Phytosterols and Cardiovascular Risk Evaluated against the Background of Phytosterolemia Cases-A German Expert Panel Statement

Phytosterols (PSs) have been proposed as dietary means to lower plasma LDL-C. However, concerns are raised that PSs may exert atherogenic effects, which would offset this benefit. Phytosterolemia was thought to mimic increased plasma PSs observed after the consumption of PS-enriched foods. This expert statement examines the possibility of specific atherogenicity of PSs based on sterol metabolism, experimental, animal, and human data. Observational studies show no evidence that plasma PS concentrations would be associated with an increased risk of atherosclerosis or cardiovascular (CV) events. Since variants of the ABCG5/8 transporter affect the absorption of cholesterol and non-cholesterol sterols, Mendelian randomization studies examining the effects of ABCG5/8 polymorphisms cannot support or refute the potential atherogenic effects of PSs due to pleiotropy. In homozygous patients with phytosterolemia, total PS concentrations are ~4000% higher than under physiological conditions. The prevalence of atherosclerosis in these individuals is variable and may mainly relate to concomitant elevated LDL-C. Consuming PS-enriched foods increases PS concentrations by ~35%. Hence, PSs, on a molar basis, would need to have 20-40 times higher atherogenicity than cholesterol to offset their cholesterol reduction benefit. Based on their LDL-C lowering and absence of adverse safety signals, PSs offer a dietary approach to cholesterol management. However, their clinical benefits have not been established in long-term CV endpoint studies.

Knowledge as to cholesterol reduction and use of phytosterol-enriched dietary foods in the general population: Insights from the Hamburg City Health Study

BACKGROUND AND AIMS

Dietary approaches to lowering cholesterol appear to be common knowledge. However, the marketing of phytosterol-enriched products and their recommendation by guidelines for individuals at increased risk of cardiovascular disease have given rise to concern, since phytosterols may be atherogenic and inappropriately used by healthy individuals of higher social status at low cardiovascular risk. Hence, we have investigated awareness of cholesterol lowering lifestyle measures and attitudes towards consumption of phytosterol-enriched foods.

METHODS

Data from validated questionnaires supplemented by queries on cholesterol lowering and phytosterol-enriched products were analyzed using data of 7223 participants of the Hamburg City Health Study, an ongoing cohort study of the general population aged 45-74 years.

RESULTS

95.9% of the participants agreed that lifestyle may lower cholesterol and 76.6% claimed knowledge of measures that lower plasma cholesterol. As to effective approaches, 80.2% suggested physical activity, 67.8% reducing dietary fat, followed by sugar-sweetened beverages or stress, increasing water consumption, or dietary fiber and only 16.2% stated statins and 9.3% phytosterol-enriched products. Compared to nonusers, the 2.0% female and 2.8% male individuals regularly using phytosterol-enriched products had a lower educational status, higher cardiovascular risk, but no difference in income and were characterized by adverse dietary habits. The study has been registered in ClinicalTrial.gov (NCT03934957).

CONCLUSIONS

In the general population awareness of hypercholesterolemia is high but knowledge on how to lower plasma cholesterol does not necessarily follow scientific evidence. There is a trend towards the use of phytosterol-enriched products by individuals at increased cardiovascular risk independent of income.

The impact of nutrition on the development and progression of peripheral artery disease: A systematic review

BACKGROUND & AIMS

This systematic review sought to identify and summarize existing evidence for the impact of nutrition on the development, progression, and outcomes of peripheral artery disease (PAD).

METHODS

We performed a systematic literature search of available studies published between January 1974 and December 2019. Randomized controlled trials (RCT), observational studies, and cross-sectional studies reporting either the primary or secondary prevention of PAD with nutritional intake were included. The quality assessment was performed for the RCTs, without pooling a meta-risk estimate.

RESULTS

Among a total of 8502 records screened, 186 full texts were assessed for eligibility, and 82 studies (30% RCT) were analyzed. The nutrients were structured in fruits, vegetables and antioxidants, fats and oils, dietary fiber, meat, proteins, vitamins and trace elements, and diets and lifestyle. The findings of the current systematic review indicate that the Mediterranean diet, nuts, and polyunsaturated fat are associated with a lower incidence of PAD and saturated fat, cholesterol, and processed meat were associated with higher rates of cardiovascular events in patients suffering from PAD.

CONCLUSIONS

The current review found evidence of a beneficial impact of the Mediterranean diet including nuts in this target population. More RCTs and high-quality registries are needed that focus on nutritional habits among patients with PAD to design appropriate preventive programs.

Perimenopause and Postmenopause - Diagnosis and Interventions. Guideline of the DGGG and OEGGG (S3-Level, AWMF Registry Number 015-062, September 2020)

Aim The aim of the interdisciplinary S3-guideline Perimenopause and Postmenopause - Diagnosis and Interventions is to provide help to physicians as they inform women about the physiological changes which occur at this stage of life and the treatment options. The guideline should serve as a basis for decisions taken during routine medical care. This short version lists the statements and recommendations given in the long version of the guideline together with the evidence levels, the level of recommendation, and the strength of consensus. Methods The statements and recommendations are largely based on methodologically high-quality publications. The literature was evaluated by experts and mandate holders using evidence-based medicine (EbM) criteria. The search for evidence was carried out by the Essen Research Institute for Medical Management (EsFoMed). To some extent, this guideline also draws on an evaluation of the evidence used in the NICE guideline on Menopause and the S3-guidelines of the AWMF and has adapted parts of these guidelines. Recommendations Recommendations are given for the following subjects: diagnosis and therapeutic interventions for perimenopausal and postmenopausal women, urogynecology, cardiovascular disease, osteoporosis, dementia, depression, mood swings, hormone therapy and cancer risk, as well as primary ovarian insufficiency.

Carotid intima-media thickness and cardiovascular risk factors in healthy volunteers

Background

Assessment of cardiovascular risk by scores lacks sensitivity and leaves the majority of future cardiovascular patients unidentified particularly individuals at low cardiovascular risk. The present analysis investigates into the correlation of carotid intima–media thickness (CIMT) and cardiovascular risk factors and derived scores as to the potential of improved cardiovascular risk prediction by combining the two.

Methods

The Stress, Atherosclerosis and ECG Study (STRATEGY) is a cross-sectional study of selectively healthy 107 women and 106 men without diagnosed and treated cardiovascular risk factors evenly distributed between 30 and 70 years. CIMT was determined by evaluating B-mode ultrasonograms offline according to a standardized protocol. The unpaired t-test was used to compare normal-distributed continuous variables, the Chi-squared test for normal-distributed categorical variables and the Mann–Whitney U test for non-normal distributed continuous variables. The association between risk prediction scores and CIMT was calculated by the Spearman rank correlation coefficient. Pearson correlation coefficient was used for the correlation between cardiovascular risk factors and CIMT. A multiple linear regression analysis was executed for the association of cardiovascular risk factors and CIMT.

Results

Age, systolic blood pressure, fasting glucose, total, LDL- and non-HDL-cholesterol and waist circumference were significantly associated with CIMT (each P ≤ 0.03). The Framingham Risk Score, the Prospective Cardiovascular Münster Study Score and the European Society of Cardiology Score correlated significantly but only moderately with CIMT. The Framingham Risk Score considering BMI correlated most strongly and predicted 27% of the CIMT variance in men and 20% in women.

Conclusion

In individuals without overt cardiovascular risk factors and thus at low cardiovascular risk, CIMT and cardiovascular risk factors correlated only partially suggesting that combining CIMT and conventional risk factors or common derived scores may improve risk prediction in individuals at low cardiovascular risk. The clinical benefit as to cardiovascular events of such combined risk prediction needs to be explored in large prospective cohorts of still healthy low-risk volunteers. DRKS ID DRKS00015209 07/02/2019 retrospectively registered https://www.drks.de/drks_web/navigate.do?navigationId=resultsExt

Peri- and postmenopause-diagnosis and interventions interdisciplinary S3 guideline of the association of the scientific medical societies in Germany (AWMF 015/062): short version

This short version of the interdisciplinary S3 guideline "Peri- and Postmenopause-Diagnosis and Interventions" is intended as a decision-making instrument for physicians who counsel peri- and postmenopausal women. It is designed to assist daily practice. The present short version summarizes the full version of the guideline which contains detailed information on guideline methodology, particularly regarding the critical appraisal of the evidence and the assignment of evidence levels. The statements and recommendations of the full version of the guideline are quoted completely in the present short version including levels of evidence (LoE) and grades of recommendation. The classification system developed by the Centre for Evidence-based Medicine in Oxford was used in this guideline.

[Lipid-lowering therapy in the elderly : Who profits from which target values?]

Lowering low-density lipoprotein (LDL) cholesterol levels has been proven to reduce the incidence of cardiovascular and cerebrovascular events and mortality. So far recommendations have not provided information as to a meaningful duration of cholesterol-lowering therapy and were largely guided by economic constraints and limited therapeutic options. In light of the decline in the price of statins, the essential therapeutic agent and the increased efficacy of therapeutic options, treatment can nowadays be geared to target values that can be expected to have an optimal effect even in old age. The most favorable level of LDL-cholesterol for primary prevention is around and below 100 mg/dl, provided continuous adherence to these low levels from adolescence onwards. With later onset of cholesterol reduction the existence of initial atheromatous deposits must be expected. Therefore, with age and the manifestation of other risk factors the optimal treatment targets increasingly converge to those for which experience has been gained from secondary prevention. Both measurements of the effect of cholesterol lowering on the volume of atheromatous plaques and of the incidence of vascular events indicate a target for LDL-cholesterol well below 70 mg/dl and in the range 50-60 mg/dl. At the onset of cholesterol lowering in advanced age, a smaller effect has to be expected but due to the increasing incidence rate of vascular events a higher number of events may be avoided; thus, the efficiency does not necessarily decrease; however, long-term studies indicate that earlier cholesterol lowering provides an advantage for more than a decade, in terms of preventing vascular disease, which tends to increase. Therefore, optimal cardiovascular prevention involves moderate measures to maintain the LDL-cholesterol below 100 mg/dl lifelong from childhood on.

Joint Data Analysis in Nutritional Epidemiology: Identification of Observational Studies and Minimal Requirements

Background

Joint data analysis from multiple nutrition studies may improve the ability to answer complex questions regarding the role of nutritional status and diet in health and disease.

Objective

The objective was to identify nutritional observational studies from partners participating in the European Nutritional Phenotype Assessment and Data Sharing Initiative (ENPADASI) Consortium, as well as minimal requirements for joint data analysis.

Methods

A predefined template containing information on study design, exposure measurements (dietary intake, alcohol and tobacco consumption, physical activity, sedentary behavior, anthropometric measures, and sociodemographic and health status), main health-related outcomes, and laboratory measurements (traditional and omics biomarkers) was developed and circulated to those European research groups participating in the ENPADASI under the strategic research area of "diet-related chronic diseases." Information about raw data disposition and metadata sharing was requested. A set of minimal requirements was abstracted from the gathered information.

Results

Studies (12 cohort, 12 cross-sectional, and 2 case-control) were identified. Two studies recruited children only and the rest recruited adults. All studies included dietary intake data. Twenty studies collected blood samples. Data on traditional biomarkers were available for 20 studies, of which 17 measured lipoproteins, glucose, and insulin and 13 measured inflammatory biomarkers. Metabolomics, proteomics, and genomics or transcriptomics data were available in 5, 3, and 12 studies, respectively. Although the study authors were willing to share metadata, most refused, were hesitant, or had legal or ethical issues related to sharing raw data. Forty-one descriptors of minimal requirements for the study data were identified to facilitate data integration.

Conclusions

Combining study data sets will enable sufficiently powered, refined investigations to increase the knowledge and understanding of the relation between food, nutrition, and human health. Furthermore, the minimal requirements for study data may encourage more efficient secondary usage of existing data and provide sufficient information for researchers to draft future multicenter research proposals in nutrition.

Treatment Options for Statin-Associated Muscle Symptoms

BACKGROUND

About 4.6 million persons in Germany are now taking statins, i.e., drugs that inhibit the enzyme 3-hydroxy-3-methylglutaryl-coenzyme A (HMGCoA) reductase. Statins lower the concentration of low-density lipoproteins (LDL) and thereby lessen the rate of cardiovascular events; the size of this effect depends on the extent of lowering of the LDL cholesterol concentration. Muscle symptoms are a clinically relevant side effect of statin treatment.

METHODS

This review is based on pertinent publications retrieved by a selective literature search, and on the current recommendations of the European Atherosclerosis Society.

RESULTS

At least 5% of patients taking statins have statin-associated muscle symptoms (SAMS). The etiology of SAMS is heterogeneous. SAMS may seriously impair quality of life and cause complications of variable severity, up to and including rhabdomyolysis (in about 1 in 100,000 cases). SAMS often lead to a reduction in the prescribed dose of the statin, while also negatively affecting drug adherence. More than 90% of patients with SAMS can keep on taking statins over the long term and gain the full clinical benefit of statin treatment after a switch to another type of statin or a readjustment of the dose or frequency of administration. If the LDL cholesterol concentration is not adequately lowered while the patient is taking a statin in the highest tolerable dose, combination therapy is indicated.

CONCLUSION

SAMS are important adverse effects of statin treatment because they lessen drug adherence. Patients with SAMS should undergo a thorough diagnostic evaluation followed by appropriate counseling. In most cases, statins can be continued, with appropriate adjustments, even in the aftermath of SAMS.

Nonalcoholic fatty liver disease is associated with excessive calorie intake rather than a distinctive dietary pattern

We aimed to assess the dietary patterns associated with nonalcoholic fatty liver disease (NAFLD) and the efficacy of dietary interventions in a real-life setting at a tertiary medical center in Northern Germany.Clinical and laboratory data as well as data obtained by a semiquantitative food frequency questionnaire of 55 consecutive patients diagnosed with NAFLD were compared to an age and gender-matched cohort of 88 healthy individuals by univariate analysis. The efficacy of the dietary intervention was assessed in a subgroup of 24 NAFLD patients 6 months after receiving dietary advice. Macronutritional components of the diet were normalized for absolute daily energy intake.NAFLD patients consumed more calories per day as compared with healthy controls (P <0.001). The absolute amounts of most nutritional components ingested by NAFLD patients were higher than those of the controls. However, there were no significant differences with regards to the relative consumption of carbohydrates (P = 0.359), fat (P = 0.416), and fructose (P = 0.353) per 1000 kcal energy intake. NAFLD patients displayed a higher intake of glucose/1000 kcal (P = 0.041) and protein/1000 kcal (P = 0.009) but a lower intake of fibers/1000 kcal (P < 0.001) and mineral nutrients/1000 kcal (P = 0.001) than healthy controls. In the longitudinal analysis patients significantly reduced their caloric intake and their ALT levels improved 6 months after the dietary counselling (P < 0.001).Our data from a German real-life cohort demonstrate that dietary patterns of patients with NAFLD display great variability and little disease specificity, while the most distinctive feature compared with healthy controls was higher energy intake in NAFLD patients.

Familial hypercholesterolemia: developments in diagnosis and treatment

BACKGROUND

Familial hypercholesterolemia (FH) is a congenital disorder of lipid metabolism characterized by a marked elevation of the plasma concentration of LDL (low-density lipoprotein) cholesterol beginning in childhood and by the early onset of coronary heart disease. It is among the commonest genetic disorders, with an estimated prevalence in Germany of at least 1 per 500 persons.

METHOD

Review of pertinent literature retrieved by a selective search.

RESULTS

FH is underdiagnosed and undertreated in Germany. It is clinically diagnosed on the basis of an elevated LDL cholesterol concentration (>190 mg/dL [4.9 mmol/L]), a family history of hypercholesterolemia, and early coronary heart disease, or the demonstration of xanthomas. The gold standard of diagnosis is the identification of the underlying genetic defect, which is possible in 80% of cases and enables the identification of affected relatives of the index patient. The recommended goals of treatment, based on the results of observational studies, are to lower the LDL cholesterol concentration by at least 50% or to less than 100 mg/dL (2.6 mmol/L) (for children: <135 mg/dL [3.5 mmol/L]). The target value is lower for patients with clinically overt atherosclerosis (<70 mg/dL [1.8 mmol/L]). Statins, combined with a health-promoting lifestyle, are the treatment of choice. Lipoprotein apheresis is used in very severe cases; its therapeutic effects on clinical endpoints and its side effect profile have not yet been documented in randomized controlled trials.

CONCLUSION

Familial hypercholesterolemia is a common disease that can be diagnosed simply and reliably on clinical grounds and by molecular genetic testing. Timely diagnosis and appropriate treatment can lower the risk of atherosclerosis in heterozygous patients to that of the general population.

[New AHA and ACC guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk : Statement of the D•A•CH Society for Prevention of Cardiovascular Diseases, the Austrian Atherosclerosis Society and the Working Group on Lipids and Atherosclerosis (AGLA) of the Swiss Society for Cardiology]

Guidelines for the reduction of cholesterol to prevent atherosclerotic vascular events were recently released by the American Heart Association and the American College of Cardiology. The authors claim to refer entirely to evidence from randomized controlled trials, thereby confining their guidelines to statins as the primary therapeutic option. The guidelines derived from these trials do not specify treatment goals, but refer to the percentage of cholesterol reduction by statin medication with low, moderate, and high intensity. However, these targets are just as little tested in randomized trials as are the cholesterol goals derived from clinical experience. The same applies to the guidelines of the four patient groups which are defined by vascular risk. No major statin trial has included patients on the basis of their global risk; thus the allocation criteria are also arbitrarily chosen. These would actually lead to a significant increase in the number of patients to be treated with high or maximum dosages of statins. Also, adhering to dosage regulations instead of cholesterol goals contradicts the principles of individualized patient care. The option of the new risk score to calculate lifetime risk up to the age of 80 years in addition to the 10-year risk can be appreciated. Unfortunately it is not considered in the therapeutic recommendations provided, despite evidence from population and genetic studies showing that even a moderate lifetime reduction of low-density lipoprotein (LDL) cholesterol or non-HDL cholesterol has a much stronger effect than an aggressive treatment at an advanced age. In respect to secondary prevention, the new American guidelines broadly match the European guidelines. Thus, the involved societies from Germany, Austria and Switzerland recommend continuing according to established standards, such as the EAS/ESC guidelines.

New AHA and ACC guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk

After the publication of the new guidelines of the European Society of Cardiology and the European Atherosclerosis Society for the prevention and treatment of dyslipidemias (Eur Heart J 32:1769-1818, 2011; Eur Heart J 33:1635-1701, 2012), a group of authors has recently published on behalf of the American Heart Association and the American College of Cardiology guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk (Circulation 2013). These new guidelines are supposed to replace the until now widely accepted, at least in the USA, recommendations of the National Cholesterol Education Program Adult Treatment Panel III from the years 2002 (Circulation 106:3143-3421, 2002) and 2004 (Circulation 110:227-39, 2004). Furthermore, they claim to be based mainly on hard evidence derived from the interpretation of results of prospective randomized controlled trials. This Joint Position Statement of the Society for the Prevention of Cardiovascular Diseases e.V. (D.A.CH), the Austrian Atherosclerosis Society and the Working Group on Lipids and Atherosclerosis (AGLA) of the Swiss Society of Cardiology concludes that the use of individualized prevention strategies based on specific indications and LDL cholesterol target concentrations, a strategy whose worth has been widely proven and accepted for more than a decade in Europe, should not be given up.

DELIGHT (delay of impaired glucose tolerance by a healthy lifestyle trial) - a feasibility study on implementing a program of sustainable diabetes prevention in German companies

BACKGROUND

Ca. 50% of Germans develop prediabetes in their lifetime. Though diabetes type 2 has been proven preventable, no screening for prediabetes has been implemented. DELIGHT was designed to assess if screening for individuals at risk and long-standing diabetes prevention is feasible in the setting of companies within the scope of the German legal health system.

MATERIALS AND METHODS

In 5 companies employees with a waist circumference of ≥ 94 (men) and ≥ 80 cm (women) were offered a check-up. Those with fasting plasma glucose ≥ 100 mg/dl (IFG) or ≥ 140 mg/dl 2 h after oral glucose load (IGT) were followed for 3 years with an optional moderate lifestyle program during the first year and quarterly assistance for another 2 years.

RESULTS

In 241 of 300 participants the self-measured waist circumference was confirmed as elevated. 3% had type 2 diabetes, while 37% had IFG (isolated in 96%) or IGT, of whom 91.4% (men) and 76.1% (women) had a metabolic syndrome. Within 3 years in those who had lost ≥ 1 kg, weight was reduced by 3.9 kg, risk factors were improved, and no case of diabetes had developed, while among those with weight loss of < 1 kg or weight gain, 10% of men and 5% of women had developed diabetes type 2. Screening for prediabetes did not increase the number or costs of drug prescriptions.

CONCLUSIONS

Companies provide a suitable setting for screening for prediabetes. Long-term diabetes prevention is successfully feasible within the narrow financial frame of a legal insurance system without rise of costs.

[Familial hypercholesterolemia]

Familial hypercholesterolemia is one of the most common hereditary metabolic disorders, untreated with grave cardiovascular consequences. A general practitioner will see at least one affected individual each month, but will rarely be aware of the diagnosis, though it is easily suspected: an LDL-cholesterol ≥ 190 mg/dl, a family history of premature cardiovascular disease, or clinical signs as arcus lipoides, tendinous xanthomata, or a thickened Achilles' tendon must draw the attention to familial hypercholesterolemia. Because of the burden of high cholesterol levels from childhood on therapy should be initiated early enough, which has become greatly ameliorated since the introduction of statins. In conjunction with additional risk factors, notably low HDL-cholesterol or elevated lipoprotein(a) the cardiovascular sequelae can be dramatic and may call for more intense therapies. However, often the routine of successful cholesterol lowering covers the diagnosis nowadays, so that a heritable metabolic disorder is not suspected, which, however, prevents an effective prevention in relatives, particularly the children of the patient.

Association of a common mineralocorticoid receptor gene polymorphism with salivary cortisol in healthy adults

A common polymorphism of the mineralocorticoid receptors (MR) gene has been associated with cortisol levels after dexamethasone. However, if and how this MR gene variant affects basal cortisol secretion throughout the day is unknown. The aim of our study was to examine the association between the MR gene polymorphism -2G/C (rs2070951) and salivary cortisol measured at four time points during the day in the Stress, Atherosclerosis, and ECG Study (STRATEGY). We recruited healthy adults from the general population (n=133, distributed equally across four age groups, 30-70 years). Salivary cortisol was assessed at 0800, 1200, 1600 and 2200 h. We found a significant effect of genotype indicating that homozygous G allele carriers had higher overall salivary cortisol levels (F=4.5, p=0.01). Furthermore, we found a significant time × group interaction indicating that the group effect was predominantly driven by higher 0800 h salivary cortisol levels in G/G homozygotes (F=2.9, p=0.02). Participants homozygous for the G allele also had greater area under the curve (AUC) cortisol secretion compared to C allele carriers (F=6.4, p=0.01). Our findings suggest that being homozygous for the G allele of the MR gene polymorphism -2G/G is associated with higher cortisol levels in healthy adults, especially in the morning during peak cortisol secretion. This polymorphism may contribute to the interindividual variability in stress responsiveness and might be involved in stress-related disorders.

Differential association of anthropometric parameters with coronary risk in women--data of the CORA study

OBJECTIVE

The predictive value of weight gain, BMI, waist circumference (WC) and waist-to-hip ratio (WHR) as to cardiovascular risk factors and coronary heart disease (CHD) is still controversial.

METHODS

200 consecutive pre- and postmenopausal women with incident CHD (cases) were compared with 255 randomized age-matched population-based controls recruited from corresponding neighborhoods of Hamburg between 1997 and 2001.

RESULTS

At the time of recruitment cases and controls did not differ in BMI, but at any BMI in WC and WHR. Both parameters of central obesity were related to coronary risk. However, after adjustment for conventional risk factors, the odds ratio of WC for CHD lost its significance while the odds ratio of WHR was still 2.20 per 0.1 unit (95% confidence interval 1.48-3.27; p = 0.0001). The pattern of weight gain differed considerably in women with WHR ≥0.85 or <0.85 and closely matched that of women with or without CHD. The dietary pattern did not distinguish women with elevated WC or WHR.

CONCLUSION

In women, an elevated WHR was closely associated with the risk for CHD independent of BMI and conventional risk factors over and above an elevated WC. An increased WC predominantly seems to reflect the presence of components of the metabolic syndrome.

Association between alcohol consumption and carotid intima-media thickness in a healthy population: data of the STRATEGY study (Stress, Atherosclerosis and ECG Study)

BACKGROUND/OBJECTIVES

Epidemiological evidence suggests a protective effect of moderate alcohol consumption on cardiovascular events. However, studies assessing the association between alcohol intake and intima-media thickness (IMT) as a marker of subclinical atherosclerosis have provided inconsistent results. The aim of this analysis of the Stress Atherosclerosis and ECG Study (STRATEGY study) was to investigate the relation between alcohol intake and IMT in a selectively healthy population.

SUBJECTS/METHODS

In a cross-sectional study, laboratory values, anthropometric data, nutrition habits and physical activity were assessed in 106 men and 107 women, evenly distributed between 30 and 70 years. Carotid IMT was determined by B-mode ultrasonography according to the standardized protocol of the Study of Health in Pomerania.

RESULTS

In men, a significant positive correlation between daily alcohol consumption and IMT was observed (P<0.0001), whereas in women the positive correlation was not significant. The type of beverage consumed did not affect this finding. The mean IMT was significantly higher in men with an alcohol intake above the upper limit of 20 g/day than in men with an alcohol intake <20 g/day (P<0.001). According to a stepwise linear regression model adjusted for age, conventional risk factors, nutrition and physical activity, the IMT increases by 0.0253 mm per 21.4 g/day intake of alcohol in men (P<0.05).

CONCLUSIONS

The STRATEGY study revealed a positive association between alcohol consumption and carotid IMT in healthy men aged 30-70 years. This relationship remained significant after adjustment for nutrition, physical activity, anthropometry and conventional cardiovascular risk factors.

Is patient self-report an adequate tool for monitoring cardiovascular conditions in patients with hypercholesterolemia?

BACKGROUND

To determine the accuracy of patient self-reports of specific cardiovascular diagnoses and to identify individual patient characteristics that influence the accuracy.

METHODS

This investigation was conducted as a part of the randomized controlled ORBITAL study. Patients with hypercholesterolemia were enrolled in 1961 primary-care centers all over Germany. Self-reported questionnaire data of 7640 patients were compared with patients' case report forms (CRFs) and medical records on cardiovascular diseases, using kappa statistics and binomial logit models.

RESULTS

kappa values ranged from 0.89 for diabetes to 0.04 for angina. The percentage of overreporting varied from 1% for diabetes to 17% for angina, whereas the percentage of underreporting varied from 8.0% for myocardial infarction to 57% for heart failure. Individual characteristics such as choice of individual general practitioner, male gender and age were associated with the accuracy of self-report data.

CONCLUSION

Since the agreement between patient self-report and CRFs/medical records varies with specific cardiovascular diagnoses in patients with hypercholesterolemia, the adequacy of this tool seems to be limited. However, the authors recommend additional data validation for certain patient groups and consideration of individual patient characteristics associated with over- and underreporting.

Depressive symptoms and metabolic risk: effects of cortisol and gender

We examined gender effects and the role of cortisol in the association between depressive symptoms and metabolic risk in the Stress, Atherosclerosis, and ECG Study (STRATEGY). In 215 healthy adults from the general population (n=107 men, n=108 women, distributed equally across four age groups, 30-70 years), we assessed depressive symptoms by the Patient Health Questionnaire (PHQ score >10) and measured variables of the metabolic syndrome: high-density lipoprotein (HDL), triglycerides, systolic and diastolic blood pressure, fasting blood glucose and waist circumference. Salivary cortisol was assessed at 08:00, 12:00, 16:00 and 22:00 h. Depressive symptoms were not associated with the metabolic syndrome as entity in the total sample or in men and women separately. However, women with depressive symptoms had larger waist circumferences, higher fasting blood glucose, lower HDL-cholesterol, higher diastolic blood pressure, and higher 16:00 and 22:00 h salivary cortisol compared to women without depressive symptoms. These results persisted after adjusting for age, education, smoking, and physical activity. In adjusted regression analyses, inclusion of cortisol attenuated the association between depressive symptoms and waist, fasting glucose, HDL and diastolic blood pressure in women. In men, we did not find an association between depressive symptoms and variables of the metabolic syndrome. In women, depressive symptoms are associated with several variables of the metabolic syndrome. Elevated afternoon and evening cortisol appear to partially mediate this association.

Efficacy and tolerability of fluvastatin XL 80 mg alone, ezetimibe alone, and the combination of fluvastatin XL 80 mg with ezetimibe in patients with a history of muscle-related side effects with other statins

Although statin treatment is generally well tolerated, it is estimated that 5% to 10% of patients develop muscle-related side effects (MRSEs), resulting in less effective nonstatin alternatives or cessation of lipid-lowering therapy completely. This study was designed to assess the efficacy and tolerability of extended-release fluvastatin (fluvastatin XL) and ezetimibe alone or in combination in patients with previous MRSEs with other statins. This was a double-blinded, double-dummy trial of 199 mostly moderate- or high-risk dyslipidemic patients randomized to fluvastatin XL 80 mg/day (n = 69), ezetimibe 10 mg/day (n = 66), or fluvastatin XL 80 mg/day plus ezetimibe 10 mg/day (n = 64) for 12 weeks. Fluvastatin XL lowered low-density lipoprotein (LDL) cholesterol by 32.8% compared with 15.6% with ezetimibe (between-group difference -17.1%, 95% confidence interval -23.6 to -10.7, p <0.0001); the fluvastatin XL/ezetimibe combination lowered LDL cholesterol by 46.1% (between-group difference vs ezetimibe -30.4%, 95% confidence interval -37.0 to -23.8, p <0.0001). Proportions of patients achieving their National Cholesterol Education Program Adult Treatment Panel III target LDL cholesterol were 84% with the fluvastatin XL/ezetimibe combination, 59% with fluvastatin XL, and 29% with ezetimibe (p <0.001 for fluvastatin XL monotherapy or combination therapy vs ezetimibe monotherapy). Incidences of MRSEs were 24% in the ezetimibe group, 17% in the fluvastatin XL group, and 14% in the combination group. There were no instances of creatine kinase increases >or=10 times upper limit of normal. In conclusion, in patients with a history of statin-associated MRSEs, fluvastatin XL alone or in combination with ezetimibe offers an effective and well-tolerated lipid-lowering option.

Factors contributing to the risk of cardiovascular disease reflected by plasma adiponectin: data from the coronary risk factors for atherosclerosis in women (CORA) study

OBJECTIVE

An inverse association of adiponectin with coronary heart disease (CHD) has been reported, but the results are inconsistent. We used data from the CORA study to investigate into plasma concentrations of adiponectin and factors that may mediate the link to incident CHD.

DESIGN

The CORA study is a population-based case-control study on 200 women with incident CHD and 255 age-matched controls.

RESULTS

Plasma concentrations of adiponectin were significantly lower in women with CHD (p<0.0001), and in women with BMI >or=25 kg/m(2) (p<0.02), even more so with central obesity (WHR >or=0.85), prevalent diabetes or insulin resistance (HOMA-IR >or=3.8), or low HDL-cholesterol (<50mg/dl), and in smokers (each p<0.0001). Adiponectin also correlated with intake of fruit and vegetables, meat and sausage and alcohol as dietary markers of cardiovascular risk. Strikingly, the trend towards lower adiponectin concentrations with increasing BMI or waist circumference was less marked than the difference of adiponectin between CHD cases and controls. In a logistic regression model the odds ratio of adiponectin of 0.943 per 1 microg/ml (CI 0.919-0.968, p<0.0001) for risk of CHD was progressively reduced by elevated WHR, obesity-related risk factors, smoking, and dietary parameters.

CONCLUSIONS

Plasma adiponectin indicates protection from CHD in women that is attenuated by combined effects of central obesity and dependent risk factors, parameters of nutrition and smoking. Thus, the impact of adiponectin goes beyond its relation to central adiposity, but may also reflect independent effects of lifestyle.