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Biomedical subjects

J C LaRosa

Publications and source records attributed to J C LaRosa.

At least 19 recordsLinked to original sources
PubMed2001

Prevention and treatment of coronary heart disease: who benefits?

Coronary heart disease (CHD) remains a leading cause of morbidity and mortality in the United States, despite our better understanding of the pathobiology of atherosclerosis, our knowledge of risk factors, the widespread availability of inexpensive cholesterol screening, and the availability of effective and well-tolerated cholesterol-lowering agents. Advances in these areas have created controversies regarding who should be screened and treated for primary or secondary prevention of coronary events. The advent of the statin class of lipid-lowering agents represented a major advance, because they are much more effective and better tolerated than previous agents. There is general agreement that patients with hypercholesterolemia and established CHD require treatment for secondary prevention of recurrent coronary events. Primary prevention is controversial in all patient groups except those with diabetes, because their risk of developing CHD is dramatically increased. Postmenopausal women and the elderly are undertreated, whereas young adults may be underdiagnosed and undertreated. Several ongoing trials may resolve the controversies about which patient groups will benefit from different prevention and treatment strategies.

Adult↗
PubMed1999

Future cardiovascular end point studies: where will the research take us?

Coronary artery disease is the most common cause of death in the world. Emerging concepts of atherosclerosis imply that atherosclerosis is a diffuse disease, and cannot be definitively treated with local, anatomic interventions, such as coronary artery bypass graft surgery or angioplasty. Cholesterol lowering, on the other hand, has been shown to dramatically lower the rate of both morbid and mortal coronary events. In trials with new statin drugs, coronary risk has been lowered by approximately 30%. Additional risk reduction will require other approaches, including (1) intervention for other risk factors, (2) more aggressive cholesterol lowering, or (3) increased attention to primary prevention. The last requires a combination of public health measures to change harmful diet and life-style patterns as well as case findings to identify and treat at-risk subjects. For all these approaches, measures that will increase compliance by both physicians and patients to regimens with proven benefits are required.

Anticholesteremic Agents↗
PubMed1999

Academic medicine and managed care: seeking common ground.

The authors report the highlights of a one-day symposium, "Academic Medicine and Managed Care: Seeking Common Ground," sponsored in early 1997 by Tulane University Medical Center. The meeting was held to foster better understanding of the gap between managed care organizations (MCOs) and academic health centers (AHCs) and to define their common ground. There were 62 participants, mainly executives froin AHCs and MCOs, plus government officials and policy researchers interested in the interface of academic medicine and managed care. The participants agreed that there are indeed some common areas in which the two types of organizations can develop programs and interests that serve the missions of both. These include (1) a commitment to high-quality health care, objectively measured by outcomes; (2) issues of "customer service"; (3) certain areas of research (e.g., examining outcomes of medical interventions; measuring cost and cost-effectiveness; measuring quality of care); and (4) preventive medicine, an area in which both AHCs and MCOs are still relatively weak. On the other hand, large elements of AHCs' basic missions of education and research are not seen by MCOs as areas for developing a common agenda. Participants agreed that AHCs must do their best to improve and demonstrate the quality of their care, address the challenges of the market (i.e., take "customer service" seriously), address the issue of how many specialists and how many generalists should be trained, and define the cost of each of their missions. On the other hand, managed care must acknowledge that the missions of AHCs greatly benefit patients and society. Participants agreed that all approaches to AHC-MCO interfaces must be flexible and local, that common ground does exist, and that understanding can grow between these two kinds of organizations if acrimonious exchanges are avoided and serious efforts are made to work together for solutions.

Academic Medical Centers↗
PubMed1998

Women, dyslipoproteinemia, and estrogens.

The most common cause of death in both men and women is coronary atherosclerosis, although atherosclerotic death in women occurs 5 to 10 years later than it does in men. Major risk factors predict coronary risk in both. Available evidence suggests that women benefit from cholesterol lowering just as men do. The role of exogenous estrogenic compounds in favorably affecting lipoprotein levels and promoting antiatherogenesis in both men and women is a promising area for future research.

Aged↗
PubMed1998

Cholesterol & atherosclerosis: a controversy resolved.

We should regard the so-called cholesterol "controversy" as resolved. Elevated cholesterol levels cause coronary disease and probably are an essential ingredient for the development of atherosclerosis. Elevated cholesterol levels should be a cause for concern. From a public health point of view, the ultimate treatment of atherosclerosis will depend on major changes in the lifestyles of populations in developed countries, including a shift to diets that are largely vegetarian, as well as the elimination of tobacco use, an increase in regular exercise, and a reduction in the propensity of to increase weight, particularly with age. For patients at high risk for coronary events, including those with other coronary risk factors and with clinically established coronary disease, cholesterol lowering is absolutely essential. In the majority of cases, it will require not only dietary change but also cholesterol-lowering medication. Taken together, these public health and medical measures can massively reduce, if not eliminate, the burden of atherosclerosis that currently plaques developed countries and now threatens the developing world.

Anticholesteremic Agents↗
PubMed1997

Triglycerides and coronary risk in women and the elderly.

There seems little doubt that triglycerides are causally related to the progress of atherogenesis. Mechanisms for this effect include adverse quantitative and qualitative changes in circulating lipoproteins. In particular, the effects of lower high-density lipoprotein levels and the production by hypertriglyceridemia of small, dense low-density lipoproteins are of great significance. The role of triglyceride-rich remnant particles in atherogenesis is likely important. These remnants, which are lipoproteins rich in both cholesterol and triglycerides, can be shown to produce cholesteryl ester-laden macrophages in vitro and are probably atherogenic in vivo. Triglyceride levels are a significant risk factor for coronary artery disease in women, more so than in men. Triglyceride levels also increase in older patients and continue to be predictors of coronary risk in both men and women older than 65 years. It is unclear whether triglyceride intervention efforts should be directed at lowering triglyceride levels (such as is accomplished with niacin or fibric acid derivatives) or lowering low-density lipoprotein levels in patients with high triglyceride levels, assuming triglyceride levels are only a passive marker of atherosclerotic risk. Until more is known about the precise role of hypertriglyceridemia in atherogenesis in women and older patients, use of triglyceride-lowering drugs should be conservative and limited to those individuals with high triglyceride levels (> 4.5 mmol/L [> 400 mg/dL]) who do not respond to diet modifications and who are at risk of coronary disease either because of a history of vascular disease or the presence of other risk factors.

Aged↗
PubMed1997

Estrogen replacement therapy and coagulation: relationship to lipid and lipoprotein changes.

OBJECTIVE: To examine the relationship of estrogen-induced changes in lipids and lipoproteins with alterations in the coagulation system. METHODS: Coagulation and lipid indices were measured in 31 postmenopausal women, ages 40-60 years, after a 3-month course of 0.625-mg conjugated equine estrogen. We analyzed changes in variables from baseline to 3 months using t tests for paired samples or the Wilcoxon matched-pairs signed-rank test. RESULTS: Unopposed estrogen replacement therapy produced statistically significant decreases in antithrombin-III antigen (P = .006) and activity (P = .001) and total protein S (P = .003) and a significant increase in protein C antigen (P = .017). C4b-binding protein also decreased significantly from baseline to 3 months (P < .001). Mean fibrinogen level decreased by 18.2 mg/dL, not a statistically significant change (P = .213). Estrogen produced the expected statistically significant changes in lipids and lipoproteins. Several correlations between changes in lipids and lipoproteins and coagulation indices were statistically significant. Protein C antigen and activity changes correlated directly with high-density lipoprotein cholesterol changes (r = .52, P < or = .005; r = .38, P < or = .05; respectively), and protein C antigen also correlated directly with increases in apoprotein A-I (r = .54, P < or = .005). Triglyceride changes correlated directly with changes in protein C antigen (r = .36, P < or = .05) and activity (r = .49, P < or = .005) and inversely with C4b-binding protein (r = -.58, P < or = .01). Apoprotein B was correlated with free protein S (r = .48, P < or = .01). CONCLUSIONS: Although several estrogen-induced changes may decrease atherosclerotic potential and hypercoagulability, others may promote coagulability. These divergent effects may be manipulated pharmacologically by other estrogen compounds or by the addition of various progestins.

Adult↗
PubMed1997

Cholesterol management in women and the elderly.

Women, like men, die mostly of coronary atherosclerosis, although atherosclerotic death in women occurs 5-10 years later than in men. Major risk factors predict coronary risk in women and men. What evidence is available suggests that women, similar to men, benefit from cholesterol lowering. Older individuals with symptomatic coronary disease but a relatively good prognosis should be offered the same benefits from secondary prevention as younger individuals.

Aged↗
PubMed1997

Psyllium-enriched cereals lower blood total cholesterol and LDL cholesterol, but not HDL cholesterol, in hypercholesterolemic adults: results of a meta-analysis.

We conducted a meta-analysis to determine the effect of consumption of psyllium-enriched cereal products on blood total cholesterol (TC), LDL cholesterol (LDL-C) and HDL cholesterol (HDL-C) levels and to estimate the magnitude of the effect among 404 adults with mild to moderate hypercholesterolemia (TC of 5.17-7.8 mmol/L) who consumed a low fat diet. Studies of psyllium cereals were identified by a computerized search of MEDLINE and Current Contents and by contacting United States-based food companies involved in psyllium research. Published and unpublished studies were reviewed by one author and considered eligible for inclusion in the meta-analysis if they were conducted in humans, were randomized, controlled experiments, and included a control group that ate cereal providing </=3 g soluble fiber/d. Eight published and four unpublished studies, conducted in four countries, met the criteria. Analysis of a linear model was performed, controlling for sex and age. Female subjects were divided into two groups to provide a rough estimate of the effect of menopausal status (premenopausal = <50 y, postmenopausal = >/=50 y) on blood lipids. The meta-analysis showed that subjects who consumed a psyllium cereal had lower TC and LDL-C concentrations [differences of 0.31 mmol/L (5%) and 0.35 mmol/L (9%), respectively] than subjects who ate a control cereal; HDL-C concentrations were unaffected in subjects eating psyllium cereal. There was no effect of sex, age or menopausal status on blood lipids. Results indicate that consuming a psyllium-enriched cereal as part of a low fat diet improves the blood lipid profile of hypercholesterolemic adults over that which can be achieved with a low fat diet alone.

Adult↗
PubMed1996

Cholesterol agonistics.

Considerable evidence links elevated blood cholesterol levels to the development of atherosclerosis. The National Cholesterol Education Program (NCEP) has recently published revised guidelines for detecting and treating hypercholesterolemia in adults. Included in these guidelines is the recommendation that all adults older than 20 years of age know their cholesterol levels. Under the NCEP guidelines, knowledge of cholesterol levels, even if the levels are elevated, does not automatically lead to drug therapy; on the other hand, under these guidelines, adults are not automatically excluded from treatment simply on the basis of age or sex. The guidelines presented by the American College of Physicians in this issue differ from the NCEP guidelines in that they recommend only limited screening, primarily for middle-aged men. This recommendation is based in part on the assumption that overuse of cholesterol-lowering drugs will otherwise become a problem. In fact, a major current problem is underuse of cholesterol-lowering medications, even in patients at high risk for coronary events. The guidelines proposed by the College minimize large elements of the database linking cholesterol to atherogenesis and make unwarranted and unproven assumptions about physician behavior. In its rationale, its potential consequences, and the process by which it was derived, this policy is in error and should be rejected.

Adult↗
PubMed1996

Photodynamic therapy to control life-threatening hemorrhage from hereditary hemorrhagic telangiectasia.

BACKGROUND AND OBJECTIVE: Photodynamic therapy (PDT) was used to stop life-threatening hemoptysis from bleeding hereditary telangiectasia in bronchi in a 42-year-old man with a 4-year history of repeated embolotherapies, tracheostomies, and ventilator dependence. At the time of his first PDT, he was 10 days past his third embolotherapy, was being ventilated through a tracheostomy and bringing up 100-200 cc of blood daily, necessitating multiple transfusions of blood and platelets. STUDY DESIGN/MATERIAL AND METHODS: Four hours after intravenous injection (60 mg/m2 body surface) of the photosensitizer dihematoporphyrin ether (DHE), bronchoscopy through his tracheostomy showed continuous oozing of non-clotting blood from bronchial vessels in both lung fields, requiring continuous suction. We performed PDT to seven bronchial sites. The 630 nm wavelength light energy to activate the photosensitizer was generated by a tunable dye argon laser system and delivered to the endobronchus through a quartz fiber modified with a 2.5 cm diffusing tip passed through the biopsy channel of the bronchoscope. The light power was 500 mW per cm of diffuser and the light dose was 200 J per cm of diffuser. At the end of the treatments, the bleeding had decreased so as not to require suctioning. The following day we treated three other sites with the same light dose. At this time the only bleeding was from the LUL, which oozed briskly after passing the bronchoscope through it. At the end of the treatment bronchoscopy there was minimal bleeding. RESULTS: One week after PDT he was discharged with a tracheosotomy and mechanical ventilator. Four months later his tracheostomy was removed. He remained free of hemoptysis for 26 months when life-threatening hemoptysis recurred. Twenty-two hours after his second injection of DHE, we treated four different endobronchial sites with PDT for bleeding from both the right and left bronchial tree. Sixteen months after his second PDT he remains free of hemoptysis. Three other patients treated for uncontrollable life-threatening hemoptysis for bronchitis have remained free of hemoptysis for 9, 17, and 23 months. CONCLUSIONS: Photodynamic therapy causes thromobosis and can control bleeding from small vessels regardless of their location or etiology.

Adult↗
PubMed1996

The pharmacology and effectiveness of specific lipid-active drugs: estrogen/sex steroids.

Estrogen has favorable effects on lipid and lipoprotein coronary risk factors when given orally. These effects are less evident when estrogen is given in non-oral forms. The effects of progestins and androgens are generally opposed to those of estrogen, although their effects on lipoprotein (a) [Lp(a)] do not follow this general rule. Estrogen-progestin and androgens have been shown to reduce Lp(a), but Lp(a) reduction is less when conjugated estrogens and medroxyprogesterone are combined than when estrogen is used alone. Overall, the effects of estrogens (both alone and in combination with progestin) on lipid levels and other coronary risk factors, are beneficial. Whether these effects translate into beneficial effects on clinical coronary disease is a question that awaits the outcome of clinical trials in progress.

Androgens↗
PubMed1996

Dyslipidemia and coronary artery disease in the elderly.

Risk factors that predict atherosclerotic cardiovascular disease in younger individuals also predict risk in older people. Although the relative risk of cardiovascular disease associated with any given risk factor may decrease as individuals get older, the absolute risk of morbidity and mortality increases markedly with age. Because the elderly carry the greatest burden of atherosclerosis, they should not be excluded automatically from cholesterol-lowering interventions with either diet or drugs. Such interventions, however, should be undertaken with special attention to their potential adverse effects in the older population.

Aged↗