The diversity of health effects of individual trans fatty acid isomers

There are multiple adverse effects of trans fatty acids (TFA) that are produced by partial hydrogenation (i.e., manufactured TFA), on CVD, blood lipids, inflammation, oxidative stress, endothelial health, body weight, insulin sensitivity, and cancer. It is not yet clear how specific TFA isomers vary in their biological activity and mechanisms of action. There is evidence of health benefits on some of the endpoints that have been studied for some animal TFA isomers, such as conjugated linoleic acid; however, these are not a major TFA source in the diet. Future research will bring clarity to our understanding of the biological effects of the individual TFA isomers. At this point, it is not possible to plan diets that emphasize individual TFA from animal sources at levels that would be expected to have significant health effects. Due to the multiple adverse effects of manufactured TFA, numerous agencies and governing bodies recommend limiting TFA in the diet and reducing TFA in the food supply. These initiatives and regulations, along with potential TFA alternatives, are presented herein.

Animal models--what they can tell us about vascular calcification in CKD

The development of cardiovascular calcifications in chronic kidney disease (CKD) patients involves multiple risk factors with additive effects. However, a number of questions concerning cardiovascular calcifications in CKD patients remain unanswered at present due to lack of clinical data or due to the impossibility of conducting clinical trials to investigate these issues. In this review, we discuss how animal models could help us understand better the pathophysiology and management of calcifying cardiovascular complications associated with CKD.

The Effects of Simultaneous Administration of Dietary Conjugated Linoleic Acid and Telmisartan on Cardiovascular Risks in Rats

Dietary conjugated linoleic acid (CLA) and the antihypertensive drug, telmisartan, have both been shown to modify cardiovascular risks. The effects of a combination of these two agents have, however, not been investigated. This 20 week study sought to assess the therapeutic potential of a CLA/telmisartan co-administration in rats fed a high-fructose high-fat diet. Thirty-three male Sprague-Dawley rats were randomly assigned to five experimental groups, including control, losartan, telmisartan, CLA, and CLA + telmisartan-treated animals. Body weight, blood pressure, and blood levels of lipids, glucose, insulin, and inflammatory markers were measured. Co-administration of CLA and telmisartan resulted in significant (P < 0.05) reductions in body weight, visceral fat, serum total cholesterol, triglycerides, glucose, plasma insulin concentrations, and systolic blood pressure compared with those in the control group. Moreover, plasma levels of IL1-alpha and IFN-gamma were reduced and levels of IL1-beta, IL-4, IL-6, and IL-10, plus TNF-alpha were increased in the co-therapy group, compared with controls. In conclusion, this study suggests that a combination of CLA with telmisartan may modify several risk factors of cardiovascular disease commonly seen in metabolic syndrome. This combination of nutraceuticals and pharmaceuticals may be a safe and cost-effective strategy in a number of high-risk subjects. Future studies will further document clinical benefits of such combination therapy.

Tailoring intervention procedures to routine primary health care practice; an ethnographic process evaluation

BACKGROUND

Tailor-made approaches enable the uptake of interventions as they are seen as a way to overcome the incompatibility of general interventions with local knowledge about the organisation of routine medical practice and the relationship between the patients and the professionals in practice. Our case is the Quattro project which is a prevention programme for cardiovascular diseases in high-risk patients in primary health care centres in deprived neighbourhoods. This programme was implemented as a pragmatic trial and foresaw the importance of local knowledge in primary health care and internal, or locally made, guidelines. The aim of this paper is to show how this prevention programme, which could be tailored to routine care, was implemented in primary care.

METHODS

An ethnographic design was used for this study. We observed and interviewed the researchers and the practice nurses. All the research documents, observations and transcribed interviews were analysed thematically.

RESULTS

Our ethnographic process evaluation showed that the opportunity of tailoring intervention procedures to routine care in a pragmatic trial setting did not result in a well-organised and well-implemented prevention programme. In fact, the lack of standard protocols hindered the implementation of the intervention. Although it was not the purpose of this trial, a guideline was developed. Despite the fact that the developed guideline functioned as a tool, it did not result in the intervention being organised accordingly. However, the guideline did make tailoring the intervention possible. It provided the professionals with the key or the instructions needed to achieve organisational change and transform the existing interprofessional relations.

CONCLUSION

As tailor-made approaches are developed to enable the uptake of interventions in routine practice, they are facilitated by the brokering of tools such as guidelines. In our study, guidelines facilitated organisational change and enabled the transformation of existing interprofessional relations, and thus made tailoring possible. The attractive flexibility of pragmatic trial design in taking account of local practice variations may often be overestimated.

Blood pressure lowering only or more? Has the jury reached its verdict?

There is a great need for antihypertensive agents that go beyond blood pressure lowering to treat the underlying pathophysiologic conditions that contribute to cardiovascular disease. However, the results of published outcome studies have been variable because they have investigated patients with complicated, high-risk hypertension. Although this ensures a sufficient number of cardiovascular events to demonstrate drug-drug differences, the potent effects of blood pressure lowering in high-risk patients obscures differential non-blood pressure effects. Despite these limitations, reductions in the risk of stroke, atrial fibrillation, and diabetes mellitus have been demonstrated with renin-angiotensin-aldosterone system blockade. Guidelines currently recommend thiazide diuretics in stage 1 hypertension, but this is based on data from high-risk patients, and extrapolation to stage 1 disease may not be appropriate. Both blood pressure and cardiovascular risk increase exponentially from early in a patient's life, leading to clinically relevant differences in the pathophysiology of stage 1 versus complicated hypertension. Importantly, patients with stage 1 hypertension typically require 30-40 years of treatment. Thus, secondary effects of antihypertensive drugs on various blood pressure-independent cardiovascular risk factors are likely to become manifest. Clinical trials in mild forms of hypertension are essential to investigate the non-blood pressure effects of antihypertensive agents.

Angiotensin receptor blockers versus angiotensin-converting enzyme inhibitors: where do we stand now?

Cardiovascular disease represents a continuum that starts with risk factors, such as hypertension, and progresses to atherosclerosis, target organ damage, and ultimately leads to heart failure or stroke. Renin-angiotensin-aldosterone system (RAAS) blockade with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) has been shown to be beneficial at all stages of this continuum. Both classes of agent can prevent or reverse endothelial dysfunction and atherosclerosis, thereby potentially reducing the risk of cardiovascular events. Such a reduction has been shown with ACE inhibitors in patients with coronary artery disease, but no such data are currently available for ARBs. Both ACE inhibitors and ARBs have been shown to reduce damage in target organs, such as the heart and kidney, and to decrease cardiovascular mortality and morbidity in patients with congestive heart failure. Trials, such as the Ongoing Telmisartan Alone in Combination with Ramipril Global Endpoint Trial (ONTARGET) and the Telmisartan Randomised Assessment Study in ACE-Intolerant Subjects with Cardiovascular Disease (TRANSCEND), that compare telmisartan, ramipril, and their combination in high-risk patients with vascular end-organ damage, should provide important new insights into the benefits of intervention with RAS blockade along the cardiorenovascular continuum.

Total cardiovascular risk management

Hypertension usually clusters with other cardiovascular risk factors, such as insulin resistance, visceral obesity, and dyslipidemia, greatly increasing an individual's risk for cardiovascular morbidity and death. Despite universal recognition that reduction in blood pressure and other cardiovascular risk factors is essential to improving long-term cardiovascular health, <25% of patients diagnosed with hypertension have adequate blood pressure control. Total cardiovascular risk is increased in the presence of risk factors, target organ damage, comorbid conditions, and the metabolic syndrome and may, to some extent, be prenatally determined. Individuals with "borderline" normal blood pressure and blood glucose are also at increased risk for cardiovascular disease, giving rise to the concept of individuals with "prehypertension" and "prediabetes." International treatment guidelines are now incorporating the concept of global cardiovascular risk assessment and management to improve long-term outcomes. Multifactorial intervention has proved to be highly effective at reducing cardiovascular risk and events in patients with type 2 diabetes mellitus, and studies suggest that reducing an array of risk factors by relatively small amounts can be more beneficial than achieving large reductions in a single risk factor. Clearly, isolated treatment of hypertension is no longer sufficient; risk factors and target organ damage need to be actively searched for and treated if long-term cardiovascular health is to be improved.

Hormone replacement therapy comes full circle

Further evidence on the early benefits and late risks does not change advice to menopausal women

Association of fruit and vegetable intake with cardiovascular risk factors in urban south Indians

The study examines the relationship between fruit and vegetable intake (g/d) and CVD risk factors in urban south Indians. The study population comprised of 983 individuals aged > or = 20 years selected from the Chennai Urban Rural Epidemiological Study (CURES), a population-based cross-sectional study on a representative population of Chennai in southern India. Fruit and vegetable intake (g/d) was measured using a validated semi-quantitative FFQ. Linear regression analysis revealed that after adjusting for potential confounders such as age, sex, smoking, alcohol, BMI and total energy intake, the highest quartile of fruit and vegetable intake (g/d) showed a significant inverse association with systolic blood pressure (beta = - 2.6 (95 % CI - 5.92, - 1.02) mmHg; P = 0.027), BMI (beta = - 2.3 (95 % CI - 2.96, - 1.57) kg/m2; P < 0.0001), waist circumference (beta = - 2.6 (95 % CI - 3.69, - 1.46) cm; P < 0.0001), total cholesterol (beta = - 50 (95 % CI - 113.9, - 13.6) mg/l; P = 0.017) and LDL-cholesterol concentration (beta = - 55 (95 % CI - 110.8, - 11.1) mg/l; P = 0.039) when compared with the lowest quartile. A higher intake of fruit and vegetables explained 48 % of the protective effect against CVD risk factors. Increased intake of fruits and vegetables could play a protective role against CVD in Asian Indians who have high rates of premature coronary artery disease.

The kidney and cardiovascular risk--implications for management: a consensus statement from the European Society of Hypertension

Cardiovascular and renal diseases share many of the same risk factors. In fact, renal failure is usually accompanied by an increased global cardiovascular risk. Thus, preservation of kidney function might simultaneously protect the heart and the brain and, conversely, addressing cardiovascular risk factors might safeguard the kidney. This review considers the evidence supporting this approach, focusing on the protective effect of blood-pressure lowering and the ancillary actions of antihypertensive agents on renal protection. We review recent evidence on renal protection in individuals with and without diabetes, and the importance of offering a high standard of care also to those with the metabolic syndrome or prediabetes in order to prevent initial forms of renal, and as a consequence, cardiovascular damage. Intervention may be appropriate even in individuals with high-normal blood pressure, if they already have early renal and/or cardiovascular risk markers. As a consequence of these insights, thresholds for starting antihypertensive therapy are gradually falling, whereas awareness of the need for an early intervention in patients at high risk of developing renal damage and simultaneously cardiovascular disease is growing.

Cardiovascular diseases in China

Statistics from the National Population Census of China revealed a significant increase in the Chinese population, from 590 million in 1953 to 1.26 billion in 2000. The average life expectancy increased to 71.4 years in 2000 compared with the expectancy of 68.6 years a decade before. World Health Organization statistics on the death rate for total cardiovascular disease, coronary heart disease, and stroke in men and women aged 35-74 years revealed discrepancies between rural and urban parts of China. The China Multicenter Collaborative Study of Cardiovascular Epidemiology indicated that cardiovascular disease was the major cause of death for both men and women, with stroke accounting for over 40% of deaths. Ischemia was shown to be the most common subtype of stroke in both sexes. Smoking was an independent risk factor for cardiovascular disease. The World Health Organization reported that the death rate attributable to tobacco was 6.0% worldwide and 9.2% in China in 1990. The latter is projected to reach 16.6% by 2020. In China, the prevalence of hypertension and diabetes mellitus, the two key risk factors of cardiovascular disease, have also increased significantly in the past 20 years. In addition, elevated blood pressure and plasma cholesterol were two important determinants of increased cardiovascular disease in eastern Asia. These studies indicate that an integrated management of comprehensive risk is urgently required to address China's increasing cardiovascular disease burden.

An analysis of mortality rates with dual-antiplatelet therapy in the primary prevention population of the CHARISMA trial

AIMS

To examine the unanticipated, excess mortality observed in patients randomized to clopidogrel and aspirin vs. aspirin alone in the prespecified 'asymptomatic' subgroup of CHARISMA, we investigated whether dual-antiplatelet therapy may be associated with adverse cardiovascular (CV) events in a primary prevention population.

METHODS AND RESULTS

Of 15 603 patients enrolled, 3284 were initially categorized as asymptomatic with CV risk factors, but 995 had a prior CV event, leaving 2289 patients to represent the primary prevention cohort. This subset was compared with 13 148 symptomatic patients with established vascular disease and both were evaluated for CV death and bleeding. A multivariate analysis analysed predictors of CV death in this group. No post mortem data were available. Compared with aspirin alone, a significant increase in CV death (P = 0.01) was observed in patients receiving dual-antiplatelet therapy in the asymptomatic population. Within the primary prevention cohort, this excess CV death was not significant (P = 0.07). Multivariate analysis of the primary prevention group showed a trend towards excess CV death (P = 0.054; HR 1.72; CI 0.99-2.97) with dual-antiplatelet therapy (aspirin plus clopidogrel). Other independent predictors of CV death included increasing age, hypertension, atrial fibrillation, and a history of heart failure. There was a non-significant increase in moderate or severe bleeding (P = 0.218) with dual-antiplatelet therapy; thus, bleeding was an unlikely explanation for the excess event rate.

CONCLUSION

These findings do not support the use of dual-antiplatelet therapy with clopidogrel and aspirin in a primary prevention population. In this subgroup analysis, CV death occurred more frequently than anticipated. The cause of this apparent harm is not elucidated, may represent play of chance, but requires further prospective evaluation.

Miracle or mirage?

More than two million people in the UK are taking statins to reduce their cholesterol. But some doctors claim that they can cause affective disorders.

Strawberry Intake, Lipids, C-Reactive Protein, and the Risk of Cardiovascular Disease in Women

OBJECTIVE

There is indirect evidence suggesting that strawberries, containing several key nutrients, may be associated with the risk of cardiovascular disease (CVD). In the Women's Health Study, we examined strawberry intake for both its prospective association with CVD risk in 38,176 women and its cross-sectional association with lipids and C-reactive protein (CRP) in a subset of 26,966 women.

METHODS

Strawberry intake was assessed from a baseline semiquantitative food frequency questionnaire, along with other self-reported lifestyle, clinical and dietary factors. Participants returned baseline bloods which were assayed for lipids and CRP. We computed the relative risks (RRs) for total CVD (1,004 cases) (including confirmed myocardial infarction, stroke, revascularization, and cardiovascular death) occurring during 10.9 years of follow-up.

RESULTS

At baseline, 25.6%, 41.9%, 24.8%, and 7.7% of women reported corresponding strawberry intake of none, 1-3 servings/month, 1 serving/week, and > or =2 servings/week. For total CVD, the multivariate RRs (95% confidence intervals) for increasing categories of strawberry intake were 1.00 (ref), 1.01 (0.85-1.19), 0.95 (0.77-1.17), and 1.27 (0.94-1.72) (P, trend = 0.06). We found a similar lack of an association for individual cardiovascular endpoints and comparing mean levels of lipids and CRP by category of strawberry intake. However, women consuming > or =2 servings/week versus none had a borderline significant, multivariate 14% lower likelihood of an elevated CRP of > or =3 mg/L.

CONCLUSIONS

Strawberry intake was unassociated with the risk of incident CVD, lipids, or CRP in middle-aged and older women, though higher strawberry intake may slightly reduce the likelihood of having elevated CRP levels. Additional epidemiologic data are needed to clarify any role of strawberries in CVD prevention.

New targets of high-density lipoprotein therapy

PURPOSE OF REVIEW

Increasing attention has focused on the development of therapeutic strategies to promote the biologic activity of HDL particles, which possess a number of functional properties that contribute to their role in cardioprotection. Currently available therapies raise levels of HDL-cholesterol by relatively modest amounts. This review describes experimental strategies that promote HDL activity.

RECENT FINDINGS

The functional quality of HDL may be more important than the absolute level of HDL-cholesterol found in the systemic circulation. This is supported by the observation that small rises in HDL-cholesterol with current therapies is associated with clinical benefit. This has major implications for the development of new therapies. A number of therapeutic strategies have been developed that promote reverse cholesterol transport, inhibit inflammatory events in the vessel wall, and modify remodeling of HDL particles within the systemic circulation.

SUMMARY

A number of emerging therapies appear to promote the biologic activity of HDL. These agents can be administered as acute infusions in the setting of acute ischemic syndromes or as oral therapy for chronic prevention of cardiovascular disease.

Vasodilator-stimulated phosphoprotein phosphorylation analysis prior to percutaneous coronary intervention for exclusion of postprocedural major adverse cardiovascular events

BACKGROUND

Despite dual antiplatelet therapy, the rate of major adverse cardiovascular events (MACE) after percutaneous coronary angioplasty remains high. Studies have shown interindividual variations in response to clopidogrel. Furthermore, there is an apparent link between clinical outcomes and clopidogrel resistance.

OBJECTIVES

To investigate the value of platelet reactivity index (PRI), assessed by vasodilator-stimulated phosphoprotein (VASP) phosphorylation analysis, for predicting MACE after percutaneous coronary intervention (PCI) with stent implantation.

METHODS

A prospective monocentric study was performed on 144 patients undergoing PCI. PR was evaluated by VASP phosphorylation analysis 24 h after they received a 300-mg loading dose of clopidogrel. MACE were recorded during a 6-month follow-up. Patients were divided into quintiles according to PRI, as assessed by VASP analysis. The receiver operating characteristic (ROC) curve served to determine the optimal cut-off value of VASP analysis to detect MACE.

RESULTS

Of the 144 patients, 34% had stable angina pectoris, 40% silent ischemia, and 26% low-risk non-ST-segment elevation acute coronary syndrome. During the follow-up, 21 MACE were observed. Patients in quintile 1 of VASP analysis had a significantly lower risk of MACE as compared with those among the four higher quintiles (0 vs. 21, P < 0.01). ROC curve analysis of VASP showed an optimal cut-off value of 50% PR to exclude MACE. The negative predictive value of the test was 100%.

CONCLUSIONS

VASP phosphorylation analysis can evaluate the individual response to clopidogrel loading dose prior to PCI and predict postprocedural MACE.

Meta-analysis of the effects of n-3 polyunsaturated fatty acids on lipoproteins and other emerging lipid cardiovascular risk markers in patients with type 2 diabetes

AIMS/HYPOTHESIS

To determine the effects of marine-derived n-3 polyunsaturated fatty acids (PUFA) on established and emerging lipid and lipoprotein cardiovascular risk markers in patients with type 2 diabetes.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of randomised controlled trials comparing dietary or non-dietary intake of n-3 PUFA with placebo in patients with type 2 diabetes by searching databases from 1966 to December 2006. Changes in the following variables were recorded triacylglycerol; total cholesterol; HDL, LDL and VLDL and their subfractions; lipid ratios; apolipoproteins; and cholesterol particle sizes.

RESULTS

There were 23 trials on non-dietary supplementation, involving 1,075 subjects with a mean treatment duration of 8.9 weeks, with sufficient data to permit pooling. Compared with placebo, n-3 PUFA had a statistically significant effect on four outcomes, reducing levels of (1) triacylglycerol (18 trials, 969 subjects) by 25% (mean 0.45 mmol/l; 95% CI -0.58 to -0.32; p < 0.00001); (2) VLDL-cholesterol (7 trials, 238 subjects) by 36% (0.07 mmol/l; 95% CI -0.13 to 0.00; p = 0.04); and (3) VLDL-triacylglycerol (6 trials, 178 subjects) by 39.7% (0.44 mmol/l; 95% CI -0.83 to -0.05; p = 0.03); while slightly increasing LDL (16 trials, 565 subjects) by 5.7% (0.11 mmol/l; 95% CI 0.00 to 0.22; p = 0.05). There were no significant effects on total cholesterol, apolipoproteins, lipid subfractions or ratios.

CONCLUSIONS/INTERPRETATION

In addition to recognised triacylglycerol-lowering effects, n-3 PUFA supplementation decreases VLDL-cholesterol and VLDL-triacylglycerol, but may have an adverse effect on LDL-cholesterol. Larger and longer term clinical trials are required to conclusively establish the effect of n-3 PUFA on cardiovascular risk markers and outcomes in type 2 diabetic patients.