Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch

OBJECTIVE

The clinical behavior of penetrating atherosclerotic ulcers of the aorta is controversial. We reviewed our experience with this entity over a 25-year interval.

METHODS

Cases were identified using the Department of Radiology database searching for the diagnoses of aortic dissection, intramural hematoma, or penetrating ulcer between 1977 and 2002. Available imaging studies were reviewed by a vascular radiologist to confirm the diagnosis of penetrating ulcer and perform serial measurements.

RESULTS

One hundred five patients with penetrating atherosclerotic ulcers of the descending thoracic aorta or arch with (n = 85) or without (n = 20) associated intramural hematoma were confirmed. Two patients with ulcers in the ascending aorta were excluded. There were 73 men and 32 women with a mean age of 72 +/- 9 years. Comorbidities included hypertension in 97 (92%), tobacco use in 81 (77%), and coronary artery disease in 48 (46%). Of nonoperated patients with follow-up studies, the mean thickness of the intramural hematoma decreased at 1 month in 89% and completely resolved at 1 year in 85%. There were 3 deaths (4%) within 30 days among 76 patients treated medically and 6 deaths (21%) among 29 patients treated surgically (P <.05). Failure of medical therapy defined as surgery or death was predicted by rupture at presentation (odds ratio = 20.6) and era of treatment (before 1990, odds ratio 9.9) but not aortic diameter, ulcer size, or extent of hematoma.

CONCLUSION

Although careful follow-up is necessary, many penetrating atherosclerotic ulcers of the thoracic aorta can be managed nonoperatively in the acute setting.

Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up study

OBJECTIVE

Asymptomatic peripheral arterial occlusive disease (PAOD) is a common atherosclerotic disorder among the elderly population. Scarce data are available on the risk of nonfatal and fatal cardiovascular diseases in these subjects. We investigated cardiovascular morbidity and mortality of asymptomatic PAOD subjects.

STUDY DESIGN AND SETTING

A sample of 3649 subjects (40-78 years of age) was selected in collaboration with 18 general practice centers and followed up after the initial screening (mean follow-up time 7.2 years). Asymptomatic PAOD was determined by means of the ankle-brachial pressure index (ABPI). Main outcome measures were nonfatal cardiovascular events and mortality.

RESULTS

Cox proportional hazard models showed that asymptomatic PAOD was significantly associated with cardiovascular morbidity (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.3-2.1), total mortality (HR 1.4, 95% CI 1.1-1.8), and cardiovascular mortality (HR 1.5, 95% CI 1.1-2.1).

CONCLUSION

Asymptomatic PAOD is a significant predictor of cardiovascular morbidity and mortality. In high-risk subjects, measurement of the ABPI provides valuable information on future cardiovascular events.

Patients undergoing infrainguinal bypass to treat atherosclerotic vascular disease are underprescribed cardioprotective medications: effect on graft patency, limb salvage, and mortality

INTRODUCTION

Established American Heart Association guidelines recommend the use of statin drugs, angiotensin converting enzyme (ACE) inhibitors, and antiplatelet agents in patients with systemic atherosclerosis, such as those undergoing operative intervention to treat peripheral atherosclerotic disease. Many of these patients have not received treatment of coronary heart disease and have not been prescribed these medications. Whether statin drugs and ACE inhibitors confer an improvement in graft patency, limb salvage, and operative mortality is unknown.

METHODS

Consecutive patients who underwent infrainguinal bypass between 1997 and 2002 were evaluated for demographic data, comorbid disease, medication use, as well as cumulative graft patency, limb salvage, and mortality. Univariate, multivariate logistical regression, and Kaplan-Meier analyses were performed. P <.05 was considered significant.

RESULTS

Two hundred ninety-three patients (mean age, 64 years; 67% men) underwent 338 infrainguinal bypass procedures with autologous vein (n = 218), prosthetic grafts (n = 88), or composite prosthetic-vein grafts (n = 32). Limb salvage was the operative indication in 75% of procedures. Coexisting diseases included hypertension (70%), diabetes (52%), hyperlipidemia (37%), coronary heart disease (51%), congestive heart failure (14%), and active tobacco use (30%). Statin drugs were taken by 56% of patients, ACE inhibitors by 54% of patients, and antiplatelet agents or warfarin sodium (Coumadin) by 93% of patients. Postoperative graft surveillance was done in 39% of patients. Cumulative graft patency was 73%, limb salvage was 85%, and mortality was 9%, with a mean follow-up of 17 months. Factors independently associated with increased graft patency included statin drug use (odds ratio [OR], 3.7; 95% confidence interval [CI], 2.1-6.4), male sex (OR, 2.8; 95% CI, 1.6-5.0), and graft surveillance (OR, 2.4; 95% CI, 1.3-4.5). Factors associated with decreased amputation rate were statin drug use (OR, 0.34; 95% CI, 6.15-0.77) and graft surveillance (OR, 0.23; 95% CI, 6.1-0.63). Factors associated with decreased mortality included graft surveillance (OR, 0.18; 95% CI, 0.1-0.56), whereas congestive heart failure (OR, 6.5; 95% CI, 2.5-17) and hemodialysis-dependent renal failure (OR, 29; 95% CI, 6.1-140) were associated with increased mortality. Kaplan-Meier analysis showed that only ACE inhibitors were associated with lower mortality (P =.05)

CONCLUSIONS

Patients undergoing infrainguinal bypass are undertreated with respect to cardioprotective medications. ACE inhibitor use is associated with lower mortality, and statin drug use is associated with improved graft patency and limb salvage. Institution of consensus guidelines concerning these medications should be considered by all vascular specialists, including vascular surgeons.

[Non-lipid effects of statins: myth or fact?]

Hydroxy-methylglutaryl coenzyme A reductase-inhibitors (HMG-CoA [statins]) are currently the most effective method to pharmacologically decrease total plasma cholesterol levels. A number of multicenter studies have demonstrated, that statins administered for several years lead to a significant reduction of cardiovascular events and mortality compared with placebo. Apart from the well known LDL- and cholesterol lowering effect, statins have been postulated to exert beneficial effects on mortality due to so called 'non-lipid effects'. There is circumstantial evidence from a number of experimental studies that statins can improve endothelial function, exert anti-inflammatory and anti-oxidative effects, stabilize arteriosclerotic plaque and inhibit proliferation and activation of smooth muscle cells. However, the clinical implications of these beneficial 'non-lipid effects' are unclear, but appear to exert only a minor role in comparison to the lowering effect of statins on total plasma cholesterol levels.

[The long-term prediction of atherosclerosis of the aortofemoral segment in patients who were not provided reconstructive operation]

The present work deals with the 10-year follow up of 225 patients presenting with Leriche's syndrome. The patients suffered from not less than stage IIb chronic arterial insufficiency of the lower limbs and did not undergo reconstruction. The study was made of the factors influencing disease prediction. The 5- and 10-year survival of patients without critical lower limb ischemia (CLLI) accounted for 55.0+/-7.9% and 20.5+/-8.4%. In patients with CLLI, it constituted 41.5+/-7.2% and 18.7+/-7.5%. After primary amputation only 5% of patients had survived toward the 5th follow up year. The presence of coronary artery disease worsened prediction. In patients without CLLI, the limb could be saved toward the 5th follow up year in 81.7+/-6.9% of cases, toward the 10th year in 78.3+/-6.9% of cases: in patients with CLLI, in 59.8+/-6.9% and 56.8+/-6.9% of cases respectively. The given indicator is significantly lower in patients with occlusion of the femoropopliteal segment. Adequate conservative therapy was carried out only in 30.5% of patients.

Fibrinogen predicts mortality in high risk patients with peripheral artery disease

OBJECTIVE

Fibrinogen plays a key role in the pathogenesis of atherosclerosis and complications of atherothrombotic disease. We investigated the prognostic impact of fibrinogen levels on mortality of high risk patients with peripheral artery disease (PAD).

METHODS

We studied 486 patients with PAD and several cardiovascular comorbidities. Atherosclerotic risk factors and fibrinogen levels were determined at initial presentation and patients were followed for median 7 years (IQR 6-10) for all-cause and cardiovascular mortality. Multivariate Cox regression analysis was applied to assess the predictive value of fibrinogen levels (in quartiles) on patients' outcome.

RESULTS

Cumulative survival rates at 1, 3, 5 and 10 years were 96, 91, 83 and 67%, respectively. Overall, 138 patients (28%) died, 70% of these patients died of cardiovascular complications (n=96). Patients with fibrinogen levels 10.2-12.2 micromol/l (third quartile) and patients with fibrinogen levels above 12.2 micromol/l (fourth quartile) had a significantly increased adjusted risk for all-cause mortality (hazard ratios [HR] 1.87 and 1.90, p=0.025 and p=0.020, respectively) compared to patients in the lowest quartile (fibrinogen below 8.6 micromol/l). A consistent effect was observed for cardiovascular causes of death. Diabetes mellitus and critical limb ischemia were the only other independent predictor variables (HR 2.08, p<0.001 and 1.88, p=0.001, respectively).

CONCLUSION

Elevated fibrinogen levels in high risk patients with PAD indicate an increased risk for poor outcome, particularly for fatal cardiovascular complications.

Cholesterol crystal embolization: an atherosclerotic disease with frequent and varied cutaneous manifestations

In this paper the basic pathogenesis of cholesterol crystal embolization (CCE) is described, its clinical characteristics are presented and diagnosis and therapy are discussed. The main focus will be on the cutaneous manifestations; however, considering that CCE is a systemic illness, findings in other organs will also be highlighted, particularly the commonly involved renal and gastrointestinal systems.

Associations of whole-grain, refined-grain, and fruit and vegetable consumption with risks of all-cause mortality and incident coronary artery disease and ischemic stroke: the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Recent epidemiologic study results showed that subjects who had high intakes of whole-grain foods had lower risks of death and heart disease than did subjects who had low intakes. However, the findings were inconsistent for fruit and vegetable intake.

OBJECTIVE

The relations of whole-grain, refined-grain, and fruit and vegetable intakes with the risk of total mortality and the incidence of coronary artery disease (CAD) and ischemic stroke were studied in the Atherosclerosis Risk in Communities (ARIC) cohort (baseline: age 45-64 y, n = 15,792).

DESIGN

Proportional hazards regression analyses were used to assess the relations of whole-grain, refined-grain, and fruit and vegetable intakes with the risk of death and the incidence of CAD and ischemic stroke, with adjustment for age, sex, ethnicity, energy intake, and cardiovascular disease risk factors. Dietary intakes were assessed by using a food-frequency questionnaire.

RESULTS

Over an 11-y follow-up period, whole-grain intake was inversely associated with total mortality and incident CAD. The relative hazards of death for quintiles 2-5 of fruit and vegetable intake were 1.08 (95% CI: 0.88, 1.33), 0.94 (0.75, 1.17), 0.87 (0.68, 1.10), and 0.78 (0.61, 1.01), respectively; P for trend = 0.02. An inverse association between fruit and vegetable intake and CAD was observed among African Americans but not among whites (P for interaction = 0.01). The risk of ischemic stroke was not significantly related to whole-grain, refined-grain, or fruit and vegetable consumption.

CONCLUSION

These observational findings suggest a beneficial effect of whole-grain and fruit and vegetable consumption on the risks of total mortality and incident CAD but not on the risk of ischemic stroke.

Induction of fatal inflammation in LDL receptor and ApoA-I double-knockout mice fed dietary fat and cholesterol

Atherogenic response to dietary fat and cholesterol challenge was evaluated in mice lacking both the LDL receptor (LDLr(-/-)) and apoA-I (apoA-I(-/-)) gene, LDLr(-/-)/apoA-I(-/-) or double-knockout mice. Gender- and age-matched LDLr(-/-)/apoA-I(-/-) mice were fed a diet consisting of 0.1% cholesterol and 10% palm oil for 16 weeks and compared to LDLr(-/-) mice or single-knockout mice. The LDLr(-/-) mice showed a 6- to 7-fold increase in total plasma cholesterol (TPC) compared to their chow-fed mice counterparts, while LDLr(-/-)/apoA-I(-/-) mice showed only a 2- to 3-fold increase in TPC compared to their chow-fed controls. This differential response to the atherogenic diet was unanticipated, since chow-fed LDLr(-/-) and LDLr(-/-)/apoA-I(-/-) mice began the study with similar LDL levels and differed primarily in their HDL concentration. The 6-fold diet-induced increase in TPC observed in the LDLr(-/-) mice occurred mainly in VLDL/LDL and not in HDL. Mid-study plasma samples taken after 8 weeks of diet feeding showed that LDLr(-/-) mice had TPC concentrations approximately 60% of their 16-week level, while the LDLr(-/-)/apoA-I(-/-) mice had reached 100% of their 16-week TPC concentration after only 8 weeks of diet. Male LDLr(-/-) mice showed similar aortic cholesterol levels to male LDLr(-/-)/apoA-I(-/-) mice despite a 4-fold higher VLDL/LDL concentration in the LDLr(-/-) mice. A direct comparison of the severity of aortic atherosclerosis between female LDLr(-/-) and LDLr(-/-)/apoA-I(-/-) mice was compromised due to the loss of female LDLr(-/-)/apoA-I(-/-) mice between 10 and 14 weeks into the study. Diet-fed female and, with time, male LDLr(-/-)/apoA-I(-/-) mice suffered from severe ulcerated cutaneous xanthomatosis. This condition, combined with a complete depletion of adrenal cholesterol, manifested in fatal wasting of the affected mice. In conclusion, LDLr(-/-) and LDLr(-/-)/apoA-I(-/-) mice showed dramatic TPC differences in response to dietary fat and cholesterol challenge, while despite these differences both genotypes accumulated similar levels of aortic cholesterol.

Inflammation, malnutrition and atherosclerosis in end-stage renal disease: a global perspective

End-stage renal disease (ESRD) is characterized by an exceptional cardiovascular mortality rate. Although traditional risk factors are common in ESRD patients, they alone may not be sufficient to account for the high prevalence of cardiovascular disease (CVD). Recent evidence demonstrated that chronic inflammation, a non-traditional risk factor which is commonly observed in ESRD patients, may cause malnutrition and progressive atherosclerotic CVD by several pathogenetic mechanisms. Although both malnutrition and inflammation have been shown to be strong predictors of cardiovascular mortality in ESRD patients, it must be remembered that the majority of studies describing the presence of inflammation and malnutrition have been performed in Western and Asian industrialized countries. As it is evident that the prevalence of malnutrition and inflammation may differ markedly between different regions of the world and developing countries face a much higher prevalence of chronic infectious diseases, comparative inter-regional studies focusing on the etiology and prevalence of the malnutrition, inflammation and atherosclerosis syndrome are warranted.

Endovascular repair of abdominal aortic aneurysm in the multifocal atherosclerotic patient

One of the major problems of treating aortic aneurysms has been the multifocal nature of atherosclerotic disease. Co-existing cardiovascular disease in the majority of patients together with chronic obstructive airways disease, renal impairment and hostile abdomen in some, has resulted in 1/3 of patients presenting with aortic aneurysms being regarded as high risk and unfit for open repair. Endovascular repair of aortic aneurysm therefore has much to recommend it since it avoids the need for laparatomy, cross clamping of the aorta and the obligatory blood loss associated with opening of the sac. Between May 1992 and March 2003 we have used the endovascular method to repair abdominal aortic aneurysms (AAA) in 583 patients. Successful repair was achieved in 563 patients (96%). The remaining 20 patients required primary conversion to open repair at the original operation. The 30-day perioperative mortality rate was 13 of 583 (2.2%). In this paper we summarise a number of studies that we have undertaken, comparing endovascular with alternative treatment methods and comparing various types of endovascular prostheses. In addition we report the long-term outcome of endovascular AAA repair as it relates to morphological changes in the proximal neck out to 9 years from operation. We conclude that despite the continuing small incidence of device failure, endovascular is the preferred method of AAA repair in the multifocal atherosclerotic patient. This view is based on the low perioperative mortality, superior survival compared with open repair and our experience of long-term stability in the proximal neck in the majority of patients.

Endovascular treatment of thoracic aortic aneurysms

Descending thoracic aortic aneurysms (TAA) and chronic dissections have high morbidity and mortality rates. For 10 years, the evolution of both imaging techniques and aortic stent-graft design has brought a new therapeutic hope for patients at high risk for surgery presenting non-ruptured or emergency cases of TAA. Our goal is to describe the endovascular technique, review its state of the art and compare its mid-term results to those of conventional surgery. We also describe surgical ways to manage complex TAA, involving the aortic arch and/or the celiac aorta, as therapeutic solutions for high risk patients for surgery with unfitted anatomy for endovascular repair. After a review of the literature dealing with the natural history, the etiology, and the surgical treatment, we describe the endovascular devices, the conventional stent-grafting technique and we detail the adjunctive procedures we used to manage complex cases. We then retrospectively report our personal 38-patient experience from October 1999 to February 2003. Thirty-three patients presented with TAA and the average age was 70 years old (35-88), while the male/female ratio was 5.3. All of them were at high risk for surgery, of which 27% required adjunctive procedures to achieve proximal and/or distal neck management. The in-hospital death rate was 9%. We reported no case of paraplegia and only 1 patient with post-operative regressive stroke (3%). All the aneurysmal sacs were successfully excluded without early endoleak. During follow-up period (mean: 2 years; 1-40 months), we observed a late death rate of 10%. All aneurysmal sac remained excluded by the endografts and no stent-graft migration was observed. No late endoleak appeared during the follow-up course, but 1 patient presented a proximal aortic enlargement, which required total transposition of the supra-aortic vessels and stent-graft extension. The endovascular repair of TAA and chronic dissections proved to be feasible and offers hopeful mid-term

RESULTS

With a very low morbidity-mortality rate, compared to surgery, the endovascular technique may represent an unquestionable therapeutic options, especially for patients at high risk for surgery. However, long-term results are needed to point out the durability of descending thoracic aortic stent-grafting. Neck management must be encouraged in order to avoid type 1 endoleaks in cases with short landing zones.

Survival after stenting of severe atherosclerotic ostial renal artery stenoses

PURPOSE

To examine long-term survival after angioplasty and stenting of atherosclerotic renal artery stenosis (RAS).

METHODS

Over a 5-year period, 241 consecutive patients (153 men; mean age 67+/-9 years, range 44-84) were treated with angioplasty and stent implantation for 355 ostial renal stenoses >70%. The procedures were performed in standard fashion using a variety of stents. For survival analysis, the patients were divided into 3 groups based on baseline creatinine levels: group 1: 115 (48%) patients with normal renal function (creatinine <1.2 mg/dL); group 2: 93 (39%) patients with moderately impaired renal function (creatinine 1.2 to 2.5 mg/dL); and group 3: 33 (13%) patients with severely impaired renal function (creatinine >2.5 mg/dL).

RESULTS

All patients were treated successfully without any procedure-related mortality. The 30-day mortality was 0.4% (1/241). Twenty-two patients died during a follow-up of 27+/-15 months (range 1-60) (overall survival 91%). The causes of death were cardiac (congestive heart failure or myocardial infarction, 73%), stroke (13.5%), and malignant disease (13.5%). The survival rate was significantly lower (29.6%) in patients with a baseline serum creatinine >2.5 mg/dL (p<0.0001) than in groups 2 (89.1%) or 1 (95.4%). Long-term survival without hemodialysis or restenosis was 66.6% at 48 months. Independent predictors for a reduced survival were left ventricle function (HR 2.59, 95% CI 1.45 to 4.63, p=0.001 for each 15% incremental decrease), age (HR 1.13, 95% CI 1.03 to 1.25, p=0.011), and baseline renal function (HR 1.58, 95% CI 1.10 to 2.29, p=0.014).

CONCLUSIONS

Survival after successful stenting for severe ostial RAS depends on baseline serum creatinine and left ventricle function. Efforts must be made to avoid the development of advanced ischemic nephropathy and congestive heart failure.

Clinical and angiographic efficacy of a self-expanding nitinol stent in saphenous vein graft atherosclerotic disease: the Stent Comparative Restenosis (SCORES) Saphenous Vein Graft Registry

BACKGROUND

The Stent Comparative Restenosis (SCORES) Saphenous Vein Graft (SVG) Registry was a multicenter, prospective registry designed to evaluate the safety and efficacy of a self-expanding, nickel-titanium (nitinol) stent for de novo SVG lesions.

METHODS

In all, 159 patients with de novo vein graft lesions > or =2.75 and < or =4.25 mm in diameter and <30 mm in length underwent stenting with the Radius self-expanding stent. The primary end point was target vessel failure (TVF) at 9 months, which was defined as a composite of procedural failure, death, myocardial infarction, or target vessel revascularization.

RESULTS

Procedural success was achieved in 96.8% of patients, and the 30-day incidence of major adverse cardiac events was 2.5%. The binary rate of restenosis at 6 months was 28.6%. By 9 months, the rate of TVF was 24.5%, and the rate of major adverse cardiac events was 23.1%. The 9-month Kaplan-Meier survival rates for freedom from TVF and target lesion revascularization were 76.0% and 87.9%, respectively. No clinical or angiographic characteristic was predictive of restenosis.

CONCLUSIONS

In de novo atherosclerotic SVG disease, the use of a self-expanding, nitinol stent was associated with high initial procedural success and favorable early and intermediate outcomes. Because few studies have examined the influence of stent composition and design in SVG disease, these findings not only show the safety and efficacy of this self-expanding stent in de novo SVG disease, but also merit further comparison with balloon-expandable stents.

Morphology of the heart and arteries in renal failure

In patients with renal failure, cardiovascular complications are a major clinical problem; cardiac death is the main cause of death in these patients. Cardiac risk is increased by a factor of 20 in uremic patients, compared with matched segments of the general population. It has been known for a long time that atherosclerosis, particularly plaque in the epicardiac coronary conduit arteries, are more frequent in patients with chronic renal failure. Recently, however, clinical studies showed that myocardial infarction is responsible for only 30% to 50% of all cardiac deaths. In contrast, 30% to 40% of patients with renal failure and ischemic heart disease show patent coronary arteries on coronary angiogram. Thus, it is very likely that in uremic patients myocardial ischemia tolerance is markedly reduced even in the absence of classical atherosclerosis (i.e., relevant stenosis of coronary arteries). This finding in uremic patients can be at least partially explained by structural and metabolic abnormalities of the myocardium, and in part by alterations of the extracardiac vasculature. The present paper focuses on structural changes of the heart and the vasculature, in particular on atherosclerosis of cardiac and extracardiac arteries, and its potential repercussions for cardiovascular function. In 1827 Richard Bright already pointed to the common presence of left ventricular hypertrophy (LVH) and thickening of the aorta in patients with end-stage renal failure (ESRF). At present, cardiovascular complications account for 45% of all deaths in uremic patients [1]. The recent report of Herzog, Ma, and Colins [2] documented a 59.3% 1-year mortality rate in dialyzed patients who survived myocardial infarction (i.e., mortality was significantly higher than in the general population). It is widely acknowledged that several specific structural and nonstructural alterations of the heart and the extracardiac vasculature are present in patients with renal failure, which presumably contribute to the markedly increased cardiovascular risk in these patients [3].

Chlamydia pneumoniae IgA seropositivity is associated with increased risk for atherosclerotic vascular disease, myocardial infarction and stroke in dialysis patients

BACKGROUND

Atherosclerotic cardiovascular disease is the major cause of morbidity and mortality in patients with chronic renal failure undergoing dialysis therapy. Aim of the study was to evaluate whether there is a correlation between a past infection with Chlamydia pneumoniae inducing antibody production and the manifestation of symptomatic atherosclerotic disease in patients with chronic renal failure on hemodialysis.

METHODS

A retrospective study was designed including 151 dialysis patients with a clinical apparent atherosclerotic disease (case subjects) and 116 dialysis patients without any symptomatic atherosclerotic manifestation (control group). An ELISA was used to measure seropositivity for IgA and IgG titers.

RESULTS

Elevated IgA titers against Chlamydia pneumoniae were found in 67% of the case subjects, but only in 29% of the controls (OR 5.34, CI 2.98-9.56). Forty-five patients of the case subjects had a history of myocardial infarction (OR 5.14, CI 2.38-11.09). Prior stroke was found in 30 patients in case subjects (OR 4.37, CI 1.73-11.01). The follow-up after 3 years showed that only 20 patients died from cardiovascular disease in the control group in comparison to 57 patients in the case group (OR 2.51). IgG seropositivity revealed an OR of 1.02 (CI 1.0-2.1).

CONCLUSION

These results indicate that IgA seropositivity is associated with an increased frequency of symptomatic atherosclerotic manifestations. Especially an increased number of patients was found with prior myocardial infarction or stroke when elevated IgA titers were detected. IgA positivity seems to be a separate prospective risk factor in patients with chronic renal failure and hemodialysis for premature cardiovascular death.

[Coronary heart disease in Mexico and the clinical epidemiological and preventive relevance]

Coronary heart disease is dominant among heart diseases in the population, a problem to control. Heart diseases have been first place in the general mortality for the last 20 years. The trend show an annual increase without control. Atherosclerosis is responsible for at least for one fourth of all deaths in the country. The combined data of mortality and morbidity, from hospital discharges or the whole country, disclose that one out of three die of acute myocardial infarction (AMI). While only 8% of all deaths registered were admitted to a hospital. Most, 92% were never admitted to any hospital for some reason. The estimated annual incidence of AMI cases is 140,000, on the basis of 3 cases surviving for each case death, accounted by the Death Certification System, which rounds 35,000. Standardized mortality rates of AMI in Mexico are greater than in USA o Canada creating a more concerned worry. The most probable explanation to that situation is lack of preventive care, which should also include the acute care and before reaching the hospital facilities. Running the same chances are hypertension crisis and strokes and diabetic complications. The appropriate care for critical situations might reduce significantly the cardiovascular mortality in the country, in a short and middle term. Prevention is not only for chronic conditions but for acute and critical situations. The programs of preventive care should also include cultural promotion and community awareness. The timely care is life and myocardium saving. The reinforcement of prior to hospital care reduces the delay for AMI adequate intervention. These activities agree quite well with the ongoing programs of CPR, organizing the surviving chain and the training programs for paramedical emergency technicians.

[Cardiovascular risk factors assessment in Rambam Center Preventive Medicine]

Atherosclerosis, expressing itself as cardiovascular disease, is the first cause of death in Israel, in people over 35 years of age. The main risk factors for atherosclerosis are generally known, and amendable, resulting in a decrease in morbidity and mortality rates. In our present article we investigate the prevalence of major atherosclerosis risk factors in the population being examined in the Rambam Center of Preventive Medicine. This is a young population, usually considered healthy. The prevalence of the major risk factors is high, and a large portion of the population is at high risk of developing cardiovascular disease. Identifying the people at high risk of developing cardiovascular disease and of instigating preventive measures is of utmost importance.

CD4 cell lymphopenia and atherosclerosis in renal transplant recipients

Several animal studies suggest that T cell-mediated immunodeficiency may play a role in the progression of atherosclerosis. This study examined the association between lymphocyte subsets and atherosclerotic events in renal transplant recipients. A total of 302 consecutive renal transplant recipients were enrolled in this prospective study. Peripheral blood lymphocyte subsets were quantified and analyzed with respect to other known cardiovascular risk factors. The patients were followed for a mean duration of 23.5 +/- 4.5 mo. Mean CD4, CD8, and CD19 cell levels were 511 +/- 290/mm(3), 553 +/- 596/mm(3), and 66 +/- 62/mm(3), respectively. CD4 levels were positively related to transplant duration (r = 0.32; P = 0.02) and inversely related to age (r = 0.35; P = 0.01). Twenty-five atherosclerotic events (AE) occurred in 25 patients (8.3%). CD4 levels were lower in patients who experienced CVE (288 +/- 170/mm(3) versus 531 +/- 290/mm(3); P < 0.0001). Cox regression analysis showed that patients in the three upper quartiles of CD4 cell count had a decreased risk of CVE compared with those in the lowest quartile. There was a linear increase in risk of CVE with decreasing CD4 cell count (P < 0.0001). A CD4 cell count in the highest quartile (>663/mm(3)) divided the risk of CVE by 10 as compared with the lowest quartile. In conclusion, CD4 lymphocytopenia is an independent risk factor for the development of cardiovascular complications in renal transplant recipients, suggesting that impaired immune response promotes accelerated atherogenesis in this population.