PRIMARY CARE PEARLS IN

CARDIOLOGY


Tom Heston, MD

Series Editor

 

Combining serum myoglobin and CK-MB in testing for acute myocardial infarction, a sensitivity of 100% was obtained during the 1st 3 hours of evaluation in the ER in this prospective study of 190 pts, 21 of which suffered an acute MI. (Ann Emerg Med 1996 ;27:0001)

 

Compared with animal protein consumption, soy protein consumption was associated with a 9% drop in total cholesterol and a 12% drop in LDL cholesterol. (NEJM 1995 ;333:0276)

 

Type "D" personality (in which individuals suppress negative emotions) was shown to be an independent risk factor for death from heart disease. (Lancet 1996 ;347:0417)

 

Ear lobe creases were shown to be associated with higher rates of cardiac events in this study of 264 consecutive patients. (Am J Med 1996 02/01;100:0205)

 

Moderate doses of vitamin E (up to 1200 IU) can be safely used in patients receiving warfarin; no drug-drug interaction was identified in this study. (Am J Cardiol 1996 03/01;77:0545)

 

In a study of 15,990 people aged 60 - 97 yrs old, reducing high blood pressure not only prevented strokes (down 35%), but also cut the heart attack rate (down 18%), and decreased all cause total mortality (down 15%). (Arch Fam Med 1995 11/01;4:0943)

 

Among women who worked rotating night shifts for a period of 6 years or more, their risk of coronary heart disease was increased by 50%. (Circulation 1995 ;92:3178)

 

Pravastatin is useful in the PRIMARY prevention of coronary heart disease; in this study of 6,500 men, all0cause mortality was reduced by 22%. (NEJM 1995 ;333:1301)

 

Simvastatin has been shown to be useful in the SECONDARY prevention of coronary heart disease; all-cause mortality was decreased by 33% in this study. (Lancet 1994 ;344:1383)

 

Sexual intercourse among permanent or married partners was not associated with a significantly increased risk of malignant cardiac arrhythmias among a group of 88 male patients with known coronary artery disease. (Chest 1996 ;109:0922)

 

In a study of 1623 patients, anger outbursts doubled the risk of myocardial infarction within the following 2 hours (relative risk =2.3). (Circulation 1995 10/01;92:1720)

 

Low serum pyridoxal 5'-phosphate (from vitamin B6) was associated with a 4 fold increased risk of coronary disease (relative risk=4.3, p < 0.05). (Circulation 1995 11/15;92:2825)

 

Smoking at least 20 cigarettes per day was a stronger risk factor for myocardial infarction in women (who had a sixfold increase) than in men (who had a threefold increase) in this study of 11,843 patients. (Circulation 1996 ;93:0450)

 

Coffee was not associated with the development of heart disease in a study of 85,747 American women. (JAMA 1996 02/14;275:0458)

 

A high dietary fiber intake was associated with a decreased risk of heart disease, independent of fat intake, in a study of 43,757 men. (JAMA 1996 02/14;275:0447)

 

Supplementation with vitamin E decreased the incidence of angina in a study of 29133 male smokers; those taking supplements had a 9% decreased risk of developing angina during the average 5 yr follow-up period. (JAMA 1996 03/06;275:0693)

 

Final infarct size among patients treated within 1 hour of symptom onset were only 40% as large as the infarct size among a similar group of heart attack patients who waited 4 - 6 hours before thrombolytic therapy. (Circulation 1996 01/01;93:0048)

 

Drinking caffeinated beverages either before or during exercise due to the abnormal increase in blood pressure caused by the caffeine, according to a study of 30 men. (Amer J Hypertension 1995 12/01;)

 

One year after coronary artery bypass surgery, those who continued to smoke had more than twice the heart attack and reoperation risk compared to those who quit, in a study of 415 patients. (Circulation 1996 01/01;)

 

Dog owners were significantly more likely to be alive 1 year after a heart attack in a study of 369 patients; cat owners did not benefit, suggesting that the need to walk the dog (in contrast to cats) was a important factor in their survival. (Am J Cardiol 1995 12/15;76:1213)

 

The death rate during the 6 months after a heart attack was cut 50% by aspirin (from 17% to 8.4%); unfortunately, a full 25% of patients were NOT prescribed aspirin (even though NO contraindications existed) in this study of 5490 medicare patients. (Ann Intern Med 1996 02/01;124:0292)

 

In pts with proven, symptomatic coronary artery disease, vitamin E (400 - 800 IU per day) reduced the rate of subsequent fatal and/or nonfatal myocardial infarction by 45% during a mean follow-up period of 510 days in a study of 2002 pts. (Lancet 1996 03/23;347:0781)

 

Although both are important in decreasing heart disease, weight loss without exercising was better than exercising without weight loss in this study of 170 nonsmoking, sedentary, obese men. (JAMA 1995 ;274:1915)

 

Postmenopausal women who engaged in leisure-time physical activities (e.g. gardening, walking) were found to have a 50% decreased risk of heart attack. (Arch Intern Med 1995 ;155:2302)

 

In a study of 49 patients who recently suffered a heart attack, giving fish oil supplements increased the heart rate variability, supporting the hypothesis that fish oil may have a protective antiarrhythmic effect (by raising the fibrillation threshold). (BMJ 1996 03/16;312:0677)

 

Out of 25 men with heart disease (CAD), 4 were free of angina but still had EKG changes indicative of angina. (Am J Cardiol 1995 08/15;76:0337)

 

Walking more than 4 hours per week versus less than 1 per week was associated with a 31% decrease in hospitalization for cardiovascular disease in this study of 1,645 Americans over 65. (J Am Geriatr Soc 1996 ;44:0113)

 

Among 30-69 year old Finns, the highest quartile of flavonoid intake had a 46% lower risk for coronary mortality and a 31% reduced total mortality (foods high in flavonoids: apples, onions, tea, read wine). (BMJ 1996 ;312:0478)

 

Transcendental Meditation, 20 minutes 2x/day, enabled pts with coronary artery disease to increase exercise capacity by 15% greater than the control group; TM was considered helpful in the prevention and treatment of coronary artery disease. (Am J Cardiol 1996 04/15;77:0867)

 

In 125 pts with suspected acute myocardial infarction, the pts given a daily regimen of antioxidant vitamins did better than the other pts in terms of cardiac death and reinfarction (vit A-50,000 IU/d, vit C-1 g/d, vit E-400 mg/d, b-carotene-25mg/d). (Am J Cardiol 1996 02/01;77:0232)

 

Treating hypertension is important in preventing congestive heart failure and other cardiovascular complications; this entire issue of JAMA covers a broad range of hypertension topics. (JAMA 1996 05/22;275(20))

 

Simvastatin, a cholesterol lowering drug, significantly reduces healthcare costs; the net effect is a cost of $0.28 per day for simvastatin, a drug shown to decrease total mortality by 30% in a select group of pts. (Circulation 1996 ;93:1796)

 

Aspirin plus low-molecular-weight heparin was superior to aspirin plus regular heparin (weight based protocol) in reducing the occurrence of acute myocardial infarction, the need for revascularization, and recurrent angina. (J Am Coll Cardiol 1995 08/26;26:0313)

 

Fish oil at a daily dose of 4 g per day was effective in lowering blood pressure and triglyceride levels in this study of 78 non-diabetics. (Ann Intern Med 1995 ;123:0911)

 

In addition to the ECG and CK-MB level, it is helpful to look at the relative lymphocyte count: pts with a differential of less than 20.3% lymphocytes were much more likely to have an acute myocardial infarction. (Ann Intern Med 1996 ;122:0335)

 

In this study of 46 black men, regular moderate aerobic exercise significantly decreased blood pressure, left ventricular hypertrophy, and medication requirements. (NEJM 1995 ;333:1462)

 

A useful screening tool for cardiovascular risks is the waist circumference: above 37.6 inches for men and 32 inches for women indicates a need for more in depth evaluation, and most likely a need for weight loss. (BMJ 1995 ;311:1401)

 

Elevated blood homocysteine levels appear to increase the risk of heart disease, fortunately lowering the level is easy- just take a multivitamin or B-Complex vitamin pill with folate daily; recommended dose is unknown, 1 mg/d probably sufficient. (Your Patient & Fitness 1996 ;10(4):0006)

 

Failure to achieve the target heart rate on exercise treadmill testing was shown to be an independent predictor of coronary heart disease, with the risk of a cardiac event increased by 75% over the average 7.7 years of follow-up. (Circulation 1996 ;93:1520)

 

Nearly 50% of participants in a 4 community wide sample of patients with a history of myocardial infarction did not take aspirin regularly indicating a severe underutilization of aspirin in the prevention of subsequent myocardial infarctions. (Am Heart J 1996 ;131:0915)

 

According to the HALT trial of 851 patients studied for 16 weeks, doxazosin effectively lowered blood pressure while also lowering total cholesterol by 2.7%, LDL cholesterol by 2.4%, and significantly reducing the ratio of total to HDL cholesterol. (Am Heart J 1996 ;131:0966)

 

The use of calcium channel blockers is associated with an increased risk of gastrointestinal bleeding compared with beta-blockers and ace-inhibitors. (Lancet 1996 ;347:1061)

 

Results of a 7-year study of over 475,000 people indicate that passive smoking is associated with an approximately 20% increased risk of heart disease death. (Circulation 1996 ;94:0622)

 

Adding progesterone to postmenopausal estrogen therapy does not appear to reduce the cardiovascular benefits of estrogen therapy. (NEJM 1996 ;335:0453)

 

A continuous infusion of furosemide was found to be more efficacious and safer than intravenous bolus administration. (JACC 1996 ;28:0376)

 

Increased anxiety was associated with an increased risk of fatality from coronary heart disease in this study of male physicians; relative risk of sudden death was 6.1 . (Circulation 1994 ;089:1992)

 

Vitamin E supplementation was associated with a 34% reduced rate of heart disease in women. (NEJM 1993 ;328:1444)

 

Long acting calcium antagonists, such as amlodipine (Norvasc) and diltiazem (Cardizem SR), achieve persistent 24-hour blood pressure control and lead to an eventual decrease in left ventricular mass. (Am J Cardiol 1996 ;078:0203)

 

Aspirin continues to be under utilized in the treatment of acute myocardial infarction. Ideally, you should take an aspirin (NOT enteric coated) at the onset of symptoms suggestive of a heart attack. (Arch Intern Med 1996 ;)

 

A rapid rule-out myocardial infarction protocol performed on clinically low risk patients with a nondiagnostic EKG: get enzymes at 0,3,6, & 9 hrs; EKG at 0,9 hrs; treadmill test at 12 hrs. If any tests positive, a longer hospital stay is warranted. (JACC 1996 ;28:0025)

 

900 mg of garlic per day with 12 g fish oil per day (providing 3.6 g n-3 fatty acids/d) lowered total cholesterol, LDL, and triacylglycerol; the combo improved the total to HDL ratio as well. (Am J Clin Nutr 1997 ;65:445)

 

ST depression in V1 or V2 has a high sensitivity (~90%) and high specificity (~90%) for identifying the LCA as the infarct-related artery in acute inferior myocardial infarction. (Am J Cardiol 1997 ;79(2):182)

 

A high carbohydrate meal preceding exercise is associated with an earlier onset of myocardial ischemia than a high fat meal preceding exercise. (JACC 1997 ;29:302)

 

A stress treadmill test alone (i.e. without an associated imaging procedure) is not useful in diagnosing CAD in symptomatic patients, although it is useful in determining functional capacity. (Circulation 1992 ;123(5):1312)

 

For the prevention of DVT: 1) Low Risk Pts- stockings. 2) Mod Risk- add low-molecular wt heparin, e.g. Enoxaparin 2000 U /d. 3) High Risk- increase LMWH, e.g. enox 4000 U/d SQ. (BMJ 1997 ;314(2):123)

 

Don't use sublingual nifedipine for htn because of the side-effect of an uncontrolled blood pressure drop causing neurologic and/or cardiac ischemia. (JAMA 1996 ;276:1328)

Water soluble dietary fiber supplementation at 15 g / d decreased total cholesterol by 6.4% and LDL by 10.5% . (Am J Cardiol 1997 ;79:34)


DISCLAIMER: The above constitutes medical information, NOT ADVICE. Please check with your doctor before making any changes in your medical care and/or lifestyle. Thank you.

First Published APRIL, 1997.
Version 1.0
1997,
Priory Lodge Education