Flow-mediated vasodilatation of the brachial artery and intima-media thickness of carotid artery in never-treated subjects

AIM

Data on the association between brachial artery flow-mediated dilatation (FMD) and common carotid intima-media thickness (IMT) are contrasting. The present study investigated the relationship between FMD and IMT and carotid atherosclerosis in never treated subjects.

METHODS

Seventy-seven subjects were investigated: 46 had no coronary heart disease (CHD) risk factors, 21 had only one, and 10 had more than one risk factor. IMT of the common carotid was measured by ultrasonography and FMD was evaluated according to standardized methods.

RESULTS

IMT increased with increasing number of risk factors (0.66+/-0.12, 0.69+/-0.12 and 0.8+/-0.17 mm, respectively, ANOVA P<0.05). FMD decreased with increasing number of risk factors (10.44+/-5.2, 6.52+/-7.11 and 7.35+/-4.42%, respectively, P<0.05). Endothelium-independent vasodilatation was similar in the 3 groups. IMT and FMD did not correlate neither in subjects without risk factors (r=-0.151, P=0.3), nor in those with 1 (r=-0.196, P=0.4) or with 2 or more risk factors (r=-0.387, P=0.2), while in the group as a whole the correlation was borderline significant (r=-0.217, P=0.058). Eleven subjects had carotid atherosclerosis and higher values of IMT, but not reduced FMD. In multiple regression analysis, diabetes and IMT, but not FMD, were associated with carotid atherosclerosis.

CONCLUSIONS

The present findings indicate that, in never treated subjects, FMD is not strictly associated with IMT or atherosclerosis of the carotid arteries.

Aortic Pulse Pressure and Aortic Pulsatility in Patients with Coronary Slow Flow

OBJECTIVE

Coronary slow flow (CSF) is an angiographic phenomenon characterized by delayed opacification of coronary arteries in the absence of obstructive coronary disease. Recently, increased aortic pulse pressure (PP) and aortic pulsatility were both linked to the presence of angiographic coronary artery disease. In this study aortic PP and aortic pulsatility, derived from the invasively measured ascending aortic pressure waveform, were analyzed in patients with CSF and otherwise normal epicardial coronary arteries and compared with those with completely normal coronary arteries.

METHODS

Fifty consecutive patients with CSF (35 men, mean age: 51.7 +/- 10 years) and fifty age and gender-matched controls (34 men, 51.1 +/- 9 years) were included in the study. For determination of coronary flow, the thrombosis in myocardial infarction (TIMI) frame count method was used. Blood pressure waveforms of the ascending aorta were measured during cardiac catheterization with a fluid-filled system. Aortic pulsatility was estimated as the ratio of aortic PP to mean pressure.

RESULTS

Study groups were well matched with respect to age, gender and atherosclerotic risk factors. Although systolic, diastolic and mean pressures of the ascending aorta were similar, aortic PP (60.5 +/- 19 vs. 51.7 +/- 14 mm Hg, p = 0.01) and aortic pulsatility (0.63 +/- 0.1 vs. 0.54 +/- 0.1, p = 0.006) were significantly higher in patients with CSF compared with the controls. Besides, in all subjects, corrected TIMI frame counts of all three coronary arteries correlated with both ascending aorta PP and aortic pulsatility values. No association was found between corrected TIMI frame counts of coronary arteries and aortic mean blood pressure or brachial blood pressure parameters.

CONCLUSION

Our findings suggest that CSF is, as with obstructive coronary artery disease, associated with more diffuse vascular disease rather than being an isolated finding.

Current strategies for the prevention of angina in patients with stable coronary artery disease

PURPOSE OF REVIEW

Angina pectoris affects at least 6.6 million people in the US and approximately 400,000 new cases of stable angina occur each year. Angina may be one of the first signs of ischemic heart disease, although it is likely not causally related to the likelihood of plaque rupture leading to an acute coronary syndrome. Modalities for treatment of angina should be used maximally to improve quality of life and decrease cardiovascular morbidity and mortality. The current recommended pharmacologic and invasive approaches, as well as novel therapies, are reviewed.

RECENT FINDINGS

Antiischemic agents, including beta-blockers, nitrates and calcium channel blockers, remain the mainstay in the prevention of angina. Revascularization via percutaneous interventions or coronary bypass surgery are appropriate in specific cases or when medical treatment fails. Noninvasive treatment options for refractory angina, metabolic agents, and vasodilator therapies are adding to the armamentarium to prevent and treat angina.

SUMMARY

A multifaceted approach is optimal to address the prevention of angina. Once angina is recognized, there are many modalities that lessen the incidence of daily life-induced and exercise-induced angina and ischemia. Angina management is best addressed by pharmacologic and lifestyle interventions.

Heart rate variability and intima media thickness

Increased activity in the sympathetic nervous system is part of the physiological stress response and is expressed in the heart rate variability (HRV). The objective of this study was to examine associations of HRV and intima media thickness (IMT). In 2002, satisfactory measurements of HRV of 78 voluntary participants were made, both during a stress test and during sleep. IMT in 2002 and the progression in IMT from 1998 to 2002 were analyzed in relation to measures of HRV. HRV was negatively associated with IMT and IMT progression both during test and sleep. In men with higher IMT measures than mean the low frequency-high frequency ratio was higher during sleep than during test, perhaps mirroring a lack of ability to recovery. HRV was negatively associated with IMT and IMT progression. HRV may be part of the pathophysiological pathway between psychological strain and atherosclerosis.

Coronary Artery Disease and Hypertension: Outcomes of a Pharmacist-Managed Blood Pressure Program

STUDY OBJECTIVE

To assess the effectiveness of a pharmacist-managed service in improving hypertension control among patients with coronary artery disease.

DESIGN

Prospective cohort study. Setting. Health maintenance organization.

PATIENTS

Three hundred seventy-six patients with uncontrolled hypertension and coronary artery disease.

INTERVENTION

Pharmacist-managed, physician-supervised population-management approach to optimize evidence-based drug management.

MEASUREMENTS AND MAIN RESULTS

Blood pressure reduction and control were evaluated, as well as the use of angiotensin-converting enzyme inhibitors and generic antihypertensive drugs during 7-month follow-up. At baseline, mean +/- SD age was 70.4 +/- 8.8 years, 247 (65.7%) were men, 201 (53.5%) had a history of myocardial infarction, and 237 (63.0%) had diabetes mellitus. Baseline mean systolic blood pressure was 151 mm Hg, and none had achieved their blood pressure goal. During follow-up, mean systolic blood pressure decreased 16.1 mm Hg overall (p<0.001), and 179 (47.6%) patients achieved their goal blood pressure (p<0.001). Blood pressure reductions were 14.7 and 18.4 mm Hg in patients with and patients without diabetes, respectively (p<0.001). The target dose for angiotensin-converting enzyme inhibitors was achieved in 252 (67.0%) patients compared with 102 (27.1%) at baseline (p<0.001). Generic fill rates for antihypertensive drugs continued to be higher than 95% during follow-up (p=0.723).

CONCLUSION

A pharmacist-managed, physician-supervised population-management approach in patients with coronary artery disease significantly improved blood pressure control. Clinically meaningful reductions in blood pressure were achieved by using evidence-based, cost-effective drug regimens.

Nuclear Cardiology: Present and Future

Nuclear cardiology has made significant advances since the first reports of planar scintigraphy for the evaluation of left ventricular perfusion and function. While the current "state of the art" of gated myocardial perfusion single-photon emission computed tomographic (SPECT) imaging offers invaluable diagnostic and prognostic information for the evaluation of patients with suspected or known coronary artery disease (CAD), advances in the cellular and molecular biology of the cardiovascular system have helped to usher in a new modality in nuclear cardiology, namely, molecular imaging. In this review, we will discuss the current state of the art in nuclear cardiology, which includes SPECT and positron emission tomographic evaluation of myocardial perfusion, evaluation of left ventricular function by gated myocardial perfusion SPECT and gated blood pool SPECT, and the evaluation of myocardial viability with PET and SPECT methods. In addition, we will discuss the future of nuclear cardiology and the role that molecular imaging will play in the early detection of CAD at the level of the vulnerable plaque, the evaluation of cardiac remodeling, and monitoring of important new therapies including gene therapy and stem cell therapy.

Physiological assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology

With advances in technology, the physiological assessment of coronary artery disease in patients in the catheterization laboratory has become increasingly important in both clinical and research applications, but this assessment has evolved without standard nomenclature or techniques of data acquisition and measurement. Some questions regarding the interpretation, application, and outcome related to the results also remain unanswered. Accordingly, this consensus statement was designed to provide the background and evidence about physiological measurements and to describe standard methods for data acquisition and interpretation. The most common uses and support data from numerous clinical studies for the physiological assessment of coronary artery disease in the cardiac catheterization laboratory are reviewed. The goal of this statement is to provide a logical approach to the use of coronary physiological measurements in the catheterization lab to assist both clinicians and investigators in improving patient care.

Role of nuclear cardiology in advancing cardiac surgery

Cardiac surgeons are commonly faced with issues regarding the balance between the potential risk and the potential benefit of a surgical procedure. Nuclear cardiology procedures [myocardial perfusion SPECT (MPS) and positron emission tomography (PET)] provide the surgeon with objective information that augments standard clinical and angiographic assessments with respect to diagnosis, prognosis, and potential benefit from intervention. Development of the technology and methodology of gated MPS acquisition and interpretation allows assessment of the extent and severity of hypoperfused but viable myocardium, as well as global LVEF and LV volume measurements, diastolic function, and LV geometry. With PET, myocardial metabolism and blood flow reserve can also be measured. This chapter provides insight into the current evidence regarding settings in which nuclear cardiology procedures are helpful to the surgeon in assessment of patients having or being considered for cardiac surgery in the setting of coronary artery disease (CAD). Overall, a risk-benefit approach to MPS results is proposed, with principal focus on identifying patients at risk for major cardiac events who may benefit from a surgical procedure.

Advanced glycation end products: sparking the development of diabetic vascular injury

Advanced glycation end products (AGEs) are proteins or lipids that become glycated after exposure to sugars. AGEs are prevalent in the diabetic vasculature and contribute to the development of atherosclerosis. The presence and accumulation of AGEs in many different cell types affect extracellular and intracellular structure and function. AGEs contribute to a variety of microvascular and macrovascular complications through the formation of cross-links between molecules in the basement membrane of the extracellular matrix and by engaging the receptor for advanced glycation end products (RAGE). Activation of RAGE by AGEs causes upregulation of the transcription factor nuclear factor-kappaB and its target genes. Soluble AGEs activate monocytes, and AGEs in the basement membrane inhibit monocyte migration. AGE-bound RAGE increases endothelial permeability to macromolecules. AGEs block nitric oxide activity in the endothelium and cause the production of reactive oxygen species. Because of the emerging evidence about the adverse effects of AGEs on the vasculature of patients with diabetes, a number of different therapies to inhibit AGEs are under investigation.

Tissue omega-6/omega-3 fatty acid ratio and risk for coronary artery disease

A ratio that estimates tissue proportions of omega-6 fatty acids (linoleic acid and/or arachidonic acid [AA]) and omega-3 fatty acids (eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], and/or alpha-linolenic acid) has been proposed as a biomarker of risk for coronary artery disease (CAD). Use of an omega-6/omega-3 fatty acid ratio instead of either fatty acid class alone is based on theoretical reasons and has not been validated. The relationship between risk for CAD events and tissue omega-3 and omega-6 fatty acid composition was evaluated by pooling data from case-control or prospective cohort studies that examined the risk for CAD end points as a function of tissue fatty acid composition. Thirteen studies were included, 11 case-control and 2 prospective cohort studies, and case-control differences in computed averages of several fatty acids and fatty acid ratios were compared. The largest and most consistent difference was for the sum of EPA + DHA (-11% in cases, p = 0.002). Proportions of EPA, DHA, and AA were about 8% lower in cases, but none of these differences was significant. Total omega-3 and omega-6 fatty acids were lower by 7% and 4%, respectively, in cases versus controls, but only the total omega-3 fatty acid difference was significant. The AA/EPA ratio was nonsignificantly lower by 10% in cases. Fatty acid ratios generally failed to distinguish cases from controls, and any discriminatory power they had derived from the omega-3 fatty acid component. Tissue EPA + DHA appears to be the best fatty acid metric for evaluating for CAD risk.

Antiatherosclerotic and antithrombotic effects of omega-3 fatty acids

Omega-3 fatty acids from both marine and plant sources have been shown to reduce the risk of coronary artery disease death. Although their beneficial cardiovascular effects are thought to be due to their antiarrhythmic properties, omega-3 fatty acids also have been shown to have a wide range of antiatherosclerotic and antithrombotic effects in animal and human studies. Review of the findings of randomized, controlled trials published through August 2005 shows that omega-3 fatty acids of marine origin consistently lower elevated plasma triglyceride levels in a dose-dependent fashion, with greater efficacy at higher triglyceride levels. Smaller effects on lowering blood pressure, improving endothelial function, and increasing plasma levels of high-density lipoprotein cholesterol were also found. No consistent effects on other lipid, hemostatic, inflammatory, glucose tolerance, or plaque stabilization parameters were found. Epidemiologic studies show more consistent reductions in the incidence of nonfatal myocardial infarction and ischemic stroke than do the clinical trials of increased omega-3 fatty acid intake, which suggests important confounding factors in observational studies. Ongoing clinical trials may clarify the non-antiarrhythmic benefits of omega-3 fatty acid supplementation.

Lack of inertia force of late systolic aortic flow is a cause of left ventricular isolated diastolic dysfunction in patients with coronary artery disease

OBJECTIVES

We investigated whether a lack of inertia force of late systolic aortic flow and/or apical asynergy provoke early diastolic dysfunction in patients with coronary artery disease (CAD).

BACKGROUND

Left ventricular (LV) isolated diastolic dysfunction is a well-recognized cause of heart failure.

METHODS

We evaluated LV apical wall motion and obtained left ventricular ejection fraction (LVEF) by left ventriculography in 101 patients who underwent cardiac catheterization to assess CAD. We also computed the LV relaxation time constant (Tp) and the inertia force of late systolic aortic flow from the LV pressure (P)-first derivative of left ventricular pressure (dP/dt) relation. Using color Doppler echocardiography, we measured the propagation velocity of LV early diastolic filling flow (Vp). Patients with LVEF > or =50% (preserved systolic function [PSF], n = 83) were divided into 2 subgroups: patients with inertia force (n = 53) and without inertia force (n = 30). No patient with systolic dysfunction (SDF) (LVEF <50%) had inertia force (n = 18).

RESULTS

The Tp was significantly longer in patients with SDF (85.7 +/- 21.0 ms) and with PSF without inertia force (81.1 +/- 23.6 ms) than in those with PSF with inertia force (66.3 +/- 12.8 ms) (p< 0.001). The Vp was significantly less in the former 2 groups than in the last group. In patients with PSF, LV apical wall motion abnormality was less frequently observed in those with inertia force than in those without (p < 0.0001).

CONCLUSIONS

An absence of inertia force in patients with PSF is one of the causes of isolated diastolic dysfunction in patients with CAD. Normal LV apical wall motion is substantial enough to give inertia to late systolic aortic flow.

Coronary artery calcification and myocardial perfusion in asymptomatic adults: the MESA (Multi-Ethnic Study of Atherosclerosis)

OBJECTIVES

This study assessed the cross-sectional association between coronary artery calcification (CAC) and myocardial perfusion in an asymptomatic population.

BACKGROUND

Clinical studies showed that the prevalence of stress-induced ischemia increased with CAC burden among patients with coronary heart disease (CHD). Whether an association between CAC and myocardial perfusion exists in subjects without a history of CHD remains largely unknown.

METHODS

A total of 222 men and women, ages 45 to 84 years old and free of CHD diagnosis, in the Minnesota field center of the MESA (Multi-Ethnic Study of Atherosclerosis) were studied. Myocardial blood flow (MBF) was measured using magnetic resonance imaging during rest and adenosine-induced hyperemia. Perfusion reserve was calculated as the ratio of hyperemic to resting MBF. Agatston CAC score was determined from chest multidetector computed tomography.

RESULTS

Mean values of hyperemic MBF and perfusion reserve, but not resting MBF, were monotonically lower across increasing CAC levels. After adjusting for age and gender, odds ratios (95% confidence intervals) of reduced perfusion reserve (<2.5) for subjects with CAC scores of 0, 0.1 to 99.9, 100 to 399, and > or =400 were 1.00 (reference), 2.16 (0.96 to 4.84), 2.81 (1.04 to 7.58), and 4.99 (1.73 to 14.4), respectively. Further adjustment for other coronary risk factors did not substantially modify the association. However, the inverse association between perfusion reserve and CAC attenuated with advancing age (p for interaction < 0.05).

CONCLUSIONS

Coronary vasodilatory response was associated inversely with the presence and severity of CAC in asymptomatic adults. Myocardial perfusion could be impaired by or manifest the progression to subclinical coronary atherosclerosis in the absence of clinical CHD.

Multislice Spiral Computed Tomography for the Evaluation of Stent Patency After Left Main Coronary Artery Stenting

Background— Surveillance conventional coronary angiography (CCA) is recommended 2 to 6 months after stent-supported left main coronary artery (LMCA) percutaneous coronary intervention due to the unpredictable occurrence of in-stent restenosis (ISR), with its attendant risks. Multislice computed tomography (MSCT) is a promising technique for noninvasive coronary evaluation. We evaluated the diagnostic performance of high-resolution MSCT to detect ISR after stenting of the LMCA.

Methods and Results— Seventy-four patients were prospectively identified from a consecutive patient population scheduled for follow-up CCA after LMCA stenting and underwent MSCT before CCA. Until August 2004, a 16-slice scanner was used (n=27), but we switched to the 64-slice scanner after that period (n=43). Patients with initial heart rates >65 bpm received β-blockers, which resulted in a mean periscan heart rate of 57±7 bpm. Among patients with technically adequate scans (n=70), MSCT correctly identified all patients with ISR (10 of 70) but misclassified 5 patients without ISR (false-positives). Overall, the accuracy of MSCT for detection of angiographic ISR was 93%. The sensitivity, specificity, and positive and negative predictive values were 100%, 91%, 67%, and 100%, respectively. When analysis was restricted to patients with stenting of the LMCA with or without extension into a single major side branch, accuracy was 98%. When both branches of the LMCA bifurcation were stented, accuracy was 83%. For the assessment of stent diameter and area, MSCT showed good correlation with intravascular ultrasound ( r =0.78 and 0.73, respectively). An intravascular ultrasound threshold value ≥1 mm was identified to reliably detect in-stent neointima hyperplasia with MSCT.

Conclusions— Current MSCT technology, in combination with optimal heart rate control, allows reliable noninvasive evaluation of selected patients after LMCA stenting. MSCT is safe to exclude left main ISR and may therefore be an acceptable first-line alternative to CCA.

Giant aneurysm of left anterior descending coronary artery treated by surgical off-pump therapy

Coronary artery aneurysms may predispose to acute thrombosis, embolisation and myocardial ischaemia or rupture with subsequent tamponade and/or sudden death. The optimal therapy for patients with coronary artery aneurysm is unknown, and controversy persists regarding the use of medical or surgical modalities. There is no doubt that surgical therapy is reserved for cases with large aneurysms or with myocardial ischaemia due to significant associated coronary artery stenoses. We discuss here the surgical management of a case with coronary artery aneurysm and concomitant coronary artery disease. Although the beating heart technique of myocardial revascularisation and repair of coronary artery aneurysm without cardiopulmonary bypass is not suitable for all patients, it should be considered for those high-risk patients who have impaired left ventricular function or who are at high risk for pulmonary or neurological complications.

Evaluation of platelet function in aspirin treated patients with CAD

BACKGROUND

Studies of platelet function in the acute coronary syndrome (ACS) have revealed both increased and unchanged platelet activation. To obtain a better understanding of platelet function in coronary artery disease in the setting of aspirin therapy, we performed platelet functional testing in patients with ACS and compared results to patients without CAD.

METHODS

We measured platelet aggregation and activation in response to ADP and epinephrine in 80 age and gender matched hospitalized patients (40 with ACS, 40 with non-cardiac chest pain (NCCP)). All subjects received ASA (81-325 mg). Platelet aggregation was performed using standard light transmission in platelet-rich plasma and activation was measured via flow cytometric analyses. We also studied platelet function under high shear rates measured by the platelet function analyzer (PFA-100).

RESULTS

ASA effect was found to be present in all subjects by blunted platelet aggregation in response to arachidonic acid. Patients with ACS showed significantly higher levels of platelet aggregation to epinephrine compared to patients with NCCP (p = 0.001). Other measures of platelet function including ADP aggregation, Pselectin, activated glycoprotein IIb/IIIa expression, and PFA-100 were unchanged between the two groups.

CONCLUSIONS

We have found conflicting results of platelet functional testing in ACS. Specifically aspirin therapy in patients with ACS is effective in suppressing the platelet release response and is effective in the partial suppression of platelet aggregation; however, it appears that ACS patients have increased platelet aggregation to adrenergic stimuli when compared to age and gender matched controls without CAD despite the use of aspirin. In some studies, because ACS patients have an accentuated response to adrenergic stimuli this might be interpreted as aspirin resistance. Our study suggests that depending on the assay used to determine aspirin resistance, not all patients with this label are resistant to the biological effects of aspirin but they may have higher than normal baseline platelet sensitivity to adrenergic stimuli.

Usefulness of conquest guidewire for retrieval of an entrapped rotablator burr

We experienced an entrapped rotablator burr that could not be retrieved even by deep seating of the guiding catheter. We successfully retrieved the burr by balloon inflation after the tapered tip of a Conquest wire managed to penetrate the quite hard plaque and pass through the outer lumen of the burr.

Sudden death secondary to cardiac arrhythmias: mechanisms and treatment strategies

PURPOSE OF REVIEW

This article reviews mechanisms and available therapeutic options for arrhythmias leading to sudden cardiac death in patients with coronary artery disease.

RECENT FINDINGS

Intensive efforts have led to a better understanding of the pathophysiology and various treatments of sudden cardiac death. Antiarrhythmic medications have not demonstrated a survival benefit. Beta-adrenergic blocking agents have been revalidated in recent studies to improve survival and reduce risk of sudden cardiac death in patients with myocardial infarction. Angiotensin-converting enzyme inhibitors and aldosterone antagonists should also be used in these patients. Data from randomized trials demonstrate significant survival benefit with an implantable cardioverter-defibrillator and indications have expanded. Patients with established ischemic cardiomyopathy do not require electrophysiologic studies for induction of tachyarrhythmias based on these trials. One recent trial did not demonstrate mortality reduction with implantable defibrillators in patients with recent myocardial infarction. Devices may not provide survival benefit in patients with advanced New York Heart Association class IV heart failure.

SUMMARY

The incidence of arrhythmia-related sudden death in the general population remains relatively high. Better risk stratification tools are needed to identify high-risk patients in the general population and in those with known coronary disease and to exclude low-risk patients.

Interactions of serum hsCRP with apoB, apoB/AI ratio and some components of metabolic syndrome amplify the predictive values for coronary artery disease

BACKGROUND

Plasma high-sensitivity CRP (hsCRP) is a marker of inflammation, and it is reported to link with coronary artery disease (CAD). Interactions between elevated serum hsCRP and other unfavorable risk factors have been proposed to cause high risk for CAD.

OBJECTIVES

To examine the potential interactions between serum hsCRP and lipids and non-lipidic risk factors.

METHODS

Markers of inflammation, the profiles of serum (apo)(lipo) proteins as well as classical risk factors were determined in 270 clinically stable angiographically documented subjects. The patients were stratified into tertiles according to hsCRP distribution.

RESULTS

The Framingham CAD scores, relative and absolute risk for CAD and the prevalence of diabetes mellitus and hypertension were significantly higher in 3rd relative to 1st tertile of hsCRP. Subjects with hsCRP levels in the upper tertile had significant higher levels of serum glucose, triglyceride, apolipoprotein (apo)B, apoB/apoAI ratio and the counts of total leukocyte and neutrophil and lower levels of HDL-C, albumin and the ratio of albumin/globulins. Analyses by bivariate correlation as well as linear regression showed that serum hsCRP was associated positively with the occurrence of diabetes and hypertension, the counts of total leukocyte and neutrophil and the levels of serum glucose, uric acid, apoB, apoB/apoAI ratio, alpha1- and alpha2-globulins and inversely with albumin, albumin/globulin ratio and HDL-C. By constructing dummy combined variables, elevated hsCRP accompanied with male sex, diabetes, hypertension and high levels of serum glucose, apoB, apoB/apoAI ratio and cholesterol exhibited amplified high risk for CAD.

CONCLUSIONS

The results show that hsCRP does interact multiplicatively with apoB and some variables of metabolic syndrome. The simultaneous assessment of hsCRP and interactive risk factors enhances discriminating value for CAD. It is suggested to use hsCRP in conjunction with apoB or apoB/apoAI ratio instead of cholesterol ratios in global risk assessment.

Should angiotensin-converting enzyme-inhibitors be used to improve outcome in patients with coronary artery disease and 'preserved' left ventricular function?

Early clinical studies investigating the role of angiotensin-converting enzyme (ACE) inhibitors in the treatment of heart failure unexpectedly demonstrated a possible reduction in coronary heart disease endpoints. Two large scale clinical trials, HOPE and EUROPA, both studies in patients with coronary artery disease (CAD) but without clinical evidence of heart failure, showed a highly significant improvement in coronary heart disease outcomes on treatment with ramipril and perindopril, respectively, in contrast, in a similar population, PEACE was unable to demonstrate such benefit with trandolapril. Meta-analyses of all trials involving ACE-inhibitors showed a highly significant improvement in coronary heart disease endpoints. Current ESC guidelines recommend ACE-inhibitor therapy in CAD patients with co-existing indications for ACE-inhibitors, such as hypertension, heart failure, left ventricular dysfunction, prior MI was left ventricular dysfunction, or diabetes (class I, level of evidence A). These guidelines also recommend ACE-inhibitor therapy in all patients with angina and proven coronary disease (class IIa, level of evidence B). However, in angina patients without independent indication for ACE-inhibitor treatment, the anticipated benefit should be weighted against the costs and risks of side effects; in these patients, only agents and doses of proven efficacy for secondary prevention should be employed.