Comprehensive cardiovascular risk management – what does it mean in practice?

The continued movement away from the treatment of individual cardiovascular (CV) risk factors to managing overall and lifetime CV risk is likely to have a significant impact on slowing the rate of increase in cardiovascular disease (CVD). However, the management of CVD is currently far from optimal even in parts of the world with well-developed and well-funded healthcare systems. Effective implementation of the knowledge, treatment guidelines, diagnostic tools, therapeutic interventions, and management programs that exist for CVD continues to evade us. A thorough understanding of the multifactorial nature of CVD is essential to its effective management. Improvements continue to be made to management guidelines, risk assessment tools, treatments, and care programs pertaining to CVD. Ultimately, however, preventing the epidemic of CVD will require a combination of both medical and public health approaches. In addition to improvements in the “high-risk” strategy, management, an increase in the utilization of population-based management strategies needs to be made to attempt to reduce the number of patients falling within the “at-risk” stratum for CVD. This review outlines how a comprehensive approach to CVD management might be achieved

Diversity at organizational levels: the effect of executive board of directors and corporate officers diversity on performance

The research of diversity effects on performance shows the need to go beyond individual or group level of analysis and to include the organizational levels of analysis. In light of current evidence that shows a positive effect of diversity on innovation and creativity performance at group levels, this study hypothesized that other performance measures may also be positively correlated at organizational levels. This relationship was examined by using 1993 and 1998 financial data and diversity representation (average between 1997 and 1998) from 127 large US companies. Two performance measures (return on asset and investment) were correlated with executive board of director and corporate officer diversity (race and gender). This statistical analysis indicated that executive board of director and corporate officer diversity are positively correlated with organizational performance. The discussion addressed: first, the advantage of organizational level of analysis over the individuals and groups approach; and second, the implications for human resources management and a need to develop a theoretical framework for diversity\u27s effect on performance

No effects on myocardial ischaemia in patients with stable ischaemic heart disease after treatment with ramipril for 6 months

OBJECTIVE: To assess the effects of a 6-month angiotensin-converting enzyme (ACE) inhibitor intervention on myocardial ischaemia. METHOD: We randomized 389 patients with stable coronary artery disease to double-blind treatment with ramipril 5 mg/day (n = 133), ramipril 1.25 mg/day (n = 133), or placebo (n = 123). Forty-eight-hour ambulatory electrocardiography was performed at baseline, and after 1 and 6 months. RESULTS: Relevant baseline variables were similar in all groups. Changes over 6 months in duration of ≥ 1 mm ST-segment depression (STD), total ischaemic burden and maximum STD did not differ significantly between the treatment groups. There was no difference in the frequency of adverse events between the groups. CONCLUSION: ACE inhibitor treatment has little impact on incidence and severity of myocardial ischaemia in patients with stable ischaemic heart disease

Elevated glutamine/glutamate ratio in cerebrospinal fluid of first episode and drug naive schizophrenic patients

BACKGROUND: Recent magnetic resonance spectroscopy (MRS) studies report that glutamine is altered in the brains of schizophrenic patients. There were also conflicting findings on glutamate in cerebrospinal fluid (CSF) of schizophrenic patients, and absent for glutamine. This study aims to clarify the question of glutamine and glutamate in CSF of first episode and drug naive schizophrenic patients. METHOD: Levels of glutamine and glutamate in CSF of 25 first episode and drug-naive male schizophrenic patients and 17 age-matched male healthy controls were measured by a high performance liquid chromatography. RESULTS: The ratio (126.1 (median), 117.7 ± 27.4 (mean ± S.D.)) of glutamine to glutamate in the CSF of patients was significantly (z = -3.29, p = 0.001) higher than that (81.01 (median), 89.1 ± 22.5 (mean ± S.D.)) of normal controls although each level of glutamine and glutamate in patients was not different from that of normal controls. CONCLUSION: Our data suggests that a disfunction in glutamate-glutamine cycle in the brain may play a role in the pathophysiology of schizophrenia

Is calcium sensitization the best strategy to improve myocardial contractility in acute heart failure?

The finely-tuned increases and decreases in the intracellular calcium levels in myocytes ultimately regulate the contraction and relaxation of the heart. Therapeutic agents can improve or interfere with this delicate balance. Calcium sensitizers enhance cardiac contraction by improving the use of calcium that is available, rather than by inundating the cell with excessive calcium, as is the case with traditional inotropes. With the sensitizing mechanism, the energy cost of contraction is maintained at a near-normal level, and the threat of arrhythmias and sudden death is low. Levosimendan is the first calcium sensitizer to become available for the treatment of patients with acute heart failure. In recent clinical studies, levosimendan increased cardiac output and stroke volume without significantly increasing oxygen demand. By its additional action as a vasodilator (via potassium channel opening), levosimendan also corrects the hemodynamic decompensation, thus lowering the pulmonary capillary wedge pressure and systemic vascular resistance. Furthermore, levosimendan increases the coronary circulation thus leading to an improved function of the stunned myocardium and lessened ischemia. Taken together, levosimendan's primary calcium-sensitizing action, along with its complementary vasodilator properties, make this new drug a highly promising agent for the treatment of patients with acute heart failure

Women - a neglected risk group for atherosclerosis and vascular disease

Women are a neglected group for cardiovascular disease. Whereas young women tend to have lower incidences of coronary artery disease, stroke and myocardial infarctions than men, the situation changes drastically at menopause, after which women are at greater risk than men. Despite this, women at all ages receive less treatment, less attention and not enough information about health risks. Most risk factors, e. g. hypertension, elevated blood lipid levels, diabetes and changes in oestrogen levels, differ between women and men. As a consequence of this, secondary prevention from coronary artery disease is likely to have different effects in women to those in men. Different kinds of antihypertensive therapy, hormone-replacement therapy and lipid-lowering treatment may be more or less suitable in women than in men. The recent development of angiotensin-receptor blockers may have beneficial effects which make them particularly effective in women

Barriers to effective implementation of guideline recommendations.

Cardiovascular disease (CVD) is the leading cause of death worldwide, and its prevention and treatment are important healthcare aims. Hypercholesterolemia is among the most important modifiable Rick factors for CVD, and numerous guidelines exist for the treatment of this condition. Nevertheless, despite the existence of well-established and safe pharmacologic therapy for lowering cholesterol and preventing CVD, surveys in the United States and Europe have revealed that many patients have elevated cholesterol levels. There is a clear gap between what is known about treating CVD and the implementation of that knowledge. A survey assessing patients' knowledge about CVD observed that many patients are unaware of the disease prevalence and have little knowledge about the main risk factors, including the importance of cholesterol. Another survey demonstrated that many physicians overestimate patients' awareness of CVD and that physicians also overestimate the extent to which guidelines are implemented in clinical practice. Guideline implementation may be improved by narrowing the discrepancies between what patients and physicians believe and the reality. Many physicians claim that lack of time hinders guideline implementation and improvement of patient education. Physicians also appear to lack the motivation to implement lipid-lowering interventions. A multifactorial approach to improving use of guidelines in clinical practice may improve the treatment and prevention of CVD

Managing cardiovascular risk: reality vs. perception

Clinical practice guidelines attempt to bridge the gap between the generation of scientific evidence and its application. For cardiovascular risk reduction, the implementation of knowledge into practice, both with respect to lifestyle change and pharmacological treatment, has been shown to be poor. There are several reasons for this 'guidelines gap', with physician factors including insufficient time and underestimation of a patient's cardiovascular risk and patient factors including tack of adherence to lifestyle modification and lack of awareness about cardiovascular risk. Survey data indicate that physicians believe that they are implementing guidelines, but the majority of patients remains undertreated. There is a need for better physician and patient education and also for simplified guidelines to encourage their use by physicians. Cardiologists should work with primary care physicians to adapt national guidelines to ensure local acceptance