RESUMEN
Background. Cardiovascular disease is the principal cause of mortality in older individuals, and more than 80% of deaths due to coronary heart disease or stroke occur in patients over 65 years of age. Hyperlipidemia is one of the main modifiable risk factors for cardiovascular disease. Current guidelines recommend the use of statins to reduce low-density lipoprotein cholesterol to appropriate targets based on an individual's cardiovascular risk, and clearly state that older age should not be a barrier to treatment. Despite extensive evidence demonstrating clear benefit with statin therapy in older individuals, this population remains chronically undertreated. Scope. This paper provides an overview of the current evidence available regarding the efficacy and safety of statin therapy to reduce cardiovascular risk in older patients. We use hypothetical case studies to address some of the questions frequently posed by physicians responsible for the cardiovascular health of older patients. Conclusions. Various factors may account for the failure to provide appropriate treatment, including a lack of awareness of clinical benefits and perceived safety issues. However, if current guidelines are followed and older patients treated to appropriate LDL-C goals, the likelihood of cardiovascular events will be reduced in this high-risk population. Employing an evidence-based approach to the management of cardiovascular risk in older patients is likely to yield benefits in terms of overall cardiovascular burden.
RESUMEN
Coronary heart disease (CHD) remains the leading cause of mortality for US women, responsible for almost 250,000 deaths annually. Preventive heart-health behavioral changes by women and aggressive coronary risk reduction can decrease the number of women disabled and killed by CHD. Angina is the predominant initial and subsequent presentation of CHD in women; categorization of chest pain and risk stratification of women assume pivotal roles. A robust evidence-based algorithm can guide cardiovascular imaging techniques to evaluate women with suspected myocardial ischemia to detect those with worsened survival. Restricted functional capacity (<5 METs) is a consistent marker of worsened prognosis. Younger women have substantially higher mortality rates than men following myocardial infarction and coronary bypass surgery. Although these women have more comorbidity and risk factors, other issues including biological differences, treatment differences, and psychosocial factors require management strategies tailored to the unique needs of women.
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Angina de Pecho/etiología , Angioplastia Coronaria con Balón , Puente de Arteria Coronaria , Enfermedad Coronaria , Técnicas de Diagnóstico Cardiovascular , Fibrinolíticos/uso terapéutico , Salud de la Mujer , Factores de Edad , Anciano , American Heart Association , Angina de Pecho/diagnóstico , Angina de Pecho/mortalidad , Angina de Pecho/patología , Angina de Pecho/terapia , Sesgo , Angiografía Coronaria , Enfermedad Coronaria/complicaciones , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/etiología , Enfermedad Coronaria/mortalidad , Enfermedad Coronaria/prevención & control , Enfermedad Coronaria/terapia , Ecocardiografía de Estrés , Medicina Basada en la Evidencia , Prueba de Esfuerzo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Guías de Práctica Clínica como Asunto , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Tomografía Computarizada de Emisión de Fotón Único , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: To examine by secondary analysis of the Treating to New Targets (TNT) study whether the benefits of intensive versus standard levels of lipid lowering are equally applicable to women. METHODS: A total of 10 001 patients (1902 women) with stable coronary heart disease (CHD) were randomised to double-blind treatment with atorvastatin 10 or 80 mg/day for a median follow-up of 4.9 years. RESULTS: In women and men, intensive treatment with atorvastatin 80 mg significantly reduced the rate of major cardiovascular events compared with atorvastatin 10 mg. Among women, the relative and absolute reductions were 27% and 2.7%, respectively (hazard ratio (HR) = 0.73, 95% confidence interval (CI) 0.54 to 1.00, p = 0.049). In men, the corresponding rate reductions were 21% and 2.2% (HR = 0.79, 95% CI 0.69 to 0.91, p = 0.001). The number needed to treat value (to prevent one cardiovascular event over 4.9 years compared with patients treated with atorvastatin 10 mg) for atorvastatin 80 mg was 29 for women and 30 for men. Rates of death of non-cardiovascular origin in the atorvastatin 80 mg and atorvastatin 10 mg were 3.6% and 1.6%, respectively (p = 0.004) among women, and 2.8% and 3.1% (p = 0.47) among men. CONCLUSION: Intensive lipid-lowering treatment with atorvastatin 80 mg produced significant reductions in relative risk for major cardiovascular events compared with atorvastatin 10 mg in both women and men with stable CHD.
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LDL-Colesterol/sangre , Enfermedad Coronaria/tratamiento farmacológico , Ácidos Heptanoicos/uso terapéutico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Pirroles/uso terapéutico , Anciano , Atorvastatina , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/prevención & control , Enfermedad Coronaria/sangre , Enfermedad Coronaria/mortalidad , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Estudios de Seguimiento , Ácidos Heptanoicos/efectos adversos , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Lípidos/sangre , Masculino , Persona de Mediana Edad , Pirroles/efectos adversos , Factores Sexuales , Análisis de Supervivencia , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
According to the most recent report of the US National Heart, Lung, and Blood Institute, mortality from coronary heart disease has declined in women from one in three to one in four. Due to massive campaigning efforts in educating the medical community and the general public, coronary heart disease has become increasingly recognized as a woman's disease. Indeed, it is the number one killer in women, exceeding cancer and infectious diseases. Numerous observational studies, clinical trials, and reports have indicated that there are gender-specific differences in the presentation, diagnosis, treatment, and outcomes of coronary heart disease. One common theme, not only in United States, but world-wide is the underutilization of known and validated medical and interventional therapies in women compared to men. Even though previously conducted large, randomized controlled trials had limited numbers of women, recent large scale cardiac trials in women have enabled the development of evidence-based guidelines for coronary heart disease diagnosis and management in women. Importantly, menopausal hormone therapy and antioxidant vitamin therapy do not protect post-menopausal women from coronary heart disease. Aggressive life-style and pharmacologic management of known coronary risk factors in women should be a top priority to improve coronary heart disease morbidity and mortality. Research data continue to emerge to fill the gaps of how gender affects atherosclerosis; in the meantime, continued patient and physician education to increase awareness of coronary heart disease may help to eliminate some of the gender-based disparities in the delivery of coronary care to women.
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Enfermedad Coronaria , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/etiología , Enfermedad Coronaria/terapia , Femenino , Humanos , Factores de RiesgoRESUMEN
"You are not required to complete the work, but neither are you at liberty to abstain from it.."-Rabbi Tarfon, Pirke Avot 2:16.
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Cardiología , Médicos Mujeres , American Heart Association , Cardiología/educación , Femenino , Humanos , Médicos Mujeres/estadística & datos numéricos , Sociedades Médicas , Estados Unidos , Recursos HumanosAsunto(s)
Sistema Cardiovascular/efectos de los fármacos , Antagonistas de Estrógenos/farmacología , Clorhidrato de Raloxifeno/farmacología , Endotelio Vascular/efectos de los fármacos , Endotelio Vascular/fisiología , Femenino , Humanos , Músculo Liso Vascular/efectos de los fármacos , Músculo Liso Vascular/fisiología , Óxido Nítrico/fisiología , PosmenopausiaRESUMEN
This overview of the management of ambulatory oral anticoagulant therapy addresses the importance of patient education and highlights tested educational techniques; describes issues of documentation of the patient encounter in the medical record; and reviews drug dosage adjustments, the management of patients with high International Normalized Ratio (INR) values, and the recommended changes of oral anticoagulation for patients who undergo invasive procedures.
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Atención Ambulatoria/métodos , Anticoagulantes/administración & dosificación , Manejo de Atención al Paciente/métodos , Atención Ambulatoria/organización & administración , Humanos , Sistemas de Registros Médicos Computarizados , Manejo de Atención al Paciente/organización & administración , Educación del Paciente como Asunto/métodos , Guías de Práctica Clínica como AsuntoRESUMEN
Raloxifene is a selective estrogen receptor modulator that lowers total and low-density lipoprotein (LDL) cholesterol, reduces the risk of vertebral fracture, and is associated with a reduced incidence of invasive breast cancer in postmenopausal women with osteoporosis. The Raloxifene Use for The Heart (RUTH) trial is designed to determine whether raloxifene 60 mg/day compared with placebo: (1) lowers the risk of the coronary events (coronary death, nonfatal myocardial infarction [MI], or hospitalized acute coronary syndromes other than MI); and (2) reduces the risk of invasive breast cancer in women at risk for a major coronary event. RUTH is a double-blind, placebo-controlled, randomized clinical trial of 10,101 postmenopausal women aged > or =55 years from 26 countries. Women are eligible for randomization if they are postmenopausal and have documented coronary heart disease (CHD), peripheral arterial disease, or multiple risk factors for CHD. Use of estrogen within the previous 6 months is an exclusion factor. The study will be terminated after a minimum of 1,670 participants experience a primary coronary end point. Secondary end points include cardiovascular death, myocardial revascularization, noncoronary arterial revascularization, stroke, all-cause hospitalization, all-cause mortality, all breast cancers, clinical fractures, and venous thromboembolic events, in addition to the individual components of the composite primary coronary end point. RUTH will provide important information about the risk-benefit ratio of raloxifene in preventing acute coronary events and invasive breast cancer, as well as information about the natural history of CHD in women at risk of major coronary events.
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Neoplasias de la Mama/prevención & control , Enfermedad Coronaria/prevención & control , Clorhidrato de Raloxifeno/uso terapéutico , Proyectos de Investigación , Moduladores Selectivos de los Receptores de Estrógeno/uso terapéutico , Angina Inestable/prevención & control , Método Doble Ciego , Femenino , Humanos , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Infarto del Miocardio/prevención & control , Osteoporosis Posmenopáusica/prevención & control , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVES: This study sought to determine the independent association of renal insufficiency with cardiovascular risk among women with known coronary heart disease (CHD). BACKGROUND: Although patients with end-stage renal disease and proteinuria are at high risk for cardiovascular events, little is known about the cardiovascular risk associated with moderate renal insufficiency. METHODS: The Heart and Estrogen/progestin Replacement Study (HERS) was a clinical trial among 2,763 women with coronary disease who were randomized to conjugated estrogen plus progestins or identical placebo and followed for a mean of 4.1 years. Women were categorized as having normal renal function (creatinine < 1.2 mg/dl; n = 2,012), mild renal insufficiency (1.2 mg/dl to 1.4 mg/dl; n = 567) and moderate renal insufficiency (>1.4 mg/dl; n = 182). We examined the independent association of renal function with incident cardiovascular events including CHD death, nonfatal myocardial infarction, hospitalization for unstable angina, stroke and transient ischemic attacks. RESULTS: Compared with women with normal renal function, those with mild and moderate renal insufficiency were older, more likely to be black, have a history of hypertension and diabetes and have higher serum levels of triglycerides and lipoprotein(a). After multivariate adjustment, both mild (relative hazards [RH] = 1.24; 95% confidence interval [CI]: 1.0 to 1.5) and moderate renal insufficiency (RH = 1.57; 95% CI: 1.2 to 2.1) were independently associated with increased risk for cardiovascular events compared with women with normal renal function. CONCLUSIONS: Renal insufficiency is an independent risk factor for cardiovascular events in postmenopausal women with known coronary artery disease. Renal function may add helpful information to CHD risk stratification.
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Enfermedad Coronaria/epidemiología , Insuficiencia Renal/epidemiología , Anciano , Comorbilidad , Enfermedad Coronaria/sangre , Creatinina/sangre , Femenino , Humanos , Persona de Mediana Edad , Posmenopausia , Insuficiencia Renal/sangre , Medición de Riesgo , Factores de RiesgoRESUMEN
Postmenopausal women with coronary heart disease (CHD) who volunteered for the Heart and Estrogen/Progestin Replacement Study (HERS) randomized clinical trial had high rates of gynecological abnormalities. We examined compliance with gynecological cancer screening and factors affecting this behavior. Women who met inclusion criteria for HERS and were seen for screening by the study gynecologist were considered eligible for this study. Data were abstracted from study records, and additional information was obtained by telephone questionnaire. Adherence to mammography, breast examination, pelvic examination, and Pap smear recommendations was assessed. Provider behavior and its effect on compliance were assessed. Compliance rates were 59.1% for monthly breast self-examination (BSE), 67.2% for yearly mammography, 73% for yearly Pap smear and pelvic examination, and 75.7% for provider breast examination. Over 50% of patients had most of their screening tests done within the last year. Provider behavior was significantly related to patient screening compliance for mammography, breast examination, Pap smear, and pelvic examination. Provider gender was not significantly related to adherence. There were no significant differences in compliance rates based on the type of most recent coronary event. Compliance rates did not differ significantly between patients with and without gynecological abnormalities, except for mammography (78.3% versus 48.3%, p = 0.02). The majority of patients were compliant with gynecological screening. Among patients with gynecological abnormalities, mammography compliance was significantly lower. Provider behavior was an important factor in influencing women to obtain preventive screening. There were no significant differences in compliance based on provider gender or type of coronary event preceding HERS enrollment.
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Neoplasias de la Mama/prevención & control , Enfermedad Coronaria , Conductas Relacionadas con la Salud , Cooperación del Paciente/estadística & datos numéricos , Posmenopausia , Neoplasias del Cuello Uterino/prevención & control , Anciano , Autoexamen de Mamas/estadística & datos numéricos , Femenino , Georgia/epidemiología , Adhesión a Directriz , Humanos , Mamografía/estadística & datos numéricos , Registros Médicos , Persona de Mediana Edad , Prueba de Papanicolaou , Ensayos Clínicos Controlados Aleatorios como Asunto , Encuestas y Cuestionarios , Frotis Vaginal/estadística & datos numéricos , Salud de la MujerRESUMEN
Moderate hyperhomocysteinemia is a putative risk factor for cardiovascular disease. Molecular studies have demonstrated increased plasma homocysteine levels in the presence of DNA mutations in either the methylenetetrahydrofolate reductase (MTHFR) enzyme found in the remethylation pathway or the enzyme cystathione beta-synthase (CBS) of the transsulfuration pathway. To determine whether the mutation C-->T677 in the MTHFR gene or the T-->C833/844ins68 and G-->A919 mutations in the CBS gene are associated with myocardial infarction (MI) in African Americans, DNA was analyzed from samples obtained from a case-control study conducted at a large, inner-city hospital. One-hundred ten African American subjects with a diagnosis of MI and 185 race- and age-matched controls were recruited. Our results demonstrated that 15% of the MI cases were heterozygous for the C-->T677 (MTHFR) mutation, while 1.8% were homozygous. When compared to the controls in which 15% were heterozygous and 2.1% were homozygous, no significant association with MI was observed. In addition, 34% of the cases were heterozygous for the T-->C833 (CBS) mutation while 6% were homozygous. This is compared to 32% and 5% of the controls having the heterozygous and homozygous genotype, respectively. No significant association was observed for the T-->C833 (CBS) mutation among the cases and controls. Although this mutation has no significant association with MI, the prevalence of the heterozygous state was higher than what has been reported for whites (12%). No mutations for G-->A919 (CBS) were detected in the cases or controls. The racial differences of the CBS T-->C833 polymorphism suggest that further investigation into the other areas of the CBS gene is needed.
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Sustitución de Aminoácidos , Negro o Afroamericano , Cistationina betasintasa/genética , Hiperhomocisteinemia/genética , Mutación Missense , Infarto del Miocardio/genética , Oxidorreductasas actuantes sobre Donantes de Grupo CH-NH/genética , Adulto , Población Negra/genética , Estudios de Casos y Controles , Comorbilidad , Cistationina betasintasa/biosíntesis , Análisis Mutacional de ADN , Inducción Enzimática , Femenino , Predisposición Genética a la Enfermedad , Genotipo , Georgia/epidemiología , Humanos , Hiperhomocisteinemia/complicaciones , Hiperhomocisteinemia/enzimología , Hiperhomocisteinemia/etnología , Hipertensión/epidemiología , Masculino , Metilenotetrahidrofolato Reductasa (NADPH2) , Persona de Mediana Edad , Infarto del Miocardio/enzimología , Infarto del Miocardio/etnología , Infarto del Miocardio/etiología , Oxidorreductasas actuantes sobre Donantes de Grupo CH-NH/biosíntesisAsunto(s)
Enfermedad Coronaria/prevención & control , Terapia de Reemplazo de Estrógeno/efectos adversos , Terapia de Reemplazo de Estrógeno/normas , Prevención Primaria/métodos , Tromboembolia/inducido químicamente , Salud de la Mujer , Actitud del Personal de Salud , Cardiología , Enfermedad Coronaria/epidemiología , Terapia de Reemplazo de Estrógeno/métodos , Medicina Basada en la Evidencia , Femenino , Humanos , Hipolipemiantes/uso terapéutico , Estilo de Vida , Selección de Paciente , Moduladores Selectivos de los Receptores de Estrógeno/uso terapéutico , Resultado del Tratamiento , Estados Unidos/epidemiologíaAsunto(s)
Infarto del Miocardio/rehabilitación , Anciano , Hospitalización , Humanos , Estilo de VidaRESUMEN
African Americans have the highest overall mortality rate from coronary heart disease (CHD) of any ethnic group in the United States, particularly out-of-hospital deaths, and especially at younger ages. Although all of the reasons for the excess CHD mortality among African Americans have not been elucidated, it is clear that there is a high prevalence of certain coronary risk factors, delay in the recognition and treatment of high-risk individuals, and limited access to cardiovascular care. The clinical spectrum of acute and chronic CHD in African Americans is similar to that in whites. However, African Americans have a higher risk of sudden cardiac death and present more often with unstable angina and non-Q-wave myocardial infarction than whites. African Americans have less obstructive coronary artery disease on angiography, but may have a similar or greater total burden of coronary atherosclerosis. Ethnic differences in the clinical manifestations of CHD may be explained largely by the inherent heterogeneity of the coronary syndromes, and the disproportionately high prevalence and severity of hypertension and type 2 diabetes in African Americans. Identification of high-risk individuals for vigorous risk factor modification-especially control of hypertension, regression of left ventricular hypertrophy, control of diabetes, treatment of dyslipidemia, and smoking cessation--is key for successful risk reduction.
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Población Negra , Enfermedad Coronaria/etnología , Factores de Edad , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/terapia , Humanos , Prevalencia , Medición de Riesgo , Factores de Riesgo , Estados Unidos/etnología , Población BlancaRESUMEN
We evaluated the relation between venous thrombosis and plasma fibrinogen levels, the HaeIII and BcI polymorphisms of the beta fibrinogen gene, and the MspI polymorphisms of the factor VII gene in a case-control study of African-Americans. The study included 91 venous thrombosis cases and 185 control subjects obtained from a hospital in Atlanta, Georgia. High plasma fibrinogen was associated with increased risk of venous thrombosis, but the finding was not statistically significant. There was little association between the HaeIII polymorphisms and the BclI polymorphisms and the risk of venous thrombosis. The prevalence of the M2/M2 genotype of the factor VII gene was higher among cases than controls, but the difference was not statistically significant. The prevalence of the HaeIII H2 allele and the BclI B2 allele of the beta fibrinogen gene, both of which have been associated with slightly higher levels of plasma fibrinogen in most studies, is considerably lower among African-Americans in this study than it is among Whites in the United States and among Northern Europeans. The study is limited by its small size. However, despite this limitation, it supports the belief that increased plasma fibrinogen levels are associated with increased venous thrombosis risk. The study also indicated that the HaeIII and the BclI polymorphisms of the beta fibrinogen gene and the MspI polymorphisms of the factor VII gene are not strong determinants of venous thrombosis.
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Población Negra/genética , Factor VII/genética , Fibrinógeno/genética , Trombosis de la Vena/genética , Adulto , Anciano , Anciano de 80 o más Años , Alelos , Estudios de Casos y Controles , Femenino , Predisposición Genética a la Enfermedad , Genotipo , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Reacción en Cadena de la Polimerasa , Polimorfismo Genético , Análisis de Regresión , Factores de Riesgo , Estados Unidos/epidemiología , Trombosis de la Vena/epidemiologíaRESUMEN
To determine whether or not the PAI-1 4G/5G and t-PA I/D polymorphisms in African-Americans were linked to cardiovascular disease, the association of these polymorphisms to disease expression was analyzed in a recently completed case-control study of myocardial infarction or venous thromboembolism among African-Americans. All African-Americans patients with a history of venous thromboembolism attending an anticoagulant clinic, and patients with a history of a MI attending a cardiology clinic at a large local urban public hospital were eligible for inclusion as cases in the study. In this study it was observed that there was a statistically significant association between the D allele of the t-PA I/D polymorphism and venous thromboembolism and a nonsignificant association between the D allele and myocardial infarction among African-Americans. t-PA antigen levels were statistically significantly higher among both myocardial infarction and venous thromboembolism cases compared with control subjects. The genotypes were unrelated to t-PA plasma levels. There was no association between either myocardial infarction or venous thromboembolism and the 4G/5G PAI-1 genotype. It was also found that genotype frequencies for both PAI-1 4G/5G and t-PA I/D polymorphisms in African-American adults were different from those reported for both U.S. Causcians and Europeans.