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PubMed2006

PHARMAC and the statin debacle.

Statins are lipid-modifying drugs which dramatically lower the total and low-density lipoprotein cholesterol levels and have been shown in large clinical trials to reduce the rate of vascular events, including heart attacks, strokes, and death. For every 1% reduction in the LDL cholesterol level, the relative risk for major coronary heart disease events is reduced by approximately 1%. Since the landmark Scandinavian Simvastatin Survival Study (4S) was published in 1994, multiple further clinical trials have reinforced the benefits of treating large numbers of patients with statins with the emphasis on achieving low LDL cholesterol levels (currently 1.6 mmol/L) for the optimal management of patients at very high risk. However PHARMAC's actions since statins were first available have significantly impaired the optimal management of New Zealand patients. A review of the methods employed during the statin era is a useful exercise in understanding how PHARMAC functions and emphasises the point that rather than achieving low-cost prices for drugs, PHARMAC simply impedes the timely delivery of modern medicines to New Zealand patients.

Drug Evaluation↗
PubMed2006

Health literacy: how visuals can help tell the healthcare story.

Herb, a 66-year old general contractor, had a major heart attack five years ago. His doctor performed an emergency coronary angiography to examine the blood vessels and chambers of his heart. After the procedure, Herb's doctor gave him a simple line drawing of the heart and arteries. She then coloured in where each artery was blocked and wrote alongside how much each was occluded. Seeing so clearly what was wrong, Herb readily agreed to participate in a cardiac rehabilitation program and change his diet and exercise habits. He did so well that he was asked to speak with other patients who had just been diagnosed with cardiovascular disease. To Herb's surprise and disappointment, not one of the more than 100 people he spoke with had ever been given a 'heart picture' like his. Herb often hears people say how these types of drawings could have helped them better understand their diagnosis and treatment recommendations.1.

Humans↗
PubMed2005

Regional variation in self-reported heart disease prevalence in Canada.

BACKGROUND: Cardiovascular disease is the leading cause of death in Canada. OBJECTIVE: To provide an analysis of the self-reported prevalence of heart disease and three specific cardiac conditions--myocardial infarction (MI), angina and congestive heart failure (CHF)--in subgroups of the Canadian population. METHODS: Data from the Public Use Microdata File from Statistics Canada's 2000/2001 Canadian Community Health Survey (CCHS) were used to estimate the crude self-reported prevalence of heart disease, MI, angina and CHF in Canada. The data are reported by age and sex groups, as well as by province or territory and health region. RESULTS: Based on the 2000/2001 CCHS data, it was estimated that among Canadians 12 years of age and older, 5.0% (n=1,286,000) have heart disease, 2.1% (n=537,000) have had a heart attack, 1.9% (n=483,000) have angina and 1.0% (n=264,000) have CHF. Marked variation in the prevalence of heart disease and the other specific cardiac conditions exists across age and sex groups, and across geographical regions. The prevalence of heart disease is low among those younger than 50 years; thereafter, the prevalence of heart disease increases and is more common among men than among women. By 70 years of age, at least one in four men and one in five women report having heart disease. Large differences in the burden of heart disease were observed across provinces, territories and health regions. Comparison of the highest and lowest prevalence rates among provinces and territories revealed a 1.9-fold difference for heart disease, a 2.8-fold difference for MI, a 2.3-fold difference for angina and a 3.3-fold difference for CHF. CONCLUSIONS: Large regional differences in the prevalence of heart disease and other specific cardiac conditions were observed across Canada. These data may assist health system planners to identify those regions and population subgroups most affected by heart disease, and to support the development of heart disease prevention and treatment programs.

Adolescent↗
PubMed1987

Electrocardiographic abnormalities and coronary heart disease mortality among hypertensive men in the Multiple Risk Factor Intervention Trial.

The Multiple Risk Factor Intervention Trial (MRFIT) was a primary prevention trial involving 12,286 middle-aged men at high risk of future heart attack, about two-thirds of them considered hypertensive at entry. The mortality results suggested an increased risk of coronary heart disease (CHD) death, particularly sudden death, possibly associated with hypertension control, following a stepped-care protocol including diuretics, among hypertensive MRFIT special-intervention (SI) participants with abnormalities in their rest ECG. No such adverse association was evident in the usual care (UC) group. ECG data from the Dalhousie ECG program revealed that for nearly every ECG abnormality considered, the risk of CHD death for hypertensive SI men was greater than for hypertensive UC men. The exception to this was ischemic response to exercise, for which the associated relative risk for UC men was 2.96 and for SI men 1.35 (p = 0.03 for SI/UC difference). The risk of CHD death for SI men with any ECG abnormalities compared to those without ECG abnormalities was 3.30. For UC men the corresponding relative risk was 1.22 (p = 0.03 for difference in relative risk). The results suggest that the influence of the presence of ECG abnormalities on the response to hypertension intervention may be heterogeneous, in that certain abnormalities (particularly repolarization abnormalities at rest, and absent or low-amplitude U waves at rest and in post-exercise ECG) may be associated with an adverse response or reduced effectiveness of hypertension intervention, whereas an ischemic ST response to exercise may be associated with a beneficial response to intensive hypertension control efforts.

Adult↗
PubMed1985

Population risk of cardiovascular disease: the Minnesota Heart Survey.

A decline in age-adjusted ischemic cardiovascular disease mortality has been observed in the United States during the past two decades. Among the leading explanatory hypotheses is improvement in the major known risk factors for heart attack and stroke in the general population, specifically hypertension, smoking, and lipid levels. To better understand risk factor trends, the Minnesota Heart Survey (MHS) began systematic risk factor surveys of the Minneapolis-St Paul population in 1980, (population 1.99 million). The metropolitan area was divided into 704 subareas (clusters) of approx. 1000 households each, utilizing geographic boundaries. In a two-stage cluster sampling technique, 40 subareas were randomly chosen and mapped. Approximately 8.75% of households were chosen from each subarea and selected residents age 25-74 years invited to participate. A total 4451 individuals participated in 1980-82. The response rate for a home interview was 81.9 and 84.4% for a subsequent survey center visit, producing an overall response of 69.1%. The age and sociodemographic characteristics of the survey participants were similar to those found in the 1980 census. The prevalence of hypertension was 18.3% in this population with 76.0% taking medications and 65.0% controlled. Total cholesterol and HDL-cholesterol levels demonstrated age and sex differences similar to those reported elsewhere. Current smoking of cigarettes was equally prevalent in men (34.5%) and women (33.5%) although more men were former smokers (35.2 vs 20.6%). Comparison of the MHS with the National HANES II data (1976-80) indicates lower regular cigarette smoking among Minnesota males, with similar rates in females. Minnesota residents had better control of high blood pressure.

Adult↗
PubMed2000

The natural history of prevalent ischaemic heart disease in middle-aged men.

OBJECTIVE: To describe the long-term outcome of different forms of symptomatic and asymptomatic ischaemic heart disease in middle-aged men. METHODS: 7735 men aged 40-59, randomly selected from 24 general practices in Britain were classified into one of seven ischaemic heart disease groups according to a questionnaire and electrocardiogram (ECG): I=diagnosed myocardial infarction; II=unrecognized myocardial infarction; III= diagnosed angina; IV=angina symptoms; V=possible myocardial infarction symptoms; VI=ECG ischaemia or possible myocardial infarction; VII=no evidence of ischaemic heart disease. The association of disease group with a range of fatal and non-fatal outcomes during 15 years of follow-up was assessed. RESULTS: At baseline 25% of men had evidence of ischaemic heart disease (groups I-VI). Risks of major ischaemic heart disease events, total and cardiovascular mortality, stroke, and major cardiovascular events tended to increase strongly from group VII to I. Diagnosed myocardial infarction was associated with a much poorer prognosis than all other groups (including unrecognized infarction) for all cardiovascular outcomes other than stroke. The relative risk associated with ischaemic heart disease at baseline declined dramatically over time. However, men with myocardial infarction who survived event-free for 10 years continued to experience a high excess risk in the subsequent 5 years, in contrast to event-free survivors of angina and other ischaemic heart disease. Adjusted to an average age of 50, the percentage of men surviving for 15 years free of a new major cardiovascular event was 44 for diagnosed myocardial infarction, 52 for unrecognized myocardial infarction, 66 for diagnosed angina, 68 for angina symptoms, 73 for possible myocardial infarction symptoms, 73 for ECG ischaemia, and 79 for no ischaemic heart disease. Comparison of outcome between prevalent and incident myocardial infarction illustrated the improved prognosis of men surviving the initial years after their event. CONCLUSIONS: Differing manifestations of prevalent ischaemic heart disease are associated with widely differing outcome, and the majority of middle-aged men in the community who have evidence of ischaemic heart disease short of myocardial infarction survive for 15 years without heart attack or stroke. The excess risk associated with myocardial infarction appears more persistent than that associated with angina and other ischaemic heart disease, remaining high even after 10 years of event-free survival.

Adult↗
PubMed1995

Estrogens and progestins in postmenopausal women: influence on lipid parameters and cardiovascular risk.

Postmenopausal women are 2-3 times more likely to have a heart attack than premenopausal women. According to the results of the Framingham study, angina is one of the main manifestations of coronary heart disease in women, whereas myocardial infarction and sudden death are more frequent in men. Cigarette smoking, high blood pressure and hypercholesterolemia are major risk factors for coronary heart disease in both men and women, while diabetes mellitus and hypo-high-density lipoproteinemia are more clearly associated with cardiovascular disease in women than in men. Endogenous and exogenous hormones may be a major determinant of the cardiovascular risk in women. Premenopausal women have a considerably lower incidence of coronary heart disease than postmenopausal women, and estrogen therapy is associated with a reduced risk in the latter. Part of this protective effect seems to be due to the influence of estrogen therapy on lipoprotein metabolism, i.e. a decrease in LDL cholesterol and an increase in HDL cholesterol. Progestins, to an extent which depends on their androgenic potency, have the opposite effects. A large study (the Postmenpausal Estrogen Progestin Intervention Trial) has been launched to test the effect of the estrogen-progestin combination on various cardiovascular risk factors.

Cardiovascular Diseases↗
PubMed2000

Implications of recent hypertension trials for the generalist physician: whom do we treat, and how?

The publication of the results of the Swedish Trial in Old Patients with Hypertension-2 (STOP-2) and the termination of the doxazocin arm of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack (ALLHAT) study again raise the question of whether all antihypertensives deliver equal cardiovascular outcome benefits. Data from research on congestive heart failure and from the Heart Outcomes Prevention Evaluation (HOPE) trial illuminate the roles and possible mechanisms of humoral mediators of vascular damage, suggesting, first, that some antihypertensives (thiazides, beta-blockers, and angiotensin-converting enzyme inhibitors) can deliver more improvement in outcomes than other agents and, second, that decisions on whom to treat are best made based on risk appraisal, not merely pressures.

Journal Article↗
PubMed2001

Myocardial regeneration: present and future trends.

Cardiomyocytes are terminally differentiated and are unable to proliferate in response to injury. Genetic modulation, cell transplantation and tissue engineering promise a revolutionary approach for myocardial regeneration and tissue repair after myocardial injury. Current data derived from animal models suggest that it may be possible to treat heart failure by inserting genetic materials or myogenic cells into injured myocardium. Success with animal models has raised the hope for new treatment after heart attacks and could prove an alternative to transplantation, particularly in elderly patients for whom there is often a lack of donor hearts. This exciting research, however, still faces significant difficulties before it can develop into a clinical therapeutic tool and many challenges need to be overcome before cell transplantation, gene therapy and tissue engineering can be considered efficient, therapeutic strategies for myocardial regeneration.

Animals↗
PubMed1976

Physiological variables during 10 years of endurance exercise.

The reported decline in Physical Working Capacity (PWC) max is from 9-15 percent during the ages of 45 to 55 years. The use of vigorous physical activity to prevent this decline and to possibly protect against fatal myocardial infarction has been suggested. The purpose of this study was to investigate the effect of an endurance type exercise program on the maximal PWC of middle-aged men during a 10 year span. Sixteen men, initially 32-56 years (M-44.6), were trained with running or swimming at an intensity above 60 percent of VO2 max during a 10 year period. The average weekly running distance was 15 miles (25 km). The criterion for PWC was directly measured VO2 using the Douglas Bag/Scholander technique. No changes were observed in body weight, resting heart rate (HR), or resting blood pressure (BP). Maximal HR declined 7 beats per minute in 10 years. Pulmonary ventilation (STPD) increased approximately 18 percent. Mean VO2 max was essentially unchanged, 3.376 and 3.303 1/min STPD. VO2 max related to body weight was 43.7 initially and 44.4 ml/min-kg after 10 years. It was concluded that the usual 9-15 percent decline in PWC or VO2 max from age 45 to 55 years can be forestalled by regular endurance exercise. The results may have implications for protecting against heart attacks.

Adult↗
PubMedDate not supplied

Cognition-behaviour links in the persistence of panic.

The cognitive theory of panic disorder proposes that panic attacks occur as a result of an enduring tendency to misinterpret bodily sensations as a sign of imminent catastrophe such as a heart attack. The persistence of such catastrophic cognitions is in part due to the tendency of patients to avoid and/or escape situations where panic occurs. It is proposed that within-situation safety seeking behaviours also have the effect of maintaining catastrophic cognitions in the face of repeated panics during which the feared catastrophe does not occur. The association between catastrophic cognitions and within-situation safety behaviours matched the pattern predicted from the cognitive theory in 147 panic disorder patients. The implications of these findings for the way in which therapy is conducted are discussed.

Agoraphobia↗
PubMed1980

Is diet an essential risk factor for coronary heart disease?

Cigarette smoking, hypertension and diet each play a major role in the development of coronary heart attacks in most industrialized nations. In some countries where cigarette smoking and hypertension are prevalent there is a low risk of coronary heart disease (CHD). Hyperlipidaemia resulting from national food habits appears to be the essential factor in the high rates of CHD in developed countries.

Adult↗
PubMed2002

Current recommendations for the treatment of hypertension: are they still valid?

Recent trials have helped to clarify indications for the initial pharmacological therapy of hypertension. Both the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and World Health Organization-international Society of Hypertension (WHO-ISH) recommendations should be revised. The more recent trials indicate that: (1) diuretics and beta-blockers appear to be as effective in reducing overall morbidity/ mortality as other agents (Swedish Trial in Old Patients with Hypertension [STOP-2], United Kingdom Prospective Diabetes Study [UKPDS], Intervention as a Goal in Hypertension Treatment [INSIGHT], Nordic diltiazem [NORDIL]); (2) the use of an a-blocker results in more cardiovascular events, especially congestive heart failure, when compared with a diuretic (Antihypertensive Therapy and Lipid Lowering Heart Attack Trial [ALLHAT]); (3)the use of an angiotensin-converting enzyme (ACE) inhibitor results in fewer myocardial infarctions and episodes of heart failure than calcium channel blockers in the elderly and in diabetic patients (Fosinopril vs. Amlodipine Cardiovascular Events Randomized Trial [FACET], Appropriate Blood Pressure Control in Diabetes [ABCD], STOP-2) - other data (Captopril Prevention Project [CAPPP]) suggest that the use of an ACE inhibitor is preferred in diabetic patients; (4) overall cardiovascular events are similar with calcium channel blockers compared with a diuretic - however, there are fewer strokes with non-dihydropyridine calcium channel blockers (NORDIL) and a trend towards an increase in heart failure and myocardial infarctions with either a dihydropyridine or non-dihydropyridine calcium channel blockers compared with a diuretic (INSIGHT, NORDIL); (5) angiotensin receptor blockers (ARBs) will decrease proteinuria and slow progression of renal disease in type 2 diabetic patients when compared with regimens that do not include an ARB or an ACE inhibitor (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan [RENAAL], Irbesartan Type II Diabetic Nephropathy Trial [IDNT], Irbesartan Type II Diabetes with Microalbuminuria [IRMA Il]). The debate over initial therapy may be moot. High-risk hypertensive patients should probably be treated initially with combination therapy, one of which should be a diuretic. The use of diuretics and beta-blockers as well as ACE-inhibitors alone or with a diuretic should be considered as initial therapy (a change from JNCVI). Alpha-blockers should be reserved for special situations, i.e. prostatic hypertrophy (in contrast to WHO-ISH recommendations). An ACE-inhibitor or ARB, usually along with a diuretic, can be considered as preferred therapy in hypertensive diabetic patients. Some data suggest equal or greater reduction in strokes with a calcium channel blocker than other medications.

Antihypertensive Agents↗
PubMed1996

Wearing an abdominal belt increases diastolic blood pressure.

The purpose of this study was to determine the effect of wearing an abdominal belt on blood pressure (systolic and diastolic) and heart rate during a variety of tasks. The belt was typical of the elastic type with suspenders and Velcro tabs for cinching the belt snug. The tasks performed included sitting at rest, sitting with the torso inclined forward at 45 degrees, standing with the torso inclined forward at 45 degrees (with and without holding an 11-kg weight), a trunk axial rotation task, and squat lifting. Blood pressure was monitored noninvasively with a FINAPRES blood pressure monitor. Twenty healthy men performed each task with and without the abdominal belt. Although no significant increases in mean systolic blood pressure or heart rate were found, there was a significant increase in diastolic blood pressure in all conditions. All people considering wearing an abdominal belt should also consider the risks and liability associated with the additional cardiovascular load, particularly heart attack and stroke.

Adult↗
PubMed2003

Opposing roles of delta and epsilonPKC in cardiac ischemia and reperfusion: targeting the apoptotic machinery.

Heart attacks, or acute myocardial infarctions (AMI), affect more than one million people in the US every year. The damage that occurs to the heart by AMI is often permanent and as a result, the morbidity and mortality rates of patients that experience AMIs continue to be high. Consequently, AMI patients are at significantly increased risks for future myocardial infarctions, decreased heart function, heart failure, and death [Heart and Stroke statistical update. In American Heart Association (2002) 4]. In this review, we discuss the events that lead to cardiac damage by AMI. Specifically, we discuss the current understanding of the role of ischemic damage vs. reperfusion damage, which is induced by the return of blood, oxygen, and nutrients to the organ. We also discuss the role of apoptosis and necrosis in cardiac damage, the means to protect the heart from damage by ischemia and reperfusion, and the role of protein kinase C in these processes.

Animals↗
PubMed1975

The diving reflex used to treat paroxysmal atrial tachycardia.

Induction of the diving reflex, by immersion of the face in cold water (2 degrees C) while the breath was held, converted paroxysmal atrial tachycardia to sinus rhythm within 15-35 seconds in seven patients (aged 22-66). Four had histories of heart attacks that had previously required vasopressor therapy, and two had been digitalised; three had no history of prior paroxysmal atrial tachycardia or heart-disease. The reported procedure, which is convenient, non-invasive, and can be self administered by the patient after brief instruction, may offer a useful adjunct to carotid-sinus massage and intravenous infusion of vasopressors for the treatment of paroxysmal atrial tachycardia.

Adult↗
PubMed2004

Protein kinase Cdelta activation induces apoptosis in response to cardiac ischemia and reperfusion damage: a mechanism involving BAD and the mitochondria.

Heart attacks caused by occlusion of coronary arteries are often treated by mechanical or enzymatic removal of the occlusion and reperfusion of the ischemic heart. It is now recognized that reperfusion per se contributes to myocardial damage, and there is a great interest in identifying the molecular basis of this damage. We recently showed that inhibiting protein kinase Cdelta (PKCdelta) protects the heart from ischemia and reperfusion-induced damage. Here, we demonstrate that PKCdelta activity and mitochondrial translocation at the onset of reperfusion mediates apoptosis by facilitating the accumulation and dephosphorylation of the pro-apoptotic BAD (Bcl-2-associated death promoter), dephosphorylation of Akt, cytochrome c release, PARP (poly(ADP-ribose) polymerase) cleavage, and DNA laddering. Our data suggest that PKCdelta activation has a critical proapoptotic role in cardiac responses following ischemia and reperfusion.

Animals↗
PubMedDate not supplied

The purpose at the heart of management.

To succeed, startup enterprises need both passion and good management. But entrepreneurs can be famous for their visionary ardor and still be lousy managers. Traditionally, the key to long-term growth is getting the company founder to step aside so professional management can take over. Sometimes, however, this means abandoning a company's greatest asset in order to improve its procedures. A better solution is for the entrepreneur to learn to manage. Kye Anderson had motivation to spare. When she was 13, her 47-year-old father suffered recurrent shortness of breath followed by a massive heart attack. For her, the result was a single-minded career in medical technology and the development of innovative systems for diagnosing heart-and-lung disease. She had the zeal and determination it took to sell her ideas to investors and doctors, found a company, and grow it. But then, on the grounds that she lacked the financial and managerial expertise to carry her business from exuberant adolescence to profitable maturity, she stepped aside. A year and a half later, Anderson came back. She picked new board members who could act as entrepreneurial mentors. She reasserted certain original core values such as the importance of R&D and the emphasis on the patient as the ultimate customer. She discarded business lines that had strayed too far afield, and she learned how and what to delegate. Most important of all, Anderson realized that a leader's greatest obligation is to preach, and she began to spend much of her time communicating with her own employees about the purpose, mission, values, and strategy that could carry the company into a billion-dollar primary-care market.

Administrative Personnel↗