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Disease Knowledge Centres

Cardiology - Disease Topic Overview

Cardiology is the medical specialty which studies the heart and its diseases. It is also linked with vascular diseases.

The heart is a hollow muscular organ that facilitates the circulation of blood through blood vessels, permitting nutrient and gas exchange throughout the body.¹ The contraction of muscle fibers of the heart is very organized and highly controlled to ensure rhythmic and powerful contractions.¹

Many diseases can affect the structure or the functioning of the heart such as; hypertension, angina pectoris, myocardial infarction, heart failure, cardiomyopathy or rhythm disturbances.¹ Recent increase in cardiovascular disease is strongly linked to lifestyle.² Indeed, the main risk factors are; stress, smoking, diabetes, obesity and excessive alcohol consumption.²

The treatment of cardiovascular disease has evolved over the past 20 years, resulting in a reduction in cardiovascular mortality among the general population.³ Despite this, cardiovascular diseases are still the leading cause of death in Western countries.⁴ They are a major source of disability and contribute, in large part, to the escalating costs of health care.²

Prevention of risk factors remains the best way to reduce the morbidity and mortality of cardiovascular disease, particularly amongst those patients at risk (diabetes, cholesterol and obesity).² The improvement of knowledge, particularly in understanding the basic mechanism of diseases and their pathophysiology, will allow developing new strategies for prevention and treatment to be more effective.⁴

1. Beers M.H. et al. The Merck manual of medical information. Merck research laboratories. Second home edition. 2003 : 113-241.
2. Benamer H. et al. Voie d’abord radiale en cardiologie interventionnelle chez la femme. Annales de Cardiologie et d'Angéiologie. December 2009 ; 58 (6) : 338-343.
3. Camm J.A. et al. The ESC Textbook of Cardiovascular Medicine. Oxford University Press. Second edition. 2009 : 424 pages.
4. Graham I. et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. European Heart Journal. August 2007 ; 28 : 2375-2414.

Cholesterol

Diagnosing and managing coronary heart disease (CHD) can be challenging. In most patients, it takes years or even decades before the underlying coronary pathology leads to clinical manifestations. Major emphasis is needed in controlling overall cardiovascular risk factors in CHD as risk factor control remains poor in these patients and increases the risk of an event.¹

The Cholesterol Knowledge Centre offers you a range of tools that will help you identify, diagnose and decide upon an appropriate treatment strategy for your patients at risk of CHD. The Centre's educational aids will allow you to keep up to date with the latest research, recommendations and guidelines. It also offers you tools to help you keep your patients engaged in their therapy, thereby significantly reducing their risk of future cardiovascular events.
ENTER the Cholesterol Knowledge Centre

References
1. Graham I et al. Eur J Cardiovasc Prev Rehab 2007; 14: E1-E40

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An elevated level of low-density lipoprotein cholesterol (LDL-C) is a form of dyslipidaemia that has been shown to be strongly associated with an increased risk of developing atherosclerosis and cardiovascular disease (CVD), leading to cardiovascular events.

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Diabetes

Diabetes is a disease that currently affects approximately 285 million people worldwide and this figure is only expected to increase1. For Europe, the IDF estimates that 55.2 million, or 8.5% of the population aged 20 to 79 years, have diabetes. This is expected to rise to 66.2 million (10.0%) by 2030. Further information on the scale of the type 2 diabetes problem can be found in the overview section of the knowledge centre.

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Diabetes is a disease that currently affects approximately 285 million people worldwide and this figure is only expected to increase1. For Europe, the IDF estimates that 55.2 million, or 8.5% of the population aged 20 to 79 years, have diabetes. This is expected to rise to 66.2 million (10.0%) by 2030. Further information on the scale of the type 2 diabetes problem can be found in the overview section of the knowledge centre.

Complications associated with diabetes mellitus include hypertension, cardiovascular disease, retinopathy, kidney damage, foot ulceration and nerve damage. Discover more about the complications connected to diabetes mellitus, as well as acceptable blood glucose and HbA1C levels and how these differ in people with diabetes mellitus here.

The majority of patients with type 2 diabetes are obese and/or have an increased proportion of visceral fat, factors which in themselves are associated with insulin resistance. Other risk factors include increasing age and sedentary lifestyle. There is also a strong genetic predisposition to type 2 diabetes².

Chronic hyperglycaemia of diabetes is associated with long-term damage, dysfunction and failure of various organ systems. Early diagnosis, adequate treatment to control hyperglycaemia, and management of associated risk factors and complications therefore are all essential to reduce the burden of diabetes. Effective screening strategies are therefore of particular importance in reducing this burden. Discover the diagnostic tests necessary to diagnose type 2 diabetes mellitus and intermediate hyperglycaemia or pre-diabetes.

The early and aggressive treatment and management of diabetes mellitus is important for a successful long term outcome in patients with diabetes mellitus. The use of oral agents and lifestyle changes are the generally accepted early treatments followed later by insulin therapy. Current treatment algorithms and IDF guidelines should be used to find the appropriate treatment regime for individual patients.

As with many diseases, our knowledge of diabetes mellitus is increasing through research. Recent developments include the use of new treatments and guidelines in clinical practice. There has been an update to the IDF guidelines concerning GLP-1 agonists. DPP-4 inhibitors are now used in the treatment of diabetes, and SGLT-2 inhibitors are being investigated for this use.

References

1. Unwin, N. et al. The IDF Diabetes Atlas: Providing Evidence, Raising Awareness and Promoting Action. Diabetes Res Clin Pract 87, 2-3 (2010).

2. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 33 Suppl 1, S62-9 (2010).

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Hypertension
Hypertension, an increasingly common and chronic disease, and its consequences like stroke, coronary heart disease, heart failure and renal damage mean an enormous financial burden for the community.

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Hypertension, an increasingly common and chronic disease, and its consequences like stroke, coronary heart disease, heart failure and renal damage mean an enormous financial burden for the community. The risk of cardiovascular morbidity and mortality is proportional to the degree of systolic or diastolic blood pressure elevation at any age and in either sex, and is markedly influenced by risk factors commonly associated with BP elevation.

The term “isolated systolic hypertension” (ISH) describes raised systolic blood pressure with normal or low diastolic blood pressure. Some guidelines recognise two grades of isolated systolic hypertension:^1,3

Increasingly, attention is becoming focused on systolic, rather than diastolic, blood pressure as the major factor to control in patients older than 50 years with essential hypertension.^1,2 Elevated systolic blood pressure (SBP) is a powerful predictor of all-cause mortality, coronary artery disease, stroke and renal disease.⁴

Diagnostic procedures are aimed at: establishing blood pressure levels; identifying secondary causes of hypertension; evaluating the overall cardiovascular risk.

It is now widely recognised that elevated blood pressure is frequently associated with obesity, insulin resistance and dyslipidaemia. The clustering of these symptoms has given rise to the concept of the ‘metabolic syndrome’, which carries a high risk of diabetes and cardiovascular disease.

Guidelines on modern management of hypertension reflect a more preventive approach with reduced target BP and risk factor evaluation. Initiation of antihypertensive treatment is based on two criteria; total level of cardiovascular risk and level of systolic and diastolic BP.

Lifestyle inverventions should be instituted whenever appropriate in all patients. Pharmacological therapy should be started gradually, and target BP achieved progressively. To reach target BP, a large proportion of patients will require combination therapy.

Enter the Hypertension Knowledge Centre

What’s in the Hypertension Knowledge Centre?
References

1. Williams B, Poulter NR, Brown MJ, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004 - BHS IV. J Hum Hypertens 2004;18:139-185
2. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 2003;289:2560-2572
3. ESH Guidelines Committee. 2003 European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003;21(6):1011-1053
4. Brooks DP, Ruffolo RR. Pharmacological mechanism of angiotensin II receptor antagonists: implications for the treatment of elevated systolic blood pressure. J Hypertens 1999;17(Suppl 2):S27-S32

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Post-Myocardial Infarction
Acute coronary syndrome (ACS) is a broad term that includes the diagnoses of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI). UA and NSTEMI are sometimes referred to collectively as non-ST-segment elevation ACS (NSTE-ACS).

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Acute coronary syndrome (ACS) is a broad term that includes the diagnoses of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI).¹ UA and NSTEMI are sometimes referred to collectively as non-ST-segment elevation ACS (NSTE-ACS).²

Regardless of the specific clinical presentation, all cases of ACS result from myocardial ischaemia, usually due to the formation of an occlusive thrombus in a coronary artery following the rupture or erosion of an atherosclerotic lesion.²

Prolonged, severe interruption of the blood flow to the myocardium (15-30 minutes) leads to necrosis, which is the pathological definition of myocardial infarction.^3,4 Complications include heart failure, conduction disturbances, arrhythmias and mitral valve regurgitation.¹

The classic symptom of ACS is chest pain, which is frequently described as retrosternal pressure or heaviness, and may radiate to the jaw, neck or arms.² Other symptoms include diaphoresis, nausea, dyspnoea, abdominal pain and syncope.²

Diagnosis and differential diagnosis is based on a combination of clinical examination, electrocardiography (ECG) and tests for cardiac enzymes (troponins) in the blood.²

Although in-hospital mortality among patients presenting with ACS has declined considerably in recent decades, the risk of dying before reaching hospital has remained relatively unchanged.⁴ Recurrent MI, heart failure and cardiogenic shock are important causes of morbidity and mortality in the ACS population, both during hospitalisation and after discharge.⁵

Following MI, a range of pharmacological and non-pharmacological interventions have been shown to reduce morbidity and mortality from cardiovascular causes.⁴ Antiplatelet agents, beta-blockers, ACE inhibitors and HMG-CoA reductase inhibitors (statins) all have a central role in post-MI care.

Non-pharmacological interventions include implantation of a defibrillator (or cardiac synchronisation device) but also diet and lifestyle modifications, such as smoking cessation and regular exercise.⁴

Enter the Post-MI Heart Failure Knowledge Centre

What’s in the Post-MI Heart Failure Knowledge Centre?
References

1. Kumar P, Clark M. Clinical medicine. 7th ed. Edinburgh: Saunders Elsevier, 2009.
2. Bassand J-P, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J 2007;28:1598-660.
3. Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardial infarction. Eur Heart J 2007;28:2525-38.
4. van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology. Eur Heart J 2008;29:2909-45.
5. Fox KAA, Steg PG, Eagle KA, et al. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. JAMA 2007;297:1892-900.

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Latest Multi Media

A Discussion of Interventional Cardiology and the Procedures Involved

Cardiology Drug Data - A-Z English

Drug Updates

Enalapril 5mg Tablets

Treatment of hypertension : All grades of essential hypertension and renovascular hypertension.

Viskaldix Tablets

Mild to moderate hypertension.

Catapres Tablets 100mcg

Catapres is indicated for the treatment of all grades of essential and secondary hypertension.

Latest Drug News

FDA approve Resolute Integrity (Medtronic Inc) Drug-Eluting Stent - 19-02-2012

The FDA has approved the Resolute Integrity Drug-Eluting Stent (DES), from Medtronic Inc, for the treatment of Coronary Artery Disease (CAD). The device’s approval stems from the results of a series of studies of the Resolute DES, which showed consistent clinical performance across a broad spectrum of patients –– including those with Diabetes, a common contributor to Coronary Artery Disease that complicates treatment. The decision was based in part on RESOLUTE US, which enrolled 1,402 patients across 128 US-based clinical trial sites and was led by Martin B. Leon, director of the center for interventional vascular therapy at New York-Presbyterian / Columbia University Medical Center. At one year of follow-up, the results included low rates of target lesion failure (TLF, 4.7%), clinically-driven target lesion revascularization (TLR, 2.8%) and definite/probable stent thrombosis (def/prob ST, 0.1%). These results were achieved despite 34 percent of the patients in the study having Diabetes, which typically drives higher event rates. The Resolute DES uses the same drug-and-polymer combination as the Resolute Integrity DES. The Resolute Integrity uses continuous sinusoid technology (CST), based on one continuous, single strand of wire that is molded into a sinusoidal wave and then wrapped in a helical pattern and laser-fused at certain points, making each stent comparable to a flexible spring. This design makes it suitable for treating Diabetic patients who may have smaller and often tortuous arteries, longer lesions, diffuse disease and a higher rate of treatment failures including relatively high rates of repeat procedures and stent thrombosis.

CHMP defines limits of aliskiren (Novartis) in Hypertension - 17-02-2012

Novartis announced that the CHMP has concluded the risk-benefit review of Rasilez (aliskiren) and combination products containing aliskiren and confirmed it remains positive in the European Union for the treatment of essential Hypertension. In addition, the CHMP has requested an update to the product information of Rasilez® (aliskiren) and combination products containing aliskiren available in the EU. The CHMP has requested that Rasilez and combination products containing aliskiren are contraindicated in patients who are receiving an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) who also have diabetes and/or moderate to severe renal impairment (GFR < 60 ml/min/1.73 m2). In addition, the CHMP has requested the inclusion of a warning against the use of Rasilez and combination products containing aliskiren in patients who are also taking an ACE inhibitor or an ARB. Novartis wrote to physicians worldwide recommending that patients with Type 2 Diabetes should not be treated with aliskiren, or combination products containing aliskiren, if they are also receiving an ACE inhibitor or ARB. This recommendation remains in place in countries outside of the EU as Novartis continues discussions with the respective health authorities, including the FDA. The CHMP has requested that Rasilez and combination products containing aliskiren are contraindicated in patients who are receiving an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) who also have diabetes and/or moderate to severe renal impairment (GFR < 60 ml/min/1.73 m2). In addition, the CHMP has requested the inclusion of a warning against the use of Rasilez and combination products containing aliskiren in patients who are also taking an ACE inhibitor or an ARB.The label changes in the EU will be applied to all approved aliskiren-based products. These products include Rasilez®, Sprimeo®, Riprazo®, Rasilez HCT®, Sprimeo HCT®, Riprazo HCT®, Rasilamlo®, and Rasitrio®.

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Latest Clinical Trials

Blood Markers for Inflammation and Coronary Artery Vasoreactivity Testing in Patients With Chest Pain and Normal Coronary Arteries (ACOVA)

The investigators are hoping to discover the cause of chest pain in patients with a normal coronary arteriogram. For patients with chest pain coronary angiography is the standard method by which the blood vessels of the heart can be visualized and any narrowing can be assessed. In some cases the investigators find totally normal coronary blood vessels or only minor disease. Such a finding is associated with an excellent long term prognosis. However, as a large proportion of patients with normal coronary arteries or mild coronary narrowings often continue to experience recurrent chest pains the investigators are interested in understanding the mechanisms responsible for this. The investigators hypothesise that in many cases, coronary artery spasms are responsible for the recurrent chest pains. These spasms usually respond to treatment with drugs known as vasodilators. The acetylcholine test (ACH-test) has been recommended by the European Society of Cardiology and the American College of Cardiology as a diagnostic test. This test can reveal whether the coronary blood vessels have a tendency to go into spasm. The investigators plan in this study to carry out the test in patients who have chest pains suggestive of coronary narrowings but are found to have normal or only mildly narrowed coronary arteries on angiography. A positive test -indicating a tendency for spasm- may help guiding therapy with vasodilators, which are often very effective to prevent coronary spasms. The investigators would also like to take blood samples during the test (before and after) from every patient to measure blood markers and see if there is a relation between these markers and the result of the ACH-test.

Observatory of Screening Aneurysms of the Abdominal Aorta During Echocardiography. National Epidemiological Survey (E2T3A)

Study of the prevalence of Abdominal Aortic Aneurysms (AAA) (> 3 cm) in patients with echocardiography (transthoracic or) during a specific day, with cardiologists in France. This is a cross-sectional epidemiological investigation, assembling evidence from a routine ultrasound screening for AAA at the waning of echocardiograms performed during a specific day. The study will be offered a list of centers selected by the Scientific Committee in the complete list of locations being in France, the subsidiary of echocardiography Echocardiography of French Society of Cardiology. These centers will be 500 in number representative of the French centers, geographically and by type of centers.

Latest Journal Publications

Current problems in cardiology

Percutaneous coronary revascularization was introduced over 30 years ago by Dr Andreas Grüntzig. This event catapulted adult invasive cardiology from a diagnostic entity to a therapeutic modality, which has since become the most frequently performed coronary revascularization procedure worldwide. This success has been built on several key concepts—problem identification, targeted solutions, applied technology, populations-based testing, postmarket surveillance, and education. These concepts will continue to be of paramount importance as novel percutaneous innovations and strategies are brought to bear on an increasingly broader group of patients with cardiovascular disease. In this review, we trace the history, review current practices, and also provide insight into future potential innovations, as it pertains to percutaneous coronary revascularization.

Current atherosclerosis reports

In 2006, a grass roots movement called SHAPE (Screening for Heart Attack Prevention and Education) published a novel practice guideline for cardiovascular screening in the asymptomatic at-risk population. It suggested the use of noninvasive tests for subclinical atherosclerosis in cardiovascular risk assessment to target intensified preventive care to those at highest risk. The SHAPE guideline received much attention but not as much support from the “official” medical societies. However, subsequent studies published since 2006 have now provided strong supportive evidence for the strategy spearheaded by the SHAPE guideline. Indeed, the latest guidelines issued jointly by the American Heart Association and the American College of Cardiology have elevated recommendation levels for noninvasive imaging of subclinical atherosclerosis. This change is widely viewed as a significant step toward the SHAPE guidelines. The background for SHAPE and the evidence behind the recommendation to use coronary artery calcium score measured by computed tomography, carotid intima-media thickness and plaque measured by ultrasound, and ankle-brachial index in cardiovascular risk assessment is reviewed in this article.

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