Preventing Ischemic Stroke in Patients With Prior Stroke

Your Heart and Nutrition

Your Heart and Nutrition

Prevention is better than a cure. Learn how to cherish your heart by taking the necessary means to keep it pumping healthily and steadily through your life.

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Natural Secrets For Healing Your Heart

This eBook is devoted to exposing the secrets that cardiologists and surgeons don't want you to know, and how to take control of your own heart and heal yourself. Eight out of every ten coronary bypasses will not actually help the patient. So why risk being in the 80% that will get no benefit from a bypass? Learn to heal your own heart and keep yourself healthy with this eBook guide. Bob Livingston has poured years of research into his findings, and is now sharing the methods that he has developed from careful, methodical research that the medical industry would never allow. It would make them go bankrupt! You will learn what supernutrient doctors don't want you to know about, and how to make an all-natural, chemical and drug-free blood thinner And even more information that doctors don't want revealed to the public. You don't have to be one of the 70% of Americans diagnosed with heart disease. You can heal your heart!

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The Atlas of Heart Disease and Stroke

The Atlas of Heart Disease and Stroke World Health Organization 2004 The atlas of heart disease and stroke Judith Mackay and George Mensah with Shanthi Mendis and Kurt Greenlund. l.Heart diseases epidemiology 2.Cerebrovascular accident epidemiology 3.Risk factors 4.Atlases I.Mensah, George. II.Mendis, Shanthi. III.Greenlund, Kurt. IV.Title.

Anatomic Pattern of Coronary Artery Disease

Coronary artery disease (CAD) mortality over 18 years according to the status of diabetes (DM) and prior myocardial infarction (MI). (From Juutilainen A, Lehto S, Ronnemaa T, et al Type 2 diabetes as a coronary heart disease equivalent An 18-year prospective population-based study in Finnish subjects. Diabetes Care 2005 28 2901-2907.) Figure 2-3. Coronary artery disease (CAD) mortality over 18 years according to the status of diabetes (DM) and prior myocardial infarction (MI). (From Juutilainen A, Lehto S, Ronnemaa T, et al Type 2 diabetes as a coronary heart disease equivalent An 18-year prospective population-based study in Finnish subjects. Diabetes Care 2005 28 2901-2907.)

Nonstelevation Acute Coronary Syndromes

The high prevalence of abnormal glucose metabolism in patients with CAD, and in particular among those with acute manifestations of the disease, was recently confirmed in large-scale surveys in both the United States and Europe. Within the U.S. CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC AHA guidelines) registry, among 46,410 patients with non-ST-elevation ACS, the prevalence of diabetes was 33 .89 Within the National Registry of Myocardial Infarction (NRMI), the prevalence of diabetes among patients presenting with ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI) was 27 and 34 , respectively.90 In the Euro Heart Survey, glucose metabolism was addressed among 2854 patients with stable CAD and 2107 patients with unstable CAD.91 The overall prevalence of diabetes was approximately 30 in both groups. Among unstable CAD patients without known diabetes, an OGTT detected IGT in 36 and diabetes in...

Stelevation Myocardial Infarction

Relationship between admission plasma glucose values and 30-day and 1-year mortality rates among patients presenting with acute myocardial infarction. (From Kosiborod M, Rathore SS, Inzucchi SE, et al Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction Implications for patients with and without recognized diabetes. Circulation 2005 111 3078-3086.) The impact of diabetes on outcomes after the acute MI phase was addressed in a contemporary large-scale study, the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial.99 The study enrolled 3400 patients with known diabetes, 580 patients with newly diagnosed diabetes, and 10,719 patients with no diabetes. At 1 year, patients with previously known and newly diagnosed diabetes had similar increased risks of mortality (adjusted HR 1.4 and 1.5, respectively) and of CV events (adjusted HR 1.4 and 1.3, respectively), compared with nondiabetics. Similarly to what is observed in the...

Changing Concepts What Constitutes Heart Disease

Concepts about what constitutes heart disease have changed a great deal in the past century. For example, the corresponding section of a predecessor to this work, August Hirsch's Handbook of Geographical and Historical Pathology (1883-6) is entitled Diseases of the Heart and Vessels, not diseases of the heart, and one of the main topics is hemorrhoids. Anatomic linkage of the heart and vessels into a single unit was common in the nineteenth century, as is shown by such titles as Diseases of the Heart and Aorta and Diseases of the Heart and Great Vessels. Around the end of the nineteenth century, however, the conceptualization of heart disease changed fundamentally. As Christopher Lawrence has pointed out, British physicians started to think about the heart in terms of its functional capacity rather than in terms of its anatomy. This led them to regard cardiac murmurs, such as would be detected by a stethoscope, as less important than physiological measurements of function. ing doom,...

Geographic Variation in Types of Heart Disease

In many parts of the world, other types of heart disease are more common than coronary heart disease. Endomyocardial fibrosis, for example, is common in the tropical rain forest belt of Africa and South America. The disease has a characteristic pathological process and leads to heart failure, accounting for up to 20 percent of patients with heart failure in Uganda, the Sudan, and northern Nigeria. It can affect people who live in the area as well as those who visit from other parts of the world. Although its precise cause is unknown, and in some instances it may be due to a parasitic infection, the underlying cause may be an increase in the number of eosinophils. In many parts of South America, the parasite Schistosoma mansoni is a common cause of heart disease. Also common in South America is Chagas' disease. Other heart diseases having characteristic geographic patterns include some forms of congenital heart disease that are more significant for people who live at high altitudes,...

STSegment Elevation Myocardial Infarction

In acute MI, fibrinolysis reduces the mortality rate by 18 , compared with conservative treatment, as was shown by a meta-analysis of the randomized trials in this setting.8 In addition to this benefit, coronary reperfusion by primary PCI reduces in-hospital mortality by an additional 35 .9 This risk reduction is consistent with the pooled analysis of registry data of more than 100,000 patients (Fig. 6-1). In addition to its effect on survival, PCI compared with fibrin-olysis reduces the risk of reinfarction and of stroke, particularly that of hemorrhagic stroke.10 The initial benefit is maintained during long-term follow-up.10 The largest survival benefit with PCI is obtained when the delay conferred by PCI compared with fibrinolysis is shorter than 35 minutes.9 Nevertheless, even with delays ranging between 35 and 120 minutes, there is a significant survival benefit with PCI, about 18 on average.9 Beyond 2 hours of delay between PCI and fibrinolysis, however, a benefit from PCI as...

NonSTSegment Elevation Acute Coronary Syndromes

In acute coronary syndromes without ST-segment elevation, there has been a long-standing debate about two competing treatment strategies.11 The conservative strategy reserves coronary angiography and revascularization for those patients who continue to have spontaneous or inducible myocardial ischemia despite maximal medical therapy. The invasive strategy, on the other hand, recommends coronary angi-ography and revascularization regardless of the primary success of medical treatment. Various studies have addressed this issue. A meta-analysis published in 2005 concluded that the invasive strategy, while increasing the risk of in-hospital death and MI (so-called early hazard), significantly reduced death and MI during the entire follow-up period, ranging from 6 months to 2 years in various studies, by 18 (95 confidence interval CI , 2 to 42 ).12 Supporting this analysis, the 5-year follow-up of RITA-3 revealed that the benefit of the invasive strategy with respect to death and MI...

Pathophysiology Ischemic Stroke

In ischemic stroke, there is an interruption of the blood supply to an area of the brain either due to thrombus formation or an embolism. Loss of cerebral blood flow results in tissue hypoperfusion, tissue hypoxia, and cell death. Tipid deposits in the vessel wall cause turbulent blood flow and lead to vessel injury, exposing vessel collagen to

Treatment Of Acute Hemorrhagic Stroke Supportive Measures

Acute hemorrhagic stroke is considered to be an acute medical emergency. Initially, patients experiencing a hemorrhagic stroke should be transported to a neurointensive care unit. There is no proven treatment for ICH. Management is based on neurointensive care treatment and prevention of complications. Treatment should be provided to manage the needs of the critically ill patient including management of increased ICP, seizures, infections, and prevention of rebleeding and delayed cerebral ischemia. In those with severely depressed consciousness, rapid endotracheal intubation and mechanical ventilation may be necessary. BP is often elevated after hemorrhagic stroke and appropriate management is important to prevent rebleeding and expansion of the hematoma.46 BP can be controlled with IV boluses of labetalol 10 to 80 mg every 10 minutes up to a maximum of 300 mg or with IV infusions of labetalol (0.5-2 mg min) or nicardipine (5-15 mg h). Deep vein thrombosis prophylaxis with...

Acute stroke units hyperacute care

Once patients are admitted to specialist stroke units, occupational therapists should be involved in screening all patients (ISWP, 2008). It is argued that for the same reason for screening in NVCs, occupational therapist should also screen TIAs who are admitted to acute stroke units (ASU). Hence, although guidelines state that occupational therapy assessment should occur within 4 days of admission (ISWP, 2008), a method of screening to prioritise and fast track high functioning patients who might be imminently discharged is required. Caseload All stroke patients - particularly those of high priority (above) (ISWP, 2008). Aim To provide early screening assessment of stroke patients admitted to

Types of cardiovascular disease

Deaths from cardiovascular diseases (CVD) coronary heart disease stroke other cardiovascular diseases hypertensive heart disease inflammatory heart disease rheumatic heart disease coronary heart disease stroke inflammatory heart disease 0.4m rheumatic heart disease 0.3m other forms of heart disease 2.4m inflammatory heart disease 0.4m rheumatic heart disease 0.3m other forms of heart disease 2.4m Coronary heart disease Rheumatic heart disease Congenital heart disease Other cardiovascular diseases Risk factors As for coronary heart disease.

Pregnancy in the Woman with Heart Disease

Before becoming pregnant, a woman may have a congenital heart defect or acquired heart disease. Many congenital defects can now be surgically repaired in infancy, and the first generation of these patients has only recently reached childbear-ing age. They represent a new kind of patient for obstetricians and cardiologists. Acquired heart disease in pregnant women includes primarily rheumatic disease involving heart valves, heart failure, and coronary artery disease. Because many women are now delaying pregnancy until they are older, acquired heart disease is somewhat more common in pregnant women than earlier in this century. When considering pregnancy in the presence of heart disease, the most important factor is the severity of the heart-related symptoms. In general, patients without symptoms or those only slightly symptomatic enjoy a good outlook for both mother and fetus. Heart disease in adults generally develops later in life. Although heart disease is not completely...

Acute Coronary Syndromes

The Fragmin and Revascularization during Instability in Coronary Artery Disease II (FRISC II) trial enrolled 2457 patients, of whom 30 were women. They found that, unlike men, women did not benefit from early invasive treatment.37 The incidence of death or Mi at 6 months in women was 10.5 in the invasive group and 8.3 in the conservative group (OR 1.26 95 CI 0.80 to 1.97).37 In men, there was a significant reduction of events at 6 months in the invasive strategy group (19 vs. 36 OR 0.53 95 CI 0.45 to 0.65).37 A similar finding was seen in the Randomized Intervention Treatment of Angina 3 (RITA 3), which enrolled 1810 ACS patients, including 38 women, to receive either invasive or conservative therapy.35 Men benefited more from an early intervention strategy, with reduction in death or nonfatal MI at 1 year (adjusted OR 0.63 95 CI 0.41 to 0.98), than did women (OR 1.79 95 CI 0.95 to 3.35 interaction P .007). Much has been reported on gender differences in diagnosis and treatment of...

Coronary Artery Disease

Heart disease is the leading cause of death for all races in the U.S. population. African Americans experience the highest rates of mortality from heart disease, 1.6 times that of whites.1 The average annual death rate due to heart disease by race is shown in Table 8-5. The prevalence of CAD is also higher in African Americans compared to their white counterparts, regardless of gender.1 Furthermore, onset of disease occurs 5 years earlier in African Americans. Death rates from stroke are also higher among African Americans. Various ethnic minority groups are experiencing increasing rates of ischemic heart disease. Rates for CAD are increasing in Asian Americans, Hispanic Americans, and Native Americans.1 Despite the increased incidence of CAD in African Americans, the presence of obstructive epicardial CAD on angi-ography is less than whites.81 Paradoxically, there is greater extent of atherosclerosis in African Americans despite less obstructive CAD. The increased prevalence of CAD...

Rheumatic fever and rheumatic heart disease

Rheumatic fever usually follows an untreated beta-haemolytic streptococcal throat infection in children. It can affect many parts of the body, and may result in rheumatic heart disease, in which the heart valves are permanently damaged, and which may progress to heart failure, atrial fibrillation, and embolic stroke. Of 12 million people currently affected by rheumatic fever and rheumatic heart disease, two-thirds are children between 5 and 15 years of age. There are around 300 000 deaths each year, with two million people requiring repeated hospitalization and one million likely to require surgery in the next 5 to 20 years. Early treatment of streptococcal sore throat can preclude the development of rheumatic fever. Regular long-term penicillin treatment can prevent rheumatic fever becoming rheumatic heart disease, and can halt disease progression in people whose heart valves are already damaged by the disease. In many developing countries, lack of awareness of these measures,...

Multiple overlapping causes of ischemic stroke

Clinical and neuroimaging features that are compatible with lacunar infarction may have associated findings of large artery atherosclerosis or a cardioembolic source (most commonly atrial fibrillation). In one study, 4 of all stroke patients had small artery disease coexisting with large artery disease or a cardiac embolic source 36 . The cause of stroke in such patients is difficult to establish on an individual basis, but large artery or cardiac causes of stroke are not always coincidental. A causative rather than coincidental role of an ipsilateral carotid stenosis (70-99 ) is indirectly suggested by a pooled analysis of individual patient data from randomized controlled trials of carotid surgery, which showed that surgery was also beneficial in a subgroup of patients with a lacunar infarct as defined by CT criteria 37 .

Cryptogenic ischemic stroke

Patients experiencing a TIA stroke frequently have no determined etiology after standard diagnostic evaluation. Previous reports show that 20-25 of stroke survivors are classified as cryptogenic stroke, but it is a matter of debate which strokes should be labeled cryptogenic - what level of evidence is needed for accepting a finding or risk factor as the cause Such debate has surrounded PFO, which can be an incidental finding or possibly an underlying mechanism methods for distinguishing incidental PFOs from pathogenic ones in cryptogenic stroke patients and for identifying patients at high risk of recurrence would be clinically most useful but are currently not available.

Nutrition for a Healthy Heart

Many healthy-heart diets and foods have a reduced fat content but, in most instances, have replaced fat with sugar and, even worse, refined sugar. As fat intake has decreased, refined sugar and processed grain intake has skyrocketed. The average American consumes more than 150 pounds of added refined sugar every year.

Cardiovascular risk factors

Testosterone plays an ambiguous role in relation to cardiovascular risk factors and its respective role has not been fully resolved (see Chapter 10). The interactions between the CAG repeat polymorphism, serum levels of sex hormones, lifestyle factors and endothelium-dependent and independent vessel relaxation of the brachial artery as well as lipoprotein levels, leptin and insulin concentrations and body composition were described in over 100 eugonadal men of a homogenous population. In agreement with previously demonstrated androgen effects on these parameters it was demonstrated that androgenic effects were attenuated in persons with longer CAG repeats while testosterone levels themselves played only a minor role within the eugonadal range. Significant positive correlations with the length of CAG repeats were seen for endothelial-dependent vasodilatation, HDL-cholesterol concentrations, body fat content, insulin and leptin levels. These results remained stable in multiple...

How Does Alcohol Reduce the Risk of Heart Disease

We have identified many of the biologic and physiologic effects of wine and alcohol that relate to protection against CAD. Alcohol affects blood lipids it increases HDL-cholesterol, the good cholesterol that lowers the risk of heart disease. Alcohol also tends to slightly decrease LDL-cholesterol, the bad cholesterol that increases atherosclerosis. Thus, individuals who have consumed moderate amounts of alcohol for most of their adult years tend to have less atherosclerosis. The progress in heart surgery and treatment of general heart disease has been remarkable over the last fifty years. Many conditions that doctors in the 1950s considered fatal are now routinely treatable with a variety of options including drugs (for hypertension, for example), surgery, and less invasive techniques. At the same time these surgical techniques have become accepted, our knowledge of cardiac disease prevention has made incredible leaps forward. New studies are beginning to show that moderate to light...

Role of functional imaging in stroke patients

For the analysis of the relationship between disturbed function and altered brain activity studies can be designed in several ways measurement at rest, comparing location and extent to deficit and outcome (eventually with follow-up) measurement during activation tasks, comparing changes in activation patterns to functional performance and measurement at rest and during activation tasks early and later in the course of disease (e.g. after stroke) to demonstrate recruiting and compensatory mechanisms in the functional network responsible for complete or partial recovery of disturbed functions. Only a few studies have been performed applying this last and most complete design together with extensive testing for the evaluation of the quality of performance finally achieved. activation patterns related to recovery of disturbed function after stroke 1-6 .

Intensive Statin Therapy In Stable Coronary Artery Disease

Complementary benefit of percutaneous coronary intervention and intensive statin therapy in patients with acute coronary syndrome. (Redrawn from Ambrose JA, Martinez EE A new paradigm for plaque stabilization. Circulation 2002 105 2000-2004.) Figure 11-4. Complementary benefit of percutaneous coronary intervention and intensive statin therapy in patients with acute coronary syndrome. (Redrawn from Ambrose JA, Martinez EE A new paradigm for plaque stabilization. Circulation 2002 105 2000-2004.)

Cant We Just Eat a Healthy Diet to Prevent Heart Disease

Some physicians argue that we do not have to use alcohol to prevent CAD because we know other ways (changes in lifestyle habits) that will prevent heart disease lose weight and change your diet. But they do not often appreciate how difficult it is for someone to lose 10 to 20 pounds (and keep it off) or how difficult it is for people to permanently adopt a very low-fat and low-cholesterol diet.

Early Benefits Of Intensive Statin Therapy For Acute Coronary Syndrome

Intravascular ultrasound data shows that acute coronary syndrome patients have multiple vulnerable or ruptured plaques. (Data from Rioufol G, Finet G, Ginon I, et al Multiple atherosclerotic plaque rupture in acute coronary syndrome A three-vessel intravascular ultrasound study. Circulation 2002 106 804-808.) Figure 11-8. Early benefit of intensive standard statin therapy within 30 days after acute coronary syndrome (ACS) in the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE IT) trial. (Data from Ray KK, Cannon CP, McCabe CH, et al, for the PROVE IT-TIMI 22 Investigators Early and late benefits of high-dose atorvastatin in patients with acute coronary syndromes Results from the PROVE IT-TIMI 22 trial. J Am Coll Cardiol. 2005 46 1405-1410.) Figure 11-8. Early benefit of intensive standard statin therapy within 30 days after acute coronary syndrome (ACS) in the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE IT) trial. (Data from Ray...

Extracranial ultrasound in acute stroke

Because ofthe interactions between extra- and intra-cranial hemodynamics, both extracranial and intracra-nial ultrasound techniques should be performed in acute stroke. Similarly, clinically silent stenoses should be detected by careful investigation of anterior, posterior or ipsi- and contralateral vasculature.

Angiotensin Receptor Blockers in Myocardial Infarction

With the demonstrated benefits of an ACE inhibitor after MI, the question of whether more selective blockade of the RAS with an ARB would result in even further improvements in clinical outcomes in this population could be done and interpreted only in the context of a comparator arm of a proven ACE inhibitor. Two major trials tested the relative value of an ARB in high-risk MI patients both used captopril titrated to 50 mg three times daily as the comparator. The Optimal Therapy in Myocardial Infarction with the Angiotensin II Antagonist Losartan (OPTIMAAL) study of more than 5000 patients showed no benefit of the ARB losartan titrated to 50 mg day compared with the proven dose of captopril.78 As in ELITE II, in heart failure patients, there was a strong trend toward better outcomes in the ACE inhibitor group.79 Together, results of ELITE II and OPTIMAAL indicate that this dose of losartan should not be considered equivalent to the proven dose of captopril in reducing cardiovascular...

Headache Attributed to Stroke and Transient Ischemic Attacks

Headache may be reported in 10-30 of patients presenting with an acute ischemic stroke and less commonly in transient ischemic attacks (TIAs). Distinguishing the focal neurologic deficit of a TIA from a migraine aura can be challenging. Deficits associated with a TIA are sudden in onset versus those related to a migraine aura, which tend to develop over 15-20 min. Headaches can also occur in association with strokes related to large vessel atherothrombotic disease, cardioembolism, and to a lesser extent small vessel atherothrombotic disease resulting in lacunar infarcts. Distinguishing TIAs from migrainous aura as clinical pearls are summarized in Table 4.9. Ischemia in the distribution of the posterior circulation is more likely to produce headaches than those involving the anterior circulation. The headache pain is often unilateral, occurring on the same side of the stroke. A stroke patient who develops progression of their neurologic deficits along with new-onset headache must be...

Heart Attack Myocardial Infarction

Although angina doesn't necessarily mean you are about to have a heart attack, any change in your condition should be acted upon quickly. Typical signals of an impending heart attack include angina that is more severe or lasts longer than a few minutes. The chest discomfort associated with a heart attack, or myocardial infarction, may last for several hours (longer than a usual angina episode) and may not respond to nitroglycerin tablets, or even intravenous nitroglycerin at the hospital. Heart attack victims may require intravenous morphine or other drugs to relieve the pain. Although heart attack symptoms are usually clear, heart attack victims may not experience any angina and may just not feel well. In some cases, patients report a sudden onset of heartburn and shortness of breath. These are often explained away as merely indigestion and only later will the actual cause become clear. Sometimes heart attacks are even discovered long after they have occurred, and, in retrospect,...

Recommendations for Beta Blockade during Acute Myocardial Infarction

Chronic Therapy after Myocardial Infarction Calcium Channel Blockade in Acute Myocardial Infarction tion Reinfarction Israeli Nifedipine Trial (SPRINT-II), the first Danish Study Group on Verapamil in Myocardial Infarction Trial (DAVIT), and three small diltiazem trials.17 None of these trials showed any significant difference in reinfarction or mortality with calcium channel blockade SPRINT-II was stopped prematurely because of increased mortality in the nifedipine group. Recommendations for Acute Coronary Syndromes Chronic Therapy after Myocardial Infarction

Diagnostic brain perfusion imaging in stroke patients

The availability of new ultrasound contrast agents (UCAs) and the development of contrast-specific imaging modalities have established the application of ultrasound in stroke patients for visualization of brain perfusion deficits. The UCAs consist of micro-bubbles composed of a gas that is associated with various types of shells for stabilization. Because of their small size, they can pass through the microcirculation. There are interactions between ultrasound and microbubbles at low ultrasound energies UCA microbubbles produce resonance, emitting ultrasound waves at multiples of the insonated fundamental frequency.

Prognostic value of ultrasound in acute stroke

During recent years, ultrasound has become an important non-invasive imaging technique for bedside monitoring of acute stroke therapy and prognosis. By providing valuable information on temporal patterns of recanalization, ultrasound monitoring may assist in the selection of patients for additional pharmacological or interventional treatment. Ultrasound also has an important prognostic role in acute stroke. A prospective, multicenter, randomized study confirmed that a normal MCA finding is predictive of a good functional outcome in more than two-thirds of subjects. After adjustment for age, neurological deficit on admission, CT scan results, and preexisting risk factors, ultrasound findings remained the only independent predictor of outcomes 23 . Applying these criteria in acute stroke the TIBI classification correlates with initial stroke severity, clinical recovery and mortality in patients treated with recombinant tissue plasminogen activator (rt-PA). The grading system can be used...

Clinical Trials Of Percutaneous Transluminal Coronary Angioplasty In Coronary Artery Disease

Overall, the objectives of coronary revasculariza-tion are the treatment of symptoms (e.g., angina), improvement in long-term survival, and prevention of nonfatal events (e.g., acute coronary syndromes, heart failure, arrhythmias). Although the risks of serious complications are small, careful patient selection must be undertaken before proceeding with PTCA. For instance, in the multicenter NHLBI Registry of PTCA experience from 1985 to 1986 of intervention in patients with single-vessel disease, the incidences of procedure-related death, nonfatal MI, and coronary artery bypass grafting (CABG) were 0.2 , 3.5 , and 2.9 respectively.9 The original indication for PTCA was for chronic stable angina due to single-vessel disease with preserved ventricular function,38 producing high success rates (> 90 ) for the treatment of simple lesions.9 This indication evolved, and the use of PTCA expanded to many patients with coronary artery disease initially, it was applied empirically, but later...

Overall lifestyle patterns and stroke risk

Recently, in the analysis of the data from the Health Professionals Follow-up Study and from the Nurses' Health Study the impact on stroke risk of a combination of healthy lifestyle characteristics was evaluated and the burden of stroke that may be attributed to these unhealthy lifestyle choices was calculated 31 . Diet and other lifestyle factors were updated from self-reported questionnaires. A low-risk healthy lifestyle was defined as (i) not smoking, (ii) a body mass index < 25kg m2, (iii) > 30min day of moderate activity, (iv) modest alcohol consumption (men, 5 to 30 g day women, 5 to 15 g day), and (v) scoring within the top 40 of a healthy diet score. Women with all five low-risk factors had a relative risk of 0.21 for total and 0.19 for ischemic stroke compared with women who had none of these factors. Among men, the corresponding relative risks were 0.31 for total and 0.20 for ischemic stroke. Among women, 47 of total and 54 of ischemic stroke cases were attributable to...

Acute Myocardial Infarction

After coronary bypass surgery, approximately 3 of patients experience acute MI annually.142 Because these patients were excluded from early reperfusion trials, therapy has been based on clinical experience and remains controversial. Reports from the Myocardial Infarction Triage and the Intervention Registry and the National Registry of Myocardial Infarction-2 indicate that patients with prior bypass surgery have a high in-hospital mortality rate with reperfusion strategies,143,144 probably attributable to the presence of multivessel disease, prior MI, advanced age, and comorbidity.144 145 In 50 to 70 of patients, the culprit vessel has been found to be a vein graft, and considerable lesion-associated thrombus was a common accompaniment.146-151 Intravenous throm-bolytic therapy was reported to be effective in a small series of patients.152 However, Grines and colleagues147 reported a 25 successful reperfusion rate with intravenous therapy, and in the Global Utilization of Figure 25-5....

Diagnosis of coronary heart disease in stroke patients

When caring for stroke patients in the acute or rehabilitation phase, it is necessary to be aware of clinical symptoms of myocardial ischemia such as chest pain or exertional dyspnea, or electrocardio-graphic abnormalities such as ST-depression, T-wave abnormalities or newly developing Q-waves 20 . The detection of myocardial injury can be improved by measuring serum levels of troponin T or troponin I, biomarkers which are found to be highly specific for myocardial necrosis 24 . Elevated troponin levels in stroke patients with signs or symptoms of myocardial ischemia should entail rhythm monitoring and cardi-ological consultation regarding further therapeutic and diagnostic measures, including coronary angio-graphy and percutaneous coronary intervention. Stroke patients with normal troponin levels but signs and symptoms suggestive of myocardial ischemia should also be referred to the cardiologist, because stress testing might be indicated. In acute stroke patients without a history or...

Myocardial infarction as a cause of embolism

Cardiogenic embolism from a left ventricular thrombus may occur as a complication of acute or subacute myocardial infarction or due to a ventricular aneur-ysm in the chronic phase of a large, mainly anterior wall infarction 27 . The incidence of left ventricular thrombi early after myocardial infarction has declined in recent years, most probably due to changes in the acute therapy of myocardial infarction, which now comprises intensive anticoagulant therapy and percutaneous coronary interventions 28 . However, left ventricular thrombi may still be detected in patients after myocardial infarction, especially if revasculariza-tion in the acute phase has not been performed or was unsuccessful or if the myocardial infarction affected large parts of the left ventricle. Thus, imaging studies to look for left ventricular thrombi, preferentially transthoracic echocardiography, should be performed in all stroke patients with a history or electrocardio-graphic signs of previous myocardial...

Distal Embolization and Periprocedural Myocardial Infarction

Coworkers24 examined the relationship between change in plaque volume before and after stenting and the degree of CK-MB release in 54 patients. In patients with unstable angina, there was a more significant reduction in plaque volume, but more importantly, such reduction significantly correlated with CK-MB release, even after adjusting for other variables influencing PMI.24 A later and more sophisticated analysis of 62 patients undergoing complex PCI by Porto and associates22 demonstrated a significant association between the change in target lesion plaque area by IVUS and the mass of myonecrosis assessed by hyperenhancement on MRI after PCI. The investigators also correlated impaired microvas-cular flow (Thrombolysis in Myocardial Infarction TIMI perfusion grade 0 or 1) with MR evidence of hyperenhancement downstream from the treated segment, suggesting that particulate matter from the atherosclerotic plaque disrupted by angioplasty drift

Cardiovascular disease

Over the last five decades cardiovascular disease (CVD) has been the most common cause of death in the Western world. Inside the EU, 44 of all deaths are attributed to CVD and this is almost twice as many as all cancers put together 2 . CVD rates have decreased during the last few decades in Western countries especially in men below the age of 75 years 3,4 . This development is in contrast to the Eastern European countries, where CVD rates have increased. The positive trend in the Northern European countries parallels a positive change in CVD risk factor levels 5,6 . The most common cardiovascular diseases are is-chemic or coronary heart disease (CHD) and stroke. CHD and thrombotic stroke are characterized by a gradual development of atherosclerosis that obstructs the vessels supplying the heart and brain, respectively, with blood. Atherosclerosis development is influenced by many factors. Although there is genetic predisposition, most risk factors are modifiable. The probability of...

Relationships between serum levels of testosterone and cardiovascular disease observational studies

The cardiovascular disease endpoints were extremely variable (mortality, morbidity such as myocardial infarction and angina, decompensated and compensated heart failure, completed stroke and transient ischemic attack, angiography, ultrasound, computer tomography, or post-mortem based diagnosis or unspecified events), study groups were heterogeneous and selection criteria diverse. Most cardiovascular disease patients willbeonmedications and have modified their lifestyle. In some studies, selection of poorly-matched controls may have introduced biases. The time interval from onset of disease to study varied from three months to several years and timing of blood sampling was not always standardised for diurnal variation of hormone levels. The majority of these studies did not adjust for confounding factors. For example, hypoandrogenemia in men and hyperandrogene-mia in women are confounded with various metabolic disorders including obesity, insulin resistance, dyslipidemia and...

Prognostic Implications of Periprocedural Myocardial Infarction

Top, The Kaplan-Meier curves for 6 months' unadjusted mortality after percutaneous coronary intervention (PCI) for increments of post-PCI creatine kinase-myocardial band isoenzyme (CK-MB). Bottom, Continuous unadjusted relationship between peak CK-MB (as times the upper limit of normal ULN ) and 6 months' mortality. The thin lines represent the 95 confidence intervals. (From Roe MT, Mahaffey KW, Kilaru R, et al Creatine kinase-MB elevation after percutaneous coronary intervention predicts adverse outcomes in patients with acute coronary syndromes. Eur Heart J 2004 25 313-321.) Myocardial infarction Q-wave MI Non-Q > 5x Non-Q 3-5x Myocardial infarction Q-wave MI Non-Q > 5x Non-Q 3-5x Figure 27-5. Kaplan-Meier estimates and hazard ratios (95 confidence intervals) for myocardial infarction in the EPISTENT trial. (From the EPISTENT investigators Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of...

Testosterone and cardiovascular disease in men

Sixteen of 32 cross-sectional studies found lower levels of testosterone in patients with coronary artery disease compared with healthy controls. Sixteen showed no difference in testosterone levels between cases and controls. In none were high levels of testosterone associated with coronary artery disease. All studies which measured levels of free or bioavailable testosterone found an inverse association with coronary artery disease (reviewed in Alexandersen etal. 1996 Wu and von Eckardstein 2003). None of six longitudinal studies in men showed any significant association between serum levels of testosterone and future coronary artery disease events (reviewed in Alexandersen etal. 1996 Wu and von Eckardstein 2003). With the limitations stated before, this suggests that testosterone plays a neutral or even beneficial role in the pathogenesis of coronary artery disease. This is also supported by the finding of a genetic case-control study, where we did not find any significant...

Testosterone and cardiovascular disease in women

By contrast to the neutral or even beneficial associations between endogenous testosterone levels and cardiovascular disease for men, the few retrospective or cross-sectional case-control studies in women revealed pro-atherogenic associations of androgens with CAD (Wu and von Eckardstein 2003). Only scanty prospective data is available on the importance of testosterone as a cardiovascular risk factor in women. Barrett-Connor and Goodman-Gruen(1995) reported a 19-year follow-up of 651 postmenopausal women. Serum levels of testosterone, bioavailable testosterone, and androstendione did not differ between those women with and those without a coronary artery disease history at baseline. Cardiovascular mortality during follow-up was not associated with any androgen serum level (Barrett-Connor and Goodman-Gruen 1995). Indirect evidence for the atherogenicity of androgens in women was derived from the findings of clinical studies that women with coronary artery disease were affected more...

Effects of testosterone on cardiovascular risk factors

The net effect of testosterone on cardiovascular risk is difficult to assess for at least six main reasons. First, the effects of testosterone on cardiovascular risk factors are contradictory depending on whether associations with endogenous testosterone or effects of exogenous testosterone have been investigated. Second, the associations between serum concentrations of endogenous testosterone and cardiovascular risk factors are confounded with mutual interactions between endogenous androgens, body fat distribution, and insulin sensitivity. Third, exogenous testosterone has profound effects on several risk factors, some of which at first sight appear beneficial, namely lipoprotein(a) (Lp(a)), insulin, fibrinogen, and plasminogen activator type 1 (PAI-1), while others are considered adverse, namely HDL-C. Fourth, the causal relationship between some of the aforementioned risk factors and atherosclerosis has not been proven. Of special importance are results of experimental and clinical...

Associations of endogenous testosterone with cardiovascular risk factors

In men testosterone plasma levels were frequently found to have positive correlations with serum levels of HDL-C as well as inverse correlations with plasma levels of triglycerides, total cholesterol, LDL-C, fibrinogen and PAI-1. However, serum levels of testosterone have even stronger inverse correlations with BMI, waist circumference, waist-hip-ratio (WHR), amount of visceral fat and serum levels of leptin, insulin and free fatty acids. After adjustment for these measures of obesity and insulin resistance, the correlations between cardiovascular risk factors with testosterone but not with visceral fat or insulin lost their statistical significance (Hergenc et al. 1999 Tchernof et al. 1996 Tsai et al. 2000). These findings indicate that a low serum level of testosterone in eugonadal men is a component of the metabolic syndrome, which is characterized by the presence of obesity, glucose intolerance or overt type 2 diabetes mellitus, arterial hypertension, hypertriglyc-eridemia, low...

Effects of puberty on cardiovascular risk factors

Longitudinal studies of puberty were informative on the effects of endogenous sex hormones on cardiovascular risk factors in children and adolescents. Prepubertal boys and girls do not differ significantly in their serum lipid and lipoprotein levels. In contrast to girls, in whom levels of HDL-C and LDL-C change little with puberty, sexually maturingboys experience a decrease in HDL-C and increases in LDL-C and triglycerides (Bagatell and Bremner 1995). However, these changes may not reflect effects of sex hormones only since they are confounded by other endocrine changes, for example in the growth hormone-IGF1 axis, which also regulates lipoprotein metabolism.

Prevention of cardiovascular disease

In summary, proof for the effect of enhanced PA on cardiovascular risk factors during childhood and adolescence is equivocal. This might be attributed to several reasons. 1 Cardiovascular risk factors might not be influenced by PA during childhood at all. This assumption is very unlikely, since a positive effect of training has been observed under certain conditions. 5 Cardiovascular risk factors are influenced not only by PA but also by other factors such as nutrition, growth and development, and genetics. If the relative importance of PA is small, it might be difficult to discern any effect.

Congenital heart disease and arrhythmia

In the 1960s and 1970s, a restriction in physical activities and sports participation was implemented in almost every child with a suspected or proven congenital heart disease or arrhythmia. The discussion and guidelines over the recent years, however, has reflected a more liberal approach towards exercise in several of the children in this group. Currently, medical counseling regarding sports participation of patients with heart disease is based on detailed guidelines 74 which are modified according to individual factors. In many cases, exercise testing is necessary to determine the individual risk of specific physical activities.

Heart Attack and Heart Failure

The medical term for heart attack is myocardial infarction. During a heart attack, a portion of the heart muscle dies. Patients usually survive small heart attacks. If the heart attack involves a significant portion of the heart, however, the victim will usually die due to arrhythmias during the beginning of the heart attack. In the event a patient survives a large heart attack, a considerable portion of heart muscle will turn into scar tissue and no longer contract. This can lead to heart failure. The patient will become short of breath and frequently fatigued because of the reduced amount of blood being pumped by the heart, resulting in a relative lack of oxygen and other nutrients getting to the body's tissues. The patient may develop swelling in the ankles or in the legs or abdomen as the heart fails and fluid backs up into the tissues. Myocardial Infarction When a portion of the heart muscle dies. Also referred to as a heart attack.

Exercise after acute myocardial infarction

In the 18th century William Heberden and Caleb H. Parry recommended physical activity for patients with angina pectoris 13,14 . Other views soon became dominant and for almost 200 years rest was a major part in the treatment of angina pectoris and in myocardial infarction. In the 1950s the bed rest period after a my-ocardial infarction was shortened and it was reported that the patients having shorter bed rest after a myocar-dial infarction returned to normal activities sooner. It was shown that patients who were mobilized early had a lower mortality rate and lower morbidity up to a year after acute myocardial infarction (AMI).

Ischaemic Heart Disease

Five per cent of patients over 35 years of age have asymptomatic ischaemic heart disease. In patients who have had a previous myocardial infarction, anaesthesia and surgery within 3 months of infarction until recently carried a 40 risk of perioperative re-infarction. This rate decreases to 15 at 3-6 months and 5 thereafter. Research findings suggest that, with intensive perioperative monitoring, much lower rates of reinfarction can be achieved (at less than 3 months and at 3-6 months). Mortality from postoperative infarction is 40-60 . Elective surgery should generally be postponed until 6 months after infarction unless it is urgent. Unstable angina is particularly associated with an increased risk of perioperative myocardial infarction. Low-dose aspirin (enteric-coated 300 mg or soluble 150 mg once daily) and systemic heparinization decrease the incidence of acute myocardial infarction in this situation. Angina should also be controlled with p-blockade and i.v. nitrate infusion...

Physical inactivity and the burden of cardiovascular disease in type 2 diabetes

Patients with type 2 diabetes have a two- to four-fold increased mortality from cardiovascular disease 6 . The ultimate goal of all therapies in type 2 diabetes is to reduce this burden. In the Aerobic Center Longitudinal Study discussed above 7 , the association between low cardiorespiratory fitness and physical inactivity and total mortality in 1263 men with type 2 diabetes was also studied. After adjustment for age, preexisting and family history of cardiovascular disease, fasting glucose and cholesterol concentrations, overweight and hypertension, type 2 diabetic men in the low fitness group had a risk for all-cause mortality of 2. i. The majority of deaths were attributable to cardiovascular disease 7 .

The Case For And Against Regionalized Care For Acute Coronary Syndromes

Where and how patients with acute ischemic heart disease are treated have been the subjects of debate. Some believe that the real issue is not whether the creation of specialized centers for care of those ACS patients would provide an important advance, but how to create them,7-9 Others contend that clear, compelling evidence of the benefits of ACS regional-ization within the United States and a better understanding of its potential consequences are needed before implementing a national policy of regionalized ACS care.10,11 Proponents assert that the treatment of patients with ACS at regional centers with dedicated facilities will save lives by providing higher-quality care and by improving access to new technologies and to specialist physicians.7-9 These beliefs are in large part based on the precedent U.S. experience with trauma and stroke, as well as on the experiences gleaned from many European countries, where regionalized systems for ACS care have been devel-oped.12-14 Although...

Future Care of Patients with STSegment Elevation Myocardial Infarction

Credentialing and criteria for the development of a level I heart attack center should include the established ability to provide prehospital diagnosis of STEMI with a transmitted 12-lead ECG by means of integration with local or regional EMS.16,23 Suggested criteria for level 1 heart attack centers are listed in Table 37-4. To be successful, a system for care of STEMI patients should have many integral components (Table 37-5), including a patient care focus, enhanced operational efficiency, appropriate system incentives i.e., (pay for performance or pay for value), specific outcome and process measures, and mechanisms for quality review with continuous quality improvement. Professional societies and organizations can and should develop the credentialing criteria for these centers. State and local government agencies could be charged with the oversight of legitimacy for regional STEMI networks. Clinical practice Table 37-4. Criteria for a Level 1 Heart Attack Center EMS, emergency...

Intensive Care Management of Acute Stroke

Table 25.4 Neuroprotective agents tested or being tested in Phase 111 acute stroke trials centre may be affected by the stroke itself whereas in cortical infarctions the dysfunction of the brainstem results from displacement and herniation caused by vasogenic oedema and raised intracranial pressure (ICP). General predictors of an early death include Age, AF cardiac failure and ischaemic heart disease, diabetes, fever, incontinence, previous stroke and a depressed conscious level (e.g. Glasgow Coma Scale < 9). Neurological features include a severe motor deficit, any visuospatial deficit and a large volume lesion with mass effect on CT. For a brainstem stroke, a decreased conscious level, conjugate gaze palsy, severe bilateral motor weakness, abnormal respiratory patterns and bilateral extensor plantars indicate a severe stroke and poor prognosis.80 81 Having survived the first few days of stroke, subsequent deaths are most often caused by consequences of immobility the most common...

Septal Rupture Secondary to Myocardial Infarction

This complication used to occur before the thrombolytic era in approx 1-2 of patients with myocardial infarction. In the current era of routine thrombolytic therapy, its frequency has fallen to about 0.2 (107). It accounts for about 5 of all deaths from myocardial infarction. The septal rupture is usually associated with the first myocardial infarction and will generally occur within the first week after the infarct. It is more common with anterior myocardial infarction than with inferior infarct. Rupture may be simple or complex and serpigenous. The electrocardiogram may show right bundle branch block or complete atrioventricular block. The onset is recognizable with the detection of a new murmur. The left ventricular volume load, because of the shunt, will not be well tolerated by the already compromised left ventricle secondary to the myocardial infarction. Eventually this may lead to the development of congestive cardiac failure within a few hours to a few days. The outcome is...

Relative risk of dementia after stroke

In the Rochester study, the relative risk of dementia (i.e. the risk of dementia in stroke survivors divided by the risk of dementia in stroke-free controls) was 8.8 one year after stroke, then declined progressively to 2.5 after 10 years, and 2.0 after 25 years 22 . The risk of AD was also doubled after 25 years 22 . In the Framingham study, the results were similar 10 years after stroke, after adjustment for age, gender, education level and exposure to individual risk factors for stroke 29 . A study where stroke was not associated with an increased risk of dementia 30 was actually conducted in non-aphasic patients, with mild first-ever strokes, and only 1 year of follow-up, i.e. the best conditions to minimize the incidence of new-onset dementia. In hospital-based studies the risk of new-onset dementia within 4 years after ischemic stroke is 5-6-fold higher than in stroke-free controls 27, 31 . Finally, the results of hospital- and community-based studies can be summarized as...

Preexisting silent brain lesions in stroke patients

Silent infarcts, i.e. cerebral infarcts seen on CT or MRI scans that have never been associated with a relevant neurological deficit, are associated with an increased risk of dementia after stroke 5 . Their influence is more important when the follow-up is longer in the Lille study, silent infarcts were associated with dementia after stroke at year 3 25 but not at year 2 and in the Maastricht study silent infarcts were independently related to dementia after 12 months, but not after 1 or 6 months 35 . Stroke patients with associated silent infarcts seem to have a steeper decline in cognitive function than those without, but this decline might be confined to those with additional silent infarcts after base-line. Global cerebral atrophy is associated with a higher risk of dementia after stroke 5 . Medial temporal lobe atrophy (MTLA) is more frequent in stroke patients who have pre-existing dementia but it may also be present in non-demented stroke patients. MTLA clearly differentiates...

Myocardial Infarction

The average incidence of myocardial infarction (MI) is 1-2 in unselected patients over 40 years of age undergoing major non-cardiac surgery. Pre-existing coronary artery disease and, in particular, evidence of a previous MI result in a higher risk. Mortality in patients who suffer a perioperative MI may be as high as 60 . Perioperative MI occurs most commonly on the third postoperative day, but may happen at any time during or after surgery. surgery is considerably higher than when surgery is performed outside the thorax and abdomen. In patients with ischaemic heart disease, postoperative MI is more likely if there is evidence of ischaemic changes on ECG during operation. Such changes are associated most commonly with episodes of intraoperative hypotension, hypertension or tachycardia the last two occur most frequently in response to noxious stimuli, e.g. tracheal intubation, surgical incision. The drugs used and the manner in which they are employed by the anaesthetist influence the...

Pregnancy after an ischemic stroke

A multicenter French study 79 conducted with 373 consecutive women who had an ischemic stroke between 15 and 40 years of age and followed-up over a 5-year period found an overall risk of recurrent stroke of 0.5 at year 5 (95 CI 0.3-0.95) in periods without pregnancy and 1.8 (95 CI 0.5-7.5) during pregnancies and puerperium, without significant difference. Therefore young women who have had an ischemic stroke have an overall low risk of recurrence during a subsequent pregnancy and do not significantly increase this risk during pregnancy 79 .

Secondary prevention after ischemic stroke in young adults

The main characteristics of ischemic stroke occurring in young patients, i.e. their causes, the overall good outcome and interference with hormonal life in women (contraception, pregnancy and future menopause), influence secondary prevention after stroke. As for elderly subjects, secondary prevention measures mainly depend on the presumed cause. For this reason, an extensive and early diagnostic work-up is required, as well as an extensive evaluation of risk factors. The overall management of secondary prevention is based on principles similar to those in elderly subjects, i.e. an optimal management of vascular risk factors, an appropriate antithrombotic therapy (oral anticoagulation and antithrombotic agents depending on the cause) and removal of the source in specific cases (severe internal artery stenosis, cardiac The specificities of stroke prevention in young adults are the following (i) oral contraceptive therapy should be avoided in most cases (ii) in the absence of...

Global burden of coronary heart disease

Map Healthy years of life lost to coronary heart disease Ounpuu S, Anand S, Yusuf S. The global burden of cardiovascular disease. Medscape cardiology, 24 January 2002 Nayha S. Cold and the risk of cardiovascular diseases. A review. International journal of circumpolar health,

Reduction Of Cardiovascular Risk

Risk factors for chronic disease can also be reduced by exercise. Several small group comparisons have suggested that persons with quadriplegia and paraplegia have significantly lower high-density lipoprotein (HDL) cholesterol levels than controls. In the first year after SCI, however, a prospective study of HDL levels in 100 patients found an increase of 26 in those with quadriplegia and 18 with paraplegia, but the levels are still low.164 A regimen of 8 weeks of wheelchair ergometer training for subjects with SCI at the moderate intensity of approximately 60 of peak oxygen uptake for 20 minutes a day for 3 days a week increased HDL cholesterol levels by 20 and lowered low-density lipoprotein (LDL) levels by 15 .165 This training could lower the long-term risk for coronary artery disease by 20 . Graded arm exercises 3 days a week for 3 months lowered LDL cholesterol by 26 and raised HDL cholesterol 10 , along with improving peak oxygen consumption by 30 and reducing cardiovas cular...

Deaths from coronary heart disease

Map Deaths from coronary heart disease Deaths from coronary heart disease compared with other causes Ounpuu S, Anand S, Yusuf S. The global burden of cardiovascular disease. Medscape cardiology, 24 January 2002 Khot UN, Khot MB, Bajzer CT et al. Prevalence of conventional risk factors in patients with coronary heart disease. Journal of the American Medical Association, 2003, 290 898-904. Chambless L, Keil U, Dobson A, Mahonen M, Kuulasmaa K, Rajakangas AM, Lowel H, Tunstall-Pedoe H. Population versus clinical view of case fatality from acute coronary heart disease results from the WHO MONICA Project 1985-1990. Multinational MONItoring of Trends and Determinants in CArdiovascular Disease. Circulation, 1997, 96(11) 3849-59.

Management of Acute Stroke

Patients suspected of having suffered an acute stroke should be stabilized in accordance with usual emergency management, which focuses initially on basic cardiopulmonary resuscitation (CPR) and support. All patients should have a thorough but timely physical examination, looking especially for head and neck trauma and cardiovascular abnormalities, followed by neurologic evaluation, including assessment of mental status, cranial nerve function, cerebellar function, and motor and sensory function, using the NIH Stroke Scale. Initial laboratory studies should generally include determination of a complete blood count (CBC) with differential and platelet count, prothrombin time and partial throm-boplastin time (PT PTT), electrolyte, blood urea nitrogen (BUN), creatinine, and glucose levels, oxygen saturation by pulse oximetry, and a metabolic panel. Depending on the clinical history, some patients should have studies for possible altered coagulation or connective tissue diseases. A CT...

Management of acute ischemic stroke and its complications

Monitoring the blood pressure (BP), glucose levels and temperature in acute stroke patients is an often neglected matter although it may have an important impact upon the patients' outcome. In the Tel Aviv stroke register, recorded between the years 2001 and 2003, 32 of acute stroke patients in the emergency room had glucose levels higher than 150 mg dl, higher systolic BP than 140 mmHg was found in 77 of the patients and 17 of patients had temperatures above 37 C on admission. These numbers are representative of other centers as well. This chapter will summarize the current knowledge regarding the management of the above.

Hypertensive blood pressure values in acute ischemic stroke

Several observations have demonstrated spontaneous elevation of blood pressure in the first 24-48 hrs after stroke onset with a significant spontaneous decline after a few days 1-3 . Several mechanisms may be responsible for the increased blood pressure, including stress, pain, urinary retention, Cushing effect due to increased intracranial pressure and the activation of the sympathetic, renin-angiotensin and ACTH-cortisol pathways. Despite the increased prevalence of hypertension following stroke, optimal management has not been yet established. Several arguments speak for lowering the elevated BP risks of hemor-rhagic transformation, cerebral edema, recurrence of stroke and hypertensive encephalopathy. On the other hand, it may be important to maintain the hypertensive state due to the damaged autoregulation in the ischemic brain and the risk of cerebral hypoperfusion exacerbated by the lowered systemic blood pressure.

Controlling BP in the acute stroke phase

The theory that elevated systemic BP may compensate for the decreased cerebral blood flow in the ischemic region led to attempts to elevate blood pressure as a treatment for acute ischemic stroke. The hemody-namic and metabolic impact of pharmacologically increased systemic blood pressure on the ischemic core and penumbra was evaluated in rats. The mild induced hypertension was found to increase collateral flow and oxygenation and to improve cerebral metabolic rate of oxygen in the core and penumbra 12 . Several small studies in humans have addressed this question and administered vasopressors, including phenylephrine and norepinephrine, to patients with acute stroke 13-15 . Despite a documented improvement in CBF 16 , the concept was abandoned because of the increased risk of hemorrhage and brain edema. In a systemic review of 12 relevant publications including 319 subjects, the small size of the trials and the inconclusive results limit conclusion as to the effects on outcomes, both...

Coronary Artery Disease and Viagra

Recently, a new medication called Viagra has become available to treat erectile dysfunction. Although effective, it should not be used with certain heart medications. Those of us who specialize in heart disease receive many questions regarding Viagra and sometimes questions on other treatment options for impotence from patients who shouldn't take Viagra. I have therefore asked my colleague, Dr. Chipriya B. Dhabuwala, who specializes in impotence and is a professor of urology at Wayne State University, to discuss Viagra as it relates to heart medication and to

Formal Cardiac Rehabilitation Programs after Heart Surgery or Heart Attacks

Some cardiologists feel strongly that all patients should be enrolled in a formal rehabilitation program. These programs typically last six to twelve weeks after heart surgery or heart attacks. Other cardiologists feel that the need to enter a formal cardiac rehabilitation program should be more individualized, and not all patients, particularly those that are already quite active, need to be enrolled. help build the patients' confidence. Patients are closely monitored for abnormal blood pressure and irregularities of the heartbeat by trained personnel in a group or class setting. They are taught to monitor their pulse rate and to look for signs of chest pain (angina type), particularly if they are coronary patients. Their activity level is slowly increased. During rehabilitation, they are educated about diet and other types of behavior modification that lead to a healthier lifestyle and a healthier heart.

Stress Anger and Cardiovascular Disease A Comprehensive Model

The model at the end of this appendix (page 283) details the theoretical relationship between stress, anger, and cardiovascular disease. Stress is often defined as the response of the body to threats or demands. The stress response is called a neuroendocrine response the brain acts like a conductor and orchestrates a cascade of neural (nerves) and endocrine (hormonal) messages that target various organs. Anger hostility is thought to be a risk factor for cardiovascular disease because all of the major stress pathways (A to E in the model) are theoretically activated when a person becomes aroused. This model depicts stress as not only a response but also a process that involves continuous interactions and adjustments (transactions) between an individual and the environment. In part, this book is about making those interactions and adjustments as appropriate and healthy as possible, thereby enabling a person to become an active agent in his or her well-being rather than a passive victim...

Local and Systemic Manifestations of Cardiovascular Disease

Valvular Heart Disease A good deal of information about cardiovascular diseases can be obtained by the thorough inspection of a patient using only the unaided senses. Inspection is a frequently overlooked aspect of cardiovascular physical diagnosis. This chapter discusses the recognition of the local and systemic manifestations of cardiovascular disease under the following headings general observations, congenital syndromes, vascular diseases, valvular heart disease, endocrine and metabolic diseases, inflammatory diseases, diseases of connective tissue and joints, pharmacological agents, musculoskeletal diseases, and tumors. Associated cardiovascular findings are placed in brackets.

Myocardial infarction See heart attack or MI

Nitroglycerin A drug used to dilate coronary arteries so more oxygenated blood can reach the heart muscle. This drug is generally used by patients with atherosclerotic coronary artery disease. open heart surgery Heart operations in which the heart-lung machine is used and the heart is opened so various structures can be repaired or replaced. However, many people also use the term to refer to any heart operation in which the heart-lung machine is used, including coronary bypass surgery, in which only the surface of the heart is worked on. palliative A treatment that improves a condition but does not cure it. A palliative heart procedure would be one that would improve the patient's condition but not cure the heart disease.

Acquired Anomalies Of Coronary Arteries Secondary To Congenital Heart Disease

Of extramural coronary arteries in adults with cyanotic congenital heart disease (Fig. 32-14).16'109 High viscosity of the erythrocytic perfusate increases endothelial shear stress' with release of vasodilatory nitric oxide and prostaglandins.177 Paradoxical emboli to the coronary arteries are rare secondary complications of cyanotic congenital heart disease.48'67 A right-to-left intracardiac shunt potentially delivers paradoxical emboli from a peripheral thromboem-bolic source. Acquired Anomalies of Coronary Arteries Secondary to Congenital Heart Disease Coronary ectasia with cyanotic congenital heart disease

Coronary Heart Disease

Heart disease is the leading cause of death in the United States, and tobacco use is a major risk factor. Up to 30 of all deaths from heart disease are caused by smoking, with a strong dose-dependent relationship. In general, smokers have two to four times the risk of coronary heart disease as nonsmokers. For women smokers, the risk may be even higher. Women who smoke only one to five cigarettes a day have 2.5 times the risk of developing coronary heart disease as nonsmokers, rising to 75 times the risk in those who smoke 40 or more cigarettes a day. Three fourths of myo-cardial infarctions in women younger than 50 have been attributed to smoking (Dunn et al., 1999 Slone et al., 1978). Women who smoke and use oral contraceptives (OCs) have up to 10 times greater risk of heart attack than women who do neither, depending on which generation of OC is used. More than half of all deaths from coronary heart disease are sudden deaths caused by cardiac arrhythmia. Nicotine is arrhythmogenic,...

Ischemic strokes and transient ischemic attacks caused by low cerebral flow posterior circulation

Vertebral Artery Tortuosity After Fall

Most patients with subclavian artery stenosis or occlusion are asymptomatic. In a large series, only 15 out of 324 patients (4.8 ) had objective signs of brachial ischemia such as aching after exercise or coolness of the arm. Among 116 patients with unilateral steal as shown by ultrasonography none had symptoms of brain ischemia 7 . Among more than 400 patients with posterior circulation TIAs or ischemic stroke only two had symptoms (TIAs) attributable to significant subclavian or innominate artery

Thyroxine and Ischemic Heart Disease

Myocardial infarction and angina are both recognized complications of levothyroxine therapy in hypothyroid patients, even in dosages as small as 25 j.g day. Forty percent of patients with a history of angina are unable to tolerate fully suppressive doses of T4.76 Patients with known cardiac disease who are older than 65 years should, therefore, be treated with caution. Levothyroxine in such patients should be initiated at 50 j.g, with 25-p.g increments at 3-month intervals until TSH is suppressed to one tenth of normal. In clinical practice, the vigor with which TSH suppression is undertaken is related more to the underlying condition for which it is prescribed than to the likelihood of worsening preexisting cardiovascular disease. Whether evidence exists for justification of suppressive therapy still remains unclear.

Coexistence of coronary heart disease and stroke

There is a frequent coexistence of coronary heart disease and stroke, most probably due to common atherosclerotic risk factors such as arterial hypertension, diabetes mellitus, smoking, and hypercholes-terolemia. A history of symptomatic coronary heart disease, either myocardial infarction or angina pec-toris, is found in up to 33 of patients with ischemic stroke 21 . An autopsy study of patients with fatal stroke found coronary plaques in 72 , coronary stenosis in 38 and myocardial infarction in 41 22 . Two-thirds of the myocardial infarctions in that study were clinically silent 22 . Coronary heart disease, however, is not only a frequent finding at autopsy but also influences the prognosis of patients surviving a stroke. Five-year follow-up studies have shown that survivors of ischemic stroke are more likely to die of cardiac causes than of recurrent stroke 21, 23 . These results stress the importance for the neurologist to be aware of cardiac symptoms of stroke patients and for...

Effects of exogenous testosterone on cardiovascular risk factors

Since low HDL-C is an important coronary artery disease risk factor and since HDL exerts several potentially anti-atherogenic actions, lowering of HDL-C by testosterone is considered to increase cardiovascular risks (Hersberger and von Eckardstein 2003). However, the epidemiological association of low HDL-C with coronary artery disease has not been proven to be causal. Instead, low HDL-C frequently coincides with other components of the metabolic syndrome and markers of chronic inflammation, and may therefore merely be a surrogate marker for a separate but linked pro-atherogenic condition. Moreover, in transgenic animal models, only increases of HDL-C induced by apoA-I overproduction but not by inhibition of HDL catabolism were consistently found to prevent atherosclerosis (von Eckardstein et al. 2001, Hersberger and von Eckardstein 2003). Therefore, the mechanism of HDL modification rather than changes in levels of HDL-C per se appear to determine the (anti)-atherogenicity of HDL...

Exogenous testosterone treatment in men with cardiovascular disease

The longterm effects of exogenous testosterone on coronary event rates has not been investigated. However, in several small studies therapeutic doses of testosterone reduced the severity and frequency of angina pectoris events and improved electrocardiographic signs of myocardial ischemia. Webb and colleagues (Webb etal. 1999) showed that a single i.v. bolus of 2.3 mg of testosterone increased time to 1-mm ST segment depression by 66 sec in 14 men with coronary artery disease and low plasma testosterone. The plasma testosterone increased from 5.2 to 117 nmol L. Infusion of testosterone over three minutes into the coronary arteries of 13 men with established coronary artery disease during coronary angiog-raphy at supraphyisological doses of 8 xmol L but not the physiological dose of 8 nmol L led to significant increases in coronary vessel diameter and blood flow at all four doses of testosterone. These results have been confirmed by a similar study (Rosano et al. 1999) in 14 men with...

Treatment Of Acute Ischemic Stroke

Severe Ischemic Stroke

Acute ischemic stroke is a medical emergency. Identification of the time and manner of stroke onset is an important determinant in treatment. The time the patient was last without symptoms is used as the time of stroke onset. Because patients typically do not experience pain, determining the onset time can be difficult. It is also important to document risk factors and the previous functional status of the patient to assess current disability due to stroke. FIGURE 11-2. Acute stroke treatment algorithm. (BP, blood pressure CEA, carotid endarterectomy DVT, deep vein thrombosis IA, intra-arterial ICA, internal carotid artery ICH, intracerebral hemorrhage NINDS, National Institute of Neurological Disorders and Stroke NS, normal saline SAH, subarachnoid hemorrhage t-PA, tissue plasminogen activator.) FIGURE 11-2. Acute stroke treatment algorithm. (BP, blood pressure CEA, carotid endarterectomy DVT, deep vein thrombosis IA, intra-arterial ICA, internal carotid artery ICH, intracerebral...

Perioperative Myocardial Infarction Pathophysiology

Similar to myocardial infarction (MI) outside the context of surgery, perioperative MI can result either from atherosclerotic plaque rupture, with subsequent thrombotic occlusion of the involved coronary artery, or from a transient stress-induced mismatch of myo-cardial oxygen supply and demand, often in the setting of a fixed coronary artery stenosis. Among patients with fatal perioperative MI, autopsy series have demonstrated histologic characteristics of recent plaque rupture in approximately 50 of cases. Clini Figure 7-1. Pathophysiologic events contributing to the genesis of perioperative myocardial infarction (MI). BP, blood pressure HR, heart rate NSTEMI, non-ST-segment elevation myocardial infarction. Figure 7-1. Pathophysiologic events contributing to the genesis of perioperative myocardial infarction (MI). BP, blood pressure HR, heart rate NSTEMI, non-ST-segment elevation myocardial infarction. The incidence of myocardial ischemia and infarction in the period surrounding...

Transient Ischemic Attacks and Strokes

Miller Fisher first described the phenomenology of TIAs as prodromal fleeting attacks of paralysis, numbness, tingling, speechlessness, unilateral blindness or dizziness, which nearly always preceded cerebral infarction in patients with occlusion of the internal carotid artery (ICA). '6 TIA is a strong indicator of a subsequent stroke. The first year after a TIA carries the greatest stroke risk (5 percent). y TIA is arbitrarily defined as a focal neurological deficit lasting less than 24 hours, but attacks are usually shorter, most episodes clearing within 1 hour. y , y If neurological deficits last 4 hours or longer, patients often have infarcts in the locations corresponding to the transient symptoms.y The clinical features of TIAs are usually similar to those of infarctions located in the arteries affected except for the transient nature of the clinical episodes.

Hemorrhagic Stroke

The pathophysiology of hemorrhagic stroke is not as well studied as that of ischemic stroke however, it is more complex than previously thought. Much of the process is related to the presence of blood in the brain tissue and or surrounding spaces resulting in compression. The hematoma that forms may continue to grow and enlarge after the initial bleed and early growth of the hematoma is associated with a poor outcome. Brain tissue swelling and injury is a result of inflammation caused by thrombin and other blood products. This can lead to increased intracranial pressure (ICP) and herniation.4,5

Heart Disease

The precise diagnosis of various forms of heart disease was achieved only after the development of pathological anatomy, auscultation, and the stethoscope. Under Chinese medical philosophy, abstract arguments concerning the pulse, combined with heart pain and shortness of breath, were used for diagnosis of heart diseases. Under the heading heart pain, the Hyangyak chipsong pang lists nine different kinds. These entries and similar discussions in other texts composed during the later years of the Yi Dynasty suggest knowledge of angina pectoris as well as other symptoms of heart disease.

Stroke risk and PFO

It is uncertain whether the recurrence rate of stroke in patients with cryptogenic stroke is dependent on the presence of a PFO. In one observational study of patients treated with aspirin, the incidence of recurrent stroke was higher in patients with than without PFO 47 . In a further prospective randomized study, the recurrence rate of stroke was the same in those with or without PFO in those treated with either warfarin or aspirin 44 . The question of whether subjects from the general population with PFO have an increased risk of ischemic stroke has been studied by two prospective cohort studies, which unanimously found that PFO was not a risk factor for future cerebrovascular events 48, 49 . Overall, it has not been demonstrated that patients with PFO are at increased risk of recurrent stroke. Furthermore, it is uncertain how many strokes in PFO patients are due to paradoxical embolism and how to treat paradoxical embolism. Results from randomized clinical trials on these issues...

Endocardial Fibroelastosis

Endocardial fibroelastosis, a self-defining term introduced in 1943 by Weinberg and Himmelfarb,74 is characterized by an opaque, pearly-white thickening (Fig. 10-1) due to proliferation of collagen and elastic fibers.12, 16, 32, 46, 48, 77 Isolated endocardial fibroelastosis resides in the endocardium of a dilated, hypertrophied left ventricle,32, 48 hence the term primary endocardial fibroelastosis of the dilated type. Conversely, albeit rarely, the left ventricular cavity is small, hence the term endocardial fibroelastosis of the contracted type.32, 48 Another type of endocardial fibroelastosis designated as secondary accompanies certain types of congenital malformations of the heart,19, 48 especially aortic stenosis,14 coarctation of the aorta,25, 52 anomalous origin of the left coronary artery from the pulmonary trunk,51 and hypoplastic left heart.50 Pathogenesis must take into account the gross and histologic endocardial abnormalities as well as the left ventricular hypertrophy...

Prevention personal choices and actions

Good control of blood pressure, blood cholesterol and blood sugar levels, and other cardiovascular risk factors is the key to reducing risks of heart disease and stroke. Personal behaviour and lifestyle choices can make a big difference to the risk of coronary heart disease and stroke. It is estimated that having a high-risk lifestyle may account for 82 of coronary events in women. Here, we identify personal choices that can lower individual risk for heart disease and stroke. The choices apply to young people and adults alike. 5 Know the signs and symptoms of heart attack and stroke and remember that both conditions are medical emergencies. Actions and choices for children and adolescents with cardiovascular disease, or risk factors, should be discussed with a paediatrician or health care provider. Probability of heart attack begins to decrease. Excess risk of coronary heart disease is half that of a continuing smoker. Risk of coronary heart disease is similar to that of people who...

Policies and legislation

The first international convention that relates specifically to cardiovascular disease is the WHO Framework Convention on Tobacco Control. It was adopted without dissent by the World Health Assembly in Geneva in May 2003, and is currently in the process of ratification. Once 40 countries have ratified the Convention, it will come into effect as a legally binding treaty among those countries. The Convention includes clauses on advertising bans, smoke-free areas, health warnings, taxation, smoking cessation and smuggling. Cardiovascular disease plans worldwide

Risk factor blood pressure

Vasan RS, Larson MG, Leip EP, Evans JC, O'Donnell CJ, Kannel WB, Levy D. Impact of high-normal blood pressure on the risk of cardiovascular disease. New England journal of medicine, 2001, 345 1291-1297. He J, Ogden LG, Vupputuri S, Bazzano LA, Loria C, Whelton PK. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. Journal of the American Medical Association, 1999, 282 2027-2034.

Risk factor tobacco

Cardiovascular risks of smoking Price JF, Mowbray PI, Lee AJ, Rumley A, Lowe GD, Fowkes FG. Smoking and cardiovascular risk factors in the development of cardiovascular disease and coronary artery disease Edinburgh Artery Study. European heart journal, 1999, 20 344-353. Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men longitudinal population study. British medical journal, 1998, 316 1043-1047. Cardiovascular risks of passive smoking Smokers don't know the risks of heart attack Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. Journal of the American Medical Association, 1999, 281 1019-1021. Bonita R, Duncan J, Truelsen T, Jackson RT, Beaglehole R. Passive smoking as well as active smoking increases the risk of acute stroke. Tobacco control, 1999, 8 156-160. Humphries SE, Talmud PJ, Hawe E, Bolla M, Day INM, Miller GJ. Apolipoprotein E4 and coronary heart disease in middle-aged men...

Risk factor obesity

Lakka HM, Lakka TA, Tuomilehto J, Salonen JT. Abdominal obesity is associated with increased risk of acute coronary events in men. European heart journal, 2002,23 706-713 (cited in Sowers JR. Obesity as a cardiovascular risk factor. American journal of medicine, Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes care, 2001, 24 683-689 (cited in Sowers JR. Obesity as a cardiovascular risk factor. American journal of medicine, Eckel RH, Krauss RM. American Heart Association call to action obesity as a major risk factor for coronary heart disease. Circulation, 1998, 97 2099-2100.

Risk factor socioeconomic status

Choiniere R, Lafontaine P, Edwards AC. Distribution of cardiovascular disease risk factors by socioeconomic status among Canadian adults. Canadian Medical Association journal, 2000, 162(9 Suppl) S13-24. Note Definitions used Physical inactivity leisure exercise less than once per week during previous month. Elevated cholesterol > 5.2 mmol l after fasting 8 hours or more. Giampaoli S, Palmieri L, Dima F, Pilotto L, Vescio MF, Vanuzzo D. Socioeconomic aspects and cardiovascular risk factors experience at the Cardiovascular Epidemiologic Observatory. Italian heart journal, 2001, 2(3 Suppl) 294-302. Steptoe A, Feldman PJ, Kunz S, Owen N, Willemsen G, Marmot M. Stress responsivity and socioeconomic status a mechanism for increased cardiovascular disease risk European heart journal, 2002, 23(22) 1757-63. Terris M. The development and prevention of cardiovascular disease risk factors socioenvironmental influences. Preventive medicine, 1999, 29(6 Pt 2) S11-17. Rao SV, Kaul P, Newby K et al....

Women a special case

Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men longitudinal population study. British medical journal, 1998, 316 1043-1047. Walking reduces coronary heart disease Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women. Is no pain, no gain pass Journal of the American Medical Association, 2001, 285 1447-1454. Kmietowicz Z. News roundup Women fail to recognise risk of heart disease. British medical journal, 2003, 326 355. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes a 26-year follow-up of the Framingham population. American heart journal, 1986, 111 383-390. McKinlay JB. Some contributions from the social system to gender inequalities in heart disease. Journal of health and social behaviour, 1996, 37 1-26. Dustan HP. Coronary artery disease in women. Canadian journal of cardiology, 1990, 6(Suppl B) 19B-21B. Roquer J, Campello...

Physical Appearance

Birth weights in infants with complete transposition are on average greater than normal, with a substantial proportion above 8 pounds,5,85 in contrast to newborns with other forms of congenital heart disease, who average less than normal birth weights for gestational age.58 The illusion of robust health is soon dispelled by the catabolic effects of congestive heart failure (Fig. 27-10).58,74 Increased anteroposterior chest dimensions are associated with hyperinflation of the lungs (see The X-Ray). Intense early cyanosis reflects poor intercirculatory mixing and low pulmonary blood flow. Mild delayed cyanosis reflects good intercirculatory mixing and increased pulmonary blood flow. Complete

Prevention population and systems approaches

Use of medications in stroke and coronary heart disease Gaps in secondary prevention of myocardial infarction and stroke WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE) in low and middle income countries. WHO-PREMISE (Phase I) Study Group. Mendis S. Role of governments in improving prevention of cardiovascular disease. Global Symposium on Cardiovascular Prevention, Marbella, Spain, 11-13 April 2003.

Anomalies Of Aortic Origin Table 322

Anomalous aortic origins of coronary arteries unassoci-ated with congenital heart disease are listed in Table 32-2. Origin of a coronary artery is considered anomalous when the ostium is located above the sinotubular junction' in the Unassociated with Congenital Heart Disease Single coronary artery, which is an anomaly that has been known since 1903,7 originates from a single ostium in the left or right aortic sinus and gives rise to the entire coronary circulation (Figs. 32-4 and 32-5).37,119,159 A second coronary ostium is neither present nor implied. An isolated single coronary artery unassociated with congenital heart disease divides into normally formed and normally distributed branches irrespective of the aortic sinus from which it originates (see Fig. 32-4C,D).14,54,119,135,139,155,159 A single coronary artery associated with congenital heart disease is characterized by branching patterns that bear no resemblance to normal.119 A single coronary artery functions normally unless...

Congenital Anomalies Involving The Coronary Sinus Table 325

Anderson RH, Becker AE, Lucchesse FE, et al Morphology of Congenital Heart Disease. Baltimore, University Park Press, 1983. 21. Caffersky EA, Crawford DW, Turner SF, et al Congenital aneurysm of the coronary artery with myocardial infarction. Am J Med Sci 257 320, 1969. 29. Cohen LS, Shaw LD Fatal myocardial infarction in an 11 year old boy associated with a unique coronary artery anomaly. Am J Cardiol 19 420, 1967. 43. Engle HJ, Torres C, Page H Major variations in anatomical origin of the coronary arteries Angiographic observations in 4,250 patients without associated congenital heart disease. Cathet Cardiovasc Diagn 1 157, 1975. 101. Newton MC' Burwell LR Single coronary artery with myocardial infarction and mitral regurgitation. Am HeartJ 95 126' 1978. 109. Perloff JK' Urschell CW Roberts WC' Caulfield WH Aneurysmal dilatation of the coronary arteries in cyanotic congenital heart disease. Am J Med 45 802' 1968. 116. Reemstma K' Longenecker CG' Creech O Jr Surgical anatomy of the...

Risk factor lipids

High levels of LDL-cholesterol, and other abnormal Lipids (fats), are risk factors for cardiovascular disease. Cholesterol is a soft, waxy substance found among the lipids in the bloodstream and in all the body's cells. It is needed to form cell membranes and hormones, and for other bodily functions. Cholesterol is transported around the body in two kinds of lipoproteins low-density lipoprotein, or LDL, and high-density lipoprotein, or HDL. A high level of LDL can lead to clogging of the arteries, increasing the risk of heart attack and ischaemic stroke, while HDL reduces the risk of coronary heart disease and stroke. The female sex hormone estrogen tends to raise HDL-cholesterol levels, which may help explain why premenopausal women are relatively protected from developing coronary heart disease.

Figure

Regarding homocysteine as a risk factor for coronary artery disease, which statement is most accurate a. It' patients with angiog'aphicallv defined coronary artery disease, homo cysteine is a significant predictor ot mortality, ir. conjunction with traditional risk factors, < 1 P and methyle netet ra 'ivdrofolate reductase i.YlTHI'R) genotype. b. In i, 'jcntv with angiograpiiKjlh defined coronary artery disease. h-rnjo vsieiiH' is siynil Lant predictot ol mortality independent ot 11< 1 lIitif.ina