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November 2007 in Review
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Little Decline in CHD mortality among young adults especially in women observed in US
Ford ES, Capewell S.
Coronary heart disease mortality among young adults in the U.S. from
1980 through 2002: concealed leveling of mortality rates.J Am Coll
Cardiol. 2007 Nov 27;50(22):2128-32
Aim: Determine
age-specific mortality rates from coronary heart disease (CHD) in
United States (US), especially among younger adults from 1988-2002
Methods: For the purposes of determining age specific CHD mortality the investigators used the vital statistics data from the U.S.. The analyses was limited to those age > 35 years. The underlying CHD death was determined using the International Classification of Diseases (ICD)-9 codes
Results:
- The age-adjusted mortality rate declined from 1980-2002 approximately 52% in men and by 49% in women.
- However
among younger individuals (35-54 years) the rate in mortality reduction
was more significant from 1980-1990 whereas the changes were less from
period 1991-2002
- Most
importantly, the authors noted that particularly the mortality rate
among younger women (35-44 years) has increased significantly by 1.3%
(95% CI 0.2 to 2.5) per year since 1997.
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SHAPE Perspective:
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This
paper describes that efforts in reducing CHD related deaths which has
seen a huge success in the last 2 decades are reaching a nadir and
actually an increase in CHD related deaths are been observed in younger
individuals.
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It
is important to note that the data reflects deaths from CHD which are
influenced by both secondary and primary preventive efforts and is not
a good indicator of how well are we doing in preventing new CHD events.
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The
findings suggest it is urgent to initiate more aggressive strategies
for prevention and treatment of risk factors, as well early detection
of subclinical disease in order to reduce the risk of increased CHD
morbidity and mortality in younger men and women.
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Lehto
HR, Lehto S, Havulinna AS, Ketonen M, Lehtonen A, Kesaniemi YA,
Airaksinen J, Salomaa V.Are coronary event rates declining slower in
women than in men - evidence from two population-based myocardial
infarction registers in Finland? BMC Cardiovasc Disord. 2007 Nov
12;7(1):35
Aim: The
aim of this study was to compare the onset as well mortality of
myocardial infarction (MI) events in women vs. men in Finland.
Methods: For
this study the authors used 2 large population-based MI registers in
Finland, the FINAMI register and the Finnish Cardiovascular Disease
Register (CVDR) and assessed the event rates among men and women aged
older than 35 years in two time periods, 1994-1996 and 2000-2002.
Results:
- In
the FINAMI register there were 4,586 (2,370 in men and 2,216 in women)
CHD events in the 1994-96, whereas 5,564 (2,882 in men and 2,682 in
women) were observed in the 220-02. The respective events in the CVDR
were 72,699 (38,849 in men and 33,850 in women) and 76,474 (39,860 in
men and 36,614 in women)
- In both registries, smaller declines in MI incidence and related deaths in women compared to men were observed.
- The decline was especially slower among women²55 years of age.
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SHAPE Perspective:
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This
study further provides support to the notion that historically women
have been underestimated and under-treated for heart disease risk.
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Some of these finding can be explained by significant underestimation by traditional risk factor assessment approaches.
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There
is an urgent need to identify new approaches to better identify high
risk individuals especially women in order to reduce the risk of
incident heart disease as well its related mortality.
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Combination of hypertension and diabetes is associated with a very high risk of occurrence of coronary heart disease
Hu G, Jousilahti P, Tuomilehto J.
Joint effects of history of hypertension at baseline and type 2
diabetes at baseline and during follow-up on the risk of coronary heart
disease. Eur Heart J. 2007 Nov 2; [Epub ahead of print]
Aim: To
evaluate the combined effect of hypertension and type 2 diabetes
mellitus (DM) on the incidence of coronary heart disease (CHD) as well
CHD related mortality.
Methods: The
study population consisted of 49 775 Finnish subjects aged 25-74
without history of cardiovascular diseases who were followed for median
of 21.5 years.
Results:
- During the follow-up period overall 5074 incident CHD events were recorded including 3134 CHD-related deaths.
- In
men, as compared to those without hypertension as well diabetes,
increasing levels of hypertension was associated with CHD outcome with
hazard ratios of 1.35-1.98 in men, whereas presence of DM was
associated with 2.54 fold higher risk of CHD event. In women the
respective hazard ratios were 1.61-2.61 and 5.88.
- On
the other hand presence of combined DM and hypertension was associated
with a much higher risk of CHD events in both men (2.28-3.65) and women
(6.65-8.66)
SHAPE Perspective:
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Both hypertension and type 2 diabetes were independently associated with an increased risk of the incidence of CHD and CHD mortality.
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However presence of both conditions is significantly related to a more adverse outcome, especially in women.
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Patients
with both these conditions need to be treated aggressively and strongly
be considered for lipid lowering therapy as well aspirin, apart from
glycemic and blood pressure control.
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Elderly women with multiple risk factors may be candidate for ultrasound screening for abdominal aortic aneurysms
Derubertis
BG, Trocciola SM, Ryer EJ, Pieracci FM, McKinsey JF, Faries PL, Kent
KC. Abdominal aortic aneurysm in women: prevalence, risk factors, and
implications for screening.J Vasc Surg. 2007 Oct;46(4):630-635
Aim: The
study aims to define the prevalence and risk factors associated with
the development of abdominal aortic aneurysm (AAA) in women
Methods: The
study population was derived of those with cardiovascular risk factors
or a family history of AAA for a abdominal ultrasound (US) assessment
of abdominal aorta from 2004-2006. All risk factors information was obtained through a questionnaire. Overall 17,540 subjects were screened for AAA, including 10,012 women and 7528 men (mean age 70 years). AAA was considered if an infra-renal aortic diameter of ³3 cm was defined as an AAA for both men and women.
Results:
SHAPE Perspective:
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Currently
national guidelines do not recommend US screening of AAA in women due
to low prevalence as also observed in this study.
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However
a subset of women who are elderly and have multiple risk factors are at
much higher risk of AAA, and may be considered as candidate for US
screening as they may more likely to benefit from such screening
efforts to reduce AAA-related mortality.
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Women more likely to have aortic atherosclerosis compared to men in absence of hypertension
Oyama
N, Gona P, Salton CJ, Chuang ML, Jhaveri RR, Blease SJ, Manning AR,
Lahiri M, Botnar RM, Levy D, Larson MG, O'Donnell CJ, Manning WJ.
Differential Impact of Age, Sex, and Hypertension on Aortic
Atherosclerosis. The Framingham Heart Study.Arterioscler Thromb Vasc
Biol. 2007 Nov 8
Aim: The
aim of the study was to assess the relationship of age, sex and
hypertension with aortic atherosclerosis using cardiac magnetic
resonance (CMR) imaging in Framingham Heart Study.
Methods: The
study population consisted of 1726 subjects from the Framingham Heart
Study who underwent CMR of the thoracic and abdominal portion of the
aorta. Atherosclerotic plaque was defined as characteristic luminal protrusions of ³1 mm in radial thickness that was visually distinguished from the blood signal in the lumen. Association of plaque in abdominal as well thoracic aorta were assessed according to age, gender and hypertension.
Results:
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SHAPE Perspective:
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In
this population-based CMR study women in absence of hypertension had a
significantly higher risk of aortic atherosclerosis, a finding
paradox to higher risk o atherosclerosis among men in other vascular
beds.
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However
emerging data has also demosntrated a higher risk of aortic
calcification, a surrogate for atherosclerosis in aorta to be higher in
women compared to women.
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As
a result identification of atherosclerotic measures in other vascular
areas apart from coronaries may identify those with early
atherosclerosis especially in women to initiate increased early
preventive treatment.
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Retinal
narrowing may identify individuals with reduced myocardial perfusion
among individuals with absence of coronary calcification
Wang L, Wong TY, Sharrett AR, Klein R, Folsom AR, Jerosch-Herold . Relationship
Between Retinal Arteriolar Narrowing and Myocardial Perfusion:
Multi-Ethnic Study of Atherosclerosis. Hypertension. 2007 Nov 12; [Epub
ahead of print]
Aim: To
assess whether retinal arteriolar narrowing which is a marker of
chronic hypertension is related to coronary microvascular abnormalities
as determined by myocardial perfusion.
Methods: The
study population consisted of 212 men and women (age 45-84 years) who
were free of known cardiovascular disease from the Multi-ethnic study
of Atherosclerosis. Retinal caliber was measured through
fundus photography and presented as central retinal arteriolar and
venular caliber equivalents. Myocardial blood flow was measured using magnetic resonance imaging (MRI) during rest as well with adenosine-induced hyperemia.
Results:
- The
mean hyperemic blood flow and perfusion reserve was significantly lower
across lower retinal arteriolar caliber among individuals with absence
of coronary calcification as measured by non-contrast CT. The
relationship persisted even after taking into account CHD risk factors.
- No
relationship between MRI measured myocardial perfusion and retinal
arteriolar caliber was noted among those with coronary calcification.
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SHAPE Perspective:
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The
study findings suggest that among individuals with absence of coronary
calcification, presence of retinal narrowing may be able to identify a
subset of individuals who may potentially be at a higher risk of future
CVD events among this very low risk cohort.
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However
in order to establish the utility of measuring retinal arteriolar
narrowing in this low risk group, it will be important to establish
that these individuals are more likely to develop coronary
calcification as well more likely to suffer an acute CHD events.
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Coronary artery calcification predict mortality among elderly men
Abbott RD, Ueshima H, Masaki KH, Willcox BJ, Rodriguez BL, Ikeda A, Yano K, White LR, Curb JD Coronary Artery Calcification and Total Mortality in Elderly Men J Am Geriatr Soc. 2007; [Epub ahead of print]
Aim: To assess the relationship between coronary artery calcification (CAC) and mortality in elderly men
Methods: The study population consisted of 224 elderly men (age 84-96 years) with good cognitive function who underwent CAC testing. These patients were followed for a mean of 3 years for an all cause mortality.
Results:
- Overall 17 deaths (8%) were noted in the follow-up period.
- No deaths were seen in those with CAC<10.
- The
risk of death rose from 13.2/1000 person years in those with CAC 10-100
up to 48.6/1000 person years with CAC scores>1000.
- In multivariate analysis, CAC was the only factor associated with risk of death.
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SHAPE Perspective:
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To
date extensive data has demosntrated that CAC is an excellent predictor
of future adverse CHD events in middle aged individuals.
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This study adds to the current literature by demonstrating excellent predictive value of measuring CAC even in the elderly (³84 years) men.
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Higher
burden of CAC in elderly men may identify a subset of very high risk
individuals requiring very aggressive preventive therapies and regular
follow-up.
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The results of this study may however not apply to women.
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Reduced ankle brachial index strongly predicts adverse CHD events among diabetic patients
Filippella
M, Lillaz E, Ciccarelli A, Giardina S, Massimetti E, Navaretta F,
Antico A, Veronesi M, Lombardi G, Colao A, Ghigo E, Benso A, Doveri
G.Ankle brachial pressure index usefulness as predictor factor for
coronary heart disease in diabetic patients. J Endocrinol Invest. 2007
Oct;30(9):721-725
Aim: To
assess whether a reduced ankle brachial index (ABI) is associated with
poor CHD outcome among patients with type 2 diabetes mellitus (DM).
Methods: The investigators followed 961 consecutive patients with Type 2 DM were followed-up for 18±5 months (range 12- 24). All patients underwent ABI assessment. Levels<0.9 were considered as reduced ABI. CHD
events were defined as myocardial infarction, unstable and resting
angina or coronary atherosclerosis at the coronary angiography and/or
perfusion stress testing.
Results:
- In the follow up time 17.5% of CHD events were recorded.
- The relative risk of CHD was significantly increased with reduced ABI<0.90 (OR: 3.7; 95% CI: 2.2- 6.2).
- The relationship remained robust event after taking into account multiple risk factors.
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SHAPE Perspective:
- By
current practices, presence of DM is considered CHD risk equivalent and
needs to be considered for lipid lowering management and treatment of
all risk factors.
- However
measures of underlying subclinical disease such as ABI may identify
those at even higher risk for CHD events and thus requiring more
aggressive treatment as well more frequent evaluations for the efficacy
of these therapies.
- However
studies are needed to identify whether utilization of subclinical
disease measurement in a very high risk population such as those with
DM will be a cost effective approach.
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Primary
health care based counseling intervention on physical activity and diet
are effective in improved behavioral modification & CHD risk
reduction
Hardcastle S, Taylor A, Bailey M, Castle R.
A randomised controlled trial on the effectiveness of a primary health
care based counselling intervention on physical activity, diet and CHD
risk factors. Patient Educ Couns. 2007 Nov 6; [Epub ahead of print]
Aim: To
determine if lifestyle counseling sessions would be result in improved
lifestyle behaviors as well reduction in CHD risk factors
Methods: The
study investigators conducted a randomized trial to compare the
counseling intervention with usual care among 334 mostly obese
patients. Patients in the intervention group received
standard exercise and nutrition information as well 5 counseling
sessions with a physical activity specialist as well a registered
dietician over a 6-month period. The control group only received the standard information.
Results:
- Over the period of the study, more than 50% participants attended at least 3 sessions.
- At
6 months follow-up those who were in the counseling group compared to
controls, were more likely to actively participating in regular
exercise and in the interim period had reduced weight, blood pressure
and cholesterol levels; although no change in diet was noted.
- In
addition participants who attended more sessions had greater increases
in activity and reductions in weight, blood pressure and cholesterol.
SHAPE Perspective:
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This
study highlights the role of multifaceted approach including
specialized counseling for physical activity as well diet are
associated with improved behavioral modification in high risk patients
and should be a part of the overall preventive treatment strategies.
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Increased physical activity and diet modification improves metabolic and vascular dysfunction in obsess children
Kelishadi R, Hashemi M, Mohammadifard N, Asgary S, Khavarian N.
Association of Changes in Oxidative and Proinflammatory States with
Changes in Vascular Function after a Lifestyle Modification Trial Among
Obese Children Clin Chem. 2007 Nov 12; [Epub ahead of print]
Aim: To assess
association of changes in oxidative and proinflammatory markers of
vascular function with diet and exercise intervention among obese
children
Methods: The investigators conducted a 6-week diet and exercise intervention study in 35 obese children (12-18 years of age). Participants
performed supervised aerobic physical activity of moderate to vigorous
intensity for 60 min, 3 days a week for 6 consecutive weeks. In
addition, received dietary advice from a registered dietitian. The
effect of these interventions were assessed on anthropometric indices,
insulin resistance, C-reactive protein (CRP), oxidized LDL (ox-LDL), as
well changes in carotid intima-media thickness (CIMT) and flow mediated
dilation (FMD) of the brachial artery.
Results:
- In the 6 month period the authors noticed a reduction in BMI as well waist circumference and body fat% with these interventions.
- Overall a significant reduction in CRP, lipid levels as well improved insulin resistance was observed over the 6 months period.
- These
children also demosntrated an improvement in FMD (p<0.05), however
the reduction in CIMT did not achieve statistical significance. were
decreased (P <0.05), but participants remained overweight (BMI
>/= 95th percentile). Although FMD improved (P <0.05), the
improvement in C-IMT did not reach statistical significance After
taking into account all risk factors, PAD was associated with a 40%
increase in mortality (hazard ratio: 1.4, 95% CI: 1.3-1.5, p<0.001).
- The
changes in obesity measures, CRP and insulin resistance had an
inverse correlation with the changes in mean FMD and CIMT after
adjustment for age and sex
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SHAPE Perspective:
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The
study demonstrates that increased obesity with associated inflammation
and abnormal lipid markers are associated with development vascular
dysfunction.
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These
changes are reversible with increased focus on exercise and diet
modifications indicating a need for an increased focus on lifestyle
modification in these young adults to prevent development of CHD during
adulthood.
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