Chelation therapy for atherosclerotic cardiovascular disease

BACKGROUND

Chelation therapy is promoted and practiced around the world as a form of alternative medicine in the treatment of atherosclerotic cardiovascular disease. It has been suggested as a safe, relatively inexpensive, non-surgical method of restoring blood flow in atherosclerotic vessels. However, there is currently limited high-quality, adequately-powered research informing evidence-based medicine on the topic, specifically regarding clinical outcomes. Due to this limited evidence, the benefit of chelation therapy remains controversial at present. This is an update of a review first published in 2002.

OBJECTIVES

To assess the effects of ethylene diamine tetra-acetic acid (EDTA) chelation therapy versus placebo or no treatment on clinical outcomes among people with atherosclerotic cardiovascular disease.

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 6 August 2019. We searched the bibliographies of the studies retrieved by the literature searches for further trials.

SELECTION CRITERIA

We included studies if they were randomised controlled trials of EDTA chelation therapy versus placebo or no treatment in participants with atherosclerotic cardiovascular disease. The main outcome measures we considered include all-cause or cause-specific mortality, non-fatal cardiovascular events, direct or indirect measurement of disease severity, and subjective measures of improvement or adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality using standard Cochrane procedures. A third author considered any unresolved issues, and we discussed any discrepancies until a consensus was reached. We contacted study authors for additional information.

MAIN RESULTS

We included five studies with a total of 1993 randomised participants. Three studies enrolled participants with peripheral vascular disease and two studies included participants with coronary artery disease, one of which specifically recruited people who had had a myocardial infarction. The number of participants in each study varied widely (from 10 to 1708 participants), but all studies compared EDTA chelation to a placebo. Risk of bias for the included studies was generally moderate to low, but one study had high risk of bias because the study investigators broke their randomisation code halfway through the study and rolled the placebo participants over to active treatment. Certainty of the evidence, as assessed by GRADE, was generally low to very low, which was mostly due to a paucity of data in each outcome's meta-analysis. This limited our ability to draw any strong conclusions. We also had concerns about one study's risk of bias regarding blinding and outcome assessment that may have biased the results. Two studies with coronary artery disease participants reported no evidence of a difference in all-cause mortality between chelation therapy and placebo (risk ratio (RR) 0.97, 95% CI 0.73 to 1.28; 1792 participants; low-certainty). One study with coronary artery disease participants reported no evidence of a difference in coronary heart disease deaths between chelation therapy and placebo (RR 1.02, 95% CI 0.70 to 1.48; 1708 participants; very low-certainty). Two studies with coronary artery disease participants reported no evidence of a difference in myocardial infarction (RR 0.81, 95% CI 0.57 to 1.14; 1792 participants; moderate-certainty), angina (RR 0.95, 95% CI 0.55 to 1.67; 1792 participants; very low-certainty), and coronary revascularisation (RR 0.46, 95% CI 0.07 to 3.25; 1792 participants). Two studies (one with coronary artery disease participants and one with peripheral vascular disease participants) reported no evidence of a difference in stroke (RR 0.88, 95% CI 0.40 to 1.92; 1867 participants; low-certainty). Ankle-brachial pressure index (ABPI; also known as ankle brachial index) was measured in three studies, all including participants with peripheral vascular disease; two studies found no evidence of a difference in the treatment groups after three months after treatment (mean difference (MD) 0.02, 95% CI -0.03 to 0.06; 181 participants; low-certainty). A third study reported an improvement in ABPI in the EDTA chelation group, but this study was at high risk of bias. Meta-analysis of maximum and pain-free walking distances three months after treatment included participants with peripheral vascular disease and showed no evidence of a difference between the treatment groups (MD -31.46, 95% CI -87.63 to 24.71; 165 participants; 2 studies; low-certainty). Quality of life outcomes were reported by two studies that included participants with coronary artery disease, but we were unable to pool the data due to different methods of reporting and varied criteria. However, there did not appear to be any major differences between the treatment groups. None of the included studies reported on vascular deaths. Overall, there was no evidence of major or minor adverse events associated with EDTA chelation treatment.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to determine the effectiveness or ineffectiveness of chelation therapy in improving clinical outcomes of people with atherosclerotic cardiovascular disease. More high-quality, randomised controlled trials are needed that assess the effects of chelation therapy on longevity and quality of life among people with atherosclerotic cardiovascular disease.

Pre-existing arterial pathologic changes affecting arteriovenous fistula patency and cardiovascular mortality in hemodialysis patients

The radiocephalic arteriovenous fistula (AVF) provides optimal vascular access for hemodialysis; it has a higher long-term patency rate and fewer complications than other vascular access methods. However, the AVF has a high primary failure rate. The presence of small-diameter vessels at anastomosis sites is an important risk factor for AVF failure. However, in a recent study, despite selecting an adequate artery and vein for creating an AVF by routine preoperative vascular mapping, AVF maturation and primary failure occurred. Thus, pre-existing arteriosclerosis at AVF anastomosis sites likely contributes to AVF failure. In this review, we discuss the relationship between pathologic changes and AVF patency in hemodialysis patients. Because arteriosclerosis of the major arteries such as the coronary and carotid arteries is associated with cardiovascular mortality, we also review the impact of arteriosclerosis of upper arm arteries at AVF anastomosis sites on cardiovascular mortality in hemodialysis patients.

Long Term Outcome of Femoropopliteal Bypass for Claudication and Critical Ischemia

We performed 167 femoropopliteal bypass surgeries in 151 patients (95 patients underwent above-knee bypass and 56 below-knee bypass) from December 1985 to December 2000 with the use of prosthetic graft or autologous vein graft. We compared primary patency rates between age, sex, graft material, distal anastomotic site and severity of ischemia, considering their survival rates to elucidate the long-term outcome of above-knee and below-knee femoropopliteal bypass. The 10 year patency rate for above-knee bypass was 47.4%, compared to 36.9% for below-knee ( p < 0.01). Better results were found after bypass surgery for claudicants than for critical ischemia ( p < 0.05). With regard to graft material and age categories, there were unexpectedly no statistical differences in either above-knee or below-knee anastomosis. The survival rate at 10 years in claudicants was 51.2%, compared to 15.9% with critical ischemia ( p < 0.01). Mortality was much influenced by ischemic heart disease ( p < 0.002) and the age of patient ( p < 0.05). The results after above-knee bypass had comparable patency, whereas the results after below-knee bypass were disappointing. Below-knee arterial reconstruction for claudicants should be carefully considered and might be recommended only to patients with critical ischemia.

Soluble P-selectin levels are associated with cardiovascular mortality and sudden cardiac death in male dialysis patients

BACKGROUND/AIMS

P-selectin is released by activated platelets and endothelium contributing to inflammation and thrombosis. We evaluated the association between soluble P-selectin and atherosclerotic cardiovascular disease (ASCVD) in dialysis patients.

METHODS

We measured soluble P-selectin in serum from 824 incident dialysis patients. Using Cox proportional hazards models, we modeled the association of P-selectin levels with ASCVD events, cardiovascular mortality and sudden cardiac death.

RESULTS

After adjustment for demographics, comorbidity and traditional cardiovascular risk factors, higher P-selectin levels were associated with increased risk of ASCVD and cardiovascular mortality among males (p = 0.02 and p = 0.01, respectively), but not females (p = 0.52 and p = 0.31, respectively; p interaction = 0.003), over a median of 38.2 months. Higher P-selectin was associated with a greater risk of sudden cardiac death among males (p = 0.05). The associations between increasing P-selectin and cardiovascular mortality as well as sudden cardiac death in males persisted after adjustment for C-reactive protein, interleukin-6, serum albumin and platelet count (p = 0.01 and p = 0.03, respectively). The risk for sudden cardiac death was more than 3 times greater for males in the highest tertile of soluble P-selectin compared with the lowest tertile after adjustment (HR: 3.19; 95% CI: 1.18 - 8.62; p = 0.02).

CONCLUSION

P-selectin is associated with ASCVD, cardiovascular mortality and sudden cardiac death among male dialysis patients.

Diet, lipids and atherosclerosis

During the Second World War there was a temporary reduction in the frequency of myocardial infarction in Finland, Norway and Sweden. This was probably due to the reduced consumption of saturated fat. The total amount of dietary fat and cholesterol presumably played only a minor role. Today it is easier to obtain reliable mortality figures and information about the fat composition of the food in a given country. A compilation of such data has shown that mortality from myocardial infarction is higher in countries with a high consumption of saturated fat. Polyunsaturated fats seem to have an opposite effect. There is no reason to dissuade people from using fat-modified food products with a lower fat content and replacement of part of the saturated fat by polyunsaturated. Refugees from countries where the diet contains very little fat should be warned against using too much of the high-fat food products widely consumed in their new countries.

Japan Arteriosclerosis Longitudinal Study (JALS) Group. Japan Arteriosclerosis Longitudinal Study-Existing Cohorts Combine (JALS-ECC): rationale, design, and population characteristics

BACKGROUND

The Japan Arteriosclerosis Longitudinal Study-Existing Cohorts Combine (JALS-ECC) is a pooled study based on individual participant data from existing prospective cohort studies in Japan. Its purpose was to consider associations between risk factors and cardiovascular disease (CVD) outcomes, as well as differences between subgroups, defined by age, gender or geographical region, which could not be detected in the smaller samples.

METHODS AND RESULTS

Individual records for 66,691 participants in 21 cohort studies were pooled, accounting for a total of 575,628 person-years. From this data, there were 409 deaths attributed to stroke and 169 deaths attributed to coronary heart disease (CHD). Total stroke and CHD events were 1,478 and 178, respectively. Of the 1,424 total stroke events with a reported stroke subtype, 975 were classified as ischemic, 267 as hemorrhagic, and 178 as subarachnoid hemorrhage.

CONCLUSION

The JALS-ECC collected data from existing cohort studies covering a diverse Japanese population, which has provided information about the effects of modifiable factors on the risks of the CVD. Such information should provide a reliable basis for establishing prevention strategies.

Influence and interaction of diabetes and lipoprotein (a) serum levels on mortality of patients with peripheral artery disease

BACKGROUND

Diabetes mellitus is a risk factor for early complications and mortality in patients with peripheral artery disease. Lipoprotein (a) [Lp(a)] is also suggested to be a marker of increased cardiovascular risk. We investigated the association and interaction between diabetes mellitus, lipoprotein(a) and mortality in high risk patients with peripheral artery disease (PAD).

METHODS

We studied 700 consecutive patients [median age 73 years, interquartile range (IQR) 62-80, 393 male (56%)] with PAD from a registry database. Atherothrombotic risk factors (diabetes, smoking, hyperlipidaemia, arterial hypertension) and Lp(a) serum levels were recorded. We used stratified multivariate Cox proportional hazard analyses to assess the mortality risk at a given patient's age with respect to the presence of diabetes and Lp(a) serum levels (in tertiles).

RESULTS

Patients with Lp(a) levels above 36 mg dL(-1) (highest tertile) and insulin-dependent type II diabetes had a 3.01-fold increased adjusted risk for death (95% confidence interval 1.28-6.64, P = 0.011) compared to patients without diabetes or patients with non-insulin-dependent type II diabetes. In patients with Lp(a) serum levels below 36 mg dL(-1) (lower and middle tertile), diabetes mellitus was not associated with an increased risk for death.

CONCLUSION

Insulin-dependent type II diabetes mellitus seems to be associated with an increased risk for mortality in PAD patients with Lp(a) serum levels above 36 mg dL(-1). PAD patients with non-insulin-dependent type II diabetes, and patients with diabetes and Lp(a) levels below 36 mg dL(-1) showed survival rates comparable to PAD patients without diabetes.

[Gender differences in vascular medicine]

In vascular medicine only a few studies concerning gender differences in vascular diseases, course of the disease and therapy exist. Risk factors are allocated differently between men and women with different influences on cardiovascular diseases. Diabetic women do have a particular high risk. The proportion of women smokers with a risk for aggravation of the other risk factors is increased. In young female smokers the hypoplastic aortoiliac syndrome is a special course of peripheral arterial disease associated with a bad prognosis. The benefit of hormone replacement therapy in vascular diseases of postmenopausal women has not yet been demonstrated. On the other hand testosterone seems to have a favourable effect on vascular diameter and endothelium of coronaries. Women with peripheral arterial disease represent high risk patients with a particular risk for cardiovascular letality. Periprocedural complications of the analysed operations or interventions are found more frequent in women. Furthermore the disease is in an advanced stage when treated. Especially men with asymptomatic high grade carotid stenosis benefit more from an operation than women because of the higher risk for ischemic stroke. Unfortunately the benefit of the operation in women is neutralized by the higher rate of periprocedural complications. Some studies demonstrate the gender bias in treatment: women seldom receive revascularisation and guideline therapy as frequently as men. The same is true with thromboembolic prophylaxis concerning in hospital patients. In pharmacotherapy women have in result of metabolism more side effects. Additionally women are underrepresented in drug admission studies compared to their percentage of population and gender prevalence of diseases. Further studies concerning gender differences in vascular medicine are definitely needed.

Non‐High‐Density Lipoprotein Cholesterol: Why Lower Is Better

Recent comparative trials of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) suggest that lower is better and that reducing low-density lipoprotein cholesterol (LDL-C) levels to below 100 mg/dL can provide additional clinical benefit. Non-high-density lipoprotein cholesterol (non-HDL-C) contains more atherogenic cholesterol than LDL-C and is considered a more accurate measurement of the total amount of atherogenic particles in the circulation. Therefore, the principle that "lower is better" may also apply to lowering levels of non-HDL-C. In persons with high triglycerides (200-499 mg/dL), LDL-C remains the primary target of therapy, but non-HDL-C is an important secondary therapeutic target. Non-HDL-C is strongly correlated with small dense LDL as well as apolipoprotein B, an established predictor of cardiovascular disease risk. Current evidence indicates that statins not only rapidly and dramatically reduce LDL-C, but also have a similar effect on non-HDL-C, and that the greater the reduction in LDL-C, the greater will be the reduction in non-HDL-C.

Long-Term Outcome of First-Generation Metallic Coronary Stent Implantation in Patients With Coronary Artery Disease Observational Study Over a Decade

BACKGROUND

In the era of drug-eluting stents, percutaneous coronary intervention (PCI) has been considered an established therapeutic modality for patients with coronary artery disease (CAD). However, little is known about the long-term prognosis.

METHODS AND RESULTS

Using data obtained from a single-center registry for cases of first-generation bare metallic stent (BMS) implantation, a 10-year follow-up study in patients with CAD was performed. Data for 125 serial patients (aged 62+/-9 years, 104 males) in whom a BMS was successfully implanted was analyzed. Cardiac death (n=16 [12.8%]), including sudden cardiac death (n=9 [7.2%]), non-cardiac death (n=17 [13.6%]) and non-fatal acute myocardial infarction (n=16 [12.8%]) were documented. At 10 years, cumulative probabilities of target and non-target lesion revascularization were 20.5% and 41.5%, respectively, and only 39.2% of the patients were free from cardiac events (cardiac death/myocardial infarction/unplanned revascularization). Age and left ventricular ejection fraction (LVEF) were significant predictors of total death, and LVEF and the use of diuretics were predictors of cardiac events.

CONCLUSIONS

Stabilization of the initial stented site was relatively good and the majority of cardiac events might have originated in non-target lesions. Prevention of systemic arteriosclerosis progression is important for patients with CAD, even after successful PCI.

Comparability between ICD-9 and ICD-10 for the leading causes of death in Spain

BACKGROUND

Implementation of a new Revision of the International Classification of Diseases can create discontinuity in mortality statistics. Revisions are nevertheless essential to ensure international comparability of health statistics. The purpose of this work was to describe the effects of the 10th Revision on mortality statistics by sex and age for leading causes of death in Spain.

METHODS

A cross-sectional study of leading causes of death was carried out when the underlying cause of death was coded using both the 9th and 10th Revisions of the International Classification of Diseases in 88,044 death certificates completed in five Autonomous Communities of Spain (Andalusia, Cantabria, Murcia, Navarra, the Basque Country), and the city of Barcelona during the year 1999. Changes introduced by the 10th Revision were described by simple correspondence, percentage of change, Kappa index and comparability ratios between the 10th and the 9th Revision along with their 95% confidence intervals by sex and five-year age group, for the leading causes of death.

RESULTS

Under the 10th Revision, AIDS deaths rose by 3.6% (comparability ratio (CR): 1.036; 95% confidence interval (CI):1.015-1.058), arteriosclerosis by 7.1% (CR: 1.071; 95% CI: 1.052-1.090), and drug overdose by 5.2% (CR: 1.052; 95% CI: 0.964-1.140). Mortality due to vascular and senile dementia and non specific dementia declined by 3.2% under the 10th (CR: 0.969; 95% CI: 0.950-0.988). In all the other causes of death the percentage of change regardless of direction was less than 2%.

CONCLUSION

The present study found good agreement between ICD-9 and ICD-10 on the leading causes of death and premature mortality in Spain. Causes of death which present differences between Revisions were AIDS, arteriosclerosis, drug overdose and senile dementia. For these causes, the comparability ratios must be taken into account when interpreting mortality statistics.

Carga de mortalidad asociada a la inactividad física en Bogotá

Estimates of the burden of mortality associated to physical inactivity (PI) have not been quantified for large urban centers located in developing countries.

OBJECTIVES

To estimate the burden of mortality due to six chronic diseases (CDZ) associated to PI and the number of potentially preventable deaths associated to reductions in the prevalence of PI.

METHODS

PI exposure prevalence obtained via population surveys was linked to mortality data registered during 2002 among adult (> 45 y) Bogotá residents. The strength of association between PI and disease-specific mortality was obtained from the literature. Population attributable risk (PAR) was used to calculate the CDZ mortality attributable to PI and to estimate the number of potentially preventable deaths associated to a 30 % reduction in the prevalence of PI.

RESULTS

A 53,2 % PI exposure prevalence was associated to a PAR of 19,3 % for coronary artery disease, 24,2 % for stroke, 13,8 % for arterial hypertension, 21 % for Diabetes Mellitus, 17,9 % for colon cancer and 14,2 % for breast cancer. An estimated 7,6 % of all-cause mortality and 20,1 % of CDZ mortality could be attributed to PI. An estimated 5% of the CDZ mortality could be prevented if PI prevalence is reduced by 30 %.

CONCLUSION

Conservative estimates indicate that a considerable proportion of deaths due to highly prevalent CDZ could be attributed to PI. Strategies to reduce the prevalence of PI in Bogotá could lead to progressive reductions in the burden of CDZ mortality.

[Effects of ethanol on circulatory system]

Moderate alcohol consumption decreases the risk of coronary heart disease (CHD). Epidemiological studies indicate that consumption of alcohol at the level 20-30 g per day can reduce risk of CHD by at least 20-25%. The mechanism of this protection has been associated with an increase in the level of HDL-cholesterol. Second of the proposed mechanisms of the protective effect of moderate alcohol intake is its beneficial effect on homeostasis.

The influence of ascending aortic atherosclerosis on the long-term survival after CABG

OBJECTIVE

Ascending aortic atherosclerosis is a risk factor for perioperative morbidity and mortality in coronary surgery. It was the aim of our study to determine the role of atherosclerosis of the ascending aorta and other factors for the survival rate during long-term follow-up after CABG.

METHODS

From 500 out of 580 CABG patients (aged 67 (33-85) years, 77% male), who underwent intraoperative epiaortic ultrasound for assessment of ascending aortic wall thickness, a complete follow up regarding long-term survival was achieved. The median follow-up time was 55 (1-78) months.

RESULTS

53/500 (11%) patients died within the follow-up period, and the cumulative survival rate was 95, 90, and 84% after 1, 3, and 5 years, respectively (including hospital deaths). A significantly lower long-term survival was present in patients with: an age of 70 years or more (P<0.001), COPD (P=0.005), preoperative elevated serum creatinine of >1.2mg/dl (P=0.007), preoperative LVEF <40% (P=0.033), ascending aortic wall thickness of 4mm or more (P=0.001), carotid artery disease (P<0.001), peripheral vascular disease (P<0.001), and acute operation (P=0.009). Multivariate analysis revealed carotid artery disease, LVEF <40%, peripheral vascular disease, and advanced age to be independent risk factors.

CONCLUSION

Patients with ascending aortic atherosclerosis are at risk for a decreased long-term survival after CABG. Besides, preoperative elevated serum creatinine, COPD, carotid artery disease, LVEF <40%, peripheral vascular disease, and advanced age are risk factors for a decreased long-term survival after CABG.

Association of low ankle brachial index with high mortality in primary care

AIMS

We aimed to assess the increased risk of death and severe vascular events in elderly individuals with subclinical or manifest peripheral arterial disease (PAD), evidenced by low ankle brachial index (ABI < 0.9) in primary care.

METHODS AND RESULTS

In this monitored prospective observational study, 6880 representative unselected patients aged >or=65 years were followed up over 3 years by 344 primary care physicians. Main outcome measures were mortality or a combined endpoint of mortality and severe vascular events. In total, 20 127 patient-years were observed. In the group of PAD patients (n=1230), 134 patients died; in the group without PAD (n=5591), 237 patients died [multivariate hazard ratio (HR) 2.0; 95% confidence interval 1.6-2.5, P<0.001]. Compared with an ABI>or=1.1, the risk of death increased linearly in the lower ABI categories: ABI 0.7-0.89, HR 1.7 (1.2-2.4, P<0.001); ABI<0.5, HR 3.6 (2.4-5.4, P<0.001).

CONCLUSION

Patients with a low ABI (PAD), who can be readily identified in a primary care setting, have a substantially increased risk of death and severe vascular events. Patients with an ABI between 1.1 and 0.9 should be considered and followed up as borderline PAD cases. Particular attention should be paid to patients with PAD and previous vascular events, as their risk is markedly increased.

Rheumatoid arthritis: a disease associated with accelerated atherogenesis

OBJECTIVES

Rheumatoid arthritis (RA) is a systemic inflammatory disease associated with an increased prevalence of coronary heart disease and a high cardiovascular (CV) mortality. In this article, a review of mechanisms implicated in the development of accelerated atherogenesis in RA was performed. The potential role of treatment to reduce the incidence of CV events in RA was also discussed.

METHODS

Retrospective review of the literature. The potential mechanisms implicated in the development of accelerated atherogenesis in RA, information on carotid ultrasonography, and the potential implication of treatment to prevent accelerated atherogenesis in individuals with RA were examined.

RESULTS

Endothelial dysfunction, which is an early step in the development of atherosclerosis, has been observed in patients with RA. Deleterious effects resulting from persistent chronic inflammation may lead to endothelial dysfunction, insulin resistance, and a dyslipidemic pattern in these patients. Other mechanisms different from those related to classic atherogenesis risk factors, such as hyperhomocysteinemia and increased oxidative stress, are considered to be implicated in the pathogenesis of atherosclerosis in RA. Increased carotid intima-media thickness and carotid plaques have been found in RA patients compared with matched controls. Active MTX treatment of the disease has been associated with decreased CV mortality. Additional drugs such as statins may be considered in the management of these patients.

CONCLUSIONS

The increased prevalence of CV mortality rate in RA cannot only be explained by the presence of traditional atherosclerotic risk factors. A chronic inflammatory response may promote the development of accelerated atherogenesis in these patients. Active treatment of the disease is required to reduce the risk of developing CV complications in individuals with RA.

[Prevention of arteriosclerosis. Importance of the treatment of arterial hypertension]

In most European countries and Northern America, cardiovascular diseases induced by atherosclerosis are the most common cause of death in older people. People surviving acute myocardial infarction or stroke suffer often by disabilities or handicaps. The lifelong care of such patients is expensive and plays a major role for increment of costs in public health systems. Prevention of atherosclerosis will reduce cardiovascular morbidity and mortality, enhance quality of life and prolong lifetime of patients. Therefore the worldwide accepted risk factors of atherosclerosis have to be treated consequently and early enough within the meaning of primary prevention. Hypertension is one of the six major cardiovascular risk factors and is defined as elevated blood pressure above 140/90 mmHg. In case of hypertension, diagnostic efforts has to be focussed on detection of additional cardiovascular risk factors, secondary forms of hypertension, end organ damage or associated diseases. All therapeutic strategies are based on life style changes, which cover weight reduction, sodium restriction, controlled alcohol consumption and increment in physical activity. Pharmacotherapy will be added in regard to the global risk of the patient and the success of the life style changes. Selection of antihypertensives and their optimal combination will be determined by associated diseases (compelling indication), side effects and individual response in blood pressure. Goal of treatment is the normalization of blood pressure below 140/90 mmHg independent of age or sex. In diabetics and in case of nephropathy the goal is set lower (below 130/80 mmHg).There is strong evidence that reduction in blood pressure is followed by a decrease in the incidence of myocardial infarction, stroke, heart failure, nephropathy, and even in cardiovascular mortality. The success of antihypertensive therapy is greater in high risk patients like older people, patients with isolated systolic hypertension or diabetics. Risk reduction correlates well with the degree in blood pressure reduction. However, to minimize cardiovascular risk in hypertensives all additional risk factors have to be treated too.

[Accelerated atherosclerosis in rheumatic systemic diseases as an example of systemic lupus erythematosus--what is the consequence?]

Large increases in mortality related to premature atherosclerosis with coronary artery disease and stroke have been reported during the last few years in patients with systemic lupus erythematosus (SLE). Studies found relative risks of 5 to 7 for myocardial infarction in SLE patients. The traditional risk factors fail to fully account for accelerated atherosclerosis in SLE and APS, in addition prolonged glucocorticoid therapy and long duration of SLE seem to be of importance. The disease SLE per se is an independent risk factor. The current pathogenic hypothesis for atherosclerosis involves an inflammatory response, autoantibodies, immune complexes (containing antibodies to phospholipids, to oxidized LDLs, and to endothelial cells), CD40/CD40 ligand interactions, and bacterial or viral infections responsible for an immune response. The determination of classic and new risk factors, together with specific autoantibody titers and the use of Doppler carotid ultrasound, are useful methods to detect early atherosclerosis. Therapeutic strategies, including early risk factor intervention and effective control of inflammation, are essential to reduce morbidity and mortality and should be incorporated into the management of connective tissue disease with the goal of protecting patients against atherosclerosis.

Long-term predictors of survival for the Seven Countries Study cohort from Crete: from 1960 to 2000

BACKGROUND

In 1960, all male inhabitants of a series of villages in rural Crete, born between 1900 and 1919, were invited to participate in the Seven Countries Study. Analysis of 25-year mortality data from the 16 cohorts of participants indicated that the cohort from Crete had the lowest age-standardised all-cause and coronary heart disease death rates.

METHODS

At baseline, 686 Cretan men (98% of those invited) participated in health examinations. Mortality data were collected over 40 years. Time-fixed and updated covariate survival analysis techniques were applied to assess eight cardiovascular disease risk factors as long-term predictors of all-cause and cardiovascular disease mortality.

RESULTS

The median survival time was 32 years. All-cause and cardiovascular mortality rates were 26 and 11 per 1000 person-years, respectively. Age (relative risk 1.11, 95% CI 1.09-1.13), diastolic blood pressure (relative risk 1.02, 95% CI 1.01-1.03), and smoking (relative risk 1.37, 95% CI 1.14-1.64) were positively associated and forced expiratory volume (relative risk 0.50, 95% CI 0.36-0.68) was negatively associated with all-cause mortality. Age (relative risk 1.13, 95% CI 1.09-1.16), diastolic blood pressure (relative risk 1.01, 95% CI 1.001-1.03), and forced expiratory volume (relative risk 0.53, 95% CI 0.32-0.89) were independent predictors of cardiovascular mortality. Serum cholesterol concentration and body mass index were not independently associated with death risk.

CONCLUSIONS

The Cretan cohort displays favourable 40-year survival. Even so, long-term predictors of the hazard of both all-cause and cardiovascular disease mortality are present.

Prognostic role of C-reactive protein in very old patients with acute ischaemic stroke

BACKGROUND AND SCOPE

Recent literature has demonstrated that inflammation contributes to all phases of atherosclerosis and brain damage caused by stroke. In acute phase of cerebrovascular diseases biochemical markers of inflammation, such as C-reactive protein (CRP), could represent an indicator of severity of stroke, but few studies have verified this hypothesis, especially in very old patients. The aim of this study was to evaluate the role of CRP on short- and long-term prognosis in 75-year old and over elderly patients with acute ischaemic stroke.

MATERIALS AND METHODS

We retrospectively evaluated CRP values (nephelometric method), performed within 12 h from hospital admission, in 196 elderly patients (124 females and 72 males with mean age+/-SD 83.32+/-10.46 years), discharged with diagnosis of acute ischaemic stroke, 68 of them with atherothrombotic large vessel stroke, 38 with lacunar stroke and 90 with cardioembolic stroke. We studied the relationship between CRP values and short-term prognosis [30-day mortality, length of hospitalization (LOS) and physical disability measured by modified Rankin scale and long-term prognosis (12-month mortality and re-hospitalization)].

RESULTS

Mean values of CRP were significantly higher in patients with cardioembolic stroke compared with atherothrombotic large vessel and lacunar stroke, in patients who died in the first 30 days from the acute event compared with survivors. LOS and physical disability score rose with increasing values of CRP for all subtypes of stroke. Higher CRP values were associated with the 12-month re-hospitalization for cerebrovascular events, whereas it did not influence the 12-month cumulative re-hospitalization and 12-month mortality.

CONCLUSIONS

Elevation of CRP values at hospital admission could represent a negative prognostic index in elderly patients with ischaemic stroke, in particular, for short-term prognosis.

Clinical significance of the physicochemical properties of LDL in type 2 diabetes

Atherosclerosis is the leading cause of death in type 2 diabetes. LDL cholesterol and atherosclerosis are related, both in healthy people and those with diabetes; however, people with diabetes are more prone to atheroma, even though their LDL cholesterol levels are similar to those in their non-diabetic peers. This is because LDL particles are modified in the presence of diabetes to become more atherogenic. These modifications include glycation in response to high plasma glucose levels; oxidative reactions mediated by increased oxidative stress; and transfer of cholesterol ester, which makes the particles smaller and denser. The latter modification is strongly associated with hypertriglyceridaemia. Oxidatively and non-oxidatively modified LDL is involved in plaque formation, and may thus contribute to the accelerated atherosclerosis. This review discusses the techniques currently used to determine the physicochemical properties of LDL, and examines the evidence that modification of these properties plays a role in the accelerated atherosclerosis associated with type 2 diabetes.

The significance of serum gamma-glutamyltransferase in cardiovascular diseases

Since early after the introduction of serum gamma-glutamyltransferase (GGT) in clinical practice as a reliable and widely employed laboratory test, epidemiological and prospective studies have repeatedly shown that this activity possesses a prognostic value for morbidity and mortality. The association is independent of possibly concomitant conditions of liver disease, and notably, a significant independent correlation of serum GGT exists with the occurrence of cardiovascular diseases (myocardial infarction, stroke). Experimental work has documented that active GGT is present in atherosclerotic plaques of coronary as well as in cerebral arteries. These findings, and the recently recognized functions of GGT in the generation of reactive oxygen species, indicate that serum GGT represents a true marker of cardiovascular diseases and underlying atherosclerosis. Further insights into potential therapeutic interest will probably be derived from studies investigating the origin of GGT activity in plaque tissue.

Incidence of Atherosclerosis by Race in the Dialysis Morbidity and Mortality Study: A Sample of the US ESRD Population

White individuals who are on dialysis experience much higher overall and cardiovascular mortality rates than black individuals despite a more favorable risk factor profile, but the incidence of nonfatal cardiovascular disease (CVD) to this racial disparity has not been well studied. A longitudinal study of 16,103 people who had ESRD and were enrolled in the United Renal Data System from 1993 to 1996 was conducted. The incidence of new and recurrent atherosclerotic CVD (ASCVD) events was determined using Medicare claims for hospitalizations and mortality among blacks and whites, stratified by ASCVD at baseline. ASCVD was defined as coronary heart disease, peripheral vascular disease, and cerebrovascular disease. Incidence of new ASCVD in people without ASCVD at baseline was 146.9 per 1000 person-years in whites and 118.7 per 1000 person-years in blacks. Incidence of recurrent ASCVD was 404.1 per 1000 person-years in whites and 317.5 per 1000 person-years in blacks. Whites were 1.35 (95% confidence interval, 1.18 to 1.55) times more likely to develop incident ASCVD compared with blacks and 1.25 (95% confidence interval, 1.14 to 1.36) times more likely to develop recurrent disease after adjusting for traditional CVD and dialysis-related risk factors. Excess risk for recurrent ASCVD in whites compared with blacks was consistently present no matter the duration of dialysis: Hazard ratio 1.42 for 0 to 6 mo and 1.40 for 6 to 12 mo. Whites who are treated with dialysis have a higher incidence of ASCVD than blacks who are on dialysis, both new and recurrent. Although differences in survival before the initiation of dialysis may contribute to the observed difference in ASCVD risk, it is not explained by baseline traditional and dialysis-related ASCVD risk factors.

Vascular complications of the intra-aortic balloon counterpulsation

From September 1994 to December 2002, 6,274 cardiosurgery operations were performed at the Department of Cardiac Surgery, University Hospital, Hradec Kralove, Czech Republic. Intra-aortic balloon counterpulsation (IABP) was applied in 192 cases (3.1%). From this group of 192 counterpulsated patients 103 were successfully treated (53.6%); 89 counterpulsated patients (46.4%) died from the surgical procedure (30-day mortality rate). In 5 cases (2.6%) from the group of 192, the IABP was introduced before the operation. Ischemic changes of the limb were observed in 11 cases (5.7%). Significant bleeding occurred at the site of puncture in 6 cases (3.1%). Dissection of the femoral and iliac arteries was found in 2 patients (1.0%), perforation of the iliac artery in 1 case (0.5%). In 2 cases (1.0%) the balloon was led into the venous system. In case report No. 1 an introduction of the balloon under a sclerotic plaque of the descending aorta and iliac artery is described. In case report No. 2 a placement of the balloon in the venous bloodstream is reported.

Prevalence of valve calcium and association of valve calcium with coronary artery disease, atherosclerotic vascular disease, and all-cause mortality in 137 patients undergoing hemodialysis for chronic renal failure

Of 137 patients (mean age 63 years) who underwent hemodialysis for chronic renal failure, 65 (47%) had mitral valve calcium, mitral annular calcium, or aortic valve calcium. Thirty-eight of 65 patients (59%) who had valve calcium died at 3.5-year follow-up versus 21 of 72 patients (29%) who did not have valve calcium and who died at 4.3-year follow-up (p = 0.0005).

Epidemiology of peripheral arterial disease

Peripheral arterial disease (PAD) is not an uncommon but a commonly neglected condition by many medical practitioners. It is a disease that threatens not only the limb but also life itself! Atherosclerosis is the commonest cause of PAD in the western nations. The cardinal symptom is intermittent claudication (IC) but majority of the patients are asymptomatic. Ankle-brachial pressure index (ABI) is an effective screening tool for PAD. A diminished ABI (< 0.9) is a definite sign of PAD. Its prevalence steadily increases with age. In Germany almost a fifth of the patients aged over 65 years suffer from it. With increasing life expectancy the prevalence of PAD is on the increase. PAD is a manifestation of diffuse and severe atherosclerosis. It is a strong marker of cardiovascular disease; a very strong association exists between PAD and other atherosclerotic disorders such as coronary artery disease (CAD) and cerebrovascular disease (CVD). PAD is an independent predictor of high mortality in patients with CAD. Smoking, diabetes mellitus and advancing age are the cardinal risk factors. A relatively small number of PAD patients lose limbs by amputation. Most paitients with PAD die of either heart attacks or strokes and they die of the former conditions far earlier than controls. PAD still remains an esoteric disease and there is a significant lack of awareness of this condition by many physicians, and therefore under-diagnosed and underestimated. Measures to promote awareness of PAD among physicians and the society in general are needed. Since most patients are asymptomatic and carry potentially significant morbidity and mortality risks, screening for PAD should be made a routine practice at primary care level.

Percutaneous and Open Renal Revascularizations Have Equivalent Long-Term Functional Outcomes

Atherosclerotic renal artery stenosis is a significant cause of poorly controlled hypertension and progressive renal dysfunction leading to ischemic nephropathy and other end-organ damage. The optimal treatment of renovascular disease contributing to hypertension and renal dysfunction is not known. This study compares the anatomic and functional outcomes of both open and endovascular therapy for chronic, symptomatic atherosclerotic renal artery disease. We performed a retrospective analysis of records from patients who underwent renal arterial interventions, endovascular or open bypass, between January 1984 and January 2004. Principal indications for intervention were hypertension (51%), chronic renal insufficiency (13%), and hypertension and elevated creatinine (36%). A total of 247 patients (109 males; mean age 69 +/- 10, range 44-89 years) underwent 314 interventions (109 open procedures; 205 angioplasties, 71% with stent placement). There was a significant difference in 30-day mortality (4% vs. <1%; p < 0.005) between the open and endoluminal groups, but not at 1, 3, or 5 years. Patients in the open group had a higher primary patency rate at 5 years (83 +/- 5% vs. 76 +/- 6%; p = 0.03), but patients in the endoluminal group had a higher assisted primary patency rate at 5 years (92 +/- 5% vs. 84 +/- 5; p = 0.03). There was no significant difference between both treatment groups in cumulative freedom from presenting symptom or in freedom from dialysis and renal-related death. Patients who presented with hypertension were more likely to have shown improvement in their blood pressure with endoluminal intervention at 1, 3, and 5 (59 +/- 6% endoluminal vs. 83 +/- 5% open; p = 0.01) years. From these results we conclude that open repair and endoluminal repair of atherosclerotic renal artery stenosis have similar immediate and long-term functional and anatomic outcomes. Patients who present with hypertension may have greater benefit with an endoluminal repair.

Heterogeneity of cardiovascular risk among smokers is related to degree of carbon monoxide exposure

BACKGROUND

Between smokers matched for daily tobacco consumption there are marked variations of the cardiovascular risk. This follow up of the population based cohort "Men born in 1914" from Malmö, Sweden, explored whether this is accounted for by the levels of carbon monoxide (CO).

METHODS

Three hundred and sixty-five men without history of cardiovascular disease (CVD) were followed over 27 years. Leg artery disease was defined as a systolic ankle-arm pressure ratio (ABPI) below 0.9 in either leg. Incidence of myocardial infarction (MI), stroke and deaths is based on linkage with regional and national registers. The distribution of CO in blood and expired air, respectively, was divided into quartiles.

RESULTS

There was a significant inverse relation between ABPI and CO in blood and expired air. Incidence of CVD events and deaths increased progressively with degree of CO exposure. Men with CO in the top quartile had significantly increased risks of CVD events (RR: 2.2; 95% CI: 1.00-4.6) and cardiovascular deaths (RR: 3.2, CI: 1.2-8.3), adjusted for daily tobacco consumption and other potential confounders.

CONCLUSIONS

In smokers, the prevalence of leg atherosclerosis and incidence of cardiovascular disease is related to the amount of carbon monoxide in blood or expired air.

Management of Peripheral Vascular Disease

The management of patients with peripheral arterial occlusive disease (PAD) has to be planned in the context of natural history, epidemiology, and apparent risk factors that predict deterioration. The ankle-brachial index to date has proved to be the most effective, accurate, and practical method of PAD detection. Given that PAD is a powerful indicator of systemic atherosclerosis and (independent of symptoms) is associated with an increased risk of myocardial infarction and stroke, as well as a six times greater likelihood of death, the prevalence and demographic distribution of measurable PAD becomes particularly relevant. Reliable information on interventions to confer symptom relief is much weaker and reflects discrepancies between published reports from centers of excellence and the experience of patients routinely treated in communities around the world. The impact of newer treatment modalities, such as complex endovascular procedures and therapeutic angiogenesis, has been a subject of recent controversy.

Safety of growth hormone replacement therapy in adults

Growth hormone (GH) is a powerful metabolic hormone that regulates fuel homeostasis through its protein anabolic and lipolytic actions. The introduction of recombinant human GH has expanded the narrow indication of treating children with severe GH deficiency (GHD) to include a broader target population of children with growth retardation and short stature and adults with hypopituitarism and severe GHD. Furthermore, because children continue to receive GH replacement therapy into adult life, the duration of treatment exposure has increased and the safety of long-term GH treatment has become increasingly important. This is of particular concern given that GH-deficient children and adults may be more vulnerable to the mitogenic stimuli of GH and insulin-like growth factor-1, both because of the underlying cause of GHD and also because of previous treatment such as radiotherapy and chemotherapy. This review focuses on the safety of treating adults with severe GHD, with specific emphasis on dose regimens, carbohydrate metabolism, neoplasia, and morbidity and mortality. Available experience from long-term replacement therapy, studies using supraphysiological doses of GH in adults and lessons learned from patients with acromegaly who have high endogenous GH levels over many years, is considered.

[Major impact of arteriosclerosis on cardiovascular morbidity and mortality]

Arterial stiffness (arteriosclerosis) is a diffuse process affecting the media of large arteries, strongly linked to the process of ageing, but influenced by several other major factors like hypertension and vascular calcifications. Arteriosclerosis has been recognized in recent years as a novel non-traditional cardiovascular risk factor both for renal and non-renal general population. Two of arterial stiffness parameters, pulse wave velocity and the augmentation index--determined by applanation tonometry, are strongly correlated with cardiovascular morbidity and mortality, as well as with the general mortality. Arterial stiffness, due to several factors related to the uremic milieu, is more pronounced in patients with end-stage renal disease compared with patients without renal dysfunction. The authors are briefly reviewing the most recent literature regarding the impact of arterial stiffness on cardiovascular outcome. Identifying the factors associated with reduced arterial compliance may positively influence cardiovascular outcome in the general population, and particularly in renal patients, plagued by a high burden of cardiovascular disease.

Outcomes of patients with atherosclerotic upper extremity tissue loss

Severe ischemia of the upper extremity causing tissue necrosis occurs much less frequently than in the lower extremity. The clinical outcome of patients diagnosed with digital nonhealing ulcer or gangrene is largely unknown. A retrospective review of patients with upper extremity tissue loss was performed. Patients with ischemia from embolic disease, steal syndromes, and vasospastic or connective tissue disorders were excluded. Thirteen patients with upper extremity ischemic gangrene and/or nonhealing ulcers were treated from January 1995 to June 2002. Comorbid conditions included diabetes mellitus in 10 patients and renal failure in 11 patients. Five patients developed bilateral upper extremity ischemia during the period of evaluation, while 8 had unilateral involvement. Nine patients had dry gangrene of a digit, 5 had nonhealing ulcers, and 1 patient developed wet gangrene from an ischemic ulcer. All 13 patients received local wound care and medical treatment with anticoagulants, calcium channel blockers, or antiplatelet agents. Ischemic lesions healed in 3 of the 5 patients with conservative management. Surgical intervention was performed on 6 patients with dry gangrene, and the patient with wet gangrene underwent amputation of the hand (53.8%). Two patients underwent sympathectomy without improvement. In the remaining 3 patients, tissue loss remained stable. Seven patients died within 2 years of presentation with upper extremity ischemia, with a survival at 24 months of only 14% by lifetable analysis. The local outcome of severe upper extremity ischemia is generally favorable, with good response to either medical management or digit amputation. However, the life expectancy of the patients with upper extremity ischemia from true atherosclerotic disease is dismal. Therefore, surgical intervention should be reserved for infection control or pain relief only.

Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study

OBJECTIVES

To determine the association between hyperkyphotic posture and rate of mortality and cause-specific mortality in older persons.

DESIGN

Prospective cohort study.

SETTING

Rancho Bernardo, California.

PARTICIPANTS

Subjects were 1,353 participants from the Rancho Bernardo Study who had measurements of kyphotic posture made at an osteoporosis visit between 1988 and 1991.

MEASURES

Kyphotic posture was measured as the number of 1.7-cm blocks that needed to be placed under the participant's head to achieve a neutral head position when lying supine on a radiology table. Demographic and clinical characteristics and health behaviors were assessed at a clinic visit using standard questionnaires. Participants were followed for an average of 4.2 years, with mortality and cause of death confirmed using review of death certificates.

RESULTS

Hyperkyphotic posture, defined as requiring one or more blocks under the occiput to achieve a neutral head position while lying supine, was more common in men than women (44% in men, 22% of women, P<.0001). In age- and sex-adjusted analyses, persons with hyperkyphotic posture had a 1.44 greater rate of mortality (95% confidence interval (CI)=1.12-1.86, P=.005). In multiply adjusted models, the increased rate of death associated with hyperkyphotic posture remained significant (relative hazard=1.40, 95% CI=1.08-1.81, P=.012). In cause-specific mortality analyses, hyperkyphotic posture was specifically associated with an increased rate of death due to atherosclerosis.

CONCLUSION

Older men and women with hyperkyphotic posture have higher mortality rates.

Asymptomatic atherosclerosis and myocardial infarction: risk modified by ability to adapt to stressful situations. Results from prospective cohort study "Men born in 1914", Malmo, Sweden

BACKGROUND

The purpose of this study was to investigate whether different behaviors in a stressful situation modify the risk of atherosclerosis in association with a myocardial infarction, cardiovascular mortality, and all-cause mortality. Many individuals have atherosclerotic changes in their arteries but may never experience any symptoms nor develop cardiovascular disease. A myocardial infarction is caused by a disruption of a vulnerable atherosclerotic plaque. The mechanisms that trigger these events are not fully understood, but among the proposed agents is psychological stress. A differential in risk exposure could be expected since individuals differ in their ability to cope with stressful situations.

MATERIAL/METHODS

In the prospective cohort study "Men born in 1914", atherosclerosis was noninvasively studied in the peripheral, carotid, and coronary arteries at a baseline examination in 1982/83. The serial Color Word Test, which is a semi-experimental way to assess how individuals adapt in a stressful situation, was administered at the same examination. Participants were followed-up regarding incidence of myocardial infarction and mortality until December 31 1996.

RESULTS

Atherosclerosis was associated with an increased risk of myocardial infarction (relative risk (RR) 2.96; 95% confidence interval (CI) 1.52 to 5.74) and cardiovascular mortality (RR 3.31; 95% CI 2.08 to 5.28) during follow-up only among the men who showed maladaptive behavior. No excess risk could be established in men with an adaptive behavior pattern.

CONCLUSIONS

The serial Color Word Test can assist in identifying men at high cardiovascular risk.

Percutaneous Intentional Extraluminal Recanalization in Patients with Chronic Critical Limb Ischemia

PURPOSE

To review percutaneous intentional extraluminal recanalization (PIER) for treatment of patients who are poor candidates for infrainguinal arterial bypass surgery (IABS) and have arterial occlusions and chronic critical limb ischemia (CCLI).

MATERIALS AND METHODS

Patients with CCLI who were poor candidates for IABS were candidates for PIER. PIER was performed to create continuous arterial flow to the foot for limb salvage. PIER was attempted in 40 patients (22 men, 18 women; median age, 69 years; age range, 44-87 years). Of these patients, 24 (60%) had diabetes, 17 (42%) had renal disease, and 26 (66%) had coronary artery disease. Wound healing was evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and amputation-free survival.

RESULTS

Fifty procedures were attempted in 44 limbs. Tissue loss was present in 40 (91%) limbs, and rest pain was present in four (9%); technical success occurred in 38 (86%). Thirty-seven (84%) of 44 limbs treated with PIER involved tibial vessels (tibial vessels only, n = 15; tibial and superior femoral artery [SFA] and/or popliteal vessels, n = 22). Sixty-six infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb) were successfully treated with PIER. Thirty-five (95%) of 37 tibial occlusions and 24 (83%) of 29 SFA and/or popliteal occlusions were longer than 10 cm. Median run-off scores were 5.3 (range, 3-8) and 6.6 (range, 3-9) for patients with tibial occlusions and SFA and/or popliteal occlusions, respectively, as scored with modified Rutherford weighting of run-off arteries. Median follow-up was 7.8 months (range, 1-24 months). Twelve months after PIER, Kaplan-Meier analysis showed limb salvage rate was 66%, survival rate was 71%, and amputation-free survival rate was 48% in these patients. The 30-day mortality rate was 2.5%. Major complications occurred in four (10%) patients, and minor complications occurred in an additional four (10%).

CONCLUSION

PIER is a useful percutaneous technique for limb salvage in patients with CCLI.

Impact of surgical era on outcomes of patients undergoing elective atherosclerotic ascending aortic aneurysm operations

OBJECTIVE

This retrospective study evaluates, if recent refinements in peri-operative management, have an impact on clinical outcome of patients undergoing elective repair of their ascending thoracic aorta.

METHODS

One hundred sixty five (n = 165) consecutive patients were operated during a 7 year period at our department. The cohort was divided in an early group I (from Jan 1997 to Dec 1999, n = 75) and a late group II (from Jan 2000 to Jan 2003, n = 90). The mean age was 60.9+/-13.1 years in group I versus 58.1+/-13.6 years in group II. In group I 50 patients (66.6%) underwent replacement of the ascending thoracic aorta alone, 17 patients (22.6%) received a composite graft, 8 patients (10.6%) had an additional aortic valve replacement and 14 patients (18.6%) needed concomitant coronary artery bypass grafting. In group II the procedures were as follows: interposition graft alone in 58 patients (64.4%), composite graft in 26 patients (28.8%), aortic valve replacement in 6 (6.6%) and CABG in 11 patients (12.2%).

RESULTS

Overall hospital mortality for the entire cohort was 6.6% (11/165) with no significant differences between the early and late group with 6.6% (5/75) and 6.6% (6/90), respectively, P = 0.985. Causes were multi organ failure in 63.3% (n = 7), stroke in 9% (n = 1) myocardial infarction in 18.1% (n = 2) and refractory bleeding in 9% (n = 1). Concomitant CABG, repair of the aortic valve and composite graft, emerged as independent risk factor for mortality in multivariate logistic regression analysis with P = 0.001. Differences, became apparent in ICU as well as hospital stay with a median ICU stay in group I of 7.1+/-12.9 days versus 4.4+/-6.8 days in group II, and median hospital stay of 16.7+/-5.3 days versus 9.5+/-8.4 days for group I and II, P < 0.05, respectively. Furthermore through the implementation of blood conservation techniques, a substantial reduction of transfusion requirements could be achieved (PRBC from 3.2+/-4 to 1.1+/-1.7 units, FFP 5.2+/-3 to 2.3+/-0.5 units, Platelets from 1.3+/-2 to 0.3+/-0.07 units).

CONCLUSIONS

Even with the implementation of various refinements in surgical and anaesthetic techniques, the current risk of mortality for ascending aortic aneurysm repair has not changed in the last 7 years. However, shortened ICU and hospital stays as well as diminished usage of blood derivates are mainly the result of a more aggressive and improved peri- and post-operative management due to economic considerations.

Long-term Cardiovascular Morbidity, Mortality, and Reintervention after Endovascular Treatment in Patients with Iliac Artery Disease: The Dutch Iliac Stent Trial Study

PURPOSE

To compare long-term cardiovascular morbidity and mortality and their determinants in a population initially treated with one of two endovascular treatment strategies for stenosis or short occlusion of an iliac artery.

MATERIALS AND METHODS

A total of 279 symptomatic patients with stenosis or short (< or =5-cm) occlusion of the iliac arteries were randomly assigned to undergo either primary stent placement or primary angioplasty followed by selective stent placement (in case of a residual mean pressure gradient greater than 10 mm Hg at the treated site). Follow-up data for all 279 patients were provided by the general practitioners and referring clinicians. Events of interest were arterial interventions, reinterventions in the iliac arteries, cardiovascular events (myocardial infarction, stroke, or extracranial bleeding), and death. Regression analysis was performed to identify predictors of reintervention and of cardiovascular morbidity and mortality.

RESULTS

The mean follow-up period was 5.6 years +/- 1.3 (+/- standard deviation). There were no significant differences between primary stent placement and primary angioplasty treatment groups in regard to number of reinterventions in the treated iliac arteries (33 [18%] of 187 segments and 33 [20%] of 169 segments, respectively) or in the ipsilateral legs (45 [25%] of 181 legs and 50 [30%] of 164 legs, respectively). The risk of other cardiovascular events in primary stent placement and primary angioplasty groups was 13% (18 of 143) and 11% (15 of 136), and the risk of death was 15% (21 of 143 patients) and 16% (22 of 136 patients), respectively. Sex, presence of critical ischemia, and length of stenosis were predictors of whether a patient would require iliac reintervention. Myocardial infarction, stroke, and vascular death were predicted on the basis of a patient's creatinine level and walking distance as tested at the time of inclusion.

CONCLUSION

No difference was found in the number of reinterventions between the two treatment groups 5 years after treatment. Patients with iliac artery disease are at high risk of cardiovascular morbidity and mortality.