Women, coronary heart disease, and dyslipidemia: does gender alter detection, evaluation, or therapy?

Gender-based differences in the prevalence, presentation, and treatment of coronary heart disease (CHD) defines an important area of controversy and research. Gender-based differences include age at onset of CHD, typical presentation of CHD symptoms, relative importance of coronary risk factors, and the potential relationship of ovarian function and estrogen status to the development of CHD. The American Heart Association reported in 1998 that the leading cause of death for American women is cardiovascular disease, with CHD responsible for the majority of total deaths. This article discusses the implication of elevated blood lipids in women. Special emphasis is placed on the role of hormone replacement therapy, an issue unique to women.

National Survey on Gender Differences in Cardiac Rehabilitation Programs. Patient characteristics and enrollment patterns.

PURPOSE: Cardiac rehabilitation (CR) programs have been shown to promote numerous health benefits among patients with active coronary heart disease (CHD), but little is known about the percentage of eligible CHD patients who enroll in CR. METHODS: A survey was performed of 500 randomly chosen CR programs in operation in the United States during 1990. Patient characteristics and enrollment data were combined with data from the 1990 National Hospital Discharge Survey to estimate the percentage of eligible patients who participated in early outpatient (Phase II) CR programs after myocardial infarction (MI), after coronary angioplasty (PTCA), or after coronary artery bypass surgery (CABS). RESULTS: Completed surveys were returned by 163 programs (32.6%) with information on 1,322 women and 1,418 men who enrolled in their programs in 1990. Women were older, more likely to be single, and had more traditional CHD risk factors than men. Only a minority of MI, PTCA, and CABS survivors enrolled in CR programs (10.8%, 10.3% and 23.4%, respectively). Enrollment was particularly low for post-MI and post-CABS women as compared with men: 6.9% versus 13.3% (P < .001), and 20.2% versus 24.6% (P < .001), respectively. Enrollment was generally lowest for nonwhites, those over age 65, and those living in the southern United States. CONCLUSIONS: Cardiac rehabilitation programs are used by a minority of eligible patients, particularly among women, nonwhites, and the elderly. To meet newly released national guidelines that recommend CR services for most patients recovering from MI, PTCA, or CABS, and to still contain costs, new methods need to be explored that can expand the delivery of CR services in clinical settings.

Endothelial function and coronary risk reduction: mechanisms and influences of nitric oxide.

The biological mechanisms related to progression and regression of CAD are indeed complex. While endothelial injury and lipid accumulation play an important role in the progression/regression of CAD, mechanisms of vascular function, particularly that of the endothelial modulation of vasodilation, cannot be ignored. Much is yet to be learned about the influences of endothelial function on the progression/regression and stabilization of CAD. Initial evidence suggesting that risk reduction interventions favorably influence vascular function argues for further investigation of this role. To date, much of the research on risk reduction has focused on lipid lowering and regression of artery plaque, a focus on artery structure. A focus on both function and structure is likely to expand our understanding of the effect of risk reduction interventions beyond lipid lowering. Given the multifactorial causes associated with development of CAD, such an approach is necessary.

Risk profile screening.

The recovery period following hospitalization for a CHD event is an ideal time to assess a patient for risk factors and to offer intervention. Frequently, the nurse is the single source of such care and has opportunity to educate the patient and offer suggestions for life-style modifications that can reduce the recurrence of CHD events. This article describes modifiable risk factors and methods of assessment, cites sources for management and general health screening method, that can provide a comprehensive assessment of health risks. Gender or ethnic-specific issues, have been highlighted. A very brief mention of age-specific risk factors is included.

Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute.

This Quick Reference Guide for Clinicians highlights the conclusions and recommendations from Cardiac Rehabilitation, Clinical Practice Guideline No. 17, which was formulated by a panel representing the major health care disciplines involved in cardiac rehabilitation. The conclusions and recommendations were derived from an extensive and critical review of the scientific literature pertaining to cardiac rehabilitation, as well as from the expert opinion of the panel. This guide addresses the role of cardiac rehabilitation and the potential benefits to be derived in the comprehensive care of the 13.5 million patients with heart disease in the United States, as well as the 4.7 million patients with heart failure and the several thousand patients undergoing heart transplantation. This Quick Reference Guide for Clinicians highlights the major effects of multifactorial cardiac rehabilitation services: medical evaluation; prescribed exercise; cardiac risk factor modification; and education, counseling, and behavioral interventions. The outcomes of and recommendations for cardiac rehabilitation services are categorized as to their effects on exercise tolerance, strength training, exercise habits, symptoms, smoking, lipids, body weight, blood pressure, psychological well-being, social adjustment and functioning, return to work, morbidity and safety issues, mortality and safety issues, and pathophysiologic measures. Patients with heart failure and after cardiac transplantation, as well as elderly patients, are specifically addressed. Alternate approaches to the delivery of cardiac rehabilitation services are presented.

Life-style changes and coronary heart disease: the influence of nonpharmacologic interventions.

Life-style habits such as diet and exercise can have powerful affects on the development and progression of coronary heart disease. This article presents evidence supporting the use of these two modalities in the treatment of coronary heart disease. Diet is discussed in terms of cholesterol, obesity, fiber, fish oils, and antioxidants. Exercise is discussed in terms of the preparation for and the components of an exercise program. Appropriate nursing interventions are offered for use when working with patients who must modify their dietary or exercise habits.

Effect of a diet high in monounsaturated fat from almonds on plasma cholesterol and lipoproteins.

The effect of almonds as part of a low saturated fat, low cholesterol, high-fiber diet was studied in 26 adults (13 men, 13 women). The baseline diet was modified in a similar way for all subjects by limiting meat, fatty fish, high-fat milk products, eggs, and saturated fat. Grains, beans, vegetables, fruit, and low-fat milk products were the foundation of the diet. During the almond diet period, raw almonds (100 mg/day) supplied 34 g/day of monounsaturated fatty acid (MUFA), 12 g/day of polyunsaturated fatty acid, and 6 g/day of saturated fatty acid. Almond oil was the only oil allowed for food preparation. There was a rapid and sustained reduction in low-density lipoprotein cholesterol without changes in high-density lipoprotein cholesterol. This was reflected in a total plasma cholesterol decrease from (means +/- SEM) 235 +/- 5.0 at baseline to 215 +/- 5.0 at 3 weeks, and to 214 +/- 5.0 mg/dl at 9 weeks (p less than 0.001). When the consumption of nuts high in MUFA increases the fat content of the diet, reduction rather than elevation of plasma cholesterol has to be expected, possibly due to the MUFA content of these nuts.

Efficacy and compliance with cholestyramine bar versus powder in the treatment of hyperlipidemia.

PURPOSE: The purpose of the study was to compare the powder and the bar forms of cholestyramine to determine efficacy and patient compliance. SUBJECTS AND METHODS: A prospective, randomized trial was conducted that included 83 healthy men and women with hyperlipidemia greater than the 90th percentile for low-density lipoprotein (LDL) or total cholesterol. Patients were randomly assigned to receive either cholestyramine powder, two packets (8 g), twice daily, or cholestyramine confectionery bar, in maple or mint flavors, two bars (8 g), twice daily. Fasting serum total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides were measured at baseline, after 6 to 8 weeks of following the American Heart Association Step I diet alone, and after 8 weeks of taking either the cholestyramine bar or powder. RESULTS: Total cholesterol decreased significantly (p less than 0.01) by 16% in the bar group and 17% in the powder group. LDL cholesterol decreased by 28% and 29% in the bar and powder groups, respectively (p less than 0.01). There was no significant change in HDL cholesterol. Triglycerides increased in both groups, by 29% in the bar group and by 25% in the powder group. There was no difference between bar and powder in the effect on blood lipids. The majority of the lipid-lowering effect was seen within 14 days. Mean patient endpoint compliance with the therapy was 91.8 +/- 3.6% in the bar group and 94.8 +/- 2.1% in the powder group. There was no difference between groups. CONCLUSION: The cholestyramine confectionery bar is as effective as cholestyramine powder in the treatment of hyperlipidemia. The majority of the lipid-lowering effect is seen within 14 days of therapy. Although patient compliance is comparable between the two forms, gastrointestinal side effects were slightly greater with the bar form. Therefore, although the bar offers an alternative form of therapy, there appears to be no advantage with regard to patient compliance or palatability.

Medically directed at-home rehabilitation soon after clinically uncomplicated acute myocardial infarction: a new model for patient care.

Medically directed at-home rehabilitation was compared with group rehabilitation which began 3 weeks after clinically uncomplicated acute myocardial infarction (AMI) in 127 men, mean age 53 +/- 7 years. Between 3 and 26 weeks after AMI, adherence to individually prescribed exercise was equally high (at least 71%), the increase in functional capacity equally large (1.8 +/- 1.0 METs) and nonfatal reinfarction and dropout rates equally low (both 3% or less) in the 66 men randomized to home training and the 61 men randomized to group training. No training-related complications occurred in either group. The low rate of reinfarction and death (5% and 1%, respectively) in the study as a whole, which included 34 patients with no training and 37 control patients, reflected a stepwise process of clinical evaluation, exercise testing at 3 weeks and frequent telephone surveillance of patients who underwent exercise training. Medically directed at-home rehabilitation has the potential to increase the availability and to decrease the cost of rehabilitating low-risk survivors of AMI.

Seven-day activity and self-report compared to a direct measure of physical activity.

To determine how well a seven-day interview-administered activity recall used in a large epidemiologic study at Stanford University reflected seven days of self-reported activity and directly measured physical activity, 30 white males, mean age 52 years, recorded daily physical activity for a week, and half of these wore an ambulatory solid-state minicomputer (Vitalog) which measures continuous heart rate and motion. Total hours of moderate, hard, and hard plus very hard activity were not significantly different for weekdays and weekends for self-report and recall and were significantly correlated. Total energy expenditure for subjects wearing the Vitalog averaged 38.5 +/- 6.7 kcal/kg/day compared to an average of 37.7 +/- 4.5 kcal/kg/day for recall or 39.6 +/- 7.2 kcal/kg/day for self-report. Conditioning activities are best remembered followed by home or leisure and job activities. Mean hours of sleep per week night were significantly greater reported by self-report than reported by recall, but the two were significantly correlated. It is concluded that a seven-day activity recall accurately reflects mean kcal/day expenditure, with conditioning activities being the best recalled. A self-report log used in conjunction with an interview-based seven-day recall might maximize accuracy of recall.

Home versus group exercise training for increasing functional capacity after myocardial infarction.

To evaluate the efficacy of exercise training for increasing functional capacity in the 6 months after clinically uncomplicated myocardial infarction, 198 men 52 +/- 9 years of age participated in a training study. They were randomly assigned to one of four exercise protocols: 8 to 26 weeks of training at home (group 1, n = 66) or in a group program (group 2, n = 61) following treadmill testing performed 3 weeks after infarction, treadmill testing at 3 weeks without subsequent training (group 3, n = 34), and treadmill testing for the first time at 26 weeks (control, n = 37). At 26 weeks functional capacity was significantly higher in patients training at home or in a group program than that in patients without training or in control patients: 8.1 +/- 1.5, 8.5 +/- 1.3, 7.5 +/- 1.8, and 7.0 +/- 1.7 METs, respectively (p less than .05 and p less than .001). No significant differences in functional capacity were noted between patients training at home and those in a group program. No training-related complications occurred. Home and group training are equally effective in increasing functional capacity of low-risk patients after myocardial infarction.