Non-HDL cholesterol and apolipoprotein B predict cardiovascular disease events among men with type 2 diabetes

OBJECTIVE: To evaluate the role of non-HDL cholesterol and apolipoprotein (apo)B, markers of all potentially atherogenic lipoproteins, as predictors of cardiovascular disease (CVD) in comparison with LDL cholesterol in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: We prospectively followed 746 diabetic men in the Health Professionals' Follow-up Study who were aged 46-81 years and free of CVD or cancer at the time of blood draw in 1993-1994. During 6 years of follow-up, we ascertained 103 incident CVD cases. RESULTS: We used Cox proportional hazard modeling to estimate the relative risk (RR) of CVD. After adjustment for age, BMI, and other lifestyle risk factors, the multivariate RR of CVD (the highest versus the lowest quartile) was 2.34 (95% CI 1.26-4.32) for non-HDL cholesterol, 2.31 (1.23-4.35) for apoB, and 1.74 (0.99-3.06) for LDL cholesterol. Comparisons of nested models indicate that non-HDL cholesterol, but not apoB, adds significantly to the prediction of CVD risk beyond LDL cholesterol. The area under the receiver operating characteristic curve was 0.685, 0.691, 0.695, and 0.722 for the CVD risk-prediction model with LDL cholesterol, apoB, non-HDL cholesterol, and total cholesterol-to-HDL cholesterol ratio (or the non-HDL-to-HDL cholesterol ratio), respectively. CONCLUSIONS: Non-HDL cholesterol and apoB are more potent predictors of CVD incidence among diabetic men than LDL cholesterol. Statistically, the ratio of total to HDL cholesterol is the best predictor of CVD in this cohort of diabetic men.     

Cardiovascular Disease in Women

Cardiovascular disease (CVD) is the leading cause of death of women in the U.S. and Canada. Experts estimate that one in two U.S. women will die of heart disease or stroke compared with one in 25 women who will die of breast cancer. Risk factors for CVD include hypertension, high cholesterol, obesity and sedentary lifestyle.     

Preventing cardiovascular disease in women

Cardiovascular disease (CVD) has been the primary cause of death in women for almost a century, and more women than men have died of CVD every year since 1984. Although CVD incidence can be reduced by adherence to a heart-healthy lifestyle and detection and treatment of major risk factors, preventive recommendations have not been consistently or optimally applied to women. The American Heart Association guidelines for CVD prevention in women provide physicians with a clear plan for assessment and treatment of CVD risk and personalization of treatment recommendations. The emphasis of preventive efforts has shifted away from treatment of individual CVD risk factors in isolation toward assessment of a woman's overall or "global" CVD risk. In addition to accounting for the presence or absence of preexisting coronary heart disease or its equivalents (e.g., diabetes, chronic kidney disease), cardiovascular risk can be further calculated with the Framingham risk score, which is based on age, sex, smoking history, and lipid and blood pressure levels. Intervention intensity and treatment goals are tailored to overall risk, with those at highest risk receiving the most intense risk-lowering interventions. Women at high risk for CVD and without contraindications should receive aspirin, beta blockers, and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in addition to pharmacologic therapy for hyperlipidemia, hypertension, and diabetes. Women who already are at optimal or low risk for CVD should be encouraged to maintain or further improve their healthy lifestyle practices. Optimal application of these preventive practices significantly reduces the burden of death and disability caused by heart attack and stroke in women.     

The assessment of vascular risk in men with erectile dysfunction: the role of the cardiologist and general physician

Erectile dysfunction (ED) and cardiovascular disease (CVD) share risk factors and frequently coexist, with endothelial dysfunction believed to be the pathophysiologic link. ED is common, affecting more than 70% of men with known CVD. In addition, clinical studies have demonstrated that ED in men with no known CVD often precedes a CVD event by 2–5 years. ED severity has been correlated with increasing plaque burden in patients with coronary artery disease. ED is an independent marker of increased CVD risk including all‐cause and especially CVD mortality, particularly in men aged 30–60 years. Thus, ED identifies a window of opportunity for CVD risk mitigation. We recommend that a thorough history, physical exam (including visceral adiposity), assessment of ED severity and duration and evaluation including fasting plasma glucose, lipids, resting electrocardiogram, family history, lifestyle factors, serum creatinine (estimated glomerular filtration rate) and albumin:creatinine ratio, and determination of the presence or absence of the metabolic syndrome be performed to characterise cardiovascular risk in all men with ED. Assessment of testosterone levels should also be considered and biomarkers may help to further quantify risk, even though their roles in development of CVD have not been firmly established. Finally, we recommend that a question about ED be included in assessment of CVD risk in all men and be added to CVD risk assessment guidelines.     

Initial experience of a community‐based prostate cancer risk assessment clinic for men of black and minority ethnicity background

We designed and implemented a community‐based prostate cancer risk assessment clinic targeting men from black and minority ethnicity (BME) background. This service had the dual aims of optimizing detection of prostate cancer within a local BME population, with a secondary goal of encouraging longer‐term engagement with primary care for follow‐up prostate‐specific antigen (PSA) testing in order to facilitate early diagnosis of future disease. “Drop‐in” clinics were set up in strategic locations and, staffed by experienced urology nurses. Risk assessment was offered in the form of a PSA test, and digital rectal examination (DRE). We targeted men of BME background aged between 45 and 75 but all attending individuals were given access to counselling and assessment as appropriate. In total, 312 men attended clinics for risk assessment. We diagnosed nine prostate cancers with histological confirmation, with a further two individuals considered to have prostate cancer based on clinical/biochemical parameters. These findings were consistent with similar previously published reports. Nurse‐led, community‐based targeted risk assessment is feasible, leads to the detection of significant numbers of prostate cancers and is well received by patients.     

Gender‐specific features of plasmatic and circulating cell alterations as risk factors in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death in the Western countries. Several epidemiological studies have hypothesized a gender disparity in the pathogenesis and progression of CVD. For instance, women develop CVD when they are about 10 years older than men and, typically, after menopause. However, considering that women are often excluded from research studies, sex differences in CVD remains a frontier for discovery. Very important is thus the identification of risk factors allowing us to diagnose or predict cardiovascular events taking into account gender disparities. In this review, we will examine some of the major challenges in the discovery and validation of cardiovascular biomarkers in a gender perspective. In particular, we will consider classical (hypertension, smoking, diabetes, dyslipidemia, physical inactivity) and novel (inflammation markers, markers of endothelial dysfunction, markers of coronary disease) risk factors reporting gender differences. The aim of this review was to provide an overview on current knowledge on sex‐associated cardiovascular determinants with the aim to improve CVD diagnostic and prognostic clinical courses and to develop new and gender‐biased prevention strategies.     

Men's cardiovascular and pulmonary health

Heart disease in men is declining steadily, but it remains the number one killer of men in the United States. CLRD, influenza/pneumonia, and lung cancer are three more causes of top 10 mortalities in men. Epidemiological and clinical studies conclude that CVD is largely preventable through lifestyle modification. CHD, COPD, occupational lung disease, and lung cancer are all preventable by primary prevention (ie, no cigarette smoking). All men should be counseled about the grave significance of heart and lung disease as a cause of illness and death, the importance of primary prevention, and the great variability in symptom presentation. Nurses are in the ideal position to educate patients, families, and colleagues about heart and lung disease.     

Recognition and prevention of cardiovascular disease in women

Cardiovascular disease (CVD) is the leading cause of mortality for women and among women, the number of deaths secondary to CVD is nearly twice the number of all cancer-related deaths. Mortality trends from 1979 to 2001 have shown a consistent decrease in cardiovascular mortality among men; however, cardiovascular mortality trends have remained steady or increased among women. This disparity in outcomes, in part, is secondary to a lack of awareness among women and their health care providers regarding a woman's risk for CVD. A woman's risk for CVD should be assessed at routine evaluation. Primary prevention, including lifestyle and medical interventions, should be undertaken based on risk assessment. Initiation of menopausal hormone therapy is not recommended for the prevention of coronary heart disease or stroke in women. The authors have stated that they do have a significant financial interest or other relationship with a product manufacturer or provider of services discussed in this article. The authors do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.     

The need for wider and appropriate utilization of aspirin and statins in the treatment and prevention of cardiovascular disease

There is an increasing burden of occlusive cardiovascular disease (CVD) in developed, as well as in developing, countries. In fact, the WHO has projected that CVD will become the leading cause of death in the world in the next 10 years. The proximate cause of virtually all occlusive vascular events is thrombosis and the principal underlying cause is atherosclerosis. Aspirin, which inhibits platelet-dependent cyclooxygenase for the entire life of the platelet, has clinically important antithrombotic effects. Statins, which principally decrease low-density lipoprotein cholesterol, triglycerides and increase high-density lipoprotein cholesterol, have clinically important antiatherogenic effects. In secondary prevention, in a wide range of patients who have survived a prior myocardial infarction (MI), occlusive stroke, transient ischemic attack, as well as other high-risk conditions, long-term use of aspirin confers statistically significant and clinically important reductions in MI, stroke and CVD death. In addition, aspirin confers similar benefits when administered during acute MI or acute occlusive stroke. In primary prevention, aspirin confers a statistically significant and clinically important reduction in risk of a first MI but the data on stroke and CVD death remain inconclusive, so aspirin should be prescribed on an individual basis by the healthcare provider who weighs this clear benefit against long-term side effects. In a meta-analysis of 14 randomized trials of 90,056 subjects treated for 5 years, statins confer statistically significant and clinically important reductions in MI, stroke, CVD death and total mortality. In a meta-analysis of randomized trials of statins, in which aspirin was used in varying frequencies, the combination of aspirin and statins conferred greater clinical benefits than either agent alone on MI, occlusive stroke and CVD death. At present, the wider and more appropriate use of aspirin and statins will reduce premature MI, stroke and CVD death.     

前列腺癌病因及肿瘤标志物的研究

目的：欧美等国家前列腺癌是最常见的恶性肿瘤及第二位肿瘤直接导致死亡的原因，几年前只有年龄，种族，家族遗传史被认为前列腺癌的危险因素，现在了解到还有营养，激素方面的原因。运用灵敏的诊断方法和特异的肿瘤标志物，对于临床早期发现前列腺癌至关重要。临床也急需对于选择最佳治疗方式有益的预后指标。方法：回顾总结近几年关于前列腺癌病因和肿瘤标志物研究的文献。结果：近几年发现了一些引起前列腺癌发生的高危因素和新的肿瘤标志物，本文不仅讨论了一些常规使用的瘤标，而且重点叙述了有研究价值和预后作用的标志物。结论：前列腺癌的发生原因很复杂，不仅有年龄，种族，家庭遗传的影响，还包括激素水平的失衡，膳食结构，尤其是肉类，脂肪，维生素D的摄入量，都与前列腺癌发生有关。目前PSA是早期诊断和监测前列腺癌有价值的瘤标，其他一些潜在的有预后价值的标志物仍需进一步的研究。     

Prostate Cancer in Primary Care

Prostate cancer is a common malignancy seen worldwide. The incidence has risen in recent decades, mainly fuelled by more widespread use of prostate-specific antigen (PSA) testing, although prostate cancer mortality rates have remained relatively static over that time period. A man’s risk of prostate cancer is affected by his age and family history of the disease. Men with prostate cancer generally present symptomatically in primary care settings, although some diagnoses are made in asymptomatic men undergoing opportunistic PSA screening. Symptoms traditionally thought to correlate with prostate cancer include lower urinary tract symptoms (LUTS), such as nocturia and poor urinary stream, erectile dysfunction and visible haematuria. However, there is significant crossover in symptoms between prostate cancer and benign conditions affecting the prostate such as benign prostatic hypertrophy (BPH) and prostatitis, making it very challenging to distinguish between them on the basis of symptoms. The evidence for the performance of PSA in asymptomatic and symptomatic men for the diagnosis of prostate cancer is equivocal. PSA is subject to false positive and false negative results, affecting its clinical utility as a standalone test. Clinicians need to counsel men about the risks and benefits of PSA testing to inform their decision-making. Digital rectal examination (DRE) by primary care clinicians has some evidence to show discrimination between benign and malignant conditions affecting the prostate. Patients referred to secondary care for diagnostic testing for prostate cancer will typically undergo a transrectal or transperineal biopsy, where a number of samples are taken and sent for histological examination. These biopsies are invasive procedures with side effects and a risk of infection and sepsis, and alternative tests such as multiparametric magnetic resonance imaging (mpMRI) are currently being trialled for their accuracy and safety in diagnosing clinically significant prostate cancer.     

Focus on oncology: vasectomy and the risk of prostate cancer

Around 10% of US men will be diagnosed with prostate cancer at some point in their life. Recent studies of the association between vasectomy and prostate cancer show conflicting results and weaknesses in methodologies. A retrospective cohort analysis of men aged 25-49 who had had a vasectomy between 1970 and 1986 did not find a link between vasectomy and an increased incidence in prostate cancer. In another retrospective study, 96 of 14,607 men who had had a vasectomy between 1976 and 1978 developed prostate cancer. In a prospective study conducted between 1986 and 1990, 300 of 10,500 men aged 40-75 who had had a vasectomy developed prostate cancer. In the latter two studies, vasectomy was found to be associated with an increased risk of prostate cancer, especially as time since vasectomy increased. This increased risk remained even when one controlled for lifestyle variables (both studies) and body mass index and area of residence (prospective study). The strengths of these studies are large sample sizes and controlling for lifestyle variables. The studies indicate that vasectomy may cause prostate cancer. Small increases in circulating androgen levels, which follow vasectomy, may facilitate prostate cancer development. The immune response to sperm antigens after vasectomy may promote tumor growth by blocking antibodies or tumor suppressor cells by sperm antigens. The vasectomy may keep inhibitors of cancer enhancing growth factors from reaching the prostate, thereby promoting prostate cancer. After vasectomy, there may be a reduced secretory rate of prostatic fluid, prolonging exposure to carcinogenic factors in this fluid. Urology nurses need to be up-to-date on these studies and be able to clarify the conflicting results for patients. They need to tell them that vasectomy may be linked to an increased risk of prostate cancer and that more information is needed. They must encourage men aged 40 and over to undergo regular prostate cancer screening. Men at high risk should be screened younger than age 40.     

Prostate cancer in black men of African-Caribbean descent

Prostate cancer is a significant health problem for middle-aged and elderly men. In the United States (US), it is the most frequently diagnosed cancer and is the second leading cause of cancer death. While men of all racial and ethnic backgrounds are at risk, black men of African descent are at especially high risk. African-Caribbean men, particularly Jamaican men, have the highest rate of prostate cancer in the world. The term "African-American" has been used to describe all black people living in the US. Use of such broad categorization ignores the existence of subcultures within the black community. While members of the black race may share similar primary, genetic characteristics, skin color cannot be equated with attitudes, knowledge, and behaviors of particular cultural groups. Therefore, prostate cancer interventions developed for African-American men may not be effective for men of African-Caribbean descent.     

Prospective study of high-sensitivity C-reactive protein as a determinant of mortality: results from the MONICA/KORA Augsburg Cohort Study, 1984-1998

BACKGROUND: C-reactive protein (CRP), an exquisitely sensitive systemic marker of inflammation, has emerged as an independent predictor of cardiovascular diseases (CVD). Because other chronic diseases are also associated with an inflammatory response, we sought to assess the association of high-sensitivity CRP (hsCRP) with total and cause-specific mortality in a large cohort of middle-aged men. METHODS: We measured hsCRP at baseline in 3620 middle-aged men, randomly drawn from 3 samples of the general population in the Augsburg area (Southern 0Germany) in 1984-85, 1989-90, and 1994-95. Outcome was defined as all deaths, fatal CVD, fatal coronary heart disease (CHD) including sudden cardiac deaths, and cancer deaths. RESULTS: During an average follow-up of 7.1 years, 408 deaths occurred (CVD 196, CHD 129, cancer 127). In multivariable Cox regression analysis, subjects with hsCRP >3 mg/L at baseline showed an almost 2-fold increased risk to die vs those with hsCRP <1 mg/L [hazard ratio (HR) 1.88, 95% CI 1.41-2.52]. HRs were 2.15 (95% CI 1.39-3.34) for fatal CVD, 1.74 (1.04-2.92) for fatal CHD, and 1.65 (1.01-2.68) for cancer mortality. In contrast, neither total nor HDL cholesterol significantly predicted all-cause or cancer mortality, and cholesterol had only modest effects on CVD mortality. CONCLUSIONS: Our results suggest that increased circulating hsCRP concentrations are associated with an increased risk of death from several widespread chronic diseases. Persistently increased hsCRP is a sensitive and valuable nonspecific indicator of an ongoing disease process that deserves serious and careful medical attention.     

Zinc for prostate disease and other conditions: a little evidence, a lot of hype, and a significant potential problem

Dietary and supplemental zinc, especially in excess, has received much attention in numerous alternative medicine resources. There is a small amount of medical evidence that zinc may alleviate some mostly rare medical conditions (such as Wilson's disease). However, in prostate conditions, such as BPH, large concentrations of zinc are found in the prostate gland. Excess intake of zinc, especially with individual supplements, has the potential to encourage the growth of prostate conditions from BPH to cancer. In fact, one large study found a significantly higher risk of advanced prostate cancer in men consuming large intakes of these supplements. Large doses of zinc can inhibit the benefits of bisphosphonate drugs, increase testosterone level, increase cholesterol, reduce levels of "good cholesterol" or HDL, and can promote immune dysfunction. More research is needed in this area, but in the meantime, the time seems more than ripe to discourage or immediately discontinue the intake of larger concentrations of zinc for most individuals until adequate research resolves this controversial issue.     

Baseline assessment. Report of a company wide risk factor survey

CVD accounts for the highest rates of morbidity and mortality among the general population. Unhealthy lifestyle practices are largely responsible for this occurrence. Risk factor prevalence of smoking, uncontrolled high blood pressure, and high serum cholesterol levels contribute to the likelihood of developing CVD. Two or more of these risk factors can place individuals at higher risk of developing CVD. Completing a heart health survey of risk factor prevalence among a working population will give occupational health professionals a basis on which to set goals and objectives for effective CVD intervention programs.     

Vitamin D status,gender and cardiovascular diseases: a systematic review of prospective epidemiological studies

Introduction: Vitamin D deficiency is highly suggested as an emerging risk factor in primary and secondary cardiovascular disease (CVD) prevention. However, there remains controversy regarding the need for vitamin D supplementation in high CVD risk individuals to prevent cardiac episodes and to achieve a better prognosis. Another literature gap is the potential existence of sex-specific associations of this factor with major CVD events or surrogate markers. The interaction of vitamin D and its metabolites with gene-mediated paths as well as lifestyle parameters sets the hypothesis for different effect of this factor on vascular health between men and women.

Areas covered: The aim of the systematic review was to summarize the hitherto data on the association of vitamin D with CVD prevention or progression, separately for men and women. Studies were eligible if they were published research epidemiological studies evaluating the gender-specific effect of vitamin D metabolic serum concentrations on CVD onset, progression or mortality.

Expert opinion: An unequivocal association between vitamin D deficiency and CVD has been demonstrated by large-scale epidemiological studies yet with inconclusive remarks from the standpoint of sex-specific highlights. Epidemiological and experimental studies designed to draw conclusions specified in men and women are demanded.     

Ischemic heart disease in women: a review for primary care physicians

Ischemic heart disease (IHD) is the leading cause of death among women in the Western world, and its prevalence is growing. The pathophysiology of heart disease in women differs from that in men. Women with chest pain and abnormal stress tests are less likely than men to have critical stenosis of coronary arteries, a phenomenon attributed to endothelial dysfunction. Hypertension, intimal injury, and cholesterol are among the various factors that contribute to endothelial dysfunction. The presenting symptoms of IHD also differ in women. Women are more likely to describe neck and throat pain and to characterize the pain as intense, sharp, or burning. A history of coronary or other vascular disease, diabetes, or chronic kidney disease places patients at high risk for IHD. Risk factor modification can be tailored based on each patient's risk. Hormone replacement therapy, antioxidants, folic acid, and aspirin in healthy women under 65 years of age have recently been shown to be ineffective in the prevention of IHD.     

Observed changes in cardiovascular risk factors among high-risk middle-aged men who received lifestyle counselling: a 5-year follow-up

Objective: To examine the long-term impact of health counselling among middle-aged men at high risk of CVD.

Design: An observational study with a 5-year follow-up.

Setting and intervention: All men aged 40 years in Helsinki have been invited to a visit to evaluate CVD risk from 2006 onwards. A modified version of the North Karelia project risk tool (CVD risk score) served to assess the risk. High-risk men received lifestyle counselling based on their individual risk profile in 2006 and were invited to a follow-up visit in 2011.

Subjects: Of the 389 originally high-risk men, 159 participated in the follow-up visits in 2011. Based on their follow-up in relation the further risk communication, we divided the participants into three groups: primary health care, occupational health care and no control visits.

Main outcome measures: Lifestyle and CVD risk score change.

Results: All groups showed improvements in lifestyles. The CVD risk score decreased the most in the group that continued the risk communication visits in their primary health care centre (6.1 to 4.8 [95% CI ?1.6 to ?0.6]) compared to those who continued risk communication visits in their occupational health care (6.0 to 5.4 [95% CI ?1.3 to 0.3]), and to those with no risk communication visits (6.0 to 5.9 [95% CI ?0.5 to 0.4]).

Conclusions: These findings indicate that individualized lifestyle counselling improves health behaviour and reduces total CVD risk among middle-aged men at high risk of CVD. Sustained improvement in risk factor status requires ongoing risk communication with health care providers.

• KEY POINTS

• Studies of short duration have shown that lifestyle changes reduce the risk of cardiovascular disease among high-risk individuals.

• Sustaining these lifestyle changes and maintaining the lower disease risk attained can prove challenging.

• Cardiovascular disease (CVD) risk assessment and individualized health counselling for high-risk men, when implemented in primary health care, have the potential to initiate lifestyle changes that support risk reduction.

• Attaining a sustainable reduction in CVD risk requires a willingness to engage in risk-related communication from both health care providers and the individual at high risk.