Hormone replacement therapy in the prevention and treatment of atherosclerosis

As the population ages, the increasing number of women at risk for cardiovascular disease represents both a potential crisis and an opportunity in healthcare management. Although the overall death rate from cardiovascular disease in the general population is decreasing, the absolute numbers for women are increasing. A reduction in modifiable risk factors in women must be aggressively pursued by clinicians and health systems. Menopause is associated with many adverse effects on cardiovascular-disease risk factors in women. Estrogen replacement therapy has been shown to favorably influence many risk factors for cardiovascular disease. Despite this biologic plausibility and supporting evidence from epidemiologic studies, data from confirmatory clinical trials are lacking. Because of this, recommendations for hormone replacement therapy should be made on an individual basis.

Use of a supermarket shelf-labeling program to educate a predominately minority community about foods that promote heart health

OBJECTIVE

The purpose of this study was to evaluate the awareness and use of a supermarket-shelf labeling program designed to encourage shoppers to make food choices that promote heart health.

DESIGN

A shelf-labeling program was implemented in 18 supermarkets serving minority communities in Detroit, Mich. Customers were given an exit survey to determine awareness and use of the program.

SUBJECTS/SETTING

Three hundred sixty-one subjects were sampled. Sixty-six percent of the sample was female, 67% African-American, and the sample population had a mean age of 51.6 years +/- 18.5 SD.

RESULTS

Overall awareness of the program was 28.8%. Awareness among minorities was significantly higher when compared with whites (35.3% vs 20.8%; P = .02). Gender, age, and education level were not predictive of program awareness but people screened for cardiovascular disease risk factors (elevated low-density lipoprotein or total cholesterol levels and/or elevated blood pressure) in the previous year had greater awareness than those not screened (32.6% vs 13.6%, P = .06). Use of the program was 56% among subjects aware of the program. This did not differ significantly by gender, age, or ethnicity.

STATISTICAL ANALYSIS

Awareness and use were evaluated with respect to ethnicity, gender, education, race, age, and previous screening history. For purposes of analysis, African-American, Hispanic, and Asian-American respondents were combined into one group called "all minorities." The other group of respondents was called "whites." Between-group differences in categorical variables were analyzed using a chi 2 statistic.

CONCLUSIONS

Awareness of the shelf-labeling program was modest, but highest among African-Americans. Subjects recently screened for cardiovascular disease risk had greater program awareness. This difference was not statistically significant. Use was relatively high among those aware of the program, suggesting that shelf labels have the potential to increase the selection of foods that promote heart health in predominately low-income, minority populations.

Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. American Heart Association Women's Heart Disease and Stroke Campaign Task Force

CONTEXT

One of 2 women in the United States dies of heart disease or stroke, yet women are underdiagnosed and undertreated for these diseases and their risk factors. Informed decisions to prevent heart disease and stroke depend on awareness of risk factors and knowledge of behaviors to prevent or detect these diseases.

OBJECTIVE

Assess (1) knowledge of risks of heart disease and stroke and (2) perceptions of heart disease and its prevention among women in the United States.

DESIGN AND SETTING

Telephone survey conducted in 1997 of US households, including an oversample of African American and Hispanic women.

PARTICIPANTS

One thousand respondents 25 years or older; 65.8% white, 13.0% African American, and 12.6% Hispanic.

MAIN OUTCOME MEASURES

Knowledge of heart disease and stroke risks, perceptions of heart disease, and knowledge of symptoms and preventive measures.

RESULTS

Only 8% of the respondents identified heart disease and stroke as their greatest health concerns; less than 33% identified heart disease as the leading cause of death. More women aged 25 to 44 years identified breast cancer as the leading cause of death than women 65 years or older. Women aged 25 to 44 years indicated they were not well informed about heart disease and stroke. Although 90% of the women reported that they would like to discuss heart disease or risk reduction with their physicians, more than 70% reported that they had not.

CONCLUSIONS

Most women do not perceive that heart disease is a substantial health concern and report that they are not well informed about their risk. Age influenced knowledge to a greater extent than ethnicity. Programs directed at young women that address the effects of lifestyle behaviors on long-term health are needed. Better communication between physicians and patients is also warranted.

Effectiveness of LASIK to correct refractive error after penetrating keratoplasty

OBJECTIVE

Refractive errors may invalidate the good results of penetrating keratoplasty (PK). The Authors evaluate the effectiveness of excimer laser in situ keratomileusis (LASIK) in the correction of refractive error after PK.

MATERIALS AND METHODS

Four patients, a 26-year-old woman, a 54-year-old man, a 19-year-old man, and a 51-year-old woman, showed refractive errors: -11 = -4.5 x 85 ; -8, -4.5 = -11 x 95 ; and -4.5 = -4 x = 1200, with a clear graft at least 20 months after penetrating keratoplasty secondary to keratoconus. However, they underwent the LASIK procedure with a nasal-hinged flap of 160 um. No sutures were placed.

RESULTS

At follow-up, 24, 18, 12, and 12 months, respectively, the graft remained clear and the endothelial cells were unchanged. The uncorrected visual acuities were 20/50, 20/25, 20/50, and 20/25, respectively with an unchanged best corrected visual acuity (20/20) for all patients. No significant complications were observed.

CONCLUSIONS

LASIK procedure seems to be an effective technique to correct refractive error after successful penetrating keratoplasty.

Enzymatic assay for the determination of olive oil polyphenol content: assay conditions and validation of the method

A new spectrophotometric assay for the determination of the polyphenolic content of olive oil is presented. It is a substrate-recycling assay for phenolic compounds that employs tyrosinase in the presence of excess NADH. The reaction of various phenols with the enzyme produces an o-quinone, which is detected by recycling between reactions with the enzyme and NADH. The method offers some advantages over the classical methods employed to determine the polyphenolic content of olive oil, that is, ease and reproducibility of the analysis, highly increased sensitivity, and selectivity toward phenolic compounds. The amount of total polyphenols was determined in virgin olive oils both with the Folin-Ciocalteu reagent and with the proposed enzymatic method. The results suggest a better estimation of the polyphenol content, as compared with the colorimetric method. This has to be attributed to the different reactivities of the two methods toward phenols and catechols. Finally, the enzymatic method demonstrates that there is a linear relationship between the olive oil phenolic content and the antioxidative capacity of oil extracts.

Patient preferences for cardiac rehabilitation and desired program elements

BACKGROUND

Data evaluating the efficacy of traditional cardiac rehabilitation programs to meet patient needs are limited. The authors studied patient-perceived preferences in cardiac rehabilitation programs and desired program elements to evaluate differences by gender or age.

METHODS

The authors surveyed 199 patients (136 men, 60.0 +/- 11.6 years; 63 women, 63.7 +/- 12.7 years; P = 0.045) discharged from a tertiary referral hospital with acute myocardial infarction. Participants completed a standardized questionnaire regarding enrollment in rehabilitation and preferences for six program types on a 10-point scale (1 = little or no agreement, 10 = strongly agree).

RESULTS

In this study, 54.3% of subjects enrolled in cardiac rehabilitation. Older patients (> or = 65 years) were more likely to enroll in home-based programs compared with younger patients (< 65 years) (11.8% versus 1.4%, P = 0.02). Younger patients preferred a short-term rehabilitation facility more than older patients (7.4 +/- 3.5 versus 5.1 +/- 4.1 units on the 10-point scale, P = 0.001), and rated the following more favorably than older patients: local health club programs (6.2 +/- 3.7 versus 4.5 +/- 4.0, P = 0.01), long-term programs (6.5 +/- 3.8 versus 4.9 +/- 4.2, P = 0.02), and comprehensive programs (6.6 +/- 3.7 versus 4.9 +/- 2.2, P = 0.02). Younger patients rated the following program elements more favorably compared with older patients: stress management (7.0 +/- 3.5 versus 5.7 +/- 4.1, P = 0.04), vocational counseling (5.1 +/- 3.9 versus 1.9 +/- 2.4, P = 0.001), and smoking cessation (4.9 +/- 4.4 versus 2.7 +/- 3.4, P = 0.001).

CONCLUSIONS

Program preferences differed significantly by age, but not gender. Older patients enrolled in home-based programs over clinic-based programs. Younger patients rated stress management, vocational counseling, and smoking cessation more favorably than older patients. Strategies to enhance patient participation in cardiac rehabilitation should incorporate patient age and preferences for program types and elements.

Fluorescence properties of melanins from opioid peptides

Recently our group synthesized a new class of melanins obtained by the tyrosinase-catalyzed oxidation of opioid peptides (opiomelanins). Owing to the presence of the peptide moiety such pigments exhibit high solubility in hydrophilic solvents, which allows spectroscopic investigations. In particular, the absence of solid-state quenching effects enables the study of melanin fluorescence properties, till now poorly investigated due to the complete insolubility of melanins produced from tyrosine or Dopa. Opiomelanins dissolved in aqueous medium show a characteristic emission peaked at 440 and 520 nm when excited around 330 nm, where a maximum is observed in the absorption spectrum. Kinetic measurements performed on the tyrosinase-catalyzed oxidation of opioid peptides show that the 440-nm fluorescence band arises in the early stages of peptide oxidation, whereas the 520-nm band appears in later stages of oxidation, i.e., during the polymerization of indole-quinone units. Moreover, molecular sieve fractionation shows that in the opiomelanin fraction with a molecular weight lower than 10 kDa the 440-nm band is dominant in the fluorescence spectrum. The breakdown of the polymer induced by hydrogen peroxide and light (i.e., the photobleaching of melanin pigments) produces a marked enhancement of the 440-nm fluorescence band while the 520-nm band disappears. Hence, our findings suggest that the observed fluorescence contains contributions from both oligomeric units (440-nm band) and high-molecular-weight polymers (520-nm band).

Family history of early cardiovascular disease in children with moderate to severe hypercholesterolemia: relationship to lipoprotein (a) and low-density lipoprotein cholesterol levels

Lipoprotein (a) (Lp(a)) is an established cardiovascular risk factor in adults. We sought to evaluate whether raised Lp(a) levels were predictive of a family history of early cardiovascular disease (CVD) in children already at increased risk for premature atherosclerosis because of elevated low-density lipoprotein (LDL) cholesterol levels. Lp(a) and serum lipid levels were measured in 69 children and offspring with established moderate to severe hypercholesterolemia (serum cholesterol > 170 mg/dL) who were aged 10.7 +/- 4.3 years (range 1.5 to 21 years) and had been referred to a pediatric lipid center. The children represented families with a positive (n = 27) or negative (n = 42) history for premature CVD (<55 years of age in parent or grandparent). In all children, Lp(a) levels ranged from 1 to 140 mg/dL, with a median of 29 mg/dL. Mean total cholesterol, LDL cholesterol, and high-density lipoprotein (HDL) cholesterol levels were 234 mg/dL, 166 mg/dL, and 45 mg/dL, respectively. There was no difference in median Lp(a) levels between the children with a positive family history and those with a negative family history (29.9 mg/dL vs 29.0 mg/dL, respectively). In contrast, children with a positive family history showed significantly higher LDL cholesterol levels (186 +/- 61 mg/dL vs 153 +/- 52 mg/dL, P = .02). Thus, in this group of hypercholesterolemic children, LDL cholesterol but not Lp(a) levels were associated with a family history of premature CVD. Further studies are needed to identify additional specific risk factors associated with the development of CVD in this population.

Lipoxygenase/H2O2-catalyzed oxidation of dihdroxyindoles: synthesis of melanin pigments and study of their antioxidant properties

5,6-Dihydroxyindole (DHI) and 5,6-dihydroxyindole-2-carboxylic acid (DHICA), which are important intermediates in melanogenesis, can be converted into the corresponding melanin pigments by the action of the lipoxygenase/H2O2 system. Kinetic and HPLC analyses indicate that both DHI and DHICA are good substrates for this enzymatic system. Enzyme activity on both substrates was measured in comparison with peroxidase and tyrosinase; the oxidizing behaviour of lipoxygenase is more similar to that of peroxidase rather than that of tyrosinase. The antioxidant properties of DHI- and DHICA-melanins have been investigated in comparison with other kinds of melanins. DHICA-melanin shows a more pronounced antioxidant effect than that of DHI-melanin and this behaviour can be ascribed to the different structure and solubility of the two pigments. The mixed polymer synthesized from DHI and DHICA is the most effective one. Some implications about the possible explanation of the above mentioned behaviour are discussed.

Treatment strategies for management of serum lipids: lessons learned from lipid metabolism, recent clinical trials, and experience with the HMG CoA reductase inhibitors

The Adult Treatment Panel (ATP) guidelines, published initially in 1988 and revised in 1993, are based on sentinel observations and early clinical trials in support of treating and preventing coronary artery disease by cholesterol lowering. With the conclusion of several large long-term trials using HMG CoA reductase inhibitors for primary and secondary coronary prevention, the ATP II recommendations, which remain remarkably accurate, can be supplemented with more evidence-based strategies. Increasing evidence suggests that thoughtful lipid management for coronary prevention should include a more complete assessment of lipoproteins with an emphasis on apolipoproteins, triglycerides, and very low-density (VLDL) remnant particles, LDL particle size, and lipoprotein(a). This review summarizes clinically relevant lipid metabolism with an emphasis on the concept of atherogenic plasma lipids, discusses the clinical benefits and specific uses of each of the lipid-lowering drug classes, and provides an analysis of recent cholesterol-lowering primary and secondary coronary prevention trials from which a new treatment strategy can be derived.

Hormone and nonhormone therapy for the maintenance of postmenopausal health: the need for randomized controlled trials of estrogen and raloxifene

Multiple health benefits have been postulated for the long-term use of hormone therapy in postmenopausal women, most notably for prevention of osteoporotic fractures and coronary heart disease, as well as several risks, including cancer of the breast and uterus and venous thromboembolism. Cardiovascular disease is the most common cause of death among postmenopausal women. If real, the reduction in risk of coronary heart disease by hormone use suggested by observational studies would likely outweigh the risks. The decision to initiate and maintain hormone therapy is complicated by uncertainties about estrogen's true benefits and risks. Raloxifene, a selective estrogen receptor modulator (SERM), appears to have many of the benefits of estrogen without the cancer risks. It is not known if SERMs can provide significant cardiovascular protection. This article reviews the relation of use of postmenopausal hormones and raloxifene to women's health and addresses the need for large randomized trials to quantify the effect of both postmenopausal estrogen and raloxifene on cardiovascular health.

Gender differences in barriers to lifestyle change for cardiovascular disease prevention

Achieving and maintaining a healthy lifestyle are important aspects of a cardiovascular disease prevention program. Few data have evaluated barriers to lifestyle change by gender. We studied self-reported barriers to lifestyle change and evaluated support systems to make positive changes in 293 patients (186 men, 107 women) enrolled in a multidisciplinary preventive cardiology clinic. Subjects were asked to rate barriers and support systems on a scale of 1 to 5, with 1 being very important and 5 not important. Women ranked self-esteem as the most important barrier and rated it significantly higher than did men (p = 0.0003). Women also rated money, knowledge, skills, and stress significantly higher than did men (p < 0.05). Physicians were rated as the most important source of support for both genders. Women, compared with men, rated dietitians, exercise physiologists, nurses, counselors, family members, and social/religious groups as more important sources of support. These data suggest that gender differences exist in barriers to lifestyle change. Psychosocial factors should be considered important elements of programs designed to help patients make positive lifestyle changes.

Greater dietary intake of simple carbohydrate is associated with lower concentrations of high-density-lipoprotein cholesterol in hypercholesterolemic children

Hypercholesterolemic children are increasingly being treated with lipid-lowering diets, but little research has focused on the effects of specific dietary substitutions on HDL cholesterol. We examined the relation between carbohydrate intake and HDL cholesterol in hypercholesterolemic children consuming fat-restricted diets. We obtained 3-d food records for 67 children (mean age: 5.8 +/- 2.5 y) referred for the treatment of hypercholesterolemia. Mean plasma HDL cholesterol was 1.12 +/- 0.21 mmol/L and total cholesterol was 5.99 +/- 1.39 mmol/L. Dietary intake comprised (percentage of total energy) 24.9 +/- 5.1% fat, 59.9 +/- 6.5% carbohydrate, and 16.5 +/- 3.4% protein. Carbohydrate intake included 30.7 +/- 7.4% from simple and 22.6 +/- 6.2% from complex carbohydrates. HDL cholesterol was positively correlated with intake of total fat (r = 0.44, P < 0.001) and saturated fatty acids (r = 0.43, P < 0.001) and inversely correlated with intake of total carbohydrate (r = -0.55, P < 0.001) and simple carbohydrate (r = -0.40, P < 0.001), but not with complex carbohydrate (r = -0.02). The significant inverse relation between simple carbohydrate intake and HDL cholesterol remained after intakes of saturated, monounsaturated, and polyunsaturated fatty acids; intake of complex carbohydrates; dietary cholesterol; plasma triacylglycerol; and age were adjusted for with multivariate techniques. In summary, higher dietary intake of simple carbohydrates was associated with lower HDL-cholesterol concentrations in hypercholesterolemic children consuming reduced-fat diets.

Preoperative smoking habits and postoperative pulmonary complications

OBJECTIVE

To examine the effect of preoperative smoking behavior on postoperative pulmonary complications.

DESIGN

Prospective cohort study.

SETTING

The Veterans Administration Medical Center, Syracuse, NY.

PARTICIPANTS

Patients scheduled for noncardiac elective surgery (n=410).

MEASUREMENTS AND RESULTS

Smoking status was determined by self-report. Postoperative pulmonary complications were determined by systematic extraction of medical record data. Postoperative pulmonary complications occurred in 31 of 141 (22.0%) current smokers, 24 of 187 (12.8%) past smokers, and 4 of 82 (4.9%) never smokers. The odds ratio (OR) for developing a postoperative pulmonary complication for current smokers vs never smokers was 5.5 (95% confidence interval [CI], 1.9 to 16.2) and 4.2 (95% CI, 1.2 to 14.8) after adjustment for type of surgery, type of anesthesia, abnormal chest radiograph, chronic cough, history of pulmonary disease, history of cardiac disease, history of COPD, education level, pulmonary function, body mass index, and age. Current smokers who reported reducing cigarette consumption prior to surgery were more likely to develop a complication compared with those who did not (adjusted OR=6.7, 95% CI, 2.6 to 17.1).

CONCLUSIONS

Current smoking was associated with a nearly sixfold increase in risk for a postoperative pulmonary complication. Reduction in smoking within 1 month of surgery was not associated with a decreased risk of postoperative pulmonary complications.

Production of melanin pigments by cytochrome c/H2O2 system

In the presence of hydrogen peroxide cytochrome c can perform the oxidation of catecholamines and their S-cysteinyl-derivatives yielding melanins as final products. The initial reaction rate is linearly dependent on cytochrome c and H2O2 concentration; the reaction follows the Michaelis and Menten kinetics both for H2O2 and hydrogen donors. Sulfhydryl compounds inhibit the formation of the pigment. The reported data indicate that a heme-containing protein belonging to the mitochondrial chain can accelerate the oxidation of catecholamines to eumelanins.

Melanins from tetrahydroisoquinolines: spectroscopic characteristics, scavenging activity and redox transfer properties

Tetrahydroisoquinolines (TIQs) are endogenous compounds deriving from the nonenzymatic Pictet-Spengler condensation of catecholamines (CA) with aldehydes. TIQs have been extensively studied in the last years not only because they have been found in the brain of postmortem specimens of Parkinson's patients, but also because they are able to induce parkinsonian symptoms if injected in animals. In the present article we demonstrate that TIQs bearing a catecholic moiety (tetrahydropapaveroline, salsolinol, laudanosoline, and apomorphine) are easily oxidized in the presence of hydrogen peroxide by various enzymes--i.e., peroxidase (POD), lipoxygenase (LOX), and xanthine oxidase (XO)--into the corresponding TIQ-melanins. The kinetic parameters of the above-mentioned reactions and some spectroscopic characteristics of the synthetized pigments are reported. In particular, UV-VIS and EPR spectra emerge as very similar to those exhibited by dopa-melanin. Furthermore, TIQ-melanins appear to be similar to dopa-melanin regarding some specific physico-chemical properties: NADH-oxidizing properties, oxy-radicals scavenging activity, and ability to form soluble mixed polymers with melanins from opioid peptides.

Clinical predictors of oxidized low-density lipoprotein in patients with coronary artery disease

Oxidized low-density lipoprotein (LDL) may play a key role in the initiation and progression of atherosclerosis. Risk factors for elevated levels of oxidized LDL are not well established and may be important in identifying individuals who may benefit from antioxidant supplementation or interventions to reduce oxidant stress. The purpose of this study was to determine if clinical parameters predict levels of oxidized LDL. We evaluated the relation between clinical parameters and oxidized LDL in 45 nonsmoking, nondiabetic patients (39 men and 6 women) with coronary artery disease. Oxidized LDL was assessed by measurement of conjugated dienes, lipid peroxides, and thiobarbituric reactive substances (TBARS) at 0 hours to evaluate baseline oxidant stress and postincubation with an oxidizing agent to assess the capacity of LDL for peroxidation. Results were lipid standardized and were not materially altered by multivariate adjustment. Significant predictors of increased oxidized LDL included female sex, family history of premature cardiovascular disease, increased percent body fat, increased body mass index, increased heart rate at rest, history of smoking, exercise <4 times per week, and no regular wine consumption. These data suggest that clinical parameters correlate with levels of oxidized LDL and may be useful in identifying patients at risk for increased oxidant stress.