Assessing risk of myocardial infarction and stroke: new data from the Prospective Cardiovascular Münster (PROCAM) study

OBJECTIVES

Based on the data of the Prospective Cardiovascular Münster (PROCAM) study, a prospective study of men and women at work in the north-west of Germany, we aimed (i) to develop a refined scoring scheme for calculating the risk of acute coronary events among adult and elderly men and women; and (ii) to generate a new scoring scheme for calculating the risk of ischaemic stroke or transient ischaemic attack (TIA).

METHODS

The coronary risk score was derived from a Weibull function using data from 18 460 men and 8515 women who were recruited before 1996 and had a mean follow-up period of 12+/-6 years. The stroke score was derived using a Cox proportional hazards model using data of 5905 men and 2225 women aged 35-65 years with at least 10 years of unbroken follow-up.

RESULTS

The coronary risk score was based on 511 major coronary events, 462 (168 fatal, 294 non-fatal) in men and 49 (18 fatal, 31 non-fatal) in women and included the risk factors LDL cholesterol, HDL cholesterol, systolic blood pressure, smoking status, triglycerides and diabetes mellitus status. It was accurate in both sexes over an age range from 20 to 75 years with an area under the receiver-operating characteristics (ROC) curve of 0.82. The stroke score was based on 85 cerebral ischaemic events (21 TIAs, 64 ischaemic strokes) and included the risk factors age, sex, diabetes mellitus status, smoking status and systolic blood pressure. It had an area under the ROC curve of 0.78 and identified a high-risk group comprising only 4% of the study population that contained 31% of all cerebral ischaemic events.

CONCLUSION

Both new PROCAM risk scores provide simple and effective ways to assess the risk of acute coronary events and ischaemic stroke in the general population and will improve the ability of physicians to target measures in an effort to prevent these potentially devastating conditions.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Treatment of Hyperlipidemia in Primary Practise in Germany: Sub-group Analyses from the 4E-registry with Particular Emphasis on Men and Women with Diabetes Mellitus

AIMS

To investigate the achievement of treatment goals for low density lipoprotein (LDL) cholesterol in men and women with diabetes mellitus receiving statins in a primary-care setting in Germany.

METHODS

6,827 men and 5,989 women with diabetes mellitus were recruited from among the 28,200 men and 24,200 women participating in the 4E registry of patients being treated with statins for primary hypercholesterolemia unresponsive to diet and lifestyle. Participants were assessed after 6 weeks and 9 months of statin therapy. Attainment of treatment targets was assessed (i) using individual LDL goals based on each participant's individual level of risk and (ii) based on the 2.6 mmol/L target recommended by current European and U.S. guidelines for persons with diabetes.

RESULTS

At baseline, patients with and without diabetes mellitus had similar LDL cholesterol levels patients (men: 4.5+/-1 vs. 4.7+/-1 mmol/L, women: 4.7+/-1 vs. 4.9+/-1 mmol/L respectively). The mean drop in LDL cholesterol on statin therapy was similar in men and women with and without diabetes, ranging from 26-27 percent all subgroups. After 9 months of statins, individual LDL goals were achieved by 25% of men and 24% of women with diabetes, while only 16% of diabetic men and 12% of diabetic women achieved the 2.6 mmol/L LDL target. These success rates were similar to those of non-diabetics, including those at high risk, in 4E.

CONCLUSIONS

Patients with diabetes mellitus in 4E responded just as well to statins as patients without diabetes. However, achievement of treatment goals in patients with diabetes was just as poor as in other high-risk groups in the 4E cohort.

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Effect of pathogen-specific clinical mastitis on herd life in two New York State dairy herds

The objective of this study was to estimate the effects of clinical mastitis (CM) (both with and without specific pathogen identification) occurring in different stages of lactation on length of herd life in two New York State dairy farms. The 2,697 cows in the study were followed for one lactation (the first-occurring one on or after 1 October 1999), until it ended because of a new lactation, culling, or end of study (31 March 2001 in one farm; 31 July 2001 in the other). A Cox proportional hazards model with time-dependent covariates, in SAS((R)), was used to measure, within a lactation, the effect of the first occurrence of CM (without specific pathogen identification) occurring 1--7, 8--66, 67--100, 101--225, or >or=226 days in milk (DIM), on how long cows remained in the herd. For the first occurrence of CM due to Streptococcus spp., Staphylococcus aureus, Staphylococcus spp., Escherichia coli, Klebsiella spp., and 'no pathogen isolated', the intervals were before and after the median DIM of first occurrence of each pathogen. There were too few cases due to Arcanobacterium pyogenes, and 'other pathogens grouped together' to split into intervals, so they were modeled as binary variables, i.e. as they occurred. CM was modeled using time-dependent covariates, to account for its differing effects throughout lactation on culling. Other variables controlled for were herd, parity, calving season, and other significant diseases. In the dataset, the lactational incidence risk of the first occurrence of CM was 18.2%; 20.0% of the cows did not survive the lactation that was studied. The overall annual culling percentage for both herds during the study period (including all cows, whether eligible for the study or not) was 35.6%. For cows with CM without pathogen identification, their highest hazard ratio (HR) of culling occurred from 67 to 100 DIM. All of the pathogens modeled markedly reduced herd life. On average over the entire lactation, cows with Staphylococcus spp. CM had the highest HRs for culling, although there were no significant differences among pathogens (at p=0.0018 (reflecting 28 pairwise comparisons)). For early-occurring (before median DIM of first occurrence) S. aureus CM, the daily rate of change of the HR of culling increased over time. The HRs for culling were particularly high for late-occurring (after median DIM of first occurrence) E. coli and Klebsiella spp. CM early in the interval, but the daily rate of change of the hazard of culling for these two pathogens decreased sharply over time. Treating CM as time-dependent therefore allowed us to measure in greater detail, its varying effects (of when it occurred) on herd life.

Effect of pathogen-specific clinical mastitis on milk yield in dairy cows

Our objective was to estimate the effects of the first occurrence of pathogen-specific clinical mastitis (CM) on milk yield in 3071 dairy cows in 2 New York State farms. The pathogens studied were Streptococcus spp.,Staphylococcus aureus, Staphylococcus spp., Escherichia coli, Klebsiella spp., Arcanobacterium pyogenes, other pathogens grouped together, and "no pathogen isolated." Data were collected from October 1999 to July 2001. Milk samples were collected from cows showing signs of CM and were sent to the Quality Milk Production Services laboratory at Cornell University for microbiological culture. The SAS statistical procedure PROC MIXED, with an autoregressive covariance structure, was used to quantify the effect of CM and several other control variables (herd, calving season, parity, month of lactation, J-5 vaccination status, and other diseases) on weekly milk yield. Separate models were fitted for primipara and multipara, because of the different shapes of their lactation curves. To observe effects of mastitis, milk weights were divided into several periods both pre- and postdiagnosis, according to when they were measured in relation to disease occurrence. Another category contained cows without the type of CM being modeled. Because all pathogens were modeled simultaneously, a control cow was one without CM. Among primipara, Staph. aureus, E. coli, Klebsiella spp., and "no pathogen isolated" caused the greatest losses. Milk yield generally began to drop 1 or 2 wk before diagnosis; the greatest loss occurred immediately following diagnosis. Mastitic cows often never recovered their potential yield. Among older cows, Streptococcus spp., Staph. aureus, A. pyogenes, E. coli, and Klebsiella spp. caused the most significant losses. Many multipara that developed CM were actually higher producers before diagnosis than their nonmastitic herd-mates. As in primipara, milk yield in multipara often began to decline shortly before diagnosis; the greatest loss occurred immediately following diagnosis. Milk loss persisted until at least 70 d after diagnosis for Streptococcus spp., Klebsiella spp., and A. pyogenes. The tendency for higher producing cows to contract CM may mask its impact on cow health and production. These findings provide dairy producers with more information on which pathogen-specific CM cases should receive treatment and how to manage these cows, thereby reducing CM impact on cow well being and profitability.

Vergleich internationaler Konsensus-Empfehlungen zur Erkennung des präsymptomatischen Hochrisikopatienten für den Herzinfarkt in Deutschland

The recommendations of the International Task Force for the Prevention of Coronary Heart Disease/International Atherosclerosis Society (ITF/IAS), the US-American Adult Treatment Panel III of the National Cholesterol Education Programs (ATP III) and the 3rd Joint European Guidelines (3JE) for the prevention coronary heart disease (CHD) show good agreement in tertiary prevention. All three guidelines recommend that patients with manifest CHD should have a blood pressure below 140/90 mm Hg and LDL-cholesterol below 2.6 mmol/l (100 mg/dl). By contrast, the three recommendations differ with respect to the prevention of cardiovascular events in asymptomatic high risk patients (secondary prevention), notably in the strategy to be used for risk assessment. Both the ITF/IAS guidelines and the 3JE guidelines can be adapted and realized in the various European countries. We therefore compared the prognostic values of the three recommendations by applying them to the data of male participants of the Prospective Cardiovascular Munster (PROCAM) Study. The ITF/IAS recommendations show the highest specificity (94.5%), positive predictive value (32.0%) and diagnostic efficacy (90.5%); the 3JE guidelines have the highest sensitivity (64.6%) but lowest specificity (77.9%), positive predictive value (17.5%) and diagnostic efficacy (77.0%). The application of the 3JE recommendations would target 25% of German men aged 35-65 years as cardiovascular high risk patients, by contrast to 7.5% through application of the ITF/IAS guidelines. In view of the limited resources in the public health systemthe application of the ITF/IAS guidelines in Germany appears more appropriate.

[Use of risk factors in determining individual coronary risk]

The "Deutschland SCORE" has low predictive power and greatly overestimates the true risk of coronary heart disease in Germany. Widespread use of this score would lead to massive over-treatment. For this reason, we cannot recommend this score for general use.

[A guideline for guidelines--methodological report and use of the guideline women's information]

Information and education is needed to empower autonomy and self-determination of patients (informed consent). Furthermore reliable and accurate medical information is necessary for patients who want to take an active part in medical decision-making. The aim of this work is to define the requirements helping to assure the development of good qualified information material relevant for women and female patients as "a guideline on women information". An example of its use is given by embeding this guideline in the guideline for early detection of breast cancer in Germany by defining the specific elements required for developing qualified information on this issue for women.

METHODS

A systematic, stepwise methodological process according to a level two guideline of the German Association of the Scientific Medical Societies (AWMF) and the Agency for Quality in Medicine (AZQ) was performed with the following elements: 1. Establishing an expert panel, 2. Generating the guideline statements by a formal, consensus based nominal group process, 3. External review process and finding supportive partners for the guideline on women information, 4. Using the guideline for guidelines: implementing the concept in the guideline of early detection of breast cancer in Germany.

RESULTS

The "guideline women information" comprises nine elements of quality assuring requirements for the development of gender-specific information material and eleven specific elements which directly relate to the guideline statements on early detection of breast cancer. After external review 30 organisations gave their written support for future implementation of the guideline. The "guideline women information" was integrated as a tool for quality assurance of lay information into the "guideline for early detection of breast cancer in Germany".

CONCLUSION

The "guideline women information" is a systematically developed, consensus-based recommendation to improve the development of qualified lay information at the point of its process by defining gender-specific aspects required for good lay information and its evaluation. As a guideline for guidelines its use is demonstrated by integrating this guideline into the "guideline for early detection of breast cancer in Germany" to ensure the development of qualified guideline compliant information.

Pharmacological modulation of experimental phasic and tonic muscle pain by morphine, alfentanil and ketamine in healthy volunteers

BACKGROUND

Muscle pain is a major clinical problem but the underlying mechanisms and its pharmacological modulation need further investigation. This study on 15 volunteers evaluates if two experimental muscle pain models are sensitive to micro -receptor agonists and to an N-methyl-D-aspartate (NMDA)-receptor antagonist.

METHODS

In the left tibialis anterior, intramuscular electrical (IMES) pain thresholds were determined for single (SPTmuscle) and five (RPTmuscle) repeated stimuli. Also pain to suprathreshold stimulation at 150% of RPTmuscle, 10 s, was assessed on a visual analog scale (VAS) as AUCimes (area under the VAS curve). In the right TA muscle, pain intensity on infusion of 0.5 ml of hypertonic saline, 5% (AUCsaline) and pain distribution indicated as local and referred were evaluated. Pain variables were assessed before, during and after intravenous infusions of morphine (10 microg x kg-1 min-1, 10 min), alfentanil (target-controlled infusion, plasma concentration; 60 ng ml-1, 60 min) and ketamine (10 microg x kg-1 min-1, 60 min). All data were normalized to baseline pain values (before drug infusions were initiated) and compared with placebo (midazolam, 2 microg x kg-1 min-1, 10 min).

RESULTS

SPTmuscle increased (log mean values +/- SD, mA) with morphine (0.11 +/- 0.17, P < 0.05), alfentanil (0.28 +/- 0.24, P < 0.001) and ketamine (0.19 +/- 0.18, P < 0.01) as compared with placebo (-0.03 +/- 0.12). Alfentanil and ketamine also increased RPTmuscle (0.25 +/- 0.21, P < 0.01 and 0.21 +/- 0.19, P < 0.05, respectively) as compared with placebo (0.00 +/- 0.17). Pain to IMES (AUCimes) was reduced (median values [25th-75th percentiles], cm x s) by alfentanil and ketamine (-19.7 [-14.6 - -29.6] and-12.8 [-8.3 - -27.8], P < 0.05, respectively) vs. placebo (-0.8 [1.6 - -12.3]). Similar drug effects were seen when pain to infusion of hypertonic saline (AUCsaline) was assessed (alfentanil:-388 [-99 - -677] and ketamine:-326 [-227 - -573], P < 0.05 compared with placebo: 150 [449--240]). Ketamine also reduced the size of the local pain area (-58.4 [-21.2 - -176.1], < 0.05) as compared with placebo (-0.4 [70.6 - -13.4]). The frequency of referred pain was also lower when ketamine was given (3/13, P < 0.05) vs. placebo (9/14).

CONCLUSION

The study demonstrates that experimental muscle pain induced in humans by electrical stimulation and infusion of hypertonic saline is sensitive to pharmacological modulation similar to preclinical animal tests and clinical trials. The data suggest that these models can be valuable tools in analgesic drug development.

Arguments in favour of a homologous concept for hemodialysis access procedures. Feasibility and results

OBJECTIVES

Autologous arterio-venous (AV) fistulas seem to be superior to prothetic grafts in hemodialysis access surgery. We used an algorithm which enabled us to use autologous vein in over 99% of all fistula operations.

DESIGN

All patients undergoing hemodialysis surgery during a three year period (n = 102) were enrolled in an open prospective observation study with the end points feasibility, perioperative complications and patency.

MATERIALS

One hundred and two patients were followed until the end of the observation period (30/6/01).

METHODS

All relevant data were recorded prospectively. The status of the individual fistula was recorded twice a year until the end of the observation period. Fistula-patency was calculated by life-table-analysis according to Kaplan-Meier.

RESULTS

Except one patient presenting with a recurrent shunt aneurysm, no patient received prothetic material. At the end of the observation period all patients alive and under dialysis could use their autologous fistula. There was no perioperative mortality. One reoperation was required for a septic anastomotic rupture. Otherwise, only minor complications were observed. Cumulative 1-year and 3-year patency were 78.5 and 62.8% respectively for the Cimino and 75.2 and 66.8% for elbow fistulas.

CONCLUSIONS

An autologous approach is nearly always possible. Besides fewer complications, the approach seems to be cost effective.

[Recognizing patients at high risk for myocardial infarct]]

Several controlled intervention trials proved the benefit of antihypertensive and hypolipidemic drugs for the prevention of coronary heart disease (CHD). International guidelines for the prevention of CHD agree in their recommendations for secondary prevention and recommend to lower blood pressure below 140/90 mm Hg and LDL-cholesterol below 3 mmol/l (or even < 2.6 mmol/l) in patients with manifest CHD. Novel recommendations for primary prevention are focused on the treatment of the presymptomatic high risk patient with an estimated risk of higher than 2% per year. For the calculation of this risk, the physician must record the following risk factors: gender, age, family history of premature myocardial infarction, smoking, diabetes, blood pressure, total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglyceride. This information allows computing the absolute risk of myocardial infarction by using scores or algorithms which have been deduced from results of epidemiological studies.

Perioperative levels of atrial natriuretic peptide and troponin-T in patients with uncomplicated coronary artery surgery

BACKGROUND

HYPOTHESIS

increased ANP levels after uncomplicated coronary artery surgery (CAS) indicate functional reduction.

METHODS

EXPERIMENTAL DESIGN

prospective, randomized. Preoperative upto the 12 week postoperative.

SETTING

Thoracic and Cardiovascular Surgery, University of Düsseldorf.

PATIENTS

15 patients (mean age: 58+/-6.1 years; 13 months, 2 weeks; no myocardial infarction, no congestive heart failure) with 3 vessel disease.

INTERVENTIONS

levels of atrial natriuretic peptide (ANP) (pg/ml; radioimmunoassay), Troponin T (TnT) (ng/ml; ELISA test), haemodynamic parameters, ECG monitoring, m-mode echocardiography (Echo).

MEASURES

increase of ANP, TnT levels during extracorporeal circulation (ECC), decrease after operation.

RESULTS

Maximal increase of ANP from preoperative 90+/-10 (M+/-SEM) pg/ml (p<0.05) up to intraoperative 380+/-38 pg/ml. Ten days postoperative ANP (26+/-33 pg/ml) still threefold increased compared to preoperative level. Increasement of TnT from preoperative 0.02+/-0.01 ng/ml upto intraoperative 3.44+/-0.47 ng/ml. Ten days postoperative TnT concentration normal (0.13+/-0.11 ng/ml). Correlation of ANP and TnT five min after bypass up to 6 hrs postoperative (p<0.05, r =3.4). Increase of left atrial diameter preoperative 42.2+/-1.1 mm up to 46.8+/-1.2 mm (p<0.05) 10 days postoperative. LVEDD, EF changed from preoperative 51.1+/-0.9 mm, 73+/-2% to 54.5+/-1.2 mm, 65+/-4% 10 days postoperative.

CONCLUSIONS

Threefold increase of ANP 10 days postoperative and return of TnT levels to normal under consideration of datas of echo show, that ANP is suitable to indicate the meanterm, functional, myocardial reduction. Increased ANP levels, atrial dilatation and dysfunction are important signs of cardial functional reduction after CAS.

Association of the GPIa C807T and GPIIIa PlA1/A2 polymorphisms with premature myocardial infarction in men

Aims Recent studies have reported an association between the platelet glycoprotein (GP) Ia C807T polymorphism and myocardial infarction, whereas other studies have reported contradictory results concerning the platelet GPIIIa PlA1/A2 polymorphism. In most of these studies the patients were older than 45 years. Thus we decided to examine both genotypes in 287 men who had their first myocardial infarction before age 45, and a group of 138 healthy controls. Methods and Results The frequency of T807 allele carriers was similar among myocardial infarction patients and among controls (54.6% vs 62.3%; odds ratio (OR) 0.73; 95% confidence interval (CI), 0.47-1.12). The frequency of PlA2 carriers was higher in cases than in controls (26.5% vs 15.2%; OR 1.65; CI, 1.09-2.54). After performing a logistic regression analysis, taking into account other cardiovascular risk factors, this difference did not remain significant. The combination of the risk alleles of both genotypes had no major effect on the myocardial infarction risk. Conclusions The GPIIIa PlA2 allele is not independently associated with the risk of premature myocardial infarction. The T807 allele of the GPIa gene alone or in combination with the PlA2 allele had no major effect on premature myocardial infarction risk.

Association of serum apolipoprotein A-I (but not high-density lipoprotein cholesterol) with healed myocardial infarction in men independent of serum insulin and C-peptide

Low serum levels of high-density lipoprotein (HDL) cholesterol or apolipoprotein A-I and high serum levels of insulin increase the risk of coronary heart disease (CHD) and can indicate insulin resistance. We tested the strength, independence, and interactions of associations between HDL cholesterol (or apolipoprotein A-I), insulin (or C-peptide), glucose, and CHD in 95 male nondiabetic patients with CHD who were <60 years old, in 92 probands from the PROCAM study, and in 61 non-cardiologic patients; all subjects were matched by age, body mass index, and smoking habits. Systemic hypertension (odds radio [OR] 2.8, 95% confidence intervals [CI] 1.6 to 4.8), high serum levels of glucose (OR 2.3, 95% CI 1.6 to 4.8), insulin (OR 2.1, 95% CI 1.3 to 3.6), and C-peptide (OR 4.1, 95% CI 2.2 to 7.5) as well as low serum levels of HDL cholesterol (OR 2.0, 95% CI 1.1 to 3.5) or apolipoprotein A-I (OR 3.9, 95% CI 2.1 to 7.1) had significant associations with CHD. At multivariate analysis, systolic blood pressure, glucose, apolipoprotein A-I, and C-peptide, but not HDL cholesterol and insulin, had consistent independent associations with CHD. Thus, the combined measurement of apolipoprotein A-I and C-peptide may improve the identification of nondiabetic patients at increased risk for CHD.

Plasma fibrinogen in relation to the severity of arteriosclerosis in patients with stable angina pectoris after myocardial infarction

BACKGROUND

Authors both of retrospective and of prospective studies have demonstrated that there is a relationship between concentration of fibrinogen in plasma and the angiographically determined severity of coronary heart disease (CHD).

OBJECTIVE

To determine the relevance of the plasma fibrinogen concentration for the severity of CHD, particularly in cases with additional arteriosclerotic changes in the extracranial arteries supplying the brain [cerebrovascular disease (CVD)], in the pelvic/leg arteries [peripheral occlusive arterial disease (POAD)], or in both.

PATIENTS AND METHODS

In a retrospective cross-sectional survey the cardiological and angiographical status of a total of 1112 male and 299 female patients with stable angina pectoris after sustained myocardial infarction and an age-matched control group of 326 male and 138 female subjects with no clinical symptoms of CHD was determined, together with measurements of plasma fibrinogen, dynamic plasma viscosity and D-dimers.

RESULTS

More than two-thirds of the patients with arteriosclerosis had plasma fibrinogen concentrations in the uppermost tertile of the control range (men > 2.75; women > 2.83 g/l). Plasma fibrinogen concentration was correlated to the severity of CHD (for men r = 0.173, P < 0.001; for women r= 0.144, P < 0.013). Patients with generalized arteriosclerosis had higher plasma fibrinogen concentrations than did those suffering from CHD only (for men, control 2.65 +/- 0.51, CHD 3.07 +/- 0.73, CHD plus POAD 3.17 +/- 0.77 and CHD plus POAD plus CVD 3.45 +/- 0.78 g/l; for women, control 2.69 +/- 0.44, CHD 3.25 +/- 0.67, CHD plus POAD 3.19 +/- 0.77, CHD plus POAD plus CVD 3.60 +/- 0.84 g/l). Multivariate analysis showed that C-reactive protein, D-dimers and dynamic plasma viscosity accounted for 48.2% (for men) and 49.4% (for women) of the variance in plasma fibrinogen concentration.

CONCLUSIONS

Our findings demonstrate that there is not only a correlation between plasma fibrinogen concentration and the severity of CHD, but also a correlation to the incidence of additional POAD or CVD.

[Obesity and cardiovascular risk]

PROBANDS AND METHOD: In the Prospective Cardiovascular Münster (PROCAM) Study, 16,288 men aged 40.5 +/- 11.3 years (mean +/- SD) and 7,328 women aged 35.8 +/- 12.3 years were enrolled between 1979 and 1991.

RESULTS

Mean body mass indices (BMI) were 25.6 +/- 3.3 kg/m2 and 23.8 +/- 4.1 kg/m2 in men and women, respectively. There was a graded positive interaction in both men and women between BMI and age-standardized levels of serum total cholesterol, low density lipoprotein cholesterol, triglycerides, fasting blood glucose, uric acid, and blood pressure (both systolic and diastolic). High density lipoprotein cholesterol tended to decrease with increases in BMI in both sexes. In the subgroup of male participants aged 40-65 years without a prior history of myocardial infarction or stroke in an 8-year follow-up 258 major coronary events were observed. Although incidences of major coronary events increased with increase in relative body weight in a multiple logistic function analysis BMI did not independently contribute to cardiovascular risk, indicating that the effect of overweight on coronary heart disease is mediated via other risk factors.

Changes in hemostasis during treatment of hypertriglyceridemia with a diet rich in monounsaturated and n-3 polyunsaturated fatty acids in comparison with a low-fat diet

High levels of fibrinogen, factor (F) VIIc, plasminogen activator inhibitor-1 (PAI-1), and plasma viscosity are associated with an increased coronary risk. As positive correlations of these parameters with triglycerides have been shown, the increased coronary risk associated with high levels of triglycerides may be assumed to be due to alterations within the hemostatic system. To reduce the coronary risk to which hypertriglyceridemic patients are exposed, dietary treatment is recommended; the optimal composition of such a diet is, however, a matter of debate. With regard to the effects on hemostasis, we compared in a sequential approach two diets for treatment of 25 nonobese male patients (age, mean+/-S.D., 40.4+/-8.7 years) with fasting triglycerides >2.3 mmol/l. The first diet (high fat) was rich in monounsaturated fatty acids (MUFA) and marine n-3 polyunsaturated fatty acids (PUFA), whereas the second diet (low-fat) was rich in complex carbohydrates and dietary fiber. The high-fat diet induced a significant lowering of FIIc, FIXc, FXc, FVIIc, FVIIa, FXIIa, PAI-1, plasma viscosity, and platelet activity, but led to an increase in fibrinogen, whereas the low-fat diet lowered FXIIc values and induced a nonsignificant decrease in fibrinogen. Probands on this diet had a slightly higher FVIIa and platelet activity than those on the high-fat diet. However, as all changes appeared to be within the normal range of each hemostatic parameter, it remains to be clarified whether the likely beneficial effects of the high-fat diet on most hemostatic factors are outweighed by the small increase in fibrinogen levels.

Effects of diets containing olive oil, sunflower oil, or rapeseed oil on the hemostatic system

Various studies have already shown that the fatty acid composition of dietary fat has different effects on hemostasis and platelet function. However, knowledge on this topic is incomplete. In the present study, fifty-eight healthy students received either a 4-week rapeseed oil [high content of monounsaturated fatty acids (MUFA) and high n-3/n-6 PUFA ratio], an olive oil (high content of MUFA, low n-3/n-6 PUFA ratio) or a sunflower oil (low content of MUFA, low n-3/n-6 PUFA ratio) diet. In each group, effects on hemostatic parameters were compared with a wash-in diet rich in saturated fatty acids with respect to intermediate-time effects on the hemostatic system and platelet function. With the olive oil diet, a reduction of coagulation factors VIIc, XIIc, XIIa, and Xc was found, whereas sunflower oil led to lower values of coagulation factors XIIc, XIIa, and IXc. In all study groups levels of plasmin-alpha2-antiplasmin were lower in week 4 than at baseline. Lower fibrinogen binding on platelets was found after the sunflower oil diet, whereas expression of CD62 and spontaneous platelet aggregation were slightly higher after the olive oil diet. However, given the major differences in the fatty acid compositions of the diets, the differences between the groups with respect to hemostasis tended to be small. Therefore, the clinical significance of the present findings remains to be evaluated.

Lipoprotein(a) further increases the risk of coronary events in men with high global cardiovascular risk

OBJECTIVES

This prospective population study was conducted to assess the role of elevated lipoprotein(a) [Lp(a)] as a coronary risk factor.

BACKGROUND

The role of elevated Lp(a) as a risk factor for coronary heart disease is controversial. In addition, little attention has been paid to the interaction of Lp(a) with other risk factors.

METHODS

A total of 788 male participants of the Prospective Cardiovascular Münster (PROCAM) study aged 35 to 65 years were followed for 10 years. Both Lp(a) and traditional cardiovascular risk factors (e.g., age, low density lipoprotein [LDL] cholesterol, high density lipoprotein [HDL] cholesterol, triglycerides, systolic blood pressure, cigarette smoking, diabetes mellitus, angina pectoris, and family history of myocardial infarction) were evaluated in 44 men who suffered from myocardial infarction, and in 744 men who survived without major coronary events or stroke. A multiple logistic function algorithm was used to estimate global cardiovascular risk by the combined effects of traditional risk factors.

RESULTS

Overall, the risk of a coronary event in men with an Lp(a) > or =0.2 g/liter was 2.7 times that of men with lower levels (95% confidence interval [CI]: 1.4 to 5.2). This increase in risk was most prominent in men with LDL cholesterol level > or =4.1 mmol/liter (relative risk [RR]: 2.6; 95% CI: 1.2 to 5.7), with HDL cholesterol < or =0.9 mmol/liter (RR 8.3; 95% CI: 2.0 to 35.5), with hypertension (RR 3.2; 95% CI: 1.4 to 7.2), or within the two highest global risk quintiles (relative risk: 2.7; 95% CI: 1.3 to 5.7).

CONCLUSIONS

Lp(a) increases the coronary risk, especially in men with high LDL cholesterol, low HDL cholesterol, hypertension and/or high global cardiovascular risk.