Prevention and regression of coronary atherosclerosis. Is it safe and efficacious therapy?

Keeping the young-elderly healthy: is it too late to improve our health through nutrition?

Healthy older individuals can take several measures to preserve and improve their health. Even if past nutritional and lifestyle practices were not optimal, much can be done to reduce the risk of chronic disease and disability in future years. The first challenge is to recognize and address the profound changes in body composition that occur with aging. Older persons tend to accumulate relatively more body fat and less lean body mass, ie, muscle and bone. With a gain in body weight, which usually occurs, these changes are exaggerated. Because muscle tissue has a much higher metabolic rate than does fat tissue, older individuals generally develop lower metabolic rates. To avoid excess weight gain, older individuals must make major restrictions in caloric intake and increases in energy expenditure. Women experience changes in body composition similar to those in men, with changes becoming more prominent at menopause. Exercise improves body composition among healthy elderly, both by reducing fat mass and by increasing bone and muscle mass, thereby helping to restore higher metabolic rates. In men and women aged >/=65 y and taking calcium and vitamin D supplements for 3 y, the rate of bone loss slowed and the incidence of nonvertebral fractures was reduced. Several population studies of older persons show that following nutritional and lifestyle guidelines for cancer prevention reduces risk by one-third. Improving serum lipid concentrations in adults over 65 y of age with coronary artery disease decreases the risk of future cardiac events by as much as 45%. Furthermore, the greatest benefit from control of hypertension is in older individuals.

Emodin Induces Growth Arrest and Death of Human Vascular Smooth Muscle Cells Through Reactive Oxygen Species and p53

Percutaneous coronary intervention is the main therapy for revascularization of occluded coronary arteries. However, a progressive artery restenosis caused by abnormal proliferation and migration of vascular smooth muscle cells (VSMC) hinders the effective treatment. In this study, we examined the effect of emodin, a natural anthraquinoid compound, on cultured VSMC. Lower doses of emodin suppressed cell proliferation and induced unscheduled DNA synthesis. Higher doses of emodin increased lumpy chromatin condensation and lysosomes in VSMC, suggesting the occurrence of apoptosis and autophagy. Emodin increased production of reactive oxygen species (ROS), which was abolished by an NADPH oxidase inhibitor diphenylene iodonium (DPI). DPI could also decrease the number of apoptosis induced by emodin, suggesting the involvement of ROS in emodin-induced apoptosis. Emodin upregulated the protein levels of p53 in a dose-dependent manner. Laser confocal microscope showed most of emodin scattering in the cytoplasms and a little within the nuclei. These findings collectively indicated that emodin induces both growth arrest and death of human VSMCs in 2 independent manners, implying it as a promising therapy for preventing restenosis.

Economic impact of community pharmacist intervention in cholesterol risk management: an evaluation of the study of cardiovascular risk intervention by pharmacists

The Study of Cardiovascular Risk Intervention by Pharmacists, a randomized, controlled trial in over 50 community pharmacies in Alberta and Saskatchewan, Canada, demonstrated that a pharmacist intervention program improved cholesterol risk management in patients at high risk for cardiovascular disease. In a substudy, costs and consequences were analyzed to describe the economic impact of the program. Two perspectives were taken: a government-funded health care system and a pharmacy manager. Costs were reported in 1999 Canadian dollars. Incremental costs to a government payor and community pharmacy manager were $6.40/patient and $21.76/patient, respectively, during the 4-month follow-up period. The community pharmacy manager had an initial investment of $683.50. The change in Framingham risk function for the intervention group from baseline also was reported. The 10-year risk of cardiovascular disease decreased from 17.3% to 16.4% (p<0.0001) during the 4 months. The intervention program in this study led to a significant reduction in cardiovascular risk in the intervention group during the 4-month follow-up period. The incremental cost to provide the program appeared minimal from both government and pharmacy manager perspectives. It is hoped that these results could support negotiations for reimbursement of clinical pharmacy services with payors.

Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP): a randomized trial design of the effect of a community pharmacist intervention program on serum cholesterol risk

OBJECTIVE

To determine the efficacy of a program of intervention by pharmacists on lipid risk management in patients at high risk for cardiovascular events.

METHODS

Randomized, multicenter (44 sites in Alberta and Saskatchewan) study of community pharmacist intervention versus usual care in 1000 patients. Patients are those at high risk of vascular events (existing atherosclerotic vascular disease, or diabetes with > or = 1 other risk factor). After obtaining consent, the pharmacist calls the Project Office to randomize. Patients allocated to intervention receive a brochure and education about cardiovascular risk factors. Pharmacists also complete a physician contact form, which lists the patient's risk factors, medications, and any recommendations. A point-of-care cholesterol test is performed, the result is discussed with the patient, and it is entered on the contact form. If appropriate, the patient is asked to see his or her primary care physician for further assessment and/or treatment, and the form is faxed to the physician. Patients are followed up at two, four, eight, 12, and 16 weeks. During follow-up visits, pharmacists provide educational reinforcement and check for primary end point occurrence. Patients allocated to usual care receive the brochure only, with minimal follow-up. The primary end point is a composite of measurement of a complete lipid panel by the physician, or addition or modification of lipid-lowering drug therapy. Substudies will evaluate economics (third-party payer and pharmacy manager perspective), patient satisfaction, and quality of life.

CONCLUSIONS

SCRIP (Study of Cardiovascular Risk Intervention by Pharmacists) is a unique ongoing trial that is evaluating a community pharmacist intervention designed to optimize cholesterol risk management in patients at high risk for cardiovascular events.

The treatment and prevention of coronary heart disease in Canada: do older patients receive efficacious therapies? The Clinical Quality Improvement Network (CQIN) Investigators

OBJECTIVES

To review the evidence for clinical efficacy and cost-effectiveness of proven medications in the treatment and prevention of myocardial infarction (MI) in older patients; to summarize Canadian data on treatment patterns and clinical outcomes for younger and older patients with coronary heart disease; to explore the reasons for gaps between best care, based on the evidence of efficacy from trials, and usual care, based on the population effectiveness audits; and to explore potential approaches to closing the care gaps.

DESIGN

Review of the recent clinical trial literature on the management of MI, highlighting results in older patients. Review of medication utilization and outcomes data from a series of large, consecutively enrolled patient cohorts with acute MI (N = 7070) in a variety of cardiac care settings (10 centers in five Canadian provinces, including university-based teaching hospitals, community hospitals, cardiologist and family physician out-patient clinics) from 1987 to 1996.

RESULTS

There is no qualitative interaction of cardiac therapies: thrombolytics, beta-blockers, acetylsalicylic acid (ASA), and statins are efficacious in all clinically relevant patient subgroups, including older people. However, there are consistent gaps between usual care and best care, particularly among older patients (in whom there is also a concomitantly higher mortality risk). Repeated multivariate analyses confirm older age to be an independent contributor to increased risk. Use of efficacious medications is, in contrast, consistently associated with increased survival. Analysis of temporal trends suggests beneficial changes in practice patterns and outcomes are possible to achieve. However, "best care" has not been rapidly or completely achieved. Review of strategies to close these care gaps suggests that audit and feedback, critical pathways, and multifactorial interventions involving patients and other members of the healthcare team as well as physicians may be the most efficacious strategies for change.

CONCLUSIONS

Despite equal or enhanced efficacy, there is consistently less prescription of proven drugs among older cardiac patients. These care patterns may contribute to their enhanced risk. The causes underlying these practice patterns are complex, and their population impact may be undervalued by clinicians and managers. Improvement of these patterns is difficult, but ultimately it would be beneficial for this presently disadvantaged, readily identified, high risk patient population.

Treating patients with documented atherosclerosis to National Cholesterol Education Program-recommended low-density-lipoprotein cholesterol goals with atorvastatin, fluvastatin, lovastatin and simvastatin

OBJECTIVES

This study compared the efficacy and safety of atorvastatin, fluvastatin, lovastatin, and simvastatin in patients with documented atherosclerosis treated to U.S. National Cholesterol Education Program (NCEP) recommended low-density-lipoprotein (LDL) cholesterol concentration (< or = 100 mg/dl [2.59 mmol/liter]).

BACKGROUND

For patients with advanced atherosclerosis, NCEP recommends lipid-lowering drug therapy if LDL cholesterol remains > or = 130 mg/dl (3.36 mmol/liter).

METHODS

A total of 318 men or women with documented atherosclerosis and LDL cholesterol > or = 130 mg/dl (3.36 mmol/liter) and < or = 250 mg/dl (6.5 mmol/liter), and triglycerides < or = 400 mg/dl (4.5 mmol/liter) participated in this 54-week, multicenter, open-label, randomized, parallel-group, active-controlled, treat-to-target study. Patients were titrated at 12-week intervals until the LDL cholesterol goal was reached. Number of patients reaching target LDL cholesterol levels and dose to reach target were evaluated.

RESULTS

At the starting doses, atorvastatin 10 mg produced significantly greater decreases (p < 0.05) in plasma LDL cholesterol than the other treatments. Subsequently, the percentage of patients reaching goal at the starting dose was 32% for atorvastatin, 1% for fluvastatin, 10% for lovastatin and 22% for simvastatin. Atorvastatin-treated patients required a lower median dose than other treatments. Median doses at week 54 with the last available visit carried forward were atorvastatin 20 mg/day, fluvastatin 40 mg/day + colestipol 20 g/day, lovastatin 80 mg/day, simvastatin 40 mg/day.

CONCLUSIONS

A significantly greater number (p < 0.05) of patients with confirmed atherosclerosis treated with atorvastatin reached the target LDL cholesterol concentration at the starting dose than patients treated with fluvastatin or lovastatin, and significantly fewer (p < 0.05) patients treated with atorvastatin required combination therapy with colestipol to achieve target LDL cholesterol concentrations than all other statins tested.

The cholesterol controversy

OBJECTIVE

To provide information about the controversy associated with lowering of cholesterol concentrations to prevent coronary heart disease (CHD).

DATA SOURCES

Studies, review articles, and editorials identified from MEDLINE searches (from 1966 to 1995) and bibliographies of identified articles.

STUDY SELECTION

Studies, review articles, and editorials addressing controversial issues related to cholesterol lowering.

DATA EXTRACTION

Pertinent information was selected and the data synthesized into a review format.

DATA SYNTHESIS

Hypercholesterolemia is a well-known CHD risk factor. Reduction of serum cholesterol concentrations has been shown to reduce the incidence of CHD. Unfortunately, cholesterol lowering also appears to increase the risk for cancer, accidental and violent death, stroke, and oddly enough, CHD when certain medications are used.

CONCLUSIONS

Significant reductions in serum cholesterol concentrations can be achieved with cholesterol-lowering interventions. However, the benefits associated with cholesterol reduction may not outweigh the risks in all patients with hypercholesterolemia. Cholesterol-lowering interventions should be recommended with caution in patients at increased risk of cancer, stroke, and depression. Caution should also be used when recommending fibric acid derivatives for patients with existing CHD.

Low incidence of assessment and modification of risk factors in acute care patients at high risk for cardiovascular events, particularly among females and the elderly. The Clinical Quality Improvement Network (CQIN) Investigators

This study defined the patterns of investigation and treatment of serum lipids and other modifiable risk factors for atherosclerosis among 3,304 hospitalized patients at high risk for future cardiovascular events. There were 2,161 men and 1,143 women; 1,955 were aged < 70 years, and 1,349 were aged > or = 70 years. Acute (61%) and chronic (65%) cardiac ischemia was the most prevalent reason for high-risk status, followed by cardiac revascularization (46%) and diabetes (28%). Only 28% of patients had lipid measurements recorded during their hospital stay, or recorded at any time between 1988 and 1993. A lipid-lowering diet or drugs were prescribed for 22% and 8% of all patients, respectively, and an adjustment in lifestyle in only 5% of all patients. Moreover, measurement and therapy of lipid risk were recorded less frequently in older patients (p < 0.01), and less often in women (p < 0.01). Logistic regression analysis revealed admission for revascularization, preadmission lipid-lowering or lifestyle therapies, and history of hyperlipidemia or diabetes to be associated with increased likelihood of in-hospital lipid measurement; age > or = 70 years was associated with reduced likelihood of lipid determinations (p < 0.01). The overall investigation and therapy of serum lipids and other risk factors in acute care patients at high risk for cardiovascular events appear less than optimal. Moreover, there is significantly fewer measurements and less treatment of risk factors in women and older patients. Improvement in these practice patterns would improve patient outcomes for the most important diseases in society.