A practical approach to risk assessment to prevent coronary artery disease and its complications

Incidence of Metabolic Syndrome in Young Japanese Adults in a 6-Year Cohort Study: The Uguisudani Preventive Health Large-Scale Cohort Study (UPHLS)

INTRODUCTION

To clarify the incidences of metabolic syndrome (MS) and risks in young Japanese adults by gender.

METHODS

A total of 58,901 adults who had undergone annual health check-ups in 2010 without a diagnosis of MS or missing data were divided into three age groups (20s through 40s) by gender. Participants were followed up for 6 years for new-onset MS according to Japanese criteria. The incidences of MS and risks were analyzed using the Cox proportional hazards model to adjust for confounding factors.

RESULTS

The incidences of MS per 1,000 person-years were 2.2, 5.5, and 10.2 for women aged in their 20s, 30s, and 40s, respectively, and 26.3, 40.5, and 57.4 in the respective men groups. Compared with the group aged in their 40s, the hazard ratios of new MS were 0.19 (95% confidence interval [CI], 0.13-0.29) for women in their 20s and 0.50 (95% CI, 0.41-0.61) for women in their 30s, and 0.46 (95% CI, 0.42-0.50) and 0.70 (95% CI, 0.66-0.73) for men in their 20s and 30s, respectively, after adjustment for lifestyle factors. For women, MS was associated with smoking in their 20s and 30s, and eating speed in their 30s, and for men, was associated with physical activity, eating speed, alcohol intake in their 20s and 30s, and smoking in their 30s.

CONCLUSION

Our findings suggest that the incidences of MS in the 20s and 30s are lower, but account for about 20-50% of women with MS and 50-70% of men with MS in their 40s. However, the data are not negligible and early lifestyle intervention for MS is necessary in young adults.

Blood pressure control and cardiovascular risk profile in hypertensive patients under specialist care in Argentina: Results from the CHARTER study

Worldwide, hypertension control rate is far from ideal. Some studies suggest that patients treated by specialists have a greater chance to achieve control. The authors aimed to determine the BP control rate among treated hypertensive patients under specialist care in Argentina, to characterize patients regarding their cardiovascular risk profile and antihypertensive drug use, and to assess the variables independently associated with adequate BP control. The authors included adult hypertensive patients under stable treatment, managed in 10 specialist centers across Argentina. Office BP was measured thrice with a validated oscillometric device. Adequate BP control was defined as an average of the three readings <140/90 mm Hg (and <150/90 in patients older than 80 years). The authors estimated the proportion of adequate BP control and the variables independently associated with it through a multiple conditional logistic regression model. Among the 1146 included patients, 48.2% were men with a mean age of 63.5 (±13.1) years old. Mean office BP was 135.3 (±14.8)/80.8 (±10) mm Hg, with a 64.8% (95% CI: 62%-67.6%) of adequate control. The mean number of antihypertensive drugs was 2.1 per participant, the commonest being angiotensin receptor blockers and calcium channel blockers. In multivariable analysis, only female sex was a predictor of adequate BP control (OR 1.33 [95% CI 1.02-1.72], P = .04). In conclusion, almost 65% of hypertensive patients treated in specialist centers in Argentina have adequate BP control. The challenge for future research is to define strategies in order to translate this control rate to the primary care level, where most patients are managed.

Reproducibility of masked uncontrolled hypertension detected through home blood pressure monitoring

Masked uncontrolled hypertension (MUCH) is an entity described in treated hypertensive subjects, where office blood pressure (BP) is well controlled and out-of-office BP is elevated. It has been related to a higher cardiovascular risk. However, the reproducibility of MUCH has been scarcely studied. In this study, we aimed to determine the reproducibility of MUCH detected through home blood pressure monitoring (HBPM). Two sets of measurements were performed in hypertensive adults under stable treatment with a 1-week interval. Each set of measurements included three office BP readings and a 4-day HBPM with duplicate readings in the morning, afternoon, and evening (the same validated oscillometric device was employed in both settings). We determined the percentage of agreement regarding the presence of MUCH in the two sets of measurements and quantified such agreement through the Cohen's kappa coefficient (κ), its 95% confidence interval, and P value. We included 105 patients (median age 58.6 [IQR 45.6-67.2] years old, 53.4% men). MUCH prevalence on at least one occasion was 22.3% (95% CI: 15.2-31.5). The reproducibility of MUCH was scant: κ = 0.19 (95% CI: 0.0002-0.38), P = 0.02, due to the poor reproducibility of the office BP component of MUCH in comparison with the home BP component: κ = 0.21 (95% CI: 0.03-0.39), P = 0.01 vs κ = 0.48 (95% CI 0.29-0.67), P < 0.001, respectively. In conclusion, the reproducibility of MUCH detected through HBPM is minimal, mainly due to the poor reproducibility of office BP measurements. An HBPM-based strategy for the management of patients with MUCH may be more adequate in terms of cardiovascular morbidity and mortality.

Effects of computer-assisted navigation versus conventional total knee arthroplasty on the levels of inflammation markers: A prospective study

Total knee arthroplasty (TKA) is a well-established modality for the treatment of advanced knee osteoarthritis (OA). However, the detrimental effects of intramedullary reaming used in conventional TKA for distal femur cutting are of concern. Avoiding intramedullary reaming with the use of computer-assisted navigation TKA can not only provide superior prosthetic alignment, but also mitigate perioperative blood loss and the dissipation of marrow emboli. We quantified local and systemic concentrations of inflammation markers for both techniques. Forty-four participants undergoing computer-assisted navigation and 53 receiving conventional TKA for advanced knee OA were recruited between 2013/02/08 and 2015/12/09. Blood samples were collected from all participants at baseline then again at 24 and 72 hours postoperatively and analyzed by ELISA for interleukin 6 (IL-6), IL-10, tumor necrosis factor alpha (TNF-α) and transforming growth factor beta 1 (TGF-β1); these markers were also measured in Hemovac drain fluid collected at 24 and 72 hours. Serum levels of IL-6, IL-10, TNF-α and TGF-β1(unit for all markers: pg/mL) were increased from baseline by smaller increments in the navigation TKA cohort compared with the conventional TKA group at 24 hours (17.06 vs 29.39, p = 0.02; 0.51 vs 0.83, p = 0.16; -0.04 vs 0.36, p < 0.01 and -48.18 vs 63.24, p< 0.01, respectively) and at 72 hours (12.27 vs 16.87, p = 0.01; -0.40 vs 0.48, p < 0.01; 0.58 vs 0.98, p = 0.07 and -55.16 vs 63.71, p < 0.01, respectively). IL-10 levels in drainage fluids collected 24 hours after TKA were also significantly lower in the navigation group versus the conventional TKA group (8.55 vs 12.32, p < 0.01). According to our evidence, the merits of computer-assisted navigation TKA are augmented by low levels of inflammation markers.

Distribution of lifestyle and emerging risk factors by 10-year risk for coronary heart disease

BACKGROUND

The Framingham risk score has been used for coronary heart disease (CHD) risk assessment. Recently, additional risk factors not included in the Framingham algorithm have received much attention and may help improve risk assessment. We examined the distributions of lifestyle and emerging risk factors by 10-year risk of CHD.

METHODS

We calculated 10-year CHD risk (<10%, 10-20%, and >20%) for 8355 participants in the National Health and Nutrition Examination Survey (NHANES) 1999-2002 using the Framingham risk score as modified by the National Cholesterol Education Program Adult Treatment Panel III guidelines. We examined the prevalence of lifestyle risk factors [body mass index (BMI) and waist circumference] and various emerging risk factors [C-reactive protein (CRP), white blood cell count, fibrinogen, homocysteine, glycosylated hemoglobin, and albuminuria] as well as prevalence of high CHD risk by levels of these risk factors.

RESULTS

All examined CHD risk factors were significantly associated with increasing 10-year CHD risk among men and women. Odds of being in the highest CHD risk group were greater at higher levels of examined risk factors. Means for most risk factors were slightly higher for women than the means for men. Sizeable proportions of participants with lower 10-year CHD risk had high levels of lifestyle and emerging risk factors: 60.8% were overweight, 33.8% had high CRP concentrations, 24.1% had serum fibrinogen >400 mg/dl and 6% had an albumin/creatinine ratio >/=30.

CONCLUSIONS

Lifestyle and emerging risk factors, in addition to those included in the Framingham risk score, may be important in CHD risk assessment.

Development of Health Parameter Model for Risk Prediction of CVD Using SVM

Current methods of cardiovascular risk assessment are performed using health factors which are often based on the Framingham study. However, these methods have significant limitations due to their poor sensitivity and specificity. We have compared the parameters from the Framingham equation with linear regression analysis to establish the effect of training of the model for the local database. Support vector machine was used to determine the effectiveness of machine learning approach with the Framingham health parameters for risk assessment of cardiovascular disease (CVD). The result shows that while linear model trained using local database was an improvement on Framingham model, SVM based risk assessment model had high sensitivity and specificity of prediction of CVD. This indicates that using the health parameters identified using Framingham study, machine learning approach overcomes the low sensitivity and specificity of Framingham model.

A common variant association study reveals novel susceptibility loci for low HDL-cholesterol levels in ethnic Arabs

The genetic susceptibility to acquiring low high density lipoprotein-cholesterol (LHDLC) levels is not completely elucidated yet. In this study, we performed a common variant association study for harboring this trait in ethnic Arabs. We employed the Affymetrix high-density Axiom Genome-Wide ASI Array (Asian population) providing a coverage of 598,000 single nucleotide variations (SNPs) to genotype 5495 individuals in a two-phase study involving discovery and validation sets of experiments. The rs1800775 [1.31 (1.22-1.42); p = 3.41E-12] in the CETP gene and rs359027 [1.26 (1.16-1.36); p = 2.55E-08] in the LMCD1 gene were significantly associated with LHDLC levels. Furthermore, rs3104435 [1.26 (1.15-1.38); p = 1.19E-06] at the MATN1 locus, rs9835344 [1.16 (1.08-1.26); p = 8.75E-06] in the CNTN6 gene, rs1559997 [1.3 (1.14-1.47); p = 9.48E-06] in the SDS gene and rs1670273 [1.2 (1.1-1.31); p = 4.81E-06] in the DMN/SYNM gene exhibited suggestive association with the disorder. Seven other variants including rs1147169 in the PLCL1 gene, rs10248618 in the DNAH11, rs476155 in the GLIS3, rs7024300 in the ABCA1, intergenic rs10836699, rs11603691 in P2RX3 and rs750134 in CORO1C gene exhibited borderline protective properties. Validation and joint meta-analysis resulted in rs1800775, rs3104435 and rs359027 retaining their predisposing properties, while rs10836699 and rs11603691 showed protective properties. Our data show several predisposing variants across the genome for LHDLC levels in ethnic Arabs.

Effects of Computer Navigation versus Conventional Total Knee Arthroplasty on Endothelial Damage Marker Levels: A Prospective Comparative Study

Total knee arthroplasty (TKA) inevitably perturbs the femoral medullary canal, which increases blood loss or morbidities associated with marrow embolization postoperatively. Computer navigation TKA reportedly minimizes medullary disturbance to alleviate perioperative blood loss. We performed a prospective comparative study, enrolling 87 patients with osteoarthritic knees from March 2011 to December 2011 in our hospital. The patients were separated into two groups, according to the surgeon they visited. Fifty-four patients underwent computer navigation TKAs and 33 had conventional TKAs. Levels of cell adhesion molecules (CAMs), including intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and platelet endothelial cellular adhesion molecule-1 (PECAM-1) in sera and hemovac drainage were measured by ELISA before and 24 hours after the surgery. We showed that patients receiving computer navigation TKAs had less blood loss and lower CAMs in serum and hemovac drainage after the operation. Less postoperative elevation of serum ICAM-1 (p=0.022) and PECAM-1 (p=0.003) from the preoperative baseline after the surgery was also noted. This study provides molecular evidence for the differential extent in vascular injury between conventional and navigation TKAs and sheds light on the possible benefits of computer navigation TKAs.

The reliability of body mass index in the diagnosis of obesity and metabolic risk in children

BACKGROUND

Body mass index (BMI) is the most widespread and the simplest method for the evaluation of body mass; it is often used as a sole technique in the diagnosis of obesity in children. The objective of the study was to evaluate the relationship between anthropometric and biochemical parameters and the incidence of the metabolic syndrome in obese children.

METHODOLOGY

A total of 110 children, aged 2-17 years, participated in the study. No overweight children (BMI 85-95 percentiles) were included. BMI was interpreted using the 2000 Centers for Disease Control and Prevention Growth Charts. The skinfold measurements were performed using an John Bull British Indicators Ltd. calipers, and interpreted using an the reference table values.

RESULTS

In addition to lower sensitivity (mentioned in several earlier studies), BMI also shows a lower specificity in the diagnosis of obesity in children: BMI showed at least 10% of non-concomitance with skinfold thickness and waist circumferences and 8% with waist-to-height ratio. In addition, subscapular skinfold thickness, waist circumference, and waist/height ratio showed stronger correlations with serum insulin levels, low-density lipoprotein cholesterol, and family history than BMI itself.

CONCLUSION

The unreliability of BMI as the sole parameter for diagnosing obesity in children was found in our study. Even when overweight children were excluded from the study, the lack of specificity of BMI was demonstrated. We propose utilization of waist circumference and waist/height ratio along with the BMI for definitive diagnosis instead of relying on BMI only. In addition, waist circumference and subscapular fold thickness may be even better in estimation of metabolic risk than BMI.

Healthcare costs of the combination of metformin/dipeptidyl peptidase-4 inhibitors compared with metformin/other oral antidiabetes agents in patients with type 2 diabetes and metabolic syndrome

OBJECTIVES

This study assessed the health costs resulting from the combination of metformin/dipeptidyl peptidase-4 (DPP-4) inhibitors compared with metformin/oral antidiabetes drugs in patients with type 2 diabetes and metabolic syndrome (MS).

PATIENTS AND METHODS

An observational retrospective study was performed. Patients ≥30 years of age who were receiving treatment with metformin who started a second oral antidiabetes therapy in 2008 and 2009 were included. Patients were divided into two groups: (a) metformin plus DPP-4 inhibitors and (b) metformin plus other oral antidiabetes drugs. The main measures were compliance, persistence, metabolic control (glycosylated hemoglobin level of <7%), and complications (hypoglycemia and cardiovascular events). Healthcare and non-healthcare costs were calculated. Patients were followed up for 2 years. An analysis of covariance was carried out (P<0.05 was considered significant).

RESULTS

Of the 1,435 patients (mean age, 67.3 years; 53.1% male) who were enrolled, 442 (30.8%) were receiving metformin plus DPP-4 inhibitors, and 993 (69.2%) were receiving metformin plus other oral antidiabetes drugs. The prevalence of MS was 72.2% (95% confidence interval, 71.1-73.3%). Patients treated with DPP-4 inhibitors had better compliance (69.1% vs. 63.8%), persistence (63.8% vs. 53.1%), and metabolic control (69.9% vs. 64.3%) (P<0.01) compared with those receiving other antidiabetes drugs, lower rates of hypoglycemia (14.3% vs. 41.1%) and cardiovascular events (2.9% vs. 5.7%) (P<0.01), and a lower mean adjusted unit cost (€2,278 vs. €2,631; P=0.003).

CONCLUSIONS

Despite the limitations of this observational study, diabetes patients with MS who were treated with metformin plus DPP-4 inhibitors had better compliance, greater metabolic control, and lower rates of hypoglycemia, causing lower costs for the Spanish national health system than patients receiving metformin plus other antidiabetes drugs.

Differential expression of microRNAs in ischemic heart disease

Recent studies provide evidence that ischemic preconditioning (IP) and ischemia/reperfusion (IR) injury lead to altered expression of microRNAs (miRNAs) that affect the survival and recovery of cardiomyocytes. These endogenous ∼22-nucleotide noncoding RNAs negatively regulate gene expression via degradation and translational inhibition of their target mRNAs. miRNAs are involved in differentiation, proliferation, electrical conduction, angiogenesis and apoptosis. These pathways can lead to physiological and pathological adaptations. This review intends to explore several facets of miRNA expression and the underlying mechanisms involved in IR injury, as well as IP as a cardioprotective strategy. In addition, we will investigate miRNA interaction with the renin-angiotensin system and the potential use of miRNAs in developing sensitive biomarkers for cardiovascular disease.

Effects of a community-based weight loss intervention on adipose tissue circulating factors

AIMS

Obesity is associated with metabolic dysfunctions, which may be mediated by changes in adipose tissue signaling factors. These molecules are denoted as Adipose Tissue Generated Mediators of CardioVascular Risk (ATGMCVR) here, and include leptin, adiponectin, C-reactive protein (CRP), interleukin 6 (IL-6), tumor necrosis factor alpha (TNFα), and plasminogen activator inhibitor 1 (PAI-1). This study examined the effect of a weight loss program on ATGMCVR in obese adults with prediabetes.

MATERIALS AND METHODS

Subjects were randomized to usual care (UC; n=15) or lifestyle weight loss groups (LWL; n=15). LWL was a community-based weight loss intervention to promote physical activity and healthy eating. ATGMCVR at 1-year were compared between groups by analysis of covariance; baseline value of the mediator was the covariate. Baseline means for ATGMCVR were compared between those with (n=21) and without (n=9) metabolic syndrome (MetS).

RESULTS

At baseline, subjects were 58±9 (SD) years, 70% female, with a BMI of 34±4kg/m(2). One-year weight loss (%) was 7.8±6.0% for LWL and 1.7±4.5% for UC. Group differences at 1-year were noted (adjusted means [95%CI] for UC and LWL, respectively) for adiponectin (8526.3 [7397.7, 9827]; 10,870.9 [9432.0, 12,529.3]ng/ml; p=0.02), leptin (30.4 [26.1, 35.4]; 23.7 [20.3, 27.5]ng/ml; p=0.02), IL-6 (0.4 [0.3, 0.5]; 0.2 [0.1, 0.2] pg/ml; p=0.001), and PAI-1 (50 [42.7, 58.7]; 36.2 [30.8, 42.4]pg/ml; p=0.01). No differences in baseline ATGMCVR were seen between subjects with and without MetS.

CONCLUSION

These findings suggest ATGMCVR can be improved with weight loss; larger studies are needed to determine if improvements in metabolic dysfunction are related to changes in ATGMCVR.

Geriatrics: (women's health series)

As women age, they face challenging health issues. Their average life expectancy is longer than their male counterparts, yet they often have multiple chronic, ongoing health problems that complicate their care, accentuate their infirmity, and reduce their quality of life. Often, they fail to receive the same quality or amount of healthcare service, sometimes because of a lack of data specific to their demographics, at other times for myriad unclear reasons. What data are available suggest that they will usually glean the same benefits as their male and younger female counterparts, often with little increased risk of adverse effects from available medical diagnostic and therapeutic options. Cardiovascular disease, malignancies, musculoskeletal disorders (particularly osteoporosis), and cognitive and psychiatric illness are the most frequent, and often most devastating, health issues in this growing segment of the population. An understanding of the differences in disease frequencies, presentations, and response to treatments is necessary to provide older adult women with optimal health care.

Postprandial hypotension detected through home blood pressure monitoring: a frequent phenomenon in elderly hypertensive patients

Postprandial hypotension (PPH) is a frequently under-recognized entity associated with increased morbidity and mortality. The prevalence of PPH detected through home blood pressure monitoring (HBPM) is unknown. To determine the prevalence and clinical predictors of PPH in hypertensive patients assessed through HBPM. Hypertensive patients of 18 years or older underwent home blood pressure (BP) measurements (duplicate measurements for 4 days: in the morning, 1 h before and 1 h after their usual lunch, and in the evening; OMRON 705 CP). PPH was defined as a meal-induced systolic BP decrease of ≥20 mm Hg. Variables identified as relevant predictors of PPH were entered into a multivariate logistic regression analysis. In total, 230 patients were included in the analysis, with a median age of 73.6 (interquartile range 16.9) years, and 65.2% were female. The prevalence of PPH (at least one episode) was 27.4%. Four variables were independently associated with PPH: age of 80 years or older (odds ratio (OR) 3.45, 95% confidence interval (CI) 1.35-8.82), body mass index (BMI) (OR 0.88, 95%CI 0.81-0.96), office systolic BP (OR 1.03, 95%CI 1.01-1.05) and a history of cerebrovascular disease (OR 3.29, 95%CI 1.03-10.53). PPH after a typical meal is a frequent phenomenon that can be detected through HBPM. Easily measurable parameters in the office such as older age, higher systolic BP, lower BMI and a history of cerebrovascular disease may help to detect patients at risk of PPH who would benefit from HBPM.

Cardiovascular risk score, cognitive decline, and dementia in older Mexican Americans: the role of sex and education

Background

The purpose of this study was to examine the associations of cardiovascular disease (CVD) risk with cognitive decline and incidence of dementia and cognitive impairment but not dementia (CIND) and the role of education as a modifier of these effects.

Methods and Results

One thousand one hundred sixteen Mexican American elderly were followed annually in the Sacramento Area Latino Study on Aging. Our sex‐specific 10‐year CVD risk score included baseline age, systolic blood pressure, total cholesterol, high‐density lipoprotein, smoking, body mass index, and diabetes. From adjusted linear mixed models, errors on the Modified Mini–Mental State Exam (3MSE) were annually 0.41% lower for women at the 25th percentile of CVD risk, 0.11% higher at the 50th percentile, and 0.83% higher at the 75th percentile (P value of CVDrisk×time <0.01). In men, 3MSE errors were annually 1.76% lower at the 25th percentile of CVD risk, 0.96% lower at the 50th percentile, and 0.12% higher at the 75th percentile (P value of CVDrisk×time <0.01). From adjusted linear mixed models, the annual decrease in the Spanish and English Verbal Learning Test score was 0.09 points for women at the 25th percentile of CVD risk, 0.10 points at the 50th percentile, and 0.12 points at the 75th percentile (P value of CVDrisk×time=0.02). From adjusted Cox models in women, compared with having <6 years of education, having 12+ years of education was associated with a 76% lower hazard of dementia/CIND (95% CI, 0.08 to 0.71) at the 25th percentile of CVD risk and with a 45% lower hazard (95% CI, 0.28 to 1.07) at the 75th percentile (P value of CVDrisk×education=0.05).

Conclusions

CVD risk score may provide a useful tool for identifying individuals at risk for cognitive decline and dementia.

Managing metabolic syndrome in women

Cardiovascular disease (CVD) death rates in women in the United States are rising. This is attributed to the obesity epidemic and its contribution to cardiometabolic risk. Various gender-related factors and strategies must be considered to effectively manage metabolic syndrome in women and improve outcomes.

Does insulin resistance drive the association between hyperglycemia and cardiovascular risk?

Background

Several studies have shown associations between hyperglycemia and risk of cardiovascular disease (CVD) and mortality, yet glucose-lowering treatment does little to mitigate this risk. We examined whether associations between hyperglycemia and CVD risk were explained by underlying insulin resistance.

Methods

In 60 middle-aged individuals without diabetes we studied the associations of fasting plasma glucose, 2-hour post oral glucose tolerance test plasma glucose, insulin sensitivity as well as body fat percentage with CVD risk. Insulin sensitivity was measured as the glucose infusion rate during a euglycemic hyperinsulinemic clamp, body fat percentage was measured by dual X-ray absorptiometry, and CVD risk was estimated using the Framingham risk score. Associations of fasting plasma glucose, 2-hour plasma glucose, insulin sensitivity and body fat percentage with the Framingham risk score were assessed in linear regression models.

Results

Both fasting and 2-hour plasma glucose levels were associated with higher Framingham risk score (fasting glucose: r² = 0.21; 2-hour glucose: r² = 0.24; P<0.001 for both), and insulin sensitivity with lower Framingham risk score (r² = 0.36; P<0.001). However, adjustment for insulin sensitivity and 2-hour glucose made the effect of fasting glucose non-significant (P = 0.060). Likewise, when adjusting for insulin sensitivity and fasting glucose, the association between 2-hour glucose and Framingham risk score disappeared (P = 0.143). In contrast, insulin sensitivity was still associated with Framingham risk score after adjusting for glucose levels (P<0.001). Body fat was not associated with Framingham risk score when taking insulin sensitivity into account (P = 0.550).

Conclusion

The association between plasma glucose levels and CVD risk is mainly explained by insulin resistance, which raises the question of whether glucose lowering per se without changes in the processes that underlie hyperglycemia should be the sole clinical paradigm in the treatment of type 2 diabetes or its prevention.

Risk of coronary heart disease events over 15 years among older adults with depressive symptoms

OBJECTIVES

To determine whether depression status is associated with an increased risk of coronary heart disease (CHD) events, defined as CHD death or nonfatal acute myocardial infarction (MI).

DESIGN

Prospective cohort study.

SETTING

An urban primary care practice.

PARTICIPANTS

Two thousand seven hundred twenty-eight adults (71.4% women, 65.5% black), age 60 years and older, who were screened for depression between 1991 and 1993.

MEASUREMENTS

Depressive symptom severity at baseline was assessed by the Center for Epidemiologic Studies Depression Scale (CES-D). Data regarding baseline demographic and clinical variables, as well as laboratory evidence of acute MI, were obtained from an electronic medical record system. All-cause mortality and CHD death were determined from the National Death Index through 2006.

RESULTS

A total of 423 (15.5%) participants reported elevated symptoms of depression (CES-D score ≥16). During the 13 to 16 years of follow-up, 1,646 (60.3%) individuals died from any cause, and 727 (26.6%) died from CHD or suffered an acute MI. Cox proportional hazards models revealed that individuals with elevated depressive symptoms were more likely to experience a CHD event, even after adjustment for demographics and comorbid health conditions (relative risk = 1.46, 95% confidence interval: 1.20-1.77). Depression status was also a significant predictor of all-cause mortality in adjusted models.

CONCLUSIONS

We report the longest prospective study to date to examine depression status as an independent risk factor for CHD among a cohort of older adults including large numbers of women and underrepresented minorities. The present findings underscore the need to consider depression as a common and modifiable risk factor for CHD events among older adults.

Genetic screening

Current approaches to genetic screening include newborn screening to identify infants who would benefit from early treatment, reproductive genetic screening to assist reproductive decision making, and family history assessment to identify individuals who would benefit from additional prevention measures. Although the traditional goal of screening is to identify early disease or risk in order to implement preventive therapy, genetic screening has always included an atypical element-information relevant to reproductive decisions. New technologies offer increasingly comprehensive identification of genetic conditions and susceptibilities. Tests based on these technologies are generating a different approach to screening that seeks to inform individuals about all of their genetic traits and susceptibilities for purposes that incorporate rapid diagnosis, family planning, and expediting of research, as well as the traditional screening goal of improving prevention. Use of these tests in population screening will increase the challenges already encountered in genetic screening programs, including false-positive and ambiguous test results, overdiagnosis, and incidental findings. Whether this approach is desirable requires further empiric research, but it also requires careful deliberation on the part of all concerned, including genomic researchers, clinicians, public health officials, health care payers, and especially those who will be the recipients of this novel screening approach.

Vitamin E regulates adipocytokine expression in a rat model of dietary-induced obesity

The aim of this study was to determine the effect of the antioxidant vitamin E (VE) on adiponectin and leptin expression in obese rats. Thirty weaning male Sprague-Dawley rats were divided into three groups as follows: (1) a control group, fed with normal chow; (2) a diet-induced obesity group (DIO), fed with a high-fat diet and (3) an intervention group, fed with a high-fat diet supplemented with VE (350 mg/kg). After 10 weeks of being fed according to these group assignments, rats were weighed and euthanized. Blood and adipose tissues were then immediately collected; mRNA and protein levels of leptin and adiponectin were measured by realtime reverse transcription-polymerase chain reaction and Western blotting. Biomarkers of oxidative stress, including serum levels of 8-epi-prostaglandin-F(2)alpha (8-epi-PGF(2)alpha) and glutathione peroxidase activity, were also examined. Adiponectin and leptin levels were lower in the DIO group than in the control group. VE intervention increased the expression of both leptin and adiponectin (P values < 0.05). Association analysis showed that serum leptin levels correlated positively with body fat mass (r = 0.601, P < 0.05). Both serum leptin and adiponectin levels were associated with the presence of serum 8-epi-PGF2 alpha (leptin, r = 0.513, P < 0.05; adiponectin, r = -0.422, P < 0.05). Administration of VE decreases leptin and adiponectin expression in obese rats. This finding is consistent with the view that antioxidants can play an important role in the treatment of obesity-related diseases.

Phosphodiesterase-5 inhibitor, tadalafil, protects against myocardial ischemia/reperfusion through protein-kinase g-dependent generation of hydrogen sulfide

BACKGROUND

Tadalafil is a novel long-acting inhibitor of phosphodiesterase-5. Because cGMP-dependent protein kinase (PKG) signaling plays a key role in cardioprotection, we hypothesized that PKG activation with tadalafil would limit myocardial ischemia/reperfusion (I/R) injury and dysfunction. Additionally, we contemplated that cardioprotection with tadalafil is mediated by hydrogen sulfide (H(2)S) signaling in a PKG-dependent fashion.

METHODS AND RESULTS

After baseline transthoracic echocardiography (TTE), adult ICR mice were injected i.p. with vehicle (10% DMSO) or tadalafil (1 mg/kg) with or without KT5823 (KT, PKG blocker, 1 mg/kg) or dl-propargylglycine (PAG, Cystathionine-gamma-lyase [CSE, H(2)S-producing enzyme] blocker; 50 mg/kg) 1 hour before coronary artery ligation for 30 minutes and reperfusion for 24 hours, whereas C57BL wild-type and CSE-knockout mice were treated with either vehicle or tadalafil. After reperfusion, TTE was performed and hearts were collected for infarct size (IS) measurement using TTC staining. Survival was increased with tadalafil (95%) compared with control (65%, P<0.05). Infarct size was reduced with tadalafil (13.2+/-1.7%) compared to vehicle (40.6+/-2.5%; P<0.05). KT and PAG abolished tadalafil-induced protection (IS: 39.2+/-1% and 51.2+/-2.4%, respectively) similar to genetic deletion of CSE (47.2+/-5.1%). Moreover, tadalafil preserved fractional shortening (FS: 31+/-1.5%) compared to control (FS: 22+/-4.8%, P<0.05). Baseline FS was 44+/-1.7%. KT and PAG abrogated the preservation of LV function with tadalafil by decline in FS to 17+/-1% and 23+/-3%, respectively. Compared to vehicle, myocardial H(2)S production was significantly increased with tadalafil and was abolished with KT.

CONCLUSIONS

PKG activation with tadalafil limits myocardial infarction and preserves LV function through H(2)S signaling.

Autophagy in atherosclerosis: a cell survival and death phenomenon with therapeutic potential

Autophagy is a reparative, life-sustaining process by which cytoplasmic components are sequestered in double-membrane vesicles and degraded on fusion with lysosomal compartments. A growing body of evidence suggests that autophagy is stimulated in advanced atherosclerotic plaques by oxidized lipids, inflammation, and metabolic stress conditions. However, despite the increasing interest in autophagy in various pathophysiological situations such as neurodegeneration, cancer, and cardiac myopathies, the process remains an underestimated and overlooked phenomenon in atherosclerosis. As a consequence, its role in plaque formation and stability is poorly understood. Most likely, autophagy safeguards plaque cells against cellular distress, in particular oxidative injury, by degrading damaged intracellular material. In this way, autophagy is antiapoptotic and contributes to cellular recovery in an adverse environment. An interesting observation is that basal autophagy can be intensified by specific drugs. Excessively stimulated autophagic activity is capable of destroying major proportions of the cytosol, leading finally to type II programmed cell death that lacks several hallmarks of apoptosis or necrosis. Because atherosclerosis is an inflammatory disorder of the arterial intima, pharmacological approaches could be developed to stabilize vulnerable, rupture-prone lesions through selective induction of macrophage autophagic death.

Biomarkers related to aging in human populations

Biomarkers are increasingly employed in empirical studies of human populations to understand physiological processes that change with age, diseases whose onset appears linked to age, and the aging process itself. In this chapter, we describe some of the most commonly used biomarkers in population aging research, including their collection, associations with other markers, and relationships to health outcomes. We discuss biomarkers of the cardiovascular system, metabolic processes, inflammation, activity in the hypothalamic-pituitary axis (HPA) and sympathetic nervous system (SNS), and organ functioning (including kidney, lung, and heart). In addition, we note that markers of functioning of the central nervous system and genetic markers are now becoming part of population measurement. Where possible, we detail interrelationships between these markers by providing correlations between high risk levels of each marker from three population-based surveys: the National Health and Nutrition Examination Survey (NHANES) III, NHANES 1999-2002, and the MacArthur Study of Successful Aging. NHANES III is used instead of NHANES 1999-2002 when specific markers of interest are available only in NHANES III and when we examine the relationship of biomarkers to mortality which is only known for NHANES III. We also describe summary measures combining biomarkers across systems. Finally, we examine associations between individual markers and mortality and provide information about biomarkers of growing interest for future research in population aging and health.

Depressive symptoms, cardiovascular risk, and diabetes self-care strategies in African American women with type 2 diabetes

This descriptive study examined depressive symptoms, cardiovascular risk, and diabetes self-care strategies in African American women (N = 45) with type 2 diabetes (T2D). All completed a questionnaire packet during structured interviews. Significant associations were found between two individual depressive symptoms and mean cardiovascular disease (CVD) risk scores, which suggest that in African American women with T2D, depressive symptoms may be correlated with a specific CVD profile and/or are unrecognized and/or unexpressed. Further analysis is warranted to determine the extent of this relationship in African American women with T2D.

Coronary fat content evaluated by morphometry in patients with severe atherosclerosis has no relation with serum lipid levels

The relationship between lipid serum levels and coronary atherosclerotic plaque fat content was studied in 51 necropsy patients. Serum lipids were measured by standard techniques, during life, in the absence of lipid-lowering drugs. Intima, intimal fat and media areas were measured using a computerized system in cryosections of the odd segments of the right, anterior descending and circumflex coronary arteries stained with Sudan-IV. Mean intimal and lipid areas were 5.74 +/- 1.98 and 1.22 +/- 0.55 mm2 (22.12 +/- 8.48%) in 26 cases with high cholesterol (>or=200 mg/dL) and 4.98 +/- 1.94 and 1.16 +/- 0.66 mm2 (22.75 +/- 9.06%) in 25 cases with normal cholesterol (<200 mg/dL; P > 0.05). Patients with high levels of low-density lipoprotein (>or=130 mg/dL, N = 15) had a higher intima/media area ratio than those with normal levels of low-density lipoprotein (<130 mg/dL, N = 13, P < 0.01). No significant difference in the morphometrical variables was found in groups with high or low serum levels of triglycerides (>or=200 mg/dL, N = 13 vs <200 mg/dL, N = 36) or high-density lipoprotein (>or=35 mg/dL, N = 11 vs <35 mg/dL, N = 17). The association between the morphological measurements and serum levels of cholesterol, its fractions, and triglycerides was also tested and the correlation coefficients were low. Although high cholesterol is a risk factor, we show here that in patients with severe atherosclerosis blood cholesterol and triglyceride levels seem to have little influence on coronary lipid content, indicating that other factors may contribute to arterial lipid deposition and plaque formation.

[Peripheral artery disease of the lower limbs and morbidity/mortality in type 2 diabetics]

OBJECTIVE

To study the relationship between the presence of peripheral artery disease (PAD) and the morbidity and mortality at 6 years, and the ankle-brachial index (ABI) as a predictor of morbidity and mortality in type 2 diabetes mellitus.

DESIGN

Retrospective cohort study. Six years follow-up.

SETTING

Urban health centre.

PARTICIPANTS

A total of 269 type 2 diabetics, of which 63 had PAD in 1996: 20 were previously diagnosed and 43 had an ABI of < or =0.90.

PRINCIPAL MEASUREMENTS

An appointed was made with the patients to find out the incidence of fatal and non-fatal microvascular and macrovascular events and the histories were reviewed. Six patients were excluded as all their data were not available.

RESULTS

Thirty nine patients had died, of whom 19 had PAD in 1996 (30.1%) and 20 did not (9.7%) (P = .001). Sixteen patients died in the group with an ABI < or =0.9 (30.2%) and 21 (10.1%) in the group with normal ABI values (P = .001). 7 (13.2%) patients died due to a cardiovascular cause with a pathological ABI, and 8 (3.9%) with a normal value (P = .009). The presence of PAD has been associated with a higher probability of having a non-fatal episode of ischaemic cardiac disease (P = .04), a cerebrovascular accident (CVA) (P < .001) and ulcers (P = .006). A low ABI has been associated with a higher probability of presenting with a fatal or non-fatal cardiovascular event (P < .001). After the multivariate analysis an increase was observed in cardiovascular (odds ratio [OR] =2.81; 95% confidence interval [CI], 1.16-6.78), CVA (OR = 3.47; 95% CI, 1.19-10.07), and cardiac failure (OR = 6.75; 95% CI, 1.34-33.81), morbidity and mortality in diabetics with an ABI of < or = 0.90.

CONCLUSIONS

The type 2 diabetics with PAD present with a higher morbidity and mortality. The ABI is a good predictor of cardiovascular disease and heart failure morbidity and mortality.

Chronic kidney disease care delivered by US family medicine and internal medicine trainees: results from an online survey

BACKGROUND

Complications of chronic kidney disease (CKD) contribute to morbidity and mortality. Consequently, treatment guidelines have been developed to facilitate early detection and treatment. However, given the high prevalence of CKD, many patients with early CKD are seen by non-nephrologists, who need to be aware of CKD complications, screening methods and treatment goals in order to initiate timely therapy and referral.

METHODS

We performed a web-based survey to assess perceptions and practice patterns in CKD care among 376 family medicine and internal medicine trainees in the United States. Questions were focused on the identification of CKD risk factors, screening for CKD and associated co-morbidities, as well as management of anemia and secondary hyperparathyroidism in patients with CKD.

RESULTS

Our data show that CKD risk factors are not universally recognized, screening for CKD complications is not generally taken into consideration, and that the management of anemia and secondary hyperparathyroidism poses major diagnostic and therapeutic difficulties for trainees.

CONCLUSION

Educational efforts are needed to raise awareness of clinical practice guidelines and recommendations for patients with CKD among future practitioners.

Management of high-risk patients with hypertension and left ventricular hypertrophy in Germany: differences between cardiac specialists in the inpatient and outpatient setting

Background

Among patients with hypertension, those with established left ventricular hypertrophy (LVH) represent a high risk cohort with poor prognosis. We aimed to investigate differences in characteristics and health care management of such patients treated as inpatients or outpatients by cardiac specialists.

Methods

Prospective cross-sectional study in patients with hypertension and LVH who were referred to either inpatient care (rehabilitation hospitals) or to outpatient care (cardiology practices).

Results

A total of 6358 inpatients (59.6% males; mean age 66.6 years) and 2246 outpatients (59.5% males; mean age 63.2 years) were followed up for a mean of 23 vs. 52 days, respectively. Inpatients compared to outpatients had a significantly higher prevalence of coronary heart disease, history of stroke, renal failure or diabetes. Mean blood pressure of inpatients compared to outpatients was significantly lower both at entry (150/84 vs. 161/93 mmHg) and at end of follow-up (129/75 vs. 139/83 mmHg). After adjustment for baseline blood pressure and a propensity score, differences between out- and inpatients at end of follow-up were 8.0/5.1 mmHg in favour of inpatients. Blood pressure goals as specified by guidelines were not met by 32% of inpatients and 55% of outpatients.

Conclusion

Inpatients had a higher rate of comorbidities and more advanced atherosclerotic disease than outpatients. Control of hypertension of inpatients was already better on admission than in outpatients, and treatment intensity in this group was also higher during the observation period. While blood pressure lowering was substantial in both groups, there were still a high proportion of patients who did not achieve treatment goals at discharge.

Psychosocial characteristics and cardiovascular risk in African Americans with diabetes

This descriptive study examined the ability of anxiety, depressive symptoms, and perceived social support to predict cardiovascular disease (CVD) risk in African American adults (N = 57) with type 2 diabetes but no prior history of CVD events. All completed a questionnaire packet during structured interviews. Participants had CVD risk profiles that indicated a greater than 20% probability of experiencing a CVD event in the next 2 to 10 years based on diabetes status alone. The variance (10%) in CVD risk accounted for by the variables examined was not statistically significant, suggesting that other variables may be better predictors of CVD risk.

Increased expression of genes that control ionic homeostasis, second messenger signaling and metabolism in the carotid plaques from patients with symptomatic stroke

The molecular mechanisms that render a carotid atherosclerotic plaque symptomatic have not yet been identified. Using an Affymetrix Human GeneChip set, we analyzed the gene expression patterns of 44 862 mRNA transcripts in surgically removed carotid artery plaques from six patients with symptomatic stroke and four non-symptomatic patients. The age, body mass index and the degree of stenosis were similar in the two groups. Some 236 transcripts (approximately 0.5% of the total transcripts analyzed) were expressed more abundantly in the symptomatic than the asymptomatic group. Of these, 61 transcripts are those that participate in ionic homeostasis, signal transduction and metabolism. The other groups of transcripts up-regulated in the symptomatic plaques include oncogenes, growth factors, tumor markers, angiogenesis promoters, transcription factors, and RNA splicing and processing factors. This study indicates that the higher metabolic activity in some atherosclerotic plaques leads to their faster growth and precipitation of stroke symptoms. The implications of these findings are that both diagnosis and prevention of stroke symptoms may become possible at the genetic level.

Framingham risk equation underestimates subclinical atherosclerosis risk in asymptomatic women

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death among American women. Currently, global risk assessment derived by Framingham risk equation (FRE) is used to identify women at increased risk for CHD. Electron-beam computed tomography (EBCT) derived coronary artery calcium (CAC) scores are validated markers for future CHD events among asymptomatic individuals. However, the adequacy of FRE for identifying asymptomatic women with CAC is unknown.

METHODS AND RESULTS

We studied 2447 consecutive non-diabetic asymptomatic females (55 +/- 10 years). Based upon FRE, 90% were classified as low-risk (FRE < or = 9% 10-year risk of hard CHD events), 10% intermediate-risk (10-20%), and none were considered as high-risk (> 20%). Coronary artery calcium was present in 33%, whereas CAC > or = 100 and CAC > or = 400 were seen in 10 and 3% of women, respectively. Overall, 20% of women had age-gender derived > or = 75th percentile CAC. According to FRE, the majority (84%) of women with significant CAC > or = 75th percentile were classified as low-risk. Approximately half (45%) of low-risk women with > or = 2 CHD risk factors and a family history of premature CHD had significant CAC.

CONCLUSION

Framingham risk equation frequently classifies women as being low-risk, even in the presence of significant CAC. Determination of CAC may provide incremental value to FRE in identifying asymptomatic women who will benefit from targeted preventative measures.

Effects of simvastatin 20 mg/d on serum lipid profiles in Japanese hyperlipidemic patients: A prospective, open-label pilot study

BACKGROUND

Hyperlipidemia is a major risk factor for ischemic heart disease. Hydroxymethylglutaryl coenzyme A reductase inhibitors ("statins") (eg, simvastatin) are considered first-line cholesterol-lowering therapy because they are effective and well tolerated, even at high doses. Based on a literature search, no studies have been published concerning the effects of simvastatin 20 mg/d in Japanese patients who had not previously received lipid-lowering treatment.

OBJECTIVE

The aim of this study was to assess the clinical tolerability and effectiveness of simvastatin 20 mg/d in achieving the target lipid concentrations recommended in the 2002 Japan Atherosclerosis Society (JAS) guidelines in Japanese patients with hyperlipidemia.

METHODS

This prospective, open-label pilot study was conducted at Kashiwa Hospital, Jikei University School of Medicine, Kashiwa, Japan. Male and postmenopausal female patients aged ≥18 to 70 years with hyperlipidemia (total cholesterol [TC], ≥220 mg/dL; triglycerides [TG], 150-400 mg/dL) who had not received lipid-lowering medications for at least 6 months before the study were enrolled. Patients received simvastatin 20 mg PO QD for 4 weeks. Effectiveness was assessed using serum concentrations of TC, low-density lipoprotein cholesterol (LDL-C), TG, and lipid peroxide, measured at 0 (baseline) and 4 weeks. Target serum TC and LDL-C concentrations as outlined by the JAS were as follows: category A, TC <240 mg/dL and LDL-C <160 mg/dL; category B1 and B2, TC <220 mg/dL and LDL-C <140 mg/dL; and category C, TC <200 mg/dL and LDL-C <120 mg/dL. A subanalysis of the correlation between baseline high-density lipoprotein cholesterol (HDL-C) and target achievement rates was conducted by baseline HDL-C concentration (<50 or ≥50 mg/dL). Tolerability was assessed using spontaneous reporting of adverse events and laboratory analysis, including liver function tests.

RESULTS

Twenty-two patients participated in the study (16 women, 6 men; mean [SD] age, 56.0 [8.0] years; mean [SD] body mass index, 23.6 [3.4] kg/m(2)). Mean serum TC, LDL-C, TG, and lipid peroxide concentrations significantly decreased from baseline (changes, -28.6%, -40.4%, -24.0%, and -14.5%, respectively; P < 0.001, <0.001, <0.001, and <0.01, respectively). The mean HDL-C concentration significantly increased from baseline (change, 7.2%; P < 0.001); the mean increase was significantly greater in patients with baseline HDL-C <50 mg/dL compared with those with baseline HDL-C ≥50 mg/dL (changes, 11.3% vs 4.4%; P < 0.05). Target TC and LDL-C concentrations were achieved in 90.9% of patients. No serious adverse events were observed, and liver enzyme and creatine kinase concentrations did not increase to above-normal values.

CONCLUSIONS

The results of this study suggest that simvastatin 20 mg/d might be useful in the clinical treatment of hyperlipidemia in Japanese patients. The study drug was well tolerated.

Changes of adiponectin oligomer composition by moderate weight reduction

Adiponectin affects lipid metabolism and insulin sensitivity. However, adiponectin circulates in three different oligomers that may also have distinct biological functions. We aimed to analyze the role of these oligomers in obesity and lipid metabolism after weight reduction. A total of 17 obese volunteers (15 women and 2 men) participated in a weight reduction program. Individuals were characterized before and after 6 months of a balanced diet. Adiponectin was determined by enzyme-linked immunosorbent assay, and oligomers were detected by nondenaturating Western blot. BMI decreased (35.1 +/- 1.2 to 32.8 +/- 1.1 kg/m(2), P < 0.001), which was associated with an improved metabolite profile. Total adiponectin increased from 5.3 +/- 0.5 to 6.1 +/- 0.6 microg/ml (P = 0.076). High (HMW) and medium molecular weight (MMW) adiponectin oligomers significantly increased during weight reduction (HMW: 0.37 +/- 0.07 to 0.4 +/- 0.08 microg/ml, P = 0.042; MMW: 2.3 +/- 0.2 to 2.9 +/- 0.3 microg/ml, P = 0.007), while low molecular weight (LMW) did not significantly change. Body weight inversely correlated with HMW (r = -0.695, P = 0.002) and positively with LMW (r = 0.579, P = 0.015). Interestingly, HDL cholesterol and HMW were strongly correlated (r = 0.665, P = 0.007). Indeed, HMW and free fatty acids before weight reduction predicted approximately 60% of HDL changes during intervention. In conclusion, weight reduction results in a relative increase of HMW/MMW adiponectin and a reduction of LMW adiponectin. Total adiponectin and especially HMW adiponectin are related to circulating HDL cholesterol.

Prehypertension and cardiovascular morbidity

PURPOSE

The Seventh Report of the Joint National Commission (JNC 7) on High Blood Pressure established prehypertension (120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic) as a new risk category. We aim to determine the risk of major cardiovascular events associated with blood pressure in the prehypertensive range in a longitudinal, population-based cohort.

METHODS

Analyses were conducted on participants in the National Health and Nutrition Examination Survey I (1971-1975) observed for 18 years for major cardiovascular disease events. Cox proportional hazard ratios were calculated to assess relative risk of cardiovascular disease, including stroke, myocardial infarction, and heart failure, in participants with prehypertension and normal blood pressure (<120/80 mm Hg).

RESULTS

Prehypertension was associated with increased risk for cardiovascular disease (1.79 [95% confidence interval (CI) 1.40-2.24]) in unadjusted analysis. After adjustment for cardiovascular risk factors, the relationship of prehypertension to cardiovascular disease was diminished but persisted (1.32 [95% CI 1.05-1.65]). Ninety-three percent of prehypertensive individuals had at least 1 cardiovascular risk factor. Low prehypertension (120-129/80-84 mm Hg) was associated with increased cardiovascular disease in unadjusted analyses (1.56 [95% CI 1.23-1.98]) but was not statistically significant in adjusted analyses (1.24 [95% CI 0.96-1.59]). High-normal blood pressure (130-139/85-89 mm Hg) remained a predictor of cardiovascular disease in unadjusted (2.13 [95% CI 1.64-2.76]) and adjusted (1.42 [95% CI 1.09-1.84]) analyses.

CONCLUSIONS

In a longitudinal, population-based, US cohort, prehypertension was associated with increased risk of major cardiovascular events independently of other cardiovascular risk factors. These findings, along with the presence of cardiovascular risk factors in the majority of participant sample with prehypertension, support recommendations for physicians to actively target lifestyle modifications and multiple risk reduction in their prehypertensive patients.

Metabolic syndrome and risk of stroke

Stroke is one of the leading causes of death in the United States and worldwide. Metabolic syndrome, comprising abdominal obesity, elevated triglyceride levels, low levels of high-density lipoprotein cholesterol, elevated blood pressure, and impaired glucose metabolism, greatly increases the risk of cardiovascular disease, including stroke. The high prevalence of metabolic syndrome among individuals who experience stroke makes the metabolic syndrome a target for aggressive intervention and therapy. In addition to lifestyle changes, therapy with statins, angiotensin-converting enzyme inhibitors, insulin sensitizers, and antithrombotic agents to aggressively treat elements of metabolic syndrome is warranted. Statins favorably affect both lipid and nonlipid risk factors for stroke, making them a useful tool for stroke prevention.

Carotid atherosclerotic plaques from symptomatic stroke patients share the molecular fingerprints to develop in a neoplastic fashion: a microarray analysis study

Identification of genetic mechanisms that promote the onset of stroke and transient cerebral ischemic attack symptoms in carotid atherosclerotic patients would further our understanding of the pathophysiology of this disease and could lead to new pharmacological and molecular therapies. Using Affymetrix Human Genome 230 GeneChip set, the present study evaluated the gene expression differences in geometrically similar carotid artery plaque samples extricated from six symptomatic stroke patients and four asymptomatic patients. There was no significant difference in the degree of stenosis between the two groups. Of the 44,860 transcripts analyzed, 289 (approximately 0.6% of the total transcripts) were differentially expressed between the plaques from the symptomatic and asymptomatic groups (236 were expressed more abundantly and 53 were expressed less abundantly in the symptomatic group). Of the 236 transcripts expressed more abundantly in the symptomatic plaques, 71% (167 transcripts) indicate an active cell proliferation and neoplastic process. These include oncogenes, growth factors, tumor promoters, tumor markers, angiogenesis promoters, transcription factors, RNA splicing factors, RNA processing proteins, signal transduction mediators and those that control the metabolism. Real-time polymerase chain reaction confirmed the increased expression of 63 transcripts in the symptomatic plaques. The other groups of transcripts expressed more abundantly in the symptomatic plaques are those that control ionic homeostasis, those that participate in the progression of degenerative neurological diseases (Alzheimer's disease, amyotrophic lateral sclerosis and Huntington's disease) and epilepsy. This indicates that symptomatic plaques are molecularly and biochemically more active than the asymptomatic plaques, or active plaque growth precipitates stroke symptoms.

Prescribe by Risk: The Utility of a Biomarker-Based Risk Calculation in Disease Management to Prevent Heart Disease

Preventive treatment for those most at risk of heart disease rather than those with the highest blood pressure or cholesterol values may be a more efficacious strategy for disease management. This depends on accurate biomarker-based risk assessment tools. An evidence-based model of heart disease risk was developed using the Framingham model with an additional five risk factors, including three of the newer blood biomarkers. This was applied to the adult population of the 3rd National Health and Nutrition Examination Survey cohort. Additionally, the selection criteria for therapeutic intervention from the Adult Treatment Panel III guidelines (for hyperlipidemia) and the 7th Report of the Joint National Committee (for hypertension) were applied to the same subjects. Of this cohort 54% qualified for at least one of these medications while 18% qualified for both. Using this 18% cutoff, the 18% of the subjects with the highest calculated heart disease risk were also identified using the developed risk model. We applied established therapeutic reductions in heart disease probability to those identified by guidelines and to those identified by risk. Applying both drugs to the high-risk group (one third the size of the guidelines group) achieved the same reduction in population risk (about one fourth) as applying the drugs to the guideline groups and required only half as many prescriptions. Intermediate results were found when an intervention group was identified by a combination of both high risk and high levels of risk factors. In this simulation, identifying patients by heart disease risk level resulted in substantially fewer people being treated with fewer drugs and achieving a similar reduction in disease risk.

Pharmacotherapeutic approaches to the prevention of Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is the most common cause of cognitive impairment in older patients and is expected to increase greatly in prevalence. Interventions that could delay disease onset would have a major public health impact.

OBJECTIVE

The objective of this article is to review evidence from epidemiologic studies and controlled trials addressing whether AD can be prevented.

METHODS

Data were gathered through a comprehensive, systematic search of MEDLINE using focused search criteria and spanning a 6-year period from January 1998 through January 2004; a hand search of reference lists from these studies and reviews; a review of the Cochrane Database of Systematic Reviews; and a hand search of relevant journals. Selection of articles was based on the clinical focus. Additional inclusion criteria were used to select key articles that contained higher-level evidence in accordance with explicit, validated criteria.

RESULTS

Preventive interventions for AD include vitamins, nonsteroidal anti-inflammatory drugs, and agents that protect the endothelium (eg, statins). Good control of hypertension with angiotensin-converting enzyme inhibitors and long-acting dihydropyridines also confers neuroprotective benefits.

CONCLUSIONS

The paradigm that AD is pharmacologically unresponsive is shifting as more effective pharmacotherapies for prevention and treatment rapidly emerge. Our understanding of the molecular mechanisms of neurodegeneration will soon allow us to more specifically target and interrupt the processes that contribute to this progressive dementia.