Reginald L. Washington

Primary Prevention of Coronary Heart Disease: Guidance From Framingham A Statement for Healthcare Professionals From the AHA Task Force on Risk Reduction

The Framingham Heart Study has contributed importantly to understanding of the causes of coronary heart disease (CHD), stroke, and other cardiovascular diseases. Framingham research has helped define the quantitative and additive nature of these causes or, as they are now called, “cardiovascular risk factors.”1 The National Cholesterol Education Program (NCEP)2 3 has made extensive use of Framingham data in developing its strategy for preventing CHD by controlling high cholesterol levels. The NCEP guidelines2 3 adjust the intensity of cholesterol-lowering therapy with absolute risk as determined by summation of risk factors. The National High Blood Pressure Education Program (NHBPEP) has set forth a parallel approach for blood pressure control. In contrast to the NCEP,2 however, earlier NHBPEP reports issued through the Joint National Committee4 did not match the intensity of therapy to absolute risk for CHD. “Normalization” of blood pressure is the essential goal of therapy regardless of risk status. Blood pressure–lowering therapy is carried out as much for prevention of stroke and other cardiovascular complications as for reduction of CHD risk. Nonetheless, risk assessment could be important for making decisions about type and intensity of therapy for hypertension. Thus, the most recent Joint National Committee report5 gives more attention to risk stratification for adjustment of therapy for hypertension. Although Framingham data have already been influential in the development of national guidelines for risk factor management, the opportunity may exist for both cholesterol and blood pressure programs to draw more extensively from Framingham results when formulating improved risk assessment guidelines and recommending more specific strategies for risk factor modification. The American Heart Association has previously used Framingham risk factor data to prepare charts for estimating CHD risk. Framingham investigators of the National Heart, Lung, and Blood Institute prepared the original charts and have now revised …

Guide to Primary Prevention of Cardiovascular Diseases A Statement for Healthcare Professionals From the Task Force on Risk Reduction

The clinical and public health approaches to primary prevention are complementary. Primary prevention refers to guidance given to persons with no known cardiovascular disease. Physicians can contribute to the public health approach through patient education. The first goal of prevention is to prevent the development of risk factors. Physicians should instruct all patients about adopting healthy life habits that will prevent intensification of risk factors. Patient education should be family oriented. Ideally, risk factor prevention begins in childhood. Preventing cigarette smoking by children and adolescents is a prime goal. Another major goal is prevention of overweight and obesity in children and weight gain in adults; overweight lies at the heart of several risk factors. Encouraging life habits that incorporate regular physical activity, especially walking, and active recreational sports likewise will decrease intensity of risk factors. Patients and their …

When to Start Cholesterol-Lowering Therapy in Patients With Coronary Heart Disease A Statement for Healthcare Professionals From the American Heart Association Task Force on Risk Reduction

At present a large number of patients with atherosclerotic disease are not receiving aggressive cholesterol-lowering therapy. Consequently they are being deprived of a cost-effective, risk-reducing treatment. Every physician who treats patients with clinical atherosclerotic disease should become fully informed about the results of cholesterol-lowering trials in patients at high risk. All physicians who care for high-risk patients should take responsibility for cholesterol management, including primary care physicians and cardiovascular specialists. Highly effective and generally safe drugs for cholesterol lowering are available. The benefits of therapy for reducing recurrent CHD and prolonging life are considerable. There is no justification for unduly delaying institution of therapy for the majority of patients. The many advantages of nonpharmaceutical therapy call for its use in almost all patients, but drug treatment should not be postponed if the target for LDL cholesterol lowering (< or = 100 mg/dL) is unlikely to be achieved in the near term by a nonpharmaceutical approach alone. The view that patients with CHD or other forms of atherosclerotic disease do not receive substantial clinical benefits from aggressive cholesterol-lowering therapy is no longer warranted. Intensive cholesterol reduction, initiated immediately, has the potential to significantly reduce both morbidity and mortality. Cholesterol-lowering therapy thus should become a routine part of clinical management to reduce risk of future coronary events and to prolong life in patients with CHD or other forms of atherosclerotic disease.

Guidelines for exercise testing in the pediatric age group. From the Committee on Atherosclerosis and Hypertension in Children, Council on Cardiovascular Disease in the Young, the American Heart Association.

Exercise testing of children differs from adult exercise testing in many ways beyond the technical issues related to test performance that are addressed in this report. Disease processes that produce myocardial ischemia are relatively rare in children compared with adults. Exercise testing may be useful in these cases, but the use of testing to assess functional capacity or cardiac rhythms will be encountered more often. Although the precise role of exercise testing in patient evaluation or long-term management of the cardiac patient will vary somewhat from center to center, exercise testing is often essential to diagnose and to direct treatment in a wide variety of clinical problems. An understanding of the role of exercise testing for children with known or suspected heart abnormalities is an essential part of the training of pediatric cardiologists. The staff of the pediatric exercise laboratory should be available to discuss with the clinician when a test might be of value in a specific case in addition to providing advice about the specifics of the performance of the test and offering age- and size-appropriate normal data from the laboratory with test interpretation.

Normal aerobic and anaerobic exercise data for North American school-age children

The purpose of this study was to establish normative data for untrained, healthy North American children by means of the James protocol for bicycle ergometry. Data were obtained on 151 of 185 children (70 girls and 81 boys). Their ages ranged from 7 years 6 months to 12 years 9 months. All subjects were divided into groups by gender and body surface area (BSA). Maximum heart rates were greater in girls. The mean difference between maximum and recovery heart rates differed significantly by gender, girls taking longer to recover than boys. Maximum oxygen consumption (measured in cubic centimeters per minute per kilogram body weight) did not differ in boys and girls. Ventilatory anaerobic threshold (VAT) occurred when there was an isolated increase in the slope for ventilatory equivalent for oxygen consumption (VE/VO2) with no change in the slope for ventilatory equivalent for carbon dioxide production (VE/VCO2) when both were plotted against time. Absolute oxygen consumption (VO2) at VAT increased with BSA in both sexes, and, when normalized to body size and expressed as a percent of VO2 maximum, no significant difference was observed between the sexes. These data may be used in the fitness evaluations of preadolescent children from North America.

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: A Scientific Statement From the American Heart Association and American College of Cardiology.

*On behalf of the American Heart Association and Arrhythmias Committee of the Council logy, Council on Cardiovascular Disease in the Cardiovascular and Stroke Nursing, Coun Genomics and Translational Biology, and the Cardiology. The American Heart Association and the A Cardiology make every effort to avoid any actual o interest that may arise as a result of an outside sonal, professional, or business interest of a m panel. Specifically, all members of the writing g complete and submit a Disclosure Questionnaire lationships that might be perceived as real or interest. The Preamble and other Task Force r ceedings are available online at www.onlinejacc.o 2015;66:2343–9; 2350–5; 2362–71; 2372–84; 2385–9 2406–11; 2412–23; 2424–8; 2429–33; 2434–8; 24 2447–50). This statement was approved by the Americ Science Advisory and Coordinating Committee on American Heart Association Executive Committee o the American College of Cardiology Board of Tr Committee on June 3, 2015. BenjaminD. Levine,MD,FAHA,FACC* Reginald L. Washington, MD, FAHA* Aaron L. Baggish, MD, FACC*

Association of toxic shock syndrome toxin-secreting and exfoliative toxin-secreting Staphylococcus aureus with Kawasaki syndrome complicated by coronary artery disease.

Kawasaki syndrome (KS) has been reported to be associated with selective expansion of Vβ2+ T cells and either staphylococcal toxic shock syndrome toxin-1 or streptococcal pyrogenic exotoxin C in uncomplicated cases. However, there have been no previous studies on the role of superantigens in KS associated with coronary artery disease, the major complication of this illness. The present study characterized bacteria isolated from three acute KS patients who developed coronary artery disease. Staphylococcus aureus secreting either TSST-1 (n = 3) or exfoliative toxin A(n = 1), both known to stimulate expansion of Vβ2+ T cells, were isolated from all three patients. The percent Vβ2+ T cells was determined in three patients with coronary artery disease. On presentation, one patient demonstrated reduction, whereas the other two showed expansion, of Vβ2+ T cells. Repeat analyses of the latter two children showed their percent Vβ2+ T cells to decrease toward normal. These observations suggest that coronary artery disease in KS may result from superantigenic stimulation of Vβ2+ T cells. This is also the first demonstration of an association of staphylococcal exfoliative toxin with acute KS. The observation that three different bacterial toxins associated with KS are potent activators of Vβ2+ T cells suggests an important role for this T cell subset in the pathogenesis of this autoimmune disease.

Sports and exercise cardiology in the United States: cardiovascular specialists as members of the athlete healthcare team.

In recent years, athletic participation has more than doubled in all major demographic groups, while simultaneously, children and adults with established heart disease desire participation in sports and exercise. Despite conferring favorable long-term effects on well-being and survival, exercise can be associated with risk of adverse events in the short term. Complex individual cardiovascular (CV) demands and adaptations imposed by exercise present distinct challenges to the cardiologist asked to evaluate athletes. Here, we describe the evolution of sports and exercise cardiology as a unique discipline within the continuum of CV specialties, provide the rationale for tailoring of CV care to athletes and exercising individuals, define the role of the CV specialist within the athlete care team, and lay the foundation for the development of Sports and Exercise Cardiology in the United States. In 2011, the American College of Cardiology launched the Section of Sports and Exercise Cardiology. Membership has grown from 150 to over 4,000 members in just 2 short years, indicating marked interest from the CV community to advance the integration of sports and exercise cardiology into mainstream CV care. Although the current athlete CV care model has distinct limitations, here, we have outlined a new paradigm of care for the American athlete and exercising individual. By practicing and promoting this new paradigm, we believe we will enhance the CV care of athletes of all ages, and serve the greater athletic community and our nation as a whole, by allowing safest participation in sports and physical activity for all individuals who seek this lifestyle.

Report of the task force on the availability of cardiovascular drugs to the medically indigent

Executive Summary ................................................ 850 Summary of Findings ............................................... 850 Recommendations ............................................... 850 Introduction ............................................... 850 Cardiovascular Disease Prevalence and Cost ................................................ 851 Prevalence ............................................... 851 Cost ............................................... 852 Demographics ............................................... 852 The Insured ............................................... 852 The Uninsured ............................................... 852 The Underinsured ............................................... 852 Lack of Access to Medical Care ......... ...................................... 852 Lack of Access to Medications ............................................... 853 Plans for Universal Access to Medical Care by Other Countries .......... ............ 853 Proposed US Programs ............................................... 853 US Programs Providing Access to Medication ............................................... 853 Community Programs ............................................... 853 State Programs ............................................... 855 Pharmaceutical Companies ............................................... 858

State-of-the-Art PaperSports and Exercise Cardiology in the United States: Cardiovascular Specialists as Members of the Athlete Healthcare Team

In recent years, athletic participation has more than doubled in all major demographic groups, while simultaneously, children and adults with established heart disease desire participation in sports and exercise. Despite conferring favorable long-term effects on well-being and survival, exercise can be associated with risk of adverse events in the short term. Complex individual cardiovascular (CV) demands and adaptations imposed by exercise present distinct challenges to the cardiologist asked to evaluate athletes. Here, we describe the evolution of sports and exercise cardiology as a unique discipline within the continuum of CV specialties, provide the rationale for tailoring of CV care to athletes and exercising individuals, define the role of the CV specialist within the athlete care team, and lay the foundation for the development of Sports and Exercise Cardiology in the United States. In 2011, the American College of Cardiology launched the Section of Sports and Exercise Cardiology. Membership has grown from 150 to over 4,000 members in just 2 short years, indicating marked interest from the CV community to advance the integration of sports and exercise cardiology into mainstream CV care. Although the current athlete CV care model has distinct limitations, here, we have outlined a new paradigm of care for the American athlete and exercising individual. By practicing and promoting this new paradigm, we believe we will enhance the CV care of athletes of all ages, and serve the greater athletic community and our nation as a whole, by allowing safest participation in sports and physical activity for all individuals who seek this lifestyle.