Dyslipoproteinemia in women and the elderly

Utilization of lipid-lowering drugs in men and women. a reflection of the research evidence?

This study analyzes the utilization of statin lipid-lowering drugs in a Canadian province using a population-wide drug prescription database. The utilization pattern is compared to the results of a systematic review of randomized controlled trials on their effectiveness. The study found that 74.7% of individuals prescribed a statin had no reported history of coronary heart disease (CHD). Women without CHD formed 23.1% of statins recipients; 32.9% of individuals filling a statin prescription were age 70 and over. Only 15.3% of men with CHD had been prescribed a statin. Based on the systematic review, 88.7% of the utilization of statins in this Canadian province was not supported by the results of the systematic review. Considering baseline lipid-levels does not substantially alter these findings. This study concludes that statins prescribing practices need to be realigned with research evidence. This implies refocusing utilization away from women and the elderly, towards men with CHD.

Weak effect of hypertension and other classic risk factors in the elderly who have already paid their toll

The aim of the CASTEL, a population-based (n=3282) prospective study which began 14 years ago, was to identify those items which had a prognostic impact in the elderly, and to evaluate whether the typical cardiovascular risk factors, particularly arterial hypertension, play a role after the age of 65 years. Initial screening, final follow-up and annual detection of mortality were performed. Mantel-Hanszel approach and multivariate Cox model were used for statistics. Cardiovascular mortality was 23.3% in normotensive, 23.3% in borderline, and 25% in the sustained hypertensive subjects (insignificant difference). In women, the incidence of stroke and coronary artery disease weakly depended on pulse pressure. Historical stroke and myocardial infarction predicted cardiovascular mortality in women; diabetes, uricaemia and high heart rate in men. In the very old, the predictors were less numerous, and blood pressure was not a predictor whatsoever; pulse blood pressure and murmurs at the neck were especially predictive in women, historical heart failure, proteinuria and tachycardia in men, historical stroke and myocardial infarction, pulmonary disease, left ventricular hypertrophy, diabetes and uricaemia in both genders. The elderly have a different cardiovascular risk pattern compared to younger people. Hypertension is not a predictor of coronary and stroke mortality. Prognosis depends on pulse pressure rather than on the label 'hypertension'. Hypercholesterolaemia is not a risk factor. This could simply indicate that elderly persons are the survivors in a population where significant mortality has already made its mark, eliminating those with the worst risk pattern. The two genders have a different risk profile due to sex-specific susceptibility to risk factors.

[Cholesterolemia control in Spain, 2000: a tool for cardiovascular disease prevention]

The document "Cholesterolemia control in Spain, 2000: a tool for cardiovascular disease prevention" reviews the current evidence on cardiovascular disease prevention and the therapeutic advances achieved in recent years, in order to aid risk-based clinical decision-making. Cardiovascular diseases rank as the first cause of death in Spain. Their demographic, health and social impact is increasing and it is likely to continue to do so in the next decades. Appropriate treatment for high blood cholesterol and other major risk factors is crucial in cardiovascular disease prevention. Individual risk stratification is essential to determine follow-up periodicity and treatment. Priorities for the control of cholesterolemia and the consequent cardiovascular risk are based on risk stratification. In primary prevention, the therapeutic objective in high risk patients has been established as LDL-cholesterol < 130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterol > or = 130 mg/dl and the therapeutic objective is LDL-cholesterol < 100 mg/dl. Statins are first line drugs for treatment of high blood cholesterol. In moderate-severe hypertriglyceridemia or low HDL-cholesterol, fibrates are preferred. In acute coronary syndrome, hypolipemiant treatment, should be started as soon as possible, when indicated. Secondary prevention programmes that continually provide good clinical and risk factor control should be provided to coronary heart disease patients.

[Control of cholesterolemia in Spain, 2000. A tool for cardiovascular prevention]

The document "Cholesterolemia Control in Spain, 2000: A Tool for Cardiovascular Disease Prevention" reviews the current evidence on cardiovascular disease prevention and the therapeutic advances achieved in recent years, in order to aid risk-based clinical decision-making. Cardiovascular diseases rank as the first cause of death in Spain. Their demographic, health and social impact is increasing and it is likely to continue to do so in the next decades. Appropriate treatment for high blood cholesterol and other major risk factors is crucial in cardiovascular disease prevention. Individual risk stratification is essential to determine follow-up periodicity and treatment. Priorities for the control of cholesterolemia and the consequent cardiovascular risk are based on risk stratification. In primary prevention, the therapeutic objective in high risk patients has been established as LDL-cholesterol < 130 mg/dl. In secondary prevention, drug treatment is indicated when LDL-cholesterol > or = 130 mg/dl and the therapeutic objective is LDL-cholesterol < 100 mg/dl. Statins are first line drugs for treatment of high blood cholesterol. In moderate-severe hypertriglyceridemia or low HDL-cholesterol, fibrates are preferred. In acute coronary syndrome, hypolipemiant treatment, should be started as soon as possible, when indicated. Secondary prevention programmes that continually provide good clinical and risk factor control should be provided to coronary heart disease patients.

Gender differences in the presentation of adult obstructive hypertrophic cardiomyopathy with resting gradient: a study of 122 patients

The present study investigated gender differences among adult patients with obstructive hypertrophic cardiomyopathy (OHCM) and resting gradient. Using outflow gradients >10 mmHg and the presence of asymmetrical septal hypertrophy of the left ventricle as inclusion criteria, 122 patients were identified among patients referred for echocardiographic examinations between May 1990 and October 1996. Clinical, echocardiographical and follow-up data were compared between male and female patients. The female patients were significantly older than male patients (mean age +/-SD 66.7+/-10.5 vs 54.8+/-12.5 years). The female patients had a smaller interventricular septal wall thickness, less frequent systolic anterior movement of the mitral valve, more frequent association with hypertension, and less frequent association with ischemic heart disease (IHD) and giant T wave inversion. In this study population, adult female patients presented with OHCM 12 years later than males. Whether this represents female patients' reluctance to seek medical attention early, a different disease process that affects predominantly elderly females, or a gender-specific end organ response to aging, hypertension, IHD and other processes, or the protective effects of estrogen remains to be determined.

Cardiovascular risk factors and behavior lifestyles of young women: implications from findings of the Bogalusa Heart Study

The primary purposes of this article are to highlight important issues related to cardiovascular risk factors and behavior life-styles in young women and to examine racial (black-white) differences in risk factors that relate to cardiovascular disease. In childhood, some girls show cardiovascular risk factors of higher blood pressure levels, dyslipidemia, and obesity, all of which continue into young adulthood. Factors that contribute to abnormal risk factors are a high-saturated fat diet, excess energy intake related to inactivity, and cigarette smoking. Trends of obesity are documented; and young white girls are continuing to use tobacco, more so than boys and black girls. Although the onset of clinical cardiovascular disease is delayed in women, the stage is set in childhood for the development of early cardiovascular risk.

Carotid endarterectomy in women versus men: patient characteristics and outcomes

PURPOSE

To examine and compare the results of carotid endarterectomy in women and men in a single-group experience.

METHODS

A review of a consecutive series of 426 carotid endarterectomy procedures performed over an 11-year period.

RESULTS

Women and men who underwent carotid endarterectomy were remarkably similar in nearly all characteristics except that women were less likely to have clinically overt coronary artery disease. Women were more likely than men to undergo patch closure of the carotid artery, but details of surgery and hospital stay were otherwise similar. A trend toward higher perioperative stroke risk in women was not significant, and late ipsilateral stroke risk was comparable in women and men. Women enjoyed a better late survival rate, presumably related to their lower prevalence of coronary artery disease.

CONCLUSIONS

Women enjoyed similarly low risks of perioperative and late stroke and a better long-term survival rate when compared with men who underwent carotid endarterectomy. Further experience and longer follow-up in prospective randomized trials may provide more definitive information regarding the comparative efficacy of carotid endarterectomy in women and men, but our results suggest that absolute results are similar and excellent in both women and men.

Recent trends in the consumption of lipid-lowering drugs in Finland

The consumption of lipid-lowering drugs in Finland and in other Nordic countries increased almost steadily in 1988-1993. The exceptions were the year 1992 in Finland and 1993 in Iceland, when consumption was lower than in the previous year. In both cases the temporary decline in consumption was associated with a reduction in reimbursement for the costs of lipid-lowering drugs. In 1993, the consumption level was 2.7 defined daily doses/1000 inhabitants/day in Finland and ranged from 2.3 to 4.0 in other Nordic countries. According to the Finnish nationwide prescription register, 0.5% of men and 0.6% of women purchased lipid-lowering drugs in the period from January to September, 1994. The rate of use was highest among people of middle age. In the early 1990s, statins took the lead in the consumption of lipid-lowering drugs, accounting for 70% of prescriptions in 1993; the percentages of fibrates, resins, and nicotinic acid derivatives declined in the same period. In 1994 the prevalence of familial hypercholesterolemia (FH) according to strictly predetermined criteria was 0.8 per 1000 among Finns, and the proportion of FH patients among all users of lipid-lowering drugs was 11%. The use of lipid-lowering drugs is not particularly high in Finland and seems to be reasonably targeted.

Cardiovascular risk screening for women

Cardiovascular disease is the leading cause of death of both men and women in Canada and the United States. The medical and societal emphasis on the occurrence of cardiovascular disease in men has resulted in an inclination to minimize its existence and severity in women. The purpose of this article is to assist clinical nurse specialists in cardiovascular risk-screening of women by providing a review of cardiovascular risk factors specific to women. Current knowledge about lipids, hypertension, diabetes, smoking, menopause, obesity, sedentary lifestyle, stress, and multiple roles are discussed. The clinical presentation for women and the clinical implications are presented. Lastly, implications for future research are described.

Unresolved issues in early trials of cholesterol lowering

A reexamination of early intervention trials in patients with coronary artery disease (CAD) shows that a pessimistic view of cholesterol reduction in such patients is inappropriate. In observational studies, individuals with documented coronary artery disease and elevated cholesterol levels fare worse than individuals with normal or low cholesterol levels. Early trials of cholesterol reduction in individuals with coronary artery disease succeeded in lowering total cholesterol levels by only 5-15%. Nevertheless, when reviewed in meta-analysis, these trials demonstrated borderline effects on total mortality, statistically significant benefits in terms of morbidity and mortality due to cardiovascular disease and CAD, and no increase in mortality from noncardiovascular causes. Substantially greater lowering of low density lipoprotein (LDL) levels was achieved in early regression studies. In these studies, examples of improvement were noted in individual coronary artery segments. What was not appreciated initially was the dramatic reduction in coronary events. Older secondary prevention trials did not definitively address the benefits of cholesterol reduction in individuals whose cholesterol levels were only modestly elevated (total cholesterol, 160-240 mg/dl [4.14-6.21 mmol/liter], and LDL cholesterol levels 100-160 mg/dl [2.59-4.14 mmol/liter]). Several other issues were not addressed in these early studies, including the effect of declines in triglyceride levels, increases in high density lipoprotein (HDL) levels, and the effects in women and individuals aged > 60 years. Even with these limitations, a comparison of meta-analyses of other medical interventions--i.e. beta blockade and aspirin therapy--indicates that declines in coronary mortality are in the same range as obtained in older studies with modest cholesterol reduction--i.e., 20-25%.(ABSTRACT TRUNCATED AT 250 WORDS)