Atherosclerotic risk factors revisited

The Effect of Clinically Indicated Liraglutide on Pericoronary Adipose Tissue in Type 2 Diabetic Patients

Vascular inflammation can be detected in the pericoronary adipose tissue (PCAT) by coronary computed tomography angiography (CCTA) attenuation. Treatment with liraglutide is associated with anti-inflammatory effects and reduces cardiovascular risk in diabetic patients. This study is aimed at examining the effect of clinically indicated liraglutide on PCAT attenuation. Asymptomatic patients with type 2 diabetes mellitus (T2DM) and without known ischemic heart disease underwent clinical examination, blood analysis, and CCTA. The main coronary arteries were outlined and PCAT attenuation was measured on the proximal 40 mm. Patients treated with liraglutide on a clinical indication were compared to patients not receiving liraglutide. The study included 190 patients; 53 (28%) received liraglutide (Lira+) and 137 (72%) did not (Lira-). There were no significant differences in PCAT attenuation between the two groups in either artery. However, PCAT attenuation measured around the left anterior descending artery (LAD) was lower in the Lira+ group after adjustment for age, sex, body mass index, and T2DM duration (b coefficient -2.4, p = 0.029). In a population of cardiac asymptomatic T2DM patients, treatment with clinically indicated liraglutide was not associated with differences in PCAT attenuation compared to nonliraglutide treatment in the unadjusted model. An association was seen in the adjusted model for the left anterior descending artery, possibly indicating an anti-inflammatory effect.

Relationship of subclinical coronary atherosclerosis and National Cholesterol Education Panel guidelines in asymptomatic Brazilian men

BACKGROUND AND OBJECTIVE

Coronary heart disease (CHD) is the leading cause of death worldwide including Brazil. Improved precision in detecting early coronary disease may aid in more targeted preventive therapy. The National Cholesterol Education Program (NCEP) provides guidelines for determining the aggressiveness of primary prevention strategies including lipid lowering based on Framingham risk equation. Identification of subclinical atherosclerosis and coronary plaque burden is a step towards identifying high-risk individuals. This investigation was designed to determine how the updated NCEP guidelines classify asymptomatic individuals with presence of any as well as advanced CACS (coronary artery calcium score), a powerful intermediary for CHD events, in asymptomatic Brazilian men.

METHODS AND RESULTS

Five hundred forty-six asymptomatic Brazilian men (mean age: 46+/-7 years) presented to a single electron beam tomography (EBT) facility in Sao Paulo. The study population was categorized into low risk (0-1 risk factors, n=166, 30%), intermediate risk (> or = 2 risk factors but < 10% risk of CHD over 10 years, n=150, 27%), moderately high risk (2 risk factors and 10-20% risk of hard CHD events in 10 years, n=147, 28%) and high-risk (> or = 2 risk factors and > 20% risk of hard CHD events in 10 years, n=83, 15%), respectively. In our study population, overall no CACS, mild CACS (1-99.9), moderate-severe CACS (> or = 100) were observed in 317 (58%), 160 (29%) and 69 (13%) men, respectively. Advanced calcification (CACS > or = 75th percentile for age) was present in 19% (n=104) men. Based on the LDL-C cutoffs recommended by the NCEP guidelines for initiation of lipid lowering, overall only 55% with CACS > or = 100 and 42% men with CACS > or = 75th percentile qualified for pharmacotherapy. As a result nearly half of individuals with CACS > or = 100 (45%) and CACS > or = 75th percentile (48%) missed eligibility for drug therapy.

CONCLUSION

Our findings reveal the potential limitation of NCEP guidelines in identifying asymptomatic Brazilian men with significant coronary atherosclerosis who are potential candidates for aggressive primary prevention. Assessment of CACS may provide incremental value to global risk assessment in high-risk Brazilian men.

Detection of high-risk young adults and women by coronary calcium and National Cholesterol Education Program Panel III guidelines

OBJECTIVES

The purpose of this study was to investigate the classification of cardiovascular risk in young individuals and women according to the National Cholesterol Education Program (NCEP) guidelines across a continuum of coronary calcium scores (CCS).

BACKGROUND

Current NCEP guidelines might underestimate cardiovascular risk in young individuals and women.

METHODS

The study population consisted of 1,611 asymptomatic individuals (67% men, mean age: 53 +/- 10 years) who presented to a single electron beam tomography facility for coronary artery calcium screening. Participants were categorized into low-risk (n = 738, 46%), intermediate-risk (n = 583, 36%), moderately high-risk (n = 263, 16%), and high-risk (n = 27, 2%) according to the NCEP Panel III guidelines.

RESULTS

Absence of calcium, CCS of 0 to 99 (mild), 100 to 399 (moderate), and > or =400 (severe), was observed in 572 (35%), 707 (44%), 192 (12%), and 140 (9%) of the patients, respectively. A high CCS percentile (> or =75th percentile) was present in 426 (26%) individuals. Overall, 59% and 78% of participants with CCS > or =400 and CCS > or =75th percentile were not identified as high risk and candidates for pharmacotherapy on the basis of NCEP categories. Furthermore, women as well as young individuals were less likely to be considered candidates for pharmacotherapy compared with men and older individuals in each CCS category.

CONCLUSIONS

The NCEP guidelines seem to underestimate cardiovascular risk in young asymptomatic individuals and women. For these individuals, assessment of plaque burden might provide incremental value to global risk assessment.

Reflections on depression as a cardiac risk factor

OBJECTIVE

Major North American cardiology organizations do not currently list depression among the officially recognized cardiac risk factors, yet many behavioral medicine specialists believe depression to be an important risk. We wondered what was missing from the available data.

METHODS

The Medline, Current Contents, and PsychInfo databases were used to perform a systematic review of the literature linking depression and depressive symptoms with cardiac disease outcomes. Because of previous reviews, we paid particular attention to publications from 2001 to 2003.

RESULTS

We identified 21 etiologic and 43 prognostic publications that had prospective designs, used recognized measures of depression, and included objective outcome measures. We also identified 79 review articles. In addition to issues of sample size, sample characteristics, and timing of measures, we noted heterogeneity in the definitions of depression, frequent repeat publications from the same data sets, heterogeneity of outcome measures, a variety of approaches for covariate selection, and a preponderance of review articles, all factors that cannot help to convince skeptics.

CONCLUSIONS

Despite these issues, the bulk of the data from prospective studies with recognized indices of depression and objective outcome measures is supportive of depression as a cardiac risk factor.