Predominance of aortic calcification as an atherosclerotic manifestation in women: the Reykjavik study

Long sleep duration is associated with abdominal aortic calcification among male adults with chronic kidney disease: NHANES 2013-2014

There are no studies exploring the correlation between sleep duration and abdominal aortic calcification (AAC). This study aims to investigate this relationship and its significance. Additionally, given the higher prevalence of sleep disorders and AAC in patients with chronic kidney disease (CKD), we conducted further studies in this population. We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 2013-2014. Sleep duration was assessed by a sleep questionnaire and categorized into 2-5, 6-8, and ≥ 9 h. The AAC-24 score is determined using the Kauppila scoring system and used for AAC assessment. Multivariable linear and logistic regression analysis were used to explore the relationship between sleep duration and AAC. Among the 2,996 participants, 14.29% reported nightly short sleep (2-5 h), 77.64% reported intermediate sleep (6-8 h), and 8.08% reported long sleep (≥ 9 h). After adjusting for potential confounding factors, among male participants with CKD, long sleep (≥ 9 h) significantly increased AAC-24 scores compared with intermediate sleep (6-8 h) (β: 2.12; 95% CI: 0.75, 3.50), and the risk of severe AAC (SAAC) was increased by 1.55 times (OR: 2.55; 95% CI: 1.02, 6.36). And among female CKD and non-CKD participants, sleep duration was not associated with AAC. Long sleep duration increases the risk of AAC among male adults with CKD. Prospective studies are needed to confirm this finding.

Arteriosclerotic Calcification and Atrial Fibrillation in the General Population: The Rotterdam Study

Limited population-based data on the gender differences and association between arteriosclerotic calcification at different sites and atrial fibrillation (AF) exist. We aimed to investigate the (gender-specific) associations between arteriosclerotic calcification at different sites with the risk of AF in the general population. Arteriosclerotic calcification was quantified using computed tomography examinations between 2003 and 2006 in 2,259 participants free of AF from the population-based Rotterdam Study. Cox proportional hazards models, adjusted for cardiovascular risk factors, were used to assess the associations of volumes of coronary artery calcification (CAC), aortic arch calcification (AAC), extracranial and intracranial carotid arteries, vertebrobasilar arteries, and the aortic valve with incident AF. During a median follow-up of 8.6 years, 182 incident AF cases occurred. A larger CAC was associated with incident AF (hazard ratio [HR], 95% confidence interval [CI] 1.25 1.09 to 1.44, p = 0.0019). The gender-stratified analyses showed that larger CAC in men (HR 1.43, 95% CI 1.10 to 1.86, p = 0.0068) and larger AAC in women were associated with incident AF (HR1.44, 95% CI 1.04 to 2.01, p = 0.0299). In conclusion, CAC in the general population, especially in men, and AAC in women were significantly associated with new-onset AF. Our findings imply that interventions to lower arteriosclerotic calcification, particularly, CAC, carry potential for the prevention of AF in the general population, especially in men.

Assessment of Subclinical Atherosclerosis in Asymptomatic People In Vivo: Measurements Suitable for Biomarker and Mendelian Randomization Studies

BACKGROUND

One strategy to reduce the burden of cardiovascular disease is the early detection and treatment of atherosclerosis. This has led to significant interest in studies of subclinical atherosclerosis, using different phenotypes, not all of which are accurate reflections of the presence of asymptomatic atherosclerotic plaques. The aim of part 2 of this series is to provide a review of the existing literature on purported measures of subclinical disease and recommendations concerning which tests may be appropriate in the prevention of incident cardiovascular disease.

METHODS

We conducted a critical review of measurements used to infer the presence of subclinical atherosclerosis in the major conduit arteries and focused on the predictive value of these tests for future cardiovascular events, independent of conventional cardiovascular risk factors, in asymptomatic people. The emphasis was on studies with >10 000 person-years of follow-up, with meta-analysis of results reporting adjusted hazard ratios (HRs) with 95% CIs. The arterial territories were limited to carotid, coronary, aorta, and lower limb arteries.

RESULTS

In the carotid arteries, the presence of plaque (8 studies) was independently associated with future stroke (pooled HR, 1.89 [1.04-3.44]) and cardiac events (7 studies), with a pooled HR, 1.77 (1.19-2.62). Increased coronary artery calcium (5 studies) was associated with the risk of coronary heart disease events, pooled HR, 1.54 (1.07-2.07) and increasing severity of calcification (by Agaston score) was associated with escalation of risk (13 studies). An ankle/brachial index (ABI) of <0.9, the pooled HR for cardiovascular death from 7 studies was 2.01 (1.43-2.81). There were insufficient studies of either, thoracic or aortic calcium, aortic diameter, or femoral plaque to synthesize the data based on consistent reporting of these measures.

CONCLUSIONS

The presence of carotid plaque, coronary artery calcium, or abnormal ankle pressures seems to be a valid indicator of the presence of subclinical atherosclerosis and may be considered for use in biomarker, Mendelian randomization and similar studies.

Evidence Accumulates: Patients with Ascending Aneurysms Are Strongly Protected from Atherosclerotic Disease

Ascending thoracic aortic aneurysms may be fatal upon rupture or dissection and remain a leading cause of death in the developed world. Understanding the pathophysiology of the development of ascending thoracic aortic aneurysms may help reduce the morbidity and mortality of this disease. In this review, we will discuss our current understanding of the protective relationship between ascending thoracic aortic aneurysms and the development of atherosclerosis, including decreased carotid intima-media thickness, low-density lipoprotein levels, coronary and aortic calcification, and incidence of myocardial infarction. We also propose several possible mechanisms driving this relationship, including matrix metalloproteinase proteins and transforming growth factor-β.

Association between Periodontitis and Aortic Calcification: A Cohort Study

The present study investigated the association between the presence of periodontitis and aortic calcification (AC) risk among Chinese adults. A total of 6059 individuals who underwent regular health check-ups and received a diagnosis of periodontitis between 2009 and 2016 were included. The outcome was AC, assessed by a chest low-dose spiral CT scan. Cox proportional hazards regression analysis was used to assess the association between periodontitis and AC risk after adjusting for several confounders. After a median follow-up period of 2.3 years (interquartile range: 1.03-4.97 years), 843 cases of AC were identified, with 532 (12.13%) and 311 (18.59%) patients in the non-periodontitis group and periodontitis group, respectively. Multivariate analyses demonstrated that, compared with those without periodontitis, the hazard ratio and 95% confidence interval for AC risk in participants with periodontitis was 1.18 (1.02-1.36) (P = .025) in the fully adjusted model. Stratified analyses showed that the positive relationship between periodontitis and AC was more evident in males and participants <65 years of age (p_interaction = .005 and .004, respectively). Our results show that the presence of periodontitis was positively associated with AC among Chinese adults, especially among males and younger participants.

Thoracic Aortic Calcification: Diagnostic, Prognostic, and Management Considerations

Thoracic aortic calcification (TAC) is associated with adverse cardiovascular outcomes, and for the cardiovascular imager, is predominantly encountered in 4 settings: 1) incidentally, for example, during a coronary artery calcium scan; 2) as part of dedicated screening; 3) in the evaluation of an embolic event; or 4) in procedural planning. This review focuses on TAC in these contexts. Within atherosclerosis, TAC is common, variable in extent, and begins in the intima with a patchy distribution. In metabolic disorders, aortitis, and radiation-associated cardiovascular disease, calcification preferentially involves the media and is often more concentric. As an incidental finding, atherosclerotic TAC provides limited incremental discriminative value, and current data do not support screening. After an embolic event, the demonstration of thoracic atheroma provides diagnostic clarity, but has limited treatment implications. Before any procedure, the plan often changes if the most severe form of TAC, a porcelain aorta, is discovered.

Aortic Arch Calcification Is a Strong Predictor of the Severity of Coronary Artery Disease in Patients with Acute Coronary Syndrome

BACKGROUND

The purpose of this study was to investigate the correlation of the extent of aortic arch calcification (AAC) detectable on chest X-rays with the severity of coronary artery disease (CAD) as evaluated by the SYNTAX score (SS) in patients with acute coronary syndrome (ACS).

METHODS

A total of 1,418 patients (344 women; 59 ± 10 years) who underwent coronary angiography for ACS and were treated with coronary revascularization were included in the present study; chest X-rays were performed on admission. The AAC extent was divided into four grades (0-3). SS was calculated based on each patient's coronary angiographic findings. The relationship between the AAC extent and SS was assessed.

RESULTS

The AAC extent was positively correlated with SS (ρ = 0.639, P < 0.001). In the multivariate analysis, compared with grade 0, odds ratios (ORs) of AAC grades 1, 2, and 3 in predicting SS >22 were 12.95 (95% CI, 7.85-21.36), 191.76 (95% CI, 103.17-356.43), and 527.81 (95% CI, 198.24-1405.28), respectively. Receiver operating characteristic curve analysis yielded a strong predictive ability of the AAC extent for SS >22 (area under curve = 0.840, P < 0.001). Absence of AAC had a sensitivity, specificity, positive prognostic value, negative prognostic value, and accuracy of 46.7%, 95.9%, 94.1%, 56.4%, and 67.3%, respectively, for SS ≤22. AAC grades ≥2 had a sensitivity of 66.3%, specificity of 89.2%, positive prognostic value of 81.5%, negative prognostic value of 78.6%, and accuracy of 79.6% for the correct identification of SS >22.

CONCLUSIONS

The extent of AAC detectable on chest X-rays might provide valuable information in predicting CAD severity in ACS patients.

Evaluation of aortic 18F-NaF tracer uptake using PET/CT as a predictor of aortic calcification in postmenopausal women: A longitudinal study

Introduction

Aortic calcification as detected by computed tomography is associated with arterial stiffening and is an important predictor of cardiovascular morbidity and mortality. Uptake of ¹⁸F-sodium fluoride (¹⁸F-NaF) in the aortic wall reflects metabolically active areas of calcification. The aim of this study was to determine if ¹⁸F-NaF uptake in the aorta is associated with calcification and progression of calcification as detected by computed tomography.

Methods

Twenty-one postmenopausal women (mean age 62 ± 6 years) underwent assessment of aortic ¹⁸F-NaF uptake using positron emission tomography/computer tomography at baseline and a repeat computed tomography scan after a mean follow-up of 3.8 ± 1.3 years. Tracer uptake was quantified by calculating the target-to-background (TBR) ratios at baseline and follow-up. Calcification was assessed at baseline and follow-up using computed tomography.

Results

Over the follow-up period, aortic calcium volume increased from 0.46 ± 0.62 to 0.71 ± 0.93 cm³ (P < 0.05). However, the change in calcium volume did not correlate with baseline TBR either unadjusted (r = 0.00, P = 1.00) or adjusted for age and baseline calcium volume (beta coefficient = −0.18, P = 0.42). TBR at baseline did not differ between participants with (n = 16) compared to those without (n = 5) progression in calcium volume (2.43 ± 0.46 vs. 2.31 ± 0.38, P = 0.58). In aortic segments identified to have the highest tracer uptake at baseline, calcium volume did not significantly change over the follow-up period (P = 0.41).

Conclusion

In a cohort of postmenopausal women, ¹⁸F-NaF uptake as measured by TBR in the lumbar aorta did not predict progression of aortic calcification as detected by computed tomography over a four-year follow-up.

[Expression of osteoprotegerin and soluble ligand of receptor of kappa-B transcription factor activator in the calcification of aortic valve]

The mechanism of valve calcification that is the main cause of aortic stenosis formation and progression is not yet clear. In recent years, the role of the OPG/RANKL/RANK system is considered as one of possible variants of pathogenesis of valve calcification. In presented work the differences in OPG and sRANKL levels involved in the calcification processes in tissues of patients with severe aortic stenosis have been examined. The study was performed using three groups of patients: group 1 - patients with aortic stenosis, group 2 - patients with aortic aneurysm, and group 3 - patients with aortic stenosis and aortic dilatation. In patients with aortic stenosis, the level of RANKL was significantly higher, and the level of RANKL was higher in valve than in tissue. The negative correlation between aortic dilatation and RANKL level indicated the lack of RANKL influence on pathogenesis of aortic dilatation. The obtained data confirm the increased expression of RANKL in patients with aortic valve calcification. The results of this study confirm importance of the OPG/RANKL/RANK system in calcification in patients with aortic stenosis. Athough patients of all groups had comparable values of OPG (including patients with aortic dilatation), the RANKL level increased only in patients with aortic stenosis. This suggest involvement of some additional mechanisms influencing the increase of RANKL expression.

Abdominal aortic calcification on dual-energy X-ray absorptiometry: Methods of assessment and clinical significance

Abdominal aortic calcification (AAC) can be accurately recognized on lateral spine images intended for vertebral fracture assessment, that are obtained with dual-energy X-ray absorptiometry (DXA). Greater amounts of AAC are common in the older population for whom DXA is routinely done, and have been consistently associated with incident atherosclerotic cardiovascular disease (ASCVD) events. AAC has also been associated with incident fractures in some prospective studies, but not in others. However, further research is needed to quantify the extent to which measurement of AAC improves prediction of ASCVD events and its impact on physician and patient ASCVD risk management. Additionally, research to develop better, more precise, automated, quantitative methods of AAC assessment on lateral spine densitometric images will hopefully lead to better prediction of clinical outcomes. In conclusion, although the prime indication for densitometric lateral spine imaging remains vertebral fracture assessment, AAC that is found incidentally on lateral spine images should be reported, so that patients and their health care providers are aware of its presence.

Estrogen Receptor Control of Atherosclerotic Calcification and Smooth Muscle Cell Osteogenic Differentiation

OBJECTIVE

Vascular calcification is associated with increased risk of myocardial infarction and stroke. The objective of this work was to examine the ability of 17β-estradiol (E2) to stimulate calcification of vascular smooth muscle cells (VSMC) in vivo, using aged apolipoprotein E-null mice with advanced atherosclerotic lesions, and subsequently to explore underlying mechanisms in vitro.

APPROACH AND RESULTS

Silastic E2 capsules were implanted into male and female apolipoprotein E-null mice aged 34 weeks. Plaque and calcified area were measured in the aortic sinus and innominate artery after 8 weeks. Immunohistochemical analysis examined expression of the estrogen receptors (estrogen receptor alpha and estrogen receptor beta [ERβ]). VSMC expression of osteogenic markers was examined using digital polymerase chain reaction. Advanced atherosclerotic lesions were present in all mice at the end of 8 weeks. In both male and female mice, E2 increased calcified area in a site-specific manner in the aortic sinus independently of plaque growth or lipid levels and occurred in association with a site-specific decrease in the proportion of ERβ-positive intimal cells. Calcified lesions expressed collagen I and bone sialoprotein, with decreased matrix Gla protein. In vitro, E2 suppressed ERβ expression and increased VSMC mineralization, demonstrating increased collagen I and II, osteocalcin and bone sialoprotein, and reduced matrix Gla protein and osteopontin. Antagonism or RNA silencing of estrogen receptor alpha, ERβ, or both further increased VSMC mineralization.

CONCLUSIONS

We have demonstrated that E2 can drive calcification in advanced atherosclerotic lesions by promoting the differentiation of VSMC to osteoblast-like cells, a process which is augmented by inhibition of estrogen receptor alpha or ERβ activity.

A review of the effect of diet on cardiovascular calcification

Cardiovascular (CV) calcification is known as sub-clinical atherosclerosis and is recognised as a predictor of CV events and mortality. As yet there is no treatment for CV calcification and conventional CV risk factors are not consistently correlated, leaving clinicians uncertain as to optimum management for these patients. For this reason, a review of studies investigating diet and serum levels of macro- and micronutrients was carried out. Although there were few human studies of macronutrients, nevertheless transfats and simple sugars should be avoided, while long chain ω-3 fats from oily fish may be protective. Among the micronutrients, an intake of 800 μg/day calcium was beneficial in those without renal disease or hyperparathyroidism, while inorganic phosphorus from food preservatives and colas may induce calcification. A high intake of magnesium (≥380 mg/day) and phylloquinone (500 μg/day) proved protective, as did a serum 25(OH)D concentration of ≥75 nmol/L. Although oxidative damage appears to be a cause of CV calcification, the antioxidant vitamins proved to be largely ineffective, while supplementation of α-tocopherol may induce calcification. Nevertheless other antioxidant compounds (epigallocatechin gallate from green tea and resveratrol from red wine) were protective. Finally, a homocysteine concentration >12 µmol/L was predictive of CV calcification, although a plasma folate concentration of >39.4 nmol/L could both lower homocysteine and protect against calcification. In terms of a dietary programme, these recommendations indicate avoiding sugar and the transfats and preservatives found in processed foods and drinks and adopting a diet high in oily fish and vegetables. The micronutrients magnesium and vitamin K may be worthy of further investigation as a treatment option for CV calcification.

The predictive value of arterial and valvular calcification for mortality and cardiovascular events

A review of the predictive ability of arterial and valvular calcification has shown an additive effect of calcification in more than 1 location in predicting mortality and coronary heart disease, with mitral annual calcification being a particularly strong predictor. In individual arteries and valves there is a clear association between calcification presence, extent and progression and future cardiovascular events and mortality in asymptomatic, symptomatic and high risk patients, although adjustment for calcification in other arterial beds generally renders associations non-significant. Furthermore, in acute coronary syndrome, culprit plaque is normally not calcified. This would tend to reduce the validity of calcification as a predictor and suggest that the association with cardiovascular events and mortality may not be causal. The association with stroke is less clear; carotid and intracranial artery calcification show little predictive ability, with symptomatic plaques tending to be uncalcified.

Correlation between Rotator Cuff Tears and Systemic Atherosclerotic Disease

The purpose of this study was to investigate the association of aortic arch calcification, a surrogate marker of atherosclerosis, with rotator cuff tendinosis and tears given the hypothesis that decreased tendon vascularity is a contributing factor in the etiology of tendon degeneration. A retrospective review was performed to identify patients ages 50 to 90 years who had a shoulder MRI and a chest radiograph performed within 6 months of each other. Chest radiographs and shoulder MRIs from 120 patients were reviewed by two sets of observers blinded to the others' conclusions. Rotator cuff disease was classified as tendinosis, partial thickness tear, and full thickness tear. The presence or absence of aortic arch calcification was graded and compared with the MRI appearance of the rotator cuff. The tendon tear grading was positively correlated with patient age. However, the tendon tear grading on MRI was not significantly correlated with the aorta calcification scores on chest radiographs. Furthermore, there was no significant correlation between aorta calcification severity and tendon tear grading. In conclusion, rotator cuff tears did not significantly correlate with aortic calcification severity. This suggests that tendon ischemia may not be associated with the degree of macrovascular disease.

Impact of ENPP1 and MMP3 gene polymorphisms on aortic calcification in patients with type 2 diabetes in a Korean population

AIMS

We investigated whether gene polymorphisms of Ecto-nucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) and matrix metalloproteinase 3 (MMP3) are associated with increased vascular calcification in patients with type 2 diabetes (T2D) and evaluated whether serum MMP3 and osteoprotegerin (OPG) levels are related to calcification.

METHODS

This study included 464 subjects: 269 patients with T2D and 195 healthy controls in South Korea. We genotyped subjects for four single nucleotide polymorphisms (SNPs): ENPP1 K121Q, ENPP1 A/G+1044TGA, MMP3 -709A>G and MMP3 -1475G>A. The presence or absence of calcifications in the aortic arch was assessed by plain chest radiography.

RESULTS

The SNPs ENPP1 K121Q and MMP3 -709A>G showed significant associations with T2D (P=0.001 and P=0.004). The SNP ENPP1 K121Q showed a significant association with aortic arch calcification in T2D (P=0.036). Serum OPG levels were significantly higher in T2D patients than in the control group (P<0.001). However, serum MMP3 levels were significantly lower in T2D patients than in the control group (P<0.001).

CONCLUSIONS

Our study demonstrates that the ENPP1 K121Q and MMP3 -709A>G polymorphisms are associated with T2D, and that the ENPP1 Q allele is associated with increased aortic arch calcification in a Korean population.

Relation of infra-renal abdominal aortic calcific deposits and cardiovascular events in patients with peripheral artery disease

In patients with peripheral artery disease, aortic calcific deposits are a common finding. The aim of this study was to assess the association of infrarenal abdominal aortic calcific deposits with prospective cardiovascular events in patients with peripheral artery disease. A consecutive series of 213 patients who presented for investigation of abdominal aortic aneurysm or intermittent claudication were assessed using computed tomographic angiography. Infrarenal abdominal aortic calcific deposits were estimated using a previously defined highly reproducible semiautomated program. Patients were followed prospectively for a median of 2.8 years (interquartile range 1.7 to 3.6), and cardiovascular events were recorded. Kaplan-Meier and Cox proportional-hazards analysis were used to examine the association of calcific deposits with cardiovascular events. A total of 45 cardiovascular events occurred during follow-up, including nonfatal myocardial infarction (n = 23), coronary revascularization (n = 6), stroke (n = 3), below-knee amputation (n = 2), and cardiovascular death (n = 11). The incidence of cardiovascular events was 21.7%, 33.0%, and 36.9% for patients with mild (<400 mm(3)), intermediate (400 to 1,700 mm(3)), and severe (>1,700 mm(3)) abdominal aortic calcific deposits, respectively (p = 0.039). Calcific deposit volume >400 mm(3) (relative risk 2.8, 95% confidence interval 1.2 to 6.6) and coronary artery disease (relative risk 2.8, 95% confidence interval 1.4 to 5.6) were independently associated with increased cardiovascular events during follow-up. In conclusion, abdominal aortic calcific deposits are prognostic for cardiovascular events in patients with peripheral artery disease.

Thoracoabdominal calcifications predict cardiovascular disease mortality in type 2 diabetic and nondiabetic subjects: 18-year follow-up study

OBJECTIVE To evaluate cardiovascular disease (CVD) and total mortality associated with thoracoabdominal calcifications. RESEARCH DESIGN AND METHODS Thoracoabdominal calcifications of native radiograms were evaluated in 833 subjects with type 2 diabetes and 1,292 subjects without diabetes, aged 45-64 years, without prior evidence of CVD. The type 2 diabetic and nondiabetic study cohorts were followed up for 18 years. RESULTS After adjustment for conventional risk factors, marked thoracoabdominal calcifications predicted CVD/total mortality with hazard ratio (HR) (95% CI) of 1.5 (0.8-3.0)/1.8 (1.1-2.9) in type 2 diabetic men, 3.0 (1.6-5.7)/3.1 (1.9-5.0) in type 2 diabetic women, 5.0 (2.2-12)/4.0 (2.2-7.4) in nondiabetic men, and 7.8 (1.8-34)/3.0 (1.3-7.0) in nondiabetic women and in the presence of C-reactive protein below/over 3 mg/l with HR of 2.4 (1.3-4.4)/3.0 (1.4-6.1) in type 2 diabetic subjects and 4.0 (1.5-10.8)/6.6 (2.7-16.0) in nondiabetic subjects. CONCLUSIONS Thoracoabdominal calcifications in native radiograms are significant predictors of CVD and total mortality, especially in type 2 diabetic and nondiabetic women with elevated high-sensitivity C-reactive protein level.

The relationship between Receptor Activator of Nuclear Factor-kappaB Ligand (RANKL) gene polymorphism and aortic calcification in Korean women

The aim of this study was to investigate the relationship between RANKL gene polymorphisms and aortic calcification in Korean women. In 237 healthy Korean women, aortic calcification in thoracic and abdominal aorta was examined in simple radiologic method and lumbar spine and femoral neck BMD were examined by dual energy X-ray absorptiometry. Serum OPG levels, bone turnover markers, such as ALP levels and urine deoxypyridinoline levels, and urine calcium excretion were measured. Genotyping of two RANKL gene polymorphisms, rs2277438 and rs9594782, was performed by allelic discrimination using the 5' nuclease polymerase chain reaction assay. The subjects with CT/CC genotypes of the rs9594782 polymorphism had a 3.9 times higher risk of aortic calcification compared with TT genotype. This significance was significant even after adjustment for age, BMI, blood pressure, fasting plasma glucose, serum high and low-density lipoprotein cholesterol levels. Mean levels of urine deoxypyridinoline were significantly higher in the subjects with AG/GG genotypes of the rs2277438 polymorphism compared with AA genotype, and this significance was persistent even after adjustment for age and BMI. There were no associations of mean values for age, BMI, serum OPG and ALP levels, urine calcium excretion, and BMD with RANKL gene polymorphisms. The RANKL gene rs9594782 polymorphism was associated with aortic calcification in Korean women. Rs2277438 polymorphism showed significant association with urine deoxypyridinoline levels, a bone resorption marker. These results suggest its role on vascular calcification and bone metabolism in humans.

Low bone mineral density is related to atherosclerosis in postmenopausal Moroccan women

BACKGROUND

Some studies have implicated several possible metabolic linkages between osteoporosis and vascular calcification, including estrogen deficiency, vitamin D excess, vitamin K deficiency and lipid oxidation products. Nevertheless, it remains unclear whether osteoporosis and atherosclerosis are related to each other or are independent processes, both related to aging. The aim of this cross-sectional study was to evaluate the correlation between arterial thickening and bone status in a sample of apparently healthy Moroccan women.

METHODS

Seventy-two postmenopausal women were studied. All patients were without secondary causes that might affect bone density. Bone status was assessed by bone mineral density (BMD) in lumbar spine and all femoral sites. Arterial wall thickening was assessed by intima-media thickness (IMT) in carotid artery (CA) and femoral artery (FA). Prevalent plaques were categorized into four groups ranging from low echogenicity to high echogenicity.

RESULTS

The mean age was 59.2 +/- 8.3 years. 84.7% had at least one plaque. By Spearman Rank correlation, CA IMT was negatively correlated to Femoral total BMD (r = -0.33), Femoral neck BMD (r = -0.23), Ward triangle BMD (r = -0.30) and Trochanter BMD (r = -0.28) while there was no association with lumbar BMD. In multiple regression analysis, CA IMT emerged as an independent factor significantly associated with all femoral sites BMD after adjusting of confounding factors. FA IMT failed to be significantly associated with both Femoral and Lumbar BMD. No significant differences between echogenic, predominantly echogenic, predominantly echolucent and echolucent plaques groups were found concerning lumbar BMD and all femoral sites BMD CONCLUSION: Our results demonstrate a negative correlation between bone mineral density (BMD) qnd carotid intima-media thickness (IMT) in postmenopausal women, independently of confounding factors. We suggest that bone status should be evaluated in patients with vascular disease to assess whether preventive or therapeutic intervention is necessarry.

Smoking, smoking cessation and aortic arch calcification in older Chinese: the Guangzhou Biobank Cohort Study

OBJECTIVE

To study the association between smoking, smoking cessation and aortic arc calcification (AAC) in an older Chinese population.

METHODS

A total of 3022 men and 7279 women aged 50-85 years were recruited and received a medical check-up including measurement of fasting plasma vascular risk factors. Two radiologists reviewed the posterior-anterior plain chest X-ray radiographs and assessed AAC together. Information on smoking status, socioeconomic and lifestyle factors was collected.

RESULTS

The crude prevalence of AAC in men (38.58%) was lower than that in women (41.37%). The adjusted odds ratios of AAC increased significantly across never, ex- and current smokers in both genders. Dose-response relationships were observed among current smokers for smoking amount (cigarettes/day), smoking duration (years) and cigarette pack-years in both genders (all p<0.01). The odds ratios decreased significantly (p=0.018) with longer duration of quitting in light ex-smoking men (<23.5 pack-years) but showed no beneficial effect (p=0.72) for heavy ex-smokers (>or=23.5 pack-years).

CONCLUSION

Smoking increased the risk of AAC in Chinese, while smoking cessation decreased the risk only in male light ex-smokers. Chest X-ray is a cheap and simple method to detect AAC, which should be an important warning signal for immediate smoking cessation.

Semiautomated quantification of the mass and distribution of vascular calcification with multidetector CT: method and evaluation

Institutional review board approval was obtained for this HIPAA-compliant study. Informed consent was obtained for prospective evaluation in 21 asymptomatic volunteers (10 women, 11 men; mean age, 60 years) but waived for retrospective (10 patients with and five patients without disease) evaluation. Prospective validation was in phantoms. Quantification of mass and calcium distribution was performed with fast semiautomated method, without calibration. For actual versus measured mass in phantoms, R(2) was 0.98; absolute and percentage errors were 1.2 mg and 9.1%, respectively. In asymptomatic volunteers, mean interscan variability for calcium mass quantification in extracoronary arteries was 24.9 mg; mean was 991 units for Agatston scoring. In coronary arteries, mean variability was 5.5 mg; mean Agatston variability was 27.7 units. At retrospective computed tomography, mean total calcified mass was 321.3 mg. Accurate quantification of mass and distribution of calcification in simulated arteries with this method can be applied in vivo, with low interscan variability.

Prediction of intermittent claudication, ischemic stroke, and other cardiovascular disease by detection of abdominal aortic calcific deposits by plain lumbar radiographs

There has been little attention to vascular calcium testing for generalized assessment of cardiovascular disease (CVD) outcomes, such as intermittent claudication (IC) and ischemic stroke (IS). We hypothesize that aortic calcium is an important predictor of CVD outcomes. Lumbar x-rays were obtained in 848 men and 1,301 women (mean ages 59.7 and 60.1 years, respectively) from the original cohort of the Framingham Heart Study. Abdominal aortic calcium (AAC) deposits were graded using a previously validated scale. Participants were categorized according to a 10-year Framingham coronary heart disease (CHD) risk score. Multivariable Cox proportional hazards analyses were performed to relate AAC to CVD outcomes. There were 199 IC events, 201 IS events, 702 CHD events, and 1,121 CVD events during 32 years of follow-up. Multivariable adjusted hazard ratios for the third versus first AAC tertile in the combined cohort were 1.68 (95% confidence interval [CI] 1.12 to 2.50) for IC, 1.73 (95% CI 1.12 to 2.65) for IS, 1.59 (95% CI 1.26 to 2.00) for CHD, and 1.64 (95% CI 1.37 to 1.97) for CVD. Hazard ratios for IC and IS were similar in magnitude to those for CHD and CVD. A high AAC score was associated with significantly higher incidence of events in subjects at intermediate Framingham CHD risk for all end points. Risk prediction based on cardiovascular risk factors improved for most outcomes when AAC was added. In conclusion, there was a graded, increasing, and independent association of AAC with incident IC and IS, similar in magnitude to risks predicted for CHD and CVD. AAC appears to be useful for risk stratification in patients at intermediate CHD risk.

Premenopausal risk factors for coronary and aortic calcification: a 20-year follow-up in the healthy women study

OBJECTIVE

It is important to understand the early development of subclinical cardiovascular disease (CVD) in women to prevent costly morbidity and mortality associated with CVD events.

METHODS

363 Women enrolled in the Healthy Women Study, Allegheny County, PA, had electron beam tomography measures of coronary (CaC) and aortic (AC) calcification on average 14.6 years after study entry in 1983; 267 had a second EBT 6.4 years later, by 2006. Risk factors were assessed when women were premenopausal and 5 years after the menopause.

RESULTS

Step-wise logistic regression analyses showed that the independent premenopausal predictors of CaC > or = 100 14.6 years later were low-density lipoprotein cholesterol, OR=1.15 (1.03-1.29 for 10 mg/dl) and current smoker, OR=2.72, 1.29-5.71. The same premenopausal risk factors were predictors of AC > or = 500, in addition to premenopausal systolic blood pressure (SBP). Similar results were obtained for predicting calcification 20.6 years later. Postmenopausal risk factors measured 5 years prior to the initial scans were unrelated to CaC and AC, after the significant premenopausal risk factors were taken into account, except for postmenopausal SBP being related to AC.

CONCLUSION

Premenopausal risk factors are strong predictors of postmenopausal CaC and AC. Clinical trials should test if reduction of premenopausal levels of risk factors reduces the risk of early calcification.

Determinants of coronary artery and aortic calcification in the Old Order Amish

BACKGROUND

Coronary artery calcification (CAC) is associated with an increased risk of cardiovascular disease; little is known, however, about thoracic aortic calcification (AC). Our goal was to characterize risk factors for CAC and AC and to estimate the genetic contribution to their variation.

METHODS AND RESULTS

The presence and quantity of CAC and AC were measured with electron beam computed tomography and fasting blood tests and cardiovascular risk factors were obtained in 614 asymptomatic Amish subjects. CAC prevalence was higher in men than women (55% versus 41%; P<0.0001), although there was no sex difference in AC prevalence (51% and 56% in men and women, respectively; P=0.95). Age was more strongly associated with AC presence (odds ratio [OR], 2.7 for 5 years) than CAC presence (OR, 1.9 for 5 years) (homogeneity P=0.001). Subjects with AC had a 3.3-fold higher odds of having CAC. Heritabilities of CAC and AC presence were 0.27+/-0.17 (P=0.04) and 0.55+/-0.18 (P=0.0008), respectively, whereas the heritabilities of quantity of CAC and AC were 0.30+/-0.10 (P=0.001) and 0.40+/-0.10 (P<0.0001), respectively. The genetic correlation between CAC and AC quantity was 0.34+/-0.19, whereas the environmental correlation between these 2 traits was 0.38+/-0.09.

CONCLUSIONS

CAC and AC have similar risk factors, except male gender is associated only with CAC and age is more strongly associated with AC. The patterns of correlations suggest that CAC and AC share some common sets of genes and environmental factors, although it is likely that separate genes and environmental factors also influence calcification at each site.

Aortic arch calcification predicts the extent of coronary atherosclerosis in patients with or without type 2 diabetes: short communication

AIM OF THE STUDY

The aim of this study was to evaluate the sensitivity and specificity of aortic arch calcification for detection of severe coronary atherosclerosis in patients suffering from coronary artery disease (CAD), with or without type 2 diabetes.

PATIENTS AND METHODS

This study included 107 type 2 diabetic patients (68 men) with a mean age of 62.4 +/- 10.7 years and a mean diabetes duration of 14.2 +/- 5.9 years and 104 patients (63 men) with a mean age of 64.5 +/- 9.3 years who did not have diabetes. All patients had CAD, documented by coronary arteriography. Severe CAD was defined as atherosclerosis of the left main branch or atherosclerosis of three coronary arteries or atherosclerosis of the proximal part of the left anterior descending artery. Aortic arch calcification was assessed by means of posteroanterior chest X-rays, studied by a radiologist kept blind to the result of coronary arteriography.

RESULTS

In type 2 diabetic patients, diagnosis of aortic arch calcification had 65.6% sensitivity and 86.9% specificity for detection of severe CAD. In patients without diabetes, diagnosis of aortic arch calcification had 47.7% sensitivity and 96.7% specificity for detection of severe CAD.

CONCLUSIONS

Aortic arch calcification has a high specificity for detection of severe coronary atherosclerosis in patients with CAD. Sensitivity is higher in patients with type 2 diabetes, while specificity is slightly higher in non-diabetic patients.

How predictive is breast arterial calcification of cardiovascular disease and risk factors when found at screening mammography?

OBJECTIVE

The purpose of this study was to examine the relationship between breast arterial calcification (BAC), commonly found on mammography, and cardiovascular disease and its risk factors.

SUBJECTS AND METHODS

The study population, nested within the European Prospective Investigation of Cancer-Norfolk (EPIC-Norfolk) cohort study, consisted of 1,590 women older than 55 years, not taking hormone replacement therapy, and with available screening mammograms. Mammograms were coded by three radiologists for presence or absence of BAC. History of coronary heart disease (CHD), stroke, and diabetes and risk factors for cardiovascular disease (including smoking status, body mass index [BMI], blood pressure, diabetes, and glycosylated hemoglobin [HbA1c]) were independently measured from health examinations in the EPIC study.

RESULTS

The prevalence of BAC was 16.0%. Women with BAC were significantly older than those without it. BAC was associated with prevalent CHD, but not stroke. The odds ratio of having CHD was 2.54 (95% confidence interval, 1.03-6.30). The sensitivity and specificity were 32.4% and 85.5%, respectively. Except for smoking, which showed an inverse association, there was no consistent significant association of BAC with cardiovascular disease risk factors including BMI, diabetes, HbA1c, or lipids.

CONCLUSION

BAC found on mammograms was associated with prevalent CHD after adjustment for age, but with low sensitivity. BAC may provide additional information toward identifying cardiovascular disease risk among otherwise healthy women.

The relationship between four single nucleotide polymorphisms in the promoter region of the osteoprotegerin gene and aortic calcification or coronary artery disease in Koreans

OBJECTIVE

Osteoprotegerin (OPG) is a recently identified cytokine that acts as a decoy receptor for the receptor activator of the NF-kappaB ligand (RANKL). OPG has been shown to be an important inhibitor of osteoclastogenesis and arterial calcification in animal models. OPG has been proposed as a link molecule between osteoporosis and arterial calcification, but the relationship between the OPG gene and the cardiovascular system in human populations is unclear. Thus, the aim of this study was to investigate the relationship between OPG gene polymorphisms and aortic calcification or coronary artery disease in Koreans.

DESIGN AND PATIENTS

Genotyping of four polymorphisms, A163G, G209A, T245G and T950C, in the promoter region of the OPG gene was performed in 251 healthy Korean women (mean age 51.3 +/- 6.9 years) and in a second study population consisting of 100 patients who underwent coronary angiography (mean age 57.0 +/- 11.9 years), by allelic discrimination using the 5' nuclease polymerase chain reaction assay. Cardiovascular risk factors and serum OPG levels were measured and aortic calcification in thoracic and abdominal aorta was examined by simple radiological methods.

RESULTS

In the first study population, the prevalence of aortic calcification increased significantly as the subjects grew older. The frequencies of mutant alleles were significantly higher in the subjects with aortic calcification compared with those without aortic calcification in G209A and T950C polymorphisms, although these significances were lost after adjustment for age. No significant relationship was found between OPG gene polymorphisms and serum OPG levels or cardiovascular risk factors. In the second study group, there were no associations between OPG promoter genotypes and aortic calcification, serum OPG levels, or coronary artery disease.

CONCLUSIONS

We observed that the four polymorphisms in the promoter region of the OPG gene were not associated with aortic calcification or coronary artery disease in Koreans. Further studies are needed to clarify this relationship.

Coronary calcification and osteoporosis in men and postmenopausal women are independent processes associated with aging

The objective of this study was to investigate whether low bone mass is directly associated with the severity of coronary atherosclerosis in men and postmenopausal women self-referred for evaluation of coronary atherosclerosis and osteoporosis. Low bone mass was evaluated by measurement of bone mineral density (BMD) using quantitative computerized tomography (QCT). Coronary atherosclerosis was evaluated by measurement of coronary calcium (CC) burden using electron beam computerized tomography (EBCT). Using a cross-sectional design, we tested the hypothesis that osteoporosis and coronary atherosclerosis are correlated, age-dependent processes. Study variables were BMD, CC scores, and other known risk factors for osteoporosis and atherosclerosis. Qualifying for the study were 313 postmenopausal women and 167 men. Men had higher baseline CC scores and higher body mass indexes compared to women. In females, those patients with coronary calcification were older and had significantly lower BMD compared to those without calcification. In males, those patients with coronary calcification were older. By univariate correlation analysis, the degree of coronary calcification was inversely associated with BMD in postmenopausal women (P < 0.0001) but not in men. However, after controlling for age, this association was absent for both men and postmenopausal women. Using multivariate logistic regression analysis in women and men separately, age was the only significant predictor of positive CC status and low BMD. Our study suggests that in postmenopausal women and in men, after controlling for age, osteoporosis and coronary atherosclerosis are independent processes.

Aortic calcification

OBJECTIVES

Vascular calcification is a complicating factor observed in advanced atherosclerosis. This review summarises the present knowledge regarding abdominal aortic calcification.

DESIGN

Literature review.

METHODS

A literature review was carried using MEDLINE and PUBMED with the search terms 'abdominal', 'aortic' and 'calcification'. Articles were assessed for data regarding mechanisms, measurement, risk factors and outcomes of aortic calcification.

RESULTS

Thirty relevant studies were identified. These demonstrated a positive correlation between abdominal aortic calcification and the following factors: older age, hypertension, and smoking. Further studies are required to critically assess other risk factors such as gender, diabetes mellitus and renal failure. Calcification of the abdominal aorta is associated with an increased risk of mortality, coronary heart disease and stroke.

CONCLUSION

Aortic calcification predicts an increased incidence of cardiovascular events, however, the reasons for this association requires further investigation. Accurate measurement of aortic calcification is likely to be increasingly used to determine the risk of cardiovascular events.

Tobacco smoking and subgingival dental calculus

OBJECTIVE

A radiographic investigation into the relationship between tobacco smoking and subgingival dental calculus was conducted in an adult population, including 48 current smokers, 57 former smokers, and 125 non-smokers.

MATERIAL AND METHODS

Assessment of subgingival calculus was based on a full set of radiographs. Mesial and distal root surfaces were assessed as to presence or absence of radiopaque deposits apical to the cemento-enamel junction. The severity of subgingival calculus deposition, labeled subgingival calculus load, was estimated from both the total number and the proportion of proximal sites affected.

RESULTS

The overall prevalence of individuals exhibiting at least one subgingival calculus positive site was 43%, ranging from 15% in age stratum 20-34 years to 72% in age stratum 50-69 years. The prevalence among current smokers, former smokers, and non-smokers was 71%, 53%, and 28%, respectively. The differences between smoking groups were statistically significant (p<0.001). The mean subgingival calculus load of current smokers, former smokers, and non-smokers was 3.4, 1.2, and 0.6 affected sites per person, respectively, or expressed as mean proportions, 6.2%, 2.4%, and 1.1%, respectively. The association between smoking and subgingival calculus load was statistically significant (p<0.001). The subgingival calculus load increased with increasing smoking exposure, suggesting a dose-response relationship.

CONCLUSION

The present observations in dentally aware adults indicate a strong and independent impact of tobacco smoking on subgingival calculus deposition.

Aortic calcification is associated with age and sex but not left ventricular mass in essential hypertension

The aim of this study was to investigate the prevalence of aortic calcification in patients with essential hypertension and its relationship with age, sex, and left ventricular hypertrophy. Two hundred ninety consecutive patients with essential hypertension were studied. A chest radiograph and an echocardiograph were performed. Aortic calcification was observed in 74/290 (25.5%) patients. Patients with calcification were mostly female (67.6%) and older (71.8+1.9 years), whereas patients without calcification were younger (59.0+0.79) and of both sexes (51.85% female). Left ventricular mass index in male patients with aortic calcification was 147.3+4.32 g/m(2) and without calcification was 132.7+2.28 g/(2) (p=0.023). Female patients' values were 131.9+4.32 g/m(2) with calcification and 121.2+2.85 g/m(2) without calcification (p=0.025). Left ventricular mass was independently associated with age and sex but not with aortic calcification. The prevalence of aortic calcification in essential hypertension is considerably higher compared to the general population. Essential hypertension and age seem to contribute to the concurrent appearance of aortic calcification and increased left ventricular mass.

Aortic valve calcification in hypertensive patients: prevalence, risk factors and association with transvalvular flow velocity

BACKGROUND

The important role of the "nonobstructive" aortic valve calcification (AVC) in cardiovascular morbidity and mortality has recently been emphasized. The present work had two goals: (1) to analyze the prevalence and factors determining the extent of AVC in hypertensive patients; (2) to investigate a possible association between the extent of AVC and flow velocity across the aortic valve.

METHODS

This was a prospective study performed in a university hospital. The sample included 263 consecutive patients (139 men and 124 women), mean age 65+/-6, who underwent echo-Doppler. The upper quartile of peak flow velocity across the aortic valve (>130 mm/s in our population) was defined as augmented flow velocity.

RESULTS

There were 31 (12%) patients in the advanced AVC group and 122 (46%) without any calcified deposits (the no AVC group). The remaining 110 (42%), who did not meet criteria for advanced AVC, comprised the trivial AVC group. Peak flow velocity was significantly higher in patients with advanced vs. trivial AVC and no AVC groups: 135+/-45, 116+/-23 and 113+/-23 cm/s, respectively; p=0.0002. Prevalence of augmented transvalvular aortic flow was significantly higher (p=0.01) among patients with advanced AVC (41.9%) vs. trivial (20.9%) and no AVC (20.5%). Multivariate analyses identified age as the only independent variable associated with advanced AVC [OR 1.6 (CI 1.2-2.3), 5 years increment]. Advanced AVC and female gender were identified as independent variables for augmented transvalvular aortic flow with OR 2.9 (CI 1.3-6.4) and 2.5 (CI 1.4-4.6), respectively.

CONCLUSIONS

Prevalence of AVC among hypertensive patients is high and clearly age-related. Female gender and advanced (but not trivial) AVC are associated with augmented aortic transvalvular peak flow. Our results stress the role of protruding calcium deposits in augmentation of rest flow velocity across the aortic valve regardless of visible restriction of leaflet opening.

Low bone mineral density in the hip as a marker of advanced atherosclerosis in elderly women

Previous studies indicate that low bone mineral density (BMD) in the hip is a useful predictor of cardiovascular mortality among the elderly. The objective of this study was to investigate whether low hip BMD is directly associated with the severity of atherosclerosis. The per-protocol population consisted of 963 women aged 60-85 years. Study variables were aortic calcification (AC) graded on lateral lumbar radiographs, BMD at various anatomic sites (distal radius, lumbar spine, proximal femur) measured by DXA, information on various risk factors, and medical history. After adjustment for age, BMD at the proximal femur, but not at the radius or spine BMD, showed statistically significant association with the severity of AC (r = -0.12-17, P < 0.001). Age, years since menopause, BMI, level of education, current and previous smoking, and weekly fitness activity were significant common risk factors (all P < 0.05) with contrasting influence on AC and hip BMD. In a multiple regression model, AC contributed significantly and independently to the variation in hip BMD (beta = -0.10, P = 0.004). Impaired blood flow represented by 40 women with documented history of intermittent claudication was not an independent contributor and did not alter the association between AC and hip BMD. However, AC and demineralization in the hip was particularly severe in women with intermittent claudication accompanied by a higher prevalence of coronary heart disease compared with age-matched controls (all P < 0.001). In conclusion, severe osteoporosis in the hip may indicate advanced atherosclerosis and thereby an increased risk for not only hip fractures but also for coronary heart disease. The results further emphasize that osteoporosis in the hip and peripheral vascular disease are linked by common risk factors and pathomechanisms.

B-mode ultrasound-detected carotid artery lesions with and without acoustic shadowing and their association with markers of inflammation and endothelial activation: the atherosclerosis risk in communities study

In a cross-sectional study of 8695 men and women free of clinical CVD, aged 45-64 years at the 1987-1989 baseline Atherosclerosis Risk in Communities (ARIC) study exam, we examined the relationship between carotid artery lesions (CALs), with and without acoustic shadowing (AS) as an index of plaque mineralization, to systemic markers of inflammation and markers of endothelial function, including endothelial adhesion molecules. A three-level variable, based on the presence of extracranial CALs and AS, identified by B-mode ultrasound of six 1 cm arterial segments, defined the outcome. Among subjects without evidence of AS, after controlling for age, gender, ethnicity, study site, body mass index, hypertension, diabetes, and smoking status, CALs were associated with systemic markers of inflammation, including higher levels of fibrinogen [OR=1.24 (95% CI: 1.09, 1.40)] and white blood cell count [OR=1.37 (95% CI: 1.21, 1.56)]. Among subjects with a CAL, after controlling for the above risk factors as well as mean far wall intima-media thickness, AS was associated with higher levels of von Willebrand factor [OR=1.38 (95% CI: 1.10, 1.74)], a marker of endothelial activation. Associations with endothelial adhesion molecules were inconsistent. Further studies aimed at elucidating the mechanisms of arterial mineralization are warranted.

Educational attainment and coronary and aortic calcification in postmenopausal women

OBJECTIVE

Low socioeconomic status is a risk factor for clinical coronary heart disease, a relatively crude outcome associated with important biases. By avoiding these biases, subclinical assessments could facilitate efforts to understand the association between socioeconomic status and coronary disease. The current study 1) evaluated the nature of the associations between educational attainment and subclinical atherosclerosis and 2) examined if biologic, behavioral, and psychosocial factors mediated these associations.

METHODS

Participants were 308 women from the Healthy Women Study who underwent a clinic examination of risk factors either 5 (N = 32) or 8 (N = 276) years after the menopausal transition. Aortic and coronary calcification were measured using electron beam tomography.

RESULTS

Logistic regression analysis with orthogonal polynomials revealed a marginally significant linear trend for coronary calcification, with the more educated groups showing lower calcification than the less educated groups. A significant linear trend was also observed for aortic calcification. In addition, a marginally significant quadratic trend was observed for aortic calcification so that the effect began to reverse at the highest level of education. Measured risk factors were associated with education and with the calcification outcomes, but they explained little of the associations between educational attainment and coronary or aortic calcification. None of the factors tested met the minimum criterion for mediation.

CONCLUSIONS

The findings show that lower education is associated with greater early stage atherosclerosis. Subclinical assessments, such as electron beam tomography, represent useful alternatives for studies of socioeconomic status and coronary artery disease.

Hormone replacement therapy and coronary heart disease. A new debate

Hormone replacement therapy is extensively used in the United States, especially for the possible prevention of heart disease, osteoporotic fractures, and, more recently, dementia. The results of recent clinical trials have raised new questions about the risk and benefits of estrogen or estrogen/progesterone therapy to prevent heart attacks, the choice of specific drug therapy such as specialized estrogen receptor modulation (SERM). The change in risk factors, especially weight gain or obesity, may determine the risks and benefits of hormone replacement therapy.

A comparison of the calcium-free phosphate binder sevelamer hydrochloride with calcium acetate in the treatment of hyperphosphatemia in hemodialysis patients

Current phosphate binders used in hemodialysis patients include calcium-based binders that result in frequent hypercalcemia and aluminum-based binders that result in total body aluminum accumulation over time. This investigation describes the use of a calcium- and aluminum-free phosphate-binding polymer in hemodialysis patients and compares it with a standard calcium-based phosphate binder. An open-label, randomized, crossover study was performed to evaluate the safety and effectiveness of sevelamer hydrochloride in controlling hyperphosphatemia in hemodialysis patients. After a 2-week phosphate binder washout period, stable hemodialysis patients were administered either sevelamer or calcium acetate, and the dosages were titrated upward to achieve improved phosphate control over an 8-week period. After a 2-week washout period, patients crossed over to the alternate agent for 8 weeks. Eighty-four patients from eight centers participated in the study. There was a similar decrease in serum phosphate values over the course of the study with both sevelamer (-2.0 +/- 2.3 mg/dL) and calcium acetate (-2.1 +/- 1.9 mg/dL). Twenty-two percent of patients developed a serum calcium greater than 11.0 mg/dL while receiving calcium acetate, versus 5% of patients receiving sevelamer (P < 0.01). The incidence of hypercalcemia for sevelamer was not different from the incidence of hypercalcemia during the washout period. Patients treated with sevelamer also sustained a 24% mean decrease in serum low-density lipoprotein cholesterol levels. Sevelamer was effective in controlling hyperphosphatemia without resulting in an increase in the incidence of hypercalcemia seen with calcium acetate. This agent appears quite effective in the treatment of hyperphosphatemia in hemodialysis patients, and its usage may be advantageous in the treatment of dialysis patients.

Aging and cardiovascular disease. Use of subclinical measurements

This article examines the use of subclinical measurements in cardiovascular disease in the elderly. In the past 10 years, the development of new technology to measure subclinical disease has provided the opportunity to evaluate the prevalence of subclinical disease, the risk factors for subclinical disease, and the risk for clinical disease given the presence or absence of subclinical disease.