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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Clinical case reports (CCRs) are a valuable means of sharing observations and insights in medicine. The form of these documents varies, and their content ...

University of California, Los Angeles

Lipid lowering in high-risk populations: how low should we go?

Elevated blood pressure is the most common chronic illness in the United States, affecting more than 50 million people. Hypertension is an even greater problem in the African American community. Traditionally, management of hypertension and cardiovascular risk reduction has focused on drug therapy; however, several studies have shown the benefits of therapeutic lifestyle changes for blood pressure lowering and cardiovascular risk reduction. Therapeutic lifestyle changes to reduce blood pressure have enormous potential as a means for preventing and controlling hypertension and thereby reducing the risk of coronary heart disease. Although the reductions in blood pressure are relatively modest with these approaches, they could potentially have a beneficial impact on overall cardiovascular morbidity and mortality when applied to the whole population. Because of their high prevalence of certain cardiovascular risk factors (e.g., obesity, diabetes mellitus) and greater salt sensitivity, therapeutic lifestyle changes have particular relevance for African Americans.

Therapeutic lifestyle changes for hypertension and cardiovascular risk reduction.

There is a complex interplay between genetic and environmental factors that influences the expression of plasma lipoprotein levels. It is therefore not surprising that differences in lipid levels have been reported between ethnic groups. There are conflicting data on racial and ethnic variations in lipids, and also limited data on the relationship between lipoprotein levels and coronary heart disease risk in specific populations. This review summarizes available data on ethnic variations in plasma lipoproteins and the potential impact on coronary morbidity and mortality.

Plasma lipoprotein concentrations in ethnic populations.

In the past decade there has been an explosion of data on the beneficial role of cholesterol reduction in the prevention and treatment of cardiovascular disease (CVD). While earlier clinical trials focused primarily on patient populations with very high cholesterol levels, more recent studies have also included individuals with somewhat lower, or "average," cholesterol levels. What is becoming clearer is that many patients with so-called "average" cholesterol levels may benefit from cholesterol reduction therapy to reduce the risk of cardiovascular events. Recent studies, such as the Heart Protection Study, provide further evidence for cholesterol reduction in the prevention and treatment of CVD and offer valuable lessons about cardiovascular risk reduction.

Lessons learned from recent lipid-lowering trials: why physicians should change clinical practice.

Type 2 diabetes mellitus is associated with a marked increase in the risk of atherosclerotic diseases, including coronary heart disease, peripheral arterial disease, and cerebrovascular disease. Insulin resistance is a key factor in the pathogenesis of type 2 diabetes mellitus. Insulin resistance and its attendant metabolic abnormalities may cause much of the increased cardiovascular risk of type 2 diabetes mellitus. Among the abnormalities associated with insulin resistance are dyslipidemia, hypertension, systemic inflammation, and a prothrombotic state. This review discusses the role that each of these disorders plays in the cardiovascular risk of type 2 diabetes mellitus.

Atherosclerosis in type 2 diabetes mellitus: the role of insulin resistance.

The metabolic syndrome describes a clustering of risk factors that predispose individuals to cardiovascular disease and type 2 diabetes mellitus. Abdominal obesity is a key component of the metabolic syndrome, increasing the incidence of insulin resistance, vascular inflammation, dyslipidemia, and hypertension. Adipose tissue (now recognized as an endocrine organ) and its hormonal products appear to play a significant role in signaling organs throughout the body in the regulation of fat and glucose metabolism. These mechanisms are clearly involved in the development of cardiovascular and metabolic disease and may also lead to increased surgical risks. The components of the syndrome that are most likely to affect surgical patients are obesity, hypertension, and disorders of glucose metabolism. This article focuses on each of these risk factors, the effects on surgical patients, and strategies to improve outcomes in the perioperative period.

Surgical risk in patients with metabolic syndrome: focus on lipids and hypertension.

Cardiometabolic risk encompasses a cluster of risk factors that may predispose individuals to cardiovascular disease and type 2 diabetes. These risk factors, some of which are currently undermanaged in clinical practice, involve multiple pathways and physiologic systems and point to a need for a comprehensive management approach. Abdominal obesity is a key component of cardiometabolic risk, increasing the incidence of insulin resistance, vascular inflammation, dyslipidemia, and hypertension. Adipose tissue, now recognized as an endocrine organ, and its hormonal products appear to play a significant role in the regulation of fat and glucose metabolism throughout the body. These mechanisms are clearly involved in the development of cardiovascular and metabolic disease. Current treatment protocols generally involve a fragmented approach to care, advocating management of only the clinically evident conditions. As cardiometabolic risk factors tend to cluster, patients often have additional subclinical conditions that would be discovered through comprehensive evaluation for the entire constellation of risk factors, thereby enabling clinicians to recommend optimal treatment to prevent cardiovascular and metabolic morbidities.

Managing cardiometabolic risk: an evolving approach to patient care.

Quality indicators for the care of ischemic heart disease in vulnerable elders.

African Americans are at greater risk for cardiovascular morbidity and mortality than European Americans or Asians. They also bear a disproportionately greater burden from type-2 diabetes mellitus. Not as much access to healthcare and less intensive use of available therapies may explain some of these disparities. However, the high prevalence of potentially modifiable risk factors, particularly hypertension and dyslipidemia, in African Americans also provides great opportunity for the prevention and treatment of cardiovascular disease in this population. In addition to lifestyle approaches, achieving aggressive goals for blood pressure (< or =130/80 mmHg) and low-density-lipoprotein cholesterol (<100 mg/dL, or <70 mg/dL for patients at very high cardiovascular risk, including those with diabetes) will necessitate the use of effective pharmacologic therapies. Clinical trial data indicate that antihypertensive regimens, particularly those that include a diuretic, are as effective in African Americans as in other racial/ethnic groups. Moreover, potent statins have been shown to decrease low-density-lipoprotein cholesterol to goal levels in African-American patients.

Cardiovascular risk reduction among African Americans: a call to action.

Coronary heart disease (CHD) remains a major cause of death in the United States, and despite continued improvements in cardiovascular care, CHD rates remain unacceptably high. Modification of cardiovascular risk factors is the major strategy for reducing coronary disease and clinical events. Lipid modification therapy has played an important role in cardiovascular risk reduction, and the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are among the most important cardioprotective medications. Early clinical trials of statin therapy utilized low or modest doses of statins. More recent trials, however, have compared low-dose with high-dose statin therapy in individuals with CHD and found high-dose statin therapy to confer more benefits. Is there, then, still a role for low-dose statin therapy? This article summarizes statin clinical trials and focuses on the potential role for low-dose statin therapy in cardiovascular risk reduction.

What is the evidence in favor of low-dose statin therapy in 2008?

Acculturation involves stress-related processes and health behavioral changes, which may have an effect on left ventricular (LV) mass, a risk factor for cardiovascular disease (CVD). We examined the relationship between acculturation and LV mass in a multiethnic cohort of White, African-American, Hispanic and Chinese subjects.

Acculturation is associated with left ventricular mass in a multiethnic sample: the Multi-Ethnic Study of Atherosclerosis.

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide and the management of blood cholesterol is a cornerstone of medical therapy for the primary and secondary prevention of cardiovascular disease. Patients with diabetes represent an important high-risk group in whom clinicians should advocate the use of statins and lifestyle modification for the reduction of ASCVD. The recent 2013 ACC/AHA guidelines on managing blood cholesterol provide an important framework for the effective implementation of this important risk reduction strategy. The guidelines identify four groups of individuals who have been shown to benefit from statin therapy and update the dosing and monitoring recommendations based on evidence from published, large-scale randomized controlled trials (RCTs) with clinical hard endpoints. Primary care physicians and specialists play key roles in identifying populations at elevated ASCVD risk and providing effective care for patients, especially those with diabetes. This article will summarize the 2013 ACC/AHA guidelines on managing blood cholesterol and provide a practical management overview in order to facilitate implementation of these guidelines for patients with diabetes. 

The 2013 ACC/AHA Cholesterol Treatment Guidelines: Applicability to Patients with Diabetes.

Slippery Slope of Triglycerides: They Are Associated With Risk, But in the Statin Era, Does Targeting Them Confer Benefit?

MY APPROACH to the Patient With Memory Loss Who Needs a Statin.

Using data from the Multi-Ethnic Study of Atherosclerosis baseline sample from 2000 to 2002 (N=5263; mean age=62) we examined cross-sectional racial/ethnic differences in ideal CVH, defined by the American Heart Association 2020 Impact Goals as a summary measure of ideal levels of blood pressure, fasting glucose, cholesterol, body mass index, diet, physical activity, and smoking. Using three different analytical approaches, we examined differences before and after adjustment for neighborhood socioeconomic, physical, and social environments. Significant racial/ethnic differences were present for all indicators of ideal CVH (excluding physical activity). Additional adjustments for neighborhood factors produced modest reductions in racial/ethnic differences. Future research is necessary to better understand the impact of neighborhood context on health disparities using longitudinal study designs.

Neighborhoods and racial/ethnic differences in ideal cardiovascular health (the Multi-Ethnic Study of Atherosclerosis).

Elevated cholesterol levels are clearly independently associated with adverse cardiovascular events. Another class of lipid particles, triglycerides, is also abundant in the human body and has been found in atherosclerotic plaques. Recent observational studies have demonstrated an association between elevated triglyceride levels and increased risk for future cardiovascular events. With this knowledge and the discovery of effective agents to lower triglyceride levels, the management of triglycerides is currently undergoing a renaissance. Unfortunately, no randomized, controlled clinical trials have been completed to date, proving that lowering triglycerides will reduce cardiovascular events. In this review we highlight some of the evidence that led to this stage and discuss the current data on pharmacologic intervention of triglyceride levels and the effect on clinical outcomes. Lastly, we want to give the reader insight on what the most recent lipid guidelines state about clinical triglyceride management, mention new pharmacological agents, and highlight the clinical evidence for safe and effective lowering of triglycerides levels with life style modification.

Article	Year
Lipid lowering in high-risk populations: how low should we go? Ethnicity & disease\| PubMed ID: 11763308	2001
Therapeutic lifestyle changes for hypertension and cardiovascular risk reduction. Journal of clinical hypertension (Greenwich, Conn.)\| PubMed ID: 12556671	2003
Plasma lipoprotein concentrations in ethnic populations. Current cardiology reports\| PubMed ID: 14558991	2003
Lessons learned from recent lipid-lowering trials: why physicians should change clinical practice. Clinical cornerstone\| PubMed ID: 14699987	2003
Atherosclerosis in type 2 diabetes mellitus: the role of insulin resistance. Journal of cardiovascular pharmacology and therapeutics\| PubMed ID: 14740074	2003
Surgical risk in patients with metabolic syndrome: focus on lipids and hypertension. Current cardiology reports\| PubMed ID: 17059795	2006
Managing cardiometabolic risk: an evolving approach to patient care. Critical pathways in cardiology\| PubMed ID: 17667880	2007
Quality indicators for the care of ischemic heart disease in vulnerable elders. Journal of the American Geriatrics Society\| PubMed ID: 17910559	2007
Cardiovascular risk reduction among African Americans: a call to action. Journal of the National Medical Association\| PubMed ID: 18277804	2008
What is the evidence in favor of low-dose statin therapy in 2008? Current atherosclerosis reports\| PubMed ID: 18366983	2008
Acculturation is associated with left ventricular mass in a multiethnic sample: the Multi-Ethnic Study of Atherosclerosis. BMC cardiovascular disorders\| PubMed ID: 26631068	2015
The 2013 ACC/AHA Cholesterol Treatment Guidelines: Applicability to Patients with Diabetes. Current diabetes reports\| PubMed ID: 26803649	2016
Slippery Slope of Triglycerides: They Are Associated With Risk, But in the Statin Era, Does Targeting Them Confer Benefit? Circulation. Cardiovascular quality and outcomes\| PubMed ID: 26957516	2016
MY APPROACH to the Patient With Memory Loss Who Needs a Statin. Trends in cardiovascular medicine\| PubMed ID: 28107839	2017
Neighborhoods and racial/ethnic differences in ideal cardiovascular health (the Multi-Ethnic Study of Atherosclerosis). Health & place\| PubMed ID: 28167269	2017
Triglycerides: A reappraisal. Trends in cardiovascular medicine\| PubMed ID: 28438398	2017
Closing the Remaining Evidence Gap: Randomized Controlled Trial Data to Support Statin Therapy for Low-Density Lipoprotein ≥190 mg/dL. Circulation\| PubMed ID: 29133529	2017

Karol Watson

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