Prevention of Cardiovascular Events in Elderly People

Preventive health examinations: protocol for a prospective cross-sectional study of German employees aged 45 to 59 years (Ü45-check)

Objective

Early identification of health-related risk factors is of great importance for maintaining workability. Screening examinations can help to detect diseases at an early stage and provide more needs-based recommendations. This study aims (1) to assess the individual need for prevention or rehabilitation based on preventive health examinations compared to a questionnaire survey, (2) to assess the results of the preventive health examinations compared to the Risk Index - Disability Pension (RI-DP), (3) to assess the results of the questionnaire survey compared to the RI-DP, (4) to assess the general health status of the sample (target population > 1,000) in German employees aged 45-59, (5) to identify the most common medical conditions. A further study question aims, and (6) to investigate the general health status of the specific occupational groups.

Methods

Comprehensive diagnostics including medical examination, anamnesis, anthropometric measurements, bioelectrical impedance analysis (BIA), handgrip strength, resting electrocardiogram (ECG), resting blood pressure, pulse wave velocity (PWV), and laboratory blood analyses added by a questionnaire are conducted. The research questions are analyzed in an exploratory manner.

Results and conclusion

We expect that the results will allow us to formulate recommendations regarding screening for prevention and rehabilitation needs on a more evidence-based level.Clinical Trial Registration: DRKS ID: DRKS00030982.

Multiscale Encoding of Electrocardiogram Signals with a Residual Network for the Detection of Atrial Fibrillation

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias, and it is an indication of high-risk factors for stroke, myocardial ischemia, and other malignant cardiovascular diseases. Most of the existing AF detection methods typically convert one-dimensional time-series electrocardiogram (ECG) signals into two-dimensional representations to train a deep and complex AF detection system, which results in heavy training computation and high implementation costs. In this paper, a multiscale signal encoding scheme is proposed to improve feature representation and detection performance without the need for using any transformation or handcrafted feature engineering techniques. The proposed scheme uses different kernel sizes to produce the encoded signal by using multiple streams that are passed into a one-dimensional sequence of blocks of a residual convolutional neural network (ResNet) to extract representative features from the input ECG signal. This also allows networks to grow in breadth rather than in depth, thus reducing the computing time by using the parallel processing capability of deep learning networks. We investigated the effects of the use of a different number of streams with different kernel sizes on the performance. Experiments were carried out for a performance evaluation using the publicly available PhysioNet CinC Challenge 2017 dataset. The proposed multiscale encoding scheme outperformed existing deep learning-based methods with an average F₁ score of 98.54%, but with a lower network complexity.

Effect of Aspirin on Activities of Daily Living Disability in Community-Dwelling Older Adults

BACKGROUND

Cerebrovascular events, dementia, and cancer can contribute to physical disability with activities of daily living (ADL). It is unclear whether low-dose aspirin reduces this burden in aging populations. In a secondary analysis, we now examine aspirin's effects on incident and persistent ADL disability within a primary prevention aspirin trial in community-dwelling older adults.

METHODS

The ASPREE (ASPirin in Reducing Events in the Elderly) trial of daily 100 mg aspirin versus placebo recruited 19 114 healthy adults aged 70+ years (65+ years if U.S. minority) in Australia and the United States. Six basic ADLs were assessed every 6 months. Incident ADL disability was defined as inability or severe difficulty with ≥1 ADL; persistence was confirmed if the same ADL disability remained after 6 months. Proportional hazards modeling compared time to incident or persistent ADL disability for aspirin versus placebo; death without prior disability was a competing risk.

RESULTS

Over a median of 4.7 years, incident ADL disability was similar in those receiving aspirin (776/9525) and placebo (787/9589) with walking, bathing, dressing, and transferring the most commonly reported. Only 24% of incident ADL disability progressed to persistent. Persistent ADL disability was lower in the aspirin group (4.3 vs 5.3 events/1000 py; hazard ratio [HR] = 0.81, 95% confidence interval [CI]: 0.66-1.00), with bathing and dressing the most common ADL disabilities in both groups. Following persistent ADL disability, there were more deaths in the aspirin group (24 vs 12).

DISCUSSION

Low-dose aspirin in initially healthy older people did not reduce the risk of incident ADL disability, although there was evidence of reduced persistent ADL disability.

Dietary policies and programs in the United States: A narrative review

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School-based and youth targeted programs and policies were most frequently studied.

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Research has rather neglected older adult, Asian, Native Hawaiian and American Indian populations.

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Despite existing research indicating effectiveness, faith-based were understudied.

Prior reviews describing approach, methodological quality and effectiveness of dietary policies and programs may be limited in use for practitioners seeking to introduce innovative programming, or academic researchers hoping to understand and address gaps in the current literature. This review is novel, assessing the “where, who, and in whom” of dietary policies and programs research in the United States over the past decade – with results intended to serve as a practical guide and foundation for innovation. This study was conducted from October 2018 to March 2019. Papers were selected through a tailored search strategy on PubMed as well as citation searches, to identify grey literature. A total of 489 papers were relevant to our research objective. The largest proportion of papers described school-based strategies (31%) or included economic incentives (19%). In papers that specified demographics, the study populations most often included children, adults and adolescents (54%, 46%, and 42% respectively); and White, Black and Hispanic populations (77%, 76% and 70%, respectively). Results highlight opportunities for future research within workplace and faith-based settings, among racial/ethnic minorities, and older adults.

Primary Prevention of Cardiovascular Risk in Octogenarians by Risk Factors Control

Primary prevention of cardiovascular events in older adults is a relevant problem, due to lack of evidence for safe and efficacious therapy, its costs and elderly quality of life, Italy's aging population is constantly increasing, so cardiovascular disease (CVD) primary prevention in the elderly is a prime objective. Life expectancy has dramatically increased over the last 2 decades, the proportion of individuals aged 80 years and older has grown rapidly in Europe and the United States, but cost / effective ratio of CVD prevention through risk factors control is debated. It is therefore important to implement cardiovascular risk factors estimation in the elderly to maximize the quality of life of patients and to lengthen their healthy life expectancy, choosing the better treatment for each patient sharing the choice with himself when it is possible, always remembering that elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of CVD prevention therapy. Nevertheless, CVD is not an inevitable concomitant of aging. Sometimes, autopsy in the elderly reveals atheroma-free coronary arteries, a normal-sized heart and unscarred valves. All primary prevention strategy decisions should consider estimated life expectancy and overall function and not just the cardiovascular event risks, magnitude and time to benefit or harm, potentially altered adverse effect profiles, and informed patient preferences. CVD primary prevention needs to be more implemented in the elderly, this might contribute to improve health status and quality of life in this growing population if correctly performed.

Multiscaled Fusion of Deep Convolutional Neural Networks for Screening Atrial Fibrillation From Single Lead Short ECG Recordings

Atrial fibrillation (AF) is one of the most common sustained chronic cardiac arrhythmia in elderly population, associated with a high mortality and morbidity in stroke, heart failure, coronary artery disease, systemic thromboembolism, etc. The early detection of AF is necessary for averting the possibility of disability or mortality. However, AF detection remains problematic due to its episodic pattern. In this paper, a multiscaled fusion of deep convolutional neural network (MS-CNN) is proposed to screen out AF recordings from single lead short electrocardiogram (ECG) recordings. The MS-CNN employs the architecture of two-stream convolutional networks with different filter sizes to capture features of different scales. The experimental results show that the proposed MS-CNN achieves 96.99% of classification accuracy on ECG recordings cropped/padded to 5 s. Especially, the best classification accuracy, 98.13%, is obtained on ECG recordings of 20 s. Compared with artificial neural network, shallow single-stream CNN, and VisualGeometry group network, the MS-CNN can achieve the better classification performance. Meanwhile, visualization of the learned features from the MS-CNN demonstrates its superiority in extracting linear separable ECG features without hand-craft feature engineering. The excellent AF screening performance of the MS-CNN can satisfy the most elders for daily monitoring with wearable devices.

Laboratory blood test results beyond normal ranges could not be attributed to healthy aging

Aging is related to a decline in the function of many organs. The results of blood tests are essential for clinical management and could change over a lifespan reflecting aging. The aim of this study was to examine serum levels of liver, kidney, and bone marrow function and to study their dynamics as a function of age and sex.The cross-sectional study conducted in Poland included 180 healthy individuals (20-90 years) divided into subgroups by sex and decade. These included subgroups of ≥65 or <65 years (men and women). We investigated serum levels of creatinine, estimated glomerular filtration rate, estimated effective renal blood/plasma flow, urine pH, urine neutrophil gelatinase-associated lipocalin (NGAL) as well as serum levels of transaminases, bilirubin, total cholesterol (TC), international normalized ratio (INR), and blood morphology.All parameters were within normal range in all groups. Urine NGAL was higher in men aged ≥65 years than women (25.67 ± 53.65 vs 16.49 ± 34.66, P = .001); serum levels of TC and platelet (PLT) count were higher in women than men aged ≥65 years (221.0 ± 41.7 vs 188.4 ± 48.2 and 250.3 ± 47.8 vs 202.5 ± 57.9, P = .003 and P = .038, respectively). The INR was lower in women (0.97 ± .06 vs 1.19 ± 0.48, P = .03).These blood tests were normal in healthy people aged ≥65 years. Higher PLT and TC and lower INR in women might indicate a higher risk of cardiovascular diseases. These changes in blood tests were not attributed to aging itself.

Association between traditional cardiovascular risk factors and mortality in the oldest old: untangling the role of frailty

Background

To date, there is no consensus regarding cardiovascular risk management in the very old. Studies have shown that the relationship between traditional cardiovascular risk factors and mortality is null or even inverted within this age group. This relationship could be modified by the presence of frailty. This study was performed to examine the effect of frailty on the association between cardiovascular risk factors and mortality in the oldest old.

Methods

The BELFRAIL study is a prospective, observational, population-based cohort study of 567 subjects aged 80 years and older. Data on cardiovascular risk factors were recorded. Frailty was assessed using three different models: the Groningen Frailty Indicator, Fried and Puts models. Participants were considered robust if they were ‘not frail’ according to all three models, and frail if they met the frailty criteria for one of the three models. The follow-up data on mortality and cause of death were registered.

Results

No cardiovascular risk factor was associated with mortality in subjects with and without cardiovascular disease. The presence of frailty was a strong risk factor for mortality [HR: 2.5, 95%CI: (1.9–3.2) for all-cause mortality; HR: 2.2, 95%CI: (1.4–3.4) for cardiovascular mortality]. In robust patients, a history of cardiovascular disease increased the risk for mortality [HR: 1.7, 95%CI: (1.1–2.5) for all-cause mortality; HR: 2.2, 95%CI: (1.2–3.9) for cardiovascular mortality]. In frail patients, there was no association between any of the traditional risk factors and mortality.

Conclusions

Traditional cardiovascular risk factors were not associated with mortality in very old subjects. Frailty was shown to be a strong risk factor for mortality in this age group. However, frailty could not be used to identify additional subjects who might benefit more from cardiovascular risk management.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0626-x) contains supplementary material, which is available to authorized users.

Association Between a Polymorphism in CASP3 and CASP9 Genes and Ischemic Stroke

Objective

To investigate whether the polymorphisms of CASP3 gene (rs4647602, intron A/C and rs1049216, UTR C/T) and CASP9 gene (rs1052576, Gln/Arg G/A and rs1052571, Ser/Val T/C) were associated with the development, and clinical severity of ischemic stroke and functional consequences after stroke.

Methods

Genomic DNA from 121 ischemic stroke patients and 201 healthy control subjects were extracted, and polymerase chain reaction products were sequenced. To investigate the association of polymorphisms and the development, and National Institutes of Health Stroke Scale (K-NIHSS), logistic regression models were analyzed.

Results

Polymorphism of the untranslational region of CASP3 (rs1049216, UTR C/T) has been associated with the development of ischemic stroke—in codominant1 model (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.29–0.88; p=0.017), in dominant model (OR, 0.57; 95% CI, 0.34–0.97; p=0.034), and in the overdominant model (OR, 0.50; 95% CI, 0.29–0.87; p=0.011). A missense SNP of CASP9 gene (rs1052571, Ser/Val T/C) was associated with the development of ischemic stroke (OR, 1.93; 95% CI, 1.05–3.55; p=0.034 in recessive model).

Conclusion

These results indicate the possibility that CASP3 and CASP9 genes are markers for the development of ischemic stroke.

Inappropriate prescribing of antithrombotic therapy in Ethiopian elderly population using updated 2015 STOPP/START criteria: a cross-sectional study

Background

Inappropriate use of antiplatelets and anticoagulants among elderly patients increases the risk of adverse outcomes. The aim of this study was to assess the prevalence of inappropriate prescribing of antithrombotic therapy in hospitalized elderly patients.

Methods

A retrospective cross-sectional, single-center study was conducted at the Gondar University Hospital. A total of 156 hospitalized elderly patients fulfilling the inclusion/exclusion criteria were included in the study. The Screening Tool for Older Person’s Prescription/Screening Tool to Alert doctors to Right Treatment criteria version 2 were applied to patients’ data to identify the total number of inappropriate prescribing (IPs) including potentially inappropriate medications and potential prescribing omissions.

Results

A total of 70 IPs were identified in 156 patients who met the inclusion criteria. Of these, 36 (51.4%) were identified as potentially inappropriate medications by the Screening Tool for Older Person’s Prescription criteria. The prevalence of IP per patient indicated that 58 of the 156 (37.2%) patients were exposed to at least one IP. Of these, 32 (55.2%) had at least one potentially inappropriate medication and 33 (56.9%) had at least one potential prescribing omission. Patients hospitalized due to venous thromboembolism (adjusted odds ratio [AOR] =29.87, 95% confidence interval [CI], 1.26–708.6), stroke (AOR =7.74, 95% CI, 1.27–47.29), or acute coronary syndrome (AOR =13.48, 95% CI, 1.4–129.1) were less likely to be exposed to an IP. An increase in Charlson comorbidity index score was associated with increased IP exposure (AOR =0.60, 95% CI, 0.39–0.945). IPs were about six times more likely to absent in patients prescribed with antiplatelet only therapy (AOR =6.23, 95% CI, 1.90–20.37) than those receiving any other groups of antithrombotics.

Conclusion

IPs are less common in elderly patients primarily admitted due to venous thromboembolism, stroke, and acute coronary syndrome, and those elderly patients prescribed with only antiplatelet. Patients with higher Charlson comorbidity index were, however, associated with increased IPs exposure. Our study may guide further research to reduce high-risk prescription of antithrombotics in the elderly.

Interleukin-6 Receptor Polymorphisms Contribute to the Neurological Status of Korean Patients with Ischemic Stroke

To investigate the contribution of the interleukin-6 receptor (IL-6R) gene single nucleotide polymorphisms (SNPs) to the neurological status of Korean patients with ischemic stroke (IS), two SNPs of the IL-6R gene (rs4845617, 5 UTR; rs2228144, Ala31Ala) were selected. IS patients were classified into clinical phenotypes according to two well-defined scores: the National Institutes of Health Stroke Survey (NIHSS) and the Modified Barthel Index scores. There were 121 IS patients and 291 control subjects. The SNP rs4845617 significantly contributed to the neurological status of patients with IS (P = 0.011 in codominant model 2, P = 0.006 in recessive model, and P = 0.008 in log-additive model). Allele frequencies of rs4845617 and rs2228144 demonstrated no significant difference in IS patients and controls. The AG and GG haplotypes differed between the NIHSS 1 (NIHSS scores < 6) group and the NIHSS 2 (NIHSS scores ≥ 6) group in patients with IS (P = 0.014, P = 0.0024). These results suggest that rs4845617 of the IL-6R gene is associated with the neurologic status of Korean patients with IS.

Age-Dependent Impact of Medication Underuse and Strategies for Improvement

Background: Medication underuse is common in aging populations and, because of the growing risk for competing deaths, the benefit of preventive medicines gradually vanishes with advancing age, thus limiting their success. Objective: To estimate the optimum time of initiation of the secondary prevention of cardiovascular events, we examined the impact of appropriate pharmacotherapy for different starting ages at which it is implemented. Methods: In the competing risk framework, we obtained the population's life course from life tables, combined it with effect estimates quantifying the real-world effectiveness of secondary prevention, and compared the outcome of patients not receiving appropriate treatment (underuse) with those receiving preventive medicines that have demonstrated a reduction in the transition to serious cardiovascular events (START criteria). Starting at the age of 55 years, the population proportions of the distinct states of the framework were calculated for each year of chronological age in subgroups of appropriate treatment and underuse. These proportions were used over a follow-up period to estimate measures of treatment effectiveness and risks of underuse. Results: Despite increasing relative effectiveness with advancing age, benefits measured by patient-relevant endpoints, such as life years gained (LYG) or gained quality-adjusted life years (QALYs), markedly dropped after the starting age of 75 years, but even at an initiation age of 85 years, QALYs gained exceeded 1 year. Conclusion: Interventions targeting medication underuse may achieve considerable benefits at any stage of later life, while the benefit is probably largest if appropriate treatment is started before 75 years.

15-Year prognostic utility of coronary artery calcium scoring for all-cause mortality in the elderly

INTRODUCTION

Prior studies have demonstrated a decline in the predictive ability of conventional risk factors (RF) with advancing age, emphasizing the need for novel tools to improve risk stratification in the elderly. Coronary artery calcification (CAC) is a robust predictor of adverse cardiovascular events, but its long-term prognostic utility beyond RFs in elderly persons is unknown.

METHODS

A consecutive series of 9715 individuals underwent CAC scoring and were followed for a mean of 14.6 ± 1.1 years. Multivariable Cox proportional hazards regression (HR) with 95% confidence intervals (95% CI) was employed to assess the independent relationship of CAC and RFs with all-cause death. The incremental value of CAC, stratified by age, was examined by using an area under the receiver operator characteristic curve (AUC) and category-free net reclassification improvement (NRI).

RESULTS

Of the overall study sample, 728 (7.5%) adults (mean age 74.2 ± 4.2 years; 55.6% female) were 70 years or older, of which 157 (21.6%) died. The presence of any CAC was associated with a >4-fold (95% CI = 2.84-6.59) adjusted risk of death for those over the age of 70, which was higher compared with younger study counterparts, or other measured RFs. For individuals 70 years or older, the discriminatory ability of CAC improved upon that of RFs alone (C statistics 0.764 vs. 0.675, P < 0.001). CAC also enabled improved reclassification (category-free NRI = 84%, P < 0.001) when added to RFs.

CONCLUSION

In a large-scale observational cohort registry, CAC improves prediction, discrimination, and reclassification of elderly individuals at risk for future death.

Upper gastrointestinal mucosal injury and symptoms in elderly low-dose aspirin users

Background. We investigated the prevalence, symptoms, and QOL impact of esophageal (EI), gastric (GI), and duodenal mucosal injury (DI) individually between low-dose aspirin (LDA) users and nonusers to reveal the clinical features of LDA-related mucosal injury. Methods. Data were extracted from the records of subjects who underwent upper gastrointestinal endoscopy at our department between April 2008 and December 2013. Responses from 3162 elderly patients on Frequency Scale for Symptoms of GERD (FSSG) and SF-8 QOL questionnaires (SF-8) were analyzed. FSSG items were classified into total score (TS), reflux score (RS), and dyspepsia score (DS). The SF-8 questionnaire consisted of the physical component summary (PCS) and mental component summary (MCS). Results. Prevalence among LDA users and nonusers, respectively, was 9.6% and 10.0% (P = 0.83) for EI, 35.9% and 27.5% (P = 0.0027) for GI, 3.3% and 3.4% (P = 0.84) for DI, and 8.2% and 5.2% (P = 0.036) for mucosal injury in 2 or more organs. LDA users diagnosed with EI had significantly lower PCS, LDA users diagnosed with GI had significantly lower DS, and LDA users diagnosed with DI had significantly lower RS and significantly lower MCS. Conclusion. These results provide important clinical information indicating that symptom-based management is not appropriate in LDA users regarding upper gastrointestinal mucosal injury.

DNA methylation of lipid-related genes affects blood lipid levels

BACKGROUND

Epigenetic mechanisms might be involved in the regulation of interindividual lipid level variability and thus may contribute to the cardiovascular risk profile. The aim of this study was to investigate the association between genome-wide DNA methylation and blood lipid levels high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, and total cholesterol. Observed DNA methylation changes were also further analyzed to examine their relationship with previous hospitalized myocardial infarction.

METHODS AND RESULTS

Genome-wide DNA methylation patterns were determined in whole blood samples of 1776 subjects of the Cooperative Health Research in the Region of Augsburg F4 cohort using the Infinium HumanMethylation450 BeadChip (Illumina). Ten novel lipid-related CpG sites annotated to various genes including ABCG1, MIR33B/SREBF1, and TNIP1 were identified. CpG cg06500161, located in ABCG1, was associated in opposite directions with both high-density lipoprotein cholesterol (β coefficient=-0.049; P=8.26E-17) and triglyceride levels (β=0.070; P=1.21E-27). Eight associations were confirmed by replication in the Cooperative Health Research in the Region of Augsburg F3 study (n=499) and in the Invecchiare in Chianti, Aging in the Chianti Area study (n=472). Associations between triglyceride levels and SREBF1 and ABCG1 were also found in adipose tissue of the Multiple Tissue Human Expression Resource cohort (n=634). Expression analysis revealed an association between ABCG1 methylation and lipid levels that might be partly mediated by ABCG1 expression. DNA methylation of ABCG1 might also play a role in previous hospitalized myocardial infarction (odds ratio, 1.15; 95% confidence interval=1.06-1.25).

CONCLUSIONS

Epigenetic modifications of the newly identified loci might regulate disturbed blood lipid levels and thus contribute to the development of complex lipid-related diseases.

The ROVIGO study (risk of vascular complications: impact of genetics in old people): protocol, study design, and preliminary results of the initial survey : cardiovascular epidemiology in the elderly

BACKGROUND

The epidemiology of cardiovascular risk (CV) in the elderly is far from being defined, and the reasons why some subjects retain a healthy body while growing old while others are affected by different diseases or die prematurely are still unknown.

AIMS

To compare the CV risk pattern in two elderly cohorts living in North-East Italy.

MATERIALS AND METHODS

The Risk Of Vascular complications: Impact of Genetics in Old people (ROVIGO) study is a population-based study including 580 unrelated elderly subjects representative of general population living in Rovigo in the Veneto region. They were compared to a cohort of 580 age-gender-matched unrelated subjects from the CArdiovascular STudy in the Elderly (CASTEL) living in the same region in Castelfranco Veneto and Chioggia.

RESULTS

Blood pressure (BP), heart rate (HR), low-density-lipoprotein cholesterol, and prevalence of coronary heart disease, heart failure and chronic pulmonary disease were lower in the ROVIGO than in the CASTEL cohort, while high-density-lipoprotein cholesterol and the prevalence of diabetes were higher in the former than in the latter. In the ROVIGO cohort, diabetes, left ventricular hypertrophy, coronary and cerebrovascular diseases were more represented in men. In the CASTEL cohort, systolic BP was higher in women. In both cohorts, the lipid pattern was less favourable and HR higher in women, chronic pulmonary disease more represented in men.

CONCLUSIONS

People living in Rovigo were at lower CV risk than those in Castelfranco Veneto and Chioggia, mainly due to lower BP values, better lipid pattern and lower prevalence of CV and pulmonary disease.

A high-salt diet further impairs age-associated declines in cognitive, behavioral, and cardiovascular functions in male Fischer brown Norway rats

Aging-associated declines in cognitive, emotional, and cardiovascular function are well known. Environmental stress triggers critical changes in the brain, further compromising cardiovascular and behavioral health during aging. Excessive dietary salt intake is one such stressor. Here, we tested the effect of high salt (HS) on anxiety, learning-memory function, and blood pressure (BP) in male Fischer brown Norway (FBN) rats. Adult (A; 2 mo) and old (O; 20 mo) male rats were fed normal-salt (NS; 0.4% NaCl) or HS (8% NaCl) diets for 4 wk after being implanted with telemeter probes for conscious BP measurement. Thereafter, tests to assess anxiety-like behavior and learning-memory were conducted. The rats were then killed, and samples of plasma, urine, and brain tissue were collected. We found that systolic BP was higher in O-NS (117 ± 1.2 mm Hg) than in A-NS (105 ± 0.8 mm Hg) rats (P < 0.05). Furthermore, BP was higher in O-HS (124 ± 1.4 mm Hg) than in O-NS (117 ± 1.2 mm Hg) rats (P < 0.05). Moreover, anxiety-like behavior (light-dark and open-field tests) was not different between A-NS and O-NS rats but was greater in O-HS rats than in A-NS, O-NS, or A-HS rats (P < 0.05). Short-term memory (radial arm water maze test) was similar in A-NS and O-NS rats but was significantly impaired in O-HS rats compared with A-NS, O-NS, or A-HS rats (P < 0.05). Furthermore, oxidative stress variables (in plasma, urine, and brain) as well as corticosterone (plasma) were greater in O-HS rats when compared with A-NS, O-NS, or A-HS rats (P < 0.05). The antioxidant enzyme glyoxalase-1 expression was selectively reduced in the hippocampus and amygdala of O-HS rats compared with A-NS, O-NS, or A-HS rats (P < 0.05), whereas other antioxidant enzymes, glutathione reductase 1, manganese superoxide dismutase (SOD), and Cu/Zn SOD remained unchanged. We suggest that salt-sensitive hypertension and behavioral derangement are associated with a redox imbalance in the brain of aged FBN rats.

Prognostic value of cardiovascular disease status: the Leiden 85-plus study

This study aimed to explore the prognosis of very old people depending on their cardiovascular disease (CVD) history. This observational prospective cohort study included 570 participants aged 85 years from the general population with 5-year follow-up for morbidity, functional status, and mortality. At baseline, participants were assigned to three groups: no CVD history, "minor" CVD (angina pectoris, transient ischemic attack, intermittent claudication, and/or heart failure), or "major" CVD (myocardial infarction [MI], stroke, and/or arterial surgery). Follow-up data were collected on MI, stroke, functional status, and cause-specific mortality. The composite endpoint included cardiovascular events (MI or stroke) and cardiovascular mortality. At baseline, 270 (47.4 %) participants had no CVD history, 128 (22.4 %) had minor CVD, and 172 (30.2 %) had major CVD. Compared to the no CVD history group, the risk of the composite endpoint increased from 1.6 (95 % confidence interval [CI], 1.1-2.4) for the minor CVD group to 2.7 (95 % CI, 2.0-3.9) for the major CVD group. Similar trends were observed for cardiovascular and all-cause mortality risks. In a direct comparison, the major CVD group had a nearly doubled risk of the composite endpoint (hazard ratio, 1.8; 95 % CI, 1.2-2.7), compared to the minor CVD group. Both minor and major CVD were associated with an accelerated decline in cognitive function and accelerated increase of disability score (all p < 0.05), albeit most pronounced in participants with major CVD. CVD disease status in very old age is still of important prognostic value: a history of major CVD (mainly MI or stroke) leads to a nearly doubled risk of poor outcome, including cardiovascular events, functional decline, and mortality, compared with a history of minor CVD.

A prospective study of risk factors for cardiovascular events among the elderly

Objective

To analyze the impact of cardiovascular (CV) risk factors on the occurrence of fatal and non-fatal CV events in elderly individuals.

Methods

The present research was a prospective cohort study of 800 elderly Brazilian outpatients (60 to 85 years old) with a 12-year follow-up period (baseline: 1997–1998). The outcome variable was CV mortality or non-fatal CV events (stroke, infarction, angina, heart failure). Hypertension, diabetes, global and abdominal obesity, dyslipidemias, and metabolic syndrome were analyzed as independent variables. The analyses were based on Cox proportional hazard models and adjusted for gender, age range, smoking, regular physical activity, and previous cardiovascular disease.

Results

A total of 233 fatal and non-fatal CV events were observed (29.1%). In the adjusted analysis, the following variables were associated with CV risk: hypertension hazard ratio (HR): 1.69; confidence interval (CI) 95%: 1.28–2.24, diabetes (HR: 2.67; CI 95%: 1.98–3.61), metabolic syndrome (HR: 1.61; CI 95%: 1.24–2.09), abdominal obesity (HR: 1.36; CI 95%: 1.03–1.79), hypertriglyceridemia (HR: 1.67; CI 95%: 1.22–2.30) and high triglyceride/HDL-c ratio (HR: 1.73; CI 95%: 1.31–2.84). Hypertension, diabetes, and dyslipidemia remained associated with CV risk regardless of abdominal obesity.

Conclusion

In this prospective study, hypertension, diabetes, metabolic syndrome, abdominal obesity, and hypertriglyceridemia were predictors of CV risk in elderly individuals. These results confirm the relevance of controlling these CV risk factors in this age group.

Aspirin for primary prevention of cardiovascular events in the elderly: current status and future directions

The role of aspirin in the secondary prevention of occlusive cardiovascular events has now been well established. Given this, aspirin in primary prevention has been the focus of several large trials and subsequent meta-analyses over the past 3 decades, and yet the issue remains controversial. Recent studies in populations with high baseline risk - such as diabetics and those with asymptomatic peripheral arterial disease - have not found the expected benefits of aspirin on cardiovascular endpoints, which contrasts with earlier studies that reported a reduced relative risk for outcomes such as myocardial infarction and ischaemic stroke, but not for mortality. Furthermore, in healthy populations, the absolute risk reduction conferred by aspirin is small and needs to be balanced against the risk of a major haemorrhage. Older adults have a higher risk for cardiovascular events and therefore might represent the group in which aspirin for primary prevention could deliver the greatest absolute benefit, yet at the same time, the elderly bear an increased vulnerability to major haemorrhage, including haemorrhagic stroke. It is also not known whether older adults experience the same risk reduction from aspirin as middle-aged individuals. The current evidence base does not sufficiently clarify whether aspirin for primary prevention confers a meaningful net benefit in the elderly.

Development and validation of a coronary risk prediction model for older U.S. and European persons in the Cardiovascular Health Study and the Rotterdam Study

BACKGROUND

Risk scores for prediction of coronary heart disease (CHD) in older adults are needed.

OBJECTIVE

To develop a sex-specific CHD risk prediction model for older adults that accounts for competing risks for death.

DESIGN

2 observational cohort studies, using data from 4946 participants in the Cardiovascular Health Study (CHS) and 4303 participants in the Rotterdam Study (RS).

SETTING

Community settings in the United States (CHS) and Rotterdam, the Netherlands (RS).

PARTICIPANTS

Persons aged 65 years or older who were free of cardiovascular disease.

MEASUREMENTS

A composite of nonfatal myocardial infarction and coronary death.

RESULTS

During a median follow-up of 16.5 and 14.9 years, 1166 CHS and 698 RS participants had CHD events, respectively. Deaths from noncoronary causes largely exceeded the number of CHD events, complicating accurate CHD risk predictions. The prediction model had moderate ability to discriminate between events and nonevents (c-statistic, 0.63 in both U.S. and European men and 0.67 and 0.68 in U.S. and European women). The model was well-calibrated; predicted risks were in good agreement with observed risks. Compared with the Framingham point scores, the prediction model classified elderly U.S. persons into higher risk categories but elderly European persons into lower risk categories. Differences in classification accuracy were not consistent and depended on cohort and sex. Adding newer cardiovascular risk markers to the model did not substantially improve performance.

LIMITATION

The model may be less applicable in nonwhite populations, and the comparison Framingham model was not designed for adults older than 79 years.

CONCLUSION

A CHD risk prediction model that accounts for deaths from noncoronary causes among older adults provided well-calibrated risk estimates but was not substantially more accurate than Framingham point scores. Moreover, adding newer risk markers did not improve accuracy. These findings emphasize the difficulties of predicting CHD risk in elderly persons and the need to improve these predictions.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute; National Institute of Neurological Disorders and Stroke; The Netherlands Organisation for Scientific Research; and the Netherlands Organisation for Health Research and Development.

The effects of diet education plus light resistance training on coronary heart disease risk factors in community-dwelling older adults

OBJECTIVES

To examine the effects of diet education (DE) plus light resistance training (RT) on coronary heart disease risk (CHD) factors, specifically dietary quality, blood lipid and C-Reactive protein (CRP) concentrations in overweight and obese older adults in a community setting.

DESIGN

Community outreach intervention with a quasi-experimental design.

PARTICIPANTS AND SETTING

A total of 96 subjects, 16 males and 80 females, aged 69.2 ± 6.2 years, community-dwelling, and from one of four senior centers in Rhode Island.

INTERVENTION

Subjects participated in 30 minutes of DE (once per week) and ~80 minutes of RT (two separate sessions per week) for eight weeks. The DE sessions were led by a registered dietitian.

MEASUREMENTS

Anthropometrics (height, weight, waist circumference, hip circumference, and body composition), clinical (blood pressure), biochemical (lipid profile, glucose, and CRP concentrations), and diet quality measured by the Dietary Screening Tool (DST).

RESULTS

A significant change was seen in DST risk categories from baseline to post-intervention, χ² (2)=20.43, p < 0.01. Significant differences were seen in triacylglycerol (p=0.028) as well as in systolic and diastolic blood pressures, weight, waist circumference, hip circumference, percent body fat, fat mass, and body mass index (all p<0.05).

CONCLUSION

This intervention effectively decreased CHD risk in overweight and obese older adults. Future research is needed to examine the effects of longer DE plus RT interventions with greater weight loss on the lipid profile and CRP concentrations in overweight and obese older adults at risk for CHD.

Impairment of pulmonary function is an independent risk factor for atrial fibrillation: the Takahata study

BACKGROUND

Chronic pulmonary disorders, such as chronic obstructive pulmonary disease (COPD) and fibrosing lung diseases, and atrial fibrillation (AF), are prevalent in elderly people. The impact of cardiac co-morbidities in the elderly, where pulmonary function is impaired, cannot be ignored as they influence mortality. The relationship between the prevalence of AF and pulmonary function is unclear. The aim of this study was to evaluate this relationship in participants in a health check.

METHODS

Subjects aged 40 or older (n = 2,917) who participated in a community-based annual health check in Takahata, Japan, from 2004 through to 2005, were enrolled in the study. We performed blood pressure measurements, blood sampling, electrocardiograms, and spirometry on these subjects.

RESULTS

The mean FEV(1) % predicted and FVC % predicted in AF subjects was significantly lower than in non-AF subjects. The prevalence of AF was higher in those subjects with airflow limitation or lung restriction than in those without. Furthermore, AF prevalence was higher in those subjects with severe airflow obstruction (FEV(1) %predicted < 50) than in those who had mild or moderate airflow obstruction (FEV(1) %predicted ≥ 50), although there was no difference between the prevalence of AF in subjects with 70≤ FVC %predicted <80 lung restriction and those with FVC %predicted <70. Multiple logistic regression analysis revealed that FEV(1) %predicted and FVC %predicted are independent risk factors for AF (independent of age, gender, left ventricular hypertrophy, and serum levels of B-type natriuretic peptide).

CONCLUSION

Impaired pulmonary function is an independent risk factor for AF in the Japanese general population.

Influence of sociodemographic inequalities and chronic conditions on influenza vaccination coverage in Italy: results from a survey in the general population

OBJECTIVE

To assess inequalities in vaccination against seasonal influenza determined by sociodemographic and health-related factors.

STUDY DESIGN

A cross-sectional study was conducted using data from 128,040 subjects aged 1-89 years who participated the national survey 'Health Conditions and Health Care Services Use', conducted by the Italian National Centre of Statistics in 2005.

METHODS

This analysis included people aged ≥65 years, and individuals of any age with chronic medical conditions. The outcome variable was vaccination or non-vaccination against influenza in the last 12 months, and the explanatory variables were gender, age, smoking habit, educational level, macro-region of residence, chronic medical conditions, occupational status, marital status, self-assessed health status and self-assessed household income. Univariate and multivariate analyses were conducted using Chi-squared test and multiple logistic regression models. For the latter analysis, results are presented as odds ratios (OR) and 95% confidence intervals (CI) of being vaccination against influenza in the last 12 months.

RESULTS

Approximately 20% of subjects had been vaccinated against influenza in the previous 12 months. Older age (≥65 years), current smoker, poor health status, poor self-assessed household income and the presence of at least one chronic condition were positively associated with influenza vaccination (P < 0.05). The lowest ORs for influenza vaccination were found in current smokers (adjusted OR vs non-smokers 0.699, 95% CI 0.697-0.701), young adults (adjusted OR 15-24 years vs ≥65 years 0.073, 95% CI 0.072-0.073; adjusted OR 25-34 years vs ≥65 years 0.097, 95% CI 0.096-0.097), subjects with a lower secondary education or professional school (adjusted OR vs primary education 0.910, 95% CI 0.908-0.913), subjects living in the Islands (adjusted OR vs North-eastern Italy 0.760, 95% CI 0.757-0.763), and unemployed subjects (adjusted OR vs employed 0.867; 95% CI 0.859-0.875). The ORs for vaccination were lower for some chronic conditions (e.g. allergies, cirrhosis) than others (e.g. cancer, stroke, bronchitis). Younger age groups, including children aged 0-14 years, had lower ORs for vaccination.

CONCLUSIONS

Socio-economic factors, such as gender, age, educational level, occupational status and macro-region of residence, affect influenza vaccination coverage rates in the Italian general population. In addition, some chronic medical conditions are an obstacle for vaccination.

Prevalence, awareness, treatment and control of hypertension in the elderly population of Singapore

A comprehensive picture of the management of hypertension in the increasing elderly population in Singapore is lacking. In this study, we assess the prevalence and correlates of hypertension and of awareness, treatment and control of hypertension among 4494 elderly Singaporeans (≥60 years) participating in a recent representative survey. The weighted prevalences of hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or current use of antihypertension medication) and of awareness, treatment and control of hypertension were assessed. We assessed the extent of association of these outcomes with socio-demographic (age, gender, ethnicity, education, housing type, living arrangement and social participation) and health (body mass, diabetes and cognitive status) variables using multivariable logistic regression. Nearly three-fourths (73.9%) of participants were found to have hypertension. Of this number, 30.8% were unaware that they had hypertension, 32.0% were not being treated for the disease and 75.9% had suboptimal control of their blood pressure. Among those aware of their hypertension, only 1.9% were untreated. However, nearly two-thirds (64.5%) of treated hypertensives had suboptimal control. Age, gender, ethnicity, education, housing type, body mass and diabetes were significantly correlated with lack of awareness, treatment and control of hypertension. Although the specific 'at-risk' subgroups varied by the outcome, men and Malays had consistently higher odds for all three unfavorable outcomes. There is a need to improve awareness, treatment and especially control of hypertension among elderly Singaporeans. Primary and secondary prevention efforts targeting the elderly and their primary health-care providers are called for, as are regular data collection efforts based on representative samples.

Comparing the probability of stroke by the Framingham risk score in hypertensive Korean patients visiting private clinics and tertiary hospitals

BACKGROUND

The purpose of this study was to investigate the pattern of distribution of risk factors for stroke and the 10-year probability of stroke by the Framingham risk score in hypertensive patients visiting private clinics vs. tertiary hospitals.

METHODS

A total of 2,490 hypertensive patients who attended 61 private clinics (1088 patients) and 37 tertiary hospitals (1402 patients) were enrolled. The risk factors for stroke were evaluated using a series of laboratory tests and physical examinations, and the 10-year probability of stroke was determined by applying the Framingham stroke risk equation.

RESULTS

The proportion of patients who had uncontrolled hypertension despite the use of antihypertensive agents was 49% (66 and 36% of patients cared for at private clinics and tertiary hospitals, respectively; p < 0.001). The average 10-year probability of stroke by the Framingham risk score in hypertensive patients was 21% (approximately 2.2 times higher than of the risk of stroke in the Korean Cancer Prevention Study [KCPS] cohort) and was higher in patients attending tertiary hospitals compared to private clinics (16 and 24% of patients attending private clinics and tertiary hospitals, respectively; p < 0.001).

CONCLUSIONS

Since the 10-year probability of stroke by the Framingham risk score in hypertensive patients attending tertiary hospitals was higher than the risk for patients attending private clinics. We suggest that the more aggressive interventions are needed to prevent and early detect an attack of stroke in hypertensive patients attending tertiary hospitals.

Factors associated with control of blood pressure among elderly people diagnosed with hypertension in a rural area of South Korea: the Chungju Metabolic Disease Cohort Study (CMC study)

OBJECTIVE

Control of blood pressure is important in old age for prevention of hypertension-associated complications. This study aimed to investigate the factors associated with control of hypertension in elderly people (>or=60 years old) diagnosed with hypertension.

METHODS

The subjects were those who had a self-reported diagnosis of hypertension (532 men and 1078 women) from a stratified random cluster sample of 4201 people aged 60 years or older. Controlled hypertension was defined as a systolic blood pressure (SBP) <140 mmHg and diastolic blood pressure (DBP) <90 mmHg, and SBP <130 mmHg and DBP <80 mmHg for subjects with diabetes.

RESULTS

The prevalence of controlled hypertension (25.9%) was low. In older women, the prevalence of isolated uncontrolled SBP was increased. After adjusting for other covariates, uncontrolled hypertension was positively associated with body mass index (BMI>or=23 kg/m(2)), and negatively associated with balanced diet and a past history of cardiovascular disease in men, whereas in women it was positively associated with waist circumference (>or=80 cm).

CONCLUSIONS

In elderly people diagnosed with hypertension general obesity (high BMI) appears to have an important influence on uncontrolled hypertension in men, whereas abdominal obesity (high waist circumference) appears to be an important factor in women.

Vaccination in older adults: development of an educational tool, Vaxisenior, in France

The benefits of vaccination in older adults are well documented yet there is poor uptake of such preventive measures, and one of the main reasons in France is a lack of recommendation and support from healthcare professionals. To address this issue a multidisciplinary group of experts has developed an educational tool, Vaxisenior, to assist in the training of physicians/healthcare workers who can act as advocates for immunization programs. The tool comprises of eight sections (general introduction; immunosenescence; diphtheria-tetanus-poliomyelitis; influenza; pneumococcus; pertussis; herpes zoster; and vaccines for travelers). In addition, it includes national immunization schedules and recommendations, practical information regarding opportunities to expand vaccine coverage that is convenient to the patient and a questions and answers section covering topics relating to particular usage and responsibilities. Implementation of vaccination policies for older adults is a major issue and will require extensive promotional campaigns, as well as active support from healthcare and public health professionals to improve overall vaccine coverage.

Current blood pressure self-management: a qualitative study

Blood pressure (BP) self-management is advocated to manage hypertension and reduce the risk of a future stroke. The purpose of this study was to identify BP self-management strategies used by individuals who had sustained a stroke or transient ischemic attack (TIA). As part of a mixed-methods study, we conducted six focus groups and achieved saturation with 16 stroke survivors and 12 TIA survivors. Each participant completed a questionnaire regarding current BP management. We analyzed and coded qualitative transcripts from the focus groups and found four emergent themes that were supported by questionnaire results. The four self-management themes include: (1) external support for BP self-management is helpful; (2) BP self-management strategies include medication adherence, routine development, and BP monitoring; (3) BP risk factor management involves diet, exercise, and stress reduction; and (4) taking advantage of the"teachable moment" may be advantageous for behavior change to self-manage BP. This research provides key elements for the development of a successful BP self-management program.

Improving the vaccination coverage of geriatric populations

Vaccination is an important component of disease prevention in the elderly; however, immunization coverage in this population is low. There is a clear need to improve vaccine coverage among this age group. To this end, various strategies can be employed. Raising awareness and improving the education of physicians and health care workers in the field of vaccination in geriatric populations play an important role. Active promotion of vaccination uptake should be implemented by health authorities and targeted to older adults. Other means, including the use of educational tools and guidelines to improve practice, should be more widely employed.

The German Coronary Artery Disease Risk Screening Model: development, validation, and application of a decision-analytic model for coronary artery disease prevention with statins

BACKGROUND

Coronary artery disease (CAD) is a major cause of death in industrial countries, leading to high health-related costs and decreased quality of life.

OBJECTIVE

To develop and validate a decision-analytic model for CAD risk screening in Germany (German Coronary Artery Disease Screening Model).

DESIGN

Markov model.

TARGET POPULATION

Age- and gender-specific cohorts of the German population.

DATA SOURCES

Mortality rates posted by the German Federal Statistical Office, the German Health Survey, social health insurance institutions, the MONICA Augsburg study, and the literature.

TIME HORIZON

Lifetime.

INTERVENTIONS

CAD risk screening for high-risk individuals using Framingham risk equation and use of statins as the primary preventive measure, compared with a setting without screening.

OUTCOME MEASURES

Life-years (LY) gained, quality-adjusted life-years (QALYs) gained.

RESULTS

The model-based CAD incidence corresponds well with empirical data from the MONICA Augsburg study. Health outcomes depend on the screening threshold (cutoff value of Framingham 10-year risk) and on the age and gender of the cohort screened (0.03 to 0.26 LYs and 0.06 to 0.42 QALYs gained per person screened in cohorts of 50- and 60-year-old men and women, respectively).

CONCLUSIONS

The model provides a valid tool for evaluating the long-term effectiveness of CAD risk screening in Germany. Using statins as a primary prevention intervention for CAD in high-risk individuals identified by screening could improve the long-term health of the German population.

Educational vaccine tools: the French initiative

Prevention is an important but neglected issue in geriatric medicine. Vaccination plays a major role in prevention of infectious diseases, but its implementation in clinical practice is far from perfect. To improve practice, a group of French experts composed of geriatricians and infectious disease specialists prepared a set of educational material about vaccination for older subjects. The tool has been designed to be used by medical teachers to help them teach this topic to other physicians, nursing staff and students. The group first defined teaching objectives and reviewed the scientific literature on the efficacy and use of various vaccines in the elderly. Results were recorded in 217 slides. These slides were grouped to allow their use for short presentations: the immune system in the elderly and general information about vaccination; universal vaccines, influenza vaccines, pneumococcal vaccines, Herpes zoster vaccine, pertussis vaccine, vaccines for old travellers. Written comments were added to most slides to help presenters teach the topics. The content and design of the slides were analyzed and discussed by the whole group. The set was collected in a CD with ready-to-use files for oral presentations. This educational tool was presented and given to French teachers in geriatrics. It has been used for educational sessions in geriatric hospital wards, for continuous medical education for general practitioners and for courses for physicians learning geriatrics. It has also been proposed to physicians in charge of medical coordination of nursing homes and is available on a web site.

Estimating the probability of stroke in Korean hypertensive patients visiting tertiary hospitals using a risk profile from the Framingham study

BACKGROUND

Hypertension is the most important single modifiable risk factor for stroke. We investigated the distribution of stroke risk factors and 10-year probability of stroke in Korean hypertensive patients.

METHODS

A total of 1,402 hypertensive patients treated by cardiology departments at 37 general hospitals nationwide were enrolled. Risk factors for stroke were evaluated using a series of laboratory tests and physical examinations, and the 10-year probability of stroke was determined by applying the Framingham stroke risk equation.

RESULTS

The proportion of patients who have uncontrolled hypertension despite use of antihypertensives was 37.2% (37.2% women, 37.3% men, p = 0.990). The average 10-year probability of stroke in hypertensive patients was 24.27% (24.17% women, 24.39% men, p = 0.825), approximately 2.4 times higher than of the risk of stroke observed in the Korean Cancer Prevention Study [KCPS] cohort. The 10-year stroke probability in patients with hypertension increased in proportion to age. In patients for hypertension, the 10-year probability of stroke increased in proportion to blood pressure.

CONCLUSION

Aggressive interventions are mandated to reduce blood pressure and alleviate the high risk of stroke in hypertensive patients.

Use of Framingham risk score and new biomarkers to predict cardiovascular mortality in older people: population based observational cohort study

OBJECTIVES

To investigate the performance of classic risk factors, and of some new biomarkers, in predicting cardiovascular mortality in very old people from the general population with no history of cardiovascular disease.

DESIGN

The Leiden 85-plus Study (1997-2004) is an observational prospective cohort study with 5 years of follow-up.

SETTING

General population of the city of Leiden, the Netherlands.

PARTICIPANTS

Population based sample of participants aged 85 years (215 women and 87 men) with no history of cardiovascular disease; no other exclusion criteria. Main measurements Cause specific mortality was registered during follow-up. All classic risk factors included in the Framingham risk score (sex, systolic blood pressure, total and high density lipoprotein cholesterol, diabetes mellitus, smoking and electrocardiogram based left ventricular hypertrophy), as well as plasma concentrations of the new biomarkers homocysteine, folic acid, C reactive protein, and interleukin 6, were assessed at baseline.

RESULTS

During follow-up, 108 of the 302 participants died; 32% (35/108) of deaths were from cardiovascular causes. Classic risk factors did not predict cardiovascular mortality when used in the Framingham risk score (area under receiver operating characteristic curve 0.53, 95% confidence interval 0.42 to 0.63) or in a newly calibrated model (0.53, 0.43 to 0.64). Of the new biomarkers studied, homocysteine had most predictive power (0.65, 0.55 to 0.75). Entering any additional risk factor or combination of factors into the homocysteine prediction model did not increase its discriminative power.

CONCLUSIONS

In very old people from the general population with no history of cardiovascular disease, concentrations of homocysteine alone can accurately identify those at high risk of cardiovascular mortality, whereas classic risk factors included in the Framingham risk score do not. These preliminary findings warrant validation in a separate cohort.

Validity of the Framingham point scores in the elderly: results from the Rotterdam study

BACKGROUND

The National Cholesterol Education Program recommends assessing 10-year risk of coronary heart disease (CHD) in individuals free of established CHD with the Framingham Point Scores (FPS). Individuals with a risk >20% are classified as high risk and are candidates for preventive intervention. We aimed to validate the FPS in a European population of elderly subjects.

METHODS

Subjects free of established CHD at baseline were selected from the Rotterdam study, a population-based cohort of subjects 55 years or older in The Netherlands. We studied calibration, discrimination (c-index), and the accuracy of high-risk classifications. Events consisted of fatal CHD and nonfatal myocardial infarction.

RESULTS

Among 6795 subjects, 463 died because of CHD and 336 had nonfatal myocardial infarction. Predicted 10-year risk of CHD was on average well calibrated for women (9.9% observed vs 10.1% predicted) but showed substantial overestimation in men (14.3% observed vs 19.8% predicted), particularly with increasing age. This resulted in substantial number of false-positive classifications (specificity 70%) in men. In women, discrimination of the FPS was better than that in men (c-index 0.73 vs 0.63, respectively). However, because of the low baseline risk of CHD and limited discriminatory power, only 33% of all CHD events occurred in women classified as high risk.

CONCLUSIONS

The FPS need recalibration for elderly men with better incorporation of the effect of age. In elderly women, FPS perform reasonably well. However, maintaining the rational of the high-risk threshold requires better performing models for a population with low incidence of CHD.

The significance of low HDL-cholesterol levels in an ageing society at increased risk for cardiovascular disease

In most developed and developing countries, the proportion of the population aged 60 years or more is growing faster than any other age group. Given that the vast majority of cardiovascular events occur in older individuals, new thinking is needed to reduce their risk. Epidemiological studies have shown an increasing prevalence of the metabolic syndrome with age, driven by nutrition inappropriate for a modern sedentary lifestyle. A low level of high-density lipoprotein (HDL)-cholesterol, a component of the atherogenic dyslipidaemia of the metabolic syndrome, has been shown to be an important determinant of coronary risk, which rises in prevalence with increasing age. Thus, raising HDLcholesterol, in addition to lowering the level of low-density lipoprotein (LDL)-cholesterol, seems a plausible approach to reduce cardiovascular risk in an ageing population. Clinical studies have shown that adding nicotinic acid, which raises HDL-cholesterol by 20-25%, to a statin enhances the reduction in progression of atherosclerosis. Results of the ongoing Atherothrombosis Intervention in Metabolic syndrome with low HDL/High triglyceride and Impact on Global Health Outcomes (AIM-HIGH) study are awaited with interest to see whether such theoretical benefit translates into clinical outcome.

Low high-density lipoprotein cholesterol predicts cardiovascular events after carotid stenting: a long-term survey

BACKGROUND

Apart from advanced age, little is known about predictors of the long-term outcome after carotid artery stenting (CAS).

OBJECTIVE

We sought to determine whether atherosclerotic risk factors predict the long-term outcome after CAS.

PATIENTS AND METHODS

We enrolled 532 patients assigned for CAS. The primary composite end-point, including stroke, myocardial infarction and all-cause mortality, was observed in 100 patients (19%) during the long-term follow-up (median 28 months, interquartile range 14-49 months).

RESULTS

Cumulative event rates at 1, 3 and 5 years were 4.4%, 17.1% and 33.4%, respectively. High-density lipoprotein (HDL) cholesterol was an independent predictor of event-free survival. The adjusted hazard ratio for the primary end-point was 0.97 per increase of 1 mg dL(-1) HDL cholesterol [95% confidence interval (CI) 0.95-0.99, P = 0.002) and 2.7 (95% CI 1.6-4.4, P < 0.001) for low HDL cholesterol (< 40 mg dL(-1) in men and < 50 mg dL(-1) in women). Inflammatory activation (leukocyte count > 10,000 mL(-1) or fibrinogen > 450 mg dL(-1) or erythrocyte sedimentation rate > 20 mm h(-1)) was the only other independent atherosclerotic risk factor (P = 0.001). Patients with low HDL cholesterol and elevated inflammatory activation were at very high risk, with a 5-year event rate of 59.4% (95% CI 43.6-75.2%) as compared to 15.1% (95% CI 8.2-22.0%) in those without both risk factors (log rank, P < 0.001). Age, occlusion of the contralateral carotid artery and heart failure were further independent risk predictors (P < 0.01 for all).

CONCLUSIONS

Low HDL cholesterol is an independent predictor of the long-term outcome after CAS. The combination of low HDL cholesterol and elevated inflammatory markers identified high-risk patients.

Stroke prevention and management in older adults

Stroke is the third leading cause of death and a foremost cause of serious, long-term disability in the United States. As cardiovascular and metabolic disease incidence rises with age, older people are more likely to experience strokes. Age is the single most important risk factor for stroke. For each successive 10 years after age 55, the stroke rate more than doubles in both men and women. However, stroke is not an inevitable consequence of aging. By identifying and modifying risk factors in older people, nurses can partner with other providers to reduce the incidence, morbidity, and mortality associated with stroke in older adults. Control of hypertension, resolution of dyslipidemia, management of diabetes mellitus, anticoagulation for atrial fibrillation, promotion of exercise and healthy diet, and cessation of cigarette smoking are of particular importance in older adults. Recognition of stroke symptoms, access to emergency evaluation and treatments, and participation in comprehensive rehabilitation may determine stroke outcomes in aging. This article presents stroke risk factors and primary and secondary prevention in the context of aging, with special considerations in the identification and management of acute stroke, recovery, and rehabilitation for older adults who survive stroke.

Cardiovascular Disease Risk Reduction in Older Adults

Preventing cardiovascular events in older persons presents unique challenges to clinicians. Cardiovascular disease accounts for a large amount of disability and mortality in older persons. Older persons are often faced with unique and multiple challenges to health, including cognitive decline, social isolation, financial constraints, and physical disabilities. As more and more older persons are enrolled in studies that aim to better understand coronary heart disease and its prevention, new information is becoming available that allow clinicians to improve outcomes in the older adult. The most recent updates in the area of medical management, as well as updates of recommendations for lifestyle changes, including physical activity and dietary recommendations for older persons at risk, are presented in this article.

A large scale study of angiotensin II inhibition therapy in an elderly population: the CHANCE study

This 8-week, multicenter study evaluated the efficacy and safety of candesartan cilexetil (CC, 8-16 mg) in elderly (>65 years) hypertensive patients. Patients (n=3013) received CC 8 mg during 8 weeks which eventually doubled to CC 16 mg at week 4 if blood pressure remained uncontrolled (> or = 140/90 mmHg). At week 8, 65.5% of patients were normalized (BP < 140/90 mmHg). Mean changes at week 8 were -25.8, -13.2, and -12.7 mmHg for systolic, diastolic, and pulse pressure, respectively. Age, sex, and diabetic status did not influence the antihypertensive effect of CC. 68% of the patients treated with, but uncontrolled or intolerant of, prior antihypertensive treatment were normalized by CC 8-16 mg. In summary, CC 8-16 mg once daily was effective and well tolerated in the management of arterial hypertension in elderly subjects.