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PubMed2000

[Hypertension--heart rate and cardiovascular risk].

Several studies have attempted to assess the effect of the heart rate on cardiovascular and non-cardiovascular mortality. The best known of these, the Framingham study, showed that an increased heart rate was associated with an increased frequency of sudden death. This study also demonstrated that the rôle of the heart rate in cardiovascular complications, especially coronary artery disease, was even greater in hypertensive patients. Nevertheless, in the other studies, when the results are corrected for other cardiovascular risk factors, the heart rate becomes insignificant. The patients with the highest heart rates often have other risk factors, especially hypertension and hypercholesterolaemia. The first large scale French trial was carried out on the data base of the Centre of Preventive and Clinical Investigations. This Centre, recognised by the Ministry of Health and Social Security, carries out 25,000 check-ups each year and has been working for the last 25 years. The check-up includes clinical, biological and radiological investigations. A significant relationship was observed between the heart rate and most of the classical cardiovascular risk factors in both sexes. Subjects with the highest heart rates (> 85 beats/min) compared with those with the lowest heart rates (< 65 beats/min) had higher systolic blood pressures by 12 mmHg and diastolic blood pressures by 7 mmHg. Similarly, most of the patients with tachycardia had higher plasma cholesterol, triglyceride and sugar levels. It was also demonstrated that rapid heart rates in men were associated with increased cardiovascular and non-cardiovascular mortality. In women, a relationship between the heart rate and cardiovascular mortality was not demonstrated. On the other hand, the heart rate was associated with non-cardiovascular mortality. The association between heart rate and cardiovascular mortality in men was mainly explained by a large increase in coronary mortality in those with the fastest heart rates. After adjustment for the other known risk factors, the increase in risk corresponding to a heart rate 20 beats/min faster was 40% for cardiovascular mortality. These epidemiological findings may be explained by at least two mechanisms: a) the increase in the number of heart beats increases the myocardial oxygen requirements, accelerate arterial fatigue and may provoke rupture of constituted atheromatous plaques; b) the increase in heart rate is a sign of increased sympathetic activation which may have negative effects on the cardiovascular system, especially the coronary circulation. In the light of these epidemiological and physiopathological data, the value of lowering the heart rate in high risk patients, especially hypertensive patients with rapid heart rates, remains to be demonstrated.

Cardiovascular Diseases↗
PubMed2001

Depression, anxiety, and the cardiovascular system: the psychiatrist's perspective.

It is becoming clear that the comorbidity of depression and cardiovascular disease does not occur by chance but rather is an inevitable consequence of the relationship between the conditions. Depression in patients with cardiovascular disease is a significant risk factor for developing symptomatic and fatal ischemic heart disease. Moreover, depressed patients have a higher than expected rate of sudden cardiovascular death. Therefore, appropriate treatment of patients with depression and cardiovascular disease cannot be restricted to considerations of either depression or cardiovascular disease in isolation. The tricyclic antidepressants (TCAs) have various effects on the cardiovascular system, including Type IA antiarrhythmic activity that has been associated with an increased risk of mortality in post-myocardial infarction patients. The selective serotonin reuptake inhibitors (SSRIs) are not associated with adverse cardiac effects. The SSRI paroxetine was compared with a therapeutic level of the TCA nortriptyline in a randomized, controlled study and demonstrated a benign cardiovascular profile, while the TCA induced a significantly higher rate of serious adverse cardiovascular events. On the basis of this favorable cardiovascular profile, the SSRIs should therefore be the preferred choice for the treatment of most patients with comorbid depression and cardiovascular disease. Investigation of putative pathophysiologic mechanisms linking depression and cardiovascular mortality, such as the role of platelet activation, will form the basis for further investigation of antidepressant treatments in order to establish if the antidepressants have a beneficial effect on the prognosis of cardiovascular diseases.

Antidepressive Agents, Tricyclic↗
PubMed1986

Differences in cardiovascular responses to peripherally administered GABA as influenced by basal conditions and type of anaesthesia.

The cardiovascular (blood pressure, heart rate, cardiac contractility) effects of i.v. gamma-aminobutyric acid (GABA) were investigated in guinea-pigs anaesthetized with barbitone or urethane. GABA (0.1-10 mg kg-1) produced a transient 'depressive' effect on cardiovascular parameters which in barbitone-anaesthetized animals was followed by a transient 'excitatory' effect. Resting cardiovascular parameters were higher in urethane-as compared to barbitone-anaesthetized animals. Picrotoxin pretreatment (2 mg kg-1, i.v.) barely affected the cardiovascular changes produced by GABA in barbitone-anaesthetized animals. In picrotoxin pretreated animals anaesthetized with urethane, GABA produced an initial depression of cardiovascular parameters followed by an excitatory phase. Hexamethonium (20 mg kg-1, i.v.) suppressed or reduced markedly the GABA-induced cardiovascular changes both in barbitone- or urethane- anaesthetized animals. Reserpine pretreatment lowered resting cardiovascular parameters. In these animals, regardless of type of anaesthesia, the effects of i.v. GABA were of the 'excitatory' type only. Reserpine pretreated animals anaesthetized with barbitone were selected for further experiments. Various GABAA receptor agonists (homotaurine, muscimol, THIP, 5-aminovaleric acid) mimicked the 'excitatory' effect of GABA in reserpine pretreated animals anesthetized with barbitone and prevented the effects of subsequent GABA administration. On the other hand (+/-)-baclofen, a selective GABAB receptor agonist, had a slight depressant effect and did not prevent the 'excitatory' cardiovascular effects of GABA. Neither bicuculline nor picrotoxin pretreatment prevented the 'excitatory' cardiovascular effect of i.v. GABA in reserpine pretreated, guinea-pigs anaesthetized with barbitone. In adrenalectomized guinea-pigs or in preparations receiving i.v. phentolamine plus propranolol, GABA produced only a small 'depressant' effect on cardiovascular parameters. These findings demonstrate that GABA exerts a neuromodulatory effect on cardiovascular function via peripheral actions which is influenced by: type of anaesthesia resting values of cardiovascular parameters degree of activity of the sympathetic nervous system and catecholamine release from the adrenal medulla.

Adrenal Medulla↗
PubMed1986

Thoracic and cardiovascular operations in the United States, 1979 to 1984.

Using data from the National Center for Health Statistics, I conducted an in-depth analysis of numbers of thoracic and cardiovascular operations from 1979 to 1984. This is the first full 5 year period since the inception of International Classification of Diseases, Ninth Revision, Clinical Modification codes, and the findings delineate the present status of thoracic and cardiovascular surgery in the United States. During the study period there was a 34% increase in total numbers of thoracic and cardiovascular operations. Since 1970 there has been a total increase in numbers of thoracic and cardiovascular operations of 150%. In 1983 thoracic and cardiovascular surgeons performed 191,000 coronary artery bypasses. This operation is the most common thoracic and cardiovascular procedure and has become the nineteenth most common operation now performed in this country. Pacemaker placement, revision, or removal (190,000) is the second most common thoracic and cardiovascular operation and the country's twentieth. The twenty most common thoracic and cardiovascular operations constitute 87% of all thoracic and cardiovascular operations. In 1983 thoracic and cardiovascular operations represented 3% of all operations completed in this country. These figures represent the dynamics of thoracic and cardiovascular surgical practice. They demonstrate that numbers of thoracic and cardiovascular operations have consistently increased over the past 15 years. However, this increase is almost entirely due to the advent of coronary artery bypass.

Cardiac Surgical Procedures↗
PubMedDate not supplied

Cardiovascular aging in Syrian hamsters: similarities between normal aging and disease.

The functional status of the cardiovascular system in health and cardiomyopathic (CM) hamsters was assessed throughout their lives by measuring heart weight and fluid in the pleural and peritoneal cavities. An index of cardiovascular age was developed from a multiple regression model of changes in these variables with chronological age. This index showed parallel changes in healthy and CM hamsters with increasing age, but CM hamsters with shorter lifespans underwent the changes at earlier ages. It was also a better predictor of viability than chronological age. The cardiovascular age index correctly predicted the early death of those hamsters which died before the average death age, whereas they should have been alive according to their chronological age. Conversely, hamsters which lived beyond the average death age had cardiovascular ages younger than the average death age, whereas their chronological ages erroneously indicated they should have been dead. This index may have been able to assess viability because it was correlated with histopathological signs of congestive heart failure in both strains of hamsters, as well as with the total amount of pathology found in them. Hamsters which die naturally at a particular age should have older cardiovascular indices than those sacrificed at the same age, and CM hamsters which died at 11-13 months of age did have older cardiovascular ages than hamsters that were sacrificed at these ages. Three experiment examined the effects of various treatments on the index of cardiovascular age. Life in constant light decreased the cardiovascular age of CM hamsters by 30% and extended life by 25%. Chronic digitalis treatment will improve cardiovascular performance, and it prevented increases in cardiovascular age during the end stages of heart failure. Finally, life-threatening chronic stress increased cardiovascular age in CM hamsters, which suggested that severe stress brought CM hamsters nearer to death. However, it was not possible to determine whether the effects of these treatments were on aging or health. Thus, the data suggested that aging, at least in hamsters, may be closely related to the natural development of heart failure which represents a common end stage of life in both cardiomyopathic hamsters and very old, supposedly healthy hamsters.

Aging↗
PubMed2003

Cardiovascular safety of salmeterol in COPD.

BACKGROUND: Patients with COPD have an increased risk of cardiovascular disease. Despite the clinical benefits of long-acting beta-agonist agents in the treatment of COPD, patients may be at an increased risk of cardiovascular toxicity, including tachyarrhythmia due to beta-adrenergic stimulation. OBJECTIVE: To evaluate the cardiovascular safety of salmeterol in COPD patients by conducting a pooled analysis of cardiovascular safety data. DESIGN: Randomized, double-blind, parallel group, multiple-dose studies, which included salmeterol, 50 micro g bid, and placebo arms. STUDY SELECTION: Seven of a total of 17 studies met the predefined inclusion requirements and were pooled. A total of 1,443 patients received placebo, while 1,410 patients received salmeterol, 50 micro g bid. The median duration of treatment was 24 weeks (range, 12 to 52 weeks). RESULTS: Treatment with salmeterol, 50 micro g bid, showed no increased risk of cardiovascular adverse events (AEs) compared with placebo (relative risk, 1.03; 95% confidence interval, 0.8 to 1.3; p = 0.838). Both groups had a similar incidence of cardiovascular events (8%), including cardiovascular deaths. The incidence of cardiovascular AEs increased with age, concurrent cardiovascular conditions, and treatment with antiarrhythmic/bradycardic agents, although increases were comparable in both treatment groups. There were no episodes of sustained ventricular tachycardia, and no clinically significant differences were observed in 24-h heart rate, ventricular and supraventricular ectopic events, qualitative ECGs, QT intervals, or vital signs between the salmeterol, 50 micro g bid, group and the placebo group. Similar findings were observed when patients were stratified for age of > 65 years or the known presence of cardiovascular disease. CONCLUSIONS: Treatment with salmeterol, 50 micro g bid, does not increase the risk of cardiovascular AEs in this population of COPD patients compared with placebo.

Adrenergic beta-Agonists↗
PubMed2002

Serum potassium and risk of cardiovascular disease: the Framingham heart study.

BACKGROUND: Published studies of the association between serum potassium concentration and risk for cardiovascular disease in community-based populations have reported conflicting results. We sought to determine the association between serum potassium concentration and cardiovascular disease risk in the Framingham Heart Study. METHODS: A total of 3151 participants (mean age, 43 years; 48% men) in the Framingham Heart Study who were free of cardiovascular disease and not taking medications affecting potassium homeostasis had serum potassium levels measured (1979-1983). Proportional hazards models were used to determine the association of serum potassium concentration at baseline with the incidence of cardiovascular disease at follow-up. RESULTS: During mean follow-up of 16 years, 313 cardiovascular disease events occurred, including 46 cardiovascular disease-related deaths. After adjustment for age, serum potassium level was marginally associated with risk of cardiovascular disease (hazard ratio [HR] per 1 mg/dL increment, 1.03; 95% confidence interval [CI], 1.00-1.05; P =.02). However, after further adjustment for multiple confounders, serum potassium level was not significantly associated with cardiovascular disease risk (HR, 1.00; 95% CI, 0.98-1.03). There were no significant associations between serum potassium level and cardiovascular disease-related death in either age- and sex-adjusted models (HR, 1.06; 95% CI, 0.99-1.12) or multivariable-adjusted models (HR, 1.04; 95% CI, 0.97-1.11). CONCLUSION: In our community-based sample of individuals free of cardiovascular disease and not taking medications that affect potassium homeostasis, serum potassium level was not associated with risk of cardiovascular disease.

Adult↗
PubMed2005

Erectile dysfunction and subsequent cardiovascular disease.

CONTEXT: The risk factors for cardiovascular disease and erectile dysfunction are similar. OBJECTIVE: To examine the association of erectile dysfunction and subsequent cardiovascular disease. DESIGN, SETTING, AND PARTICIPANTS: Men aged 55 years or older who were randomized to the placebo group (n = 9457) in the Prostate Cancer Prevention Trial at 221 US centers were evaluated every 3 months for cardiovascular disease and erectile dysfunction between 1994 and 2003. Proportional hazards regression models were used to evaluate the association of erectile dysfunction and cardiovascular disease. In an adjusted model, covariates included age, body mass index, blood pressure, serum lipids, diabetes, family history of myocardial infarction, race, smoking history, physical activity, and quality of life. MAIN OUTCOME MEASURES: Erectile dysfunction and cardiovascular disease. RESULTS: Of the 9457 men randomized to placebo, 8063 (85%) had no cardiovascular disease at study entry; of these men, 3816 (47%) had erectile dysfunction at study entry. Among the 4247 men without erectile dysfunction at study entry, 2420 men (57%) reported incident erectile dysfunction after 5 years. After adjustment, incident erectile dysfunction was associated with a hazard ratio of 1.25 (95% confidence interval [CI], 1.02-1.53; P = .04) for subsequent cardiovascular events during study follow-up. For men with either incident or prevalent erectile dysfunction, the hazard ratio was 1.45 (95% CI, 1.25-1.69; P<.001). For subsequent cardiovascular events, the unadjusted risk of an incident cardiovascular event was 0.015 per person-year among men without erectile dysfunction at study entry and was 0.024 per person-year for men with erectile dysfunction at study entry. This association was in the range of risk associated with current smoking or a family history of myocardial infarction. CONCLUSIONS: Erectile dysfunction is a harbinger of cardiovascular clinical events in some men. Erectile dysfunction should prompt investigation and intervention for cardiovascular risk factors.

Aged↗
PubMed2005

Hormone replacement therapy for preventing cardiovascular disease in post-menopausal women.

BACKGROUND: There is apparently compelling evidence, from observational studies, that hormone replacement therapy (HRT) may have benefits in reducing cardiovascular events in post-menopausal women. However, these observational data are subject to biases and confounding and require support from formally designed randomised controlled trials of the effects of HRT on cardiovascular disease risk. OBJECTIVES: To assess the effects of HRT for the primary and secondary prevention of cardiovascular diseases in post-menopausal women. SEARCH STRATEGY: We searched MEDLINE (1998 to December 2002)), EMBASE (1998 to December 2002), the Cochrane Controlled Trials Register (CCTR) (Issue 4 2002), the National Research Register (1998 to present), Clinical Trials.gov (1998 to present), and the database of Spanish Clinical Trials (1998 to present) and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials comparing HRT with controls (placebo or no treatment) with a minimum follow up of 6 months for treating or preventing cardiovascular disease in postmenopausal women with or without cardiovascular disease. DATA COLLECTION AND ANALYSIS: Three independent reviewers extracted information from the articles, solving discrepancies by consensus. All outcomes studied were dichotomous. Risk ratios and 95% confidence intervals (CI) were calculated for each study and plotted. Random effects meta-analysis was used in efficacy outcomes (cardiovascular events) and fixed-effects meta-analysis in variables regarding side effects (deep venous thrombosis). MAIN RESULTS: No protective effect of HRT was seen for any of the cardiovascular outcomes assessed: all cause mortality, cardiovascular death, non-fatal MI, venous thromboemboli or stroke. Higher risks of venous thromboembolic events (Relative risk (RR) 2.15, 95% CI 1.61 to 2.86), pulmonary embolus (RR 2.15, 95% CI 1.41 to 3.28), and stroke (RR 1.44, 95% CI 1.10 to 1.89) was found in those randomised to HRT compared with placebo. No substantial heterogeneity (p <0.1) was detected in any of the outcomes studied. AUTHORS' CONCLUSIONS: At present, a recommendation for initiating HRT for the reason of preventing cardiovascular events in post-menopausal women (with or without cardiovascular disease) should not be made. Women with other risk factors for venous thromboembolic events should be discouraged from using HRT if the sole goal is to prevent cardiovascular events.

Cardiovascular Diseases↗
PubMed2003

Cardiovascular mortality of cockpit crew in Germany: cohort study.

Pilots and other cockpit crew in civil aviation are regularly screened for medical problems that could influence their work performance. Fitness particularly in terms of cardiovascular health is of major importance for this group. While previous studies had shown a low cardiovascular mortality risk of pilots, there is conflicting evidence concerning the prevalence of cardiovascular risk factors in this group. We investigated the cardiovascular mortality of German cockpit crew in a retrospective cohort study. A cohort that included all cockpit crew employed for two German airlines (n=6061) from 1960-1997 was compiled. We calculated the Standardised Mortality Ratio (SMR) and 95% confidence intervals as the ratio of observed and expected numbers of cardiovascular deaths with the German general population as comparison. The influence of age, age at hire and employment duration were analysed in stratified and regression analyses. Overall mortality from cardiovascular causes among cockpit crew was reduced. For mortality from all cardiovascular causes we found an SMR of 0.5(95% CI 0.3-0.6), for acute myocardial infarction the SMR was 0.4 (95% CI 0.3-0.7). Cockpit crew taking up employment at age 30 or later had a more than twofold cardiovascular mortality risk compared with those beginning employment earlier, but there was no risk gradient with duration of employment. Overall, cockpit crew has a relatively low cardiovascular mortality to which a low smoking prevalence and an early detection of cardiovascular health problems are likely to contribute. Cockpit crew employed before age 30 has the lowest cardiovascular mortality risk.

Adult↗
PubMed1991

Cardiovascular health knowledge in the United States: findings from the National Health Interview Survey, 1985.

Knowledge of the risk precursors to cardiovascular disease is thought to be a key component of health decision making. Many intervention programs have been aimed at increasing the nation's general knowledge of risk factors for cardiovascular disease, although the determinants of the level of cardiovascular disease knowledge are not thoroughly understood. We examined cardiovascular knowledge in a nationally representative sample of the United States population with data from the 1985 Health Promotion and Disease Prevention supplement of the National Health Interview Survey. Interviews with 12,551 white women, 770 Hispanic women, 2,547 black women, 9,832 white men, 576 Hispanic men, and 1,440 black men were used in this analysis. We constructed a seven-item index for cardiovascular disease knowledge. After adjustment for age and education, white men and women scored higher on the cardiovascular disease knowledge index than either their Hispanic or black counterparts. We also examined the relationships of age, education, income, marital status, access to medical care, geographic region, and seven self-reported cardiovascular disease risk factors to the levels of cardiovascular disease knowledge. Education was the strongest predictor of cardiovascular disease knowledge. The variables examined accounted for a small portion of the variance in knowledge. Levels of cardiovascular disease knowledge were lower among respondents with less education and income, those who were not married, those with less access to medical care, and those who were smokers or physically inactive. Therefore, efforts to improve levels of cardiovascular disease knowledge should be directed toward subgroups.

Age Factors↗
PubMed2003

Depression and cardiovascular morbidity and mortality: cause or consequence?

BACKGROUND: Depression after myocardial infarction has been associated with increased cardiovascular mortality. This study assessed whether depressive symptoms were associated with adverse outcomes in people with a history of an acute coronary syndrome, and evaluated possible explanations for such an association. METHODS AND RESULTS: Depressive symptoms were assessed using the General Health Questionnaire at least 5 months after hospital admission for acute myocardial infarction or unstable angina in 1130 participants of the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study, a multicentre, placebo-controlled, clinical trial of cholesterol-lowering treatment. Cardiovascular symptoms, self-rated general health, cardiovascular risk factors, employment status, social support and life events were also assessed at the baseline visit. Cardiovascular death (n=114), non-fatal myocardial infarction (n=108), non-fatal stroke (n=53) and unstable angina (n=274) were documented during a median follow-up period of 8.1 years. Individuals with depressive symptoms (General Health Questionnaire score >/=5; 22% of participants) were more likely to report angina, dyspnoea, claudication, poorer general health, not being in paid employment, few social contacts and/or adverse life events (P<0.05 for all). There was a modest association between depressive symptoms and cardiovascular events (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.13-1.77), but not cardiovascular death (HR 1.12. 95% CI 0.71-1.77). After adjustment for symptoms related to cardiovascular disease, the HR for cardiovascular events was 1.22 (95% CI 0.97-1.53). After further adjustment for employment status, social support and life events, the HR was 1.13 (95% confidence interval 0.87-1.47). CONCLUSIONS: There was no significant association between depressive symptoms and fatal or non-fatal cardiovascular events after adjustment for cardiovascular symptoms associated with poorer prognosis. Previously observed associations between depression and cardiovascular mortality may not be causal.

Adult↗
PubMed2005

Glutathione peroxidase-1 and homocysteine for cardiovascular risk prediction: results from the AtheroGene study.

OBJECTIVES: This prospective study was designed to evaluate the effect of joint determination of two important contrary biomarkers--homocysteine and glutathione peroxidase (GPx)-1--on cardiovascular risk stratification. BACKGROUND: Homocysteine plasma levels have been associated with cardiovascular risk. Experimental data suggest that antioxidative GPx-1 activity modulates cardiovascular risk associated with homocysteine. METHODS: In 643 patients with coronary artery disease, we performed a prospective study to assess the risk of homocysteine plasma levels and GPx-1 activity on long-term cardiovascular risk with a median follow-up of 7.1 years. RESULTS: Both homocysteine and GPx-1 were among the strongest univariate predictors of future cardiovascular risk, even after adjustment for cardiovascular confounders. Homocysteine levels were significantly elevated in individuals with future cardiovascular events (15.4 vs. 13.4 micromol/l; p < 0.0001); GPx-1 activity was lower (45.3 +/- 13.1 vs. 50.2 +/- 11.0 U/g hemoglobin; p < 0.0001). In patients with GPx-1 activity below the median value, homocysteine plasma levels above the median were associated with a 3.2-fold (95% confidence interval 1.8 to 5.6; p < 0.0001) increase in cardiovascular risk, whereas it lost its independent risk prediction in individuals with increased antioxidative capacity, as reflected by high GPx-1 activity. In contrast to single determination, combined assessment revealed a significant increase in the area under the curve of cardiovascular risk predictive models from 0.72, including traditional risk factors to 0.75 and also including homocysteine levels and GPx-1 activity. CONCLUSIONS: Plasma homocysteine levels and GPx-1 activity are complementary in identifying individuals at high cardiovascular risk. Joint determination of both biomarkers provides substantial information on top of classic risk factors in cardiovascular risk assessment.

Aged↗
PubMed2004

Cardiovascular risk profile of patients with spondylarthropathies, particularly ankylosing spondylitis and psoriatic arthritis.

OBJECTIVE: To evaluate the cardiovascular risk profile of spondylarthropathy patients, particularly ankylosing spondylitis and psoriatic arthritis. METHODS: A Pubmed literature search was performed to collect English-language articles for this clinically orientated review. Studies were selected if they included (cardiovascular) mortality and morbidity and/or data about cardiovascular risk factors in spondylarthropathies. RESULTS: Ankylosing spondylitis as well as psoriatic arthritis appear to be associated with an increased cardiovascular mortality and morbidity. Several factors, ie, smoking, altered lipid profile, hypertension, increased fibrinogen level, enhanced number of platelets, and hypercoagulability might explain the enhanced cardiovascular risk. Moreover, a decline in physical activity, the presence of HLA-B27, and inflammation may play a role. Finally, undertreatment of cardiovascular morbidity also may contribute to the higher cardiovascular risk. CONCLUSIONS: The available data indicate an increased cardiovascular risk in spondylarthropathy patients, particularly those with ankylosing spondylitis and psoriatic arthritis. RELEVANCE: Rheumatologists should be aware of the enhanced cardiovascular risk in patients with ankylosing spondylitis and psoriatic arthritis. If modifiable cardiovascular risk factors are identified, treatment could ultimately result in a lower cardiovascular morbidity and mortality.

Arthritis, Psoriatic↗
PubMed1998

Hormonal contraception and risk of cardiovascular disease. An international perspective.

The most frequent major adverse effect of hormonal contraception is an increased risk of cardiovascular disease. The effect on the risk of venous thromboembolism (VTE), ischemic and hemorrhagic stroke, and myocardial infarction (MI) differs and is strongly influenced by smoking and the presence of other cardiovascular risks factors, such as hypertension and diabetes mellitus. The incidence of each disease rises with age and there are differences in risk among hormonal contraceptive preparations. This article provides a framework within which to assess the balance of risks among types of hormonal contraceptives according to individual circumstances. Data on cardiovascular disease mortality rates in women of reproductive age in different countries of the world were compiled from nationally reported statistics and supplemented where possible with reported disease incidence rates. Risks associated with current use of hormonal contraception were compiled from the most recent publications on the cardiovascular effects of steroid hormone contraception. These were combined to estimate the total cardiovascular incidence and mortality according to baseline cardiovascular risk and individual characteristics. Mortality rates for cardiovascular diseases are very low in women of reproductive age. Myocardial infarction mortality rates rise from < 0.4 per 100,000 woman-years at age 15-24 years to the range 2 to 7 per 100,000 woman-years at age 35-44 years. Stroke mortality rates similarly rise steeply with age and are between 3 and 5 times higher than those for MI. VTE mortality rates rise less steeply with age and are approximately one-tenth the MI mortality rates at age 35-44 years. The adverse effect of oral contraceptives (OC) on the risk of VTE is the most important contributor to the total number of cardiovascular cases attributable to OC use. The increased risk of stroke and MI dominate the patterns of mortality in OC users and smokers. The additional risks attributable to smoking are greater than the additional risks attributable to OC use. The risk attributable to OC use in women < 35 years of age is small, even if they smoke, but there are substantially increased risks in older women who both smoke and use OC. The additional mortality attributable to OC use can be reduced by screening users, as this results in lower relative risks of ischemic stroke and MI. Differences between OC types in the relative risk of VTE contribute little to the total cardiovascular mortality associated with OC use, even though the total number of cardiovascular events is increased. A potential reduction in the risk of MI with desogestrel and gestodene compared with levonorgestrel-containing OC would have little difference on overall mortality rates in women in their 20s and 30s, but may result in a net reduction in OC-attributable mortality in women aged 40-44 years who smoke. An overall quantification of the risks for different types of oral contraceptive users is necessary for an informed choice of contraceptive method, and any assessment of the balance of cardiovascular risks is complex. The model provides a tool to assess, at the level of the individual, the risks associated with use of different OC according to personal circumstances. It is important to consider the user's age and smoking status when determining OC attributable risks.

Cardiovascular Diseases↗
PubMed2002

Moderate renal insufficiency and the risk of cardiovascular mortality: results from the NHANES I.

BACKGROUND: Conflicting evidence exists concerning whether renal insufficiency is an independent risk factor for cardiovascular disease in the general population. The objective of this study was to determine whether moderate renal insufficiency was associated with total and cardiovascular mortality, independent of traditional cardiovascular risk factors, in a community sample representative of the U.S. general non-institutionalized population. METHODS: Participants in the U.S. First National Health and Nutrition Examination Survey (NHANES I, 1974-1975) and NHANES I Epidemiologic Follow-up Study (NHEFS, 1992, 18 year follow-up) were evaluated. The primary analysis was limited to 2352 adults with complete data, and no baseline cardiovascular disease. A creatinine of 104 to 146 micromol/L in women, and 122 to 177 micromol/L in men (approximate glomerular filtration rate of 30 to 60 mL/min/1.73 m2) was defined as moderate renal insufficiency. Supplementary analyses included participants with marked renal impairment and baseline cardiovascular disease. RESULTS: The unadjusted hazard ratio for moderate renal insufficiency compared to preserved renal function was significant for total mortality (hazard ratio 1.7; 95% confidence interval 1.3 to 2.2), and for cardiovascular mortality (2.2; 1.5 to 3.1). After adjustment for traditional cardiovascular risk factors, there was no independent association between moderate renal insufficiency and total mortality (1.0; 0.8 to 1.4), or cardiovascular mortality (1.2; 0.8 to 1.8). These results were consistent in supplementary analyses. CONCLUSIONS: These results do not support moderate renal insufficiency as an independent risk factor for cardiovascular disease in the general population. The association between moderate renal insufficiency and cardiovascular disease, demonstrated in other epidemiologic studies, appears to be due to co-occurrence of renal insufficiency with traditional cardiovascular risk factors.

Adult↗
PubMed1992

Familial clustering of cardiovascular disease in patients with insulin-dependent diabetes and nephropathy.

BACKGROUND: Patients who have insulin-dependent diabetes mellitus and nephropathy have an excess of cardiovascular disease. Familial factors may in part account for this phenomenon. METHODS: We identified 61 white patients under 65 years of age with insulin-dependent diabetes who had nephropathy, and then matched them with 61 diabetic patients without nephropathy. We determined the prevalence of cardiovascular disease in the parents of these patients with use of information obtained from death certificates or from the World Health Organization questionnaire for cardiovascular disease. RESULTS: The rates of ascertainment of information were 96 percent (n = 117) for the parents of diabetic patients with nephropathy and 95 percent (n = 116) for the parents of patients without nephropathy. Cardiovascular disease was more often a direct cause of death among the parents of diabetic patients with nephropathy (40 percent vs. 22 percent, P less than 0.03), and the combined morbidity and mortality from cardiovascular disease in this group was greater than that in the parents of diabetic patients without nephropathy (31 percent vs. 14 percent, P less than 0.01). The age-adjusted and sex-adjusted relative risk of cardiovascular disease in this group of parents was 2.9 (95 percent confidence interval, 1.5 to 5.5; P less than 0.001). Moreover, a paternal history of cardiovascular disease was associated with a significantly increased risk of nephropathy in the diabetic patient after the analysis was adjusted for age, sex, and duration of diabetes (odds ratio, 3.2; 95 percent confidence interval, 1.3 to 7.9; P less than 0.01). Among the diabetic patients with nephropathy, those who had had a cardiovascular event were much more likely to have a family history of cardiovascular disease (odds ratio, 6.2; 95 percent confidence interval, 2.0 to 19.0; P less than 0.005) than those who had not had such an event. CONCLUSIONS: Among patients with insulin-dependent diabetes, a parental history of cardiovascular disease is significantly associated with the development of nephropathy and, among those with nephropathy, increases the likelihood of cardiovascular disease.

Adolescent↗
PubMed2002

Role of anaemia in cardiovascular mortality and morbidity in transplant patients.

Cardiovascular complications are a major cause of morbidity and the leading cause of mortality in renal transplant recipients. Multiple cardiovascular risk factors are often present before transplantation. Prior ischaemic heart disease, cerebrovascular disease and peripheral vascular disease predict post-transplantation mortality, as do older age, diabetes mellitus, smoking and length of time on dialysis. After transplantation, immunosuppressive agents and/or graft dysfunction may increase cardiovascular risk by causing hypertension, hyperlipidaemia and diabetes mellitus or glucose intolerance. Graft dysfunction may also contribute to cardiovascular risk by causing anaemia or hyperhomocysteinaemia. To assess the relative importance of potential cardiovascular risk factors in renal transplant recipients, a retrospective analysis has been performed on data from 911 patients at the Ospedale Maggiore, Milan, Italy. Preliminary findings confirm that cardiovascular complications are the leading cause of death in renal transplant recipients, accounting for 32% of all deaths. Other major factors predicting post-transplantation cardiovascular events include pre-transplant cardiovascular events, age, smoking, diabetes mellitus (often acquired after transplantation) and hypertension. Careful selection and adequate preparation of patients in addition to appropriate treatment of cardiovascular risk factors are needed before transplantation to reduce the risk of post-transplantation cardiovascular events. After transplantation, appropriate treatment of diabetes, hypertension and hyperlipidaemia, as well as avoidance of smoking, obesity and physical inactivity may reduce the risk of cardiovascular complications further.

Anemia↗