Cardiology

It is difficult to make generalizations about treatment of elderly diabetic patients with coronary artery disease (CAD).

We compared blood pressure control among white and African American hypertensive men in Veterans Affairs (VA) and non-VA sites, and found that the dis parity between the two ethnic groups was 40% less at VA sites. Better access to care and medications for African Americans at the VA sites may explain the difference.

The article by Rehman and colleagues (page 27) offers two important observations about the control of hypertension in African American men.

Using data from 8,725 participants in the Framingham Heart Study who were followed for 176,166 person-years, we estimate that the lifetime risk of developing atrial fibrillation (AF) is 1 in 4 for men and women aged 40 years and older. Even when there is no antecedent congestive heart failure or myocardial infarction, the lifetime risk of AF is high (1 in 6). This significant lifetime risk highlights the major public health problem resulting from AF and the need for further study into causes, prevention, and treatment.

Data from the Framingham study provide yet more valuable prognostic information, this time related to the most common cardiac arrhythmia, atrial fibrillation.

Pharmacologic inhibition of the renin-angiotensin aldosterone system (RAAS) has become a widely accepted ap­proach to lowering blood pressure (BP).

Few medical treatment goals are more important yet more troublesome than the prevention of thromboembolic complications in patients with atrial fibrillation (AF).

We evaluated the prognostic role of metabolic syndrome after myocardial infarction and found that metabolic syndrome correlated with an increased risk of cardiovascular events and death. The risk of developing diabetes decreased with weight loss in patients with metabolic syndrome. These results indicate that a more aggressive approach to the treatment of patients with metabolic syndrome, particularly with regard to changes in lifestyle, would be beneficial.

If only we could do for diabetes what we have done in the past decade for hyperlipidemia.

Our study aimed to clarify whether white-coat hypertension represents a transient state in the development of hypertension outside medical settings. We followed up 128 subjects with white-coat hypertension and compared their risk of progression to home hypertension with that of 649 sustained normotensive subjects. After 8 years of follow-up, subjects with white-coat hypertension had an approximately 3-fold higher risk of eventually manifesting home hypertension. We concluded that patients with white-coat hypertension should be carefully monitored.

For 50 years, hypertension has been recognized as the most significant risk factor for the development of symptomatic cardiovascular disease in Western society.

We showed that a significant reduction in thoracic aortic plaques and low-density lipoprotein cholesterol levels occurred after 12 months of treatment with atorvastatin. In the abdominal aorta, however, the change in atherosclerotic plaques correlated with age. These results show that plaques in the thoracic and abdominal aortas may respond differently to lipid-lowering therapy, and other factors, such as aging, may be more important for plaque progression in the abdominal aorta.

It was not until Virchow identified the cellular contributions to thrombosis that physicians began to visualize arteries as dynamic tissues.

The recent Management of Atherothrombosis with Clopidogrel in High-risk Patients Trial showed that adding acetylsalicylic acid (aspirin) to clopidogrel in high-risk patients with recent ischemic stroke or transient ischemic attack is associated with a favorable but nonstatistically significant trend toward fewer vascular events. However, the risk of life-threatening bleeding is increased by the addition of aspirin to clopidogrel. These results do not support the routine use of aspirin in addition to clopidogrel in the patient population that was studied in MATCH.

The negative results of the Management of Atherothrombosis with Clopidogrel in High-risk patients (MATCH) Trial1 are disappointing and surprising, but perhaps this can be said about the conduct of the trial itself.

We investigated 1209 patients with valvular and nonvalvular atrial fibrillation who were treated with standard anticoagulant therapy, the cyclooxygenase inhibitor triflusal, or combined therapy with triflusal and an anticoagulant. Compared with patients receiving standard anticoagulation treatment, the addition of antiplatelet therapy to reduced-intensity anticoagulation in patients stratified for risk of stroke significantly reduced the vascular event rate.

Women with acute coronary syndromes continue to be undertreated with pharmacologic therapy and invasive procedures, despite the fact that they receive the same benefits from therapy as men. Although the older age at diagnosis for women adds complexity to clinical decision making, studies show that an aggressive medical or interventional approach to acute coronary syndromes is often warranted and should be based on patient size, comorbidity, and renal function.

Drs Pfeifer and Steingart (page 11) provide a timely report on recent findings affecting the assessment and treatment of women with acute coronary syndromes.

Cardiovascular drugs affect women differently than they do men because of differences in pharmacokinetics, pharmacodynamics, and physiology. Results of recent studies on the use of cardiovascular agents in women are presented, with an emphasis on the need to include an appropriate proportion of women in future studies, to adapt the dosage to the weight of the patient, and to incorporate hormonal aspects into the analysis.

A patient's response to drugs may be influenced by many factors, including age, race, sex, ethnic background, metabolic phenotype, body fat content and distribution, and body size. Drug–drug and drug–disease interactions are also important.