Using stress testing to guide primary prevention of coronary heart disease among intermediate-risk patients: a cost-effectiveness analysis

BACKGROUND

Noninvasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease, but it is unclear if such a strategy would be cost effective.

METHODS AND RESULTS

We compared the status quo, in which the current national use of aspirin and statins was simulated, with 3 other strategies: (1) full implementation of Adult Treatment Panel III guidelines, (2) a treat-all strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only), and (3) a test-and-treat strategy in which all persons with an intermediate risk of coronary heart disease underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, coronary heart disease events, and quality-adjusted life years from 2011 to 2040 were projected. Under a variety of assumptions, the treat-all strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other test-and-treat strategies, but it was less expensive than treat all only if statin cost exceeded $3.16/pill or if testing increased adherence from <22% to >75%. However, stress electrocardiography could be cost effective in persons initially nonadherent to the treat-all strategy if it raised their adherence to 5% and cost saving if it raised their adherence to 13%.

CONCLUSIONS

When generic high-potency statins are available, noninvasive cardiac stress testing to target preventive medications is not cost effective unless it substantially improves adherence.

Decoupling neuronal oscillations during subthalamic nucleus stimulation in the parkinsonian primate

Subthalamic nucleus (STN) stimulation is a popular treatment for Parkinson's disease; however, its effect on neuronal activity is unclear. We performed simultaneous multi-electrode recordings in the STN and its targets, the globus pallidus internus (GPi) and externus (GPe) in the parkinsonian non-human primate during high frequency STN macro-stimulation. Our results indicate that in the parkinsonian state the abnormal neuronal oscillatory activity in the 10-15 Hz range is coherent within and between nuclei. We further show that STN macro-stimulation results in a reduction of oscillatory activity in the globus pallidus. In addition, a functional decoupling of the STN from its pallidal targets is evidenced by the reduced STN-GPi coherence, that effectively removes the STN synchronous oscillatory drive of basal ganglia output. This decoupling results in reduced coherence between neurons within the GPi which resume an independent neuronal activity pattern. This decorrelation of the basal ganglia output may result in a reduction of the fluctuations of the basal ganglia inhibitory control over thalamic neurons which may potentially contribute to the beneficial effects of deep brain high-frequency stimulation.

The impact of the aging population on coronary heart disease in the United States

BACKGROUND

The demographic shift toward an older population in the United States will result in a higher burden of coronary heart disease, but the increase has not been quantified in detail. We sought to estimate the impact of the aging US population on coronary heart disease.

METHODS

We used the Coronary Heart Disease Policy Model, a Markov model of the US population between 35 and 84 years of age, and US Census projections to model the age structure of the population between 2010 and 2040.

RESULTS

Assuming no substantive changes in risks factors or treatments, incident coronary heart disease is projected to increase by approximately 26%, from 981,000 in 2010 to 1,234,000 in 2040, and prevalent coronary heart disease by 47%, from 11.7 million to 17.3 million. Mortality will be affected strongly by the aging population; annual coronary heart disease deaths are projected to increase by 56% over the next 30 years, from 392,000 to 610,000. Coronary heart disease-related health care costs are projected to rise by 41% from $126.2 billion in 2010 to $177.5 billion in 2040 in the United States. It may be possible to offset the increase in disease burden through achievement of Healthy People 2010/2020 objectives or interventions that substantially reduce obesity, blood pressure, or cholesterol levels in the population.

CONCLUSIONS

Without considerable changes in risk factors or treatments, the aging of the US population will result in a sizeable increase in coronary heart disease incidence, prevalence, mortality, and costs. Health care stakeholders need to plan for the future age-related health care demands of coronary heart disease.

Coronary heart disease and stroke attributable to major risk factors is similar in Argentina and the United States: the Coronary Heart Disease Policy Model

BACKGROUND

Cardiovascular disease is the leading cause of death in Argentina and the U.S. Argentina is 92% urban, with cardiovascular disease risk factor levels approximating the U.S.

METHODS

The Coronary Heart Disease (CHD) Policy Model is a national-scale computer model of CHD and stroke. Risk factor data were obtained from the Cardiovascular Risk Factor Multiple Evaluation in Latin America Study (2003-04), Argentina National Risk Factor Survey (2005) and U.S. national surveys. Proportions of cardiovascular events over 2005-2015 attributable to risk factors were simulated by setting risk factors to optimal exposure levels [systolic blood pressure (SBP) 115 mm Hg, low-density lipoprotein cholesterol (LDL) 2.00 mmol/l (78 mg/dl), high-density lipoprotein cholesterol (HDL) 1.03 mmol/l (60 mg/dl), absence of diabetes, and smoking]. Cardiovascular disease attributable to body mass index (BMI) >21 kg/m² was assumed mediated through SBP, LDL, HDL, and diabetes.

RESULTS

Cardiovascular disease attributable to major risk factors was similar between Argentina and the U.S., except for elevated SBP in men (CHD 8% points higher in Argentine men, 6% higher for stroke). CHD attributable to BMI >21 kg/m² was substantially higher in the U.S. (men 10-11% points higher; women CHD 13-14% higher).

CONCLUSIONS

Projected cardiovascular disease attributable to major risk factors appeared similar in Argentina and the U.S., though elevated BMI may be responsible for more of U.S. cardiovascular disease. A highly urbanized middle-income nation can have cardiovascular disease rates and risk factor levels comparable to a high income nation, but fewer resources for fighting the epidemic.

A low frequency of pancreatic islet insulin-expressing cells derived from cord blood stem cell allografts in humans

AIMS/HYPOTHESIS

We sought to establish if stem cells contained in cord blood cell allografts have the capacity to differentiate into insulin-expressing beta cells in humans.

METHODS

We studied pancreases obtained at autopsy from individuals (n = 11) who had prior opposite-sex cord blood transplants to reconstitute haematopoiesis. Pancreatic tissue sections were stained first by XY-fluorescence in situ hybridisation and then insulin immunohistochemistry. Pancreases obtained at autopsy from participants without cord blood cell infusions served as controls (n = 11).

RESULTS

In the men with prior transplant of female cord blood, there were 3.4 ± 0.3% XX-positive insulin-expressing islet cells compared with 0.32 ± 0.05% (p < 0.01) in male controls. In women with prior transplant of male cord blood cells we detected 1.03 ± 0.20% XY insulin-expressing islet cells compared with 0.03 ± 0.03 in female controls (p < 0. 001).

CONCLUSIONS/INTERPRETATION

Cord blood stem cells have the capacity to differentiate into insulin-expressing cells in non-diabetic humans. It remains to be established whether these cells have the properties of beta cells.

Cervical cytology/histology discrepancy: a 4-year review of patient outcome

OBJECTIVE

To investigate the diagnosis, review and management of women identified as having a cytology/histology discrepancy.

METHODS

A review of all patients diagnosed with a discrepancy between referral smear and cervical histology was performed between January 2003 and December 2004. Cases were followed for a minimum of 4 years and patient management and outcome reviewed.

RESULTS

A significant discrepancy was identified in 79 cases, 0.1% of all smears (n = 80,926) analysed during the study period. A discrepancy between cytology and histology, obtained from large loop excision of the transformation zone (LLETZ), was confirmed by multidisciplinary review in 42 cases (53.2%). In 37 cases (46.8%) the cytological and/or histological diagnosis was revised; the cytology was significantly more likely than the histology to be amended (chi square P = 0.005), most often because cytology had been overcalled. Of the confirmed discrepancy cases, 33 (78.6%) were due to high-grade squamous cell or glandular abnormalities on cytology with a negative, inflammatory or human papillomavirus (HPV) infection on histology (HGC/NH). HGC/NH cases were managed by cytological follow-up in 29 (87.9%), of which 72.4% of the smears were negative when performed at least 6 months post-excision. During the 4-year follow-up period six women with a confirmed HGC/NH underwent a repeat cervical excision (hysterectomy or LLETZ), and of these, HPV effect was seen in two cases but no cervical intraepithelial neoplasia was detected in any of the histological specimens.

CONCLUSION

Cytology overcall was responsible for the majority of cytology/histology discrepancies. A confirmed discrepancy is not an indication for a further excisional biopsy but follow-up is essential because a small percentage of patients may have disease that has been missed.

Enhanced oxidative stress and increased mitochondrial mass during efavirenz-induced apoptosis in human hepatic cells

BACKGROUND AND PURPOSE

Efavirenz (EFV) is widely used in the treatment of HIV-1 infection. Though highly efficient, there is growing concern about EFV-related side effects, the molecular basis of which remains elusive.

EXPERIMENTAL APPROACH

In vitro studies were performed to address the effect of clinically relevant concentrations of EFV (10, 25 and 50 microM) on human hepatic cells.

KEY RESULTS

Cellular proliferation and viability were reduced in a concentration-dependent manner. Analyses of the cell cycle and several cell death parameters (chromatin condensation, phosphatidylserine exteriorization, mitochondrial proapoptotic protein translocation and caspase activation) revealed that EFV triggered apoptosis via the intrinsic pathway. In addition, EFV directly affected mitochondrial function in a reversible manner, inducing a decrease in mitochondrial membrane potential and an increase in mitochondrial superoxide production, followed by a reduction in cellular glutathione content. The rapidity of these actions rules out any involvement of mitochondrial DNA replication, which, until now, was thought to be the main mechanism of mitochondrial toxicity of antiretroviral drugs. Importantly, we also observed an increase in mitochondrial mass, manifested as an elevated cardiolipin content and enhanced expression of mitochondrial proteins, which was not paralleled by an increase in the mtDNA/nuclear DNA copy number ratio. The toxic effect of EFV was partially reversed by antioxidant pretreatment, which suggests ROS generation is involved in this effect.

CONCLUSION AND IMPLICATIONS

Clinically relevant concentrations of EFV were shown to be mitotoxic in human hepatic cells in vitro, which may be pertinent to the understanding of the hepatotoxicity associated with this drug.

Associations of acculturation and kidney dysfunction among Hispanics and Chinese from the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Acculturation affects health, but it has never been studied with kidney disease.

METHODS

We studied the association of language spoken at home, generation and birth place with kidney function among Hispanics and Chinese in the Multi-Ethnic Study of Atherosclerosis (n = 2999). Kidney function was determined by cystatin C (eGFRcys) and albumin/creatinine ratio (ACR). We evaluated mediators in models: Model 1 = age, sex, income, education; Model 2 = Model 1 + behaviors; and Model 3 = Model 1 + comorbidities.

RESULTS

Among Hispanics, speaking mixed Spanish/English was significantly associated with lower eGFRcys (- 2.83 mL/min/1.73 m(2), - 5.69-0.04) and higher ACR (RD 40%, 17-68%) compared with speaking Spanish only; this was mildly attenuated by behaviors (- 2.29, - 5.33-0.75; RD 42%, 18-72%) but not comorbidities (- 3.04, - 5.83 to - 0.23); RD 35%, 14-59%). US-born Hispanics had lower eGFRcys compared with foreign-born Hispanics [1.83 mL/min/1.73 m(2) lower (0.97-1.31) for Generation 1; 1.37 mL/min/1.73 m(2) lower (0.75-1.57) for Generation ≥ 2]. In contrast, Chinese who spoke any English had higher eGFRcys (2.53, 95% CI: - 1.70-6.78), but similar ACR (RD - 5%, 95% CI: - 26-23%) compared with those speaking Chinese only, but associations were not statistically significant.

CONCLUSION

Higher acculturation was associated with worse kidney function in Hispanics, mediated perhaps by behavioral factors but not comorbidities. Associations may be in the opposite direction among Chinese. Future studies are needed to elucidate these mechanisms.

Managing diabetes in cystic fibrosis

Cystic fibrosis related diabetes (CFRD) is the most common co-morbidity in persons with cystic fibrosis (CF). As the life expectancy of persons with CF continues to increase, the need to proactively diagnose and aggressively treat CFRD and its potential complications has become more apparent. CFRD negatively impacts lung function, growth and mortality, making its diagnosis and management crucial in a population already at high risk for early mortality. Compared to type 1 and type 2 diabetes, CFRD is a unique entity, requiring a thorough understanding of its unique pathophysiology to facilitate the creation and utilization of an effective medical treatment plan. The physiology of CFRD is complex, likely consisting of a combination of insulin deficiency, insulin resistance and a genetic predisposition towards the development of diabetes. However, the hallmark of CFRD is insulin deficiency, necessitating the use of exogenous insulin as the mainstay of therapy. Insulin administration, in combination with a multidisciplinary team of health professionals with expertise in the care of patients with CF and CFRD, is the cornerstone of the care for these patients. The goals of treatment of the CFRD population are to reverse protein catabolism, maintain a healthy weight, and reduce acute and chronic diabetes complications. Creating a partnership between the treatment team and the patient is the ideal way to accomplish these goals and is essential for successful diabetes care.

Future cardiovascular disease in china: markov model and risk factor scenario projections from the coronary heart disease policy model-china

BACKGROUND

The relative effects of individual and combined risk factor trends on future cardiovascular disease in China have not been quantified in detail.

METHODS AND RESULTS

Future risk factor trends in China were projected based on prior trends. Cardiovascular disease (coronary heart disease and stroke) in adults ages 35 to 84 years was projected from 2010 to 2030 using the Coronary Heart Disease Policy Model-China, a Markov computer simulation model. With risk factor levels held constant, projected annual cardiovascular events increased by >50% between 2010 and 2030 based on population aging and growth alone. Projected trends in blood pressure, total cholesterol, diabetes (increases), and active smoking (decline) would increase annual cardiovascular disease events by an additional 23%, an increase of approximately 21.3 million cardiovascular events and 7.7 million cardiovascular deaths over 2010 to 2030. Aggressively reducing active smoking in Chinese men to 20% prevalence in 2020 and 10% prevalence in 2030 or reducing mean systolic blood pressure by 3.8 mm Hg in men and women would counteract adverse trends in other risk factors by preventing cardiovascular events and 2.9 to 5.7 million total deaths over 2 decades.

CONCLUSIONS

Aging and population growth will increase cardiovascular disease by more than a half over the coming 20 years, and projected unfavorable trends in blood pressure, total cholesterol, diabetes, and body mass index may accelerate the epidemic. National policy aimed at controlling blood pressure, smoking, and other risk factors would counteract the expected future cardiovascular disease epidemic in China.

Left ventricular mass and ventricular remodeling among Hispanic subgroups compared with non-Hispanic blacks and whites: MESA (Multi-ethnic Study of Atherosclerosis)

OBJECTIVES

The purpose of this study was to examine the prevalence of left ventricular hypertrophy (LVH) and left ventricular (LV) remodeling patterns within Hispanic subgroups compared with non-Hispanic whites in the MESA (Multi-Ethnic Study of Atherosclerosis).

BACKGROUND

Hispanics are the largest and fastest-growing ethnic minority in the U.S., but there are no data on LVH and LV geometry among Hispanic subgroups.

METHODS

Cardiac magnetic resonance imaging was performed in 4,309 men and women age 45 to 84 years without clinical cardiovascular disease. Hispanics were categorized into subgroups based on self-reported ancestry. LVH was defined as the upper 95th percentile of indexed LV mass in a reference normotensive, nondiabetic, nonobese population, and LV remodeling according to the presence/absence of LVH and abnormal/normal LV mass to LV end-diastolic volume ratio.

RESULTS

Among Hispanic participants, 574 were of Mexican origin, 329 were of Caribbean origin, and 161 were of Central/South American origin. On unadjusted analysis, only Caribbean-origin Hispanics (prevalence ratio = 1.2; 95% confidence interval [CI]: 1.03 to 1.4) had greater prevalence of hypertension than non-Hispanic whites. Hispanic subgroups were more likely to have LVH than non-Hispanic whites after adjustment for hypertension and other covariates (Caribbean-origin Hispanics = odds ratio [OR]: 1.8, 95% CI: 1.1 to 3.0; Mexican-origin Hispanics = OR: 2.2, 95% CI: 1.4 to 3.3; Central/South Americans = OR: 1.5, 95% CI: 0.7 to 3.1). All Hispanic subgroups also had a higher prevalence of concentric and eccentric hypertrophy compared with non-Hispanic whites (p < 0.001).

CONCLUSIONS

Caribbean-origin Hispanics had a higher prevalence of LVH and abnormal LV remodeling compared with non-Hispanic whites. A higher prevalence of LVH and abnormal LV remodeling was also observed among Mexican-origin Hispanics, despite a lower prevalence of hypertension. Differences among Hispanic subgroups regarding LVH and LV remodeling should be taken into account when evaluating cardiovascular risk in this population.

Poor Progress in Breast Cancer Control in the Elderly in the UK

Background:In 1998 England introduced a national cancer target, to reduce cancer mortality in the under 75 year olds from 1996 to 2010 by 20%. This might potentially lead to inequalities between younger and elderly cancer patients. In this study we assessed progress in breast cancer control in the elderly in the UK by comparing cancer mortality rates in the elderly with younger age groups in the UK and by comparing the elderly in the UK with other similar countries.Material and Methods:Mortality data for the UK, USA, Northern Europe (Denmark, Finland, Iceland, Sweden and Norway) and Western Europe (Germany, Netherlands, Luxembourg, Austria, France Switzerland) was obtained from the WHO mortality database. Age specific cancer mortality rates for the age bands 55-64, 65-74, 75-84 and 85 plus were calculated for the different geographies for the three year periods 1995-97 and 2003-05. Change in the differences between the age bands was assessed as the ratio between the youngest age group 55-64, which was set to 1, and the older age groups. The number of excess deaths in the UK was calculated by applying the lowest rate observed in each age band to the UK population, assuming that the UK could achieve the same rate.Results:Compared to other countries the UK had the highest breast cancer mortality rates in all age bands in 1995-07 and 2003-05 and rates were statistically significantly higher in 2003-05 at the 95% Confidence interval limit. In the younger age groups (55-64 and 65-74) the UK had the biggest decrease from 1995-97 to 2003-05 and is decreasing the gap to the other countries. In contrast the UK was the only geography with an increase in mortality rates in the over 85 year olds and only ranked second after the USA in the 75 to 84 year olds. If the UK had the same mortality rates as the lowest observed in each age band 681 breast cancer deaths could be prevented in the 55 to 74 year olds and 1590 in the over 75 year olds each year. The UK also had the greatest increase in the ratio between the 55-64 year olds and 85plus year olds, with and increase of a 100% from 3.5 to 4.5 from 1995-97 to 2003-05. The USA had the lowest rates in each age group.Conclusion:Little progress has been made in decreasing breast cancer mortality rates in the elderly in the UK. The gap in breast cancer mortality in the elderly compared to the younger age groups as well as the other countries is increasing. The gap with other countries will be closed only if there is a marked decrease in death rates in the over 75s. Future analysis should also look at the causes of higher mortality in the UK, taking the USA as the gold standard.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2059.

Existential boredom: the experience of living on haemodialysis therapy

Empathy is an essential component of professional nursing practice. In order to empathise appropriately with patients, it is crucial that nurses appreciate, understand and respond to their patients' experience of illness. This study sought to explore the experiences of 16 people with end stage renal disease on haemodialysis therapy in Ireland. A hermeneutical phenomenological methodology was employed incorporating qualitative interviews. The data were analysed using qualitative interpretive analysis. The experience of waiting was significant for the participants in the study. The experience of waiting was constituted by two themes labelled killing time and wasting time. It is suggested that the participants' experience of waiting is reminiscent of Heidegger's existential account of boredom. Moreover, the existential perspective of boredom contained within the participants' accounts is also depicted by Beckett in his play Waiting for Godot. Consequently, the literature of both existential writers is incorporated to provide a more in-depth description of the participants' experience of waiting. It is hoped that the insights provided in this paper will enable practitioners to gain a new awareness and understanding of patients' experiences of end stage renal disease and haemodialysis therapy. This would subsequently enable these professionals to empathise more effectively with their patients' situation and respond more appropriately to their care needs.

Revealing neuronal functional organization through the relation between multi-scale oscillatory extracellular signals

The spatial organization of neuronal elements and their connectivity make up the substrate underlying the information processing carried out in the networks they form. Conventionally, anatomical findings make the initial structure which later combines with superimposed neurophysiological information to create a functional organization map. The most common neurophysiological measure is the single neuron spike train extracted from an extracellular recording. This single neuron firing pattern provides valuable clues on information processing in a given brain area; however, it only gives a sparse and focal view of this process. Even with the increase in number of simultaneously recorded neurons, inference on their large-scale functional organization remains problematic. We propose a method of utilizing additional information derived from the same extracellular recording to generate a more comprehensive picture of neuronal functional organization. This analysis is based on the relationship between the oscillatory activity of single neurons and their neighboring neuronal populations. Two signals that reflect the multiple scales of neuronal populations are used to complement the single neuron spike train: (1) the high-frequency background unit activity representing the spiking activity of small localized sub-populations and (2) the low-frequency local field potential that represents the synaptic input to a larger global population. The three coherences calculated between pairs of these three signals arising from a single source of extracellular recording are then used to infer mosaic representations of the functional neuronal organization. We demonstrate this methodology on experimental data and on simulated leaky integrate-and-fire neurons.

Geographical and temporal distribution of cancer survival in teenagers and young adults in England

Background:

Between 1979 and 2001, an analysis of cancer survival in young people in England, aged 13 to 24 years, showed overall improvements. However, for some diagnostic groups, little or no increases were observed. The aim of this study was to analyse the regional distribution of cancer survival in teenagers and young adults in England in order to identify patterns and potential for improvements at a regional scale.

Methods:

We examined geographical and temporal patterns in relative survival in cancer patients aged 13–24 years in England during the time period 1979–2001. Cancer cases were grouped according to an internationally recognised morphology-based diagnostic scheme.

Results:

For most diagnostic groups, there was little variation in survival between regions, except for testicular germ cell tumours (P=0.006) and colorectal carcinoma (P=0.002). For certain diagnostic groups, the temporal pattern in survival differed between regions. However, in regions that showed poor survival during the early part of the study period, greatest improvements were observed in groups such as acute lymphoid leukaemia, acute myeloid leukaemia, testicular tumours and melanoma.

Conclusion:

In conclusion, there was a reduction in the differences in survival between regions during the study period.

Changes in postmenopausal hormone replacement therapy use among women with high cardiovascular risk

After randomized trials failed to support the use of hormone replacement therapy (HRT) for preventing cardiovascular disease (CVD), HRT use for postmenopausal women declined. Our analysis of 1999-2000 and 2003-2004 National Health and Nutrition Surveys (NHANES) shows that HRT use decreased 19% (from 27.6 to 8.4%; P<.001) among women with CVD versus 3% (from 19.8 to 16.8%; P=.68) among low-risk women, suggesting that most of the drop in HRT use may be among women prescribed HRT as an unproven treatment to prevent CVD.

Restraint and seclusion: a distressing treatment option?

The effectiveness of restraint and seclusion interventions in the nursing management of disturbed and aggressive clients remains questionable. Considerable debate continues regarding the use of these treatment options in psychiatric hospitals. The existing literature suggests that the controversial nature of restraint and seclusion creates a complex dilemma for nurses, which initiates emotional distress. This study specifically explored the emotions and feelings experienced by a group of psychiatric nurses working in Ireland in relation to incidents of restraint and seclusion. A qualitative research approach was employed incorporating focus group discussions. A total of 23 nurses participated in three focus group interviews. The data were analysed using qualitative interpretive analysis. Three themes were created consisting of: (1) the last resort - restraint and seclusion; (2) emotional distress; and (3) suppressing unpleasant emotions. It is suggested that the nurses' experience of restraint and seclusion created a dynamic movement between the release and suppression of distressing emotions. The oscillatory characteristics embedded within the nurses' emotional responses were reminiscent of a model of suffering developed by Morse in 2001. Consequently, this model is incorporated throughout the discussion of the findings to provide a more in-depth description of the emotional distress experienced by the nurses in the study.

Growth hormone deficiency and cardiovascular risk factors in childhood cancer survivors

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Background: Childhood cancer survivors (CCS) have a high frequency of growth hormone deficiency (GHD) and risk of early cardiovascular disease (CVD). This study examined the relations between GHD and risk factors for CVD in CCS. Methods: Anthropometrics, blood pressure, lipids, growth hormone (GH) stimulation test, dual-energy x-ray absorptiometry, abdominal CT, and insulin resistance (IR) (euglycemic, hyperinsulinemic clamp - low M/lbm signifies IR) were obtained in 174 CCS, mean age 15±2 years and 89 healthy sibling controls, mean age 13.5±3 years. Linear regression evaluated the relations between GHD and CVD risk factors, adjusted for sex, age, pubertal stage, and body mass index (BMI) or visceral fat. Results: 62 CCS (36%) had GHD. There were no significant measurement differences between non-GHD CCS and controls. Compared to controls, GHD CCS who never received GH (N = 34) had greater BMI (24.8 vs 20.8 kg/m2, p < 0.0001), percent body fat (36.1% vs 25.8%, p < 0.0001), visceral fat (34.8 vs 19.6 cm2, p < 0.0001), and triglycerides (TG) (120.2 vs 83.8 mg/dL, p = 0.001) and were more IR (M/lbm 11.1 vs 14.2 mg/kg/min, p = 0.0006). Adjustment for BMI and visceral fat did not change the IR or TG results. GHD CCS currently on GH had lower BMI (21.9 kg/m2, p = 0.02), percent body fat (31.2%, p = 0.08), and visceral fat (26.5 cm2, p = 0.03) compared to those not treated. IR and TG were not different between treated and not treated GHD CCS. Conclusions: GHD is a common finding in CCS and is significantly associated with adiposity, IR, and elevated TG.There is a suggestion that GH treatment had a positive impact on adiposity, but not IR and TG levels. These study findings imply that CVD risk factors are present in CCS with GHD independent of body fatness, suggesting that the cancer diagnosis or treatments received may lead to early cardiovascular disease in childhood cancer survivors.

No significant financial relationships to disclose.

Cardiometabolic risk in survivors of childhood cancer who received hematopoietic cell transplant (HCT)

6532

Background: Evidence suggests that survivors of childhood cancer are at increased risk for cardiovascular disease (CVD) and type 2 diabetes with even higher risk in those who received HCT. The purpose of this study was to compare the cardiometabolic risk factor profile in HCT patients and healthy sibling controls. Methods: Measures of insulin resistance (euglycemic hyperinsulinemic clamp adjusted for lean body mass [Mlbm], low Mlbm represents insulin resistance), fasting glucose, insulin, lipids, anthropometry, blood pressure (BP), and carotid artery compliance and distensibility (lower values represent arterial stiffness) were determined in 87 children and young adults (current age 27.3 yr, 57% male) who had received HCT for hematologic malignancy during childhood (mean age at HCT 11.8 yr) and 55 healthy sibling controls (current age=25.2 yr, 51% male). Linear regression models were used to evaluate risk factors between groups after adjusting for age, gender, pubertal stage, body mass index (BMI), and carotid lumen diameter (stiffness measures only). Results: Metabolic syndrome (ATP III criteria for adults, modified criteria for children) was present in 13 (14.9%) HCT survivors and 4 (7.3%) controls (p=0.19). Thirty-one (35.6%) survivors and 9 (16.4%) controls had two or more components of the metabolic syndrome (p=0.11). There were no differences between groups for BMI, waist circumference, percent body fat, or BP. HCT survivors had higher triglycerides, fasting glucose and insulin, lower HDL cholesterol, arterial distensibility, and were more insulin resistant (Table). Conclusions: HCT survivors have increased cardiometabolic risk factors independent of obesity suggesting that cancer itself and/or associated treatment exposures have a direct influence on CVD risk and that early screening and management of cardiometabolic risk factors should be considered in HCT survivors.

[Table: see text]

No significant financial relationships to disclose.

Comparing impact and cost-effectiveness of primary prevention strategies for lipid-lowering

BACKGROUND

Lipid-lowering therapy is costly but effective at reducing coronary heart disease (CHD) risk.

OBJECTIVE

To assess the cost-effectiveness and public health impact of Adult Treatment Panel III (ATP III) guidelines and compare with a range of risk- and age-based alternative strategies.

DESIGN

The CHD Policy Model, a Markov-type cost-effectiveness model.

DATA SOURCES

National surveys (1999 to 2004), vital statistics (2000), the Framingham Heart Study (1948 to 2000), other published data, and a direct survey of statin costs (2008).

TARGET POPULATION

U.S. population age 35 to 85 years.

TIME HORIZON

2010 to 2040.

PERSPECTIVE

Health care system.

INTERVENTION

Lowering of low-density lipoprotein cholesterol with HMG-CoA reductase inhibitors (statins).

OUTCOME MEASURE

Incremental cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS

Full adherence to ATP III primary prevention guidelines would require starting (9.7 million) or intensifying (1.4 million) statin therapy for 11.1 million adults and would prevent 20,000 myocardial infarctions and 10,000 CHD deaths per year at an annual net cost of $3.6 billion ($42,000/QALY) if low-intensity statins cost $2.11 per pill. The ATP III guidelines would be preferred over alternative strategies if society is willing to pay $50,000/QALY and statins cost $1.54 to $2.21 per pill. At higher statin costs, ATP III is not cost-effective; at lower costs, more liberal statin-prescribing strategies would be preferred; and at costs less than $0.10 per pill, treating all persons with low-density lipoprotein cholesterol levels greater than 3.4 mmol/L (>130 mg/dL) would yield net cost savings.

RESULTS OF SENSITIVITY ANALYSIS

Results are sensitive to the assumptions that LDL cholesterol becomes less important as a risk factor with increasing age and that little disutility results from taking a pill every day.

LIMITATION

Randomized trial evidence for statin effectiveness is not available for all subgroups.

CONCLUSION

The ATP III guidelines are relatively cost-effective and would have a large public health impact if implemented fully in the United States. Alternate strategies may be preferred, however, depending on the cost of statins and how much society is willing to pay for better health outcomes.

FUNDING

Flight Attendants' Medical Research Institute and the Swanson Family Fund. The Framingham Heart Study and Framingham Offspring Study are conducted and supported by the National Heart, Lung, and Blood Institute.

Ambulatory blood pressure monitoring and all-cause mortality in elderly people with diabetes mellitus

In a multiethnic cohort of older people with diabetes (n=1178), we assessed whether ambulatory blood pressure (BP) monitoring improves prediction of all-cause mortality and cardiovascular mortality when added to baseline covariates, including office BP and heart rate (HR). Secondary analyses assessed whether albuminuria may mediate the association of pulse pressure with mortality. The ambulatory arterial stiffness index was calculated as "1-slope" from the within-person regression of diastolic-on-systolic ambulatory BP readings. Mean follow-up was 6.6+/-0.4 years. There were 287 deaths; death certificates were available for 215 deaths (75%), and 110 of them were deemed of cardiovascular cause. Cox models were built incrementally. First, models using clinical and laboratory variables selected albuminuria and office HRs as independent predictors of all-cause and cardiovascular mortality. When ambulatory monitoring data were added, sleep:wake HR ratio and ambulatory arterial stiffness index added significantly to the prediction of all-cause mortality, but only sleep:wake HR ratio added to the prediction of cardiovascular mortality. Office HR and albuminuria retained significance as predictors of both types of mortality. Secondary analyses without adjustment for albuminuria confirmed the predictive value of office HR and sleep/wake HR, whereas 24-hour pulse pressure and sleep systolic BP were also independently predictive of all-cause and cardiovascular mortality, respectively. In conclusion, office HR and albuminuria were strong predictors of mortality. Ambulatory monitoring improved the prediction of risk through its assessment of sleep HR dipping and of ambulatory arterial stiffness index, a measure of the dynamic relationship between systolic and diastolic BPs. Albuminuria may mediate the association between BP and mortality.