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Focuses on the effect of chronic illness and disability on health care costs and provides students with skills in policy process and analysis as applied to acute care, long-term care, and health promotion for elders and people with disabilities. Health System Credits: 3 Not Repeatable for Credit Offered by Health Administration and Policy Explores the U. Health System focusing on historical development, current configuration and possible future direction. Includes study of health system development, key influencers, accessibility, financing, changing components and effects system has on patients, providers, financers, employers, government, insurers and society. Role of population health management and public health is explored, including impact of social, cultural, economic, and environmental factors on health care systems and practices. 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Formal invasive electrophysiologic testing can be useful in the diagnosis of ventricular or supraventricular wide-complex tachycardia, and it is critical for guiding a wide array of new invasive electrophysiologic therapies (see Chapter 53). Key preventive strategies, including diet modification, recognition and treatment of hyperlipidemia, cessation of cigarette smoking, and adequate physical exercise, should be part of the approach to every patient, with or without heart disease. Atherosclerosis can also be found in other arterial beds, especially the renal arteries, where it causes about two thirds of cases of renal artery stenosis (see Chapters 55 and 112). These observations have raised the question of whether this decline in mortality is due to a true reduction in incidence at the population level, which could logically be attributed to improved prevention, or simply to a decline in case-fatality rates, which would presumably be attributable mostly to better treatment. Several studies have evaluated this question, and the consensus is that both prevention and therapy have contributed, so that both population incidence rates and case-fatality rates have declined. These fatty streaks can progress to raised lesions, which can progressively occlude the lumen of the artery. Symptoms that typically occur in vascular beds well before the lesions completely occlude the lumen include angina pectoris from lesions in the coronary arteries (see Chapter 59), transient ischemic attacks from lesions in the cerebrovascular arteries (see Chapter 470), and intermittent claudication from lesions in the arteries in the lower extremities (see Chapter 67). Although each of these pain syndromes has a classic prototype, patients can present with quite atypical symptoms despite significant disease. In general, the strength of the causal inference one can draw from a study increases along this continuum, with policy changes typically appropriate only when supported by solid clinical trial evidence. Nonetheless, these risk factors are important to consider in evaluating an individual patient at risk. Event rates are three to four times higher in regular smokers, with a dose-response relationship. Although much of the interindividual variability in cholesterol is genetic, dietary consumption of cholesterol, saturated fat, and trans-fatty acids (typically formed by partial hydrogenation [saturation] of unsaturated vegetable fat) increases serum cholesterol. The similarity of the amino acid sequences of Lp(a) and plasminogen suggests the possibility of a connection between atherogenesis and thrombosis. Intervention, however, is somewhat problematic, with only niacin and estrogen showing some effect in lowering Lp(a). Meta-analyses of pharmacologic treatment of mild hypertension have also shown benefit. Systolic pressure rises with age throughout life in Western populations, whereas diastolic pressure plateaus in late mid-life and decreases somewhat thereafter. Randomized trials of cardiac rehabilitation for secondary prevention also suggest benefit. Prior concerns about the possible acute risk of exercise for cardiac ischemia in susceptible persons are clearly outweighed by the benefits for most individuals; nevertheless, it is appropriate to evaluate high-risk individuals before beginning an exercise program. In type I diabetes the risks are even higher, particularly in patients with proteinuria. However, controversy persists as to whether reduction of glucose levels will improve macrovascular risk. New oral agents that lower glucose and insulin and improve insulin resistance may help resolve this issue. Maximum overall benefit for alcohol is reached at a single drink per day, and consumption of more than 2 drinks per day is associated with increases in morbidity and mortality from total cardiovascular causes, cirrhosis, accidents and violence, and certain cancers. Of particular concern is the consistent increase in breast cancer in women observed in epidemiologic studies even with only modest levels of drinking. For the just mentioned reasons, and given the high abuse potential of alcohol, it seems unwise to recommend alcohol for cardioprotection. The potential for intervention is theoretically quite good, since folic acid supplementation alone or in combination with other B vitamins is known to lower total plasma homocysteine levels. Many individuals with normal homocysteine levels may show hyperhomocysteinemia after methionine loading.
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