Determinants of a positive response to carotid sinus massage and head-up tilt testing

BackgroundOrthostatic hypotension (OH) and carotid sinus hypersensitivity (CSH) are common causes of syncope in older people. The aim of this study was to determine if patient's age, sex and presenting symptoms influence the result of carotid sinus massage and head-up tilt testing.MethodsRetrospective analysis of the database and reports was carried out between 1995 and 2006 at a tertiary referral centre. Patient's age, sex, presenting symptoms and test result were examined. Presenting symptoms were classified as syncope, falls or dizzy spells.ResultsOf the 1583 tests reported, OH was present in 402 patients (25.4%), of whom 175 (11.1%) were symptomatic. 188 of 1464 (12.8%) patients undergoing carotid sinus massage had evidence of CSH, of which 156 were symptomatic.Male patients were significantly more likely to have symptomatic CSH than female patients (odds ratio 2.28, 95% CI 1.54 to 3.04, p < 0.01).There were non-significant trends to increased diagnosis of symptomatic OH with increasing age, male sex and referral with syncope. There were non-significant trends to increased diagnosis of symptomatic CSH with increasing age and referral with syncope.ConclusionMale sex, increasing age and being referred with syncope were all associated with an increased likelihood of receiving a diagnosis of either OH or CSH. The overall prevalence of CSH was lower than in previous studies, which may reflect different patient populations.     

Predicting falls among Egyptian nursing home residents: A 1-year longitudinal study

Background/PurposeFalls and their related complications are serious health problems among the institutionalized older population. This study aimed to evaluate the incidence of falls and the risk factors among nursing home residents in Cairo, Egypt.MethodsA one-year prospective cohort study was done in three nursing homes in Cairo. Overall, 84 residents aged over 60 years participated in this study. Baseline demographic characteristics and results of comprehensive geriatric assessments, e.g. cognition, depression, functional and nutritional status, previous falls, fear of falling, assistive device use, and assessment by the timed up-and-go test (TUG) test were collected. All falling accidents were recorded by the nursing home staff during the study period.ResultsDuring the study period, 163 incident falls (1940 falls/ 1000 resident-years) were identified in 53 fallers (631 fallers/1000 resident-years) were recorded. On average, fallers may fall twice a year (mean ± SD 2.0 ± 2.1 episodes, range 1–6). Compared to nonfallers, fallers were older, more likely to have hadprevious falls, fear of falling, frailty, impaired instrumental activities of daily living, poor cognitive status, malnutrition or its risk, assistive device use, and slower TUG. The most sensitive (86.8%) and specific (90.3%) predictor for falls in this study was TUG >14 seconds.ConclusionSixty-three percent of Egyptian nursing home residents may fall during one year follow-up with the incidence of 1019 falls/1000 resident-years. The most important predictive factor for falls in this study was the TUG >14 seconds.     

Recurrent falls and its risk factors among older men living in the veterans retirement communities: A cross-sectional study

AimTo evaluate the prevalence of recurrent falls and their risk factors among older men living in the Veterans Homes in Taiwan.MethodsThis cross-sectional study enrolled 871 residents and all participants received the comprehensive geriatric assessment, including Barthel Index, Mini-Mental Status Examination (MMSE), Geriatric Depression Scale-5 questions (GDS-5), Mini-Nutrition Assessment Short Form (MNA-SF), the status of urinary incontinence, stool incontinence, polypharmacy, past history of falls, multimorbidity, and medication history.ResultsOverall, 871 subjects (mean age: 85.5 ± 5.2 years, all males) participated in this study, whereas 222(25.5%) of them had experienced falls in the past year, and 91 were recurrent fallers. Comparisons between non-fallers, single fallers and recurrent fallers disclosed that they were significantly different in the following characteristics: diabetes mellitus, chronic kidney disease, coronary artery disease, Charlson Comorbidity Index (CCI), Barthel Index, GDS-5, MNA-SF, polypharmacy, use of hypnotics, urinary incontinence, and stool incontinence (P for trend all <0.05). Multiple regression analysis identified that GDS-5 was significantly associated with single falls and recurrent falls (OR 1.256, 95% CI 1.094–1.441, P = 0.001 for single fallers; OR 1.480, 95% CI 1.269–1.727, P < 0.001 for recurrent fallers). Besides, urinary incontinence was the independently associated with recurrent fallers only (OR 2.369, 95% CI 1.449–3.817, P < 0.001), but not single fallers.ConclusionUrinary incontinence and depressive symptoms were independent associated factors for falls among older men living in the retirement communities. However, urinary incontinence was associated with recurrent falls, but not single falls. Intervention study is needed to reduce recurrent falls through management of urinary incontinence.     

Reducing falls among older people in general practice: The ProAct65+ exercise intervention trial

BackgroundFalls are common in the older UK population and associated costs to the NHS are high. Systematic reviews suggest that home exercise and group-based exercise interventions, which focus on progressively challenging balance and increasing strength, can reduce up to 42% of falls in those with a history of falls. The evidence is less clear for those older adults who are currently at low risk of falls.AimProAct65+, a large, cluster-randomised, controlled trial, investigated the effectiveness of a home exercise programme (Otago Exercise Programme (OEP)) and a group-based exercise programme (Falls Management Exercise (FaME)) compared to usual care (UC) at increasing moderate to vigorous physical activity (MVPA). This paper examines the trial’s secondary outcomes; the effectiveness of the interventions at reducing falls and falls-related injuries.Setting & participants1256 community-dwelling older adults (aged 65 + ) were recruited through GP practices in two sites (London and Nottingham). Frequent fallers (≥3 falls in last year) and those with unstable medical conditions were excluded, as were those already reaching the UK Government recommended levels of physical activity (PA) for health.MethodsBaseline assessment (including assessment of health, function and previous falls) occurred before randomisation; the intervention period lasted 24 weeks and there was an immediate post-intervention assessment; participants were followed up every six months for 24 months. Falls data were analysed using negative binomial modelling.Outcome measuresFalls data were collected prospectively during the intervention period by 4-weekly diaries (6 in total). Falls recall was recorded at the 3-monthly follow-ups for a total of 24 months. Balance was measured at baseline and at the end of the intervention period using the Timed Up & Go and Functional Reach tests. Balance confidence (CONFbal), falls risk (FRAT) and falls self-efficacy (FES-I) were measured by questionnaire at baseline and at all subsequent assessment points.Results294 participants (24%) reported one or two falls in the previous year. There was no increase in falls in either exercise group compared to UC during the intervention period (resulting from increased exposure to risk). The FaME arm experienced a significant reduction in injurious falls compared to UC (incidence rate ratio (IRR) 0.55, 95% CI 0.31, 0.96; p = 0.04) and this continued during the 12 months after the end of the intervention (IRR 0.73, 95% CI 0.54, 0.99; p = 0.05). There was also a significant reduction in the incidence of all falls (injurious and non-injurious) in the FaME arm compared with UC (IRR 0.74, 95% CI 0.55, 0.99; p = 0.04) in the 12 month period following the cessation of the intervention. There was a non-significant reduction in the incidence of all falls in the OEP arm compared with UC (IRR 0.76, 95% CI 0.53, 1.09; p = 0.14) in the 12 months following the cessation of the intervention. The effects on falls did not persist at the 24 months assessment in either exercise arm. However, when those in the FaME group who continued to achieve 150 min of MVPA per week into the second post-intervention year were compared to those in the FaME group who did not maintain their physical activity, there was a significant reduction in falls incidence (IRR = 0.49, 95% CI 0.30, 0.79; p = 0.004). CONFbal was significantly improved at 12 months post intervention in both intervention arms compared with UC. There were no significant changes in any of the functional balance measures, FES-I or FRAT, between baseline and the end of the intervention period.ConclusionCommunity-dwelling older adults who joined an exercise intervention (FaME) aimed at increasing MVPA did not fall more during the intervention period, fell less and had fewer injurious falls in the 12 months after cessation of the intervention. However, 24 months after cessation of exercise, the beneficial effects of FaME on falls reduction ceased, except in those who maintained higher levels of MVPA. OEP exercise appears less effective at reducing falls in this functionally more able population of older adults.     

Blunted baroreflex sensitivity: An underestimated cause of falls in the elderly?

BackgroundAutonomic nervous system disturbance and cardiovascular disorders may be underestimated causes of falls. Heart rate turbulence (HRT), heart rate variability (HRV) and QT dynamicity parameters are noninvasive cardiac autonomic activity markers. The aim of this study was to evaluate autonomic cardiovascular markers in falling older adults.MethodsThis was a case-control study conducted at a geriatric medicine outpatient clinic of a university hospital. Study group consisted of 33 older adults who had falls in the last 12 months and the control group included 31 subjects who had never experienced falls. The patients in the study group were examined with 24-hour Holter electrocardiogram (ECG) and carotid sinus massage was done under monitorization. The 24-hour Holter ECG data were recorded and assessed with the ELATEC software. HRV, QT dynamicity and HRT parameters were analysed.ResultsThirty-three faller and 31 non-faller patients were examined in this study. Age and gender were similar between groups. All patients and control subjects had normal ejection fraction. Carotid sinus massage was done to the patients in the study group and three of 33 were positive (9.09%). There was no significant difference in HRV and QT dynamicity parameters between groups. Both HRT onset (2.51 ± 1.48 vs. 7.29 ± 3.28 P < 0.001) and turbulence slope (0.15 ± 1.10 vs. ?0.73 ± 1.89; P = 0.031) were significantly different between the groups.ConclusionElderly subjects with recent falls have significantly worse HRT parameters than matched non-falling counterparts. Blunted baroreflex sensitivity and impaired cardiac autonomic function can be an important reason for falls in the geriatric age group.     

Atherosclerosis and arterial stiffness in obstructive sleep apnea--a cardiovascular magnetic resonance study

ObjectiveObstructive sleep apnoea (OSA) has been linked to cardiovascular risk factors, such as hypertension, and clinical cardiovascular endpoints. Our aim was to assess whether OSA is independently associated with atherosclerosis and vascular dysfunction as assessed by cardiovascular magnetic resonance (CMR).Methods58 patients with OSA and 39 matched control subjects without OSA underwent CMR of the aorta and carotid arteries. Carotid and aortic wall thickness and aortic distensibility were measured. Multi-weighted, high resolution CMR imaging was used for carotid atheroma characterization according to the American Heart Association (AHA) atheroma classification, modified for CMR.ResultsCarotid [1.47 ± 0.03 mm vs. 1.26 ± 0.05 mm, (P < 0.01)] and aortic wall thickness [2.95 ± 0.09 mm vs. 2.05 ± 0.07 mm, (P < 0.001)] were increased in patients with OSA compared to controls. Aortic distensibility was decreased in patients with OSA [3.62 ± 0.3 vs. 4.75 ± 0.2 mmHg^?1 × 10^?3, (P < 0.05)]. Prevalence of carotid plaque, average carotid atheroma class, and prevalence of high risk features of carotid atheroma were increased in patients with OSA (P < 0.005 for all). On multivariate analysis, Oxygen desaturation index (ODI) emerged as an independent predictor of carotid and aortic wall thickness, but not of aortic stiffness.ConclusionsOSA is associated with increased carotid and aortic atheroma burden and with advanced, high risk carotid atherosclerotic plaques, but not with aortic stiffening.     

Recently postmenopausal women have the same prevalence of subclinical carotid atherosclerosis as age and traditional risk factor matched men

ObjectiveTo compare the prevalence of subclinical atherosclerosis between postmenopausal women and men of similar age early after the onset of menopause.MethodsIn the first part of this cross-sectional study 186 non-diabetic young postmenopausal women (n = 101, menopausal age ≤10 years) and men (n = 85) aged 40–60 years without overt CVD were consecutively recruited from the outpatients clinics of an academic hospital. Subclinical carotid atherosclerosis was assessed by high-resolution ultrasonography. The presence of carotid atherosclerosis was defined as either increased carotid intima-media thickness (IMT > 0.9 mm) and/or the presence of plaques. In the second part, 1:1 matching for age and traditional risk factors (hyperlipidemia, smoking, hypertension and BMI) was performed between men and women of this cohort resulting in a matched sub-sample of 76 subjects.ResultsBy multivariate analysis, gender was not an independent determinant of any measure of carotid atherosclerosis. In the matched sub-sample, carotid IMT and the number of segments with atherosclerosis did not significantly differ between women and men (0.734 ± 0.119 mm and 1.47 ± 1.6 versus 0.717 ± 0.138 mm and 1.47 ± 1.5, p = 0.575 and p = 0.999, respectively). Also, the prevalence of increased IMT (60.5% in both genders), carotid plaques and subclinical atherosclerosis (31.6% and 63.2% versus 28.9% and 65.8%, p = 0.803 and p = 0.811, respectively) was similar between men and women.ConclusionsThe prevalence and severity of carotid atherosclerosis was similar between men and young postmenopausal women matched for traditional risk factors. Whether these women may be better risk stratified irrespective of gender should be further assessed in prospective studies.     

The Physiological Profile Assessment: Clinical validity of the postural sway measure and comparison of impairments by age

BackgroundThe Physiological Profile Assessment (PPA) assesses falls risk in older adults by measuring impairments most associated with multiple falls. To date, no study has investigated the change in PPA impairment profile with age.ObjectiveTo describe impairment profiles, by age and ability to complete the postural sway measure, of older adults fallers.ParticipantsWe note that 885 older adults referred to multidisciplinary falls clinics located within two inner London boroughs (UK).MethodsAnonymised data was extracted from the PPA falls risk database. For comparisons, data was grouped by gender, age, and ability to complete the postural Sway test.ResultsThere were significant differences between all age groups in PPA falls risk, edge contrast sensitivity, quadriceps strength (Quad), postural sway and reported falls within the previous year (P < 0.01). The oldest age group (90+) had the highest PPA falls risk (P < 0.01), yet reported significantly less falls than the youngest age group (60 to 69; P < 0.05). There was significant variability in test results, with younger age groups displaying greater variability across PPA measures, and older age groups displaying more consistency (P < 0.05); 15.1% (n = 134) of patients that were able to perform the postural sway measure received a higher risk score for this test than those unable to complete the task.ConclusionsGreater variability in younger age groups indicates that specific impairments may provide the cause of falls, whereas widespread global reduction in function and frailty may provide the cause for falls in the older age groups. The postural sway scoring does not reflect ability to perform the test.     

Neurally mediated syncope and unexplained or nonaccidental falls in the elderly

Falls and syncope are among the leading causes for which older patients seek hospital admissions. The prevalence of unexplained or nonaccidental falls is high in this group. The clinical spectrum of falls and syncope has been shown to overlap significantly in the elderly. Carotid sinus syndrome and vasovagal syncope, the two common examples of neurally mediated syncope (NMS), have been increasingly recognised as important attributable causes for unexplained falls and syncope. However, in clinical practice NMS is not widely investigated as a cause of fall and is likely to be underdiagnosed.     

Phenotype of sarcopenic obesity in older individuals with a history of falling

BackgroundAlthough sarcopenic obesity is associated with disability in middle-aged community-dwelling individuals, the phenotype of sarcopenic obesity in people 65 and older, especially those with a history of falls, remain unknown. To fill this knowledge gap, the goal of this study was to obtain a comprehensive phenotype of sarcopenic obesity in this high-risk population.MethodsCross-sectional study of 680 subjects (mean age = 79 ± 9, 65% female) assessed between 2009 and 2013 at the Falls and Fractures Clinic, Nepean Hospital (Penrith, Australia). The assessment included a comprehensive examination, posturography, gait velocity, grip strength, bone densitometry and body composition by DXA, and blood tests for biochemical status. Patients were divided into four groups based on DXA and clinical criteria: 1) sarcopenic obese; 2) non-sarcopenic obese; 3) sarcopenic and; 4) non-sarcopenic/non-obese. The difference between groups was assessed by one-way ANOVA, chi-square analysis, and multivariable linear regression.ResultsSarcopenic obese subjects were older (81.1 ± 7.3), mostly female and more likely to have lower bone mineral density, lower grip strength, slower gait velocity, and poor balance. Sarcopenic obese individuals also showed significantly higher parathyroid hormone and lower vitamin D.ConclusionsWe identified a particular set of clinical and biochemical characteristics in our subgroup of sarcopenic obese older fallers. Identification of these particular characteristics in the clinical setting is essential in order to prevent poor outcomes in this high-risk population.     

Midodrine hydrochloride in the management of older adults with neurocardiogenic syncope and orthostatic hypotension: A prospective observational study

BackgroundMidodrine hydrochloride has been shown to be effective in the management of syncope in adults with reflex syncope, orthostatic hypotension and orthostatic intolerance syndromes; however, its use, tolerability and side effects have not been monitored specifically in the older old, particularly not over a prolonged period of time.ObjectivesWe aim to document changes in patients’ symptoms, drug dosages employed and adverse drug reactions to midodrine therapy in older adults with a diagnosis of neurocardiogenic syncope assessed and managed at a specialist falls and syncope outpatient unit.MethodsProspective observational study of 135 consecutive subjects with a mean age of 84 years started on midodrine after comprehensive geriatric assessment, structured falls evaluation, positive tilt table testing (TT) or a mixed/vasodepressor response to carotid sinus massage (CSM).ResultsNinety-seven individuals (71%) commenced on midodrine treatment and followed up for a mean of 2.7 years, reported either significant improvement or abolition of symptoms across all TT/CSM diagnosis. Forty-nine percent of individuals achieved sustained clinical improvement after an initial dosage of 2.5 mg three times per day and only four patients required dosages above 7.5 mg three times daily. One hundred and one individuals (75%) continued midodrine until the end of the monitoring period, and although 19 subjects developed adverse drug reactions, most were minor and only six resulted in drug withdrawal.ConclusionsMidodrine hydrochloride appears to be safe and well tolerated in older adults and should be considered, independent of age, in the management of patients with symptomatic orthostatic hypotension, vasovagal syncope and vasodepressor or mixed carotid sinus syndrome. This observation requires further confirmation by larger multicenter randomised control studies.     

Coronary calcification is more predictive of carotid intimal medial thickness in black compared to white middle aged men

BackgroundRace-specific data for the association between coronary artery calcification (CAC) and carotid intimal medial thickness (IMT) are limited. We sought to compare black-white specific associations of these two measures.MethodsWe conducted a population-based study of 379 randomly selected men aged 40–49 years (84 black and 295 white) from Allegheny County, US (2004–2006). Agatston CAC score was evaluated by electron-beam tomography and carotid IMT was evaluated by ultrasonography.ResultsCompared to white men, black men had similar prevalence of CAC (p = 0.56) and higher total carotid IMT (p < 0.001). In black and white men, CAC score had significant positive correlations with total carotid IMT (r = 0.47 and r = 0.24, respectively, p < 0.001 for both) as well as the IMT for the common carotid artery (CCA), internal carotid artery and carotid bulb. The associations of CAC with total and CCA IMT were significantly stronger in black (β = 0.07 and β = 0.05, respectively) than white men (β = 0.03 and β = 0.01, respectively) after adjustment for traditional coronary risk factors (p = 0.046 and p = 0.036, respectively).ConclusionsIn black and white middle aged men, CAC score had significant positive correlations with total and segmental carotid IMT. CAC was more predictive of total and CCA IMT in black than white men independent of coronary risk factors.     

Single polymorphism nucleotide rs1333049 on chromosome 9p21 is associated with carotid plaques but not with common carotid intima-media thickness in older adults. A combined analysis of the Three-City and the EVA studies

ObjectivesTo address the relationship of rs1333049, the 9p21 variant showing the strongest association with coronary heart disease (CHD), with carotid plaques and plaque-free common carotid artery intima-media thickness (CCA-IMT) in older adults from 2 French population-based cohorts.MethodsWe genotyped for rs1333049, 4097 CHD-free participants including 3191 aged 65–86 years from the Three-City (3C) Study and 906 aged 59–71 years from the Vascular Aging Study (EVA). Plaque-free mean CCA-IMT and the presence of carotid plaques were assessed.ResultsIn multivariate analysis, each C allele copy of rs1333049 was associated with baseline carotid plaques (odds ratio (OR) = 1.24; 95% confidence interval (CI) = 1.13–1.36; p < 0.001) but not with baseline CCA-IMT (p = 0.19). Among the EVA participants, the C allele was associated with 4-year plaques progression (p = 0.04) but not with CCA-IMT progression.ConclusionThe chromosome 9p21 locus might influence CHD risk through carotid plaques development.     

The circumstances,orientations, and impact locations of falls in community-dwelling older women

ObjectiveWe sought to characterize the circumstances, orientations, and impact locations of falls in community-dwelling, ambulatory, older women.MethodsFor this longitudinal, observational study, 125 community-dwelling women age ≥ 65 years were recruited. Over 12-months of follow-up, fall details were recorded using twice-monthly questionnaires.ResultsMore than half (59%) of participants fell, with 30% of participants falling more than once (fall rate = 1.3 falls per person-year). Slips (22%) and trips (33%) accounted for the majority of falls. Approximately 44% of falls were forward in direction, while backward falls accounted for 41% of falls. About a third of all falls were reported to have lateral (sideways) motion. Subjects reported taking a protective step in response to 82% of forward falls and 37% of backward falls. Of falls reporting lateral motion, a protective step was attempted in 70% of accounts. Common impact locations included the hip/pelvis (47% of falls) and the hand/wrist (27%). Backwards falls were most commonly reported with slips and when changing direction, and increased the risk of hip/pelvis impact (OR = 12.6; 95% CI: 4.7–33.8). Forward falls were most commonly reported with trips and while hurrying, and increased the risk of impact to the hand/wrist (OR = 2.6; 95% CI: 1.2–5.9).ConclusionFalls in older ambulatory women occur more frequently than previously reported, with the fall circumstance and direction dictating impact to common fracture locations. Stepping was a common protective recovery strategy and that may serve as an appropriate focus of interventions to reduce falls in this high risk population.     

Slow heart rate recovery after exercise is associated with carotid atherosclerosis

ObjectiveSlow heart rate recovery (HRR) after exercise is an estimate of impaired parasympathetic tone and predictor of all-cause and cardiovascular mortality. Carotid atherosclerosis is associated with high risk of developing coronary heart disease (CHD) and stroke. We tested the hypothesis that slow HRR is associated with carotid atherosclerosis in a cross-sectional study of 12,712 middle-aged men (age 49.1 ± 8.9 years).MethodsCarotid atherosclerosis was measured using B-mode ultrasonography and defined as stenosis >25% and/or intima–media thickness >1.2 mm. HRR was calculated as the difference between peak heart rate during a graded exercise treadmill test and heart rate 2 min after cessation of exercise.ResultsThe prevalence of carotid atherosclerosis was 8.4%. The prevalence of atherosclerosis was significantly higher among subjects in the lowest (<44 bpm) versus the highest (>61 bpm) quartile of HRR (14.4% versus 4.1%, p < 0.001). In multivariable logistic regression models adjusted for established CHD risk factors, inflammatory markers, and exercise capacity, subjects in the lowest quartile of HRR (<44 bpm) were 1.50 times (95% CI: 1.13–2.00) more likely to have carotid atherosclerosis than subjects in the highest quartile (HRR >61 bpm).ConclusionsSlow heart rate recovery after exercise, an index of decreased parasympathetic activity, is associated with carotid atherosclerosis independent of established risk factors in middle-age men.     

Anemia-prevalence and risk factors in pregnancy

BackgroundTo assess the prevalence of decreased iron stores and anemia in pregnant women. To determine whether the risk factors: socio-demographic background, age, BMI, and parity are associated with abnormal hemoglobin concentrations and/or abnormal iron status.MethodsA longitudinal study was carried out at the Department of Obstetrics, University Hospital of Zurich to establish the risk factors and prevalence of the decreased iron stores and anemia in early pregnancy. In order to determine the hematological parameters and ferritin levels, venous blood samples of 470 singleton pregnancies between 16 and 20 pregnancy weeks were collected. According to hemoglobin and iron status, the patients were divided into four groups: patients with iron deficiency anemia, patients with decreased iron stores, patients with anemia for other reasons and normal patients. The determinants socio-demographic background, age, BMI and parity were explored using multiple logistic regression analysis.ResultsThe prevalence of decreased iron stores (ferritin < 20 μg/l) was observed in 31.8% of subjects (149/470) and anemia (Hb < 110 g/l) in 18.5% (87/470). The prevalence of iron deficiency anemia was higher among women coming from former Yugoslavia and developing countries (p = 0.004 and p = 0.012). In patients coming from developing countries, a significant increase of anemia for other reasons was observed (p = 0.027) and in patients older than 30 years, a significant increase of decreased iron stores (p = 0.018).ConclusionsIn our study population with low parity, the prevalence of abnormal hemoglobin and abnormal iron status was 50.2% (236/470), and socio-demographic background was the most important risk factor of anemia.     

Age and Gender Differences in Quality of Care and Outcomes for Patients with ST-segment Elevation Myocardial Infarction

BackgroundYoung patients (aged ≤ 45 years) presenting with ST-segment elevation myocardial infarction present unique challenges. The quality of care and in-hospital outcomes may differ from their older counterparts.MethodsA total of 31,544 patients presenting with ST-segment elevation myocardial infarction and enrolled in the American Heart Association's Get With the Guidelines Coronary Artery Disease registry were analyzed. The cohort was divided into those aged 45 years or less and those aged more than 45 years.ResultsYoung patients accounted for 10.3% of all ST-segment elevation myocardial infarction cases. Compared with older patients, younger patients were less likely to have traditional cardiovascular risk factors and had similar or better quality/performance measures with lower in-hospital mortality (unadjusted rate 1.6 vs 6.5%, P <.0001; adjusted odds ratio [OR], 0.37; 95% confidence interval [CI], 0.29-0.46). Time trend analysis (2002-2008) suggested an increase over time in the “all or none” composite performance measure in both the younger and older patients (68%-97% and 69%-96%, respectively). However, there was significantly lower quality of care and worse outcomes in women (vs men) and in the very young (≤35 vs 36-45 years). Significant interaction was seen between age and gender for in-hospital death, such that the gender difference was greater in the younger cohort. Similar interaction was seen for door-to-thrombolytic time such that the gender delay was greater in the younger cohort (women:men ratio of means = 1.73, 95% CI, 1.21-2.45 [younger] vs 1.08, 95% CI, 1.00-1.18 [older]; P_interaction = .0031).ConclusionYoung patients aged 45 years or less presenting with ST-segment elevation myocardial infarction overall had similar quality of care and in-hospital outcomes as older counterparts. However, quality of care was significantly lower and mortality was higher in young women (vs young men) and the very young (≤35 vs 36-45 years).     

Usefulness of lipoprotein ratios in assessing carotid atherosclerosis in Japanese type 2 diabetic patients

ObjectiveIt is indicated that total/HDL cholesterol and LDL/HDL cholesterol ratios have more predictive power for cardiovascular disease compared to classic lipid parameters. However, there have been few reports about the usefulness of these indices for the assessment of early stage atherosclerosis in Japanese type 2 diabetic subjects.MethodsWe examined the relation between various lipid parameters and carotid atherosclerosis in 934 type 2 diabetic subjects without apparent atherosclerotic diseases (males, 71.7%; age, 59.6 ± 10.5 years (mean ± SD)). Serum concentrations of total cholesterol (TC), HDL cholesterol (HDL-C), and triglyceride were measured. LDL cholesterol (LDL-C) level was calculated using the Friedewald formula. The presence of carotid plaque and intima-media thickness (IMT) were evaluated by ultrasonography.ResultsA stepwise multivariate regression analysis demonstrated that HDL-C (β = ?0.110, p < 0.001), TC/HDL-C (β = 0.132, p < 0.001) and LDL-C/HDL-C ratios (β = 0.132, p < 0.001) were independent determinants of IMT even after adjustment of other conventional risk factors. However, there was no significant correlation between IMT and TC, triglyceride, LDL-C, and non-HDL-C levels. TC/HDL-C and LDL-C/HDL-C ratios and non-HDL-C levels were significantly higher, but HDL-C levels were significantly lower in patients with carotid plaque than those without it (p < 0.05). There was no significant difference between the groups regarding TC, LDL-C, and triglyceride levels. Furthermore, TC/HDL-C (OR; 1.34, p < 0.001) and LDL-C/HDL-C (OR; 1.54, p < 0.001) ratios showed a positive and linear relationship with the prevalence of carotid plaque, whether covariates were adjusted or not.ConclusionsTC/HDL-C and LDL-C/HDL-C ratios are useful as a tool to assess the risk of early stage atherosclerosis in Japanese type 2 diabetic patients.     

Intima-media thickness is a useful marker of the extent of coronary artery disease in patients with impaired renal function

ObjectiveThe aim of the study was the assessment of intima-media thickness (IMT) in peripheral arteries (the carotid and the femoral artery) and its correlation with the extent of coronary artery disease (CAD). The second task was the analysis of the renal function's influence within IMT complex.Methods231 patients (men, mean age 52.8), who had undergone coronary angiography due to symptoms of CAD were enrolled. The ultrasound measurement of IMT in the common carotid artery (CCA), carotid bulb and common femoral artery (CFA) was performed. The relationship between IMT, renal function and the extent of CAD was evaluated.ResultsSignificantly higher values of IMT in the peripheral arteries were observed in patients with CAD than in those without (CCA—0.91 vs 0.61 mm, carotid bulb—1.31 vs 0.67, CFA—1.38 vs 0.63 respectively, p < 0.0001). The GFR values in the CAD patients significantly negatively correlated with IMT complex in CCA (p < 0.001) and carotid bulb (p < 0.05). Lower values of GFR in patients with three-vessel disease were observed than in those patients with one- or two-vessel disease (p < 0.05). In multifactoral analysis (post-hoc NIR test) we found that glomerular filtration rate (GFR) is strongly determined by age (p < 0.0001), BMI (p < 0.0001), value of carotid intima-media thickness (p < 0.001), value of IMT in the carotid bulb (p < 0.02) and the treatment with ACE-I (p < 0.05). In multifactoral analysis we did not find any statistical influence of lipid profile and glucose disturbances on GFR.ConclusionsHigher peripheral artery IMTs in patients with CAD than in those without and patients with three-vessel disease indicate that IMT may be used as an early marker of atherosclerosis and reflect the severity of CAD. A significant negative correlation between the value of a GFR and the IMT confirmed the usefulness of this noninvasive method for the estimation of preclinical stages of atherosclerotic changes’ development in patients with impaired renal function.     

Impact of dyslipidaemia on arterial structure and function in urban indigenous Australians

BackgroundPremature cardiovascular disease (CDV) is highly prevalent in urban Indigenous Australians. We studied arterial structure and function in 144 volunteers aged 15–66 years to assess the role of dyslipidaemia and other traditional vascular risk factors on cardiovascular risk in young and older urban Indigenous Australians.MethodsWe assessed carotid intima-media thickness (CIMT) by high-resolution B-mode ultrasound imaging of the common carotid artery and peripheral wave reflection using applanation tonometry to obtain the aortic augmentation index (AI) in Indigenous Australian participants of the Darwin Region Urban Indigenous Diabetes (DRUID) study.ResultsParticipants aged 15–24 years demonstrated fewer cardiovascular risk factors than the older group (25–66 years) and predictors of CIMT and AI differed between younger and older groups. CIMT was higher in the older group (0.67 mm vs. 0.61 mm, p = 0.004) and in those with diabetes (0.81 mm vs. 0.67 mm, p < 0.001). AI was higher in the older group (24% vs. 0%, p < 0.001), but was not affected by diabetes status. On multivariate regression analysis, low HDL-cholesterol was the only independent predictor of CIMT in the younger group; triglycerides, heart rate (inverse) and height (inverse) were independent predictors of AI in the same group.ConclusionDyslipidaemia (low HDL-cholesterol or elevated triglycerides) is independently associated with non-invasive measures of cardiovascular disease in a relatively healthy and young subgroup of this high-risk population. We propose that triglycerides and low HDL-cholesterol may represent the most useful commonly measured clinical indicators of cardiovascular risk in young, urban Indigenous Australians.