Cardiovascular risk

Another study (84), which enrolled men and women between the ages of 21—55 who had mild hypertension and no recognizable cardiovascular risk factors, showed no significant differences in mortaUty between dmg- and placebo-treated patients. Significant reductions in hypertensive complications were noted, but atherosclerotic complications were not reduced. 

In a study with 3427 male and female patients having DBP of 95—109 mm Hg (12—15 Pa), and no clinical evidence of cardiovascular diseases, half of the patients were placebo-treated and half were SC antihypertensive dmg-treated, ie, step 1, chlorothiazide step 2, methyldopa, propranolol [525-66-6], or pindolol [13523-86-9], and step 3, hydralazine, or clonidine [4205-90-7] (86). Overall, when the DBP was reduced below 100 mm Hg (13 Pa), there were more deaths in the dmg-treated group than in the placebo group. The data suggest reduction of blood pressure by antihypertensive dmg treatment that includes a diuretic is accompanied by increased cardiovascular risks. 

Criteria for initiation of drug treatment now take into consideration total cardiovascular risk rather than blood pressure alone, such that treatment is now recommended for persons whose blood pressure is in the normal range but still bear a heavy burden of cardiovascular risk factors. Thus, the role of simultaneous reduction of multiple cardiovascular risk factors in improving prognosis in hypertensive patients is stressed. In addition, more aggressive blood pressure goals are recommended for hypertensive patients with comorbid conditions such as diabetes mellitus or renal insufficiency. 

Tegeder I, Geisslinger G (2006) Cardiovascular risk with cyclooxygenase inhibitors general problem with substance specific differences Naunyn Schmiedebergs Arch Pharmacol 373 1—17... 

Blacher J, Safar ME Homocysteine, folic acid, B vitamins and cardiovascular risk. J Nutr Health Aging 2001 5 196. 

HERMANSEN K, SONDERGAARD M, HOIE L, CARSTENSEN M and BROCK B (2001) Beneficial effects of a soy-based dietary supplement on lipid levels and cardiovascular risk markers in type 2 diabetic subjects. Diabetes Care. 24 (2) 228-33. 

WAGNER J D, CEFALU W T, ANTHONY M S, LITWAK K N, ZHANG L and CLARKSON T B (1997) Dietary soy protein and estrogen replacement therapy improve cardiovascular risk factors and decrease aortic cholesteryl ester content in ovariectomized cynomolgus monkeys. ... 

DAVIDSON M H, MAKI K C, MARX P, MAKI A C, CYROWSKI M S, NANAVATI N, ARCE J C (2000) Effects of continuous estrogen and estrogen-progestin replacement regimens on cardiovascular risk markers in postmenopausal women . Archives of Internal Medicine, 160, 3315-25. 

QURESHI A A, BRADLOw B A, SALSER w A, BRACE L D (1997) Novel tocotiienols of rice bran modulate cardiovascular risk parameters of hypercholesterolemic humans. J Nutri Biochem, 8 290-8. 

Trout, D.L. (1991). Vitamin C and cardiovascular risk factors. Am. J. Clin. Nutr. 53, 322S-325S. 

Laboratory Tests The following tests may indicate additional cardiovascular risk factors or poor control of diabetes. Elevated fasting lipid panel Elevated fasting blood glucose Hemoglobin A1c greater than 7.0%... 

For overall cardiovascular risk reduction, stop smoking. 

Patients with diabetes and hypertension should initially be treated with either P-blockers, ACE inhibitors, ARBs, diuretics, or calcium channel blockers. There is a general consensus that therapy focused on RAAS inhibition by ACE inhibitors or ARBs may be optimal if the patient has additional cardiovascular risk factors such as left ventricular hypertrophy or chronic kidney disease.2,3,59,67... 

Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine the VALUE randomised trial. Lancet 2004 363(9426) =2022-2231. 

Factors that predispose an individual to IHD are listed in Table 4—2. Hypertension, diabetes, dyslipidemia, and cigarette smoking are associated with endothelial dysfunction and potentiate atherosclerosis of the coronary arteries. The risk for IHD increases two-fold for every 20 mm Hg increment in systolic blood pressure and up to eight-fold in the presence of diabetes.5,6 Physical inactivity and obesity independently increase the risk for IHD, in addition to predisposing individuals to other cardiovascular risk factors (e.g., hypertension, dyslipidemia, and diabetes). 

Patients with multiple risk factors, particularly those with diabetes, are at the greatest risk for IHD. Metabolic syndrome is a constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin... 

A thorough medical history and physical exam are necessary to ascertain cardiovascular risk factors and to exclude non-ischemic... 

Several studies have investigated whether statins possess pharmacologic properties in addition to their LDL cholesterollowering effect that may confer additional benefits in IHD.24 These studies were prompted by evidence that patients with normal LDL cholesterol derived benefit from statins. Statins have been shown to modulate the following characteristics thought to stabilize atherosclerotic plaques and contribute to the cardiovascular risk reduction seen with these drugs ... 

Recent data suggest that COX-2 inhibitors, including rofe-coxib, valdecoxib, and celecoxib, may increase the risk for MI and stroke.47 There is also some evidence that the non-selective NSAIDs may increase the risk for cardiovascular events.47,48 Rofecoxib was withdrawn from the market in late 2004 because of safety concerns. The FDA requested the withdrawal of valdecoxib from the market in 2005. The FDA also asked the manufacturers of celecoxib and non-selective NSAIDs (prescription and over-the-counter) to include information about the potential adverse cardiovascular effects of these drugs in their product labeling. The cardiovascular risk with COX-2 inhibitors and NSAIDs may be greatest in patients with a history of, or with risk factors for, cardiovascular disease. The American Heart Association recommends that the use of COX-2 inhibitors be limited to low-dose, short-term therapy in patients for whom there is no appropriate alternative.48 Patients with cardiovascular disease should consult a clinician before using over-the-counter NSAIDs. 

Niacin can raise uric acid levels, and in diabetics can raise blood glucose levels. However, several clinical trials have shown that niacin can be used safely and effectively in patients with diabetes.33 Due to the high cardiovascular risk of patients with diabetes, the benefits of improving the lipid profile appear to outweigh any adjustment in diabetic medication(s) that is needed.33... 

Genest J. Lipoprotein disorders and cardiovascular risk. J Inherit Metab Dis 2003 26 267-287. 

Longer-term studies evaluating the cardiovascular risks associated with the use of COX-2 inhibitors have found a higher incidence of cardiovascular mortality with the use of these agents compared to traditional NSAIDs.29,33,34 This prompted the withdrawal of both rofecoxib and valdecoxib from the market and the inclusion of a black box warning in... 

The progenitor cells of the kidney produce 90% of the hormone erythropoietin (EPO), which stimulates red blood cell (RBC) production. Reduction in nephron mass decreases renal production of EPO, which is the primary cause of anemia in patients with CKD. The development of anemia of CKD results in decreased oxygen delivery and utilization, leading to increased cardiac output and left ventricular hypertrophy (LVH), which increase the cardiovascular risk and mortality in patients with CKD. 

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