Does aortic stiffness improve the prediction of coronary heart disease in elderly? The Rotterdam Study

It has been demonstrated that aortic stiffness is an independent predictor of cardiovascular disease. We investigated whether this measure is of use in cardiovascular risk stratification in clinical practice for elderly subjects (mean age 71.5 years). Within the framework of the Rotterdam Study, we stratified subjects free of coronary heart disease (CHD) at baseline into categories of low (<10%), intermediate (10-20%) and high (>20%) 10-year risk of CHD based on Framingham risk factors. Within each risk category, we determined the percentages of subjects moving into a higher or lower risk category when adding aortic stiffness to the Framingham risk factors. Among 2849 participants, 223 CHD events occurred during a median follow-up of 7.9 years. In the low risk group, 5% of the subjects could be reclassified and in the high-risk group, 6% of the subjects could be reclassified to the intermediate-risk group. In the intermediate-risk group 3% could be reclassified to the high-risk group and 6% to the low-risk group. In a population of elderly subjects, aortic stiffness measurement in addition to Framingham risk factors leads to a limited reclassification of subjects in 10-year cardiovascular disease-risk categories. Therefore, aortic stiffness is associated with the risk of CHD in elderly, but provides no additional value in cardiovascular risk stratification.     

Hyperlipidaemia and primary prevention of coronary heart disease: are the right patients being treated?

BACKGROUND: In 1997, the Standing Medical Advisory Committee report suggested that patients with a coronary heart disease risk of 3% per year or greater should be considered appropriate for lipid-lowering medication. The report stated that cholesterol concentration alone is a poor predictor of absolute risk of coronary heart disease and recommended the Sheffield table as a method of estimating the coronary heart disease risk. OBJECTIVE: To assess the impact of the Standing Medical Advisory Committee report on the management of patients with hyperlipidaemia in the primary prevention of coronary heart disease in primary care. METHOD: A survey questionnaire giving the clinical details of 20 patients with various coronary heart disease risk factors was sent to 200 general practitioners in the West Midlands, UK. RESULTS: Forty-eight percent of the respondents used clinical assessment/perception as the sole means of risk assessment and 26% used the Sheffield table. In patients who did not require treatment, 40.1% of the decisions were inappropriate and, in patients who required treatment, 35.1% of the decisions were inappropriate. Overall, inappropriate decisions were made in 37.9% of the responses. Despite the clear advice in the Standing Medical Advisory Committee report on the importance of incorporating multiple risk factors in estimating absolute coronary heart disease risk, only total cholesterol and triglycerides were significant in influencing treatment decisions. CONCLUSIONS: The Standing Medical Advisory Committee recommendations on the management of hyperlipidaemia in primary prevention of coronary heart disease are not widely used. Large savings could be made by correctly identifying and treating individuals at high risk. We recommend use of the full Framingham risk score in assessment of coronary heart disease risk in primary care.     

Are statins indicated for the primary prevention of coronary heart disease in octogenarians? protagonist viewpoint

Statins should be given to octogenarians for primary prevention of coronary heart disease. There is a substantial burden of disease and disability in this population that statin treatment can address in an effective manner. It has been shown that statin treatment is both effective and safe, and details of the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) trial are reviewed. It may be useful to "tease out" those at particularly high risk who would benefit from statin treatment. In this regard, a low high-density lipoprotein cholesterol level, high-sensitivity C-reactive protein level, and subclinical measures of atherosclerosis may be particularly useful.     

Primary prevention of coronary heart disease? What is cost effective in the clinical practice?

In the primary prevention of coronary heart disease (CHD), the effect of aspirin and statins is well documented in several controlled randomized trials. For aspirin the results can be transferred into clinical practice due to its low price; for the more expensive statins, however, serious economic problems exist. In contrast to secondary prevention these drugs do not reach cost-efficiency in primary prevention; due to their high prices for the criteria of the randomized controlled studies values >60 000 or >100 000 [US dollars/YLS] are gained. Data from England and Scotland indicate that according to the inclusion criteria of the WOSCOPS- and AFCAPS/TexCAPS studies almost 20 and 60%, respectively, of the adult population had to be treated with a statin. Results of newer studies may even increase these numbers. These costs cannot be covered by any health care system. Primary prevention of CHD with statins reveals paradigmatically that for financial reasons evidence-based medicine can no longer be transferred into clinical practice. The limited resources of all health care systems make rationing with treatment allocation only to the high risk groups necessary. The American, European and German guidelines propose a > or =2% annual risk of CHD as the limit, for financial reasons the Britisch recommendations favor a limit of 3%; in order to save >50% of the costs. Despite the financial restraints of the German health care system, the limit of > or =2% annual risk of CHD as proposed by the German Cardiac Society may be realistic when the different preventive measures are applied following a step-by-step plan based on the costs. According to the Procam algorithms, persons without diabetes mellitus or familiar disposition, who in case of nicotine abuse have given up smoking and if hypertensive have blood pressure values within the therapeutic range, statins are only to be given under the following conditions: LDL-cholesterol > or =175 or > or =190 mg/dl, for a HDL-cholesterol < or =35 or < or =45 mg/dl, or triglyceride levels > or =200 or > or =175 mg/dl, respectively. Diabetics without CHD have the same risk as non-diabetics with CHD. Therefore, in diabetics the same measures should be taken for primary prevention as in non-diabetics for secondary prevention. Evaluation of cost-efficiency indicates that intensive blood sugar control as well as intensive antihypertensive treatment and application of statins are all cost-effective in primary prevention of diabetics.     

Dietary recommendations in the prevention and treatment of coronary heart disease: do we have the ideal diet yet?

To respond to the question of the best "heart-healthy" diet, we reviewed the effects of common diets on lipids, their efficacy, advantages, and limitations. The high-protein, low-carbohydrate diet is effective for weight loss over the short term, but its long-term benefits remain unproved. The very low-fat diet decreases levels of total and low-density lipoprotein cholesterol and, with lifestyle modifications, may slow progression of coronary atherosclerosis. The high-protein and very low-fat diets are difficult to follow over the long term. The American Heart Association diet, which is rich in fruits, vegetables, and nuts, decreases blood pressure and may be acceptable to most patients. However, it is rich in carbohydrates and may not be suitable for patients who are obese and/or have high levels of triglycerides. In such patients, diet based on foods with a low glycemic index may be an alternative. There is also immense interest in the Mediterranean diet, which is acceptable to most patients, may decrease some biomarkers of coronary atherosclerosis, and may decrease cardiovascular events and death. Despite these options, there is no "fits all" dietary recommendation for prevention of coronary heart disease. Importantly, dietary discretion is only 1 part of lifestyle changes, such as exercise and smoking cessation.     

Is there a role for the glycemic index in coronary heart disease prevention or treatment?

The clinical application of the glycemic index (GI) to the prevention and treatment of chronic diseases is controversial. No evidence exists for the implementation of low-GI diets for a reduction in coronary heart disease (CHD) mortality, events, or morbidity. Observational studies report conflicting evidence on the role of low-GI diets in CHD and risk factors for CHD. Randomized clinical trials report a small reduction in total cholesterol (-6.6 mg/dL) from low-GI diets compared with high-GI diets, but no reduction in other risk factors, such as low-density lipoprotein or high-density lipoprotein cholesterol, triglycerides, fasting glucose, insulin, or body weight. Currently, the research suggests a minimal role for the implementation of low-GI diets in the prevention or treatment of CHD.     

Do apolipoproteins improve coronary risk prediction in subjects with metabolic syndrome? Insights from the North Italian Brianza cohort study

Objective

We assessed predictive abilities and clinical utility of CVD risk algorithms including ApoB and ApoAI among non-diabetic subjects with metabolic syndrome (MetS).

Methods

Three independent population-based cohorts (3677 35–74 years old) were enrolled in Northern Italy, adopting standardized MONICA procedures. Through Cox models, we assessed the associations between lipid measures and first coronary events, as well as the changes in discrimination and reclassification (NRI) when standard lipids or apolipoproteins were added to the CVD risk algorithm including non-lipids risk factors. Finally, the best models including lipids or apolipoproteins were compared.

Results

During the 14.5 years median follow-up time, 164 coronary events were validated. All measures showed statistically significant associations with the endpoint, while in the MetS subgroup HDL-C and ApoAI (men, HR = 1.59; 95%CI: 0.96–2.65) were not associated. Models including HDL-C plus TC and ApoB plus ApoAI for lipids and apolipoproteins, respectively, showed the best predictive values. When ApoB plus ApoAI replaced TC plus HDL-C, NRI values improved in subjects with MetS (13.8; CI95%: −5.1,53.1), significantly in those previously classified at intermediate risk (44.5; CI95% 13.8,129.6). In this subgroup, 5.5% of subjects was moved in the high (40.0% of expected events) and 17.0% in the low risk class (none had an event at 10 years).

Conclusions

ApoB and ApoAI could improve coronary risk prediction when used as second level biomarkers in non-diabetic subjects with MetS classified at intermediate risk. The absence of cases moved downward suggests the gain in avoiding treatments in non-cases and favor the use of apolipoproteins for risk assessment.     

Multifactorial approach to the prevention of coronary heart disease: from computer to paper and pencil?

BACKGROUND: In Europe the multifactorial clinical approach to the prevention of coronary heart disease is based on the Framingham equation presented in graphical form including age, sex, level of total serum cholesterol, systolic blood pressure and smoking. OBJECTIVE: To propose a straightforward paper-and-pencil score (Global Coronary Risk Score) including level of high-density lipoprotein cholesterol for the Belgian or more broadly western European population derived from 10-year follow-up mortality of a Belgian national population sample. RESULTS: This score has the same predictive power as the Framingham equation both for men aged 35-74 years and for women aged 50-74 years. It gives a ranking of subjects into four groups according to their relative risks. CONCLUSION: Coronary Risk Score is user friendly and probably has pedagogical virtues.     

Do clinical and angiographic parameters predict failure of medical therapy in patients suitable for coronary angioplasty?

AIMS: Recent studies have suggested that patients with coronary disease suitable for angioplasty have an equally good outcome with medical therapy if clinically stable. Complex lesion morphology may predict acute events without intervention and stenosis severity influences the degree of collateralisation. This study was designed to assess the influence of these factors on clinical outcome. METHODS AND RESULTS: A retrospective review of patients suitable for angioplasty who were randomised to initial medical therapy as part of a multicentre study. Angiograms were reviewed for lesion characteristics, TIMI flow grade, and degree of collateralisation. Angiograms were available on 79 patients (13 female, 66 male). Mean age was 54.8 years (range 43-68) in the group crossing-over to revascularisation, and 58.4 (range 37-78) in the group who did not (P=ns). Seventeen patients crossed-over (two to CABG, 15 to PTCA) at 5.4 months (range 0-10) after initial angiography. Disease progression had occurred in 10/17 patients (58.8%), three of whom developed a new occlusion. Collateralisation was more likely in smokers, independent of lesion severity (P<0.05). Time to cross-over was not influenced by progression of disease. Crossing-over was not affected by age, diabetic status, cholesterol level, vessel involved, lesion severity, TIMI flow, lesion morphology, collateralisation, or the number of vessels diseased, but was more likely in females (P<0.05). CONCLUSION: This group of patients generally does well with medical therapy. Whilst the numbers are relatively small, there does not appear to be any reliable prospective marker, including the presence of spontaneous collateral channels on diagnostic angiography, to indicate which patients will fail medical therapy and require revascularisation.     

Single-chamber ICD, single-zone therapy in primary and secondary prevention patients: the simpler the better?

Background

It is now well established that implantable cardioverter defibrillator (ICD) implantation reduces mortality in patients at increased risk of sudden cardiac death. However, the best programming parameters remain controversial. Our traditional policy has followed a simple approach in the vast majority of patients. In accordance with ICD programming in the major randomized clinical trials, we programmed a single high-rate, shock-only therapy zone. We aimed to demonstrate in this observational study that simple programming is not associated with higher shock rates or mortality when compared to other published studies.

Methods

Consecutive patients who underwent single-chamber ICD implantation with single-zone, high-rate programming at our institution between 1993 and 2008 were retrospectively studied. Data were collected prospectively in a database regarding details of ICD implantation, demographic data, and indication.

Results

Three hundred thirty-two patients were included in our study, 31?% primary prevention and 68?% secondary prevention. Mean ejection fraction (EF) is 33.7?±?15.3. Over a mean follow-up period of 62.5?±?38.1?months, 135 patients experienced ICD shock (annualized event rate 7.7?%); 89 patients (26.8?%) appropriate shock in VT?Cventricular fibrillation (VF), 68 patients (20.5?%) inappropriate shocks, and 22 patients (6.6?%) both. Twenty-nine patients (8.7?%) were reprogrammed to additional VT?CATP zones. Twenty-two (6.6?%) patients underwent heart transplantation. Sixty-two patients (18.6?%) died during follow-up, 43.6?% out of them due to cardiac cause, mainly progressive heart failure.

Conclusion

Our results show that simpler settings with single-zone, high-rate programming is associated with ICD shock rates and long-term mortality that does not appear to be worse when compared with contemporary studies which include multizone ICD programming with antitachycardia pacing activated.     

How well does the metabolic syndrome defined by five definitions predict incident diabetes and incident coronary heart disease in a Chinese population?

We evaluate the ability of the metabolic syndrome (MetS) defined by five definitions for predicting both incident CHD and diabetes combined, diabetes alone, and CHD alone in a Chinese population. The screening survey for type 2 diabetes was conducted in 1994. A follow-up study of 541 high-risk non-diabetic individuals who were free of CHD at baseline was carried out in 1999 in Beijing area. The MetS was defined by the World Health Organization (WHO), European Group for the Study of Insulin Resistance (EGIR), American College of Endocrinology (ACE), the International Diabetes Federation (IDF), and the National Cholesterol Education Program and the American Heart Association (AHA) (updated NCEP) criteria. From a multiple logistic regression adjusting for age, sex, education, occupation, smoking, family history of diabetes, and total cholesterol, the relative risk of the ACE-defined MetS for incident diabetes alone (67 cases) was 2.29 (95% CI, 1.20-4.34). The MetS defined by the five definitions was associated with a 1.8-3.9 times increased risk for both incident CHD and diabetes combined (59 cases), and with a 1.9-3.0 times for total incident diabetes (126 cases). None of the five definitions predicted either incident CHD alone (177 cases) or total incident CHD (236 cases). In conclusion, the MetS defined by the current definitions appears to be more effective at predicting incident diabetes.