardiac output curve, this in turn causing increased urine output and progressive shift of the venous return curve to the left. Graphical analysis of two types of conditions that can cause highoutput cardiac failure (1) arteriovenous (AV) fistula and (2) beriberi heart disease.

Cardiovascular Risk Factors

These same risk factors leading to the manifestation of ED are shared with coronary artery disease (CAD). Studies suggest ED as a strong predictive factor for CAD 13,14 . Vasculogenic impotence has been reported to be the first sign of a generalized arteriopathy suggesting that physicians should check ED patients for ischemic heart disease, which can be diagnosed by stress ECG or other investigations prior to starting treatment for ED 15,16 . The presence of silent co-existing myocardial ischemia should be considered in men who present with ED, particularly when they have other cardiovascular risk factors 17 .

Why do we need systematic reviews A patient with myocardial infarction in 1981

A likely scenario in the early 1980s, when discussing the discharge of a patient who had suffered an uncomplicated myocardial infarction, is as follows a keen junior doctor asks whether the patient should receive a beta-blocker for secondary prevention of a future cardiac event. After a moment of silence the consultant states that this was a question which should be discussed in detail at the Journal Club on Thursday. The junior doctor (who now regrets that she asked the question) is told to assemble and present the relevant literature. It is late in the evening when she makes her way to the library. The MEDLINE search identifies four clinical trials.23-26 When reviewing the conclusions from these trials (Table 1.1) the doctor finds them to be rather confusing and contradictory. Her consultant points out that the sheer amount of research published makes it impossible to keep track of and critically appraise individual studies. He recommends a good review article. Back in the library...

Inherited Low Maximal Oxygen Uptake Cardiovascular Risk Profile and Metabolic Syndrome

A specific aim of our research has been to determine whether rats selected on the basis of low versus high intrinsic exercise performance also differed in VO2max, mitochondrial oxidativepathways, and cardiovascular risk factors linked to the metabolicsyndrome.After eleven generations of selective breeding based upon aerobic treadmill running, contrasting rat lines of Low Capacity Runners (LCR) and High Capacity Runners (HCR) were obtained 66, 67 . HCR were superior to the LCR for distance run to exhaustion (347 ) and VO2max (60 ). LCR demonstrated a cluster of risk factors for cardiovascular disease, i.e., higher levels of factors such as body mass, visceral adiposity, blood pressure, insulin, glucose, free fatty acids, and triglycerides. This risk profile resembles the metabolic syndrome as described in humans 66 thus, the LCR rat model serves as an experimental model for this condition that is not based upon single-gene, chemical, or physical manipulation, but on artificial...

Pregnancy in the Woman with Heart Disease

Before becoming pregnant, a woman may have a congenital heart defect or acquired heart disease. Many congenital defects can now be surgically repaired in infancy, and the first generation of these patients has only recently reached childbear-ing age. They represent a new kind of patient for obstetricians and cardiologists. Acquired heart disease in pregnant women includes primarily rheumatic disease involving heart valves, heart failure, and coronary artery disease. Because many women are now delaying pregnancy until they are older, acquired heart disease is somewhat more common in pregnant women than earlier in this century. When considering pregnancy in the presence of heart disease, the most important factor is the severity of the heart-related symptoms. In general, patients without symptoms or those only slightly symptomatic enjoy a good outlook for both mother and fetus. Heart disease in adults generally develops later in life. Although heart disease is not completely...

Fibrillation of the Ventricles After Myocardial Infarction

Ischemia of the muscle causes an injury current, which is described in Chapter 12 in relation to electrocardiograms in patients with acute myocardial infarction. That is, the ischemic musculature often cannot completely repolarize its membranes after a heart beat, so that the external surface of this muscle remains negative with respect to normal cardiac muscle membrane potential elsewhere in the heart. Therefore, electric current flows from this ischemic area of the heart to the normal area and can elicit abnormal impulses that can cause fibrillation. 4. Cardiac muscle weakness caused by the myocardial infarction often causes the ventricle to dilate excessively. This increases the pathway length for impulse conduction in the heart and frequently causes abnormal conduction pathways all the way around the infarcted area of the cardiac muscle. Both of these effects predispose to development of circus movements because, as discussed in Chapter 13, excess prolongation of conduction...

Heart Attack and Heart Failure

The medical term for heart attack is myocardial infarction. During a heart attack, a portion of the heart muscle dies. Patients usually survive small heart attacks. If the heart attack involves a significant portion of the heart, however, the victim will usually die due to arrhythmias during the beginning of the heart attack. In the event a patient survives a large heart attack, a considerable portion of heart muscle will turn into scar tissue and no longer contract. This can lead to heart failure. The patient will become short of breath and frequently fatigued because of the reduced amount of blood being pumped by the heart, resulting in a relative lack of oxygen and other nutrients getting to the body's tissues. The patient may develop swelling in the ankles or in the legs or abdomen as the heart fails and fluid backs up into the tissues. Myocardial Infarction When a portion of the heart muscle dies. Also referred to as a heart attack.

Cardiovascular Disease

A potentially deadly form of cardiovascular disease affecting the coronary arteries is currently being treated with stem cells in animal models. Coronary arteries carry blood to the cardiomyocytes, or heart muscle cells, and if they become blocked or otherwise damaged, the cardiomyocytes die from lack of oxygen. In serious cases, this can lead to a massive heart attack and death of the patient. In milder cases, damage to the heart is minimal, but coronary circulation is insufficient to allow the patient a normal lifestyle. Stem cells, stimulated to differentiate into cardiomyocytes, could be injected directly into the heart muscle in order to repair the damage. The stem cell transplants may be augmented with gene therapy by introducing a gene directly into the heart that codes for a blood vessel growth factor that stimulates the growth and repair of the coronary arteries, in order to reestablish an adequate blood flow. Stem cell therapy to treat cardiovascular disease is still in a...

Cant We Just Eat a Healthy Diet to Prevent Heart Disease

Some physicians argue that we do not have to use alcohol to prevent CAD because we know other ways (changes in lifestyle habits) that will prevent heart disease lose weight and change your diet. But they do not often appreciate how difficult it is for someone to lose 10 to 20 pounds (and keep it off) or how difficult it is for people to permanently adopt a very low-fat and low-cholesterol diet.

Coronary Artery Disease

A cardiologist should follow all patients with known coronary artery disease (CAD). Clinical evaluation includes both the regular workup for CAD and a full evaluation to look for other manifestations of cancer therapy-related cardiotoxicity. In the general work-up for CAD,resting ECG and ECHO are performed, as well as an ECG stress test (with or without an imaging study with exercise). The presence of ischemic changes and exercise-induced arrhythmias can be detected by an ECG stress test. However, ECG changes on a stress test may not correlate well with the presence of CAD in an already-damaged myocardium. As a result, in addition to the ECG stress test, an imaging study such as RNA or echocardiography may be needed to directly visualize areas of ischemic myocardium or abnormal wall motion that may indicate clinically significant CAD. A problem with RNA is that it lacks the specificity to differentiate ischemic myocardium due to the initial radiation damage from that of other causes....

Serum cholesterol reduction and risk of ischaemic heart disease

The randomised controlled trials of serum cholesterol reduction have been the subject of a number of meta-analyses1419 20 and much controversy. In conjunction with the review of the 10 prospective studies just described, the results of 28 randomised trials available in 1994 were summarised 14 this omits the results of trials of serum cholesterol reduction, notably those using statins, that have become available more recently. The aim was to quantify the effect of serum cholesterol reduction on the risk of ischaemic heart disease in the short term, the trials having an average duration of about five years. There was considerable clinical heterogeneity between the trials in the interventions tested (different drugs, different diets, and in one case surgical intervention using partial ileal bypass grafting), in the duration of the trials (0-3-10 years), in the average extent of serum cholesterol reduction achieved (0-3-1-5 mmol l), and in the selection criteria for the patients such as...

Heart Disease

Both untreated hypothyroidism (see Chapter 3) and thyrotoxicosis (see Chapter 4) can lead to cardiovascular complications (complications involving the heart, arteries, and veins) or a worsening of risk factors for cardiovascular disease. The term heart disease generally refers to any type of heart trouble, including irregular or rapid heart rhythms blockages of the blood supply to the heart muscle causing chest pain (angina) or a heart attack (myocardial infarction) or weakening of the pumping of the heart, causing congestive heart failure. Atherosclerotic cardiovascular disease (ASCVD) refers to fatty blockages of blood vessels anywhere in the body. When it occurs in the coronary arteries that feed the heart muscle, it puts you at risk for a heart attack. When ASCVD occurs in blood vessels in the brain, it puts you at risk for having a stroke, in which part of the brain fed by the blocked blood vessel dies. When ASCVD affects arteries that feed your arms or your legs, it causes a...

Policies and legislation

The first international convention that relates specifically to cardiovascular disease is the WHO Framework Convention on Tobacco Control. It was adopted without dissent by the World Health Assembly in Geneva in May 2003, and is currently in the process of ratification. Once 40 countries have ratified the Convention, it will come into effect as a legally binding treaty among those countries. The Convention includes clauses on advertising bans, smoke-free areas, health warnings, taxation, smoking cessation and smuggling. Cardiovascular disease plans worldwide

Risk factor obesity

Lakka HM, Lakka TA, Tuomilehto J, Salonen JT. Abdominal obesity is associated with increased risk of acute coronary events in men. European heart journal, 2002,23 706-713 (cited in Sowers JR. Obesity as a cardiovascular risk factor. American journal of medicine, Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes care, 2001, 24 683-689 (cited in Sowers JR. Obesity as a cardiovascular risk factor. American journal of medicine, Eckel RH, Krauss RM. American Heart Association call to action obesity as a major risk factor for coronary heart disease. Circulation, 1998, 97 2099-2100.

Risk factor socioeconomic status

Choiniere R, Lafontaine P, Edwards AC. Distribution of cardiovascular disease risk factors by socioeconomic status among Canadian adults. Canadian Medical Association journal, 2000, 162(9 Suppl) S13-24. Note Definitions used Physical inactivity leisure exercise less than once per week during previous month. Elevated cholesterol > 5.2 mmol l after fasting 8 hours or more. Giampaoli S, Palmieri L, Dima F, Pilotto L, Vescio MF, Vanuzzo D. Socioeconomic aspects and cardiovascular risk factors experience at the Cardiovascular Epidemiologic Observatory. Italian heart journal, 2001, 2(3 Suppl) 294-302. Steptoe A, Feldman PJ, Kunz S, Owen N, Willemsen G, Marmot M. Stress responsivity and socioeconomic status a mechanism for increased cardiovascular disease risk European heart journal, 2002, 23(22) 1757-63. Terris M. The development and prevention of cardiovascular disease risk factors socioenvironmental influences. Preventive medicine, 1999, 29(6 Pt 2) S11-17. Rao SV, Kaul P, Newby K et al....

Prevention population and systems approaches

Use of medications in stroke and coronary heart disease Gaps in secondary prevention of myocardial infarction and stroke WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE) in low and middle income countries. WHO-PREMISE (Phase I) Study Group. Mendis S. Role of governments in improving prevention of cardiovascular disease. Global Symposium on Cardiovascular Prevention, Marbella, Spain, 11-13 April 2003.

Milestones in knowledge of heart and vascular disorders

1785 England William Withering described the use of digitalis in coronary heart disease in his monograph An Account of the Foxglove. Foxglove had been used for centuries by American Indians. 1912 James B. Herrick described heart disease resulting from hardening of the arteries. 1920 USA First ECG of acute myocardial infarction by Harold Pardee. 1948 USA California physician Lawrence Craven noticed that 400 of his male patients who took aspirin for two years had no heart attacks. By 1956, he had chronicled the health of 8000 patients taking aspirin and found no heart attacks in the group. 1953 USA First demonstrated coronary artery disease among young US soldiers killed in action in Korea (later observed in the casualties of the Viet Nam War too) by William F. Enos, Robert H. Holmes and James Beyer. 1954 India Called on WHO to address the coming epidemic of cardiovascular disease in developing countries. 1959 WHO established Cardiovascular Diseases programme. 1960 Framingham, USA...

Risk factor blood pressure

Vasan RS, Larson MG, Leip EP, Evans JC, O'Donnell CJ, Kannel WB, Levy D. Impact of high-normal blood pressure on the risk of cardiovascular disease. New England journal of medicine, 2001, 345 1291-1297. He J, Ogden LG, Vupputuri S, Bazzano LA, Loria C, Whelton PK. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. Journal of the American Medical Association, 1999, 282 2027-2034.

Risk factor tobacco

Cardiovascular risks of smoking Price JF, Mowbray PI, Lee AJ, Rumley A, Lowe GD, Fowkes FG. Smoking and cardiovascular risk factors in the development of cardiovascular disease and coronary artery disease Edinburgh Artery Study. European heart journal, 1999, 20 344-353. Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men longitudinal population study. British medical journal, 1998, 316 1043-1047. Cardiovascular risks of passive smoking Smokers don't know the risks of heart attack Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. Journal of the American Medical Association, 1999, 281 1019-1021. Bonita R, Duncan J, Truelsen T, Jackson RT, Beaglehole R. Passive smoking as well as active smoking increases the risk of acute stroke. Tobacco control, 1999, 8 156-160. Humphries SE, Talmud PJ, Hawe E, Bolla M, Day INM, Miller GJ. Apolipoprotein E4 and coronary heart disease in middle-aged men...

Price 6f weekly dose of medication

P If just 10 of adults began walking regularly, Americans could save US 5.6 billion in costs related to heart disease. - President George W. Bush, 2002. Health problems related to obesity, such as heart disease and type 2 diabetes, cost the USA an estimated US 177 billion a year. Global costs of heart disease medication The number of people who die or are disabled by coronary heart disease and stroke could be halved with wider use of a combination of drugs that costs just US 14 a year. WHO, 2002 abnormal electrocardiograms, a history of diabetes or previous heart attacks

Prevention personal choices and actions

Good control of blood pressure, blood cholesterol and blood sugar levels, and other cardiovascular risk factors is the key to reducing risks of heart disease and stroke. Personal behaviour and lifestyle choices can make a big difference to the risk of coronary heart disease and stroke. It is estimated that having a high-risk lifestyle may account for 82 of coronary events in women. Here, we identify personal choices that can lower individual risk for heart disease and stroke. The choices apply to young people and adults alike. 5 Know the signs and symptoms of heart attack and stroke and remember that both conditions are medical emergencies. Actions and choices for children and adolescents with cardiovascular disease, or risk factors, should be discussed with a paediatrician or health care provider. Probability of heart attack begins to decrease. Excess risk of coronary heart disease is half that of a continuing smoker. Risk of coronary heart disease is similar to that of people who...

Women a special case

Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men longitudinal population study. British medical journal, 1998, 316 1043-1047. Walking reduces coronary heart disease Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women. Is no pain, no gain pass Journal of the American Medical Association, 2001, 285 1447-1454. Kmietowicz Z. News roundup Women fail to recognise risk of heart disease. British medical journal, 2003, 326 355. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes a 26-year follow-up of the Framingham population. American heart journal, 1986, 111 383-390. McKinlay JB. Some contributions from the social system to gender inequalities in heart disease. Journal of health and social behaviour, 1996, 37 1-26. Dustan HP. Coronary artery disease in women. Canadian journal of cardiology, 1990, 6(Suppl B) 19B-21B. Roquer J, Campello...

Risk factor lipids

High levels of LDL-cholesterol, and other abnormal Lipids (fats), are risk factors for cardiovascular disease. Cholesterol is a soft, waxy substance found among the lipids in the bloodstream and in all the body's cells. It is needed to form cell membranes and hormones, and for other bodily functions. Cholesterol is transported around the body in two kinds of lipoproteins low-density lipoprotein, or LDL, and high-density lipoprotein, or HDL. A high level of LDL can lead to clogging of the arteries, increasing the risk of heart attack and ischaemic stroke, while HDL reduces the risk of coronary heart disease and stroke. The female sex hormone estrogen tends to raise HDL-cholesterol levels, which may help explain why premenopausal women are relatively protected from developing coronary heart disease.

Deaths from stroke

Previous stroke significantly increases risk of further episodes. Certain racial, ethnic and socioeconomic groups are also at greater risk of stroke. The most important modifiable cause of stroke is high blood pressure for every ten people who die of stroke, four could have been saved if their blood pressure had been regulated. Among those aged under 65, two-fifths of deaths from stroke are linked to smoking. Other modifiable risk factors include unhealthy diet, high salt intake, underlying heart disease, diabetes and high blood lipids.

Research

From the description of how a heart muscle cell contracts to the elucidation of the human genome, scientific advances in basic, clinical, and population research in cardiovascular disease, and their global impact, have been phenomenal. New and improved treatments have become possible, and novel markers of future risk have been identified. The MONICA (Multinational MONItoring of trends and determinants in CArdiovascular disease) Project involved teams from 38 populations in 21 countries from the mid-1980s to the mid-1990s, the largest such collaboration ever undertaken. It was set up to explain the diverse trends in cardiovascular disease mortality observed from the 1970s onwards. The project monitored a study population of 10 million men and women, aged 25 to 64 years. MONICA was important in measuring levels and trends in cardiovascular diseases and their risk factors in different populations, in monitoring prevention policies in different countries, and in demonstrating the...

Organizations

The World Health Organization's Cardiovascular Disease Programme is conducted through its Geneva headquarters, and regional and national offices worldwide. The World Heart Federation helps people achieve a longer, better life through prevention and control of heart disease and stroke, focusing on low- and middle-income countries. In addition to the nongovernmental organizations (NGOs) highlighted here, there are many international NGOs from the World Medical Association to Consumers International that include cardiovascular disease control as part of their activities. The capacity of virtually all cardiovascular disease control organizations is inadequate to meet the challenge of the CVD epidemic. World Conferences on Cardiovascular Diseases International Heart Health Conferences

Treatment

In 1931, Paul Dudley White noted that there was no specific treatment for coronary heart disease. He described the treatment of high blood pressure as difficult and almost hopeless. Today, effective and relatively inexpensive medication is available to treat nearly all cardiovascular diseases, including high blood pressure. In addition, marked disparities in the quality of treatment can be seen in groups of different race, ethnicity, sex, and socioeconomic status. In essence, many patients who could benefit from treatment remain untreated, or inadequately treated. In future, increased emphasis needs to be placed on the appropriate use of proven treatments for everyone with coronary heart disease or stroke. Percentage of people with established 17 coronary heart disease advised 2 Coronary heart disease Percentage reduction in two-year risk of heart attack, stroke or death from CVD in patients with previous coronary heart disease or stroke

World Data Table

Heart disease Rheumatic heart disease Number of publications on cardiovascular disease 1991-2001 ACE inhibitors angiotensin-converting-enzyme inhibitors. Drugs used to treat high blood pressure, and to aid healing after a heart attack. Cardiovascular disease (CVD) any disease of the heart or blood vessels, including stroke and high blood pressure. Cerebrovascular disease also called a stroke or the brain equivalent of a heart attack. A condition in which a blood vessel in the brain bursts or is clogged by a blood clot, leading to inadequate blood supply to the brain and death of brain cells. Coronary artery bypass surgery (CABG) A type of heart surgery that re-routes blood around clogged arteries or bypasses them to improve the supply of blood and oxygen to the heart. Coronary heart disease heart disease in which the coronary arteries are narrowed and the supply of blood and oxygen to the heart therefore decreased. Also called coronary artery disease or ischaemic heart disease. It...

Economic costs

Global costs of heart disease medication Kmietowicz Z. News WHO warns of heart disease threat to developing world. British medical journal, 2002, 325 853. American Heart Association. Heart disease and stroke statistics 2004 update. Dallas, American Heart Association, 2003, Chapter 12 42. WHO cardiovascular Disease Programme. Pilot survey on cost of cardiovascular drugs 2003 (unpublished data). Liu K, Daviglus ML, Yan LJ, Garside DB, Greenland P, Manheim LM, Dyer AR, Stamler J. Cardiovascular disease (CVD) risk factor status earlier in adulthood and cumulative health care costs from age 65 to the point of death. Circulation, 2004, 108 IV-722. Lifetime costs of coronary heart disease Dickson M, Jacobzone S. Pharmaceutical use and expenditure for cardiovascular disease and stroke a study of 12 OECD countries. Paris, Organisation for Economic Co-operation and Development, 2003 (OECD Health working papers, DELSA ELSA WD HEA(2003)1), Table 1.

Future

American Federation for Aging Research. What is the future of heart disease research likely to tell us Crossman D. Science, medicine, and the future. The future of the management of ischaemic heart disease. British medical journal, 1997, 314 356-359. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80 . British medical journal, 2003, 326 1419. Rodgers A, Lawes C, MacMahon S. Reducing the global burden of blood pressure-related cardiovascular disease. Hypertension, 2000, 18(1 Suppl) S3 6.

Useful contacts

Cardiovascular disease Diabetes http www.cosehc.org East Meets West http www.eastmeetswest.org Eastern Mediterranean Network on Heart Health, (EMNHH) http www.fctc.org G8 Telematics Heart Health Project http www.internationalstroke .org index.php International Task Force for the Prevention of Coronary Heart Disease http www.chd-taskforce.de

The future

Unlike Einstein, we have to think of the future, and plan now, to reduce the numbers of deaths from coronary heart disease and stroke. Predictions are by their nature speculative. Nevertheless, this much is certain the global epidemic of cardiovascular disease is not only increasing, but also shifting from developed to developing nations. Action can work. There are currently about 800 million people with high blood pressure worldwide. Studies now indicate that in North America, Western Europe, and the Asia-Pacific region, each 10 mmHg lowering of systolic blood pressure is associated with a decrease in risk of stroke of approximately one-third, in people aged 60 to 79 years. Globally, if diastolic blood pressure (DBP) can be reduced by 2 , and by 7 in those with DBP over 95 mmHg, a million deaths a year from coronary heart disease and stroke could be averted by 2020 in Asia alone. Unless current trends are halted or reversed, over a billion people will die from cardiovascular disease...

Risk factor diabetes

Diabetes is a risk factor for coronary heart disease and stroke, and is the most common cause of amputation that is not the result of an accident. In developing countries, coronary heart disease has historically been more common in the more educated and higher socioeconomic groups, but this is beginning to change. In industrial countries, such as Canada, the United Kingdom, and the United States, there is a widening social class difference in the opposite direction. Studies in developed countries suggest that low income is associated with a higher incidence of coronary heart disease, and with higher mortality after a heart attack. The prevalence of risk factors for heart disease, such as high blood pressure, smoking and diabetes, is also higher. The use of medications is lower, especially of lipid-lowering agents and ACE inhibitors, as well as other treatments, such as cardiac catheterization. The pathways by which socioeconomic status might affect cardiovascular disease include...

Risk factors

The search for new risk factors for coronary heart disease occupational therapy for epidemiologists International journal of epidemiology, 2002, 31(6) 1117-22 author reply 1134-5. Inter-Society Commission for Heart Disease Resources A Primary prevention of the atherosclerotic diseases. Circulation, 1970, 42 A55-A95.

Preface to the Third Edition

All other chapters were revised to reflect the current practices of the editors and leading specialists in the field of congenital heart disease contributing to this edition. Major changes and updates were made in the chapters on echocardiography, invasive investigation and exercise testing, anaesthesia, postoperative care, vascular rings, anomalous pulmonary venous return, tetralogy of Fallot, pulmonary atresia with ventricular septal defect, surgery of left ventricular outflow tract atrio-ventricular discordance, hypoplastic left heart syndrome and paediatric heart and heart lung transplantation.

Foreword to the Third Edition

Their textbook Surgery for Congenital Heart Disease was first published in 1983, was revised in 1994, and again revised in 2006 as this 3rd edition. The book has become a reliable and trusted friend. It has a proven ''track record'' and contains sage and practical advice for the present and future progress of our specialty. The original publication grew from the authors' teaching sessions. In the preface to the 1983 edition, they state ''The successful outcome of many operations depends to a large extent on the careful planning and precise execution of a series of minor technical steps''. Stark and de Leval provide a recipe for successful surgical outcomes by clearly defining the technical details that are often overlooked or assumed in other textbooks. In the current edition, Stark and de Leval have added a new editor, their younger colleague Victor Tsang, who continues their tradition of excellence in clinical surgery and clear unambiguous description of the essence of surgical care...

Foreword to the Second Edition

The book is clearly more broadly based than it would be had it been written only by the staff at the Great Ormond Street hospital. In a sense it could be considered a contribution of London, England, to the expanding knowledge of all aspects of congenital heart disease the major contributions from this area over a period of many years also make the text invaluable. In addition, however, Drs Stark and de Leval have selectively tapped the resources of the rest of the medical world in developing this superb text. This book becomes available at a particularly important and probably pivotal time in the area of congenital heart disease. In some parts of the world, there now exists the capability of eliminating congenital heart disease from the population, using prenatal echocardiographic diagnosis and abortion of an affected fetus. Ironically, this comes at a time when the results of many types of interventions for congenital cardiac disease are outstandingly good. For some types of...

The Basis of Statistical Reasoning in Medicine

You learn that your new patient, a cigarette smoker, didn't lost consciousness or convulse. She does use birth control pills. Your exam reveals a frightened but well-groomed adult female who is unable to communicate and can't control the right side of her body. Finishing your workup, you correctly diagnose an acute stroke and orchestrate her emergency care. Right here your colleague interjects, pointing to the abstract. The study says the risk of a bleed is low and that patients do better with tPA administration even out to five hours after stroke symptoms.

Foreword to the First Edition

The entire discipline dealing with the surgical treatment of congenital heart disease is unique in retaining much of its original awesomeness. Perhaps this is because the act of opening a child's chest to manipulate in or about the heart still evokes the feeling that this is an incredibly impertinent thing to do. Even after all these years, the act seems to fly in the face of that which is natural and possible. Perhaps it is because of the great gravity of the procedure, the sometimes narrow margin between failure and success, with an entire unlived lifetime in the balance. Or perhaps it is because the surgical capability to invade the heart developed more recently than for any other organ indeed, within the professional lifetime of some of its still-pioneering pioneers. It is unquestionably true of each of the surgical disciplines that success or failure is related to the availability of fundamental knowledge, advanced technology and artistic skill. But perhaps those who are involved...

Limitations of a single study

A single study often fails to detect, or exclude with certainty, a modest, albeit relevant, difference in the effects of two therapies. A trial may thus show no statistically significant treatment effect when in reality such an effect exists - it may produce a false negative result. An examination of clinical trials which reported no statistically significant differences between experimental and control therapy has shown that false negative results in health care research are common for a clinically relevant difference in outcome the probability of missing this effect given the trial size was greater than 20 in 115 (85 ) of the 136 trials examined.34 Similarly, a recent examination of 1941 trials relevant to the treatment of schizophrenia showed that only 58 (3 ) studies were large enough to detect an important improvement.35 The number of patients included in trials is thus often inadequate, a situation which has changed little over recent years.34 In some cases, however, the...

Table 17 A casecontrol study of Chlamydia infection and coronary atherosclerosis13

Confounding arises when exposed and unexposed subjects are not comparable for a variable which represents a risk factor for the outcome of interest. Tables 1.8 and 1.9 give an example. In Table 1.8, results of a cohort study of the association between radiotherapy to the chest for Hodgkin's disease and subsequent mortality from coronary artery disease are presented.14 The risk of coronary disease death was 2.0 in the exposed (70 3530), and 4.0 in the unexposed (54 1360). The relative risk was therefore 0.5 ( 2 4 ), indicating a reduced coronary disease mortality after radiation to the chest. This result was surprising, as the investigators' hypothesis, arising from previous research in other types of patients and also from animal models, was that exposure to radiation would increase, and not decrease, coronary disease mortality. Further analysis of these data revealed, however, that these results were biased because of the confounding effect of age. Table 1.9 presents results of the...

Exploration and MRFIT

A prime example of the harm that comes from exploratory analyses that are represented as confirmatory is one of the results from the Multiple Risk Factor Intervention Trial (MRFIT) 3 study. Published in 1982, it was designed to demonstrate that reductions in the risk factors associated with atherosclerotic cardiovascular disease would be translated into reduction in clinical events, e.g., myocardial infarction and stroke. Patients in the intervention group received treatment for elevated blood pressure, joined cigarette smoking cessation programs, reduced their weight, and lowered their serum lipid levels patients in the control group followed their usual accepted standard of living. At the conclusion of the study, the investigators found and reported that there was no difference in clinical outcome between those patients who received risk factor intervention and those who did not. The real question however, was, Is it just a distorted treatment effect For years after this finding,...

Nutrients Growth And The Development Of Programmed Metabolic Function

Abstract For each individual, the genetic endowment at conception sets the limits on the capacity or metabolic function. The extent to which this capacity is achieved or constrained is determined by the environmental experience. The consequences of these experiences tend to be cumulative throughout life and express themselves phenotypically as achieved growth and body composition, hormonal status and the metabolic capacity for one or other function. At any time later in life the response to an environmental challenge, such as stress, infection or excess body weight is determined by an interaction amongst these factors. When the metabolic capacity to cope is exceeded, the limitation in function is exposed and expresses itself as overt disease. During early life and development the embryo, fetus and infant are relatively plastic in terms of metabolic function. The effect of any adverse environmental exposure is likely to be more marked than at later ages and the influence is more likely...

Transbronchial TBB versus surgical lung SLB biopsy

A 10 year retrospective review of 24 mechanically ventilated patients undergoing SLB found that a diagnosis was made histologically in 46 .23 Intraoperative complications were generally well tolerated, although 17 had persistent air leaks and two patients died as a consequence of the procedure. Complication rates in other series have been lower and the estimates of diagnostic usefulness have been considerably higher.24-27 For example, in 27 patients with ARF, persistent air leak occurred in six following SLB but there were no perioperative deaths.27 In a retrospective review of 27 OLBs in patients with ARF, persistent air leak occurred in six but there were no perioperative deaths.27 In a retrospective series of 80 patients,26 many of whom were immunosuppressed, eight had a persistent air leak with one perioperative myocardial infarction.

Presenting combining and interpreting results

Once studies have been selected, critically appraised and data extracted the characteristics of included studies should be presented in tabular form. Table 2.1 shows the characteristics of the long term trials that were included in a systematic review24 of the effect of beta blockade in secondary prevention after myocardial infarction (we mentioned this example in Chapter 1 and will return to it later in this chapter). Freemantle et al.24 included all parallel group randomised trials that examined the effectiveness of beta blockers versus placebo or alternative treatment in patients who had had a myocardial infarction. The authors searched 11 bibliographic databases, including dissertation abstracts and grey literature databases, examined existing reviews and checked the reference lists of each identified study. Freemantle et al. identified 31 trials of at least six months' duration which contributed 33 comparisons of beta blocker with control groups (Table 2.1).

Fetal Origins Of Adult Disease

Until recently it was generally considered that the chronic non-communicable diseases of adulthood, heart disease, hypertension, diabetes and cancer, were caused by a genetic predisposition acting with lifestyle factors such as smoking, diet and activity. Over the last decade it has become clear that other factors may play a substantial role, and in particular programming of the metabolic capacity during early life may be especially important. The first evidence for this proposition came form a series of epidemiological studies carried out by Barker and his colleagues which suggested that growth during early life potentially represents a major risk factor for the later development of ischaemic heart diseases4 13 The proposition is that early nutritional exposure programmes future metabolic competence and behaviour by imprinting a change upon genomic expression. The first evidence came from ecological studies which showed that geographical differences in death from ischaemic heart...

Host Risk Factors For Severity Of Illness

Host factors related to underlying diseases and enhanced oxidative stress also appear to determine severity of rickettsioses. Patients with diabetes mellitus have an increased risk of a fatal outcome with Mediterranean spotted fever. Anecdotal descriptions suggest that alcohol abuse and cardiovascular disease may be risk factors for severity of rickettsial illness.

Cardiovascular Changes

But even mild hypothyroidism may aggravate your risk for heart disease if you have other risk cofactors. For example, if you are hypothyroid, it's not unusual to notice chest pain (which may be confused with angina), shortness of breath when you exert yourself, or calf pain (which is caused by dysfunction of the muscles in the leg). Fluid may also collect, causing swollen legs and feet. For more on cardiovascular disease see Chapter 25.

Characteristics of Stroke

According to the World Health Organization, a stroke consists of rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent causes other than that of vascular origin. Global refers to patients in deep coma and those with subarach-noid hemorrhage. This definition excludes transient ischemic attacks (TIAs), a condition in which signs last less than 24 hours. Strokes are the most common life-threatening neurological disease and the third leading cause of death, after heart disease and cancer, in Europe and the United States. Death rates from strokes vary with age and sex for example, in the United States, the rates for males are 11.9 per 100,000 for those aged 40-44 and 1,217 per 100,000 for those aged 80-84. For females, the respective rates are 10.9 and 1,067. Large differences in cerebrovascular disease (CVD) mortality have been noted among races. For Strokes are a heterogeneous entity...

Relative or absolute measures of effect

The relative risk of death associated with the use of beta-blockers after myocardial infarction is 0-80 (95 confidence interval 0-74 to 0-86) (Figure 2.2). The relative risk reduction, obtained by substracting the relative risk from 1 and expressing the result as a percentage, is 20 (95 confidence interval 14 to 26 ). The relative measures ignore the underlying absolute risk. The risk of death among patients who have survived the acute phase of myocardial infarction, however, varies widely.55 For example, among patients with three or more cardiac risk factors, the probability of death at two years after discharge ranged from 24 to 60 .55 Conversely, two-year mortality among patients with no risk factors was less than three percent. The absolute risk reduction, or risk difference, reflects both the underlying risk without therapy and the risk reduction associated with therapy. Taking the reciprocal of the risk difference gives the number of patients who need to be treated to prevent...

Sullivan and V M Gooch

Analysis of structural heart disease in infants and children is ideally suited to two-dimensional (2D) and Doppler echocardiography. Infinite imaging planes are available for displaying anatomy, which is frequently complex. In comparison with cardiac structures in adults, those in infants and children are close to the body surface, which means that higher-frequency ultrasound, which has poorer tissue penetration but provides better image resolution, can be used. Doppler signals of better quality can also be obtained more easily in infants and children because of the shorter distances involved. The technique is non-invasive, painless and safe these considerations are important in all patients but especially so in neonates and infants who are haemodynamically unstable. Echocardiographic studies can be performed in the intensive care unit, operating theatre or catheter laboratory, serial studies are easy to conduct, and the technique is affordable in comparison with other forms of...

MMode and Twodimensional Echocardiography

However, it was superseded in the diagnosis of structural heart disease by 2D echocardiography, developed in the late 1970s, which has since been also used to select the sites for M-mode sampling (Figure 3.1). 2D echocardiography provides images of a sector of the heart. The ultrasound beam is swept through an arc to produce a sector image made up of many adjacent lines of M-mode information. Each set of lines constitutes a single frame. Under most circumstances, sufficient frames per second are obtained to give the visual illusion of continuous motion of the heart. In recent years, increasingly sophisticated formation of the transmitted ultrasound waveform and processing ofthe received echo has been developed. This has led to improved spatial resolution, greatly increased frame rates and progressive improvement in image quality. Multiple frequency transducers have been developed, allowing operator selection of a range of transmit and receive ultrasound frequencies. This includes...

Hypoxic Liver Cell Necrosis

Ischemic necrosis of the liver may follow episodes of congestive heart failure, hypovolemic shock, hepatic artery thrombosis, myocardial infarction and cardiac tamponade.119 The underlying mechanism involves a reduction of hepatic blood flow which results in centrilobular hepatic necrosis. In many cases the reduction in blood flow is transient, resulting in minimal liver injury. However, massive necrosis will result in FHF associated with marked serum transaminase level elevation.120 Many of these patients are not suitable candidates for liver transplantation due to severe cardiovascular disease.

Clinical Manifestations 521 GH Deficiency

The growth rate is typically slow in children who are undergoing treatment for cancer and usually improves (or catches up) after completion of cancer therapy (Fig. 5.8). Children whose growth rate does not improve or whose growth rate is less than the mean for age and sex should be evaluated for growth failure (Fig. 5.9). Causes of slow growth other than GH deficiency include hypothyroidism, radiation damage in growth centers of the long bones or the spine, chronic unresolved illness, poor nutrition, and depression. In individuals who have attained adult height, GH deficiency is usually asymptomatic 71 , but may be associated with easy fatigability, decreased muscle with increased fat mass, and increased risk for cardiovascular disease 12,16 .

The corticospinal tract

In humans, strokes affecting the white matter in the territory of the middle cerebral artery frequently damage the corticospinal tract, as well as other structures, resulting in hemiparesis. Relatively isolated lesions of the corticospinal tract can occur in humans when a small ischemic lesion is located in the posterior limb of the internal capsule or in the basis pon-tis, resulting in the clinical syndrome of pure motor hemiparesis (Fisher and Curry, 1964 Fisher, 1979). After damage to the corticospinal tract, axons carried in the uncrossed ventral corticospinal tract from the opposite hemisphere may be able to exert compensatory control over muscles on the affected side of the body (Fisher, 1992 Cao et al., 1998). These uncrossed axons terminate in the ventromedial portion of the ventral horn and are likely to exert more control over proximal and axial rather than distal musculature (Kuypers and Brinkman, 1970). This spared ventromedial input to spinal motoneurons controlling the...

What You Should Know About Your Heart During Pregnancy

Pregnancy is also associated with symptoms that mimic heart disease. Pregnant women often complain of chest pain, leg swelling, and shortness of breath. In women who are not pregnant, these may signal an underlying cardiac problem. For the woman born with heart disease or who develops heart disease in young adulthood, pregnancy-related risks may increase from the extra demands on the heart. Pregnancy may also unmask a previously undi-agnosed heart problem. However, with few exceptions, the majority of women, even those with heart disease, are able to safely com-

The Importance of the Hypoxic Microenvironment

(e.g. blood vessel precursors in burns injuries3 or ischaemic cardiovascular disease,4-6 mesenchymal stem cells for bone and cartilage repair, and for preventing graft versus host disease in patients undergoing allogeneic haemopoietic stem cell transplants,1,3,7,8), and is generally applicable in other situations requiring tissue repair and regeneration. In contrast, infiltration of the bone marrow, particularly in cases of acute leukaemia and myeloma, or of other tissues with malignant cells is very often associated with an increased blood supply to the tumour, with the improved vascular-isation promoting survival and growth of the malignant clones.9,10 Here, understanding the mechanisms by which endothelial stem progenitor cells perpetuate themselves and contribute to this neovascularisation of tumours would allow the development of improved therapeutics to limit this vascu-larisation and, hence, the supply of nutrients to the malignant cells. Finally, cancer stem cells can adapt...

Modifiable Psychological Variables

Know people who seem to possess the ability to cope with life's most challenging stressors (like becoming quadriplegic or losing the family home in a hurricane) without apparent distress we also know others who experience extreme distress if they are five minutes late for an appointment. Clearly, these individuals differ regarding the sorts of coping skills they have learned throughout life. Lazurus and Folkman (1984) used the term 'coping' to refer to the cognitive and behavioral efforts that a person made to manage the specific stressors that were appraised as taxing or exceeding their resources. They categorized these groups of skills into two types emotion-focused coping and problem-focused coping. Problem-focused coping involves cognitive and behavioral efforts on the part of the person to deal directly with the source of the stress. For example, a person with considerable job-related stress might generate strategies to become more efficient on the job or make suggestions to the...

Modifiable Social Variables

Among these variables is the influence of one's social network and the support an individual receives from it. Strong social support networks are associated with lesser risk for a wide variety of chronic diseases, including cardiovascular disease and cancer (Uchino et al., 1996). The onset of chronic diseases, at times resulting in fatal outcomes, is quite prevalent following the loss of significant sources of social support, like the loss of a spouse. In order to examine the role of this type of stressstress response relation, several investigators have taken these questions into the laboratory. Laboratory investigations of social support have demonstrated that the magnitude of an acute stress response can be significantly reduced by simply having a supportive friend present during the stress presentation (Kamarck, Annunziato, and Amateau, 1995 Uchino, Cacioppo, and Kiecolt-Glaser, 1996). In several of these laboratory demonstrations, the magnitude of the cardiovascular response to...

Outcome measures for clinical care

Walking speed over 10 m or 50 ft, 2- or 6-min walking distance and heart rate change from rest, a timed stand up and walk task, and measures of impairment such as the Berg balance scale, Fugl-Meyer motor assessment, and ASIA motor score provide quick and reliable measures relevant to walking after stroke or SCI (Steffen et al., 2002 Duncan et al., 2003b). These measures may be more sensitive to changes during a subacute intervention compared to a treatment in chronically disabled subjects. The Multiple Sclerosis Functional Composite scale includes a 25-foot timed walk that, with its other two measures, has proven valuable for clinical trials (Kalkers et al., 2000). Serial monitoring of walking speed can serve as both

Natural course of depression

Our first longitudinal study of acute stroke patients was reported in 1983 (Robinson et al. 1983). A consecutive series of 103 patients admitted to the hospital with acute stroke, and diagnosed for depression using diagnostic and statistical manual (DSM-III) criteria were prospectively studied over a 2-year period. We have recently examined diagnostic outcomes using DSM-IV criteria in a larger group of 215 patients (i.e., the 103 previously described patients, who were re-diagnosed with DSM-IV criteria, plus a new group of 112 patients). These data have not previously been published. Follow-up was obtained for 142 of these patients (3 months n 75, 6 months n 78, 12 months n 69, 24 months n 70). (see Chapter 5). The findings from this larger group were generally consistent with those found in the initial group of 103. Of the 27 patients (19 of the overall group) with major depression in-hospital, 18 had no depressive diagnosis at 3 months, (38 still had major depression, and 44 had...

Dimensions of external validity

External validity relates to the applicability of the results of a study to other populations, settings, treatment variables, and measurement variables.14 External validity is a matter of judgement which will depend on the characteristics of the patients included in the trial, the setting, the treatment regimens tested, and the outcomes assessed (Box 5.1).14 In recent years large meta-analyses based on individual patient data have demonstrated that important differences in treatment effects may exist between patient groups and settings. For example, antihypertensive treatment reduces total mortality in middle-aged hypertensive patients40 but this may not be the case in very old people.41 The benefits of fibrinolytic therapy in suspected acute myocardial infarction has been shown to decrease linearly with the delay between the start of symptoms and the initiation of treatment.42 In trials of cholesterol lowering the benefits in terms of reduction of non-fatal myocardial infarction and...

Foetal Echocardiography

The first detailed descriptions of the appearance of the normal human foetal heart as seen by cross-sectional ultrasound were published in 1980 (Lange etal., 1980 Kleinman et al., 1980 Allan et al., 1980). Since then, a complete spectrum of congenital heart disease (CHD) has been recognized in prenatal life (Allan et al., 1984,1994). With experience and modern equipment, anomalies can now be reliably detected from as early as 12 weeks gestation, up to term (Huggon et al., 2002). The most easily obtained view of the foetal heart is the four-chamber view, and identifying the normality of this one section rules out many major defects. Nowadays, it is increasingly standard practice during the routine obstetric ultrasound examination to analyse not only the four-chamber view but also views of the great arteries. As the majority of pregnancies in the UK are now offered a routine anomaly scan, there is therefore the opportunity of screening all pregnancies for major forms of CHD (Fermont et...

Case Study 1 Deliriuma Common Disorder Of Attentional Function And Working Memory

A 58-year-old female with a history of coronary artery disease was found in a disoriented and mildly agitated state one morning, wandering outside her apartment after she failed to show up at work. All laboratory studies were negative. Head computed tomography (CT) revealed a relatively small right anterior pontine infarct just inferior

Stem Cell Heterogeneity And Regulation

Brain (Bjornson et al., 1999 Brazelton et al., 2000) furthermore, subsets of cells from these organs can repopulate blood and marrow. The design and interpretation of the work required understanding normal regeneration in each tissue. Liver is usually quiescent, but cell proliferation starts rapidly in hepatocytes in response to injury. When hepatocyte cell division is inhibited, a special class of liver cells, called oval cells, divide these cells may be liver stem cells that can give rise to hepatocytes. Muscle stem cells, sometimes called satellite cells, are present between muscle fibers these both proliferate and differentiate to maintain muscle mass. Satellite cells are not present in cardiac muscle after a myocardial infarction, the heart heals by fibrosis, rather than by muscle regeneration. Adult neurons are unable to proliferate. Brain does contain a population of glial cells that can divide, giving rise to progeny with long, branching extensions. Such cells are most readily...

Effects of interhemispheric and intrahemispheric lesion location

We first examined the effect of unilateral ischemic lesions on depression in a series of patients who had no known risk factors for depression and were admitted to hospital after an acute stroke lesion (Robinson et al. 1984a). All patients were right-handed and had a single stroke lesion of the right or left hemisphere which was visible on computed tomography (CT) scan. Patients were included only if they had no previous personal or family history of psychiatric disorder. Studies by other investigators have sometimes shown similar lateralized effects of stroke lesions but sometimes have not. The variable which seemed most likely to account for differences in findings between studies was time since stroke. For example, in contrast to our studies of acute stroke patients examined 1-2 weeks following stroke, a study of 88 Australian patients seen in a rehabilitation hospital 8.4 weeks (average) following stroke found that 43 of patients with left hemisphere lesions had major or minor...

Abnormalities of Connection

The echocardiographic method of diagnosing cardiac abnormalities prenatally generally follows the same rules as in postnatal life. For example, in tricuspid atresia, no patent valve is seen in the normal position between the right atrium and right ventricle. The associated right ventricular hypoplasia and ventricular septal defect are also appreciable (Figure 4.6). The connections of the great arteries in this condition must be identified because this will influence the prognosis. Figure 4.7 shows a common atrio-ventricular valve, closed during systole, in a complete atrio-ventricular septal defect. This is one of the commonest forms of heart disease seen in prenatal life (Machado etal., 1988), representing almost 20 of foetal series, in comparison with the expected rate of around 5 found in postnatal life. This type of defect is found prenatally mainly in association with trisomy 21

Changes over time in lesion locations associated with depression

Stroke patients with 2-year follow-up (i.e., 142 patients), we identified patients who had a single stroke lesion involving either the right or left middle cerebral artery (MCA) distribution that was visible on CT scan and who had a follow-up evaluation either at 3 or 6 months (short-term follow-up) or at 12 or 24 months (long-term follow-up). Of 60 patients who met these qualifications, 41 were seen at short-term follow-up and 46 were seen at long-term follow-up. There were no statistically significant differences between the short- and long-term follow-up groups in terms of age, gender, race, marital status, education, socioeconomic status, frequency of family or personal psychiatric history or prevalence of major or minor depression (39 of the short-term follow-up patients and 43 of the long-term follow-up patients had in-hospital major or minor depression). The frequency of depression in patients with right and left hemisphere lesions during the initial evaluation and at the...

Additional Abnormalities

Cardiac tumours are not infrequently seen in prenatal life. They carry a high risk of blood flow obstruction, foetal hydrops and intrauterine death. Cardiac teratomas have been identified, but the majority of tumours are rhabdomyomas histologically and are associated with tuberous sclerosis. Coarctation of the aorta is a common form of heart disease, but the cases recognized prenatally constitute the more severe end of the spectrum of this disease. The association of cystic hygroma, foetal hydrops, coarctation and Turner's syndrome is

Implications Of Foetal Echocardiography

The spectrum of disease seen in prenatal life is different from that observed in infants (Allan etal., 1984b). Malformations detected tend to be the most severe forms of heart disease, and defects that are not commonly seen postnatally, such as tricuspid dysplasia and cardiac tumours, are disproportionately frequently recognized prenatally. Some affected foetuses do not survive intrauterine life, which accounts partly for the discrepancy between prenatal and postnatal incidences of severe CHD. A higher proportion (12-20 ) of cardiac abnormalities detected in prenatal series are associated with chromosomal defects than the proportion found postnatally. The possibility of chromosomal defects must be included in the counselling of the parents, and karyotyping must be discussed with the mother when appropriate. The presence of multiple congenital anomalies contributes to the high mortality rates found in prenatally detected heart disease. The severity of the spectrum of disease seen is...

Surgical Treatment of Coronary Disease

In many patients with coronary ischemia, the constricted areas of the coronary arteries are located at only a few discrete points blocked by atherosclerotic disease, and the coronary vessels elsewhere are normal or almost normal. A surgical procedure was developed in the 1960s, called aortic-coronary bypass, for removing a section of a subcutaneous vein from an arm or leg and then grafting this vein from the root of the aorta to the side of a peripheral coronary artery beyond the atherosclerotic blockage point. One to five such grafts are usually performed, each of which supplies a peripheral coronary artery beyond a block. Coronary Angioplasty. Since the 1980s, a procedure has been used to open partially blocked coronary vessels before they become totally occluded. This procedure, called coronary artery angioplasty, is the following A small balloon-tipped catheter, about 1 millimeter in diameter, is passed under radiographic guidance into the coronary...