Effect of intensive lipid lowering, with or without antioxidant vitamins, compared with moderate lipid lowering on myocardial ischemia in patients with stable coronary artery disease: the Vascular Basis for the Treatment of Myocardial Ischemia Study.

BACKGROUND: Lipid lowering with statins prevents adverse cardiac events. Both lipid-lowering and antioxidant therapies may favorably affect vasomotor function and thereby improve ischemia. METHODS AND RESULTS: In a randomized, double-blind, placebo-controlled trial, 300 patients with stable coronary disease, a positive exercise treadmill test, 48-hour ambulatory ECG with > or =1 episode of ischemia, and fasting total cholesterol of 180 to 250 mg/dL were assigned to 1-year treatment with intensive atorvastatin to reduce LDL to <80 mg/dL (n=96), intensive atorvastatin to reduce LDL to <80 mg/dL plus antioxidant vitamins C (1000 mg/d) and E (800 mg/d) (n=101), or diet and low-dose lovastatin, if needed, to reduce LDL to <130 mg/dL (n=103; control group). Ischemia end points, including ambulatory ECG monitoring and exercise treadmill testing, and endothelial assessment using brachial artery flow-mediated dilation were obtained at baseline and at 6 and 12 months. Baseline characteristics were similar in all groups. LDL decreased from approximately 153 mg/dL at baseline in the 2 atorvastatin groups to approximately 83 mg/dL at 12 months (each P<0.0001) and from 147 to 120 mg/dL in the control group (P<0.0001). During ambulatory ECG monitoring, mean number of ischemic episodes per 48 hours decreased 31% to 61% in each group (each P<0.001; P=0.15 across groups), without a change in daily heart rate activity. Mean duration of ischemia for 48 hours decreased 26% to 62% in each group (each P<0.001; P=0.06 across groups). Mean exercise duration to 1-mm ST-segment depression significantly increased in each group, but total exercise duration and mean sum of maximum ST depression were unchanged. Angina frequency decreased in each group. There was no incremental effect of supplemental vitamins C and E on any ischemia outcome. Flow-mediated dilation studies indicated no meaningful changes. CONCLUSIONS: Intensive lipid lowering with atorvastatin to an LDL level of 80 mg/dL, with or without antioxidant vitamins, does not provide any further benefits in ambulatory ischemia, exercise time to onset of ischemia, and angina frequency than moderate lipid lowering with diet and low-dose lovastatin to an LDL level of <120 mg/dL.

Lay beliefs about high blood pressure in a low- to middle-income urban African-American community: an opportunity for improving hypertension control.

PURPOSE: Lay beliefs about illness are a potential barrier to improving the control of hypertension. We investigated the extent to which lay beliefs about hypertension diverge from current medical understanding. METHODS: We conducted street intercept interviews and focus group discussions in six predominantly African-American census tracts in the southern sector of Dallas County, Texas. Sixty subjects, aged 18 to 67 years, were stopped along popular thoroughfares and administered a brief survey. Additionally, 107 participants were interviewed in 12 homogeneous focus groups, balanced by sex and age (18 to 74 years). Participants were asked about the meaning, causes, consequences, and treatment of high blood pressure. RESULTS: The street intercept data indicated that 35% (n = 21) of respondents related high blood pressure to eating pork or other foods that makes the blood travel too fast to the head, and only 15% (n = 9) related hypertension to an elevated pressure in blood vessels. The focus group data indicated that hypertension was causally linked to eating pork in 8 of the 12 groups; was perceived as a symptomatic illness in all 12 groups; and was considered treatable with vitamins, garlic, and other herbs in 11 groups, with prescription medications in 10 groups and with lifestyle modifications such as weight loss in 8 groups. Hypertension was mentioned as a leading cause of death among African Americans in none of the 4 focus groups of 18-year-old to 29-year-old participants, in 2 of the 4 focus groups of 30-year-old to 49-year-old participants, and in 3 of the 4 focus groups of 50-year-old to 74-year-old participants. CONCLUSIONS: In a low- to middle-income urban African-American community, the predominant beliefs about hypertension diverged sharply from current medical understanding. Lack of appreciation of these lay beliefs by providers may contribute to noncompliance and poor rates of hypertension control.