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PubMed1992

Implications of third heart sounds in patients with valvular heart disease. The Veterans Affairs Cooperative Study on Valvular Heart Disease.

BACKGROUND: The presence of third heart sounds in patients with valvular heart disease is often regarded as a sign of heart failure, but it may also depend on the type of valvular disease. METHODS: We assessed the prevalence of third heart sounds and the relation between third heart sounds and cardiac function in 1281 patients with six types of valvular heart disease. RESULTS: The prevalence of third heart sounds was higher in patients with mitral regurgitation (46 percent) or aortic regurgitation (28 percent) than in those with aortic stenosis (11 percent) or mitral stenosis (8 percent). The left ventricular ejection fraction was significantly lower (P less than 0.001) when a third heart sound was detected in patients with aortic stenosis (0.38, vs. 0.56 in those without third heart sounds) or mixed aortic valve disease (0.40 vs. 0.55). However, the ejection fraction was only slightly lower in patients with mitral regurgitation and third heart sounds (0.51 vs. 0.57, P = 0.03). The pulmonary-capillary wedge pressure was higher (P less than 0.001) when a third heart sound was detected in patients with aortic stenosis (18.6 mm Hg, vs. 12.1 mm Hg in those without third heart sounds). There was no association between the wedge pressure and third heart sounds in patients with mitral regurgitation. The prevalence of third heart sounds increased with the severity of mitral regurgitation. CONCLUSIONS: In patients with mitral regurgitation, third heart sounds are common but do not necessarily reflect left ventricular systolic dysfunction or increased filling pressure. In patients with aortic stenosis, third heart sounds are uncommon but usually indicate the presence of systolic dysfunction and elevated filling pressure.

Adult↗
PubMed1985

Peripartum heart disease.

Peripartum heart disease is reviewed in the light of reports in the literature and personal experience from the University College Hospital, Ibadan. It is concluded that it is worldwide in distribution but appears most commonly in multiparous black women with a low socioeconomic background. The clinical features are the same as those of dilated cardiomyopathy, with the exception of cases from Zaria, northern Nigeria, where heart failure may be induced by high salt and fluid intake. The possible causes of peripartum heart disease are reviewed. Glomerulonephritis, toxemia of pregnancy, and malnutrition have not been shown convincingly to be causal, and infection, hypertension, and alcoholism have been suggested. Hypertensive heart failure and toxemia of pregnancy can induce peripartum heart disease. It is concluded that the myocardial disorder in peripartum heart disease is probably the same condition as dilated cardiomyopathy, and that infection may be an important element. However, diverse other factors may also play a part.

Black People↗
PubMed2001

[Early management of neonates with suspected congenital heart disease].

Congenital heart diseases may remain asymptomatic for days or weeks after birth. Early diagnosis of prenatally undiagnosed congenital heart diseases rests upon familial history of congenital heart disease and clinical signs such as cyanosis intrauterine growth retardation, tachypnea, excessive sweating, feeding difficulties, or abnormal cardiac auscultation. Hyperoxia test, blood gas determination, chest x-ray and electrocardiogram are the most useful complementary tests before the anatomical evaluation by the pediatric cardiologist. The initial medical management includes mechanical ventilation and oxygen supplementation, insertion of a good quality central or peripheral vascular line, correction of metabolic disorders, sedation, and prostaglandin administration in order to maintain the opening of the ductus arteriosus.

Diagnosis, Differential↗
PubMed1990

Pregnancy and congenital heart disease.

Congenital heart disease as a complicating factor in pregnancy has assumed increasing clinical importance because improved techniques of surgical repair have resulted in a larger proportion of affected women living to the reproductive age. The most serious forms are those associated with pulmonary hypertension (such as the Eisenmenger syndrome), which carry a prohibitively high risk of maternal death. Complex forms of cyanotic heart disease, of which the commonest is the tetralogy of Fallot, are only slightly less dangerous. It has recently been recognized that children born to women with congenital heart disease are at increased risk of having cardiac defects; fetal echocardiography is therefore an important diagnostic test. Optimal care of the pregnant woman with congenital heart disease is best provided by a team consisting of internist-cardiologist, obstetrician-perinatologist, obstetric anesthesiologist, and ultrasonographer-echocardiographer.

Delivery, Obstetric↗
PubMed1995

Risk factors of coronary heart disease and total mortality among elderly men with and without preexisting coronary heart disease. Finnish cohorts of the Seven Countries Study.

OBJECTIVES: We attempted to determine whether elevated levels of the classic coronary heart disease risk factors are associated with increased coronary risk and all-cause mortality among elderly men with and without coronary heart disease at baseline. BACKGROUND: The strength of any association between the classic coronary risk factors and survival among elderly men with and without coronary heart disease has not been established. METHODS: The classic coronary risk factor levels and risk of coronary events and total mortality during a 5-year follow-up interval were studied among men aged 65 to 84 years. Coronary events were fatal myocardial infarction (n = 71), any myocardial infarction (n = 96) and, among the men without disease, other nonfatal coronary heart disease events (n = 80). RESULTS: Among the 171 men with prevalent coronary heart disease, significant (p < 0.05) risk factors for fatal myocardial infarction (n = 42) in multivariate analyses were low high density lipoprotein cholesterol (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.1 to 0.8 for 1-mmol/liter increase), high ratio of total to high density lipoprotein cholesterol (OR 1.4, 95% CI 1.1 to 1.7 for 1-U increase), and smoking more than nine cigarettes daily (OR 6.0, 95% CI 1.5 to 24.9 vs. values in men who had never smoked). Among the 476 men without prevalent coronary heart disease, only high serum total cholesterol was a risk factor for fatal myocardial infarction (n = 29) (OR 1.4, 95% CI 1.0 to 2.0 for 1-mmol/liter increase). Among men with prevalent coronary heart disease, the only significant (p < 0.05) risk factor for total mortality was smoking more than nine cigarettes daily (OR 3.9, 95% CI 1.1 to 13.4 vs. values among men who had never smoked). Among men without prevalent coronary heart disease, only the use of antihypertensive medication (OR 2.0, 95% CI 1.2 to 3.3 between men with and without such medication) was a risk factor for total mortality. CONCLUSIONS: The classic risk factors for coronary heart disease appear to be of importance even in old age, especially among men with prevalent coronary heart disease.

Age Factors↗
PubMed1994

Estimated contribution of coronary artery bypass graft surgery to the decline in coronary heart disease mortality: the Minnesota Heart Survey.

OBJECTIVES: This study assessed the possible contribution of coronary artery bypass graft surgery to the decline in coronary heart disease mortality in the Minneapolis-St. Paul metropolitan area population between 1970 and 1984. BACKGROUND: Coronary artery bypass graft surgery is a major contemporary therapeutic approach for coronary heart disease. Its use has increased over the past two decades because it provides relief of symptoms and, in certain circumstances, prolongs life. During the period that age-adjusted coronary heart disease mortality has decreased, the use of coronary artery bypass graft surgery has increased dramatically, suggesting a relation. METHODS: All 30- to 74-year old Minneapolis-St. Paul area residents undergoing coronary artery bypass graft surgery between 1970 and 1984 (9,548 patients) were registered; their medical records were abstracted; and their survival was ascertained. These data were used in a medical survival probability model using a multivariate analytical approach developed from registries of patients treated medically. The model assumed that coronary artery bypass graft surgery was not available. Two annual mortality rates were compared: the observed Minneapolis-St. Paul annual coronary heart disease mortality rate and the modeled annual coronary heart disease mortality rate. The difference between these rates was the estimated contribution of coronary artery bypass graft surgery to the decline in coronary heart disease mortality rates. RESULTS: Between 1970 and 1984, the estimated surgical contribution increased from 0.2% (increased mortality) to +6.6% of the annual decrease in Minneapolis-St. Paul coronary heart disease mortality. CONCLUSIONS: Between 1970 and 1984, the contribution of coronary artery bypass graft surgery to the decline in coronary heart disease mortality, although small, gradually increased. This change appeared to be related to an increased frequency of coronary artery bypass graft surgery, improved operative mortality and changes in the clinical mix of surgical patients.

Adult↗
PubMed2003

MRI and CT revealing carcinoid heart disease.

Carcinoid heart disease is a frequent complication of the carcinoid syndrome, usually presenting as right-sided valvular heart disease. Although the diagnosis is most often made with cardiac ultrasound, MRI and CT are valuable techniques for diagnosing carcinoid heart disease.

Aged↗
PubMed2003

MRI and CT revealing carcinoid heart disease.

Carcinoid heart disease is a frequent complication of the carcinoid syndrome, usually presenting as right-sided valvular heart disease. Although the diagnosis is most often made with cardiac ultrasound, MRI and CT are valuable techniques for diagnosing carcinoid heart disease.

Aged↗
PubMed2000

[Prevention of thromboembolic disease in patients with heart disease].

OBJECTIVE: To evaluate the adequacy to thromboembolic disease prophylaxis protocol in patients with heart disease. DESIGN: Cross-sectional study. SUBJECTS: Patients older than 14 years affected of heart disease in a semi-urban health primary-care clinic with a population of 10,610 persons and 5582 clinical records. METHODS: Data about age, sex, cardiovascular risk factors, heart disease, prophylactic treatment and its adequacy to the protocol of the "thromboembolic disease commission" of the reference hospital were analysed. RESULTS: Age 67 +/- 13 years (mean +/- SD). Cardiovascular risk factors: hypertension 40%, diabetes 33%, dyslipemia 15%, smoking 21%. Heart disease: ischemic cardiopathy 48%, atrial fibrillation 15%, valvulopathy 19%, dilated myocardiopathy 4% and other 14%. In 20% of cases had two different affections (80% with atrial fibrillation). Prophylactic therapy: 52% of patients were under prophylactic treatment (35% antiaggregation, 18% anticoagulation). Among antiaggregants, drugs used were acetylsalicylic acid 73.5%, triflusal 14.7%, dipyridamole, 8.8% and ticlopidine 3%. In 53% of people without prophylactic treatment antiaggregation criteria were present. 15% of patient under antiaggregation therapy did not meet antiaggregation criteria, and 6% fulfilled anticoagulation criteria. 67% treatments accorded the reference protocol, without significant differences between kind of heart disease or sex. The only statistically significant difference was found in age: 46% of patients older than 80 year were correctly treated, in front 75% adequacy in younger people. CONCLUSION: Prophylactic antithrombotic therapy was according the reference protocol in 67% of cases. In older patients, with greater risk of thromboembolic disease, the adequacy is worse.

Age Factors↗
PubMed2005

Prescribe by risk: the utility of a biomarker-based risk calculation in disease management to prevent heart disease.

Preventive treatment for those most at risk of heart disease rather than those with the highest blood pressure or cholesterol values may be a more efficacious strategy for disease management. This depends on accurate biomarker-based risk assessment tools. An evidence-based model of heart disease risk was developed using the Framingham model with an additional five risk factors, including three of the newer blood biomarkers. This was applied to the adult population of the 3rd National Health and Nutrition Examination Survey cohort. Additionally, the selection criteria for therapeutic intervention from the Adult Treatment Panel III guidelines (for hyperlipidemia) and the 7th Report of the Joint National Committee (for hypertension) were applied to the same subjects. Of this cohort 54% qualified for at least one of these medications while 18% qualified for both. Using this 18% cutoff, the 18% of the subjects with the highest calculated heart disease risk were also identified using the developed risk model. We applied established therapeutic reductions in heart disease probability to those identified by guidelines and to those identified by risk. Applying both drugs to the high-risk group (one third the size of the guidelines group) achieved the same reduction in population risk (about one fourth) as applying the drugs to the guideline groups and required only half as many prescriptions. Intermediate results were found when an intervention group was identified by a combination of both high risk and high levels of risk factors. In this simulation, identifying patients by heart disease risk level resulted in substantially fewer people being treated with fewer drugs and achieving a similar reduction in disease risk.

Biomarkers↗
PubMed1997

The future of the management of ischaemic heart disease.

Ischaemic heart disease will kill over 150,000 people in the next year in Britain, more than any other single disease process, and cost more than 1.4bn pounds in health care alone. Faced with the continuing problems arising from ischaemic heart disease cardiological clinician scientists are moving from technology based solutions to basic sciences. This article explains how basic science may contribute to new understanding and treatments for patients with ischaemic heart disease. Highlighted are three problems which face any clinical cardiologist on a daily basis and for which basic science may provide solutions: the uncertainty of plaque stability in coronary disease; restenosis after percutaneous transluminal angioplasty; and the shortage of organs for cardiac transplant programmes for patients with heart failure.

Angioplasty, Balloon, Coronary↗
PubMed2000

Exercise-based rehabilitation for coronary heart disease.

BACKGROUND: The burden of cardiovascular disease world-wide is one of great concern to patients and health care agencies alike. Circulatory diseases, including myocardial infarction (MI) and stroke, kill more people than any other disease. Cardiac rehabilitation aims to restore patients who have suffered myocardial infarction to optimal health through exercise only based rehabilitation or comprehensive cardiac rehabilitation (eg. smoking cessation advice, diet and counselling as well as exercise). Data from two published and widely cited meta-analyses (Oldridge 1988, O'Connor 1989) of over 4,000 patients each have demonstrated that patients randomised to exercise-based cardiac rehabilitation after MI have a statistically significant reduction in all-cause and cardiac mortality of about 20 to 25% compared to patients receiving conventional care. However, the trials included were small and often of poor methodological quality. Incomplete literature review methods may have resulted in publication bias thereby resulting in an over-estimate of the benefit of cardiac rehabilitation. The randomised controlled trials used in the reviews have focused almost exclusively on low-risk, middle-aged males post MI, thereby excluding women and the elderly. OBJECTIVES: To determine the effectiveness of exercise only rehabilitation and exercise in addition to other rehabilitation interventions (termed comprehensive cardiac rehabilitation) compared with usual care on the mortality, morbidity, health-related quality of life (HRQoL) and modifiable cardiac risk factors of patients with coronary heart disease. SEARCH STRATEGY: Electronic databases were searched for randomised controlled trials, using standardised trial filters, from the earliest date available to December 31st 1998. SELECTION CRITERIA: Men and women of all ages, in both hospital-based and community-based settings, who have had myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty, or who have angina pectoris or coronary artery disease defined by angiography have been included. Studies involving participants following heart transplant, heart valve surgery or heart failure have been excluded. Follow up periods of less than 6 months were excluded. DATA COLLECTION AND ANALYSIS: Studies were selected independently by two reviewers, and data extracted independently. Authors were contacted where possible to obtain missing information. MAIN RESULTS: The current systematic review has allowed analysis of an increased number of patients from approximately 4500 in the earlier meta-analyses to 7683 (2582 in exercise only and 5101 in the comprehensive cardiac rehabilitation group). The quality of reporting overall was poor, with generally high losses to follow up. The pooled effect estimate for total mortality for the exercise only intervention shows a 27% reduction in all cause mortality (random effects model OR 0.73 (0.54, 0.98)). Similarly, comprehensive cardiac rehabilitation reduced all cause mortality compared to usual care, but to a lesser degree (OR 0.87 (0.71, 1.05)). Total cardiac mortality was reduced by 31% (random effects model OR 0.69 (0.51, 0.94)) and 26% (random effects model OR 0.74 (0.57, 0.96)) in the exercise only and comprehensive cardiac rehabilitation intervention groups respectively when compared to usual care. Neither intervention had any effect on the ocurrence of non-fatal myocardial infarction. There was a significant net reduction in total cholesterol in the comprehensive cardiac rehabilitation group (pooled WMD random effects model -0.57 mmol/l (-0.83, -0.31)), but not the exercise only rehabilitation group. Similarly, LDL was significantly reduced in the comprehensive cardiac rehabilitation group (pooled WMD random effects model -0.51 mmol/l (-0.82, -0.19). The effect of exercise only rehabilitation or comprehensive cardiac rehabilitation interventions on revascularisation rates, blood pressure or smoking behaviour could not be determined by this meta-analysis due to the small number of trials reporting these outcomes and heterogeneity between trials. It was not possible to combine the data from studies reporting HRQoL as an outcome. Eighteen different instruments were used to assess HRQoL in the 11 studies reporting it as an outcome. The data are presented qualitatively, only one trial reporting significant improvements with the intervention. REVIEWER'S CONCLUSIONS: Exercise-based cardiac rehabilitation appears to be effective in reducing cardiac deaths but the evidence base is weakened by poor quality trials. It is not clear from this review whether exercise only or a comprehensive cardiac rehabilitation intervention is more beneficial. The population studied in this review is still predominately male, middle aged and low risk. Identification of the ethnic origin of the participants was seldom reported. (ABSTRACT TRUNCATED)

Coronary Disease↗
PubMed1984

Ten-year incidence of coronary heart disease in the Honolulu Heart Program. Relationship to nutrient intake.

Nutrient intake was determined in over 8000 men of Japanese ancestry residing on the island of Oahu. Nutrient determination took place at the initial examination during the years 1965-1968. This report relates nutrient intake to the risk of developing coronary heart disease in the 10 years subsequent to the initial examination. Men who developed coronary heart disease had a lower average intake of calories, carbohydrates, starch, and vegetable protein than men who remained free of coronary heart disease. Men who developed coronary heart disease also had a higher mean intake of percentage of calories from protein, fat, saturated fatty acids, and polyunsaturated fatty acids than men who remained free of coronary heart disease. These men also had a significantly lower mean percentage of calories from carbohydrates and a higher mean ingestion of cholesterol per 1000 calories than men who remained free of coronary heart disease. In multivariate analyses including age, systolic blood pressure, serum cholesterol, cigarettes smoked per day, and physical activity index, carbohydrates, vegetable protein, percentage of calories from saturated fatty acids, and percentage of calories from polyunsaturated fatty acids are no longer significantly related to incidence.

Aged↗
PubMed1990

Geographical clustering of risk factors and lifestyle for coronary heart disease in the Scottish Heart Health Study.

A large cross sectional study, the Scottish Heart Health Study, of 10,359 men and women from 22 districts of Scotland was undertaken to try to explain the geographical variation of coronary heart disease mortality. Analysis by district showed that of the classic risk factors only cigarette smoking was strongly associated with heart disease mortality among both men and women. Mean diastolic blood pressure was weakly associated with rates among men and high density lipoprotein cholesterol showed a strong negative association among women. Total cholesterol showed a weak negative association with heart disease mortality, but, because the serum concentrations of cholesterol were uniformly high in all districts, a strong association with mortality would not be expected. In both men and women many dietary factors showed moderate or strong associations with mortality from coronary heart disease in a district--of these a low consumption of vitamin C was most notable. Other factors associated with heart disease included alcohol consumption and serum triglycerides among men, and obesity, physical activity, and serum triglycerides among women. Many factors associated with heart disease showed strong intercorrelations. Clustering of risk factors (including smoking, alcohol, and diet among men, and smoking, diet, and obesity among women) was associated with much of the regional variation in heart disease mortality in Scotland.

Adult↗
PubMed2003

Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease.

OBJECTIVE: We sought to compare mitral valve repair and replacement as treatments for degenerative mitral valve disease with coexisting ischemic heart disease. Specifically, we sought to (1) identify differences between patients undergoing repair and replacement, (2) determine whether the choice of mitral valve procedure affected survival after adjusting for those differences, and (3) discover which patients were predicted to benefit from mitral valve repair and which from replacement. METHODS: From 1973 to 1999, 679 patients (mean age, 67 +/- 9.1 years; 73% men) with degenerative mitral valve and ischemic heart diseases underwent combined coronary artery bypass grafting and either mitral valve repair (66%) or replacement (34%). Factors associated with repair and replacement were used for multivariable propensity matching. Risk factors for death were identified by means of multivariable, multiphase hazard-function analysis. RESULTS: Patients more likely to undergo repair had isolated posterior chordal rupture (P <.0001) or more recent date of operation (P <.0001); those more likely to undergo replacement were older (P =.0003) or had bileaflet prolapse (P <.0001). Unadjusted survival at 30 days and 1, 5, and 10 years was 97%, 92%, 79%, and 59% after repair and 94%, 88%, 70%, and 37% after replacement. After adjusting for comorbid factors, the extent and effect of ischemic heart disease, and propensity score, the survival benefit of repair became evident after 2 years (P =.01). Eighty-nine percent of patients were predicted to benefit from repair. CONCLUSIONS: In patients with degenerative mitral valve and ischemic heart diseases, mitral valve repair confers a survival advantage over replacement that becomes evident about 2 years after the operation.

Aged↗
PubMed2004

Tracking women's awareness of heart disease: an American Heart Association national study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality in men and women in the United States, yet prior research has shown a lack of awareness of risk among women. The purpose of this study was to assess the contemporary awareness, knowledge, and perceptions related to CVD risk among American women and to evaluate trends since 1997, when the American Heart Association initiated a national campaign to improve awareness of CVD among women. METHODS AND RESULTS: A telephone survey of a nationally representative random sample of women was conducted in June and July 2003, with an oversampling of black and Hispanic women; results were compared with those of similar surveys in 2000 and 1997. The present survey included 1024 respondents age > or =25 years; 68% were white, 12% black, 12% Hispanic, and 8% other ethnicities. Awareness, knowledge, and perceptions about heart disease were evaluated by use of a standard interviewer-assisted questionnaire. A shift in awareness of heart disease as the leading killer of women has occurred since 1997. In 2003, 46% of respondents spontaneously identified heart disease as the leading cause of death in women, up from 30% in 1997 (P<0.05) and 34% in 2000 (P<0.05). In contrast, the percentage of women citing cancer as leading cause of death has significantly decreased. Black, Hispanic, and younger women (<45 years old) had lower awareness of heart disease as their leading cause of death than did white and older women. Nearly all women reported comfort in discussing prevention with healthcare providers, but only 38% of women reported that their doctors had ever discussed heart disease with them. CONCLUSIONS: Awareness of CVD has increased, although a significant gap between perceived and actual risk of CVD remains. Educational interventions to improve awareness and knowledge are needed, particularly for minority and younger women.

Adult↗