Changes in fasting plasma glucose and subclinical atherosclerosis: A cohort study from VIPVIZA trial

BACKGROUND AND AIMS

Studies on the influence of fasting plasma glucose (FPG) on the development of carotid plaque (CP) and intima media thickness (CIMT) mainly focused on single FPG measures. We investigated whether changes in FPG (ΔFPG) are associated with incident CP and CIMT change (ΔCIMT) over time.

METHODS

Analyses were based on information from 1896 participants from the VIPVIZA trial (Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention), with baseline and 3-year follow-up data on FPG, ultrasonographic CP (none or ≥1 lesion/s) and CIMT assessments. We studied the association between baseline FPG (prior to intervention) or 3-year ΔFPG (mmol/L) and incident CP (logistic regression) or ΔCIMT (linear regression). Analyses were adjusted for multiple potential confounders.

RESULTS

1896 and 873 individuals, respectively, were included in the analysis on incident CP and ΔCIMT. Participants were 60 years old at baseline and 61% and 54% were females, in the CP and CIMT analyses, respectively. Every mmol/L increase in FPG was associated with an increased odds of incident CP (odds ratio: 1.42, 95% confidence interval [CI]: 1.17, 1.73), but there was no association with ΔCIMT (mean difference: 0.002 mm, 95% CI: -0.003, 0.008) after 3 years. Baseline FPG was not associated with incident CP nor ΔCIMT progression.

CONCLUSIONS

In middle-aged individuals with low to moderate risk for cardiovascular diseases, 3-year ΔFPG was positively associated with the risk of incident CP, but not with ΔCIMT. Single measures of FPG may not be sufficient in estimating cardiovascular risk among individuals with low to moderate risk.

COVID-19 Prevention: Vitamin D Is Still a Valid Remedy

Seven meta-analyses and systematic reviews and three later clinical trials argued that low vitamin D status increased susceptibility to COVID-19 and the risk of greater disease severity and mortality [...].

Obesity strongly predicts COVID-19-related major clinical adverse events in Coptic Clergy

Background and aims

The Coptic Clergy, due to their specific work involving interaction with many people, could be subjected to increased risk of infection from COVID-19. The aim of this study, a sub-study of the COVID-19-CVD international study of the impact of the pandemic on the cardiovascular system, was to assess the prevalence of COVID-19 among Coptic priests and identify predictors of clinical adverse events.

Methods

Participants were geographically divided into three groups: Group-I: Europe and USA, Group II: Northern Egypt and Group III: Southern Egypt. Participants' demographic indices, cardiovascular risk factors, possible source of infection, number of liturgies, infection management and major adverse events (MAEs), comprising death, re-infection or mechanical ventilation, were assessed.

Results

Out of the 1,570 clergy serving in 25 dioceses, 226 (14.39%) were infected. Their mean age was 49.5±12 years and mean weekly number of liturgies was 3.44±1.0. The overall prevalence rate was 14.7% and did not differ between Egypt as a whole and overseas (p=0.23). Disease prevalence was higher in Northern Egypt clergy compared to Europe and USA combined (18.4% vs 12.1%, p=0.03) and tended to be higher than in Southern Egypt (18.4% vs. 13.6%, p=0.09). Ten priests (4.42%) died of COVID-19 related complications, 2 (0.9%) had re-infection and 27 (11.9%) suffered a MAE. The clergy from Southern Egypt were more obese but the remaining risk factors were less prevalent compared to those in Europe and USA (p=0.01). In multivariate analysis, obesity OR 4.184 (2.483 to 12.14; p=0.01); age OR 1.070 (0.014 to 1.130; p=0.02), and systemic hypertension OR 0.932 (0.874 to 0.994; p=0.007) predicted MAEs. Obesity was the most powerful independent predictor of MAE in Southern Egypt and systemic hypertension in Northern Egypt (p<0.05 for both).

Conclusion

Obesity is very prevalent among Coptic clergy and seems to be the most powerful independent predictor of major COVID-19-related adverse events.

Funding Acknowledgement

Type of funding sources: None. Prevalence of SARS-CoV2 among Clergy

Combined cardiac risk factors predict COVID-19 related mortality and the need for mechanical ventilation in Coptic Clergy

Background and aims

The clinical adverse events of COVID-19 among clergy worldwide have been found higher than among ordinary communities, probably because of the nature of their work. The aim of this study, was to assess the impact of cardiac risk factors on COVID-19-related mortality and the need for mechanical ventilation in Coptic clergy.

Methods

Of 1576 Coptic clergy participating in the COVID-19-Clergy study, serving in Egypt, USA and Europe, 213 had the infection and were included in this analysis. Based on the presence of systemic arterial hypertension (AH), participants were divided into two groups: Group-I, Clergy with AH (n=77) and Group-II, without AH (n=136).Participants' demographic indices, cardiovascular risk factors, COVID-19 management details and related mortality were assessed.

Results

Clergy with AH were older (p<0.001), more obese (p=0.04), had frequent type 2 diabetes (DM) (p=0.001), dyslipidemia (p=0.001) and coronary heart disease (CHD) (p=0.04) compared to those without AH. COVID-19 treatment at home, hospital or in intensive care did not differ between the patient groups (p>0.05 for all). Clergy serving in Northern and Southern Egypt had a higher mortality rate compared to those from Europe and the USA combined (5.22%, 6.38%, 0%; p=0.001). The impact of AH on mortality was significant only in Southern Egypt (10% vs. 3.7%; p=0.01) but not in Northern Egypt (4.88% vs. 5.81%; p=0.43).

In multivariate analysis, CHD OR 1.607 [(0.982 to 3.051); p=0.02] and obesity, OR 3.403 [(1.902 to 4.694); p=0.04]predicted COVID-19 related mortality. A model combining cardiac risk factors (systolic blood pressure (SBP) ≥160 mmHg, DM, obesity, dyslipidemia and history of CHD), was the most powerful independent predictor of COVID-19-related mortality, OR 4.813 [(2.011 to 7.017); p=0.008]. The same model also proved the best independent multivariate predictor of mechanical ventilation OR 1.444 [(0.949 to 11.88); p=0.001].

Conclusion

In Coptic clergy, the cumulative impact of risk factors is the most powerful predictor of mortality and the need for mechanical ventilation in Coptic clergy.

Funding Acknowledgement

Type of funding sources: None.

Combined Cardiac Risk Factors Predict COVID-19 Related Mortality and the Need for Mechanical Ventilation in Coptic Clergy

BACKGROUND AND AIMS

The clinical adverse events of COVID-19 among clergy worldwide have been found to be higher than among ordinary communities, probably because of the nature of their work. The aim of this study was to assess the impact of cardiac risk factors on COVID-19-related mortality and the need for mechanical ventilation in Coptic clergy.

METHODS

Of 1570 Coptic clergy participating in the COVID-19-Clergy study, serving in Egypt, USA and Europe, 213 had the infection and were included in this analysis. Based on the presence of systemic arterial hypertension (AH), participants were divided into two groups: Group-I, clergy with AH (n = 77) and Group-II, without AH (n = 136). Participants' demographic indices, cardiovascular risk factors, COVID-19 management details and related mortality were assessed.

RESULTS

Clergy with AH were older (p < 0.001), more obese (p = 0.04), had frequent type 2 diabetes (DM) (p = 0.001), dyslipidemia (p = 0.001) and coronary heart disease (CHD) (p = 0.04) compared to those without AH. COVID-19 treatment at home, hospital or in intensive care did not differ between the patient groups (p > 0.05 for all). Clergy serving in Northern and Southern Egypt had a higher mortality rate compared to those from Europe and the USA combined (5.22%, 6.38%, 0%; p = 0.001). The impact of AH on mortality was significant only in Southern Egypt (10% vs. 3.7%; p = 0.01) but not in Northern Egypt (4.88% vs. 5.81%; p = 0.43). In multivariate analysis, CHD OR 1.607 ((0.982 to 3.051); p = 0.02) and obesity, OR 3.403 ((1.902 to 4.694); p = 0.04) predicted COVID-19 related mortality. A model combining cardiac risk factors (systolic blood pressure (SBP) ≥ 160 mmHg, DM, obesity and history of CHD) was the most powerful independent predictor of COVID-19-related mortality, OR 3.991 ((1.919 to 6.844); p = 0.002). Almost the same model also proved the best independent multivariate predictor of mechanical ventilation OR 1.501 ((0.809 to 6.108); p = 0.001).

CONCLUSION

In Coptic clergy, the cumulative impact of risk factors was the most powerful predictor of mortality and the need for mechanical ventilation.

The relationship between carotid and coronary calcification in patients with coronary artery disease

BACKGROUND

Atherosclerosis is a multi-system pathology with heterogeneous involvement. We aimed to investigate the relationship between the presence and severity of carotid and coronary calcification in a group of patients with coronary artery disease.

METHODS

Sixty-three patients presenting with unstable angina or positive stress test for myocardial ischaemia were enrolled in this study. All patients underwent CT scanning of the carotid and coronary arteries using the conventional protocol and Agatston scoring system. Risk factors for atherosclerosis were also analyzed for correlation with the extent of arterial calcification.

RESULTS

Total coronary artery calcium score (CAC) was several times higher than total carotid calcium score (1274 (1018) vs 6 (124), p = 0·0001, respectively). The left carotid calcium score correlated strongly with the right carotid calcium score (rho = 0·69, p < 0·0001). The total CAC score correlated modestly with the total carotid calcium score (rho = 0·34, p = 0·007), in particular with left carotid score (rho = 0·38, p = 0·002), but not with the right carotid score. The left coronary calcium score correlated with the right coronary calcium score (rho = 0·35, p = 0·004), left carotid calcium score (rho = 0·33, p = 0·007) and left carotid calcium score at the bifurcation (rho = 0·34, p = 0·006). While hypertension correlated with carotid calcium score, diabetes and dyslipidaemia correlated with left CAC score.

CONCLUSION

In patients with coronary disease, the carotid calcification pattern appeared to be similar between the right and left system in contrast to that of the coronary arteries. CAC correlated only modestly with the carotid score, despite being significantly higher. Hypertension was related to carotid calcium score while diabetes and dyslipidaemia correlated with coronary calcification.

Sickness behavior may follow fracture as well as infection

Sickness behavior, induced by pro-inflammatory cytokines in the early stages of an infection, is well known. A case report of three fracture patients, who were not taking analgesic medication, suggests that the initial symptoms experienced, particularly fatigue and mood changes, mirror those of the sickness behavior of infection. A mini-review only found studies investigating one physical, mental or emotional symptom in fracture patients and none drew a parallel with sickness behavior, suggesting that this is a hitherto unrecognised phenomenon which would benefit from further investigation.

Environmental Contaminants and Congenital Heart Defects: A Re-Evaluation of the Evidence

Congenital heart defects (CHDs) are a common birth defect of largely unknown etiology, with high fetal and neonatal mortality. A review of CHDs and environmental contaminant exposure found that meta-analyses showed only modest associations for smoking, vehicle exhaust components, disinfectant by-products and proximity to incinerators, with stronger results from the newer, larger and better quality studies masked by the typical absence of effect in older studies. Recent studies of exposure to agricultural pesticides, solvents, metals and landfill sites also showed associations. Certain contaminants have been associated with certain CHDs, with septal defects being the most common. Frequent methodological problems include failure to account for potential confounders or maternal/paternal preconception exposure, differences in diagnosing, defining and classifying CHDs, grouping of defects to increase power, grouping of contaminants with dissimilar mechanisms, exclusion of pregnancies that result in death or later life diagnosis, and the assumption that maternal residence at birth is the same as at conception. Furthermore, most studies use measurement estimates of one exposure, ignoring the many additional contaminant exposures in daily life. All these problems can distort and underestimate the true associations. Impaired methylation is a common mechanism, suggesting that supplementary folate may be protective for any birth defect.

Coronary Calcification and Male Gender Predict Significant Stenosis in Symptomatic Patients in Northern and Southern Europe and the USA: A Euro-CCAD Study

Background and Aims: Significant stenosis is the principal cause of stable angina but its predictors and their variation by geographical region are unclear.Methods and Results: From the European Calcific Coronary Artery Disease (Euro-CCAD) cohort, we retrospectively investigated 5515 symptomatic patients from northern Europe (Denmark, France, Germany), southern Europe (Italy, Spain) and USA. All had conventional cardiovascular risk factor assessment, angiography and CT scanning for coronary artery calcium (CAC) scoring. There were differences in the patient characteristics between the groups, with the USA patients being younger and having more diet and lifestyle-related risk factors, although hypertension may have been better controlled than in Europe. USA patients had a two-fold increase in prevalence of significant stenosis and a three-fold increase in median CAC score. In all three groups, the log CAC score proved to be the strongest predictor of >50% stenosis followed by male gender. In the USA group, there were no additional independently predictive risk factors, although in northern Europe obesity, hypertension, smoking and hypercholesterolaemia remained predictive, with all risk factors other than hypertension proving to be predictive in the southern Europe group. Without the CAC score as a variable, male gender followed by diabetes were the most important predictors in all three regions, with hypertension also proving predictive in northern Europe.Conclusion:  In symptomatic patients, the CAC score and male gender were the two most important predictors of significant stenosis in symptomatic patients in northern and southern Europe and the USA.

Caloric Restriction and Its Effect on Blood Pressure, Heart Rate Variability and Arterial Stiffness and Dilatation: A Review of the Evidence

Essential hypertension, fast heart rate, low heart rate variability, sympathetic nervous system dominance over parasympathetic, arterial stiffness, endothelial dysfunction and poor flow-mediated arterial dilatation are all associated with cardiovascular mortality and morbidity. This review of randomised controlled trials and other studies demonstrates that caloric restriction (CR) is capable of significantly improving all these parameters, normalising blood pressure (BP) and allowing patients to discontinue antihypertensive medication, while never becoming hypotensive. CR appears to be effective regardless of age, gender, ethnicity, weight, body mass index (BMI) or a diagnosis of metabolic syndrome or type 2 diabetes, but the greatest benefit is usually observed in the sickest subjects and BP may continue to improve during the refeeding period. Exercise enhances the effects of CR only in hypertensive subjects. There is as yet no consensus on the mechanism of effect of CR and it may be multifactorial. Several studies have suggested that improvement in BP is related to improvement in insulin sensitivity, as well as increased nitric oxide production through improved endothelial function. In addition, CR is known to induce SIRT1, a nutrient sensor, which is linked to a number of beneficial effects in the body.

Diabetes and male sex are key risk factor correlates of the extent of coronary artery calcification: A Euro-CCAD study

BACKGROUND AND AIMS

Although much has been written about the conventional cardiovascular risk factor correlates of the extent of coronary artery calcification (CAC), few studies have been carried out on symptomatic patients. This paper assesses the potential ability of risk factors to associate with an increasing CAC score.

METHODS

From the European Calcific Coronary Artery Disease (Euro-CCAD) cohort, we retrospectively investigated 6309 symptomatic patients, 62% male, from Denmark, France, Germany, Italy, Spain and the USA. All had conventional cardiovascular risk factor assessment and CT scanning for CAC scoring.

RESULTS

Among all patients, male sex (OR = 4.85, p<0.001) and diabetes (OR = 2.36, p<0.001) were the most important risk factors of CAC extent, with age, hypertension, dyslipidemia and smoking also showing a relationship. Among patients with CAC, age, diabetes, hypertension and dyslipidemia were associated with an increasing CAC score in males and females, with diabetes being the strongest dichotomous risk factor (p<0.001 for both). These results were echoed in quantile regression, where diabetes was consistently the most important correlate with CAC extent in every quantile in both males and females. To a lesser extent, hypertension and dyslipidemia were also associated in the high CAC quantiles and the low CAC quantiles respectively.

CONCLUSION

In addition to age and male sex in the total population, diabetes is the most important correlate of CAC extent in both sexes.

Coronary calcification compromises myocardial perfusion irrespective of luminal stenosis

Aim

The aim of this study was to evaluate the relationship between coronary artery calcification (CAC) assessed by multi-detector computed tomography (MDCT) and myocardial perfusion assessed by cardiac magnetic resonance imaging (CMR) in a group of symptomatic patients.

Method

Retrospective analysis of 120 patients (age 65.1 ± 8.9 years, 88 males) who presented with atypical chest pain to Bethanien Hospital, Frankfurt, Germany, between 2007 and 2010 and who underwent CAC scoring using MDCT, CMR, and conventional coronary angiography. Patients were divided into those with high-grade (HG) stenosis (n = 67, age 65.1 ± 9.4 years) and those with no-HG stenosis (n = 53, age 65.1 ± 8.6 years).

Results

There were more males with HG stenosis (82.1% vs. 62.3%, p = 0.015), in whom the percentage and number of abnormal perfusion segments were higher at rest (37.3% vs. 17%, p = 0.014) but not different with stress (p = 0.83) from those with no-HG stenosis. Thirty-four patients had myocardial perfusion abnormalities at rest and 26 patients developed perfusion defects with stress. Stress-induced myocardial perfusion defects were 22.4% sensitive and 79.2% specific for detecting HG stenosis. The CAC score was lower in patients with no-HG stenosis compared to those with HG stenosis (p < 0.0001). On the ROC curve, a CAC score of 293 had a sensitivity of 71.6% and specificity of 83% in predicting HG stenosis [(AUC 0.80 (p < 0.0001)]. A CAC score of 293 or the presence of at least 1 segment myocardial perfusion abnormality was 74.6% sensitive and 71.7% specific in detecting HG stenosis, the respective values for the 2 abnormalities combined being 19.4% and 90.6%. The severity of CAC correlated with the extent of myocardial perfusion in the patient group as a whole with stress (r = 0.22, p = 0.015), particularly in those with no-HG stenosis (r = 0.31, p = 0.022). A CAC score of 293 was 31.6% sensitive and 87.3% specific in detecting myocardial perfusion abnormalities.

Conclusion

In a group of patients with exertional angina, coronary calcification is more accurate in detecting high-grade luminal stenosis than myocardial perfusion defects. In addition, in patients with no stenosis, the incremental relationship between coronary calcium score and the extent of myocardial perfusion suggests coronary wall hardening as an additional mechanism for stress-induced angina other than luminal narrowing. These preliminary findings might have a clinical impact on management strategies of these patients other than conventional therapy.

The effect of statins therapy in aortic stenosis: Meta-analysis comparison data of RCTs and observationals

Aortic stenosis has been shown to share the same risk factors as atherosclerosis which suggested a potential benefit from statins therapy. Fourteen studies which provided the effect of statins treatment on aortic stenosis (AS) were meta-analyzed, including 5 randomized controlled trials (RCTs) and 9 observational studies. In the RCTs, statins did not have any influence on peak aortic valve velocity, peak valve gradient, mean valve gradient, aortic valve area and aortic calcification compared to controls. In the observational studies, the peak valve velocity, peak gradient and aortic valve area showed less progression in the statins group compared to controls. This article describes data related article title “The effect of statins on valve function and calcification in aortic stenosis: a meta-analysis” (Zhao et al., 2016) [1].

The coronary calcium score is a more accurate predictor of significant coronary stenosis than conventional risk factors in symptomatic patients: Euro-CCAD study

AIMS

In this retrospective study we assessed the predictive value of the coronary calcium score for significant (>50%) stenosis relative to conventional risk factors.

METHODS AND RESULTS

We investigated 5515 symptomatic patients from Denmark, France, Germany, Italy, Spain and the USA. All had risk factor assessment, computed tomographic coronary angiogram (CTCA) or conventional angiography and a CT scan for coronary artery calcium (CAC) scoring. 1539 (27.9%) patients had significant stenosis, 5.5% of whom had zero CAC. In 5074 patients, multiple binary regression showed the most important predictor of significant stenosis to be male gender (B=1.07) followed by diabetes mellitus (B=0.70) smoking, hypercholesterolaemia, hypertension, family history of CAD and age but not obesity. When the log transformed CAC score was included, it became the most powerful predictor (B=1.25), followed by male gender (B=0.48), diabetes, smoking, family history and age but hypercholesterolaemia and hypertension lost significance. The CAC score is a more accurate predictor of >50% stenosis than risk factors regardless of the means of assessment of stenosis. The sensitivity of risk factors, CAC score and the combination for prediction of >50% stenosis when measured by conventional angiogram was considerably higher than when assessed by CTCA but the specificity was considerably higher when assessed by CTCA. The accuracy of CTCA for predicting >50% stenosis using the CAC score alone was higher (AUC=0.85) than using a combination of the CAC score and risk factors with conventional angiography (AUC=0.81).

CONCLUSION

In symptomatic patients, the CAC score is a more accurate predictor of significant coronary stenosis than conventional risk factors.

Cardiovascular Calcification and Bone: A Comparison of the Effects of Dietary and Serum Vitamin K and its Dependent Proteins

<p style="margin: 0cm 0cm 0pt;"> </p><p style="margin: 0cm 0cm 0pt;"><span style="font-family: Times New Roman;"><span style="font-size: medium;">This review compares the effect of vitamin K on cardiovascular (CV) calcification and bone health and shows that, in principal, the γ-carboxylation of the vitamin K-dependent proteins matrix Gla protein (MGP) and its bone equivalent osteocalcin (OC), generally ensures that hydroxyapatite is kept out of the CV system and is deposited in bone. This is an important finding, since there is currently no reliable treatment for CV calcification.</span><span style="font-size: medium;">Vitamin K2 (menaquinone) may be more effective in the arteries, while vitamin K1 (phylloquinone) is more active in bone. Nevertheless, there remains considerable uncertainty over the precise scope of the functions of MGP and OC, and their carboxylated and under-carboxylated forms, as well as the newly discovered vitamin K-dependent proteins. Although a diet high in vegetables could deliver adequate phylloquinone, supplementation of menaquinone may be necessary for those at risk of CV calcification. Several animal studies and one human study have demonstrated that arterial calcification could be reduced with vitamin K supplementation and there are further trials in progress. Patients on warfarin are particularly prone to CV calcification but there has been concern that supplementation would either counter warfarin treatment or destabilise INR. In fact, studies suggest that low dose phylloquinone did not increase coagulation and may improve the stability of anticoagulant therapy. Furthermore, use </span><span style="mso-bidi-font-size: 12.0pt; mso-bidi-font-family: 'Times New Roman';"><span style="font-size: medium;">of oral anticoagulants which do not affect vitamin K metabolism, such as ximelagatran, could be used when there is a need for vitamin K supplementation for artery or bone health. </span></span></span></p><p style="margin: 0cm 0cm 0pt;"> </p>

Cardiovascular calcification and bone: a comparison of the effects of dietary and serum antioxidants

<p>Severe cardiovascular (CV) calcification can manifest as fully formed bone and is regularly found with osteoporosis; both have been shown to be associated with oxidative stress. Studies of the effect of antioxidants on CV calcification are few, but show that deficiency can induce both CV calcification and bone loss, while in conditions of oxidative stress such as renal failure, diabetes and smoking or in osteoporosis and fracture, antioxidants can reduce CV calcification and improve bone. The benefit of antioxidants in healthy adults is less clear and some may be detrimental. Higher intake of <em>α</em>-tocopherol (105.5mg/d vs 76.4mg/d) and β-cryptoxanthin may increase risk of CV calcification while high intake of retinol (≥3000mcg/d) may increase hip fracture risk, although possibly only with vitamin D intake ≤440IU/d; the carotenoids lycopene and β-carotene, however, appear beneficial in bone. Vitamin C shows little effect on CV calcification, although longer term supplementation may improve bone mineral density where calcium intake is &gt;500mg/d. Potential reasons for this include a U-shaped dose/response curve for the fat-soluble antioxidants vitamins A and E (with peak bone mass achieved with retinol intake of 600–840 mcg/d), a failure to measure baseline concentrations so that the response cannot be stratified by requirement, the need to be replete in calcium and vitamin D and supplementation of the wrong isomer of vitamin E. Finally, although little studied, tocotrienols, tocopherols (with the exception of α-tocopherol), resveratrol, epigallocatechin gallate, quercetin, α-lipoic acid and N-acetylcysteine may be effective in both the CV system and bone. </p>

Cardiovascular Calcification and Bone: A Comparison of The Effects of Dietary and Serum Calcium, Phosphorous, Magnesium and Vitamin D

This comparison of the effects of calcium, phosphorus, magnesium and vitamin D on cardiovascular (CV) calcification and<br />bone has shown that in general the micronutrients that promote bone health also protect the arteries. We have shown that<br />adequate amounts of all three minerals should be ingested, paying particular attention to supplementing calcium to bind high<br />phosphorus and to ensure the maximum benefit from supplementing vitamin D. It appears that the optimum intake for bone is<br />&gt;800 mg/d calcium, with postmenopausal women possibly requiring a total intake of &gt;1100mg/d. Both CV and bone studies<br />suggest achieving a serum 25(OH)D level of &gt;75nmol/l. These relationships are valid for a Caucasian population, however,<br />and may not hold in African Americans and Asians. The recent concerns that calcium supplementation may increase CV<br />disease risk has largely proved groundless, with higher calcium intake improving dyslipidaemia, hypertension and mortality.<br />With respect to higher serum phosphate, there is an association with CV calcification and CVD risk even within the normal<br />range, suggesting that the reference ranges may need to be redefined for ‘at risk’ patients. CV calcification was reduced in<br />CKD patients with magnesium intake in the range 384-669mg/d. When considering the complex interplay of the action of the<br />minerals together with their regulators vitamin D, PTH and FGF23, it is clear that this is a very sophisticated system which<br />attempts to maintain calcium homeostasis to the possible detriment of bone and arteries. This reinforces the need to ensure<br />adequate calcium intake before supplementing vitamin D.

Ectopic calcification and bone: a comparison of the effect of dietary carbohydrates, sugars and protein

A number of studies have shown that severe calcification of the arteries, heart and kidneys commonly coexists with<br />osteoporosis, particularly in renal disease. We have already shown that with respect to dietary fats, those that promote<br />ectopic (mainly cardiovascular) calcification are also detrimental to bone, with a similar relationship seen in fats which inhibit<br />ectopic calcification. This review of dietary carbohydrates, sugars and protein has shown a similar correspondence of effect,<br />with protein proving protective against ectopic calcification, at least in animals, and beneficial to bone. There appears to be<br />an interaction with calcium intake, with the beneficial effects of high protein being negated in a calcium deficiency, while a<br />high calcium intake enhances the dangers of a low protein intake; the cut-off for calcium intake may be around 800mg/d<br />for bone health. The results of studies on carbohydrates are unclear. Although there are no human studies on ectopic<br />calcification and intake of sugars, diabetes mellitus, insulin resistance and high blood glucose are known risk factors and are<br />also detrimental to bone. Fructose consistently promotes ectopic calcification in animals and is detrimental to bone in both<br />animals and humans, although the results for sucrose, glucose and lactose are mixed. Protein and prebiotics, both protective<br />against ectopic calcification and beneficial to bone, appear to act by increasing calcium absorption. Mechanisms of action<br />shared between inhibition of ectopic calcification and increased bone mineral density (BMD) include insulin-like growth factor<br />(IGF)-1, which can be directly induced by protein and glucose, and advanced glycation end products (AGEs), which decrease<br />expression of IGF-1 and generate reactive oxygen species, promote ectopic calcification and increased bone resorption.

South Asians and their increased cardiovascular risk: A review of risk factors and diet and lifestyle modification

South Asians (SAs) have a significantly higher incidence and severity of type 2 diabetes and cardiovascular disease (CVD)<br />than Caucasians and can present with atypical ischaemic symptoms. This can present a challenge for health professionals<br />who may not be aware of the lowered thresholds recommended for SA body mass index, waist circumference and age.<br />Although SAs are likely to have all the hallmarks of metabolic syndrome: central obesity, insulin resistance, impaired glucose<br />tolerance, reduced high density lipoprotein, high triglycerides and hypertension, conventional risk factors alone do not fully<br />predict the increased CVD risk among this community. Furthermore, SAs themselves may not be aware of their increased<br />predisposition to disease nor of the dietary and lifestyle modifications which could reduce the risk and severity of their<br />condition. Even where some modification has been attempted, there may be cultural pressure to conform to a traditional<br />diet and the requirements for fasting and feasting. Principally, SAs should avoid large late meals, reduce sugary sweets and<br />drinks, alcohol and foods fried in plant oils which create damaging transfats, while increasing protein and non-fried vegetables<br />to help glycaemic control. Chewing paan, with or without added tobacco, is a particular risk factor for both CVD and cancer,<br />on a par with the dangers of smoking. Although not in the culture, exercise would also be of great benefit.

Correlation between coronary and valve calcification: Review of current evidence

<p>We carried out a review of the correlation between calcification of different arteries and valves and their risk factors to determine the extent of the association. We found a strong correlation between calcification presence, extent and progression between different arterial beds and the aortic valve, suggesting that calcification is a systemic diffuse disease, affecting the arterial tree as a whole. Despite this strong association, a comparison between coronary artery calcification (CAC) and calcification of other arteries may not be strictly valid, since only intimal calcification is seen in the coronary artery while other arteries may also contain medial calcification, with current scanning modalities being incapable of detecting the difference. Furthermore the pathogenesis of each type may be different.</p><p>Calcification seems to appear first in the coronary artery in younger adults but may be more prevalent in the aorta in the elderly, although the incidence is notably higher in the abdominal aorta among women. Mitral annulus calcification (MAC) occurs less frequently than aortic valve calcification (AVC) in asymptomatic subjects only. MAC is correlated with calcification of the aorta and advanced MAC is found with higher CAC but there is little relationship with AVC and calcification of other arterial beds. As with the coronary artery, in the aorta and aortic valve, calcium begets calcium. Although age, male gender and possibly systolic hypertension are most frequently associated with arterial calcification, there is little consistency for other conventional risk factors and MAC and</p><p>abdominal aortic calcification may be more prevalent among postmenopausal women. When the presence of CAC is factored in as a risk factor for calcification of the other arteries, multivariate analysis shows no additional significant risk factors except age.</p><p>Although AVC has been viewed as a cardiac manifestation of atherosclerosis, we found little evidence to suggest that this is also true of MAC.</p>

The acid-ash hypothesis revisited: a reassessment of the impact of dietary acidity on bone

The acid-ash hypothesis states that when there are excess blood protons, bone is eroded to provide alkali to buffer the net acidity and maintain physiologic pH. There is concern that with the typical Western diet, we are permanently in a state of net endogenous acid production, which is gradually reducing bone. While it is clear that a high acid-producing diet generates increased urinary acid and calcium excretion, the effect of diet does not always have the expected results on BMD, fracture risk and markers of bone formation and resorption, suggesting that other factors are influencing the effect of acid/alkali loading on bone. High dietary protein, sodium and phosphorus intake, all of which are necessary for bone formation, were thought to be net acid forming and contribute to low BMD and fracture risk, but appear under certain conditions to be beneficial, with the effect of protein being driven by calcium repletion. Dietary salt can increase short-term markers of bone resorption but may also trigger 1,25(OH)2D synthesis to increase calcium absorption; with low calcium intake, salt intake may be inversely correlated with BMD but with high calcium intake, salt intake was positively correlated with BMD. With respect to the effect of phosphorus, the data are conflicting. Inclusion of an analysis of calcium intake may help to reconcile the contradictory results seen in many of the studies of bone. The acid-ash hypothesis could, therefore, be amended to state that with an acid-producing diet and low calcium intake, bone is eroded to provide alkali to buffer excess protons but where calcium intake is high the acid-producing diet may be protective.

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

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

Coronary and carotid atherosclerosis: how useful is the imaging?

The recent advancement of imaging modalities has made possible visualization of atherosclerosis disease in all phases of its development. Markers of subclinical atherosclerosis or even the most advanced plaque features are acquired by invasive (IVUS, OCT) and non-invasive imaging modalities (US, MRI, CTA). Determining plaques prone to rupture (vulnerable plaques) might help to identify patients at risk for myocardial infarction or stroke. The most accepted features of plaque vulnerability include: thin cap fibroatheroma, large lipid core, intimal spotty calcification, positive remodeling and intraplaque neovascularizations. Today, research is focusing on finding imaging techniques that are less invasive, less radiation and can detect most of the vulnerable plaque features. While, carotid atherosclerosis can be visualized using noninvasive imaging, such as US, MRI and CT, imaging plaque feature in coronary arteries needs invasive imaging modalities. However, atherosclerosis is a systemic disease with plaque development simultaneously in different arteries and data acquisition in carotid arteries can add useful information for prediction of coronary events.

Coronary and carotid atherosclerosis: similarities and differences

Although a relationship is commonly accepted between coronary and carotid arterial disease, suggesting that atherosclerosis is a systemic condition, the extent of this association and correspondence has not been fully elucidated. This review discusses recent research in this field and highlights areas for future study. The prevalence of severe carotid stenosis increases with prevalence of coronary stenosis, with the latter being found in a significant number of stroke patients, while those with carotid stenosis may be at higher risk of myocardial infarction than stroke. There also appear to be common risk factors (age, diabetes, hypertension, smoking and dyslipidemia), although the effects in both vascular systems may not be identical. Furthermore, while the degree of stenosis in the coronary artery has little ability to predict acute coronary syndrome, which is caused by local thrombosis from a ruptured or eroded plaque, severe carotid stenosis causing hypoperfusion is highly predictive of stroke, although this effect may be time-limited. This apparent difference in event mechanism in the two arteries is interesting as is the difference in the rate of development of collaterals. Overall, the evidence shows that a clear relationship exists between disease in the coronary and carotid arteries, since conventional risk factors and the extent of stenosis and/or previous events emanating from one artery have a strong bearing on the prevalence of events in the other artery. Nevertheless, the exact correspondence between the two arteries is unclear, with sometimes contradictory study results. More research is needed to identify the full extent of risk factors for severe stenosis and cardio- or cerebral vascular events, among which, inflammatory biomarkers such as hs-CRP and prior vascular events are likely to play a key role.

The human heart: application of the golden ratio and angle

The golden ratio, or golden mean, of 1.618 is a proportion known since antiquity to be the most aesthetically pleasing and has been used repeatedly in art and architecture. Both the golden ratio and the allied golden angle of 137.5° have been found within the proportions and angles of the human body and plants. In the human heart we found many applications of the golden ratio and angle, in addition to those previously described. In healthy hearts, vertical and transverse dimensions accord with the golden ratio, irrespective of different absolute dimensions due to ethnicity. In mild heart failure, the ratio of 1.618 was maintained but in end-stage heart failure the ratio significantly reduced. Similarly, in healthy ventricles mitral annulus dimensions accorded with the golden ratio, while in dilated cardiomyopathy and mitral regurgitation patients the ratio had significantly reduced. In healthy patients, both the angles between the mid-luminal axes of the pulmonary trunk and the ascending aorta continuation and between the outflow tract axis and continuation of the inflow tract axis of the right ventricle approximate to the golden angle, although in severe pulmonary hypertension, the angle is significantly increased. Hence the overall cardiac and ventricular dimensions in a normal heart are consistent with the golden ratio and angle, representing optimum pump structure and function efficiency, whereas there is significant deviation in the disease state. These findings could have anatomical, functional and prognostic value as markers of early deviation from normality.

Alcohol and the heart

Alcohol consumption and disease or mortality display a J-shaped curve, with moderate amounts of alcohol being more protective than abstention, binge drinking, or heavy drinking. Red wine appears to be particularly protective for cardiovascular disease and associated conditions such as type 2 diabetes. There are, however, controversies concerning the effect of red wine on hypertension, in which there may be significant gender and ethnic differences. Overall, it seems that both ethanol and the polyphenols in red wine may contribute to the protective effect.

Extensive coronary calcification: a clinically unrecognised condition

Atheroma calcification is a common feature of advanced atherosclerosis, however with the advent of CT scanning it has become possible to detect extensive coronary calcification in the absence of flow-limiting lesions. While this phenomenon is known in renal disease, it also exists in some patients with exertional angina. Vascular pathology suggests biomineralisation associated with development of osteoblast-like cells in the arterial wall. While some conventional risk factors are shared with atheroma formation, others such as ethnicity and medications appear more specific to extensive calcification and may mirror those for osteoporosis. Similarly an atherogenic diet can predispose to both conditions while some elements promote or inhibit coronary calcification but not atheroma formation. The immune and endocrine systems contribute to both conditions but not necessarily in the same way, with vitamins D and K more related to calcification than atheroma formation. Finally, statins significantly lower low density lipoprotein (LDL) cholesterol and reduce atheroma formation but are largely powerless against extensive calcification. Although investigations into the exact cause of extensive coronary calcification are in their infancy, early results suggest that it is sufficiently different in nature from atheroma formation to be considered as a separate condition. Further research would yield a greater understanding, which would aid management and the development of specific biomarkers to reduce the cost and radiation risk of CT scanning.

Ginger (Zingiber officinale Roscoe): a hot remedy for cardiovascular disease?

Ginger is now exciting considerable interest for its potential to treat many aspects of cardiovascular disease. This letter reviews the more recent trials, which suggest that ginger shows considerable anti-inflammatory, antioxidant, anti-platelet, hypotensive and hypolipidemic effect in in vitro and animal studies. Human trials have been few and generally used a low dose with inconclusive results, however dosages of 5 g or more demonstrated significant anti-platelet activity. More human trials are needed using an appropriate dosage of a standardised extract. Should these prove positive, ginger has the potential to offer not only a cheaper natural alternative to conventional agents but one with significantly lower side effects.

The actions of synaptically released zinc at hippocampal mossy fiber synapses

Zn2+ is present at high concentrations in the synaptic vesicles of hippocampal mossy fibers. We have used Zn2+ chelators and the mocha mutant mouse to address the physiological role of Zn2+ in this pathway. Zn2+ is not involved in the unique presynaptic plasticities observed at mossy fiber synapses but is coreleased with glutamate from these synapses, both spontaneously and with electrical stimulation, where it exerts a strong modulatory effect on the NMDA receptors. Zn2+ tonically occupies the high-affinity binding site of NMDA receptors at mossy fiber synapses, whereas the lower affinity voltage-dependent Zn2+ binding site is occupied during action potential driven-release. We conclude that Zn2+ is a modulatory neurotransmitter released from mossy fiber synapses and plays an important role in shaping the NMDA receptor response at these synapses.

The role of the synthetic enzyme GAD65 in the control of neuronal gamma-aminobutyric acid release

We have studied GABAergic synaptic transmission in retinal ganglion cells and hippocampal pyramidal cells to determine, at a cellular level, what is the effect of the targeted disruption of the gene encoding the synthetic enzyme GAD65 on the synaptic release of gamma-aminobutyric acid (GABA). Neither the size nor the frequency of GABA-mediated spontaneous inhibitory postsynaptic currents (IPSCs) were reduced in retina or hippocampus in GAD65-/- mice. However, the release of GABA during sustained synaptic activation was substantially reduced. In the retina both electrical- and K(+)-induced increases in IPSC frequency were depressed without a change in IPSC amplitude. In the hippocampus the transient increase in the probability of inhibitory transmitter release associated with posttetanic potentiation was absent in the GAD65-/- mice. These results indicate that during and immediately after sustained stimulation the increase in the probability of transmitter release is not maintained in GAD65-/- mice. Such a finding suggests a decrease in the size or refilling kinetics of the releasable pool of vesicles, and various mechanisms are discussed that could account for such a defect.

Structural and functional characterisation of human sulfotransferases

The human aryl sulfotransferases HAST4 and HAST4v vary by only two amino acids but exhibit markedly different affinity towards the sulfonate acceptor p-nitrophenol and the sulfonate donor 3'-phosphoadenosine-5'-phosphosulfate (PAPS). To determine the importance of each of these amino acid differences, chimeric constructs were made of HAST4 and HAST4v. By attaching the last 120 amino acids of HAST4v to HAST4 (changing Thr235 to Asn235) we have been able to produce a protein that has a Km for PAPS similar to HAST4v. The reverse construct, HAST4v/4 produces a protein with a Km for PAPS similar to HAST4. These data suggests that the COOH-terminal of sulfotransferases is involved in co-factor binding.