Coronary artery calcium score, risk factors, and incident coronary heart disease events

BACKGROUND: Whether the absence of coronary artery calcium, or conversely the presence of high volumes of coronary artery calcium, may alter assessment of coronary heart disease risk based on traditional risk factors is uncertain. We sought to identify a potential threshold of coronary artery calcium for clinical use and examine the predictive power of coronary artery calcium in individuals categorized using conventional coronary heart disease risk assessment. METHODS: The study included 10,746 men and women (36.3%) with a mean age of 53.8+/-9.9 years who were either physician- or self-referred for electron beam tomography scanning to a preventive medical clinic. Coronary heart disease risk factors were elicited by use of a questionnaire. RESULTS: During a mean follow-up of 3.5 years, 81 primary events (coronary heart disease death or nonfatal myocardial infarction) occurred. Among individuals with a coronary artery calcium score of zero, the primary event rate was very low (0.4 events per 1000 person-years of observation). When participants were stratified by self-reported coronary heart disease risk factors (0-2, or 3-4), a coronary artery calcium score >or=100 was associated with substantially increased risk of coronary heart disease events within each level of stratification. In a subgroup of participants with available clinical data, similar results were found when participants were categorized by Framingham risk scores. CONCLUSIONS: Coronary artery calcium score can identify individuals at increased risk for coronary heart disease events who otherwise would be considered low-risk based on clinical assessment. A coronary artery calcium score of zero is associated with very low risk for coronary heart disease in the short to intermediate term ( approximately 3.5 years) regardless of the number of risk factors present.     

Left ventricular mass and incidence of coronary heart disease in an elderly cohort. The Framingham Heart Study

OBJECTIVE: To examine the association of echocardiographically determined left ventricular mass with incidence of coronary heart disease in an elderly cohort. DESIGN: Cohort study with a follow-up period of 4 years. SETTING: Population-based. SUBJECTS: Elderly original volunteer subjects of the Framingham Heart Study who were free of clinically apparent coronary heart disease. This group included 406 men (mean age, 68 years: range, 60 to 90) and 735 women (mean age, 69 years: range, 59 to 90). MEASUREMENTS AND MAIN RESULTS: During 4 years of follow-up, coronary heart disease events occurred in 37 men and 33 women. Baseline echocardiographically determined left ventricular mass was associated with incidence of coronary disease in both sexes (P less than 0.01). After adjusting for age, systolic blood pressure, smoking, and the ratio of total/high density lipoprotein cholesterol, the relative risk for a coronary event, per 50 g/m increment in left ventricular mass/height, was 1.67 in men (95% CI, 1.24 to 2.23) and 1.60 in women (95% CI, 1.10 to 2.32). CONCLUSIONS: Echocardiographic assessment of left ventricular mass offers prognostic information beyond that provided by traditional risk factors, which can improve our ability to identify individuals at high risk for coronary heart disease. These findings may have widespread implications regarding the applications of echocardiography in clinical practice.     

The association between the length of the QT interval and mortality in the Cardiovascular Health Study

PURPOSE: A long QT interval is a risk factor for arrhythmic events and sudden death. Whether moderate QT prolongation is associated with clinical events in community-dwelling elderly patients is uncertain. METHODS: We measured the QT interval in a population-based sample of 5888 men and women at least 65 years of age who were participants in the Cardiovascular Health Study. The association between Bazett's rate-corrected QT (QTc, in ms) and mortality during the subsequent 10 years was evaluated. We stratified participants by the presence or absence of coronary heart disease status at baseline, and adjusted for coronary heart disease risk factors. RESULTS: The rates of all-cause and coronary heart disease mortality were greater in participants with longer QTc intervals. Among participants without known coronary heart disease, those whose QTc interval was >450 ms were at increased risk of all-cause mortality (relative risk [RR] = 1.34; 95% confidence interval [CI]: 1.07 to 1.67) and coronary heart disease mortality (RR = 1.6; 95% CI: 1.0 to 2.5) when compared with participants whose QTc interval was <410 ms. The associations were stronger among those with known coronary heart disease (RR for all-cause mortality = 2.3; 95% CI: 1.6 to 3.3; and RR for coronary heart disease mortality = 2.0; 95% CI: 1.1 to 3.7). CONCLUSIONS: The QT interval from the standard electrocardiograms is of value for identification of elderly persons at increased risk of coronary heart disease and total mortality. A QTc interval >450 ms should prompt clinical evaluation and possible interventions to reduce the risk of coronary events.     

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.     

Gender difference in coronary events in relation to risk factors in Japanese hypercholesterolemic patients treated with low-dose simvastatin.

BACKGROUND: Gender differences between the risk factors for coronary heart disease and coronary events were examined in the Japan Lipid Intervention Trial, a 6-year observational study. METHODS AND RESULTS: Men (12,575) and women (27,013) were analyzed for risk of coronary events (acute myocardial infarction and sudden cardiac death). Simvastatin reduced serum low-density lipoprotein cholesterol (LDL-C) by 27% in both genders, and increased serum high-density lipoprotein cholesterol (HDL-C) in men (5%) and women (4%). The incidence of coronary events was lower in women (0.64/1,000 patient-years) than in men (1.57/1,000 patient-years). The risk of coronary events increased by 18% in men and 21% in women with each 10 mg/dl elevation of LDL-C, and decreased by 39% in men and 33% in women with each 10 mg/dl elevation of HDL-C. The risk increased proportionally with aging in women, but not in men. Diabetes mellitus (DM) was more strongly related to the risk of coronary events for women (relative risk 3.07) than for men (relative risk 1.58). CONCLUSIONS: The incidence of coronary events is lower in women. Serum LDL-C is related to an increased risk of coronary events to the same extent in both genders. DM seems to be a more important risk factor in women, trading off the lower risk of coronary events among them.     

Short stature and coronary heart disease: a 35-year follow-up of the Finnish cohorts of The Seven Countries Study

OBJECTIVES: To examine whether short stature is associated with an increased risk of coronary heart disease. DESIGN: Follow-up study. SETTING: Two geographically defined areas in eastern and western Finland. SUBJECTS: A total of 1441 men who were free of coronary heart disease at the start of the follow-up. MAIN OUTCOME MEASURES: Hazard ratios for fatal and non-fatal coronary heart disease RESULTS: Height was inversely related to fatal coronary heart disease and incident non-fatal coronary heart disease during the follow-up. These relationships persisted after adjusting for other major cardiovascular risk factors. Comparing the high-risk area in eastern Finland with the low-risk area in south-western Finland, no difference in fatal coronary heart disease and cumulative incidence of non-fatal coronary heart disease was seen in tall men. The increase in risk of coronary heart disease death was 19% for a 10 cm decrease in height (OR = 0.81, 95% CI = 0.68-0.95). CONCLUSIONS: Our results show that short stature is an independent risk factor for coronary heart disease. Differences in stature partly explain the Finnish east-west difference in the incidence of coronary heart disease.     

Traditional risk factors and subclinical disease measures as predictors of first myocardial infarction in older adults: the Cardiovascular Health Study.

BACKGROUND: Risk factors for myocardial infarction (MI) have not been well characterized in older adults, and in estimating risk, we sought to assess the individual and joint contributions made by both traditional risk factors and measures of subclinical disease. METHODS: In the Cardiovascular Health Study, we recruited 5888 adults aged 65 years and older from 4 US centers. At baseline in 1989-1990, participants underwent an extensive examination that included traditional risk factors such as blood pressure and fasting glucose level and measures of subclinical disease as assessed by electrocardiography, carotid ultrasonography, echocardiography, pulmonary function, and ankle-arm index. Participants were followed up with semiannual contacts, and all cardiovascular events were classified by the Morbidity and Mortality Committee. The main analytic technique was the Cox proportional hazards model. RESULTS: At baseline, 1967 men and 2979 women had no history of an MI. After follow-up for an average of 4.8 years, there were 302 coronary events, which included 263 patients with MI and 39 with definite fatal coronary disease. The incidence was higher in men (20.7 per 1000 person-years) than women (7.9 per 1000 person-years). In all subjects, the incidence was strongly associated with age, increasing from 7.8 per 1000 person-years in subjects aged 65 to 69 years to 25.6 per 1000 person-years in subjects aged 85 years and older. Glucose level and systolic blood pressure were associated with the incidence of MI, but smoking and lipid measures were not. After adjustment for age and sex, the significant subclinical disease predictors of MI were borderline or abnormal ejection fraction by echocardiography, high levels of intimal-medial thickness of the internal carotid artery, and a low ankle-arm index. Forced vital capacity and electrocardiographic left ventricular mass did not enter the stepwise model. Excluding subjects with clinical cardiovascular diseases such as prior angina or congestive heart failure at baseline had little effect on these results. Risk factors were generally similar in men and women. CONCLUSIONS: After follow-up of 4.8 years, systolic blood pressure, fasting glucose level, and selected subclinical disease measures were important predictors of the incidence of MI in older adults. Uncontrolled high blood pressure may explain about one quarter of the coronary events in this population.     

High density lipoprotein as a protective factor against coronary heart disease. The Framingham Study.

Lipid and lipoprotein values, including fasting triglycerides and high density lipoproteins (HDL), low density lipoproteins (LDL) and total cholesterol levels, were obtained on 2,815 men and women aged 49 to 82 years chiefly between 1969 and 1971 at Framingham. In the approximately four years following the characterization of lipids, coronary heart disease developed in 79 of the 1,025 men and 63 of the 1,445 women free of coronary heart diseases. At these older ages the major potent lipid risk factor was HDL cholesterol, which had an inverse association with the incidence of coronary heart disease (p less than 0.001) in either men or women. This lipid was associated with each major manifestation of coronary heart disease. These associations were equally significant even when other lipids and other standard risk factors for coronary heart disease were taken into consideration. A weaker association with the incidence of coronary heart disease (p less than 0.05) was observed for LDL cholesterol. Triglycerides were associated with the incidence of coronary heart disease only in women and then only when the level of other lipids was not taken into account. At these ages total cholesterol was not associated with the risk of coronary heart disease.     

Fifteen-year risk of major coronary events predicted by Holter ST-monitoring in asymptomatic middle-aged men.

BACKGROUND: Ambulatory electrocardiogram monitoring (Holter) with ST-analysis as a measure of myocardial ischemia has in populations with coronary heart disease been shown to predict major coronary events: death, myocardial infarction or coronary revascularization. There has, however, been conflicting evidence regarding the usefulness of this technique in identification of healthy subjects with increased risk for coronary heart disease. The aim of this study was to assess if Holter monitoring with ST-analysis could be used to predict future major coronary events in asymptomatic middle-aged men with a defined aggregation of traditional risk factors for coronary heart disease. METHODS: One hundred and fifty-five asymptomatic participants from the city of Malm?, Sweden, with known levels of conventional cardiovascular risk factors underwent Holter monitoring for analysis of transient ST-segment depression at the age of 55 years. Fifteen years after the Holter monitoring, hospital records, diagnosis and death registries were revisited for major coronary events. RESULTS: An ST-segment depression of 1 mm or greater (0.1 mV) was considered significant for myocardial ischemia and was found in 54 of the 155 men. There were no significant differences in risk factors in the two groups at baseline. The 15-year incidence of a first major coronary event was significantly higher in men with ST-segment depression (39%) than in men without ST-segment depression (20%) (P<0.015). A Holter electrocardiogram could predict future major coronary events with a positive and negative predictive value of 35 and 80%, respectively. CONCLUSIONS: Holter monitoring can be used as a complement to conventional risk factor evaluation in deciding whether or not to treat risk factors for CHD in asymptomatic subjects.     

Coronary heart disease risk factors ranked by importance for the individual and community. A 21 year follow-up of 12 000 men and women from The Copenhagen City Heart Study.

AIMS: The importance of coronary heart disease risk factors may differ between individuals and community and by sex and age. METHODS AND RESULTS The Copenhagen City Heart Study followed for 21 years a random sample of 5599 men and 6478 women aged 30 to 79 years at baseline. The importance of risk factors in individuals and the community were evaluated as relative- and population-attributable risks. We traced 2180 coronary events. In Cox regression analysis with ten risk factors entered simultaneously, relative risks for coronary heart disease in men ranged from 1.69 to 1.20 with the highest risks for diabetes, hypertension, smoking, and physical inactivity. In women, relative risks ranged from 2.74 to 1.19 with the highest risks for diabetes, smoking, hypertension, and physical inactivity. Population-attributable risks in men ranged from 22% to 3% with the highest risks for smoking, hypertension, and no daily alcohol intake. In women, attributable risks ranged from 37% to 3% with the highest risks for smoking, hypertension, and hypercholesterolaemia. Several of these rankings differed by age. CONCLUSIONS: The importance of coronary heart disease risk factors may differ for individuals, the community, and by sex and age. Consequently, prevention strategies should be tailored accordingly.     

Screening asymptomatic adults for cardiac risk factors: the serum cholesterol level

From our review of the epidemiologic and clinical literature, we have developed recommendations for using the serum cholesterol test as a component of strategies to prevent coronary heart disease in asymptomatic adults. Total cholesterol, high-density lipoprotein, and low-density lipoprotein levels are risk factors for coronary disease and early mortality in middle-aged men. Weaker evidence suggests that hypercholesterolemia increases the risk for coronary disease in women or elderly men, or that hypertriglyceridemia increases the risk in men or women. A reduction in cholesterol levels lowers the incidence of and the mortality from coronary disease in asymptomatic, hypercholesterolemic, middle-aged men, but has not been shown to reduce overall mortality. The efficacy of treatment in women and elderly persons has not been studied. Screening and treatment plans should be individualized; a 5-year period between tests is adequate for asymptomatic, low-risk men, whereas more frequent testing is appropriate for high-risk men. Screening is optional for women and elderly persons.     

Prevalence of coronary heart disease risk factors in Northern-Italian male and female employees

A cross-sectional study of 2650 male and 751 female employeesof the IBM company in the Milan area was conducted in 1987 tocompare risk profiles for coronary heart disease between menand women and to analyse the awareness of risk status of peopleat risk. After age adjustment, the rate of cigarette smokingwas higher in women (35%) than in men (25%). Other coronaryheart disease risk factors were more common in men than in women.After controlling for age, 38% of the men and 19% of the womenmet the study criteria for hypertension, and 22% of the menand 17% of the women had high blood cholesterol. However, ananalysis by age groups showed that, although in the youngerage groups women had lower levels of cardiovascular risk factors,except smoking, compared to men, in the age brackets 50 or olderwomen had similar or more adverse risk factor profiles thanmen. Of the people with hypertension, only 22% of the men and19% of the women were aware of their hypertension, and only2% of the men and 4% of the women had successful control bydrugs. Even when subjects with mild hypertension were excluded,high proportions of undiagnosed and uncontrolled hypertensionwere found in both sexes. Of the individuals with serum cholesterol 240 mg. dl^–1, less than half of the men and less than20% of the women were aware of their high blood cholesterollevels. Multiple risk factors were frequently present in thesame individuals, especially among males and older women. Weestimated that i9% of the men and 5% of the women were potentialcandidates for pharmacological intervention because of highblood cholesterol. Although our occupational sample is likelyto be healthier and more educated than the general Italian population,a considerable proportion of participants was found to be athigh risk for coronary heart disease. Among people at risk,the awareness of risk status was low in both men and women.Our results indicate that more resources should be directedtoward educating individuals and health professionals on cardiovasculardisease prevention in Italy.     

Coronary calcification and predicted risk of coronary heart disease in asymptomatic men with hypercholesterolaemia

OBJECTIVE: To document the relationship between coronary calcification and coronary risk assessed clinically in asymptomatic patients with hypercholesterolaemia. DESIGN: Prospective observational study. SETTING: Health screening clinic. PATIENTS: A total of 286 asymptomatic men aged 45-64 with plasma cholesterol >or= 6.5 mmol/l. INTERVENTIONS: Electron beam computed tomography to measure coronary calcium score. MAIN OUTCOME MEASURES: The Framingham equation was used to separate subjects into groups with either low 10-year risk of coronary artery disease (or= 20%). Coronary calcium score was assessed in each group. RESULTS: The mean log calcium score was significantly higher in the 97 high-risk men than in the 189 low-risk men (1.58 +/- 0.84 versus 1.00 +/- 0.85, < 0.001). Arithmetic means (158 versus 55), and the proportion with a score > 400 (11% versus 2%, p < 0.01) were also greater. However, 27% of the high-risk group had a low calcium score (or= 20% in 10 years have minimal coronary calcification. They may therefore represent a subset at lower risk of disease. However, uncertainties about the predictive power of coronary calcification for coronary events must be resolved before electron beam computed tomography can be used to select high-risk patients for primary prevention.     

Cardiovascular monitoring of a city over 30 years

This lecture on population studies was given in memory and honourof the late Professor Frederick Epstein. It relates to studiesperformed in Göteborg, Sweden. The main topics discussedin the presentation are: Coronary heart disease and stroke incidence according to theMONICA Project. Risk factors with special emphasis on relative and populationattributable risk. Incidence and mortality of coronary heart disease in hospitaland out of hospital. Quantitative aspects on treatment and prevention of myocardialinfarction. The analysis was based upon a Myocardial Infarction Registerwhich started in 1970, cross-sectional and prospective populationstudies primarily among men which started in 1963, cross-sectionalstudies among men and women based upon population studies (theMONICA Project) as well as studies of myocardial infarction.We have also been involved in many intervention trials in primaryand secondary prevention regarding physical training, beta-blockers,thrombolytics, aspirin, anti-arrhythmics, ACE-inhibitors andlipid lowering drugs. In the Primary Prevention Study it was found during a 16 years'follow-up that the coronary heart disease risk was related toentry level of serum cholesterol both among those who had signsof coronary heart disease or angina pectoris, as well as amongthose with no such previous coronary heart disease events atentry. For each cholesterol level, the risk was about seventimes higher among those who had had a myocardial infarctioncompared to those without any coronary heart disease event atentry. In those with angina the risk was about three to fourtimes higher. An example shows how important it is to take theso-called ‘regression dilution bias’ into account,which results in steeper risk factor-incidence curves. The concept of ‘population attributable risk’ isalso discussed. It is a general finding that the many with moderateelevations of risk factors contribute to most disease events.This is true for smoking, serum cholesterol, blood pressureetc. Results from various prospective studies have repeatedlydemonstrated three main risk factors for coronary heart disease:cholesterol, high blood pressure and smoking, and they explainmore than 90% of infarct cases in the middle-aged population.Other risk factors, including psychological, are, however, alsoof some importance and they are discussed briefly. The Göteborg population studies started in 1963. The datato 1990 show that among men there has been a decline in serumcholesterol and blood pressure, which has resulted in a declinein risk for coronary heart disease of 37%, well compatible withthe registered decline of 30–40% in coronary heart diseaseincidence among men aged 45–54 years. Simultaneously,there has been a marked decline, especially among men, of 28-dayfatality among hospitalized patients, but because most deathsoccur outside hospital the decline in incidence has had greaterimportance for overall coronary heart disease mortality. Several studies have demonstrated the importance of stoppingsmoking, at least after myocardial infarction. Other interventionsafter a myocardial infarction are also important for the outcome,which has improved considerably over the last 20 years. In thegeneral population in whom there is no sign of coronary heartdisease, it is important to reduce risk factors among the manywith moderate risk, by stopping smoking and changing diet.     

Lipid lowering strategies in women

Hyperlipidemia is one of the major modifiable risk factors for coronary heart disease in men and women. There is substantial epidemiological data showing the relationship between elevations in total and low density lipoprotein cholesterol, triglycerides and low high density lipoprotein cholesterol, and coronary heart disease in women. Yet hyperlipidemia is undertreated in women. This may be due to limited data to support intervention for the primary prevention of coronary heart disease, confusion in national guidelines, and inadequate counseling on diet and exercise in clinical practice. Lipid levels should be evaluated in women with established coronary heart disease, cerebrovascular disease, peripheral vascular disease, and diabetes. These women should be targeted for aggressive lipid lowering with diet, exercise, and medication. Women with multiple risk factors and early family history of coronary heart disease should also be evaluated. Asymptomatic young women with elevated or borderline lipids should be counseled with regard to lifestyle and behavioral interventions such as diet and exercise.     

Plasma fibrinogen explains much of the difference in risk of coronary heart disease between France and Northern Ireland. The PRIME study

The incidence of coronary heart disease is higher in Northern Ireland than in France. These differences have not been adequately explained. We have investigated the associations of plasma fibrinogen concentration and factor VII activity with the incidence of coronary heart disease in a prospective cohort study involving 10600 men aged 50-59 living in four regions (Lille, Strasbourg, and Toulouse in France, Belfast in Northern Ireland). Baseline fibrinogen and factor VII were measured in 9489 men free of coronary heart disease at entry (7167 in France and 2322 in Northern Ireland). Over 5 years of follow-up, 161 participants developed myocardial infarction (MI) or coronary death (100 in France and 61 in Belfast) and 151 developed angina pectoris (94 in France and 57 in Belfast). The risk of future coronary events was 1.9 times higher in Belfast than in France (95% confidence interval: 1.5-2.4). Baseline mean levels of fibrinogen were significantly higher in Belfast than in France and they were higher in participants who experienced coronary events compared with those who did not in both countries. The age-adjusted relative risk of coronary heart disease associated with a rise of one standard deviation in fibrinogen level was 1.56 (95% confidence interval: 1.29-1.95, P<0.0001) in the whole cohort. This association remained significant after adjustment for other cardiovascular risk factors (relative risk:1.36; 95% confidence interval: 1.14-1.68; P<0.0001). There was no clear geographical variation in factor VII and no significant association between factor VII levels and the risk of coronary events was observed. Classic risk factors explained 25% of the excess risk of coronary heart disease in Belfast compared with France, while fibrinogen alone accounted for 30%. These findings add to the epidemiological evidence that elevated fibrinogen is a major risk factor for coronary heart disease.     

Risk factors for coronary heart disease: implications of gender

It has been recognized over the past years that women form a distinct subpopulation within patients with coronary heart disease. This phenomenon should be acknowledged in the management and in the assessment of coronary heart disease. Over the past years remarkable progress has been made concerning our knowledge of cardiovascular risk factors related to gender. For instance, diabetes, high density lipoproteins and triglycerides levels have been found to have a greater impact on coronary heart disease risk in women compared to men. On the other hand, evidence showing that lipoprotein (a) is a cardiovascular risk factor seems to be stronger in men than in women. For optimal treatment and prevention of coronary heart disease it is necessary to acknowledge that it is not self-evident that women and men show similar responses to risk factors or to treatment. This review article addresses the role of cardiovascular risk factors focusing on the differential impact they might have on men and women.     

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.     

Carotid ultrasound for risk clarification in young to middle-aged adults undergoing elective coronary angiography

BACKGROUND: An important aspect of risk prediction is the apparent difference between calculated risk and true risk. Current risk predictor models are not sensitive enough to identify many subjects at risk for future events or to prevent overuse of expensive tests. The aim of this study was to determine the usefulness of carotid ultrasound for risk stratification in subjects undergoing elective coronary angiography. METHODS: A total of 253 individuals (men < or =55 years of age and women < or =65 years of age) who were scheduled for elective coronary angiography underwent carotid ultrasonography. Noncoronary atherosclerosis was defined based on a maximal intima-media thickness of > or =1.0 mm or the presence of focal plaque. RESULTS: Of the subjects, 236 completed all of the tests. The mean age was 51 +/- 8 years, and 58% were women and 42% men. Severe angiographic disease (> or =50%) was present in 72 subjects. Carotid atherosclerosis was present in 141 subjects. Use of the Framingham risk score classified 172 subjects as low risk. Carotid atherosclerosis was diagnosed in 57% of the low-risk group compared with 70% of the high-risk group (P = .122). Carotid atherosclerosis was associated with severe coronary angiographic disease (OR = 2.2, CI = 1.2 to 4.0). CONCLUSION: Noncoronary atherosclerosis was associated with severe coronary disease as determined by angiography. Carotid atherosclerosis had a high negative predictive value in subjects with negative stress test results or risk-stratified as low risk. Noninvasive imaging by carotid ultrasonography for noncoronary atherosclerosis may be a good adjunct to clinical risk stratification for premature coronary heart disease.     

Treatment and secondary prevention of ischemic coronary events in Croatia (TASPIC-CRO study).

AIMS: The objective of this study is to determine the status of major risk factors for coronary heart disease in patients with established coronary heart disease in Croatia and whether the Joint European Societies' recommendations on coronary heart disease prevention are being followed in Croatia and whether secondary prevention practices have improved between 1998 and 2003. METHODS: Five surveys were undertaken in 35 centres covering the geographical area of the whole of Croatia between 1 June, 1998 and 31 March, 2003. Consecutive patients of both sexes were identified after coronary-bypass grafting or a percutaneous transluminal coronary angioplasty or a hospital admission with acute myocardial infarction or ischaemia. Data collection was based on a review of medical records and the methodology used was similar to the one used in the EUROASPIRE study. RESULTS: Fifteen thousand, five hundred and twenty patients were enrolled (64.6% men); 35% of patients smoked cigarettes, 66% had raised blood pressure, 69% elevated serum total cholesterol, 69% elevated serum low-density lipoprotein (LDL) cholesterol, 42% low high-density lipoprotein (HDL) cholesterol, 37% elevated triglycerides, 30% diabetes and 34% family history of coronary heart disease. More men were smokers and had low HDL cholesterol, but more women had elevated total and LDL cholesterol, hypertension and diabetes. More men had Q wave acute myocardial infarction, but more women had angina. Over 5 years, the prevalence of hypercholesterolemia decreased substantially from 82.7 to 65%. Eighty-three percent of patients received aspirin and this percentage did not change during the study. The use of diuretics, calcium antagonists and nitrates did not change either. The reported use of statins, angiotensin-converting enzyme inhibitors and beta-blockers increased significantly. CONCLUSION: This survey shows a high prevalence of modifiable risk factors in Croatian patients with coronary heart disease. Although the higher use of statins, angiotensin-converting enzyme inhibitors and beta-blockers is encouraging, the fact that most coronary heart disease patients are still not achieving the recommended goals remains a concern. There is real potential to reduce the very high coronary heart disease morbidity and mortality in Croatia.