The Framingham risk score and heart disease in nonalcoholic fatty liver disease

The accuracy of the Framingham risk score (FRS) in identifying patients with nonalcoholic fatty liver disease (NAFLD) at higher 10-year coronary heart disease (CHD) risk remains unknown. We aimed at evaluating both the baseline probability of CHD as predicted by the FRS and the actual long-term occurrence of CHD in NAFLD patients. This was a longitudinal study of a community-based cohort. A total of 309 NAFLD patients were followed up for 11.5 ± 4.1 years (total 3554 person-years). The overall calculated 10-year CHD risk was significantly higher in the NAFLD cohort than the absolute CHD risk predicted by the FRS for persons of the same age and gender (10.9 ± 9.3% vs. 9.9 ± 5.9%, respectively, P < 0.0001), and higher in men than women (12.6 ± 10.3% vs. 9.6 ± 8.1%, respectively, P = 0.006). New onset CHD occurred in 34 patients (11% vs. 10.9% predicted at baseline, P = NS), whereas 279 (89%) patients did not develop CHD. Using multivariable analysis, the FRS was the only variable significantly associated with new onset CHD (OR = 1.13, 95% CI = 1.05-1.21; P = 0.001). A FRS cut-point of 11 in women, and 6 in men had a sensitivity of 80% and 74%, respectively, and a negative predictive value of 97% and 93% respectively. NAFLD patients have a higher 10-year CHD risk than the general population of the same age and gender. The FRS accurately predicts the higher 10-year CHD risk in NAFLD patients, and helps identify those patients expected to derive the most benefit from early intervention to prevent CHD events.     

Predicted risk of coronary heart disease among persons with type 2 diabetes

BACKGROUND: Diabetes is an independent risk factor for the development of coronary heart disease (CHD). We evaluated whether there are racial/ethnic differences in predicted probability of CHD among persons with type 2 diabetes from the 1999-2002 National Health and Nutrition Examination Survey. METHODS: Adults with type 2 diabetes without cardiovascular disease (n=585) were evaluated; the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine was used to develop estimates of CHD and Framingham Risk Score (FRS) was used to assess the 10-year CHD risk. Chi-square tests and analysis of variance were used to assess differences between racial/ethnic groups in risk factors and predicted probability for CHD. RESULTS: Risk factors for CHD differed significantly amongst the three racial/ethnic groups. Whites had lower mean A1C concentrations (7.3%+/-0.2) than blacks (8.1%+/-0.2, P<0.05) or Mexican Americans (8.1%+/-0.2, P<0.05). Systolic blood pressure was higher in blacks compared with whites (P<0.05) and in Mexican American men compared with white men (P<0.05). Total cholesterol differed insignificantly by race/ethnicity whereas high-density lipoprotein cholesterol was higher in blacks compared with whites and Mexican Americans. Blacks had the greatest 5, 10, 15, and 20-year predicted risks of CHD among men, whereas whites had the greatest predicted risks among women. When evaluated by the FRS, the 10-year predicted risk of CHD was estimated to be 22.5% by UKPDS and 17% using FRS. CONCLUSIONS: UKPDS estimates of probability of CHD were similar across race/ethnicities, indicating that the risk factors tended to balance out. Despite differences in individual risk factors, the estimated risk for CHD was similar for all persons with diabetes.     

The joint associations of occupational, commuting, and leisure-time physical activity, and the Framingham risk score on the 10-year risk of coronary heart disease.

AIMS: To determine joint associations of different kinds of physical activity and the Framingham risk score (FRS) with the 10-year risk of coronary heart disease (CHD) events. METHODS AND RESULTS: Study cohorts included 41 053 Finnish participants aged 25-64 years without history of CHD and stroke. The multivariable-adjusted 10-year hazard ratios (HRs) of coronary events associated with low, moderate, and high occupational physical activity were 1.00, 0.66, and 0.74 (Ptrend<0.001) for men, and 1.00, 0.53, and 0.58 (Ptrend<0.001) for women, respectively. The multivariable-adjusted 10-year HRs of coronary events associated with low, moderate, and high leisure-time physical activity were 1.00, 0.97, and 0.66 (Ptrend=0.002) for men, and 1.00, 0.74, and 0.54 (Ptrend=0.003) for women, respectively. Active commuting had a significant inverse association with 10-year risk of coronary events in women only. The FRS predicted 10-year risk of coronary events among both men and women. The protective effects of occupational, commuting, or leisure-time physical activity were consistent in subjects with a very low (<6%), low (6-9%), intermediate (10-19%), or high (>or=20%) risk of the FRS. CONCLUSION: Moderate or high levels of occupational or leisure-time physical activity among both men and women, and daily walking or cycling to and from work among women are associated with a reduced 10-year risk of CHD events. These favourable effects of physical activity on CHD risk are observed at all levels of CHD risk based on FRS assessment.     

Changes in predicted cardiovascular disease risk after biliopancreatic diversion surgery in severely obese patients

Objective

To determine the impact of biliopancreatic diversion with duodenal switch (BPD-DS) surgery on cardiovascular risk profile and predicted cardiovascular risk in severely obese patients.

Materials/Methods

We compared 1-year follow-up anthropometric and metabolic profiles in severely obese who underwent BPD-DS (n = 73) with controls (severely obese without surgery) (n = 33). The 10-year predicted risk for coronary heart disease (CHD) was estimated using the Framingham risk-tool. We assigned 10-year and lifetime predicted risks to stratify subjects into 3 groups: 1) high short-term predicted risk (≥ 10% 10-year risk or diagnosed diabetes), 2) low short-term (< 10% 10-year risk)/low lifetime predicted risk or 3) low short-term/high lifetime predicted risk.

Results

During the follow-up period, body weight and body mass index decreased markedly in the surgical group (− 52.1 ± 1.9 kg and − 19.0 ± 0.6 kg/m² respectively, p < 0.001) vs. (− 0.7 ± 1.0 kg and − 0.3 ± 0.4 kg/m², p = 0.51). Weight loss in the surgical group was associated with a reduction in HbA_1C (6.2% vs. 5.1%), HOMA-IR (61.5 vs. 9.3), all lipoprotein levels, as well as blood pressure (p < 0.001). The 10-year CHD predicted risk decreased by 43% in women and 33% in men, whereas the estimated CHD risk in the non surgical group did not change. Before surgery, none of the women and only 18% of men showed low short-term/low lifetime predicted risk, whereas a significant proportion of subjects had high short-term predicted risk (36% in women and 12% in men). Following surgery, 52% of women and 55% of men have a low short-term/low lifetime predicted risk.

Conclusions

These results highlight the cardiovascular benefits of BPD-DS and suggest a positive impact on predicted CHD risk in severely obese patients. Long-term studies are needed to confirm our results and to ascertain the effects on CHD risk estimates after BPD-DS surgery.     

A coronary heart disease risk score based on patient-reported information

To develop a simple, patient self-report-based coronary heart disease (CHD) risk score for adults without previously diagnosed CHD (Personal Heart Early Assessment Risk Tool [HEART] score), the Atherosclerosis Risk In Communities (ARIC) Study, a prospective cohort of subjects aged 45 to 64 years at baseline, was used to develop a measure for 10-year risk of CHD (n = 14,343). Variables evaluated for inclusion were age, history of diabetes mellitus, history of hypercholesterolemia, history of hypertension, family history of CHD, smoking, physical activity, and body mass index. The 10-year risk of CHD events was defined as myocardial infarction, fatal CHD, or cardiac procedure. The new measure was compared with the Framingham Risk Score (FRS) and European Systematic Coronary Risk Evaluation (SCORE). The Personal HEART score for men included age, diabetes, hypertension, hypercholesterolemia, smoking, physical activity, and family history. In men, the area under the receiver-operator characteristic curve for predicting 10-year CHD for the Personal HEART score (0.65) was significantly different from that for the FRS (0.69, p = 0.03), but not for the European SCORE (0.62, p = 0.12). The Personal HEART score for women included age, diabetes, hypertension, hypercholesterolemia, smoking, and body mass index. The area under the curve for the Personal HEART score (0.79) for women was not significantly different from that for the FRS (0.81, p = 0.42) and performed better than the European SCORE (0.69, p = 0.01). In conclusion, the Personal HEART score identifies 10-year risk for CHD based on self-report data, is similar in predictive ability to the FRS and European SCORE, and has the potential for easy self-assessment.     

Impact of bariatric surgery--induced weight loss on heart rate variability

Obesity is associated with an increased risk of sudden death that may be due to abnormal cardiac vagal modulation reflected by reduced heart rate variability (HRV). Few studies have been conducted analyzing the effect of bariatric surgery-induced weight loss on HRV assessed by 24-hour Holter monitoring. The aim of this study was to assess weight loss effect after bariatric surgery on HRV and ventricular size and function. Ten morbidly obese patients, 6 women and 4 men aged 24 to 47 years, underwent bariatric surgery. Seven morbidly obese patients without active obesity treatment were used as controls. Twenty-four-hour Holter monitoring and echocardiogram were obtained before and at 6 to 12 months after surgery or at follow-up in control patients. Changes in minimal, maximal, and mean heart rate along with HRV during daytime and nighttime were compared before and after surgery. Baseline characteristics in the control group did not differ significantly from the treatment group. Average weight in the treatment group was 141 +/- 31 kg (mean +/- SD) at baseline and decreased to 101 +/- 18 kg at follow-up, corresponding to a body mass index of 52.3 +/- 7.6 kg/m(2) at baseline and 37.7 +/- 5.3 kg/m(2) at follow-up. There was a decrease in minimal heart rate (48 +/- 10 vs 40 +/- 6 beats per minute, P = .021) and mean heart rate (82 +/- 7 vs 66 +/- 10 beats per minute, P < .001) during the Holter monitoring. Spectral analysis showed a significant enhancement in HRV parameters (high- and low-frequency power) because there was an increase in the standard deviation of normal to normal R-R intervals (116 +/- 25 vs 174 +/- 56 milliseconds, P < .001), the standard deviation of the mean R-R intervals calculated over a 5-minute period (104 +/- 25 vs 148 +/- 45 milliseconds, P < .001), the square root of the mean of the squared differences between adjacent normal R-R intervals (25 +/- 8 vs 50 +/- 20 milliseconds, P < .001), and the percentage of differences between adjacent normal R-R intervals exceeding 50 milliseconds (5% +/- 5% vs 22% +/- 13%, P < .001). Echocardiographic measures remained unchanged when comparing the groups. Weight loss after bariatric surgery enhances HRV and decreases mean and minimal heart rate during Holter monitoring through a better cardiac parasympathetic modulation.     

Effects of weight loss after bariatric surgery on epicardial fat measured using echocardiography

Epicardial fat assessed using echocardiography is associated with abdominal visceral adipose tissue and cardiovascular risk factors. Because of its location, epicardial fat may directly affect the coronary vasculature and myocardium through local secretion of bioactive molecules. This study examines the effects of weight loss after bariatric surgery on epicardial adipose tissue in patients with severe obesity. Clinical data and echocardiograms of 23 patients with severe obesity who had echocardiograms recorded before and 8.3 +/- 3.7 months after undergoing bariatric surgery were retrospectively reviewed. Epicardial fat thickness was measured as the hypoechoic space anterior to the right ventricle in both the parasternal long- and short-axis views, and an average was obtained. At baseline, patients had increased epicardial fat compared with normal-weight controls matched for age, gender, and ethnicity (5.3 +/- 2.4 vs 3.0 +/- 1.1 mm, p <0. 001). Epicardial fat thickness was associated with the patient's initial weight in severely obese patients (r = 0.51, p = 0.011). Patients lost an average of 40 +/- 14 kg after surgery. Epicardial fat thickness decreased from 5.3 +/- 2.4 to 4.0 +/-1.6 mm (p = 0.001). Change in epicardial fat correlated with initial epicardial fat thickness measured using echocardiography (r = 0.71, p <0.001). In conclusion, epicardial fat thickness decreases in severely obese patients who have substantial weight loss after bariatric surgery. Measuring epicardial fat thickness using echocardiography may be useful to monitor visceral fat loss with weight reduction therapies.     

Coronary artery calcium scores and risk for cardiovascular events in women classified as "low risk" based on Framingham risk score: the multi-ethnic study of atherosclerosis (MESA)

OBJECTIVE: To assess coronary artery calcium (CAC) score and subsequent risk for coronary heart disease (CHD) and cardiovascular (CVD) events among asymptomatic women judged to be at low risk by the Framingham risk score (FRS), a common approach for determining 10-year absolute risk for CHD. Based on population survey data, 95% of American women are considered at low risk based on FRS. METHODS: The Multi-Ethnic Study of Atherosclerosis (MESA) included 3601 women aged 45 to 84 years at baseline. The CAC score was measured by coronary computed tomography. Cox proportional hazard models were used to examine the CHD and CVD risk associated with CAC score among women classified as "low risk" based on FRS. RESULTS: Excluding women with diabetes and those older than 79 years, 90% of women in MESA (mean +/- SD age, 60 +/- 9 years) were classified as "low risk" based on FRS. The prevalence of CAC (CAC score > 0) in this low-risk subset was 32% (n = 870). Compared with women with no detectable CAC, low-risk women with a CAC score greater than 0 were at increased risk for CHD (hazard ratio, 6.5; 95% confidence interval, 2.6-16.4) and CVD events (hazard ratio, 5.2; 95% confidence interval, 2.5-10.8). In addition, advanced CAC (CAC score > or = 300) was highly predictive of future CHD and CVD events compared with women with nondetectable CAC and identified a group of low-risk women with a 6.7% and 8.6% absolute CHD and CVD risk, respectively, over a 3.75-year period. CONCLUSIONS: The presence of CAC in women considered to be at low risk based on FRS was predictive of future CHD and CVD events. Advanced CAC identified a subset of low-risk women at higher risk based on current risk stratification strategies.     

The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery

CONTEXT: The polycystic ovary syndrome (PCOS) is frequently associated with obesity. However, there are very few data about PCOS in morbid obesity, especially with regard to its evolution after bariatric surgery. OBJECTIVE: The objective of this study was to evaluate the response of PCOS to the sustained and marked weight loss achieved by bariatric surgery in morbidly obese women. DESIGN: This was a longitudinal prospective nonrandomized evaluation. SETTINGS: The study was performed at an academic hospital. PATIENTS: Thirty-six consecutive premenopausal women submitted to bariatric surgery were screened for PCOS, which was present in 17. INTERVENTIONS: Bariatric surgery was performed. MAIN OUTCOME MEASURES: Hyperandrogenism, menstrual function, and insulin resistance were estimated before and at least 6 months after bariatric surgery in 12 patients with PCOS. RESULTS: Weight loss (41 +/- 9 kg after 12 +/- 5 months) was paralleled by decreases in the hirsutism score (from 9.5 +/- 6.8 to 4.9 +/- 4.2; P = 0.001), total (69 +/- 32 to 42 +/- 19 ng/dl; P < 0.02) and free testosterone (from 1.6 +/- 0.7 to 0.6 +/- 0.3 ng/dl; P < 0.005), androstenedione (from 4.1 +/- 1.5 to 3.0 +/- 0.9 ng/ml; P < 0.02), and dehydroepiandrosterone sulfate (from 2000 +/- 1125 to 1353 +/- 759 ng/ml; P < 0.005); amelioration of insulin resistance estimated by homeostasis model assessment (from 6.0 +/- 3.0 to 1.6 +/- 1.0; P < 0.001); and restoration of regular menstrual cycles and/or ovulation in all patients. CONCLUSIONS: The PCOS is a frequent finding in women with morbid obesity and may resolve after weight loss induced by bariatric surgery.     

Factors related to the development of diabetes during a 20-year follow-up. A prospective study in a homogeneous group of middle-aged men

BACKGROUND AND AIMS: To investigate factors associated with the development of type 2 diabetes mellitus (DM) during a 20-year follow-up in a homogeneous group of initially healthy middle-aged men with similar socioeconomic status. METHODS AND RESULTS: We studied 1802 executives and businessmen, born 1919-34, without type 2 DM at baseline and with coronary heart disease (CHD) risk factor measurements in 1974-75. Diagnosis of type 2 DM during the follow-up was based on entitlement to re-imbursement for type 2 DM medication during 1975-1995, retrieved from national registers, self-report of type 2 DM or fasting blood glucose (> or = 6.7 mmol/L) in 1985-1986 (72% of the initial cohort re-evaluated). During the follow-up (up to 1995) type 2 DM was diagnosed using the above criteria in 94 men (5.2%). At baseline, men who later developed type 2 DM smoked more (p = 0.01), and had significantly higher body mass index (BMI), systolic and diastolic blood pressure, pulse pressure, serum triglycerides, and fasting and one-hour blood glucose. In a subset of high-risk men, those who developed type 2 DM also showed signs of white-coat effect on blood pressure (p = 0.008). Already at baseline, the CHD risk score was 23% higher in future type 2 DM subjects (p = 0.008). Re-evaluation in 1985-1986 showed essentially similar results for risk factors, but in addition, LDL cholesterol without lipid lowering drugs was significantly lower (p = 0.0018) in type 2 DM subjects. During the follow-up, 23.4% of the men with type 2 DM developed CHD as compared to 13.4% of those without (p = 0.008). CONCLUSIONS: During a 20-year follow-up, several cardiovascular risk factors, including smoking, pulse pressure and the white-coat effect, predicted the development of type 2 DM in initially healthy middle-aged men. However, despite the higher incidence of CHD, development of type 2 DM was associated with lowered LDL cholesterol.     

Cardiovascular risk after bariatric surgery for obesity

Obese patients have an increased prevalence of cardiovascular (CV) risk factors, which improve with bariatric surgery, but whether bariatric surgery reduces long-term CV events remains ill defined. A systematic review of published research was conducted, and CV risk models were applied in a validation cohort previously published. A standardized MEDLINE search using terms associated with obesity, bariatric surgery, and CV risk factors identified 6 test studies. The validation cohort consisted of a population-based, historical cohort of 197 patients who underwent Roux-en-Y gastric bypass and 163 control patients, identified through the Rochester Epidemiology Project. Framingham and Prospective Cardiovascular Munster Heart Study (PROCAM) risk scores were applied to calculate 10-year CV risk. In the validation cohort, absolute 10-year Framingham risk score for CV events was lower at follow-up in the bariatric surgery group (7.0% to 3.5%, p <0.001) compared with controls (7.1% to 6.5%, p = 0.13), with an intergroup absolute difference in risk reduction of 3% (p <0.001). PROCAM risk in the bariatric surgery group decreased from 4.1% to 2.0% (p <0.001), whereas the control group exhibited only a modest decrease (4.4% to 3.8%, p = 0.08). Using mean data from the validation study, the trend and directionality in risk was similar in the Roux-en-Y group. The test studies confirmed the directionality of CV risk, with estimated relative risk reductions for bariatric surgery patients ranging from 18% to 79% using the Framingham risk score compared with 8% to 62% using the PROCAM risk score. In conclusion, bariatric surgery predicts long-term decreases in CV risk in obese patients.     

Cardiovascular risk factors after bariatric surgery: Do patients gain more than expected from their substantial weight loss?

BACKGROUND: While it has been established that even limited weight loss (5-10%) improves obesity-associated cardiovascular risk factors, it is not known if considerable weight loss following laparoscopic adjustable silicone gastric banding (LASGB) results in a cardiovascular risk profile that is comparable, worse, or even better than that of matched control subjects. METHODS: Cardiovascular risk factors were compared in three groups of 24 women each: an index group that had lost considerable weight following LASGB for morbid obesity (BMI>40 kg/m(2)), a control group with the same BMI that the index group achieved after weight loss, and a pre-weight loss group of women with a BMI above 40 kg/m(2). Anthropometric measures, fasting serum glucose, insulin, lipids, C-reactive protein, and homocysteine levels were determined and insulin sensitivity was estimated using a homeostasis model assessment index (HOMA-IR). RESULTS: After bariatric surgery, the index group had a BMI of 32.0+/-0.8 kg/m(2). This resulted in a significantly better cardiovascular risk profile than that of the pre-weight loss group (BMI 42.8+/-0.6 kg/m(2)). Unexpectedly, after weight loss, the index group had significantly lower systolic blood pressure, fasting serum insulin, and HOMA-IR than the BMI-matched (32.8+/-0.9 kg/m(2)) control group. Although not significant, diastolic blood pressure, LDL-cholesterol, and CRP levels were also lower. CONCLUSION: Considerable weight loss following bariatric surgery leads to a greater improvement in cardiovascular risk factors than might be expected from the weight loss.     

Elevated serum alanine aminotransferase activity and calculated risk of coronary heart disease in the United States

In the United States, elevated serum alanine aminotransferase (ALT) activity in the absence of viral hepatitis or excessive alcohol consumption is most commonly attributed to nonalcoholic fatty liver disease (NAFLD). NAFLD is related to predictors of coronary heart disease (CHD) such as insulin resistance and central obesity. We examined the association between elevated serum ALT activity and the 10-year risk of CHD as estimated using the Framingham risk score (FRS). We performed a cross-sectional analysis comparing participants in the Third National Health and Nutrition Examination Survey with normal and elevated ALT activity (>43 IU/L), examining the mean levels of FRS. Among participants without viral hepatitis or excessive alcohol consumption, those with elevated ALT activity (n=267) had a higher FRS than those with normal ALT activity (n=7259), both among men (mean difference in FRS 0.25, 95% CI 0.07-0.4; hazard ratio for CHD 1.28, 95% CI 1.07-1.5) and women (mean difference in FRS 0.76, 95% CI 0.4-1.1; hazard ratio for CHD 2.14, 95% CI 1.5-3.0). The ALT threshold for increased risk of CHD was higher in men (>43 IU/L) than in women (>30 IU/L). Elevated ALT activity was not associated with higher FRS among nonobese participants with viral hepatitis or excessive alcohol consumption. In condusion, individuals with elevated serum ALT activity in the absence of viral hepatitis or excessive alcohol consumption, most of whom have NAFLD, have an increased calculated risk of CHD. This association is more prominent in women.     

Orlistat and cardiovascular risk profile in hypertensive patients with metabolic syndrome: the ARCOS study

Weight loss improves metabolic abnormalities and reduces cardiovascular risk in obese hypertensive patients. To evaluate the impact of a sustained weight loss on coronary risk, 181 hypertensive patients with metabolic syndrome underwent to orlistat therapy, 120 mg, t.i.d., plus diet for 36 weeks. During therapy, Framingham risk scores (FRS) were calculated for determination of coronary heart disease risk in ten years. Body mass index decreased from 35.0 +/- 4.2 to 32.6 +/- 4.5 kg/m(2) (p< 0.0001) and waist circumference from 108.1 +/- 10.1 to 100.5 +/- 11.1 cm (p< 0.0001), at the end of the study period (week 36). Systolic and diastolic blood pressure showed reductions after the two first weeks, which were maintained up to the end of the study. A clear shift to the left in FRS distribution curve occurred at the end of the study, compared to baseline, indicating a reduction in coronary risk. Over all patients at risk, 49.2% moved to a lower risk category. A weight loss > 5% occurred in 64.6% of all patients, associated with improvement in glucose metabolism. Among those with abnormal glucose metabolism, 38 out 53 patients (71.7%) improved their glucose tolerance (p< 0.0005). In conclusion, long-term orlistat therapy helps to reduce and maintain a lower body weight, decreasing risk of coronary disease and improving glucose metabolism, thus protecting against type 2 diabetes.     

Long-term results after primary stenting of distal aortic stenosis.

PURPOSE: To review the long-term results of primary stent placement in the distal aorta above the bifurcation. METHODS: Fourteen patients (8 men; mean age 62 years, range 46-82) underwent primary stent implantation performed by an interdisciplinary radiosurgical team. In 10 patients, a long-term follow-up examination consisting of patient history, clinical examination, and duplex sonography was performed. The ankle-brachial index (ABI) for the posterior tibial artery was calculated on the basis of Doppler pressure measurements. RESULTS: The clinical success rate at the first follow-up examination (mean 2.9 months, range 2.1-4.4) was 100% (n = 14). The mean baseline ABI of 0.64 +/- 0.12 had risen to 1.02 +/- 0.10 (p < 0.0001). At midterm follow-up (mean 22.8 months, range 14-42) in 12 patients, the ABI was 0.96 +/- 0.12 (p < 0.0001 versus baseline). At a mean 86 months (range 51-119) after stent treatment, the ABI in 10 patients was 0.90 +/- 0.20 (p < 0.0001 versus baseline). Over the long term, the clinical success rate was 70%. Deterioration was due to the progression of atherosclerosis distal to the aorta; duplex sonography showed no aortic restenosis or occlusion. CONCLUSION: In view of the excellent long-term results in our small series, primary stent placement in focal abdominal aortic stenosis in properly selected patients is a durable treatment. In addition, the mortality and morbidity risks are markedly reduced compared with open surgery.     

Clinical impact of metabolic syndrome by modified NCEP-ATPIII criteria on carotid atherosclerosis in Japanese adults

AIM: The present study aimed to clarify the clinical impact of modified NCEP-ATP III criteria for metabolic syndrome (MS) and Framingham Risk Score (FRS) on carotid atherosclerosis in 615 Japanese adults (319 men and 296 women) including 307 with type 2 diabetes. METHODS: Waist circumference was the only component from the original NCEP-ATP III criteria based on Japanese criteria. The intima-medial thickness (IMT) and stiffness parameter beta of the carotid artery were measured by ultrasound. RESULTS: Both IMT and stiffness parameter beta were significantly increased with the number of coexisting components of MS, and higher in subjects with MS than in those without MS (all Ps < 0.0001). In a logistic regression analysis with each component of MS as independent factors, hyperglycemia and hypertension had the highest odds ratio for progressors of IMT and stiffness parameter beta , respectively. Univariate odds ratios of MS for both IMT and stiffness parameter beta were comparable with that of an increase of 10% in 10-year coronary heart disease (CHD) risk by FRS (CHD risk/ 10%) but inferior to CHD risk by FRS >/= 20%. CONCLUSION: The modified NCEP-ATP III criteria for MS revealed an additive predictive impact on carotid atherosclerosis but no superiority to FRS.     

Metabolic syndrome is associated with coronary artery calcium in asymptomatic white Brazilian men considered low-risk by Framingham risk score

The authors investigated whether the metabolic syndrome is associated with coronary artery calcium (CAC) independently of 10-year coronary heart disease risk assessment by Framingham risk scores (FRS) in asymptomatic white Brazilian men. In a group of 458 men (mean age 46+/-7 years), the 10-year coronary heart disease risk was 9%+/-8%, and the metabolic syndrome and CAC were present in 24% and 41% of the participants, respectively. Compared with those classified as low risk (<10% FRS; n=256), men with FRS of 10% or more had an odds ratio of 4.57 (95% confidence interval, 3.08-6.82; P<.0001) for the presence of any CAC. The prevalence of CAC increased monotonically with the increasing number of metabolic syndrome components (none=29%, 1 or 2=44%, and >or=3=51%, P=.002 for trend). The presence of the metabolic syndrome was associated with an increased risk of CAC: odds ratio, 1.94 (95% CI, 1.05-3.61); however, this finding was significant only in those individuals classified as low risk (FRS <10%). In conclusion, metabolic syndrome is associated with subclinical atherosclerosis in Brazilian participants considered at low risk according to FRS.     

Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery

OBJECTIVE: To determine the point prevalence of painful musculoskeletal (MSK) conditions in obese subjects before and after weight loss following bariatric surgery. DESIGN: Longitudinal, interventional, unblended.Subjects:Forty-eight obese subjects (47 women, one man, mean age 44+/-9 years; mean body mass index (BMI) 51+/-8 kg/m(2)) recruited from an academic medical center bariatric surgery program. MEASUREMENTS: Comorbid medical conditions; MSK findings; BMI; Western Ontario McMaster Osteoarthritis Index (WOMAC) for pain, stiffness and function; and SF-36 for quality of life. METHODS: Consecutive subjects were recruited from the University Hospitals of Cleveland Bariatric Surgery Program. Musculoskeletal signs and symptoms and non-MSK comorbid conditions were documented at baseline and at follow-up. Subjects completed the SF-36 and the WOMAC questionnaires. Analyses were carried out for each MSK site, fibromyalgia syndrome (FMS) and for the cumulative effect on the spine, upper and lower extremities. The impact of change in comorbid medical conditions, BMI, physical and mental health domains of the SF-36 on the WOMAC pain subscale score was evaluated. SF-36 outcomes were compared to normal published controls. RESULTS: Forty-eight subjects were available for baseline and a follow-up assessment 6-12 months after gastric bypass surgery. They lost an average of 41+/-15 kg and the mean BMI decreased from 51+/-8 to 36+/-7 kg/m(2). Baseline comorbid medical conditions were present in 96% before surgery and 23% after weight loss. There was an increased prevalence of painful MSK conditions at baseline compared to general population frequencies. Musculoskeletal complaints had been present in 100% of obese subjects before, and 23% after weight loss. The greatest improvements occurred in the cervical and lumbar spine, the foot and in FMS (decreased by 90, 83, 83 and 92%, respectively). Seventy-nine percent had upper extremity MSK conditions before and 40% after weight loss. Before surgery, 100% had lower extremity MSK conditions and only 37% did after weight loss. The WOMAC subscale and composite scores all improved significantly, as did the SF-36((R)). Change in BMI was the main factor impacting the WOMAC pain score. CONCLUSION: There was a higher frequency of multiple MSK complaints, including non-weight-bearing sites compared to historical controls, before surgery, which decreased significantly at most sites following weight loss and physical activity. These benefits may improve further, as weight loss may continue for up to 24 months. The benefits seen with weight loss indicate that prevention and treatment of obesity can improve MSK health and function.     

Insulin resistance syndrome predicts the risk of coronary heart disease and stroke in healthy middle-aged men: the 22-year follow-up results of the Helsinki Policemen Study

The interpretation of conventional multivariate analyses concerning the relation of insulin to the risk of atherosclerotic disease is complex because of correlations of insulin with other risk factors. Therefore, we applied factor analysis to study the clustering of risk factors in the baseline data of the Helsinki Policemen Study (970 healthy men aged 34 to 64 years) and investigated whether these clusterings predict coronary heart disease (CHD) and stroke risk. Areas under the glucose and insulin response curves (AUC glucose and AUC insulin) were used to reflect glucose and insulin levels during oral glucose tolerance tests. During the 22-year follow-up, 164 men had a CHD event, and 70 men had a stroke. Factor analysis of 10 risk factor variables produced 3 underlying factors: insulin resistance factor (comprising body mass index, subscapular skinfold, AUC insulin, AUC glucose, maximal O(2) uptake, mean blood pressure, and triglycerides), lipid factor (cholesterol and triglycerides), and lifestyle factor (physical activity and smoking). In multivariate Cox models, the age-adjusted hazard ratio for insulin resistance factor during the 22-year follow-up was 1.28 (95% CI 1.10 to 1.50) with regard to CHD risk and 1.64 (95% CI 1.29 to 2.08) with regard to stroke risk. Lipid factor predicted the risk of CHD but not that of stroke, and lifestyle factor predicted a reduced CHD risk. Factor analysis including only 6 risk factor variables proposed to be central components of insulin resistance syndrome (body mass index, subscapular skinfold, AUC insulin, AUC glucose, mean blood pressure, and triglycerides) produced only a single insulin resistance factor that predicted the risk of CHD and stroke independently of other risk factors.     

Clinical and sequential angiographic follow-up six months and 10 years after successful percutaneous transluminal coronary angioplasty

Sequential angiographic follow-up is needed for interpreting coronary events that occur after successful percutaneous translumial coronary angioplasty (PTCA). One hundred eight consecutive patients who had undergone successful dilatation were followed for 10 years, and quantitative sequential angiograms were recorded at 6 months (n = 101) and 10 years (n = 68). The 10-year event rate was: 5.8 +/- 2.4% for cardiac death, 9.7 +/- 3.3% for Q-wave acute myocardial infarction, 18.3 +/- 4.5% for additional surgery, and 22.4 +/- 4.9% for repeated angioplasty. Using Cox's proportional-hazards regression, multivessel coronary artery disease (CAD) (RR 5.6; 95% confidence intervals [CI] 1.2 to 24.7; p = 0.02), restenosis within 6 months (RR 7.8; 95% CI 3.1 to 20.0; p = 0.0001), and CAD progression over 10 years (RR 10.6; 95% CI 1.3 to 87.1; p = 0.004) were the strongest predictors of all-cause death, repeated PTCA, and additional surgery, respectively, after controlling for age and coronary risk factors. The minimal luminal diameter of 48 narrowings with complete sequential angiographic follow-up and without restenosis remained stable from 6 months (2.13 +/- 0.60 mm) to 10 years (2.18 +/- 0.61 mm). Disease progression was similar in nondilated arteries and dilated arteries (32% vs 30%). The 10-year risk of coronary events was higher in patients with baseline multivessel CAD than in those with 1-vessel CAD because of more frequent progression of CAD (RR 3.8; 95% CI 1.6 to 6.8; p = 0.001). Thus, early cardiac events after successful PTCA were related to restenosis, and late events to CAD progression. Nevertheless, after the restenosis period, the target lesion remained stable for the next 10 years. Coronary disease progression was not related to the angioplasty procedure.