The Best Ways to Treat Cardiovascular Disease

The Big Heart Disease Lie

The Big Heart Disease Lie is a book written by doctors who are members of the International Truth In Medicine Council they are also the authors of The Big Diabetes Lie. In this book you will be getting over 500 pages of scientifically proven, doctor verified information that you will not find anywhere else, not even bookstores.If you have high blood pressure or cholesterol, fatigue, shortness of breath, irregular heartbeat, swollen feet or ankles, chest pain, fainting, diabetes, asthma or allergies, pain, fatigue, inflammation, any troubling health issue, or simply want to discover the most powerful health and anti-aging program, then you really need to read this book. The book is a step by step guide that contains techniques scientifically verified and proven by doctors to reverse the symptoms of heart disease, and normalize blood pressure and cholesterol levels. These techniques have been used successfully by tens of thousands of people all over the world, and allowed them to take health into their own hands, ending the need for drugs, hospitals, doctors' visits, expensive supplements or grueling workouts. Continue reading...

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Stem Cell Therapy for Cardiovascular Disease

The adult mammalian heart lacks the potential for effective regeneration. The infarcted myocardium is usually transformed into a noncontractile fibrous scar. This remodeling process leads to expansion of the initial infarcted area and dilatation of the left ventricular lumen (8). A novel and attractive approach to the cure of ischemic heart disease is the use of stem cells (9-13). Pluripotent stem cells are cells that have not taken on the identity of any specific cell type and are not yet committed to any dedicated function they can divide indefinitely and may be induced to give rise to one or more specialized cell types. Murry et al. (14) and Balsam et al. (15) recently reported that hematopoietic stem cells failed to transdifferentiate into cardiac myocytes in myocardial infarcts. The stem cells, however, developed into different blood cell types, despite being in the heart. Thus, for physicians, the use of stem cell therapy in treating cardiac-muscle diseases remains a worthy, but...

Progress Toward Understanding The Molecular Mechanisms Of Cvbinduced Inflammatory Heart Disease

Two findings have made important strides in the overall understanding of intracellular molecular mechanisms of viral heart disease. The src kinase p56lck plays a role in CVB3 heart disease in knock-out mice mice lacking p56lck did not develop CVB3-induced disease.112 Although the mechanism of this finding has not been derived, the findings suggest that p56lck might be targeted to intervene in CVB-caused disease. Importantly, these findings extended to other organs besides the heart, making the possibility of an anti-p56lck compound of significant interest. In other work, using mice with the inducible nitric oxide synthase gene knocked out, Zaragoza and colleagues115 have demonstrated that CVB3-induced heart disease is worse than in normal mouse controls similar results hold for pancreatitis,116 a likely precursor to CVB-induced myocarditis.84 The inflammatory response defines myocarditis the inducible nitric oxide synthase gene can be induced by Th1-type cytokines such as interferon...

Cardiovascular disease

Patients with heart disease frequently present with the sensation of breathlessness in a variety of clinical circumstances, and the mechanism of this is poorly understood. Acute heart failure may induce left ventricular failure leading to pulmonary dema, which is the probable cause of breathlessness. Ischemic heart disease can trigger transient left ventricular failure.

Protective Dietary Changes For Cardiovascular Disease Patients

Since dietary support and advice by health professionals and self-help materials are effective at reducing cardiovascular risk, at least in the short term, what actual changes to diet are effective in protecting people from cardiovascular disease Again considering systematic reviews of randomised controlled trials as the best level of evidence, we are lucky that quite a few have been published in the area of diet and cardiovascular disease. The most important studies show that dietary intervention actually makes a difference to health or mortality. To date, the most effective dietary intervention for people who already have cardiovascular disease is omega-3-rich fish oil. Evidence for this comes from a high-quality systematic review of randomised controlled trials.14 Advice to increase intakes of long chain omega-3 fats for people with some cardiovascular disease (compared with no such advice) appears to reduce the risk of fatal myocardial infarction (relative risk 0.7, 95 CI 0.6 to...

Pharmacogenetic Targets In Cardiovascular Disease

Atherosclerosis is, at least in part, attributed to an underlying immune-mediated process with onset early in life, ultimately leading to severe clinical manifestations, such as myo-cardial infarction, unstable angina, and cerebral stroke. The increased incidence of cardiovascular events in the western societies is attributed to the underlying immune process, which is amplified by additional cardiovascular risk factors, such as hypercholesterolemia, hypertension, smoking, diabetes, and obesity, which by themselves have their own genetic background. This section provides a summary of some of the key issues for a full discussion, see the chapter on cardiovascular disease.

Hemorrhagic and Ischemic Stroke

In patients with hemorrhagic stroke, control of blood pressure is important to prevent further hemorrhage. However, it is important to rule out the occurrence of hypertension secondary to increase in ICP (Cushing's response), in which event the mean arterial pressure should be reduced gradually, and not below 130 mmHg in known hypertensive patients, and lower (100 mmHg) in previously normotensive patients. On the other hand, mild-to-moderate hypertension (160-180 systolic and 90-100 diastolic blood pressure) should be left untreated in patients with ischemic stroke. Vasopressors to support blood pressure may be necessary.

Cardiovascular Risk Factors

The role of exercise and the prevention of coronary heart disease in the general population have been well documented, but there is less evidence of a similar effect in people with diabetes. Modification of risk factors for CHD, including decreased total and LDL (low-density lipoprotein) cholesterol and triglyceride concentrations, have been demonstrated in Type 1 diabetes (20). People with Type 2 diabetes have two to four times the cardiovascular risk of those without diabetes and low cardiorespiratory fitness has been shown to be a predictor of mortality in men with diabetes (21).

Of Cytokines In Patients With Heart Diseases

Several clinical studies have confirmed the expression of excessive concentrations of tumor necrosis factor (TNF)-a in the plasma of patients with congestive heart failure.7-9 There is disagreement with regard to the correlation between severity of symptoms and magnitude of increase in cytokine concentrations. We found increased TNF-a concentrations in asymptomatic patients with dilated or hypertrophic cardiomyopathy.8 In that study, increased concentrations of interleukin (IL)-1a and IL-1P were detected in patients with acute myocarditis. Similarly, granulocyte CSF (G-CSF) was often increased in myocarditis, cardiomyopathies, acute myocardial infarction, and angina pectoris, suggesting activation of macrophages or endothelial cells (or both), although this increase was not disease specific.

Stroke patients may require immediate treatment

There are several reasons why many patients require urgent inpatient care following an acute stroke. First, stroke may lead to a variety of potentially life threatening complications such as airway obstruction and respiratory failure, swallowing problems with the risk of aspiration, dehydration, and malnutrition, venous thromboembolic complications, seizures, and infections.16-20 These may arise within hours of stroke onset and require early assessment and intervention so that they can be anticipated, prevented, and treated. Furthermore, although stroke has represented an area of therapeutic nihilism for many years, a variety of acute and potentially effective treatments (medical and surgical) are now becoming available.

Homocysteine And Heart Disease

Several vitamins interact through the metabolism of homocysteine. Most studies189-191 but not all192 demonstrate a link between hyperhomocysteinaemia and increased risk of cardiovascular disease. Levels of only 12 above the upper limit of normal are associated with a three-fold increase in risk of acute myocardial infarction.190 Individuals of Asian Indian origin living in the U.K. who have higher mortality rates from cardiovascular disease also have higher average homocysteine levels.193 A genetic mutation in the methylenetetrahydrofolate reductase gene that causes hyperhomocysteinemia increased the risk for vascular disease in some194 but not all studies.195

ENOS Glu298Asp G T and Cardiovascular Disease

Associations with the Glu298Asp polymorphism and cardiovascular disease have been reported in many studies (95,96), The Asp298 polymorphism has been shown to have significantly higher (P 0.001) median plasma NOx than those without this mutation (97). How this reflects NO levels in the vasculature is unclear. Not all studies have shown positive associations Nassar et al. (99) examined the prevalence of this polymorphism in patients with early-onset coronary artery disease (CAD) compared with those manifesting CAD later in life and found no association of the eNOS Asp298 allele with premature CAD, no association was found in a Taiwanese population (100), or a Finnish population (101).

Prevention Of Coronary Heart Disease As The Goal

Atherosclerosis is the primary cause of coronary heart disease. Markedly lowering blood cholesterol can halt and even reverse to some extent the progression of atherosclerosis. For these reasons, prevention should be the goal, with the focus on decreasing elevated blood cholesterol. About 20 of Americans between 20 and 75 years of age have blood total cholesterol levels above 240 mg dL, a level requiring management, and up to 40 of some middle aged groups have this elevation. terol, saturated fatty acids, and trans fatty acids and increased exercise and stress management. In fact, a recent study employing intensive lifestyle changes in patients with coronary heart disease achieved a 37 lowering of LDL (low-density lipoprotein) cholesterol, a 91 decline in anginal episodes, and a decline in coronary artery stenosis within a year all without drugs. A prescription for lifestyle changes should accompany the one for a hypocholesterolemic drug. Principal risk factors for heart disease are...

Milk and heart disease

There are strong statistical links between heart disease and both milk carbohydrates and nonfat milk. Seely published these studies in the 1980s, but the science has yet to surpass the propaganda.1 3 Interestingly, an especially strong statistical correlation emerges between heart disease and milk carbohydrates. Although a correlation cannot scientifically be considered the same as a cause-and-effect association, the data relating the increase in heart disease to increased sugar consumption (as noted in the last chapter) certainly suggest that the sugar in milk carbohydrates may be playing a similar role. Milk sugar, or lactose, is readily absorbed in the gut after being split into equal amounts of glucose, and another simple sugar, galactose. Further, the pasteurization process appears to allow a more rapid absorption of lactose, increasing the rate of glucose delivery into the system. Consistent with this observation, pasteurized milk promotes weight gain more effectively than...

Myocarditis Mimicking Acute Myocardial Infarction

Myocarditis is not infrequently associated with chest pain, which is typically pleuritic in nature and related to accompanying pericardial inflammation. Patients with myocarditis may also present with angina-like chest discomfort, despite the absence of epicardial coronary artery disease. Myocarditis has been reported at autopsy in patients who presented with acute myocardial infarction, normal coronary anatomy, and documented coxsackie B viral disease.57 Because myocarditis is associated with focal or multifocal myocardial inflammation and necrosis, it is not surprising that it may be associated with increased serum concentration of creatine kinase, electrocardiographic repolarization abnormalities, abnormal QS waves, and segmental wall motion abnormalities on left ventriculography.57-61 At our institution, 34 patients with clinical signs and symptoms of acute myocardial infarction underwent right ventricular endomyocardial biopsy during a 6.5-year period after angiographic...

Cardiovascular diseases

Patients with acute myocardial infarction may suffer from sleep disturbances. Anginal pain may disturb the patient, causing frequent awakenings and impaired sleep efficiency. Sleep disturbance associated with periodic breathing and hypoxaemia has been described in patients with congestive cardiac failure. Cheyne-Stokes respiration commonly associated with congestive cardiac failure may cause hypoxaemia, hypercapnia, sleep disruption due to repeated arousals, excessive daytime sleepiness, and impaired cognitive function. It is important to diagnose sleep apnoea syndrome in congestive cardiac failure as treatment with nocturnal oxygen administration or continuous positive airway pressure titration may improve the patient. Systemic hypertension is associated with a high prevalence (22-48 per cent) of sleep apnoea and related symptoms. Treatment of obstructive sleep apnoea can reduce daytime as well as night-time blood pressure.

Cardiovascular Risk Factor Reduction

Patients with OSA are at increased risk of developing cardiovascular disease (21). In part, this is related to the concomitant presence of a variety of cardiovascular risk factors. That is, these patients have a high prevalence of the following male gender, smoking, diabetes, obesity, hypertension, and increased cholesterol (22). We recommend a low threshold for screening all patients with sleep apnea for the presence of hypercholesterolemia, hypertension, and diabetes and initiating appropriate therapy if indicated.

Improvement of Cardiovascular Risk Profile by Metformin

During the last two decades a number of studies showed beneficial effects of metformin on traditional and non-traditional cardiovascular risk factors 11,47-58 . Metformin reduces fasting and postprandial insulin levels 3 , insulin resistance 4-6 and has beneficial effects on lipids, thrombosis and blood flow. Metformin has a weight-lowering effect 11,13,15 and reduces hypertriglyceridaemia 11 , elevated levels of PAI-1 47 , factor VII 49 , C-reactive protein 51,52,54 and intact proinsulin and des 31,32 proinsulin concentrations 48 . In randomized head-to-head comparisons (Fig. 2) of oral anti-diabetic drugs metformin treatment reduced triglycerides by 10 and increased HDL-cholesterol by 7 , whereas pioglitazone reduced triglycerides by 19 and increased HDL-cholesterol by 14 11 . By contrast, LDL-cholesterol decreased by 4 under metformin therapy, but increased by 8 under pioglitazone. Remarkably, HbA1c improvement was very similar and the prognostically important total cholesterol...

Cardiovascular disorders Ventricular dysrhythmias

Frasure-Smith et al.'(7 found that deaths within 18 months of a myocardial infarction were concentrated among depressed patients with 10 or more premature ventricular contractions per hour. In this group of patients, 83 per cent of mortality was due to 'arrhythmic deaths'. Among individuals at risk (e.g. those with pre-existing heart disease or dysrhythmias), activities which precipitate adrenergic discharge may produce ventricular dysrhythmias for example, public speaking, dread of an upcoming unwanted task, 'road rage,' and recall of emotionally charged events. (6,8,9) In one series of patients, psychological stressors were more reliable inducers of dysrhythmias than physical manoeuvres such as carotid sinus massage, hyperventilation, and the Valsalva manoeuvre. (89) Simple and inexpensive

Surgery for the correction of congenital heart disease

Patients undergoing correction of simple congenital defects (e.g. atrial and ventricular septal defects), do not normally present particular difficulties in perioperative care. Many different anomalies, with specific requirements related to cardiopulmonary interactions, may be encountered in adolescents and adults with an increase in exposure to corrected cyanotic congential heart disease. Patients with certain forms of cyanotic congenital heart disease, including tricuspid atresia and univentricular hearts, undergo redirection of systemic venous blood to the pulmonary circulation, bypassing the right ventricle. Surgery may be staged, employing the Glenn shunt (superior vena cava to the right pulmonary artery) initially or a single Fontan-type procedure (right atrium anastomosed to the right pulmonary artery). Such circulations essentially rely on a passive (i.e. venous-pressure-driven) transpulmonary gradient to provide left heart filling. Any increase in pulmonary vascular...

Coronary artery disease

Transplant-associated coronary artery disease replaces infection and rejection as the predominant cause of morbidity and mortality after the first 2 years post-transplant. This accelerated form of coronary disease has an annual incidence of 5 to 10 per cent each year after the first, and a prevalence as high as 50 per cent by 5 years. Transplant coronary disease affects heart transplant recipients regardless of preoperative age or diagnosis. Autopsy examinations have revealed significant transplant-associated coronary artery disease in heart transplant recipients as young as 4 years old. The cause of transplant-associated coronary artery disease is unknown and probably multifactorial. None of the normal risk factors for developing coronary artery disease, except hyperlipidemia, appear to be independent predictors for developing transplant-associated coronary artery disease. Cytomegalovirus may play an additional role in the development of this disease, but this remains controversial....

Fetal Origin Of Adult Heart Disease

Fetal and infant nutrition have been postulated to influence adult onset cardiovascular and metabolic diseases, namely coronary heart disease, hypertension, and maturity onset diabetes mellitus. Scattered reports as early as 1934 made the observation that early environment in which a child grows may exert long-lasting effects on health.150151 The hypothesis was formally suggested and substantiated first by David Barker and his team from the Medical Research Council's Environmental Epidemiology Unit at Southampton, U.K. They observed that the impact of the 20th century epidemic of coronary heart disease in Western countries paradoxically coincided with improved standards of living and nutrition, while prevalence was greatest in the most deprived areas.152 These areas in the early 20th century had high rates of neonatal mortality and possibly of low birth weight. This led to the postulate that impaired fetal growth may have predisposed the survivors to heart disease in later life. The...

Fetal Growth and Coronary Heart Disease

These studies depend heavily on availability of accurate anthropometric measurements at birth and during infancy. Barker's group originally examined cardiovascular mortality in men born in Hertfordshire, England, in the early decades of the 20th century, for whom reliable records of weight at birth and at 1 year were available. They studied 5654 men born between 1911 and 1930 and found a progressive fall in future deaths from coronary heart disease between birth weights of 2500 and 4310 g.153 In a similar study involving 1586 men at Sheffield, standardized mortality ratios for cardiovascular disease fell from 119 in men with birth weights of 2495 g or less to 74 in those who weighed more than 3856 g.154 Records of head circumference and length were also available for these patients, and the association of increased cardiovascular mortality also held true with decreasing head circumference and decreasing ponderal index (weight length2). Periods of famine during the siege of Leningrad...

Clinical Features Of Chagas Heart Disease

The percentage of infected individuals ultimately developing heart disease depends on how carefully the disease is sought. Approximately 30 to 40 of infected individuals develop detectable cardiac abnormalities during their lifetime,117'118 such as an abnormal ECG or echocardiogram, whereas overt symptomatic cardiac involvement develops in 10 to 20 .119 Of the remainder, usually classified as indeterminate, many actually have subclinical cardiac involvement when studied carefully.120 Therefore, clinically evident Chagas heart disease represents only the tip of the iceberg of the cardiomyopathy. Clinical Classification of Chagas Heart Disease

Clinical Manifestations Of Chagas Heart Disease

Because the panmyocarditis of Chagas heart disease progressively involves the various cardiac tissues, patients may present with a wide variety of clinical manifestations. The most important of these are ventricular arrhythmias, congestive heart failure, thromboembolism, and complete atrioventricular block. The initial clinical manifestations of the 34 women and 8 men in our series are shown in Table 20-3. Most had received treatment for other presumed cardiac diagnoses, usually coronary artery disease or idiopathic dilated cardiomyopathy, before Chagas disease was considered.

Coronary Heart Disease

Reduced incidence of myocardial infarction metabolic profile of Type 2 diabetes, together with small dense LDL and low concentrations of HDL cholesterol. Hypertriglyceridaemia is an independent risk factor for coronary artery disease especially for people with Type 2 diabetes reduction of alcohol intakes tight glycaemic control and weight loss can help to reduce this risk (29). In subjects with alcohol-induced hypertriglyceridaemia, alcohol withdrawal has beneficial effects on the LDL profile by shifting the particle size from small to large, thus reducing susceptibility to oxidation. With moderate alcohol consumption the increase in HDL becomes the predominant feature in the reduction of CHD risk and maximal benefit appears to be at the level of one drink per day (30). In irregular binge drinkers the increase in HDL cholesterol is not seen, adverse changes in LDL are acquired (31) and cardiovascular risk increases (Table 13.3). Antioxidants in alcoholic beverages, especially...

Diagnosis Of Chagas Heart Disease Outside Of Endemic Areas

To correctly diagnose and treat Chagas heart disease, clinicians outside of endemic areas must become familiar with its protean manifestations and aware of its true prevalence. North American physicians may believe that Chagas heart disease does not exist there or that it is found only in persons from South America. With increased awareness on the part of North American clinicians, it is likely that Chagas heart disease will be recognized more often and earlier. One reason for problems in diagnosis is that Chagas disease may mimic other forms of heart disease, particularly coronary artery disease, and commonly used noninvasive tests cannot reliably distinguish them. Chest pain is a frequent complaint of patients with Chagas disease. Although it is usually atypical of angina, it may prompt diagnostic evaluation. ECG changes suggestive of myocardial infarction or ischemia are quite typical of this disease. Further complicating matters, radionuclide perfusion scans are consistently...

Polymorphism In Cardiovascular Disease

The list of genes, implicated as playing a significant role in the regulation of cardiovascular signaling pathways, is certainly large. Table 1 summarizes some of these genes and their polymorphisms associated with altered cardiovascular function. In this chapter, we focus on (i) the major pathways with their well-established proteins and polymorphisms, (ii) the emerging proteins and polymorphisms of the cardiovascular matrix and arterial stiffening, which are recognized as independent predictors of increased cardiovascular risk, (iii) the lipid, inflammation and coagulation system polymorphisms that are important in predicting increased cardiovascular risk, (iv) genetic polymorphism of cardiovascular drug metabolism (e.g., cytochrome P450 system), (v) evidence for genetic polymorphisms affecting responses to drugs with adverse reactions, and (vi) a perspective on pharmaco-genetics in cardiovascular medicine.

Valvular and congenital heart disease

Although for many years cardiac catheterization was the method of choice to establish a diagnosis of valvular or congenital heart disease and assess its severity, echocardiography is probably the most important imaging modality in this setting at present. Two-dimensional echocardiography can characterize the morphology of cardiac valves and the etiology of valvular disease. Doppler imaging can measure flow velocity across stenotic or regurgitant valves and estimate corresponding pressure gradients using the modified Bernoulli equation ( CD Eigure 4). Doppler studies have also been shown to quantify stenotic valve areas reliably using the continuity equation and pressure half-time methods. Color Doppler imaging permits identification and characterization of regurgitant flow and thus helps to assess the severity of regurgitant lesions or shunt flow.

Associated cardiovascular disease

Heart disease is frequently present in patients with embolic CRAO, particularly patients under the age of 40. In a retrospective study 30 of younger and 23 of older patients had cardiac valvular disease as a source of the embolus.8 In a prospective study 56 of patients under age 50 had a potential cardiac source of embolus, compared with 24 in the older age group. Aortic stenosis was the commonest finding and, in the majority, the aortic valve disease was not of haemodynamic significance.25 These data emphasise the importance of a careful cardiac assessment, especially in younger patients, and echocardiography.

Ischemic Stroke Subtypes

Hemodynamic factors, embolism and small vessel disease are the most common mechanisms by which ischemic strokes occur. The most frequent conditions leading to cerebral ischemia are atherosclerosis, embolism secondary to cardiac disease, small vessel disease and cryptogenic infarction. Ischemic strokes caused by embolism usually have a cardiac source. It is estimated that car-dioembolic events account for 15-20 of all ischemic strokes 9 . It is also estimated that 75 of cardiac emboli travel to the brain. Once in the brain, emboli can lodge themselves in arteries that are too small for them to pass, leading to vessel occlusion. Mural thrombi can form after a myocardial infarction (MI) and ischemic events follow an acute MI in 2-5 of cases 10 . Other common sources of cardiac embolism include atrial fibrillation, atrial myxoma, dilated cardiomyopathy, patent foramen ovale, atrial septal aneurysms, prosthetic heart valves, infective endocarditis, mitral valve prolapse and mitral annular...

Evaluation and Management of the Acute Ischemic Stroke Patient

The acute onset of a neurological deficit in a vascular distribution should prompt emergent clinical and radiographic evaluation to identify, treat and prevent recurrence of an ischemic stroke. Common neurological deficits include hemiparesis, aphasia, gaze palsies, hemianopia, dysarthria, confusion, hemineglect, hearing loss and ataxia. The evaluation and management of the acute ischemic stroke patient begin in the ED, although efforts are underway to educate emergency medical technicians and paramedics so as to improve pre-hospital-phase care. pressure, pulse and oxygen saturation. Patients with severe deficits, including loss of consciousness, and those unable to protect their own airway should undergo emergent endotra-cheal intubation and mechanical ventilation. Adequate oxygen saturation is indispensable, as hypoxia can worsen cerebral ischemia. Appropriate laboratory studies (Table 38.2) and diagnostic studies (Table 38.3) should be obtained so as to determine the cause of the...

Ischemic Stroke And Carotid Endarterectomy

Finally, the efficacy of this procedure in symptomatic patients depends on an acceptable level of perioperative morbidity and mortality. Acceptable guidelines are 3 operative risk for asymptomatic patients, 5 for patients with TIAs, 7 for patients with ischemic stroke and 10 for patients with recurrent stenosis.

Lycopene And Cardiovascular Disease

The Kuopio Ischaemic Heart Disease Risk Factor Study is an ongoing investigation of an eastern Finland population that has the highest rate of cardiovascular disease recorded. The investigators are studying the risk factors for different aspects of CVD, atherosclerosis, and associated problems in the male population between the ages of 46 to 64.41 Rissanen et al.42 studied the relationship of serum lycopene concentration to the intima media thickness of the common carotid artery. The study included 1028 subjects who were asked to refrain from smoking and drinking alcohol for 3 days and fast for 12 hours before blood was drawn after 30 minutes of relaxing. Intima media thicknesses of the subjects' common carotid arteries were measured by high resolution B-mode ultrasonography. Serum lycopene, beta-carotene, and alpha-tocopherol levels were determined. The preventing role that lycopene may play in CVD may be due to the hydrocarbon carotenoids including beta-carotene and lycopene that...

Fatty Acids Gene Expression and Coronary Heart Disease CHD

Research in this area is in its relative infancy, and has for the most part focussed on the expression of hepatic genes directly involved in fatty acid metabolism or lipid transport as lipoproteins. However, data on the ability of fatty acids to modulate gene expression in other tissues such as adipose tissue, endo-thelial cells, and macrophages are beginning to emerge in the literature. Although findings thus far have provided a valuable insight into the impact of dietary fat on the human genome, it is likely that it only represents the tip of the iceberg. Given the vast body of evidence implicating dietary fat composition in the pathology of many chronic diseases including coronary heart disease (CHD), such nutrient-gene interaction information could provide us with valuable insights into how fatty acids changes can be used as a measure to reduce the public health burden of such diseases.

75 Year Old Man Has Inoperable Coronary Artery Disease

Case Study Therapy for Inoperable Coronary Artery Disease A 75-year-old man has inoperable coronary artery disease with an EF of 31 . He is receiving digoxin, furosemide, and an ACE inhibitor. He is unable to walk more than 50 feet on flat ground before getting short of breath (dyspnea on exertion at 50 feet). His heart rate at rest is 85 beats per minute and his blood pressure while seated is 130 85. His neck veins are flat carotid upstrokes are normal lungs are clear and heart examination reveals no murmurs, gallops, or rubs. His extremities reveal no cyanosis, clubbing, or edema. The remainder of the physical examination is unremarkable. What is your next therapeutic option

Myocardial infarction

Myocardial ischaemia often leads to myocardial infarction. Acute myocardial infarction can develop at rest or with normal activity, and can be the first clinical manifestation of coronary heart disease. Typically, an acute myocardial infarction is accompanied by severe chest pain that lasts more than 30 min the pain is not relieved by sublingual nitroglycerine. Most deaths associated with acute myocardial infarction occur during the first few hours after the onset of symptoms, and are the result of ventricular fibrillation. (19 It is important that patients know the warning signs and seek care promptly when symptoms develop. Unfortunately, as many as 20 per cent of myocardial infarctions are unrecognized. Denial of acute myocardial infarction symptoms and warning signs by individuals, particularly men, are a frequent source of mortality and morbidity. The most common precipitant of myocardial ischaemia among patients with pre-existing coronary artery disease is psychological stress.(...

Myocardial Infarction and Unstable Angina

Diagnosis Rule out myocardial infarction Glycoprotein IIb IIIa Blockers for Acute Coronary Syndromes Absolute Contraindications to Thrombolytics Active internal bleeding, history of hemorrhagic stroke, head trauma, pregnancy, surgery within 2 wk, recent non-compressible vascular puncture, uncontrolled hypertension ( 180 110 mmHg).

The Cell Biology of Atherosclerosis Heart Attacks and Strokes

In this concluding section we examine the relation between lipid metabolism and atherosclerosis, the most common cause of heart attacks and strokes. Atherosclerosis accounts for 75 percent of deaths due to cardiovascular disease in the United States. Advances in our understanding of the molecular mechanisms underlying lipid metabolism and its regulation are having an enormous effect on the treatment and prevention of this major health problem. Atherosclerotic Plaques Can Impede Blood Flow, Leading to Heart Attacks and Strokes heart attack occlusion of an artery feeding the brain can cause a stroke.

HDLcholesterol plasma triacylglycerol and coronary heart disease

Although an elevated LDL-cholesterol concentration is certainly an important marker for risk of coronary heart disease, it is also true that if people who suffer a heart attack, especially those who do so at a relatively early age, are studied, a large proportion will not have elevated cholesterol concentrations. In terms of total risk in the population, factors other than LDL-cholesterol are more important. One important marker of risk is the combination of reduced HDL-cholesterol and elevated triacylglycerol concentrations. Unlike LDL-cholesterol, elevated HDL-cholesterol concentrations are associated with decreased risk of coronary heart disease (Fig. 9.6). The converse is that a low HDL-cholesterol concentration is a marker of increased risk. It was mentioned earlier that, in studies of large numbers of people, an inverse relationship is observed between plasma triacylglycerol and HDL-cho-lesterol concentrations. We have seen already (Section 9.3.2) how the inverse relationship...

Cholesterol And Heart Disease

The irrational attack on the effects of cholesterol on health has resulted primarily from the chronic misinterpretation of statistical data. High cholesterol levels are statistically associated with higher rates of heart disease. This is a fact that has been conclusively demonstrated. However, a statistical association does not mean there is a cause-and-effect relationship. Cause-and-effect means there is an association, but an association alone does not assure cause-and-effect. Just because the police consistently show up at the scene of a crime doesn't mean that you can later conclude that the police committed the crime. But if we were to use the same statistical reasoning in this police example as modern science uses in the cholesterol-heart disease relationship, we could proceed directly to this ridiculous conclusion without any further thought. If a factor is actually protecting against an unhealthy (and usually unperceived) force, and that factor reliably emerges when that force...

Heart Disease In Children Infected With Human Immunodeficiency Virus

Human immunodeficiency virus (HIV) infection is increasingly recognized as an important cause of heart disease, particularly myocarditis and DCM. However, the pathogenesis of the heart-muscle disease in the acquired immunodeficiency syndrome is unclear. CMV sequences have been detected in myocardial samples. For example, Wu et al.43 reported a study of the role of CMV infection in the development of HIV-associated cardiomyopathy. Using probes derived from the CMV immediate-early and delayed-early genes, they analyzed by in situ hybridization EMB samples from 12 HIV-infected patients with global left ventricular hypokinesis demonstrated on 2-dimensional echocardiography and 8 autopsy cardiac samples from HIV-infected patients without cardiac disease during life. Of the 12 EMB specimens, 6 had hybridization for transcripts of the CMV immediate-early gene, consistent with nonpermissive or latent infection. Similar patterns were not found in any of the 8 autopsy control samples. All 6...

Risk Factors for Ischemic Stroke

Ischemic stroke can occur in people of all ages, at any time and without predilection for sex or race. Age, however, is the most important determinant of stroke, with most strokes occurring in individuals older than 65. Atherosclerosis affecting the extracranial and intracranial circulation differs according to race and ethnic group. For example, extracranial atherosclerotic lesions are more common in whites, while intracranial lesions are more common in blacks, Hispanics and Asians. Several disease processes and lifestyle habits can predispose or facilitate cerebral ischemia. For example, following age, hypertension is the most powerful stroke risk factor. People with cardiac disease, specifically with atrial fibrillation, valvular heart disease, coronary artery disease, myocardial infarction, congestive heart failure, as well as those with electrocardio-graphic evidence of left ventricular hypertrophy, are also at an increased risk for ischemic stroke. Other disorders, such as...

Cardiovascular Diseases Introduction

Atherosclerosis and its related complications, coronary heart disease (CHD), myo-cardial infarction and stroke, have been identified as the major causes of mortality and morbidity in the Western world. Atherosclerosis is a progressive build-up of fatty streaks on the interior arterial walls that prevents adequate blood supply to the myocardium. Although many factors are involved in atherosclerosis, oxidation of low-density lipoprotein (LDL) by free radicals may initiate the lesions and lead to the development and progression of cardiovascular disease (CVD).

Gene Transfer and Gene Therapy for Cardiovascular Disease

Although drug therapy is available for the treatment of cardiovascular disease, cardiovascular morbidity and mortality are poorly controlled throughout the world. Many of the pharmacological agents used to treat cardiovascular disease are expensive and therefore unavailable to poor segments of all societies. The available drugs are transient or short lasting in effect (usually

Garlic and Cardiovascular Diseases

Cardiovascular disease (CVD) is the number one killer in the U.S. and Western Europe. Among many factors related to the onset of CVD, high-fat diets, sedentary living, smoking, excess consumption of alcohol, Type A personality (excessive stress), genetic potential, and other environmental factors are blamed as causes. Diet and lifestyle seem to be only factors that can be controlled. ischemic heart disease.74 The consumption of 3 g fresh raw garlic (a single clove daily) by study subjects for 16 weeks resulted in 21 reductions in serum cholesterol levels. This significant reduction was gradual and not observed until 4 weeks into the study. A significant reduction in serum thromboxane levels was also observed.67 McCrindle et al. studied the effect of commercially available garlic extract (Kwai ) on serum cholesterol and lipoproteins in children 8 to 18 years of age with familial hypercholesterolemia. They were given 300 mg garlic extract 3 times a day (900 mg day) in a controlled...

Ischemic Stroke

A lower incidence of ischemic stroke occurs in premenopausal women compared to men.5-9 Explanations for this difference include lifestyle, vascular differences,10 direct and indirect effects of estrogen on the blood vessel wall,11-13 and other endocrine in-fluences.14 Similar sex differences in the incidence of stroke have also been documented in animal studies. For example, in one such study, a greater proportion of male gerbils showed clinical signs of stroke during a 3-hour unilateral carotid occlusion than did the females.15

Heart Attack

A common predictor of heart attack is angina, a pain in the chest usually experienced upon exertion or after eating. The pain occurs because there is not sufficient blood reaching the heart due to atherosclerosis or a narrowing of the arteries. The actual cause of most heart attacks is the formation of a blood clot in a coronary artery that has been narrowed by atherosclerosis. The clot blocks the supply of blood carried by the artery and that portion of the heart subsequently dies. What happens mechanically at the time of death from a heart attack is ventricular fibrillation, an erratic heartbeat that interrupts delivery of oxygenated blood to the brain. The determining factor of whether the death of a portion of the heart muscle actually results in the whole heart expiring may depend on the condition of the autonomic nervous system that governs involuntary actions like breathing, digestion, and heartbeat. If the autonomic nervous system is in sympathetic mode, which has a...

Heart Disease

Hyperglycemia, systolic hypertension, and fasting hypertriglyceridemia) that has a well-known association with ischemic heart disease.184 McCance et al. reported in 1994 a higher rate of diabetes in adults with birth weights 2500 g compared to those with weights between 2500 and 4499 g (odds ratio 3.8) when age, sex, BMI, maternal diabetes during pregnancy, and birth year were controlled.185 A study published in 2002188 evaluated the influence of size at birth, during infancy, and throughout childhood growth (from ages 3 to 11 years) on the occurrence of coronary heart disease, type II diabetes mellitus, and hypertension. This longitudinal study by Barker et al. involved 13,517 men and women born from 1924 through 1944. Men and women who had birth weights above 4 kg and whose prepubertal BMIs at age 11 were in the lowest fourth had half the risk of coronary heart disease when compared with people whose birth weights were below 3 kg and BMIs were in the highest fourth. Similar strong...

Acute stroke

Both CT and MRI will, with careful interpretation, demonstrate almost all detectable cerebral infarcts within the first 12 h. They will show the early appearance of hemorrhage, although in some cases CT may be easier to interpret. Primary hemorrhages are often distinguishable from hemorrhagic stroke the former usually show surrounding brain damage confined to the periphery of the hematoma and not extending in the territory of a major artery.

What Dietitians Offer

It is vital that we do more than give lip service to the idea of evidence-based practice we must understand it and use it in everyday healthcare. This chapter will explore the evidence on who should provide dietary advice to reduce cardiovascular risk and the best evidence-based advice to help people with cardiovascular diseases alter the foods that they eat every day. It will start with a short introduction to evidence-based practice.

Who Should Give Dietary Advice

What evidence indicates who should give dietary advice to reduce cardiovascular risk A systematic review of randomised controlled trials addresses this issue.9,10 These studies were carried out in the U.K., the U.S., and Australia in a variety of settings including general practices, workplaces, and clinics. Some participants had heart disease at baseline others had slightly or distinctly raised serum cholesterol and some had risk factors for diabetes. Duration of studies varied from 6 to 104 weeks, and data were used only for participants who did not take or had stopped taking lipid lowering medications (so that the outcomes were not biased by the effects of these medications in some groups). Outcome measures in the trials included total serum cholesterol in all studies, along with low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, blood pressure, weight, and patient satisfaction in one or more studies. Participants seen by dietitians tended to be...

Epidemiology Of Chd In Subsaharan African Populations

Africans were diagnosed with CHD in 1992,13 51 in 1993, and 65 in 1994.14 However, of the 65 diagnosed in 1994, only 36 were Sowetans the rest lived elsewhere. In 2000, the hospital treated 50 Sowetan CHD patients. This is still a very low annual incidence rate of approximately 5.0 per 100,000 population.15At urban Pirenyatwa Hospital, the main referral center for neighboring Zimbabwe, six African patients on average were diagnosed annually with acute myocardial infarction from 1988 to 1993.16 In 1996 in Nigeria, a comprehensive review concluded, CHD is still rare despite increased incidence in recent years. 17 Clearly, CHD remains uncommon among urban Africans in South Africa and other sub-Saharan African countries.1318 Regarding a perspective on the epidemiological situation described, one important question is how does the uncommonness of CHD in Africans compare in magnitude with its high frequency in socioeconomically better placed Western populations In Soweto, sick Africans...

Epidemiology Of Chd In African American And White Populations

To provide additional perspective regarding the continuing low rates of CHD in sub-Saharan African populations, it is valuable to consider both some past and present international epidemiological data. In 1979, an analysis was made of 6414 emergency visits in 3 hospitals in St. Louis, MO.21 Although African Americans were involved in half of all visits, myocardial infarction was found to be 15 times more common in the white population. Thus, roughly a generation or so ago, CHD was very uncommon in African Americans. What a tremendous contrast to the present situation. In 1998, in populations aged 35 years and over, following increases in risk factors, the mortality rate in African American men rose to be only slightly lower than that in white men, namely 321 versus 440 per 100,000 population. Moreover, the rate in African American women compared with white women was higher 264 versus 202 per 100,000.22 pathology department of the London Hospital performed one or two necropsies per...

Dietary Prevention Of Sudden Cardiac Death

The hypothesis that eating fish may protect against SCD is derived from the results of a secondary prevention trial, the Diet and Reinfarction Trial (DART), which showed a significant reduction in total and cardiovascular mortality (both by about 30 ) in patients who ate at least two servings of fatty fish per week.3 The authors suggested that the protective effect of fish might be explained by a preventive action on ventricular fibrillation (VF), since no benefit was observed on the incidence of nonfatal acute myocardial infarction (AMI). This hypothesis was consistent with experimental evidence suggesting that n-3 polyunsaturated fatty acids (PUFAs), the dominant fatty acids in fish oil and fatty fish, have important effects on the occurrence of VF in the setting of myocardial ischemia and reperfusion in various animal models, both in vivo and in vitro.4,5 In the same studies, it was also apparent that saturated fatty acids are proarrhythmic as compared to unsaturated fatty acids.

Introductory Comments

The relationship between obesity and cardiovascular disease is well established and has been extensively reviewed.1-4 The coexistence of obesity and hypertension provides a compelling rationale to examine specific mechanisms that contribute to obesity and evaluate whether these mechanisms explain the relationship between blood pressure (BP) and increased levels of body fat. The discovery of leptin, an adipocyte-derived hormone, in 19945 marked the beginning of rapid progress in understanding signals involved in responding to nutritional input, central pathways regulated by these signals, and efferent mechanisms regulated by leptin and these

Epidemiologic Evidence

Observational studies of dietary intake and serum levels of antioxidants including descriptive, case-control, and cohort studies point toward preventive effects of antioxidants on coronary heart disease. However the protective effects were consensually described only for high consumption of antioxidant-rich foods, particularly for vitamin E from dietary sources. This inverse relation has been consensually described only for the upper levels of consumption of fruits, vegetables, and other foods containing vitamins, particularly vitamin E.28-32 A review33 reporting measures of association between fruit and vegetable intakes and coronary heart disease found nine of ten ecological studies, two of three case-control studies, and six of sixteen cohort studies that reported significant protective associations of consumption of fruit and vegetables or their antioxidant constituents with the disease. Large secondary prevention studies of antioxidant vitamins in people who already had clinical...

Hcholf Diets And Triglyceride Metabolism

The concept of carbohydrate-induced hypertriglyceridemia emerged as soon as the first studies comparing plasma lipid concentrations during high-fat and high-CHO diets were performed in the 1950s.9 24 Since high TG level appears as an independent risk factor for coronary heart disease (CHD),25 this possible adverse effect raised, in addition to the decrease in HDL cholesterol, concerns about using high-CHO diets for the prevention of atherosclerosis.13

Evidence Of Cardioprotection By Mediterranean Diets

For years, serum cholesterol has been accepted as a major risk factor for coronary artery disease (CAD).1 This view led to the hypothesis that reduction of plasma cholesterol by dietary means might reduce cardiovascular risk. It must be noted, however, that among all the many dietary trials conducted, only those reproducing Mediterranean or Asian-vegetarian types of diets have shown significant reduction of CAD morbidity and mortality.2 The phenomenon occurred independent of dietary effects on plasma cholesterol.3-5

Antioxidant Potential Of Mediterranean Diets

In the Cambridge Heart Antioxidant Study,23 2002 patients with coronary atherosclerosis were randomly assigned to receive 400 to 800 IU of vitamin E per day (or placebo). After a median follow-up of 1.4 years, a large reduction in the number of patients with nonfatal myocardial infarction was observed (relative risk 0.60). These findings are supported by the results of the GISSI Prevenzione Study26 and the Heart Outcomes Prevention Evaluation (HOPE).27 Patients who had myo-cardial infarctions were randomly assigned to receive 30026 and 40027 mg of vitamin E per day, respectively. After 3.5 (GISSI) and 4.5 (HOPE) years of follow-up, the results indicate that such treatments had no effects on the risk of death or cardiovascular event. Because higher vitamin E consumption was associated with higher intakes of other antioxidants20 in the epidemiological studies that found an association between higher vitamin E intake and lower rates of CHD, it is possible that vitamin E supplementation...

Implications For Soy As A Complementary Hormone Replacement Therapy

Accumulating evidence suggests that significant interactions occur between plasma estradiol and soy isoflavones that may decrease risk factors for cardiovascular disease. In 1997, Wagner and coworkers reported on a study with cynomolgus macaque females with preexisting diet-induced coronary artery atherosclerosis.67 Both soy and estradiol reduced aortic cholesterol ester content but more importantly, as shown in Figure 13.13, the soy and estradiol combination resulted in a greater reduction in cholesterol ester concentration than with either treatment alone (soy protein X estradiol interaction, p 0.02). Similarly, as mentioned earlier in the chapter, a significant (p 0.05) interactive effect of soy and estradiol on vascular reactivity of postmenopausal monkeys has also been reported.47

Poor Intake and Absorption

Edema of the intestinal wall and mucosal surfaces may lead to impaired nutrient absorption and lymphatic drainage. Sondheimer and Hamilton120 reported calorie losses in stools as both proteins and fats, but Menon and Poskitt114 found no significant difference between stool losses of infants with heart disease and control patients. This factor is of importance when aggressive nutritional therapy with supplemental enteral feedings is attempted in these children. Excessive vomiting caused partly by gastroesophageal reflux may reduce the net intake of food.121

Influence of Fetal and Infant Nutrition on Adult Onset Cardiovascular and Metabolic Diseases

Low birth weight is associated with increased risk of coronary heart disease, hypertension, and adult onset diabetes mellitus. mellitus (Table 14.10). The most unfavorable growth pattern seems to be smallness and thinness at birth, continued slow growth in early childhood, and then accelerated growth secondary to dietary excesses. In the case of hypertension, the risk has been shown to be increased by low social class, few rooms in the home, and poor educational achievement. Improving maternal and infant health may be the key to effective prevention of cardiovascular disease in adult life.

What Are Plant Sterols And Stanols

As mentioned, plant sterols and stanols effectively lower serum cholesterol concentrations. To understand (1) why these effects are beneficial with respect to the development of cardiovascular disease and (2) the mechanisms of actions of plant sterols and stanols, it is necessary to be familiar with some basic principles of cholesterol metabolism and the relation between cholesterol concentrations and cardiovascular disease. These issues will be discussed in Section 15.3 and Section 15.4 before the discussion of the effects of plant sterols and stanols on lipid and lipoprotein metabolism.

Metabolism of Plant Sterols and Stanols

Sitosterolemia is a rare inherited disease characterized by xanthomas in skin, tendons, and coronary arteries and early development of atherosclerosis. It often results in an early myocardial infarction, sometimes before the age of 20.4344 These patients have extremely high serum concentrations of plant sterols and stanols. Sitosterol in particular is extremely elevated and plasma concentrations in these patients are about 0.48 mmol L. In nonsitosterolemic people, concentrations are more than 40 times lower. The high serum plant sterol and stanol concentrations are due to increased absorption of plant sterols and stanols in combination with slow elimination. Patients with sitosterolemia have mutations in ABCG5 and ABCG8 that may result in reduced transport from plant sterols and stanols from enterocytes back into the intestinal lumen and in reduced secretion into bile.45-47 Mice overexpressing ABCG5 and ABCG8 showed clear reductions in plasma sitosterol and campesterol concentrations...

Expression Of iNos In Heart Failure

In end-stage ischemic or nonischemic heart failure, the expression of iNOS in cardiac myocytes of failing hearts was found by other authors.22,27 Saito et al. found induction of iNOS during myocardial infarction (MI) exerts negative effects on cardiac function and structure, and long-term administration of a selective iNOS inhibitor (S-methylisothiourea) is beneficial in the treatment of MI and congestive heart failure.30 Feng et al. found mortality is significantly decreased and LV myo-cardial contractility is increased after MI in iNOS knockout mice compared with wild-type mice.31 Although cardiac dysfunction and heart failure may have different etiologies, both are related to iNOS expression, and inhibition of iNOS activity with selective iNOS inhibitors can improve the heart function.

Homocysteine And Folate

In a study of subjects with very early onset vascular disease, Brattstrom et al. observed that blood vitamin B12 and folic acid concentrations were significantly and inversely related to fasting homocysteine concentrations.19 Folate and B12 concentrations explained 23 and 5 , respectively, of the variation in basal homocysteine in cardiovascular disease patients. Pyridoxal phosphate (B6) was not significantly related to basal homocysteine. A subset of these patients was treated with 240 mg pyridoxine hydrochloride for 2 weeks. The treatment produced no change in basal homocysteine and a 26 reduction in post-methionine load homocysteine elevations. A further 2 weeks of pyridoxine treatment combined with 10 mg folic acid produced a mean 53 reduction in basal homocysteine and a 39 reduction in post-load homocysteine increases. This study highlights the separate effects of folic acid and pyridoxal phosphate on homocysteine metabolism. The effect of pyridoxal phosphate was confined to...

Diet And Prevention Of Plaque Inflammation And Rupture

In 1987, we proposed that inflammation and leukocytes play roles in the onset of acute CHD events.62 This has recently been confirmed.63-66 It is now accepted that one of the main mechanisms underlying the sudden onset of acute CHD syndromes, including unstable angina, myocardial infarction, and SCD, is the erosion or rupture of an atherosclerotic lesion63 64 that triggers thrombotic complications and considerably enhances the risk of malignant ventricular arrhythmias.65 66 Leukocytes have been also implicated in the occurrence of ventricular arrhythmias in clinical and experimental settings67,68 and contribute to myocardial damage during both ischemia and reperfusion.67 Clinical and pathological studies showed the importance of inflammatory cells and immune mediators in the occurrence of acute CHD events, and prospective epidemiological studies showed a strong and consistent association between acute CHD and systemic inflammation markers. A major question is to know why macrophages...

Indian Girl Ka 664266

Bostick RM, Kushi LH, Wu Y, Meyer KA, Sellars TA, and Folsom AR. Relation of calcium, vitamin D, and dairy food intake to ischaemic heart disease mortality among postmenopausal women. Am J Epidemiol 1999 149 151-61. Bashir Y, Sneddon JF, and Staunton A. Effects of oral magnesium chloride replacement in CHF secondary to coronary artery disease. Am J Cardiol 1993 72 1156-62. Gottlieb SS, Baruch L, and Kuklin ML. Prognostic importance of the serum magnesium concentration in patients with congestive heart failure. J Am Coll Cardiol 1990 16 827-31. Hasan RA, Zureikat GY, and Nolan BM. Torsade de pointes associated with Astem-izole overdose treated with magnesium sulfate. Pediatr Emerg Care 1993 9 23-5. Woods KL, Fletcher S, Roffe C, and Haider Y. Intravenous magnesium sulphate in suspected acute myocardial infarction results of the second Leicester Intravenous Magnesium Intervention Trial (LIMIT-2). Lancet 1992 339 1499-503. ISIS-4 Collaborative Group. ISIS-4 a randomised factorial trial...

Interpretation of Abbreviations and Computation of Parameters of LV Function

Cardiac Medical Abbreviation Plb

Taken together, ryanodine receptors, SERCA 2a, and PLB are key calcium cycling proteins, targets for many drugs, and the mode of some cardiovascular diseases, including the aging process. For the majority of individuals free of cardiovascular disease, the aged heart adapts well to performing its required systolic (pump) function in the basal state at rest (see Table 17.2). Based on existing techniques such as echocardiography and magnetic resonance imaging (MRI), no evidence points to an age-related decline of resting systolic function (characterized by cardiac output) in individuals free of cardiovascular disease.18 The resting LV function is maintained though the Frank-Starling mechanism by increasing preload (Ved) resulting in increased stroke volumes. Cardiac output is equal to stroke volume times heart rate.

Thrifty Phenotype Hypothesis

The structural and metabolic alternations induced in utero by adverse environment entrain both selective preservation of key organs and metabolic adaptations that are of advantage in a restricted postnatal life. If nutrition becomes plentiful postnatally, these changes predispose to obesity and impaired glucose tolerance. This has been substantiated by the Dutch Famine study in which poor nutrition in the first trimester was associated with increased obesity in 19-year-old males.197 This obesity and the consequent metabolic syndrome predispose an individual to coronary heart disease later in life. These studies led to the thrifty phenotype hypothesis that attributes these suggested associations to the programming of metabolism and function of a tissue or organ as a result of diminished supplies of certain nutrients during critical stages of development.184 198 The effects of impaired fetal growth are modified by subsequent growth the highest risks of heart disease, type II diabetes,...

Cardiovascular And Autonomic Effects Of Leptin

Increasing attention is focused on the cardiovascular disease risk linked to the tachycardia commonly seen in obese patients.43031 Is increased circulating leptin a primary cause of the tachycardia associated with obesity Some human studies have observed correlations between circulating leptin levels and resting heart rate (HR), although the results are quite variable.32-34 In one study where HR was not correlated with leptin per se, spectral analysis suggested a relationship between elevated leptin and increased relative cardiac sympathetic tone.33

Grape Seeds and Red Wine

Evidence has increasingly shown protective effects of red wine consumption on established heart disease. Pataki et al.14 demonstrated that red grape seed proantho-cyanidins improve cardiac recovery after ischemia in animals. Two groups of rats were fed either 50 or 100 mg grape seed proanthocyanidins kg for 3 weeks a third group served as controls. After 30 minutes of ischemia and 2 hours of reperfusion, the animals treated with proanthocyanidins had reduced incidences of abnormal heart contractions equal to 42 and 25 respectively as compared with 92 in the control group. Proanthocyanidin treatment of 100 mg kg significantly reduced oxygen free radical formation by 75 compared with control animals. After 60 minutes of reperfusion, an improvement of 32 coronary blood flow, 98 aortic blood flow, and 37 in blood pressure was observed in the highest treatment group compared with controls.15 Another study using similar methodology indicated proanthocyanidins in red wine have protective...


NUTRITION and HEART DISEASE Heart disease is the primary cause of death and disability in Western countries. Research indicates that nutrition and diet play key roles in both preventing and causing many types of heart damage and dysfunction. By understanding the complex relationship between diet and disease, new prevention measures can be established and millions of lives can be saved. Heart Disease


Ronald Ross Watson, Ph.D., is an internationally recognized nutritionist and immunologist. He directs several biomedical grants funded by the National Institutes of Health (NIH) relating to the causes of heart disease. Dr. Watson has studied the importance of fats in the diet for 20 years. His model studies have involved dietary deficiencies and excesses. Dr. Watson has edited 54 biomedical books, including a recent book Alcohol and Heart Disease. He contributed several chapters to this book based on research from his four grants from the National Heart, Lung, and Blood Institute to study cardiovascular disease.


The research evidence suggests that dietitians are needed to give dietary advice to those at high risk of cardiovascular disease, in lieu of or in addition to dietary advice from physicians. In what circumstances trained nurses or self-help materials can substitute for a dietitian's role is not clear (more research is needed), but they can serve as useful allies when a dietitian's time is limited. Dietary advice for people with cardiovascular disease should include advice to increase long-chain omega-3 fats first and foremost. Other useful advice is to replace saturated fats with unsaturated fats and to adopt a Mediterranean-style diet. These steps represent the most important dietary advice known to reduce illness and mortality and should be given before patients receive additional advice to alter specific risk factors in their diets.

Useful Contacts

The Cochrane Collaboration developed in response to Archie Cochrane's call for systematic, up-to-date reviews of all relevant randomised clinical trials of healthcare. Cochrane's suggestion that the methods used to prepare and maintain reviews of controlled trials in pregnancy and childbirth should be applied more widely was taken up by the Research and Development Programme initiated to support the United Kingdom's National Health Service. Funds were provided to establish a Cochrane Centre to collaborate with other organizations in the U.K. and elsewhere to facilitate systematic reviews of randomised controlled trials across all areas of healthcare. For more information about the Cochrane Collaboration see http . The sections of the Cochrane Collaboration that relate most specifically to cardiovascular disease include


Our study was the first prospective investigation of the role of dietary fish and shellfish on cardiovascular disease mortality in a Chinese population.19 We noted that middle-aged or older men in Shanghai who consumed at least one serving of fish and shellfish per week experienced 44 reductions in risk of fatal MI compared to less frequent consumers. The current study has a number of strengths. Among them are (1) the prospective study design that eliminates the possibility of recall bias (2) adjustment for various known cardiovascular disease risk factors at baseline including serum total to HDL Our study also has several limitations. The principal limitation is reliance on death certificates as the sole diagnostic sources of cardiovascular disease mortality. However, we reviewed hospital records and other supporting medical documents related to all cardiovascular deaths among cohort members and found no evidence of other more probable causes of death in these individuals. Among CHD...

Other Compounds

Myocardial biopsies in patients with heart disease have shown mitochondrial ubiquinone depletion, so ubiquinone deficiency may therefore play a role in the pathogenesis of both heart failure and ischemic heart disease.145 Patients with heart failure have lower myocardial levels of ubiquinone than normal individuals,146 and low serum ubiqinone levels are associated with increased mortality in heart fail-ure.147 The production of ubiquinone is reduced by HMG CoA reductase inhibitors (statins) leading to low serum levels148,149 although tissue levels remain stable with short-term statin therapy.150,151 Non-randomised studies in patients with dilated cardiomyopathy and ischemic heart disease-induced systolic dysfunction have shown positive results for ejection fraction, exercise tolerance, and New York Heart Association (NYHA) status with ubiquinone supplementation.152-154 Most placebo-controlled trials,155,156 but not all of them,157 support these findings and also show reductions in...

Oxidative Stress

Elevated levels of markers of oxidative stress, such as exhaled pentane159 and plasma or urinary malondialdehyde, have been reported in heart failure patients.160,161 The presence of these markers in CHF patients correlates with functional class and inversely with exercise tolerance, antioxidant levels, and indices of prognosis.162-165 Patients with coronary artery disease also show evidence of greater oxidative stress, which correlates with endothelial dysfunction and predicts cardiac events.166 Vitamins C and E suppress free radical production in the leukocytes of patients with acute myocardial infarction.133 184 They also retard the progression of transplant-associated coronary arteriosclerosis.185 A study examining the effects of profound lipid lowering and antioxidant vitamin therapy in patients at high risk for cardiovascular events confirmed the results of retrospective studies of reported vitamin intake and the incidence of cardiovascular events.186 In the Heart Protection...

Mechanisms Of Action

LDLs initially cross the endothelium in a concentration- and size-dependent manner and become trapped in the subendothelial space where they can be oxidized by resident vascular structures such as smooth muscle cells, endothelial cells, and macrophages. Monocytes differentiate into macrophages that internalize oxidized LDL, leading to foam cell formation. Further oxidation leads to endothelial dysfunction and injury as well as foam-cell necrosis.15 The presence of antioxidants inhibits LDL oxidation and limits cellular responses to oxidized LDL, resulting in less monocyte adhesion, less foam-cell formation, less cytotoxicity to vascular cells, and improved vascular function.17-19 The role of antioxidants in preventing the clinical manifestations of coronary heart disease (CHD) may additionally comprise mechanisms such as plaque stability, modification of vasomotor function, and reduction of thrombosis.17,20


9.2.1 Associations with Cardiovascular Disease In 1969, McCully linked the vascular outcomes associated with these enzyme defects to the common underlying homocystinuria and speculated that homocys-teine may be toxic to the vascular endothelium.2 Soon after this, Wilcken and Wilcken demonstrated an association between modest elevations in homocysteine and premature vascular disease.3 Since then, several studies have demonstrated a concurrent association between homocysteine and cardiovascular disease, while an ecological analysis showed a strong correlation between mean plasma homocysteine and cardiovascular mortality among 13 countries participating in the WHO MONICA Project.4 Stampfer et al. reported the first prospective nested case-control study of the association between homocysteine and vascular disease in 1992.5 Of an original cohort of 14,916 healthy male physicians aged 40 to 84 years who provided plasma samples at baseline, 271 subsequently suffered myocardial infarctions...

Genetic Explanations

Three genetic mechanisms have been postulated to explain the fetal origin of adult heart disease, but none has been confirmed by strong evidence. The thrifty genotype hypothesis200 suggests that in the early stages of evolution, a series of genes that adapted the individual to the intermittent availability of food may have been selected. This survival advantage may be detrimental to health when food availability is in abundance leading to cardiovascular and metabolic diseases.

LDL Cholesterol

High serum concentrations of LDL cholesterol are positively and causally related to the risk of coronary heart disease.7 Reducing serum LDL cholesterol concentrations will decrease the risk of coronary heart disease. Serum LDL cholesterol concentrations can be lowered by drugs that inhibit HMG-CoA-reductase, the rate limiting enzyme for endogenous cholesterol synthesis. These drugs are called statins and they reduce serum concentrations of total cholesterol by approximately 20 and LDL cholesterol by approximately 30 .8-11 The decreases are associated with reductions in the relative risk of death from coronary heart disease of 24 to 42 .8-11 One reason LDL cholesterol is atherogenic is the presence of several components in the LDL that are easily oxidized like the unsaturated fatty acids from phospho-lipids. The formation of oxidized LDL is an important step in the development of atherosclerosis. Oxidized LDL is not recognized by LDL receptors, but is instead efficiently cleared by...

Potential for Growth

Cyanotic heart disease is associated with proportionate retardation of weight and height, the severity depending on the degree of cyanosis.127 Some studies suggest lower oxygen consumptions in cyanotic patients compared to those in heart fail-ure,122,128 although low calorie intake and high metabolic rate may still play roles in growth retardation in these children. Endocrine factors have also been implicated. Cyanotic newborn lambs have decreased levels of serum insulin-like growth factor I (IGF-I) without corresponding decreases in growth hormone and hepatic growth factor receptors. saturation. Thus, chronic hypoxemia may exert a direct or indirect effect to reduce serum IGF-I concentrations, thereby contributing to growth failure. Kanazawa found that children with left-to-right shunt lesions had poorer glucose tolerance and lower levels of serum insulin that improved after surgical correction of the heart disease.131

Epidemiological aspects

Sudden unexpected cardiac arrest in adults has an incidence of 0.1 to 0.2 per cent in the general population, with 80 per cent of cases due to coronary heart disease. The incidence of cardiac arrest increases exponentially with age, reflecting the escalating frequency of coronary heart disease, but at all ages men are at greater risk than women. For coronary heart disease populations, hereditary factors producing hypertension, diabetes, lipid abnormalities, and male-pattern baldness predispose to cardiac arrest. Racial characteristics are important, with increased risks in colored populations, although the reasons for this are unclear. Cigarette smoking is the major acquired (and preventable) risk factor, although sedentary occupation and diet also play significant roles. Although acute and chronic alcohol abuse is associated with an increased frequency of arrhythmias, moderate intake may have a protective effect on coronary heart disease and cardiac arrest by increasing 'protective'...

The pathogenesis of cardiac arrhythmia initiation

The development of an arrhythmia is believed to result from the superimposition of a 'transient' factor on a pre-existing or static factor. owever, an arrhythmic death may occur in the absence of clinically detectable cardiac disease. Only 20 per cent of cardiac arrest patients with coronary heart disease are subsequently shown to have developed an acute myocardial infarct with an acute plaque fissure causing platelet aggregation and subsequent thrombus formation. Transient myocardial ischemia-reperfusion causes the transient factor in the remainder, and in the presence of left ventricular hypertrophy or a previously healed myocardial infarction is particularly liable to be arrhythmogenic.

Electromechanical dissociation

Circadian variation and triggers of cardiovascular disease. Cardiology, 85 (Supplement 2), 3-10. Myerburg, R.J. and Castellanos, A. (1992). In Heart disease a textbook of cardiovascular medicine (4th edn) (ed. E. Braunwald), p. 756. W.B. Saunders, Philadelphia, PA.

Nutritional Deficiencies And Cvb3induced Myocarditis

Murine models of CVB3-induced myocarditis have also been exploited to examine the effects of deficient, nutrient-limited, or excessive nutrition (hypercholesterol) diets on the severity or outcome of an infection. In general, mice on diets with nutrient deprivation or hypercholesteremic, vitamin E-deficient, or selenium-deficient diets develop more severe myocarditis than matched groups on normal healthy diets.48,174 Recall that most naturally occurring CVB3 strains are not cardiovirulent for susceptible mouse strains.53,129 An important finding from selenium- and vitamin E-deficient diet studies was that revertant cardiovirulent variants were readily selected from the challenge inocula population of non-cardiovirulent CVB3 viruses, established residence in heart tissues, and induced severe heart disease.174 Early studies of mice on deficient diets that were forced to exercise reported higher titers of virus in heart tissues and more severe disease, often leading to death (reviewed in...

Conclusions And Predictions

The voluminous data on murine models of CVB-, predominantly CVB3-, induced myocarditis show that many factors contribute to recovery from acute myocarditis or the transformation to chronic myocarditis. Chance determines whether a person is infected with a cardiovirulent CVB3 or reacts unfavorably to a noncardiovirulent strain when immunosuppressed or consuming an inadequate diet. Murine models have established that a heart disease outcome depends on the genetic background, sex, and age of the host nutritional and immunologic status of the host and innate and immunologic systems responses to the CVB infection. The researcher has the advantage of being able to control most of these variables to design the disease needed for further study. Decades have been spent searching for diagnostic tests whose results would covary with detection or severity of myocarditis induced in CVB3-murine models. Perhaps a potential method has been found in the use of polymerase chain reaction to monitor...

Circulatory management after successful cardiac resuscitation Pharmacological interventions

Pharmacological interventions optimizing left ventricular afterload and preload remain the mainstay for the treatment of post-resuscitation myocardial dysfunction. Nitroglycerin and nitroprusside are the predominant vasodilator drugs in current use. At medium and high doses (5-10 g kg min) nitroglycerin relaxes both venous and arterial smooth muscle. The more selective coronary vasodilation produced by nitroglycerin also favors its use in the management of post-resuscitation myocardial dysfunction in which cardiac arrest was caused by ischemic heart disease. At low doses, nitroglycerin acts primarily as a venodilator which decreases preload. Intermittent treatment with nitroglycerin after 24 h mitigates tachyphylaxis which accounts for loss of hemodynamic efficacy. In patients with coronary atherosclerosis, coronary vasodilation may reduce blood flow of partially occluded vessels (coronary steal). This may explain the increased frequency of angina in patients with ischemic heart...

Tissue Plasminogen Activator

Tissue plasminogen activator (tPA) enzyme dissolves blood clots and is therefore used for the treatment of myocardial infarction and thrombolytic occlusions. Alternative products that were available, such as urokinase and streptokinase, were less specific and could cause general internal bleeding and other side effects. A means of producing tPA had been sought for many years but production levels from endothelial cells were too low to form a production process. Even a rich in vivo source such as the human uterus only yielded 1 mg tPA 5 kg uterus (0.01 mg purified tPA uterus) (Griffiths & Electricwalla 1987). Some tumour cell lines, such as the Bowes melanoma, secrete tPA at a higher rate (0.1 mg l) (Cartwright 1992), but this was still considered uneconomical for production, and at the time was considered unsafe, coming from a human melanoma. tPA was thus an ideal product for recombinant enhancement as it was a high-activity low-concentration product with a huge clinical demand....

The Role Of The Dietitian In Diabetes Care

Ideally, it is the role of the dietitian to provide the dietetic intervention. A vital part of the dietetic consultation is the assessment of readiness to change eating behaviour (19). Exploration of barriers to change and awareness of psychosocial issues form part of the dietary consultation process. In the short term, food intake needs to be regulated and balanced against medication, in order to optimise blood glucose control. This also includes assessment of whether current medication matches the meal pattern and therefore whether it is appropriate, as well as the management and prevention of hypoglycaemia and hyperglycaemia. Long-term dietary control can offer protection against cardiovascular disease with weight management and modification of other lifestyle factors being essential. Dietary counselling should be innovative and specific to the requirements of the individual, rather than being rigid, prescriptive and restricted to a particular system of teaching, as may be the case...

A pAdrenergic receptor blockers

P-blockers are recommended first-line agents in uncomplicated hypertension, or in hypertensive patients with angina pectoris, cardiac arrhythmias, mitral valve prolapse, a history of myocardial infarction (MI), diastolic dysfunction, or migraine headaches. p-blockers are preferred in young Caucasian hypertensive patients (younger than 40-50). African-Americans tend to respond less well to p-blockers.

Gene Analysis in the Injured and Hypertrophied Heart

Accumulating evidence indicates that cardiovascular diseases are associated with changes in gene expression. Identification of new candidate genes involved in heart disease will provide the molecular basis for diagnosis, prevention, and intervention. It is important to determine whether the changes in gene expression cause heart diseases or are secondary to heart diseases. It is interesting that different mutations inducing hypertrophic cardiomy-opathy are associated with different prognoses and survival times. With respect to the genetic diagnosis of cardiac diseases such as hypertrophic cardiomyo-pathy or the long QT syndrome, it has become possible to characterize genetic mutations responsible for some heart diseases. Chapters 16 and 17 provide protocols for delineating and evaluating genes involved in cardiac hypertrophy in response to pressure overload. Perhaps a better way to determine the role of a specific gene in pressure-overload hypertrophy is to evaluate the hypertrophic...

Epidemiology And Burden

In general, health statistics focus primarily on quantifying the health status of populations and suffer from several limitations that reduce their practical value to policy-makers. The statistical information is partial and fragmented and in many countries even the most basic data (e.g. the annual number of deaths from particular causes) are not available. Further, the simple head count approach does not allow policy-makers to compare the relative cost-effectiveness of different interventions, for example the treatment of conditions such as acute stroke versus the long-term care of patients with chronic disorders such as Parkinson's disease or multiple sclerosis. At a time when people's expectations of health services are growing and funds are constrained, such information is essential for the rational allocation of resources.

Energy Balance And Body Weight

Obesity is recognised as a leading cause of insulin resistance (21). It therefore contributes to the development of Type 2 diabetes. This is particularly true for a central distribution of body fat, associated with a range of metabolic disturbances. Weight management is crucial in controlling blood glucose levels in people with Type 2 diabetes, although from UKPDS there is evidence that to normalise glucose tolerance usually requires major weight loss. Studies suggest that at least 80 of newly diagnosed patients with Type 2 diabetes are overweight and weight loss in people with Type 2 diabetes who are overweight increases life expectancy. Obesity is an additional risk factor for coronary heart disease and stroke. All cardiac risk factors (glycaemia, hypertension, lipids) are improved with weight management (22). This is true for individuals with Type 1 diabetes as well as Type 2 diabetes. However, it is also important to make sure that energy requirements are adequate in children and...

Adenoviruses Introduction

Human Ad have been highlighted as probable causes of human myocarditis. The Ad are double-stranded DNA viruses with linear genomes of approximately 40 kbp.121,122 Like picornaviruses, their capsids consist of proteins arranged in an icosahedral design.123 The discovery of the receptor protein, CAR, used by the CVB to enter human cells (see above) and subsequent work has shown that CAR is also the primary receptor used by Ad. Because the ability of a virus to enter cells represents a primary first step toward causing a disease in a given tissue, the ability of both CVB and Ad to use CAR as their receptor and their linkage to human inflammatory heart disease are perhaps not surprising. Nonetheless, viral pathogenesis requires more than mere cell access many viruses can infect various tissues but cause no disease. Thus, much remains to be done to understand the propensity for Ad to replicate and cause disease in myocardial cells.

Assessing The Risk And Benefit Of Surgery

The indications and contraindications to treat heart diseases with surgery continue to evolve and a full discussion is beyond the scope of this handbook. How ever, certain principles and basic rules will be discussed. Surgeons must know the natural history of heart diseases and how therapeutics can modify them. Surgery is a form of therapy which is always associated with morbidity and, unfortunately, mortality. These factors must be weighed against the natural history of the disease and or medical treatment. The influence of co-morbid conditions must also be weighed in the evaluation of the natural history and outcomes of medical and surgical therapy. Ventricular function is the most important determinant of outcome of all heart diseases. Patients with severe LV dysfunction usually have a poor prognosis but surgery can sometimes dramatically change it. LV dysfunction due to CAD is among the most difficult to assess and to determine the effect of revascularization. A simple rule is...

The Obesity Epedemic in America

The significance of overweight or obese BMI is that it correlates with an increased relative risk for developing chronic diseases and cancers. The data from a 10-year follow-up of the combined Nurses' Health Study and the Physician's Health Professionals Follow-Up Study show men and women who are overweight, compared to a normal BMI of 18 to 24.9, are more likely to develop gallstones, hypertension, high cholesterol, and heart disease. The relative risk (RR) for developing diabetes of an individual with a BMI 35 or greater is 20 times greater than for someone with a normal BMI 18 . The American Heart Association's scientific statement on obesity as an independent risk factor for heart disease states obesity not only relates to but independently predicts coronary atherosclerosis 19 . The relative risk (RR) of cardiovascular death increases with BMI. A BMI of 19 to 21.9 has an RR of 1, and a BMI 32 has a RR over 3 20 .

Computerised Tomography

CT scanning has been successfully used for demonstrating abnormalities in bone (particularly around the skull base), detecting acute haemorrhages (following a stroke) and highlighting brain tumours (Fig. 1). On the other hand, the main disadvantage with this technique is that the fine structural details of the soft tissues of the brain are not well seen. Another disadvantage is that X-radiation is used, so radiation safety issues become important. A contrast agent may need to be injected into a peripheral blood vessel for some studies where the integrity of the blood-brain barrier is being investigated (e.g. tumours, acute stroke), hence adding an invasive element to the investigation. This method of investigation may sometimes remain the only safe viable option, as the patient may have previously been implanted with a pacemaker, or other metallic device that prevents them from being safely scanned using magnetic resonance imaging (see below).

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