management and prevention for Heart attacks

Prevention of heart attacks and strokes

There are two distinct uses of aspirin for prophylaxis of cardiovascular events: primary prevention and secondary prevention. Primary prevention is about decreasing strokes and heart attacks in the general population of those who have no diagnosed heart or vascular problems. Secondary prevention concerns patients with known cardiovascular disease.^[45]

Low doses of aspirin are recommended for the secondary prevention of strokes and heart attacks. For both males and females diagnosed with cardiovascular disease, aspirin reduces the chance of a heart attack and ischaemic stroke by about a fifth. This translates to an absolute rate reduction from 8.2% to 6.7% of such events per year for people already with cardiovascular disease. Although aspirin also raises the risk of hemorrhagic stroke and other major bleeds by about twofold, these events are rare, and the balance of aspirin's effects is positive. Thus, in secondary prevention trials, aspirin reduced the overall mortality by about a tenth.^[45]

For persons without cardiovascular problems, the benefits of aspirin are unclear. In the primary prevention trials aspirin decreased the overall incidence of heart attacks and ischaemic strokes by about a tenth. However, since these events were rare, the absolute reduction of their rate was low: from 0.57% to 0.51% per year. In addition, the risks of hemorrhagic strokes and gastrointestinal bleeding almost completely offset the benefits of aspirin. Thus, in the primary prevention trials aspirin did not change the overall mortality rate.^[45] Further trials are in progress.^[45]

The expert bodies diverge in their opinions regarding the use of aspirin for primary prevention, such as can be accomplished by including aspirin in a polypill for the general population. The US Government Preventive Services Task Force recommended making individual case by case choice based on the estimated future risk and patient's preferences.^[46][47] On the other hand, Antithrombotic Trialists’ Collaboration argued that such recommendations are unjustified since the relative reduction of risk in the primary prevention trials of aspirin was same for persons in high- and low-risk groups and did not depend on the blood pressure. The Collaboration suggested statins as the alternative and more effective preventive medication

management and prevention for Asthma

Management

A specific, customized plan for proactively monitoring and managing symptoms should be created. Someone who has asthma should understand the importance of reducing exposure to allergens, testing to assess the severity of symptoms, and the usage of medications. The treatment plan should be written down and adjusted according to changes in symptoms.^[99]

The most effective treatment for asthma is identifying triggers, such as cigarette smoke, pets, or aspirin, and eliminating exposure to them. If trigger avoidance is insufficient, medical treatment is recommended. Medical treatments used depends on the severity of illness and the frequency of symptoms. Specific medications for asthma are broadly classified in to fast acting and long acting.^[100][101]

Bronchodilators are recommended for short-term relief of symptoms. In those with occasional attacks, no other medication is needed. If mild persistent disease is present (more than two attacks a week), low-dose inhaled glucocorticoids or alternatively, an oral leukotriene antagonist or a mast cell stabilizer is recommended. For those who suffer daily attacks, a higher dose of inhaled glucocorticoid is used. In a severe asthma exacerbation, oral glucocorticoids are added to these treatments.^[90]

[edit]Lifestyle modification

Avoidance of triggers is a key component of improving control and preventing attacks. The most common triggers include: allergens, smoke (tobacco and other), air pollution, non selective beta-blockers, and sulfite-containing foods.^[90][102]

[edit]Medications

Medications used to treat asthma are divided into two general classes: quick-relief medications used to treat acute symptoms; and long-term control medications used to prevent further exacerbation.^[103]

Fast acting

Salbutamol metered dose inhaler commonly used to treat asthma attacks.

• Short acting beta₂-adrenoceptor agonists (SABA), such as salbutamol (albuterol USAN) are the first line treatment for asthma symptoms.^[3]
• Anticholinergic medications, such as ipratropium bromide provide addition benefit when used in combination with SABA in those with moderate or severe symptoms.^[3] Anticholinergic bronchodilators can also be used if a person cannot tolerate a SABA.^[9]
• Older, less selective adrenergic agonists, such as inhaled epinephrine, have similar efficacy to SABAs.^[104] They are however not recommended due to concerns regarding excessive cardiac stimulation.^[105]

Long term control

Fluticasone propionate metered dose inhaler commonly used for long term control.

• Glucocorticoids are the most effective treatment available for long term control.^[106] Inhaled forms are usually used except in the case of severe persistent disease, in which oral steroids may be needed.^[106] Inhaled formulations may be used once or twice daily, depending on the severity of symptoms.^[107]

• Long acting beta-adrenoceptor agonists (LABA) have at least a 12-hour effect. They are however not to be used without a steroid due to an increased risk of severe symptoms.^{[108][109][110]} In December 2008, members of the FDA's drug-safety office recommended withdrawing approval for these medications in children. Discussion is ongoing about their use in adults.^[111]
• Leukotriene antagonist ( such as zafirlukast) are an alternative to inhaled glucocorticoids, but are not preferred. They may also be used in addition to inhaled glucocorticoids but are second line to LABD.^[106]
• Mast cell stabilizers (such as cromolyn sodium) are another none preferred alternative to glucocorticoids.^[106]

Delivery methods

Medications are typically provided as metered-dose inhalers (MDIs) in combination with an asthma spacer or as a dry powder inhaler. The spacer is a plastic cylinder that mixes the medication with air, making it easier to receive a full dose of the drug. A nebulizer may also be used. Nebulizers and spacers are equally effective in those with mild to moderate symptoms however insufficient evidence is available to determine whether or not a difference exist in those severe symptomatology.^[112]

Safety and adverse effects

Long-term use of glucocorticoids carries a significant potential for adverse effects. The incidence of cataracts is increased in people undergoing treatment for asthma with corticosteroids, due to altered regulation of lens epithelial cells.^[113] The incidence of osteoporosis is also increased, due to changes inbone remodeling.^[114][115]

[edit]Other

When an asthma attack is unresponsive to usual medications, other options are available for emergency management.

• Oxygen is used to alleviate hypoxia if saturations fall below 92%.^[116]
• Magnesium sulfate intravenous treatment has been shown to provide a bronchodilating effect when used in addition to other treatment in severe acute asthma attacks.^[117][118]
• Heliox, a mixture of helium and oxygen, may also be considered in severe unresponsive cases.^[118]
• Intravenous salbutamol is not supported by available, evidence and is thus used only in extreme cases.^[116]
• Methylxanthines (such as theophylline) were once widely used, but do not add significantly to the effects of inhaled beta-agonists.^[116]
• The dissociative anesthetic ketamine is theoretically useful if intubation and mechanical ventilation is needed in people who are approaching respiratory arrest; however, there is no evidence from clinical trials to support this.^[119]

[edit]Complementary medicine

Many asthma patients, like those who suffer from other chronic disorders, use alternative treatments; surveys show that roughly 50% of asthma patients use some form of unconventional therapy.^[120][121] There is little data to support the effectiveness of most of these therapies. Evidence is insufficient to support the usage of Vitamin C.^[122] Acupuncture is not recommended for the treatment as there is insufficient evidence to support its use.^[123][124] Air ionisers show no evidence that they improve asthma symptoms or benefit lung function; this applied equally to positive and negative ion generators.^[125]

Dust mite control measures, including air filtration, chemicals to kill mites, vacuuming, mattress covers and others methods had no effect on asthma symptoms.^[126] However, a review of 30 studies found that "bedding encasement might be an effective asthma treatment under some conditions" (when the patient is highly allergic to dust mite and the intervention reduces the dust mite exposure level from high levels to low levels).^[127] Washing laundry/rugs in hot water was also found to improve control of allergens.^[9]

A study of "manual therapies" for asthma, including osteopathic, chiropractic, physiotherapeutic and respiratory therapeutic manoeuvres, found there is insufficient evidence to support or refute their use in treating.^[128] The Buteyko breathing technique for controlling hyperventilation may result in a reduction in medications use however does not have any effect on lung function.^[129] 

management and prevention for Hypertension

Prevention

The degree to which hypertension can be prevented depends on a number of features including current blood pressure level, sodium/potassium balance, detection and omission of environmental toxins, changes in end/target organs (retina, kidney, heart, among others), risk factors for cardiovascular diseases and the age at diagnosis of prehypertension or at risk for hypertension. A prolonged assessment in which repeated measurements of blood pressure are taken provides the most accurate assessment of blood pressure levels. Following this, lifestyle changes are recommended to lower blood pressure, before the initiation of prescription drug therapy. The process of managing prehypertension according the guidelines of theBritish Hypertension Society suggest the following lifestyle changes:

• Weight reduction and regular aerobic exercise (e.g., walking): Regular exercise improves blood flow and helps to reduce the resting heart rate and blood pressure.^[47]
• Reducing dietary sugar intake
• Reducing sodium (salt) in the diet: This step decreases blood pressure in about 33% of people (see above). Many people use a salt substitute to reduce their salt intake.^[48]
• Additional dietary changes beneficial to reducing blood pressure include the DASH diet (dietary approaches to stop hypertension) which is rich in fruits and vegetables and low-fat or fat-free dairy products. This diet has been shown to be effective based on research sponsored by the National Heart, Lung, and Blood Institute.^[49] In addition, an increase in dietarypotassium, which offsets the effect of sodium has been shown to be highly effective in reducing blood pressure.^[50]
• Discontinuing tobacco use and alcohol consumption has been shown to lower blood pressure. The exact mechanisms are not fully understood, but blood pressure (especially systolic) always transiently increases following alcohol or nicotine consumption. Abstaining from cigarette smoking reduces the risk of stroke and heart attack which are associated with hypertension.^[51]

Limiting alcohol intake to less than 2 standard drinks per day can reduce systolic blood pressure by between 2-4mmHg.^[52]

• Reducing stress, for example with relaxation therapy, such as meditation and other mindbody relaxation techniques,^[53] by reducing environmental stress such as high sound levelsand over-illumination can also lower blood pressure. Jacobson's Progressive Muscle Relaxation and biofeedback are also beneficial,^[54] such as device-guided paced breathing,^[55][56]although meta-analysis suggests it is not effective unless combined with other relaxation techniques.^[57]

Increasing omega 3 fatty acids can help lower hypertension. Fish oil is shown to lower blood pressure in hypertensive individuals. The fish oil may increase sodium and water excretion.^[58]

management and prevention for Diabetes

Management

Main article: Diabetes management

Diabetes mellitus is a chronic disease which is difficult to cure. Management concentrates on keeping blood sugar levels as close to normal ("euglycemia") as possible without presenting undue patient danger. This can usually be with close dietary management, exercise, and use of appropriate medications (insulin only in the case of type 1 diabetes mellitus. Oral medications may be used in the case of type 2 diabetes, as well as insulin).

Patient education, understanding, and participation is vital since the complications of diabetes are far less common and less severe in people who have well-managed blood sugar levels.^[17][18] Wider health problems may accelerate the deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of regular exercise.

Lifestyle modifications

Main article: Diabetic diet

There are roles for patient education, dietetic support, sensible exercise, with the goal of keeping both short-term and long-term blood glucose levels within acceptable bounds. In addition, given the associated higher risks of cardiovascular disease, lifestyle modifications are recommended to control blood pressure.^[19]

Medications

Oral medications

Main article: Anti-diabetic drug

Routine use of aspirin has not been found to improve outcomes in uncomplicated diabetes.^[20]

Insulin

Main article: Insulin therapy

Type 1 treatments usually include combinations of regular or NPH insulin, and/or synthetic insulin analogs.