Do lipids and apolipoproteins predict coronary heart disease under statin and fibrate therapy in the primary prevention setting in community-dwelling elderly subjects? The 3C Study

PURPOSE

To evaluate associations of standard lipids and apolipoproteins with incident coronary heart disease (CHD) in older adults according to lipid-lowering treatment (LLT) in the primary prevention setting.

METHODS

Within the 3C Study of men and women aged ≥ 65 years, standard lipids, apolipoproteins A-1 and B100 and hs-CRP were measured in baseline blood samples from 199 participants who developed a first CHD event over 4 years of follow-up and from 1081 subjects randomly selected from the initial cohort (case cohort study). Standardized hazard ratios (HRs) were estimated by the Cox proportional hazard model.

RESULTS

In the random sample, 75.3% were free of LLT (non-users), 11.5% received statins and 13.4% fibrates. Among the non-users, all lipid parameters were significantly associated with future CHD (n = 145) after adjustment for age, gender, study center and educational level, and their HRs were comparable. For instance, the HR for LDL-cholesterol was 1.38 (95% CI: 1.13-1.69). These associations also existed and were stronger among statin users (n = 27 CHD), as shown by an HR for LDL-cholesterol of 2.20 (95% CI: 1.27-3.81). Additional adjustment for traditional risk factors and hs-CRP marginally modified HR estimates in those receiving or not receiving statins. Among fibrate users (n = 27 CHD), significant associations were observed for triglycerides only (1.68; 95% CI = 1.04-2.72) in fully adjusted analyses.

CONCLUSION

In older adults, standard lipids and apolipoproteins are stronger predictors of CHD in those receiving statins than in those who are not in the primary prevention setting. Under fibrate treatment, only triglycerides were independent predictors of CHD.

Organization of postural equilibrium in several planes in ballet dancers

This study analyzed the balance strategies of ballet dancers during postural equilibrium in three single leg balance conditions with and without vision and regard to age. Dancers participating formed two groups of 20 dancers each, one aged between 8 and 16 years (young group) and the other aged between 17 and 30 years (adult group). Ground reaction forces (GRFs) (mediolateral (ML), anteroposterior (AP) components, vertical (V)) were recorded. Results analysis enabled us to extract some spatiotemporal data for each component of the GRF (number of GRF oscillations, variability and impulses). Young dancers are characterized, compared to adult dancers, by an instability combined with an increase of oscillations number and a decrease variability mainly visible on the ML component. In the two groups, the absence of vision implies an increase of AP, ML and V impulsions and GRF variability. Balance with the gesturing limb to the rear increases the age and vision effect compared to balances with the limb forward or to the side. Young dancers are less efficient at controlling their balance than adult dancers. This observation may be related to the number of hours practicing dance, which differs between groups. The dancers have a visual dependence to control the postural balance.

[CT scan, MR imaging and anatomopathologic correlation in the glottic carcinoma T1-T2]

OBJECTIVES

Endoscopy and imaging are necessary to diagnose glottis carcinoma. Today, CT scan is the gold standard but MR imaging should be more sensitive for neoplastic invasion detection. The purpose of this study was to determine which exam to perform (CT scan or MRI) for neoplastic invasion.

MATERIAL AND METHODS

This prospective study span a 18 months period. Seven patients with glottis carcinoma (TI-T2) underwent CT and MR imaging before surgery. Findings at imaging and pathologic examination were compared.

RESULTS

Both CT and MR imaging were interesting, more specific (90%) than sensitive (74%). The anterior commissure, ventricles, subglottis, thyroid and arytenoid cartilages are the more difficult area analyzing.

CONCLUSION

CT imaging stays the gold standard. MR imaging is more effective on second intention to refine the data. Indications are being improved, with complete cure and more preserved laryngealfunctions.

Asthma, airway inflammation and epithelial damage in swimmers and cold-air athletes

Endurance athletes show an increased prevalence of airway hyperresponsiveness. The aim of the present study was to evaluate the long-term effects of training on airway responsiveness, inflammation and epithelial damage in swimmers and cold-air athletes. In total, 64 elite athletes (32 swimmers and 32 cold-air athletes), 32 mild asthmatic subjects and 32 healthy controls underwent allergy skin prick testing, methacholine challenge and induced sputum analysis. Overall, 69% of swimmers and 28% of cold-air athletes had airway hyperresponsiveness. Sputum neutrophil count correlated with the number of training hours per week in both swimmers and cold-air athletes. Eosinophil counts were higher in swimmers than in healthy subjects, although they were lower than in asthmatic subjects, and correlated with airway hyperresponsiveness in swimmers only. The eosinophil count in cold-air athletes was similar to that in healthy subjects. Bronchial epithelial cell count was not correlated with airway hyperresponsiveness but was significantly increased in swimmers, compared with healthy and asthmatic controls. In conclusion, the present authors observed significant airway inflammation only in competitive athletes with airway hyperresponsiveness. However, the majority of elite athletes showed evidence of bronchial epithelial damage that could possibly contribute to the development of airway hyperresponsiveness.

Silent sinus syndrome with spontaneous orbital floor reconstruction

PROBLEM

Silent sinus syndrome is rare and its pathophysiology is unclear. We report a case of silent sinus syndrome characterized by progressive enophtalmos with chronic maxillary atelectasis and asymptomatic chronic maxillary sinusitis.

METHODOLOGY

The patient had no history of sinusitis, facial trauma, or sinus surgery. Computed tomography revealed opacification of the right maxillary sinus and inferior bowing of the osteopenic orbital floor. Silent sinus syndrome was diagnosed and functional endoscopic maxillary antrostomy without orbital floor reconstruction was performed.

RESULTS

At one-year follow-up, computed tomography showed optimal ventilation of the maxillary sinus, restoration of the orbital floor, and withdrawal of the orbital content to its normal position.

CONCLUSION

Endoscopic maxillary antrostomy without orbital floor reconstruction is effective and associated with limited risks for complications; however, the results are observed in the long term.

Responses of the marine bacterium Pseudomonas fluorescens to an excess of heavy metals: physiological and biochemical aspects

A Pseudomonas fluorescens strain was isolated from oxic marine sediments obtained from the strand zone of the St Anne Bay (a moderately metal-contaminated site to the west of Cherbourg harbour). The strain, which exhibited a high tolerance to metal contamination when cultivated (minimal inhibitory concentration=950 microM [62 mg L(-1)] for Zn, 660 microM [42 mg L(-1)] for Cu, and 505 microM [57 mg L(-1)] for Cd), was further characterized by its physiological and biochemical responses to metal additions to the culture medium. Bacterial growth was significantly disturbed by 380 microM Zn (25 mg L(-1)), 315 microM Cu (20 mg L(-1)) and 90 microM Cd (10 mg L(-1)). The Zn-containing alkaline phosphatase was studied as an intoxication biomarker. Its activity was stimulated (+9%) by an excess of Zn, but inhibited by Cd (-55%) and Cu (-10%), these two elements could displace the native Zn or/and disturb the enzyme 3D-structure. Bacterial O(2) consumption was recorded as a global physiological response to metal stress. This parameter dropped with increasing Cd and Cu contamination (-49% and -45%, respectively, at 20 mg L(-1)). By contrast, Zn increased O2 consumption (approximately +40% for the different tested concentrations). The proteomes of bacteria grown in the presence or absence of 20 mg metal L(-1) were characterized by 2D-gel electrophoresis. The number of spots exhibiting a difference in intensity between the contaminated sample and the control was 65, 68, and 103, for Zn, Cu and Cd, respectively. Among them, 45, 61 and 82 spots respectively appeared de novo or increased in intensity, indicative of metal-stimulated synthesis, particularly for Cu and Cd. In summary, whereas Cd and Cu treatments both stressed cells and slowed down primary metabolism to differing extents, Zn has a stimulating action on several physiological and biochemical parameters.

ACE inhibition and endothelial function: main findings of PERFECT, a sub-study of the EUROPA trial

Background

ACE inhibition results in secondary prevention of coronary artery disease (CAD) through different mechanisms including improvement of endothelial dysfunction. The Perindopril-Function of the Endothelium in Coronary artery disease Trial (PERFECT) evaluated whether long-term administration of perindopril improves endothelial dysfunction.

Methods

PERFECT is a 3-year double blind randomised placebo controlled trial to determine the effect of perindopril 8 mg once daily on brachial artery endothelial function in patients with stable CAD without clinical heart failure. Endothelial function in response to ischaemia was assessed using ultrasound. Primary endpoint was difference in flow-mediated vasodilatation (FMD) assessed at 36 months.

Results

In 20 centers, 333 patients randomly received perindopril or matching placebo. Ischemia-induced FMD was 2.7% (SD 2.6). In the perindopril group FMD went from 2.6% at baseline to 3.3% at 36 months and in the placebo group from 2.8 to 3.0%. Change in FMD after 36 month treatment was 0.55% (95% confidence interval −0.36, 1.47; p = 0.23) higher in perindopril than in placebo group. The rate of change in FMD per 6 months was 0.14% (SE 0.05, p = 0.02) in perindopril and 0.02% (SE 0.05, p = 0.74) in placebo group (0.12% difference in rate of change p = 0.07).

Conclusion

Perindopril resulted in a modest, albeit not statistically significant, improvement in FMD.

[Laryngeal schwannomas]

Laryngeal schwannoma is a rare benign tumour of the larynx. Schwannomas derive from the Schwann cells. The majority occurs in supraglottic area and may arise at any age. Magnetic resonance imaging (MRI) is the best imaging tool for suggesting the diagnosis in the appropriate clinical context. Conservative surgery is the treatment of choice. These tumors have to be distinguished from neurofibromas. We report 2 cases of laryngeal schwannoma. The first one concerned an 8-month-old baby with a laryngeal stridor history which seemed to be related to laryngomalacia. The second case was a 22-year-old man with a 5-year history of dysphonia. On nasofibroscopic examination, a sub mucosal mass enlarged the posterior part of the right false vocal cord in both cases. Both CT scan and MRI sequences showed a well margined lesion in the same place. Histological biopsies identified a schwannoma. External surgeries were subsequently and successfully performed. Diagnosis (imaging), specific treatment (endoscopic or external surgery), and possible association of laryngeal schwannomas are discussed.

Comparison of liquid chromatography and capillary electrophoresis methods for quantification of sodium residuals

Liquid chromatography (LC) and capillary electrophoresis (CE) methods were developed to perform the determination of residual sodium in mother liquors and successive washes of an active pharmaceutical ingredient (API). The addition of sodium chloride to the product solution results in rapid and complete crystallization of the API. The LC method was coupled to evaporative light scattering detection (ELSD) while the CE approach was based on indirect UV detection. Both methods were fully validated. Selectivity, response function, trueness, precision, accuracy, linearity and limits of detection (LOD) and quantification (LOQ) were the criteria investigated. The LC-ELSD method was found to be more sensitive than the CE/indirect UV approach. The methods were found to be valid over concentration ranges of 62-500 and 235-1500 ppm for the LC and the CE methods, respectively. Both methods were compared and used for the determination of actual samples coming from different batches of the same API chemical synthesis.

Adverse prognosis associated with the metabolic syndrome in established coronary artery disease: data from the EUROPA trial

OBJECTIVE

To assess the prevalence of metabolic syndrome, and its effect on cardiovascular morbidity and mortality in patients with established coronary disease and to explore the inter-relationships between metabolic syndrome, diabetes, obesity and cardiovascular risk.

METHODS

The presence of metabolic syndrome was determined in 8397 patients with stable coronary disease from the European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease, with mean follow-up of 4.2 years. Metabolic syndrome was defined using a modified version of the National Cholesterol Education Programme criteria.

RESULTS

Metabolic syndrome was present in 1964/8397 (23.4%) of the population and significantly predicted outcome; relative risk (RR) of cardiovascular mortality = 1.82 (95% CI 1.40 to 2.39); and fatal and non-fatal myocardial infarction RR = 1.50 (95% CI 1.24 to 1.80). The association with adverse outcomes remained significant after adjustment, RR of cardiovascular mortality after adjustment for conventional risks and diabetes = 1.39 (95% CI 1.03 to 1.86). In comparison with normal weight subjects without diabetes or metabolic syndrome, normal weight dysmetabolic subjects (with either diabetes or metabolic syndrome) were at substantially increased risk of cardiovascular death (RR = 4.05 (95% CI 2.38 to 6.89)). The relative risks of cardiovascular death for overweight and obese patients with dysmetabolic status were nominally lower (RR = 3.01 (95% CI 1.94 to 4.69) and RR = 2.35 (95% CI 1.50 to 3.68), respectively).

CONCLUSIONS

Metabolic syndrome is associated with adverse cardiovascular outcome, independently of its associations with diabetes and obesity. A metabolic profile should form part of the risk assessment in all patients with coronary disease, not just those who are obese.

Tethered polyelectrolytes under the action of an electrical field: a molecular-dynamics study

For a polyelectrolyte undergoing electrophoretic motion, it is predicted (D. Long, J.L. Viovy, A. Ajdari, Phys. Rev. Lett. 76, 3858 (1996); D. Long, A. Ajdari, Electrophoresis 17, 1161 (1996)) that the mechanical force necessary to stall the molecule is substantially smaller than the sum of electrical forces applied on all monomers. In fact, it should be proportional to its hydrodynamic friction coefficient and therefore to the size of its conformation. In our work we examine this prediction using coarse-grained molecular-dynamics simulations in which we explicitly include the polymer, the solvent, the counterions and salt. The electrophoretic mobility of polyelectrolytes is evaluated, the mechanical force necessary to keep the molecules tethered is measured and the resulting anisotropic polymer conformations are observed and quantified. Our results corroborate Long et al.'s prediction.

Low negative predictive value of dobutamine stress echocardiography before abdominal aortic surgery

BACKGROUND

According to previous studies, a negative dobutamine stress echocardiography (DSE) test before major vascular surgery indicates that postoperative myocardial necrosis is very unlikely. We believe that the use of new cardiac troponin assays which can detect small amounts of myocardial necrosis results in a lower DSE negative predictive value for myocardial necrosis.

METHODS

A total of 418 consecutive patients were screened using the ACC/AHA Guideline for Perioperative Cardiovascular Evaluation for Noncardiac Surgery before scheduled abdominal aortic surgery. Of these 143 met ACC/AHA criteria for non-invasive testing and underwent DSE. Patients with a negative DSE were deemed to be fit for surgery. A positive DSE led to a coronary angiogram. DSE was negative in 110 (77%) and positive in 33 (23%) patients. Myocardial necrosis was monitored up to the third postoperative day by daily cardiac troponin I (cTnI) measurement and a daily 12-lead ECG.

RESULTS

Coronary angiography showed artery stenosis in 27 (84%) of 32 patients with a positive DSE. The negative predictive value of DSE for cTnI elevation was 92.7% (95% CI 86.2-96.8%). This was significantly lower than the lowest value of negative predictive value for myocardial necrosis assessed in previous studies.

CONCLUSION

A negative DSE prescribed before scheduled aortic surgery according to ACC/AHA guidelines does not rule out postoperative myocardial necrosis.

Long-term achievement of the therapeutic objectives of lipid-lowering agents in primary prevention patients and cardiovascular outcomes: An observational study

AIMS

Lowering elevated cholesterol levels reduces cardiovascular (CV) morbidity and mortality. Nonetheless, most patients treated with lipid-lowering agents (LLA) do not reach recommended therapeutic objectives. In a setting of primary care in France, we investigated the association between LDL-cholesterol goal attainment and the occurrence of CV events in primary prevention patients with multiple CV risk factors (> or = 3). According to national guidelines, the therapeutic objective (TO) for such patients is an LDL-cholesterol value below 130 mg/dL.

METHODS

579 patients treated with LLA and with LDL-cholesterol values documented at least once a year over a period of at least 3 years (2000-2002) were allocated to three groups based on the number of years the TO was attained during the follow-up period: in all 3 years (TO+++: n=145), only part of the time (TO intermediate: n=256), and never (TO---: n=178). CV events (angina pectoris, myocardial infarction, heart failure, stroke, peripheral artery disease) occurring during the last year of observation (2002) were retrospectively collected. The occurrence risk (OR) of CV events was assessed based on TO status, with a logistic regression model to adjust for baseline differences in CV risk factors.

RESULTS

Only a quarter of patients attained TO during all 3 study years. CV events during the third year of observation occurred in 5.5%, 10.5% and 12.9% of patients in the TO+++, TO intermediate and TO--- groups, respectively. Compared with TO+++ patients, the risk of CV events increased significantly in TO intermediate (OR=2.34, 95% CI=[1.01-5.39]) and TO--- patients (OR=2.99, 95% CI=[1.26-7.08]).

CONCLUSION

In real practice, a prolonged attainment of TO is rarely observed in high CV risk patients treated with LLA as primary prevention. Therapeutic failure is related to an increased incidence of cardiovascular morbidity. Our data strongly support the need to improve adherence to treatment guidelines to achieve effective cardiovascular prevention.

Ineffectiveness of lipid-lowering therapy in primary care

BACKGROUND

Evidence confirms the positive effects of lipid-lowering agents on the risk of cardiovascular disease. Local guidelines in France (AFSSAPS) have defined therapeutic objectives for LDL-cholesterol. These objectives vary with the number of cardiovascular risk factors in addition to dyslipidaemia. We determined the proportions of patients at therapeutic objective in different classes of cardiovascular risk to test the hypothesis that compliance with guidelines varies across the levels of risk. Comparison with international guidelines (ANDEM) was also performed.

METHODS

A group of 3173 dyslipidaemic patients treated with lipid-lowering agents and managed by general practitioners was randomly selected from BKL-Thales panel, a French computerized database. For each patient, history of coronary heart disease and the number of cardiovascular risk factors were documented. Compliance with guidelines was assessed from achievement of therapeutic objective.

RESULTS

The study population included 79% primary prevention patients (1.6, 25.5, 31.7 and 20.1%, with 1, 2, 3, and >3 risk factors, respectively) and 21.0% secondary prevention patients. Applying AFSSAPS guidelines, the proportions of primary prevention patients not at LDL-cholesterol objectives varied across risk categories (P < 0.0001), from 3.9% for patients with one risk factor to 46.5% for patients with >3 risk factors, and therapeutic failure reached 39.9% in secondary prevention. Only 26% of patients who were at high cardiovascular risk (>3 risk factors or prior coronary heart disease) and not at therapeutic objective received high doses (>standard recommended doses) of lipid-lowering agents in monotherapy. Applying ANDEM guidelines, 74% of secondary prevention patients were not at treatment goal.

CONCLUSION

Compliance with guidelines varied inversely with the level of cardiovascular risk. Besides, most patients not at therapeutic objective were not up-titrated. The use of lipid-lowering agents is inadequate, depriving many patients of an effective protection against cardiovascular diseases.