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Coronary Heart Disease

We are going to be reviewing atherosclerosis, angina, ischemia, unstable angina, acute myocardial infarction. It is estimated that approximately 14 million Americans have some form of cardiovascular disease. Nearly a million died in 1995. This figure is about constant, comprised of about 41% of total deaths. This is not a disease solely of the elderly. One-sixth of the deaths were below age 65. Nearly one-third were below the age of 75. At least for men, there has been a very encouraging drop in the heart disease rating from the late 1970ís into the 1990ís.

Primary prevention and risk factors. There the so-called three modifiable risk factors: cigarette smoking, hypertension and hypolipoproteinemia. For instance, cigarette smoking current goal is complete cessation for every American and we do that by questioning the patient at every visit and intervening by encouraging cessation, utilizing nicotine replacement, counseling and now we have an antidepressant drug called Wellbutrin that is very helpful in breaking the habit.

Screening for hypertension is another unambiguously valuable intervention, specifically looking for blood pressures of 140/90, screening every two years and of course intervening certainly with lifestyle, and medications for persistent elevation. Again, shown here from the Framingham study are the data both for men and for women in which utilizing blood pressure, low here and high here, there is a rise in atherosclerotic risk in both genders.

Now hyperlipidemia is the last of the principle modifiable risk factors and the current National Cholesterol Education Project Standards asked us to screen patients at least every five years, with both dietary history total and HDL cholesterol. The goal is to keep the LDL cholesterol between 138-160 if you are minimal on the risks, but down this level is 100-130.

The most exciting news in the last five years in the management of patients in primary prevention has been the impact of lowering cholesterol substantially through the use of medications when diet fails, to get LDL levels down. The first of these studies was a study done with the drug pravastatin, Pravachol. The study was called the Western Scotland Coronary Prevention Study, WSCPS. It showed a 31% reduction in non-fatal MI or coronary heart disease death and a 32% reduction in all cardiovascular deaths. This started within six months of institution of therapy. As shown here, at least for the curve regarding non-fatal MI or coronary heart disease death, the population which was a rather high risk factor population with rather substantially elevated cholesterol, cigarette smoking, some even with coronary disease, were put on pravastatin up to 40 mg a day, and the curve started to divert in six months and continued out all the way to six years. So this was not an epi-phenomenon of an early phase, this was a persistent improvement that took place over time.

Confirming this more recently has been a trial done with the initial statin agent, lovastatin, Mevacor, that was done in Texas reported how Dr. Delgado and company, or I should say collaborators, 20-40 mg daily of lovastatin versus placebo, looking for the first major event and just not looking now at the life times but just in terms of the outcomes in five years, major events were reduced substantially. Revascularization need was reduced substantially, unstable angina reduced and coronary events all were reduced. Remember, these are patients with no known coronary disease just put on therapy.

What about other adjunctive therapies to these more potent impacts? Well, we have anti-platelet therapy with aspirin and we now still have the - the FDA recommended that aspirin should be given to patients at high risk for cardiovascular disease. In England, however, the British are in favor of it for all patients who do not have allergies. Doses between 75-325 a day. Other choices for intervention include hormone replacement therapy - a few words about that a little later - antioxidant vitamin therapy, and a new rage is looking for homocystine heterozygotic states and treating with vitamins for that.

Atherosclerosis can be stabilized and can regress. In a recent randomized controlled trial, you take over 2,700 women who had coronary artery disease, who had their uterus, and hence could be treated and treat them in this case with a combo product called Prempro that combines conjugated equine estrogen Premarin with hydroxyprogesterone, versus placebo. The expectation was that by taking such patients who had known coronary disease you would reduce event rates. So they took patients and looked for the development of MI or death, or secondary end points of hospitalization. Followed them out to 4.1 years. This was not expected. The secondary prevention was not demonstrated. There was not a reduction in overall coronary heart disease risk. In terms of primary events occurs paralleled each other, crossed over. There is a question of benefit only later on when patients went out 3-4 years. And there were a substantial number of side effects for wholesale administration of estrogen in this fashion. Gall bladder disease and most importantly the venous thrombi levels increased three fold in trials. Does this mean that you should never have a patient on estrogens or progesterone? Everyone is very cautious right now. There is clearly another larger scale trial ongoing looking at estrogen therapy alone, looking at natural estrogens - that is to say, not derived from pregnant mares urine - and then primary prevention. But if you have a postmenopausal woman who presents with a myocardial infarction, the take-home message is donít put her on Prempro.

Now there are some, if you will, health food approaches. Alternative therapies for the management of angina.. The concept that this fellow Dirk thinks angina is a dirty word, and really canít give you a good idea about what natural remedy to take. But if you go to the Internet at this location you will pick them up. There are a lot of concepts out there that patients may utilize in terms of vitamin E, which we still utilize because of the antioxidant benefit. Garlic therapy, Ginkgo and so forth. Iím not trying to recommend any of these instead of looking at the more safe approach, which are in the ACCH, ADCP guidelines that Iíve alluded to that are mnemonically put forth as ABCD and E. And Iíd like to review them. Aspirin and the anti-anginals, beta-blocker blood pressure control, cholesterol and cigarettes, diet and diabetes, and education and exercise.