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PubMed2004

Cardiovascular side effects of new antidepressants and antipsychotics: new drugs, old concerns?

The cardiovascular toxicity of older generation of tricyclic antidepressants (e.g. imipramine, desipramine, amitriptyline, clomipramine) and neuroleptics (e.g. haloperidol, droperidol, thioridazine, pimozide) is well established. These drugs inhibit cardiovascular Na(+), Ca(2+) and K(+) channels often leading to life-threatening arrhythmia. To overcome the toxicity of old generation of antidepressants and antipsychotics, selective serotonin reuptake inhibitor antidepressants (SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, venlafaxin) and several new antipsychotics (e.g. clozapine, olanzapine, risperidone, sertindole, aripiprazole, ziprasidone, quetiapine) were introduced during the past decade. Although these new compounds are not more effective in treating psychiatric disorders than older medications, they gained incredible popularity since they have been reported to have fewer and more benign side effect profile (including cardiovascular) than predecessors. Surprisingly, an increasing number of case reports have demonstrated that the use of SSRIs and new antipsychotics (e.g. clozapine, olanzapine, risperidone, sertindole, aripiprazole, ziprasidone, quetiapine) is associated with cases of arrhythmias, prolonged QTc interval on electrocardiogram (ECG) and orthostatic hypotension in patients lacking cardiovascular disorders, raising new concerns about the putative cardiovascular safety of these compounds. In agreement with these clinical reports these new compounds indeed show marked cardiovascular depressant effects in different mammalian and human cardiovascular preparations by inhibiting cardiac and vascular Na(+), Ca(2+) and K(+) channels. Taken together, these results suggest that the new generation of antidepressants and antipsychotics also have clinically important cardiac as well as vascular effects. Clinicians should be more vigilant about these potential adverse reactions and ECG control may be suggested during therapy, especially in patients with cardiovascular disorders. The primary goal of this review is to shed light on the recently observed clinically important cardiovascular effects of new antidepressants and antipsychotics and discuss the mechanism beyond this phenomenon.

Animals↗

PubMed2005

[Predictors of non fatal cardiovascular events in a Chilean cohort: results of the San Francisco Project].

BACKGROUND: The San Francisco Project is a prospective study aiming to determine the most important cardiovascular risk factors in the Chilean population. AIM: To report the results of the San Francisco Project after a mean follow up of five years. MATERIAL AND METHODS: Between 1997 and 1999, 920 subjects (aged 39.5 +/- 16.3 years, 382 males), free of cardiovascular events, were examined to determine their cardiovascular risk factors. The prevalence of risk factors was compared with the Chilean National Health Survey. All non fatal cardiovascular events were registered until 2003. A logistic regression model including gender, obesity, family history, educational level and classical cardiovascular risk factors, was performed to identify independent predictors of cardiovascular events. RESULTS: The prevalence of cardiovascular risk factors in the studied population was similar to that of the Chilean National Health Survey, except for serum lipid levels, that were lower in the latter. The mean follow up was 5.3 +/- 0.3 years (range 4-6 years), and 26 cardiovascular events were registered. The independent predictors of these events were age, with a relative risk (RR) of 4.3 and 95% confidence intervals (CI) of 1.9 to 9.5 (p <0.001), high blood pressure with a RR of 5.2 (95% CI 2.3-11.7, p <0.001), diabetes mellitus with a RR of 4.5 (95% CI 1.9-10.7, p <0.01) and a low socioeconomic level with a RR of 3.5 (95% CI 1.5-7.9, p <0.01). The model did not accept serum lipid levels, smoking and alcohol intake as independent predictors. CONCLUSIONS: In this cohort of Chilean people, the independent predictors of non fatal cardiovascular events were high blood pressure, diabetes mellitus and a low socioeconomic level.

Adolescent↗

PubMed1989

Health care utilization and costs of adult cardiovascular conditions United States, 1980.

Cardiovascular conditions have a major economic as well as health impact on adults in the United States. In the National Medical Care Utilization and Expenditure Survey, conducted during 1980, health service data were obtained from a national sample of 17,123 civilian noninstitutionalized individuals. These data have been analyzed to define the impact and demographic patterns of health care utilization and costs attributable to adult cardiovascular conditions. Approximately 28 million persons in the United States, or 17.3 percent of the total civilian noninstitutionalized population 17 years of age and over, had a cardiovascular condition during 1980. Cardiovascular conditions were reported with increasing frequency in successively older age groups and were reported most frequently by black persons. The prevalence and economic impact differed by specific type of cardiovascular condition and whether the condition was complicated by another disease. To examine these differences, persons reporting cardiovascular conditions were categorized into four mutually exclusive groups: persons with hypertension alone, persons with arteriosclerotic cardiovascular and cerebrovascular disease associated with hypertension, persons with arteriosclerotic cardiovascular disease alone, and persons with cardiovascular disease associated with other conditions that might alter medical care utilization and disability. The disability, service utilization, and health care charges were compared among these groups, and data for each group were compared with those for the overall U.S. population. Survey participants were asked to rate their health relative to that of other people their age. The self-rating of persons reporting hypertension alone was lower than the national average. Only 17 percent of the general population rated their health as "fair" or "poor," but 27 percent of persons with hypertension alone used these descriptions. Overall, persons with hypertension alone were much less likely to be employed than the general population (52.2 percent versus 71.6 percent). However, when controlling for age, it was found that persons with hypertension alone were about as likely to be employed as the general population. On the average, persons with hypertension reported only slightly more work-loss days than did the general population (6.5 versus 4.9 days). A modest restriction of activity was reported by those with hypertension alone (20.1 days per year on the average compared with 15.6 for the general population). The mean number of ambulatory visits per year for those with hypertension alone was 7.9, only slightly greater than the 5.7 average for the overall population.(ABSTRACT TRUNCATED AT 400 WORDS)

Activities of Daily Living↗

PubMed2000

Regional differences in cardiovascular mortality in Minnesota.

Cardiovascular disease is the leading cause of death in the United States. Initial results from our health survey in the Red River Valley of Minnesota suggested elevated cardiovascular mortality in men and women in younger age groups there compared with the rest of the state. Similarly, earlier published longitudinal studies of cardiovascular mortality in Minnesota revealed increased cardiovascular mortality in counties west of a diagonal line drawn through the tip of the arrowhead region (northeast Minnesota) to the southwest corner of the state. In this study we examined cardiovascular mortality by geographic region with respect to economic factors, residence patterns, and ethnic group. Since these regions vary in geology and major land use, environmental factors were considered as well. Our present data show a significant elevation in cardiovascular mortality from 1987-1997 in men and women aged 25-59 in northwest and northeast Minnesota counties compared with central-metro counties. In contrast, south-central Minnesota shows a rate of cardiovascular mortality for that age group similar to that seen in the central-metro region. The increase in cardiovascular deaths from myocardial infarct in the younger groups in the more rural, less affluent areas of northwest Minnesota is nearly two times higher than in the central-metro counties. Genetic factors may play a role in the increased mortality recorded for northeast Minnesota. Environmental contaminants such as pesticides are additional considerations. Finally, our data suggest the need to address long-standing regional cardiovascular mortality differences and rural health care access in Minnesota.

Adult↗

PubMedDate not supplied

[Prevention in cardiovascular pathology].

National and international recommendations on the management of arterial hypertension and hypercholesterolemia suggest a treatment decision based on the evaluation of absolute cardiovascular risk. In order to evaluate the cardiovascular risk level, Anderson's equation (Framingham) has been proposed but does not apply to the French population. In medical practice, cardiovascular risk has to be appreciated according to the estimated cardiovascular risk of the country or area. The limits of a decision based on cardiovascular risk have been emphasized, particularly the balance age/life expectancy in respect of early prevention of atherosclerosis. However, the benefit of treatment of hypertension with beta-blockers, diuretics and recently ACE inhibitors and calcium antagonists or hypercholesterolemia with statins has been clearly stated--the higher the cardiovascular risk the higher the benefit. Secondary prevention in patients with major cardiovascular events is effective and necessary. The discussion concerns only primary prevention and from an economic point of view may concern patients at high cardiovascular risk. The general population have to be informed on cardiovascular risk factors, and patient education must be encouraged and developed via the healthcare network.

Antihypertensive Agents↗

PubMed2002

[Cardiovascular risk in patients with chronic renal failure. Patients in renal replacement therapy].

Dialysis patients constitute a high-risk subset of patients for developing cardiovascular disease, which accounts for nearly 50% of deaths. After stratification for age, race and gender, cardiovascular mortality is 10-20 times higher in dialysis patients than in the general population. Cardiovascular disease in this population cannot be fully explained by the high prevalence of classical cardiovascular risk factors (age, hypertension, diabetes, hyperlipidemia, smoking, etc.). Thus, the involvement of "new" cardiovascular risk factors (hyperhomocysteinemia, hyperfibrinogenemia, high lipoprotein (a) levels, oxidative stress, inflammation, etc.), and uremia-related factors (anemia, impaired calcium-phosphorus metabolism, hyperparathyroidism, accumulation of endogenous inhibitors of nitric oxide synthesis, etc.) has been also invoked to play a role in the increased cardiovascular risk in these patients. Endothelial dysfunction is the initial event in the development of atherosclerosis. Uremic patients exhibit an endothelial dysfunction, even before starting dialysis, which persists o is even aggravated under dialysis treatment. Uremic patients must be considered at high risk of developing cardiovascular disease. Thus cardiovascular risk factors in these patients should be managed early, aggressive and multifactorially in order to reduce their high cardiovascular morbidity and mortality.

Arteriosclerosis↗

PubMed2002

[Correlation between body mass index, lipoprotein (a) level and positive family history of cardiovascular diseases in children and adolescents with obesity, hypertension and diabetes].

The study was carried out in a group of 285 children and adolescents aged 4-20 yrs. Children were divided according to their main disease: group with obesity, obesity and coexisting hypertension, hypertension and diabetes. Each group was divided into children with positive or negative family history of cardiovascular diseases. We assessed routine lipid parameters, body mass index and new atherosclerosis risk factors: lipoprotein (a), apolipoproteins A-I and B, homocysteine, fibrinogen, t-PA and PAI-1. Positive family history of cardiovascular diseases was found in 28% families, and in 8% families it was premature cardiovascular disease. In 48% children we found hypertension in family. Children with positive family history had significantly higher body mass index (25.4 vs 23.8 kg/m2). In the group with obesity and hypertension we found significantly higher cholesterol (182 vs 160 mg/dl) and LDL-cholesterol level (114 vs 93 mg/dl). Lipoprotein(a) level was significantly higher in children with positive family history (38 vs 28 mg/dl). Significant differencies were also found in apolipoprotein B level (90 vs 84 mg/dl). In logistic regression analysis only BMI and lipoprotein(a) were significant in predicting future cardiovascular events in children. Obese, hypertensive and diabetic children often come from families with cardiovascular diseases. Hypertension is the most often prevalent atherosclerosis risk factor in families. Children with positive family history of cardiovascular diseases have significantly higher body mass index. Out of new atherosclerosis risk factors lipoprotein(a) and apolipoprotein B may have real value in predicting future cardiovascular disease in the child. The aim of the study was to compare obese, hypertensive and diabetic children with positive and negative family history of cardiovascular diseases. In the work we have tried to find which of the new atherosclerosis risk factors may have the real value in predicting future cardiovascular events in children already predisposed to atherosclerosis.

Adolescent↗

PubMed2003

[Prevalence of diabetes mellitus and cardiovascular disease among immigrants from Turkey and Morocco and the indigenous Dutch population].

OBJECTIVE: To gain insight into the prevalence of diabetes mellitus and cardiovascular disease among Turkish and Moroccan immigrants in the Netherlands. DESIGN: Secondary analysis of data from a cross-sectional study in 1999/'00. METHOD: The prevalence of self-reported diabetes and cardiovascular disease was studied in a sample of 743 Turkish, 641 Moroccan and 537 ethnic Dutch persons aged 35 to 74 years from the population of Amsterdam, the Netherlands, using an oral questionnaire. Ethnic differences in the prevalence of diabetes and cardiovascular disease were studied by logistic regression analysis controlling for age, sex and educational level. Further, in the case of diabetes, we examined whether or not the differences could be explained by overweight and physical inactivity, and in the case of cardiovascular disease we investigated the relationship with smoking and diabetes. In addition, the association between diabetes and cardiovascular disease was investigated. RESULTS: The Turkish and Moroccan population reported diabetes more often than did the ethnic Dutch (12.3, 12.4 and 3.0%, respectively). The differences were still present after controlling for sex, age, educational level, overweight and physical inactivity. Cardiovascular disease was more prevalent among the Turks (10.6%) than among the indigenous Dutch population (5.0%), but this was not true for the Moroccans (5.4%). The difference between Turkish and ethnic Dutch people still persisted after controlling for educational level, overweight, physical inactivity, smoking and diabetes. The association between diabetes and cardiovascular disease was consistent for all groups studied. CONCLUSIONS: The prevalence of diabetes was higher among Turkish and Moroccan immigrants than among the indigenous Dutch population. Cardiovascular disease was more prevalent among the Turks, but not among the Moroccans. The association between diabetes and cardiovascular disease was consistent for all three ethnic groups.

Adult↗

PubMed2003

[The SEOT-Urbe project:an observational study on the cardiovascular profile of a young population living in the Roman suburb].

BACKGROUND: Although several observational studies regarding clinical aspects of different populations have been performed, information about the cardiovascular profile and the lifestyle of young Italian people is poor. METHODS: A group of physicians working in the Roman area visited a population of outpatients aging between 20 and 50 years, with a medical history characterized by the absence of cardiovascular events. They collected information about the prevalence of cardiovascular risk factors, lifestyle, and the number of medical and instrumental controls performed by each patient. RESULTS: 5581 consecutive patients (2795 males, 2786 females, mean age 36 +/- 8 years) were included in this study. They were living in three different areas of the Roman suburb: civic zone, rural area, and seaside. At least one cardiovascular risk factor was observed in 4825 people (86.5%). Moreover 549 people (9.8%) reported more than three risk factors. Physical inactivity resulted the most frequently found risk factor; indeed its prevalence is high in every subgroup of patients, regardless of gender or geographical distribution. Regular medical controls are performed by 2774 people (49.7%), most of them being visited by general practitioners; 288 people (5.2%) complain of symptoms like dyspnea or palpitations. Cardiovascular therapy is taken more frequently than non-cardiovascular one (13.3 vs 3.7%). Very few instrumental exams (electrocardiogram, echocardiogram, physical stress test) show alterations. The analysis of the lifestyle and cardiovascular risk profile of people living in the different areas failed to show any significant differences. CONCLUSIONS: Despite the young age of the population, a great number of people show an increased cardiovascular risk profile and report a potentially dangerous lifestyle. The need for a primary prevention policy turns up in order to avoid the occurrence of as more expected cardiovascular events as possible.

Adult↗

PubMed2004

Prevalence and prognostic role of cardiovascular complications in patients with exacerbation of chronic obstructive pulmonary disease admitted to Italian respiratory intensive care units.

BACKGROUND: Cardiovascular complications are frequently observed in patients with chronic obstructive pulmonary disease (COPD) admitted to respiratory intensive care units and may affect the prognosis. The aims of this study were to evaluate a) the prevalence of cardiovascular complications in patients with COPD exacerbation admitted to respiratory intensive care units, b) which parameters detected at admission were predictive of cardiovascular complications, and c) the prognostic role of cardiovascular complications. METHODS: A series of 278 consecutive patients with COPD admitted to 11 Italian respiratory intensive care units between November 1997 and January 1998 has been retrospectively analyzed. All cardiovascular complications were recorded. RESULTS: One hundred and ten patients (39.6%) developed cardiovascular complications: congestive heart failure 49 (17.6%), arrhythmias 40 (14.4%), shock 13 (4.7%), and hypotension 11 (4%). Multivariate analysis showed that the APACHE II score, ECG abnormalities (supraventricular ectopic beats, right and/or left ventricular hypertrophy) and digoxin therapy were independent predictors of cardiovascular complications. The overall mortality was 9% being 4.7% in patients without and 15.5% in patients with cardiovascular complications (p = 0.0044). Multivariate analysis showed that the APACHE II score, respiratory rate, pneumonia and end-stage respiratory diseases were independent predictors of mortality. CONCLUSIONS: Cardiovascular complications occurred in many patients with COPD exacerbation admitted to respiratory intensive care units, and identify a subset of patients with higher mortality.

APACHE↗

PubMed2005

[Cardiovascular disease epidemiology and risk factors in primary care].

INTRODUCTION AND OBJECTIVES: To study the prevalence of and risk factors for cardiovascular disease in primary care. PATIENTS AND METHOD: A cross-sectional study was carried out at an urban health center in Barcelona, Spain. In total, 2248 patients > or =15 years old were selected randomly from medical records. The study investigated cardiovascular diseases such as ischemic heart disease, cerebrovascular disease and peripheral arterial disease, and cardiovascular risk factors such as age, sex, smoking, high blood pressure, hypercholesterolemia, hypertriglyceridemia, and diabetes mellitus. RESULTS: The patients' mean age was 49.1 (18.9) years and 53.5% were male. Cardiovascular risk factor prevalences were: smoking, 35.2%; high blood pressure, 33.7%; hypercholesterolemia, 21.9%; hypertriglyceridemia,12.7%; and diabetes mellitus, 15.8%. Overall, 57.9% of patients had at least 1 cardiovascular risk factor. Significantly more males presented with each risk factor (P<.05), apart from high blood pressure. The prevalence of all risk factors, except smoking, increased with age until 74 years and then stabilized, except high blood pressure, which continued to increase. Around 10% had cardiovascular disease, with myocardial ischemia in 5.5%, cerebrovascular disease in 3.7%, and peripheral arterial disease in 2.4%. All except cerebrovascular disease were significantly more common in males (P<.05). The prevalence of cardiovascular disease was low in individuals <55 years old, particularly women, and increased with age for all forms of disease. Some 68.3% were > or =65 years old. CONCLUSIONS: The high prevalence of cardiovascular risk factors was confirmed. Cardiovascular disease was more common in males and the elderly.

Adolescent↗

PubMed2005

Serum uric acid concentration as a risk factor for cardiovascular mortality: a longterm cohort study of atomic bomb survivors.

OBJECTIVE: To elucidate the association of serum uric acid concentration with cardiovascular mortality risk. METHODS: Serum uric acid level measured from 1966 through 1970 in 10,615 Japanese individuals from a cohort of atomic bomb survivors was analyzed for association with subsequent cardiovascular and all-cause mortality until 1999 using the Cox proportional hazard model. RESULTS: During an average followup of 24.9 years, 5225 deaths occurred, of which 1984 were ascribed to cardiovascular disease. In men, after adjustment for age, elevated serum uric acid level was associated with both cardiovascular and all-cause mortality. After additional adjustment for potential cardiovascular disease risk factors including body mass index, smoking status, alcohol consumption, systolic blood pressure, cholesterol level, and histories of hypertension, diabetes and cardiovascular disease, elevated serum uric acid level in men was associated with all-cause mortality but not with cardiovascular mortality. In women, even after these adjustments, elevated serum uric acid level was significantly associated with cardiovascular and all-cause mortality. CONCLUSION: Increased serum uric acid level is a significant and independent risk factor for cardiovascular mortality in women and for all-cause mortality in both men and women.

Adult↗

PubMed2006

[How to evaluate the cardiovascular and renal risk at the individual level?].

The cardiovascular impact of the non-steroidal anti-inflammatory drugs and the higher cardiovascular mortality during treatment of inflammatory rheumatism impose a rigorous evaluation of the cardiovascular risk of rheumatic patients. Large epidemiological studies have identified risk factors for cardiovascular diseases such as the age, male gender, family history (infarct, stroke), tobacco consumption, systolic arterial pressure, renal insufficiency, hypercholesterolemia, diabetes mellitis, sedentariness, obesity and "electric" ventricular hypertrophy. Some equations make it possible to evaluate the absolute cardiovascular risk at the individual level, which corresponds to the onset risk of a stroke in the 10 years to come in a subject according to the number and importance of each of his risk factors. It has been demonstrated that the correction of one or more risk factors reduce the overall cardiovascular risk justifying the strategies for evaluating this risk to define therapeutic intervention thresholds. The impact of a long-term anti-inflammatory treatment or an inflammatory disease such as rheumatoid arthritis has not been the subject of specific epidemiological study allowing these elements to be included in an equation of the estimation of the cardiovascular risk. However, the introduction of on anti-inflammatory treatment, likely to increase the cardiovascular risk of a patient, certainly justifies an evaluation of the absolute cardiovascular risk.

Adult↗

PubMed1989

Cardiovascular mortality trends in Harris County, Texas: 1980 to 1986.

Cardiovascular diseases are the leading causes of death in Texas and in the United States. This study determines the trend in mortality rates attributed to cardiovascular diseases in Harris County from 1980 to 1986. The region of the county that does not include the City of Houston was specifically studied. Mortality of cardiovascular diseases in these two areas follow patterns similar to that of the United States in the same time period. Both the entire county and Harris County excluding Houston show declines in cardiovascular mortality rates in the 7-year period. The populations were divided into four ethnic categories (white, black, Hispanic and "other"), and each ethnic group reported significant declines in overall cardiovascular mortality except in the "other" population, which showed an increase in the male group. Significant downward trends were noticed in the white and Hispanic population in the two major subcategories of cardiovascular diseases: diseases of the heart and cerebrovascular diseases. The black population in each geographic area studied was consistently higher in cardiovascular mortality than the other three ethnic groups observed (white, Hispanic and "other"). Knowledge of cardiovascular disease mortality rates by ethnicity, sex, and age as well as temporal changes in mortality rates within Harris County are important for health planners in continuing and implementing programs aimed at awareness, prevention, and treatment of cardiovascular diseases.

Cardiovascular Diseases↗

PubMed1993

Elevated risk of anaphylactoid reaction from radiographic contrast media is associated with both beta-blocker exposure and cardiovascular disorders.

BACKGROUND: A case-control study, with both retrospective and concurrent subject selection, was performed (1) to determine whether greater risk for anaphylactoid reaction from contrast media associated with beta-blocker exposure reflects presence, or is independent of underlying cardiovascular disorder; and (2) to characterize further the risk of anaphylactoid reaction from contrast media in patients with cardiovascular disorders and patients with asthma. METHODS: Adverse reactions from intravenous contrast media were recorded in accordance with quality assurance guidelines. Anaphylactoid reactions were classified as mild to moderate (urticaria/angioedema), severe (stridor, bronchospasm, or hypotension), or major and life-threatening (hypotension with or without the need for subsequent hospitalization). Medical records from reactors were compared with those from matched (gender, age, date, and type of contrast study) controls who received conventional contrast media without adverse reaction. RESULTS: Of 34,371 intravenous contrast media procedures performed, 122 anaphylactoid reactions were recorded. The risk of anaphylactoid reaction was significantly associated with asthma (odds ratio [OR], 8.74; 95% confidence interval [CI], 2.36 to 32.35; P = .0012). The risk of bronchospasm was associated with beta-blocker exposure (OR, 3.73; 95% CI, 1.18 to 11.75; P = .025) and with asthma (OR, 16.39; 95% CI, 4.30 to 62.46; P = .0001). The risk of major and life-threatening reaction was associated with the presence of cardiovascular disorder (OR, 7.71; 95% CI, 1.04 to 57.23; P = .046). Among patients with severe reactions, the risk of hospitalization was elevated by the presence of cardiovascular disorder (P = .001), exposure to beta-blockers (OR, 7.67; 95% CI, 1.79 to 32.85; P = .029), or asthma (OR, 20.7; 95% CI, 1.21 to 355.55; P = .065). Although beta-blocker exposure and the presence of cardiovascular disorder were highly associated (chi 2 = 49, P < .001), a greater risk of bronchospasm with severe reaction was observed in nonasthmatic patients with cardiovascular disorders receiving beta-blockers (OR, 15.75; P = .023). Among reactors with asthma, receiving beta-blockers, or with a cardiovascular disorder, 60.8% (31/51) experienced severe anaphylactoid reactions, compared with 35.2% (25/71) of patients without these risk factors (OR, 3.62; P = .005). CONCLUSIONS: beta-Blocker exposure and cardiovascular disorder are both statistically significant risk factors for severe anaphylactoid reaction from contrast media. Thus, patients receiving beta-adrenergic blockers and patients with asthma, on the basis of greater risk for bronchospasm, and patients with cardiovascular disorders, on the basis of elevated risk of major and life-threatening reaction, are appropriate target populations for risk reduction measures before receiving intravenous infusion of contrast media.

Adrenergic beta-Antagonists↗

PubMed1997

Cardiovascular events and correlates in the Veterans Affairs Diabetes Feasibility Trial. Veterans Affairs Cooperative Study on Glycemic Control and Complications in Type II Diabetes.

BACKGROUND: The risks and benefits of intensive therapy in non-insulin-dependent diabetes mellitus (NIDDM) need to be defined. In preparation for a long-term trial, a feasibility study of 153 men in 5 medical centers compared standard vs intensive insulin therapy. OBJECTIVE: To assess the rate of development of new cardiovascular events and their correlates. METHODS: Patients with a mean +/- SD age of 60 +/- 6 years and diagnosis of NIDDM for 7.8 +/- 4.0 years were randomly assigned to a standard (1 insulin injection every morning) or to an intensive treatment arm (stepped plan from 1 evening injection of insulin, alone or with glipizide, to multiple daily injections) designed to attain near-normal glycemia levels. A 2.07% separation of glycosylated hemoglobin (HbA1c) was sustained for a mean follow-up of 27 months (P < .001). Predefined cardiovascular events were assessed by a committee unaware of treatment assignment. RESULTS: Mild and moderate hypoglycemic events were more frequent in the intensive than in the standard treatment arm (16.5 vs 1.5 per patient per year, respectively). Mean insulin dose was 23% lower in the standard treatment arm (P < .001). There were 61 new cardiovascular events in 24 patients (32%) in the intensive treatment arm and in 16 patients (20%) in the standard treatment arm (P = .10). There was no difference in total and cardiovascular mortality (n = 5 and n = 3 in the intensive and standard treatment arms, respectively) or in new events in patients with cardiovascular history (n = 10 in each arm). In Cox regression analysis, the only significant correlate for new cardiovascular events was previous cardiovascular disease (P = .04). Entering in the analysis any baseline cardiovascular abnormality, the regression model indicated a lower HbA1c level prior to the event as the only correlate for new cardiovascular events (P = .05). CONCLUSION: A long-term prospective trial is needed to assess the risk-benefit ratio of intensive insulin therapy for NIDDM in patients who require it.

Aged↗

PubMed2026

Adverse pregnancy outcomes and long-term cardiovascular disease risk.

Pregnancy provides a unique physiological stress test for the cardiovascular system, during which, adverse pregnancy outcomes (APOs) can unmask latent susceptibility to future disease. Common complications, including hypertensive disorders of pregnancy (HDP), gestational diabetes, and preterm birth (delivery before 37 weeks' gestation), identify women at substantially higher long-term risk of cardiovascular morbidity and mortality compared with women without a history of APOs. These excess risks likely reflect the combined effects of pre-existing cardiometabolic and genetic susceptibility, as well as the haemodynamic and metabolic stressors of pregnancy, heralding accelerated risk factor trajectories, relative impairment in endothelial and microvascular function, and early disease onset. This final Review in the Series extends the focus from cardiovascular disease during pregnancy and HDP to the long-term cardiovascular implications of APOs after delivery. We synthesise epidemiological data quantifying cardiovascular risk across major APO phenotypes and emerging evidence linking maternal APO history with cardiometabolic risk trajectories in offspring. We also delineate putative mechanistic pathways and summarise guidelines and consensus-informed recommendations for short-term and long-term follow-up after APOs. Finally, we propose practical approaches for integrating APO history into cardiovascular disease risk assessment and guideline-directed prevention across the female life course. We highlight key knowledge gaps, including uncertainty about optimal follow-up models, the limitations of current risk-stratification tools, and the absence of APO-specific prevention trials. We also outline priorities for mechanistic and implementation research. Positioning APOs as early, sex-specific indicators of cardiovascular risk offers a key window of opportunity to shift prevention upstream and improve cardiovascular health outcomes for women.

Humans↗

PubMed2006

Increased case fatality rates following a first acute cardiovascular event in patients with rheumatoid arthritis.

OBJECTIVE: Among patients with rheumatoid arthritis (RA), cardiovascular mortality is increased compared with the rate among unaffected peers. In this study, 30-day mortality rates following a first acute cardiovascular event (myocardial infarction or stroke) were compared between RA patients and the general population. METHODS: All cases of a first acute cardiovascular event between July 1, 2001 and November 30, 2003 in Victoria, Australia were identified from hospital discharge data. Individuals were classified as having RA when an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification code for RA was recorded at the index admission or during the previous 5 years. Thirty-day mortality rates were determined from linkage to the state death registry. RESULTS: A total of 29,924 patients experienced a first cardiovascular event during the study period, 359 (1.2%) of whom had RA. Thirty-day cardiovascular mortality was 17.6% in RA patients versus 10.8% in non-RA patients. In fully adjusted models, the odds ratio (OR) for cardiovascular death in RA patients following a first acute cardiovascular event was 1.6 (95% confidence interval [95% CI] 1.2-2.2). Analysis of index event subgroups revealed that this increased case fatality rate in patients with RA was accounted for almost entirely by excess deaths following myocardial infarction. The adjusted ORs for cardiovascular death in RA after myocardial infarction and stroke were 1.9 (95% CI 1.3-2.7) and 1.2 (95% CI 0.7-2.0), respectively. CONCLUSION: RA patients have a substantially increased risk of 30-day case fatality following myocardial infarction, but not stroke, compared with non-RA patients. This higher case fatality rate is likely to contribute to the observed overall excess of cardiovascular deaths in RA populations.

Aged↗