Renin-angiotensin-aldosterone system in the elderly: rational use of aliskiren in managing hypertension

The overall purpose of hypertension treatment is 2-fold. First, patients often have symptoms that are related to their high blood pressure and although subtle in many instances may be improved dramatically by blood pressure control. The main reason for blood pressure treatment, however, is to reduce the burden of cardiovascular complications and end organ damage related to the condition. This may be considered the ultimate goal of blood pressure treatment. In this respect, actual blood pressure measurements may be seen as surrogate end points as the organ protective effects of two antihypertensive agents may differ significantly even though their blood pressure lowering effects are similar. Thus beta-blockers, once seen as first-line treatment of hypertension for most patients, now are considered as third- or fourthline agents according to the latest NICE guidelines (National Institute for Health and Clinical Excellence, www.nice.org.uk/CG034). On the other hand, agents that inhibit the activity of the renin-angiotensin-aldosterone system (RAAS) system are being established as safe, effective and end organ protective in numerous clinical trials, resulting in their general acceptance as first-line treatment in most patients with stage 2 hypertension. This shift in emphasis from beta-blockers and thiazide diuretics is supported by numerous clinical trials and has proven safe and well tolerated by patients. The impact of this paradigm shift will have to be established in future long-term randomized clinical trials. The optimal combination treatment with respect to end organ protection has yet to be determined. Most combinations will include either a RAAS active agent and calcium channel blocker or two separate RAAS active agents working at different levels of the cascade. In this respect direct renin inhibitors and angiotensin receptor blockers seem particularly promising but the concept awaits evaluation in upcoming randomized clinical trials. Although safety data from the randomized clinical trials to date have been promising, we still lack data on the long-term effect of aliskiren on mortality and there still are patient groups where the safety of aliskiren is unexplored

Exploration of TRPV1 Splice Variant Expression in Rat Dorsal Root Ganglia Following Sciatic Nerve Injury

Transient Receptor Potential Vanilloid 1 (TRPV1) is ligand-gated ion channel that plays an important role in the pain signaling pathway. It is predominantly expressed by sensory neurons located in trigeminal ganglia or dorsal root ganglia (DRG). TRPV1 has been shown to play a crucial role in the generation and maintenance of inflammatory and neuropathic pain. The involvement of splice variants of TRPV1 in pain pathways is not well known. In this study, the mRNA expression of TRPV1 and 3 splice variants (TRPV1.b, TRPV1.β, and TRPV1.var) in DRG was measured following chronic constriction injury of the sciatic nerve in rats. This is the first study to isolate TRPV1.β in rat DRG. The expression of TRPV1 mRNA was elevated following peripheral nerve damage, but not TRPV1.b, TRPV1.var or TRPV1.β. These novel findings suggest that the expression of TRPV1 splice variants is not regulated by sciatic nerve injury

Health policy interventions: the pathway to public health.

Langvinnir sjúkdómar eru algengasta orsök ótímabærra dauðsfalla í heiminum og helsta ógn samtímans við efnahagslega og félagslega framþróun á þessari öld.1,2 Þessir sjúkdómar eiga rót í óheilbrigðum lífsstíl, svo sem reykingum, óhollu mataræði, hreyfingarleysi og ofneyslu áfengis.3 Þetta leiðir til háþrýstings, offitu, sykursýki og langvinnrar lungnateppu svo dæmi séu tekin. Sýnt hefur verið fram á að með lýðgrunduðum inngripum má draga verulega úr helstu áhættuþáttum langvinnra sjúkdóma meðal þjóðarinnar.4 Til þess þarf markvissa stefnumörkun sem tekur mið af þeim vísindalegu rökum sem fyrir liggja. Þannig má draga úr ótímabærum dauðsföllum og veikindum af völdum þessara sjúkdóma.Chronic non-communicable diseases (NCDs) are currently the main cause of premature death and disability in the world. Most of these NCDs are due to unhealthy lifestyle choices i.e. tobacco, unhealthy diet, lack of physical exercise and alcohol consumption. Studies have shown that health policy interventions aiming at improving diet and physical activity and reducing tobacco consumption are inexpensive, effective and cost saving. In this paper we address the political health policy interventions that have been shown to improve public health. We discuss some of the theories of behavioral economics which explain the processes involved in our every-day choices regarding lifestyle and diet

Chronic non-communicable diseases: a global epidemic of the 21st century

Neðst á síðunni er hægt að nálgast greinina í heild sinni með því að smella á hlekkinn View/OpenChronic non-communicable diseases (NCDs) are the cause of 86% of all deaths in the EU and 65% of deaths worldwide. A third of these deaths occur before the age of sixty years. The NCDs affect 40% of the adult population of the EU and two thirds of the population reaching retirement age suffers from two or more NCDs. The NCDs are a global epidemic challenging economic growth in most countries. According to the WHO, NCDs are one of the major threats to worldwide social and economic development in the 21st century. The problem is of great concern to the international community and was discussed at a High level meeting at the UN General Assembly in September 2011. In this paper we review the epidemic of NCDs both from a national and international perspective. We discuss the causes and consequences. In a second review paper we reflect on the political health policy issues raised by the international community in order to respond to the problem. These issues will become a major challenge for social and economic development in most countries of the world in the coming decades.Nýr heimsfaraldur er í uppsiglingu. Faraldur þessi leggur að velli fleiri íbúa jarðarinnar en nokkur annar hefur gert frá því að drepsóttir geisuðu í byrjun síðustu aldar. Hann er orsök 86% dauðsfalla í Evrópu og um 65% allra dauðsfalla í heiminum.1 Þriðjungur þessara dauðsfalla verða hjá fólki fyrir sextugt.2 Faraldurinn á uppruna sinn í þróuðum ríkjum Vesturlanda en teygir sig yfir til Asíu, Afríku og Eyjaálfu. Þetta er faraldur langvinnra sjúkdóma (Chronic Non-Communicable Diseases) sem eru að mestu leyti tengdir við þann lífsstíl sem við höfum tamið okkur á síðustu 5 áratugum.3 Vandinn er af þeirri stærðargráðu að hann stendur í vegi fyrir hagvexti um allan heim og er að sliga heilbrigðiskerfi samtímans.4,5 Alþjóðaheilbrigðismálastofnunin (WHO) hefur skilgreint langvinna sjúkdóma sem helstu ógn heimsbyggðarinnar við félagslega og efnahagslega framþróun á 21. öld.6 Þetta leiddi til þess að langvinnir sjúkdómar voru gerðir að sérstöku umfjöllunarefni á leiðtogafundi allsherjarþings Sameinuðu þjóðanna í byrjun september 2011. Í þessari grein er fjallað orsakir og afleiðingar langvinnra sjúkdóma og um mismunandi tegundir forvarna sem beita má í baráttunni við þá

Comparison of treatment and prognosis after acute myocardial infarction in two university hospitals in Reykjavik, Iceland 1996

Neðst á síðunni er hægt að nálgast greinina í heild sinni með því að smella á hlekkinn View/OpenIntroduction: The treatment of patients after acute myocardial infarction (AMI) is in part related to the available technology at the hospital of admission. In Iceland percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) was only performed at Landspítalinn at the time of the research. We compared the treatment and prognosis of patients after AMI in 1996 at the two university hospitals in Reykjavík, Iceland, Landspítalinn (LSP) and Sjúkrahús Reykjavíkur (SHR). Material and methods: We retrospectivly collected informations on all patients admitted with AMI at LSP and SHR in 1996 and compared mortality, morbidity and interventional procedures at one year after admission. Results: The one-year mortality was 17.7% among patients admitted to LSP compared with 20.8% among patients admitted to SHR (p=0.55). Upon discharge from LSP 82% of patients received aspirin and 68% received a ss-blocker versus 71% and 57% of patients discharged from SHR (p=0.021 and p=0.028 respectively). Conversely 29% of patients were disharged with a calsium-antagonist and 76% with a nitrate from SHR compared with 16% and 51% at LSP (p=0.004 and p<0.001 respectively). There was no diffirence in the use of thrombolytics, angiotensin converting enzyme inhibitors, digoxin, diuretics or antiarrhythmics. Within one year 32% of patients admitted to LSP had undergone PTCA but only 13% of patients admitted to SHR (p<0.001). Further, 10% of patients had undergone CABG within one year at LSP compared with 11% at SHR (p=0.75). On average patients at LSP had a 10 days shorter waiting period from admission to PTCA (p=0.001). Discussion: Despite greater use of PTCA, aspirin and ss-antagonist at LSP compared with SHR there was no significant diffirence in one-year mortality between the hospitals. The greater use of calcium-antagonists and nitrates at discharge among patients discharged from SHR might indicate that they were more symptomatic than patients discharged from LSP. We find the great difference in treatment of patients after AMI according to hospital of admission unacceptable. This problem could possibly be solved by implying clinical guidelines.Inngangur: Meðferð sjúklinga eftir bráða kransæðastíflu fer að nokkru eftir tækjabúnaði sjúkrahússins sem sjúklingar leggjast inn á við greiningu. Á Íslandi eru kransæðavíkkanir og -hjáveituaðgerðir aðeins framkvæmdar á Landspítala Hringbraut. Við bárum saman meðferð og horfur sjúklinga með brátt hjartadrep árið 1996 á Sjúkrahúsi Reykjavíkur (SHR) annars vegar og Landspítalanum (LSP) hins vegar. Efniviðir og aðferðir: Upplýsingum var safnað afturskyggnt um alla sjúklinga sem fengu greininguna brátt hjartadrep á Landspítalanum og Sjúkrahúsi Reykjavíkur árið 1996. Dánartíðni, fjöldi endurinnlagna vegna hjartasjúkdóma og notkun kransæðavíkkana eða -hjáveituaðgerða á fyrsta ári eftir innlögn voru borin saman milli sjúkrahúsanna. Niðurstöður: Eins árs dánarhlutfall á Landspítalanum var 17,7% en 20,8% meðal sjúklinga á Sjúkrahúsi Reykjavíkur (p=0,55). Sjúklingar á Landspítalanum útskrifuðust í 82% tilvika á asetýlsalisýlsýru og í 68% tilvika á ß-hamla á móti 71% og 57% tilvika á Sjúkrahúsi Reykjavíkur (p=0,021 og p=0,028). Hins vegar útskrifuðust sjúklingar á Sjúkrahúsi Reykjavíkur í 29% tilvika á kalsíumhamla og í 76% tilvika á nítrötum borið saman við 16% og 51% á Landspítalanum (p=0,004 og p<0,001). Ekki reyndist munur á notkun segaleysilyfja, angíótensín breyti (converting) ensím- hamla, digoxíns, þvagræsilyfja eða lyfja við hjartsláttartruflunum. Sjúklingar á Landspítalanum fóru í 32% tilvika í kransæðavíkkun innan árs á móti 13% tilvika á Sjúkrahúsi Reykjavíkur (p<0,001). Sjúklingar á Landspítalanum fóru í 10% tilvika í kransæðahjáveituaðgerð innan árs á móti 11% á Sjúkrahúsi Reykjavíkur (p=0,75). Meðalbiðtími sjúklinga Sjúkrahúsi Reykjavíkur eftir kransæðavíkkun reyndist um 10 dögum lengri en á Landspítalanum (p=0,001). Umræða: Ekki reyndist tölfræðilega marktækur munur á eins árs dánartíðni sjúklinga á Sjúkrahúsi Reykjavíkur og Landspítalanum 1996 þrátt fyrir mun meiri notkun kransæðavíkkana, asetýlsalisýlsýru og ß-hamla. Hins vegar gæti meiri notkun nítratlyfja og kalsíumhamla sjúklinga við útskrift af Sjúkrahúsi Reykjavíkur bent til að þeir hefðu meiri einkenni kransæðasjúkdóms við útskrift. Við teljum óeðlilegt að sjúklingar með brátt hjartadrep hafi fengið mismunandi meðferð eftir því hvort þeir lögðust inn á Sjúkrahús Reykjavíkur eða Landspítalann. Þessi munur kallar á aukna samhæfingu í starfsemi hjartadeilda sjúkrahúsanna og gerð klínískra leiðbeininga

Effect of coronary calcification on diagnostic accuracy of the 64 row computed tomography coronary angiography.

Þekkt er að kalk í kransæðum veldur truflunum í tölvusneiðmyndarannsókn (TS) sem torveldar mat á kransæðaþrengslum. Markmið rannsóknarinnar var að meta nánar áhrif kalks í kransæðum á greiningargildi 64 sneiða TS á kransæðum í íslensku þýði, með hjartaþræðingu sem viðmið. Þessi afturskyggna rannsókn náði til 417 einstaklinga sem bæði höfðu komið í TS-kransæðarannsókn og hjartaþræðingu með 6 mánaða millibili. Einstaklingum var skipt eftir Agatston-skori (kalkmagn í kransæðum): [0], [0,1-10], [10,1-100], [100,1-400], [400,1-750] og [>750]. Hæfni TS-kransæðarannsóknar til að greina ≥50% kransæðaþrengingu var metin með hjartaþræðingu sem viðmið. Þá voru tengsl á milli Agatston-skors og ≥50% kransæðaþrengingar skoðuð. Alls voru rannsökuð 1668 kransæðasvæði í 417 einstaklingum (68,6% karlar og meðalaldur 60,2 ± 8,9 ár). Agatston-skor var að meðaltali 420 (spönn frá 0-4275). Næmi tölvusneiðmyndarannsóknar við greiningu ≥50% kransæðaþrengingar í kransæð var 70,1%, sértæki 79,9%, jákvætt forspárgildi 55,4% og neikvætt forspárgildi 88,2%. Neikvætt forspárgildi lækkaði úr 93,0% fyrir Agatston-skor núll og niður í 78,3% fyrir Agatston-skor ˃>750. Agatston-skor 363 spáði best fyrir um ≥50% kransæðaþrengingu með 49,6% næmi. Greiningargildi TS-kransæðarannsóknar er almennt gott með háu neikvæðu forspárgildi og sértæki. Kalk hefur töluverð áhrif á greiningargildið en neikvætt forspárgildi skerðist lítið fyrir Agatston-skor allt að 400. Agatston-skor er ekki gott til að spá fyrir um ≥50% kransæðaþrengingu í þessu þýði. Ekkert ákveðið Agatston-skor gildi fannst sem spáði fyrir um ónothæfa æðarannsókn með TS.Coronary artery calcium is known to complicate the evaluation of stenoses using computer tomography (CT). The aim of this study was to analyze the effect of coronary calcification on the diagnostic accuracy of CT coronary angiography in an Icelandic population. The study was a retrospective analysis of 417 consecutive subjects that underwent CT coronary angiography and subsequent conventional coronary angiography within 6 months. Subjects were divided based on total Agatston score: 0, 0.1-10, 10.1-100, 100.1-400, 400.1-750 and >750. Sensitivity, specificity, positive and negative predictive values were calculated for ≥50% stenoses diagnosed with the CT, using the conventional coronary angiography as a reference. Correlation between Agatston score and ≥50% stenoses was calculated. A total of 1668 coronary artery segments in 417 individuals were evaluated (68.6% men, mean age 60.2 ± 8.9). The total mean Agatston score was 420 (range from 0-4275). CT detected >50% stenoses with a sensitivity of 70.1%, specificity of 79.9% and positive and negative predictive values of 55.4% and 88.2%, respectively. The negative predictive value was 93.0% for Agatston score zero but 78.3% for Agatston score ˃750. An Agatston score threshold of 363 predicted ≥50% coronary stenoses with 49.6% sensitivity. Diagnostic accuracy is moderate with good negtive predictive value and specificity. Although coronary calcification reduces diagnostic accuracy, negative predictive value is only mildly affected for Agatston score as high as 400. Agatston score is not a good predictor of ≥50% coronary artery stenoses. No particular Agatston score cut-off level was identified to indicate whether CT angiography was useless or not

Thinking as shaped by framing sensitivity

A major aim of the present study was to investigate effects of sensitivity-to-framing (Witkin’s EFT test) on rational and intuitive thinking. A booklet of relevant tests was distributed to university students who served as participants. It was found that field independent participants scored higher on rational thinking tasks than field-dependent participants did. Sensitivity-to-framing was also found to be a better predictor of rational thinking than was analytical intelligence. The results are discussed and related to the more general issue how cognitive style may impact upon rational and intuitive thinking

Bringing prevention to the population: an important role for cardiologists in policy-making.

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Regulation of e-cigarette sale and use in Iceland

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Pay for disease or invest in health?

To access publisher full text version of this article. Please click on the hyperlink in Additional Links field.Hjärt–kärlsjukdom är den ledande enskilda orsaken till död och ohälsa i vår del av världen. Den medicinska och ekonomiska bördan av dessa sjukdomar är enorm. Även om nyinsjuknandet och dödligheten i tex hjärtinfarkt har minskat i vårt land, liksom i många europeiska länder, är antalet människor som insjuknar i förtid och som lever med resttillstånd efter olika hjärt–kärlsjukdomar snarast i stigande, vilket sammanhänger med att vi lever längre och att överlevnaden efter hjärtinfarkt och slaganfall har ökat. Största delen av dessa sjukdomar liksom av andra kroniska, icke-smittsamma sjukdomar (cancer, lungsjukdom, diabetes osv) sammanhänger med påverkbara, livsstilsrelaterade riskfaktorer. Hälsosamma val, dvs bra mat, fysisk aktivitet, frånvaro av tobaksbruk och undvikande av överkonsumtion av alkohol, kan förhindra eller i vart fall fördröja ett insjuknande. Den medicinska professionen bör ta som sin uppgift att i samverkan med politiker, hälsovårdsadministratörer och medier upplysa allmänheten om dessa enkla fakta. Genom kloka policybeslut kan man underlätta för befolkningen att göra hälsosamma val redan från de tidiga barnaåren och genom hela livscykeln