Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes
N Engl J Med 2008 Feb 7; 358:580.
Peter Gæde, M.D., D.M.Sc., Henrik Lund-Andersen, M.D., D.M.Sc., Hans-Henrik Parving, M.D., D.M.Sc., and Oluf Pedersen, M.D., D.M.Sc.
ABSTRACT
Background
Intensified multifactorial intervention — with tight glucose regulation and the use of renin–angiotensin system blockers, aspirin, and lipid-lowering agents — has been shown to reduce the risk of nonfatal cardiovascular disease among patients with type 2 diabetes mellitus and microalbuminuria. We evaluated whether this approach would have an effect on the rates of death from any cause and from cardiovascular causes.
Methods
In the Steno-2 Study, we randomly assigned 160 patients with type 2 diabetes and persistent microalbuminuria to receive either intensive therapy or conventional therapy; the mean treatment period was 7.8 years. Patients were subsequently followed observationally for a mean of 5.5 years, until December 31, 2006. The primary end point at 13.3 years of follow-up was the time to death from any cause.
Results
Twenty-four patients in the intensive-therapy group died, as compared with 40 in the conventional-therapy group (hazard ratio, 0.54; 95% confidence interval [CI], 0.32 to 0.89; P=0.02). Intensive therapy was associated with a lower risk of death from cardiovascular causes (hazard ratio, 0.43; 95% CI, 0.19 to 0.94; P=0.04) and of cardiovascular events (hazard ratio, 0.41; 95% CI, 0.25 to 0.67; P<0.001). One patient in the intensive-therapy group had progression to end-stage renal disease, as compared with six patients in the conventional-therapy group (P=0.04). Fewer patients in the intensive-therapy group required retinal photocoagulation (relative risk, 0.45; 95% CI, 0.23 to 0.86; P=0.02). Few major side effects were reported.
Conclusions
In at-risk patients with type 2 diabetes, intensive intervention with multiple drug combinations and behavior modification had sustained beneficial effects with respect to vascular complications and on rates of death from any cause and from cardiovascular causes.
Showing posts with label Cardiac Risk. Show all posts
Showing posts with label Cardiac Risk. Show all posts
Thursday, February 7, 2008
Thursday, January 10, 2008
Athletes and Electrocardiograms
Athletes and Electrocardiograms
Journal Watch Cardiology January 9, 2008
Abnormal ECG findings were associated with an increased risk for heart disease in a cohort of highly trained athletes.
The death of a young athlete is the kind of tragedy that inspires poetry and shakes communities. Although such events are rare, there is great interest in identifying individuals at risk and intervening before a fatal event occurs.
Physicians are often challenged to make judgments about risk in individuals who have abnormal 12-lead electrocardiograms but no evidence of structural heart disease. To determine whether an abnormal ECG is a marker of risk in athletically conditioned individuals, investigators analyzed a database of electrocardiographic and echocardiographic findings from 12,550 Italian athletes. The investigators identified 81 athletes with electrocardiographic — but no echocardiographic — abnormalities at initial examination (mean age, 23) and for whom serial follow-up data were available. Inclusion criteria for these cases were marked repolarization abnormalities, defined as inverted T waves in at least three leads. A total of 229 control patients with normal ECGs were matched with case patients by age, sex, and duration of follow-up.
Case patients had participated in a variety of sports (most commonly, soccer and rowing or canoeing). During a mean follow-up of 9 years, 11 athletes with initial electrocardiographic abnormalities developed a cardiovascular disorder (cardiomyopathy in 5, other disorders in 6).
One athlete died from an undetected arrhythmogenic right ventricular cardiomyopathy. None of the control patients developed a cardiomyopathy (P=0.001); four developed other
cardiovascular disorders (P=0.05).
Comment: This small but important study suggests that we clinicians should not dismiss an abnormal electrocardiogram in a trained athlete just because the echocardiogram findings are normal. However, the question remains: How best to advise these athletes? They may be at increased risk, but it is not clear if that risk can be modified, and most of the athletes in this study did not develop cardiovascular problems.
Harlan M. Krumholz, MD, SM
Published in Journal Watch Cardiology January 9, 2008
Citation(s):
Pelliccia A et al. Outcomes in athletes with marked ECG repolarization abnormalities. N Engl J Med 2008 Jan 10; 358:152.
Original article (Subscription may be required)
Journal Watch Cardiology January 9, 2008
Abnormal ECG findings were associated with an increased risk for heart disease in a cohort of highly trained athletes.
The death of a young athlete is the kind of tragedy that inspires poetry and shakes communities. Although such events are rare, there is great interest in identifying individuals at risk and intervening before a fatal event occurs.
Physicians are often challenged to make judgments about risk in individuals who have abnormal 12-lead electrocardiograms but no evidence of structural heart disease. To determine whether an abnormal ECG is a marker of risk in athletically conditioned individuals, investigators analyzed a database of electrocardiographic and echocardiographic findings from 12,550 Italian athletes. The investigators identified 81 athletes with electrocardiographic — but no echocardiographic — abnormalities at initial examination (mean age, 23) and for whom serial follow-up data were available. Inclusion criteria for these cases were marked repolarization abnormalities, defined as inverted T waves in at least three leads. A total of 229 control patients with normal ECGs were matched with case patients by age, sex, and duration of follow-up.
Case patients had participated in a variety of sports (most commonly, soccer and rowing or canoeing). During a mean follow-up of 9 years, 11 athletes with initial electrocardiographic abnormalities developed a cardiovascular disorder (cardiomyopathy in 5, other disorders in 6).
One athlete died from an undetected arrhythmogenic right ventricular cardiomyopathy. None of the control patients developed a cardiomyopathy (P=0.001); four developed other
cardiovascular disorders (P=0.05).
Comment: This small but important study suggests that we clinicians should not dismiss an abnormal electrocardiogram in a trained athlete just because the echocardiogram findings are normal. However, the question remains: How best to advise these athletes? They may be at increased risk, but it is not clear if that risk can be modified, and most of the athletes in this study did not develop cardiovascular problems.
Harlan M. Krumholz, MD, SM
Published in Journal Watch Cardiology January 9, 2008
Citation(s):
Pelliccia A et al. Outcomes in athletes with marked ECG repolarization abnormalities. N Engl J Med 2008 Jan 10; 358:152.
Original article (Subscription may be required)
Wednesday, January 9, 2008
Physical Activity, Moderate Alcohol Intake Associated with Improved Survival
Physical Activity, Moderate Alcohol Intake Associated with Improved Survival
Physical activity and moderate alcohol consumption may help reduce fatal ischemic heart disease (IHD) and all-cause mortality, reports the European Heart Journal.
Nearly 12,000 Danish adults without previous IHD reported their alcohol intake and physical activity level and then were followed for about 20 years. Overall, about half died, with IHD accounting for 20% of the deaths.
After adjustment for confounders such as age and smoking status, active subjects had lower risks for fatal IHD and all-cause mortality than inactive subjects, and moderate drinkers (1 to 14 drinks a week) had lower mortality risks than nondrinkers. A combination of physical activity and moderate drinking appeared most beneficial — active subjects who consumed at least one drink weekly had up to a 50% lower risk for fatal IHD and up to a 33% lower all-cause mortality risk.
European Heart Journal article (Free PDF)
Abstract:
The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischaemic heart disease and all-cause mortality
Aims
To determine the combined influence of leisure-time physical activity and weekly alcohol intake on the risk of subsequent fatal ischaemic heart disease (IHD) and all-cause mortality.
Methods and results
Prospective cohort study of 11 914 Danes aged 20 years or older and without pre-existing IHD. During _20 years of follow-up, 1242 cases of fatal IHD occurred and 5901 died from all causes. Within both genders, being physically active was associated with lower hazard ratios (HR) of both fatal IHD and all-cause mortality than being physically inactive. Further, weekly alcohol intake was inversely associated with fatal IHD and had a U-shaped association with all-cause mortality. Within level of physical activity, non-drinkers had the highest HR of fatal IHD, whereas both non-drinkers and heavy drinkers had the highest HR of all-cause mortality. Further, the physically inactive had the highest HR of both fatal IHD and all-cause mortality within each category of weekly alcohol intake. Thus, the HR of both fatal IHD and all-cause mortality were low among the physically active who had a moderate alcohol intake.
Conclusion
Leisure-time physical activity and a moderate weekly alcohol intake are both important to lower the risk of fatal IHD and all-cause mortality.
Physical activity and moderate alcohol consumption may help reduce fatal ischemic heart disease (IHD) and all-cause mortality, reports the European Heart Journal.
Nearly 12,000 Danish adults without previous IHD reported their alcohol intake and physical activity level and then were followed for about 20 years. Overall, about half died, with IHD accounting for 20% of the deaths.
After adjustment for confounders such as age and smoking status, active subjects had lower risks for fatal IHD and all-cause mortality than inactive subjects, and moderate drinkers (1 to 14 drinks a week) had lower mortality risks than nondrinkers. A combination of physical activity and moderate drinking appeared most beneficial — active subjects who consumed at least one drink weekly had up to a 50% lower risk for fatal IHD and up to a 33% lower all-cause mortality risk.
European Heart Journal article (Free PDF)
Abstract:
The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischaemic heart disease and all-cause mortality
Aims
To determine the combined influence of leisure-time physical activity and weekly alcohol intake on the risk of subsequent fatal ischaemic heart disease (IHD) and all-cause mortality.
Methods and results
Prospective cohort study of 11 914 Danes aged 20 years or older and without pre-existing IHD. During _20 years of follow-up, 1242 cases of fatal IHD occurred and 5901 died from all causes. Within both genders, being physically active was associated with lower hazard ratios (HR) of both fatal IHD and all-cause mortality than being physically inactive. Further, weekly alcohol intake was inversely associated with fatal IHD and had a U-shaped association with all-cause mortality. Within level of physical activity, non-drinkers had the highest HR of fatal IHD, whereas both non-drinkers and heavy drinkers had the highest HR of all-cause mortality. Further, the physically inactive had the highest HR of both fatal IHD and all-cause mortality within each category of weekly alcohol intake. Thus, the HR of both fatal IHD and all-cause mortality were low among the physically active who had a moderate alcohol intake.
Conclusion
Leisure-time physical activity and a moderate weekly alcohol intake are both important to lower the risk of fatal IHD and all-cause mortality.
Monday, January 7, 2008
Anxiety Predicts Increased MI Risk
Anxiety Predicts Increased MI Risk
MedPage Today
LOS ANGELES, Jan. 7 -- Among older men with no history of coronary disease, anxiety predicts an increased risk of myocardial infarction, irrespective of cardiac risk factors, investigators here found.
The adjusted relative risk of MI associated with each standard deviation increase in anxiety was 1.43 (95% confidence interval: 1.17 to 1.75), Biing-Jiun Shen, Ph.D., of the University of Southern California, and colleagues reported in the Jan. 8 issue of the Journal of the American College of Cardiology.
In addition to overall anxiety, several specific manifestations of anxiety also independently predicted an increased risk of MI, the researchers said.
"The results suggest that moderately elevated anxiety is associated with a modest risk of MI and severe anxiety represents an MI risk that may warrant attention," the authors concluded.
"The findings indicate that anxiety not only represents an independent, prospective, and unique risk factor for MI, but may also explain the associations between MI and other psychosocial risk factors observed in earlier studies."
Several psychological conditions, including anxiety, have been associated with the onset of coronary artery disease, independent of conventional CAD risk factors, the authors noted.
However, previous studies left a variety of conceptual and methodologic issues unaddressed.
In an effort to explore some of them, the researchers evaluated 735 older men (mean age 60) enrolled in the prospective Normative Aging Study. The men had no history of coronary artery disease or diabetes at baseline.
The investigators assessed anxiety by means of four scales from the Minnesota Multiphasic Personality Inventory: psychasthenia, social introversion, phobia, and manifest anxiety. Overall anxiety was calculated from scores on the four scales.
After a mean follow-up of 12.4 years, anxiety traits independently predicted MI risk after controlling for age, education, marital status, fasting glucose, body mass index, HDL cholesterol, and systolic blood pressure.
The following adjusted relative risks emerged from the analysis:
Psychasthenia, 1.37 (95% CI: 1.12 to 1.68)
Social introversion, 1.31 (95% CI: 1.05 to 1.63)
Phobia, 1.36 (95% CI: 1.10 to 1.68)
Manifest anxiety, 1.42 (95% CI: 1.14 to 1.76)
Overall anxiety, 1.43 (95% CI: 1.17 to 1.75)
The relationships remained significant after further adjustment for health behaviors, use of medications for hypertension, hypercholesterolemia, and diabetes during follow-up, and additional psychological variables.
The authors suggested several potential explanations for the findings:
Associations between anxiety and repeated and chronic elevations of stress
Dysregulation of stress-related pathophysiologic pathways (such as hypothalamic-pituitary-adrenal axis and disturbed platelet activation)
Stimulation of systemic inflammation
Reduced vagal tone and heart-rate variability
The study was performed mainly in otherwise healthy Caucasian men, which limits extrapolation of findings to other groups.
Although anxiety was the strongest predictor of MI risk among psychological variables, the authors cautioned against dismissing other psychological factors, such as depression and hostility.
"Psychological factors are interrelated and may contribute to one another in a reciprocal fashion," they stated. "Recognizing multiple psychosocial risk components may better inform risk assessment and management for people at higher risk for MI."
MedPage Today
LOS ANGELES, Jan. 7 -- Among older men with no history of coronary disease, anxiety predicts an increased risk of myocardial infarction, irrespective of cardiac risk factors, investigators here found.
The adjusted relative risk of MI associated with each standard deviation increase in anxiety was 1.43 (95% confidence interval: 1.17 to 1.75), Biing-Jiun Shen, Ph.D., of the University of Southern California, and colleagues reported in the Jan. 8 issue of the Journal of the American College of Cardiology.
In addition to overall anxiety, several specific manifestations of anxiety also independently predicted an increased risk of MI, the researchers said.
"The results suggest that moderately elevated anxiety is associated with a modest risk of MI and severe anxiety represents an MI risk that may warrant attention," the authors concluded.
"The findings indicate that anxiety not only represents an independent, prospective, and unique risk factor for MI, but may also explain the associations between MI and other psychosocial risk factors observed in earlier studies."
Several psychological conditions, including anxiety, have been associated with the onset of coronary artery disease, independent of conventional CAD risk factors, the authors noted.
However, previous studies left a variety of conceptual and methodologic issues unaddressed.
In an effort to explore some of them, the researchers evaluated 735 older men (mean age 60) enrolled in the prospective Normative Aging Study. The men had no history of coronary artery disease or diabetes at baseline.
The investigators assessed anxiety by means of four scales from the Minnesota Multiphasic Personality Inventory: psychasthenia, social introversion, phobia, and manifest anxiety. Overall anxiety was calculated from scores on the four scales.
After a mean follow-up of 12.4 years, anxiety traits independently predicted MI risk after controlling for age, education, marital status, fasting glucose, body mass index, HDL cholesterol, and systolic blood pressure.
The following adjusted relative risks emerged from the analysis:
Psychasthenia, 1.37 (95% CI: 1.12 to 1.68)
Social introversion, 1.31 (95% CI: 1.05 to 1.63)
Phobia, 1.36 (95% CI: 1.10 to 1.68)
Manifest anxiety, 1.42 (95% CI: 1.14 to 1.76)
Overall anxiety, 1.43 (95% CI: 1.17 to 1.75)
The relationships remained significant after further adjustment for health behaviors, use of medications for hypertension, hypercholesterolemia, and diabetes during follow-up, and additional psychological variables.
The authors suggested several potential explanations for the findings:
Associations between anxiety and repeated and chronic elevations of stress
Dysregulation of stress-related pathophysiologic pathways (such as hypothalamic-pituitary-adrenal axis and disturbed platelet activation)
Stimulation of systemic inflammation
Reduced vagal tone and heart-rate variability
The study was performed mainly in otherwise healthy Caucasian men, which limits extrapolation of findings to other groups.
Although anxiety was the strongest predictor of MI risk among psychological variables, the authors cautioned against dismissing other psychological factors, such as depression and hostility.
"Psychological factors are interrelated and may contribute to one another in a reciprocal fashion," they stated. "Recognizing multiple psychosocial risk components may better inform risk assessment and management for people at higher risk for MI."
Friday, January 4, 2008
Single-lead ST-segment deviation after primary angioplasty
Single-lead ST-segment deviation after primary angioplasty
By Caroline Price
04 January 2008
Heart 2008; 94: 44-47
MedWire News: Residual ST-segment deviation in a single lead 3 hours after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is an “easy and accurate” predictor of 1-year mortality, cardiologists report.
Electrocardiography (ECG) is a simple way to measure reperfusion outcomes, with ST-segment deviation providing better prognostic accuracy than ST-segment resolution, explain A van’t Hof (Hospital De Weezenlanden, Zwolle, The Netherlands) and team.
To evaluate the prognostic role of postprocedural single-lead ST-segment deviation (STD) in primary angioplasty, relative to single-lead ST-segment resolution and elevation, and 12-lead ST-segment deviation, the researchers prospectively studied 1660 STEMI patients undergoing the procedure between 1997 and 2002.
Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow, residual stenosis <50%, and myocardial blush grade (MBG) 2-3. ECGs were recorded at 3 hours after the procedure.
As reported in the journal Heart, maximal residual STD correlated well with postprocedural MBG 3, distal embolization, enzymatic infarct size, and predischarge left ventricular ejection fraction.
At 1 year of follow-up, 63 (3.8%) patients had died. In multivariate analysis, after correction for baseline characteristics, maximal residual single-lead STD was the strongest predictor of mortality of all postprocedural ECG measures, at a hazard ratio of 1.87 (p<0.001).
Using receiver operating characteristic curves, the researchers identified ≥2 mm as the optimal threshold for maximal single-lead STD.
“The simple evaluation of maximal residual STD in a single lead 3 hours after the procedure is the best electrocardiographic measure for the evaluation of myocardial perfusion and prognostic stratification of patients with STEMI treated with primary angioplasty,” the authors write.
Link: http://heart.bmj.com/cgi/content/abstract/94/1/44
By Caroline Price
04 January 2008
Heart 2008; 94: 44-47
MedWire News: Residual ST-segment deviation in a single lead 3 hours after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is an “easy and accurate” predictor of 1-year mortality, cardiologists report.
Electrocardiography (ECG) is a simple way to measure reperfusion outcomes, with ST-segment deviation providing better prognostic accuracy than ST-segment resolution, explain A van’t Hof (Hospital De Weezenlanden, Zwolle, The Netherlands) and team.
To evaluate the prognostic role of postprocedural single-lead ST-segment deviation (STD) in primary angioplasty, relative to single-lead ST-segment resolution and elevation, and 12-lead ST-segment deviation, the researchers prospectively studied 1660 STEMI patients undergoing the procedure between 1997 and 2002.
Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow, residual stenosis <50%, and myocardial blush grade (MBG) 2-3. ECGs were recorded at 3 hours after the procedure.
As reported in the journal Heart, maximal residual STD correlated well with postprocedural MBG 3, distal embolization, enzymatic infarct size, and predischarge left ventricular ejection fraction.
At 1 year of follow-up, 63 (3.8%) patients had died. In multivariate analysis, after correction for baseline characteristics, maximal residual single-lead STD was the strongest predictor of mortality of all postprocedural ECG measures, at a hazard ratio of 1.87 (p<0.001).
Using receiver operating characteristic curves, the researchers identified ≥2 mm as the optimal threshold for maximal single-lead STD.
“The simple evaluation of maximal residual STD in a single lead 3 hours after the procedure is the best electrocardiographic measure for the evaluation of myocardial perfusion and prognostic stratification of patients with STEMI treated with primary angioplasty,” the authors write.
Link: http://heart.bmj.com/cgi/content/abstract/94/1/44
Statins for Secondary Prevention in Elderly Patients
Statins for Secondary Prevention in Elderly Patients
A Hierarchical Bayesian Meta-Analysis
Jonathan Afilalo, Gustavo Duque, Russell Steele, J. Wouter Jukema, Anton J.M. de Craen, and Mark J.
J Am Coll Cardiol Volume 51, Issue 1, January 1/8, 2008
Objectives: This study was designed to determine whether statins reduce all-cause mortality in elderly patients with coronary heart disease.
Background: Statins continue to be underutilized in elderly patients because evidence has not consistently shown that they reduce mortality.
Methods: We searched 5 electronic databases, the Internet, and conference proceedings to identify relevant trials. In addition, we obtained unpublished data for the elderly patient subgroups from 4 trials and for the secondary prevention subgroup from the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) trial. Inclusion criteria were randomized allocation to statin or placebo, documented coronary heart disease, 50 elderly patients (defined as age 65 years), and 6 months of follow-up. Data were analyzed with hierarchical Bayesian modeling.
Results: We included 9 trials encompassing 19,569 patients with an age range of 65 to 82 years. Pooled rates of all-cause mortality were 15.6% with statins and 18.7% with placebo. We estimated a relative risk reduction of 22% over 5 years (relative risk [RR] 0.78; 95% credible interval [CI] 0.65 to 0.89). Furthermore, statins reduced coronary heart disease mortality by 30% (RR 0.70; 95% CI 0.53 to 0.83), nonfatal myocardial infarction by 26% (RR 0.74; 95% CI 0.60 to 0.89), need for revascularization by 30% (RR 0.70; 95% CI 0.53 to 0.83), and stroke by 25% (RR 0.75; 95% CI 0.56 to 0.94). The posterior median estimate of the number needed to treat to save 1 life was 28 (95% CI 15 to 56).
Conclusions: Statins reduce all-cause mortality in elderly patients and the magnitude of this effect is substantially larger than had been previously estimated.
A Hierarchical Bayesian Meta-Analysis
Jonathan Afilalo, Gustavo Duque, Russell Steele, J. Wouter Jukema, Anton J.M. de Craen, and Mark J.
J Am Coll Cardiol Volume 51, Issue 1, January 1/8, 2008
Objectives: This study was designed to determine whether statins reduce all-cause mortality in elderly patients with coronary heart disease.
Background: Statins continue to be underutilized in elderly patients because evidence has not consistently shown that they reduce mortality.
Methods: We searched 5 electronic databases, the Internet, and conference proceedings to identify relevant trials. In addition, we obtained unpublished data for the elderly patient subgroups from 4 trials and for the secondary prevention subgroup from the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) trial. Inclusion criteria were randomized allocation to statin or placebo, documented coronary heart disease, 50 elderly patients (defined as age 65 years), and 6 months of follow-up. Data were analyzed with hierarchical Bayesian modeling.
Results: We included 9 trials encompassing 19,569 patients with an age range of 65 to 82 years. Pooled rates of all-cause mortality were 15.6% with statins and 18.7% with placebo. We estimated a relative risk reduction of 22% over 5 years (relative risk [RR] 0.78; 95% credible interval [CI] 0.65 to 0.89). Furthermore, statins reduced coronary heart disease mortality by 30% (RR 0.70; 95% CI 0.53 to 0.83), nonfatal myocardial infarction by 26% (RR 0.74; 95% CI 0.60 to 0.89), need for revascularization by 30% (RR 0.70; 95% CI 0.53 to 0.83), and stroke by 25% (RR 0.75; 95% CI 0.56 to 0.94). The posterior median estimate of the number needed to treat to save 1 life was 28 (95% CI 15 to 56).
Conclusions: Statins reduce all-cause mortality in elderly patients and the magnitude of this effect is substantially larger than had been previously estimated.
Thursday, January 3, 2008
Metabolic Effects of Weight Loss on a Very-Low-Carbohydrate Diet Compared With an Isocaloric High-Carbohydrate Diet in Abdominally Obese Subjects
Metabolic Effects of Weight Loss on a Very-Low-Carbohydrate Diet Compared With an Isocaloric High-Carbohydrate Diet in Abdominally Obese Subjects
J Am Coll Cardiol 2008 51: 59-67.
Jeannie Tay, Grant D. Brinkworth, Manny Noakes, Jennifer Keogh, and Peter M. Clifton.
Two types of diets, one with very low carbohydrates and high fat (VLCHF) and one with high-carbohydrates and low fat (HCLF), were compared in a randomized study of obese adults. Unlike previous diet comparisons, total calorie intake was matched between the study arms.
The findings, published in the Journal of the American College of Cardiology, demonstrate that the two diets achieved equal weight loss. The HCLF diet, however, had a better effect on lipid profile.
Investigators in Australia randomized 118 obese adults to one of two diets. Participants were matched by age, gender and body mass index prior to randomization. The VLCHF diet was designed to provide 4% carbohydrate, 35% protein, and 61% fat (20% saturated fat). The HCLF diet, in contrast, was 46% carbohydrates, 24% protein and 30% as fat (less than 8% saturated fat). Patients had to remain on the diet for 24 weeks. Food was provided for the first 8 weeks, and thereafter vouchers were provided. Around 80% of patients in both arms completed the course of diet, leaving 89 patients to analyze. Baseline characteristics were very similar between groups. The average age was 50 years old and the average body mass index was 33. Baseline lipid profiles and medication use were similar. The diets had a planned 30% energy restriction.
The mean weight loss was around 10 kg, and there was no difference in weight loss between the two study arms. Plasma ketone levels were higher in those on the VLCHF diet—levels peaked at 8 weeks and were much lower by week 24. Weight loss correlated with plasma ketone level in patients on the VLCHF diet. Total cholesterol and LDL cholesterol decreased significantly in patients randomized to the HCLF diet (decrease of 0.54 and 0.46 mmol/l, respectively) but not those eating VLCHF. Triglycerides, however, were better lowered by the VLCHF diet (decrease of 0.64 mmol/l) than on the HCLF diet (decrease of 0.35 mmol/l). Weight loss reduced blood pressure, fasting glucose and insulin levels, with similar effect in both diets.
There are a number of purported benefits to a VLCHF diet. The better weight loss achieved by this diet in previous studies has been suggested to be due to reduced efficiency in using fats as energy source. The authors note that changes in energy intake on the VLCHF diet likely explains much of the benefit to weight loss observed in previous studies. When calorie intake was equalized, the current study saw no difference in weight loss. The beneficial effect of the VLCHF diet on triglycerides suggests that perhaps this diet would be more suitable for an obese individual with impaired glucose tolerance, visceral adiposity, and hypertriglyceridemia.
Again, we are left with the unfortunate law of conservation of energy.
J Am Coll Cardiol 2008 51: 59-67.
Jeannie Tay, Grant D. Brinkworth, Manny Noakes, Jennifer Keogh, and Peter M. Clifton.
Two types of diets, one with very low carbohydrates and high fat (VLCHF) and one with high-carbohydrates and low fat (HCLF), were compared in a randomized study of obese adults. Unlike previous diet comparisons, total calorie intake was matched between the study arms.
The findings, published in the Journal of the American College of Cardiology, demonstrate that the two diets achieved equal weight loss. The HCLF diet, however, had a better effect on lipid profile.
Investigators in Australia randomized 118 obese adults to one of two diets. Participants were matched by age, gender and body mass index prior to randomization. The VLCHF diet was designed to provide 4% carbohydrate, 35% protein, and 61% fat (20% saturated fat). The HCLF diet, in contrast, was 46% carbohydrates, 24% protein and 30% as fat (less than 8% saturated fat). Patients had to remain on the diet for 24 weeks. Food was provided for the first 8 weeks, and thereafter vouchers were provided. Around 80% of patients in both arms completed the course of diet, leaving 89 patients to analyze. Baseline characteristics were very similar between groups. The average age was 50 years old and the average body mass index was 33. Baseline lipid profiles and medication use were similar. The diets had a planned 30% energy restriction.
The mean weight loss was around 10 kg, and there was no difference in weight loss between the two study arms. Plasma ketone levels were higher in those on the VLCHF diet—levels peaked at 8 weeks and were much lower by week 24. Weight loss correlated with plasma ketone level in patients on the VLCHF diet. Total cholesterol and LDL cholesterol decreased significantly in patients randomized to the HCLF diet (decrease of 0.54 and 0.46 mmol/l, respectively) but not those eating VLCHF. Triglycerides, however, were better lowered by the VLCHF diet (decrease of 0.64 mmol/l) than on the HCLF diet (decrease of 0.35 mmol/l). Weight loss reduced blood pressure, fasting glucose and insulin levels, with similar effect in both diets.
There are a number of purported benefits to a VLCHF diet. The better weight loss achieved by this diet in previous studies has been suggested to be due to reduced efficiency in using fats as energy source. The authors note that changes in energy intake on the VLCHF diet likely explains much of the benefit to weight loss observed in previous studies. When calorie intake was equalized, the current study saw no difference in weight loss. The beneficial effect of the VLCHF diet on triglycerides suggests that perhaps this diet would be more suitable for an obese individual with impaired glucose tolerance, visceral adiposity, and hypertriglyceridemia.
Again, we are left with the unfortunate law of conservation of energy.
Dark Chocolate May Not Always Be Good For Your Heart
Dark Chocolate May Not Always Be Good For Your Heart
Medical News Today
03 Jan 2008
According to an Editorial in the Lancet, dark chocolate that is rich in flavenols might be good for the heart. However, to gain the health benefits from dark chocolate might prove difficult.
According to a study in Circulation, in 11 heart transplant recipients, dark chocolate which is rich in flavenols , induced coronary vasodilatation and improved coronary vascular function, compared with patients consuming a flavenol-free control chocolate. Dark chocolate has been shown to have cardiovascular benefits in other studies too.
For dark chocolate to have any health benefit flavenols have to be present in the chocolate. However, some chocolate manufacturers take out the flavenols from the darkened cocoa solids; this means that the chocolate has no health benefit.
Manufacturers often do not label their products with information about flavenols . So, before you go out to buy dark chocolate beware of the catch, states the Editorial.
Dark chocolate is rich in calories, so in order to gain any health benefit from flavenol-rich dark chocolate, you would have to reduce your intake of other foods to balance the calories. The editorial warns, "The devil in the dark chocolate is the fat, sugar, and calories it contains."
The Editorial concludes: "Of course some would say that, in terms of food intake, the best and simplest health message would be to stay away from the chocolate and eat a healthy, balanced diet, low in sugar, salt, and fat, and full of fresh fruit and vegetables." "The devil in the dark chocolate"
The Lancet Volume 370, Number 9605, 22 December 2007 page 2070
Click here to view Full Article online (login required)
Medical News Today
03 Jan 2008
According to an Editorial in the Lancet, dark chocolate that is rich in flavenols might be good for the heart. However, to gain the health benefits from dark chocolate might prove difficult.
According to a study in Circulation, in 11 heart transplant recipients, dark chocolate which is rich in flavenols , induced coronary vasodilatation and improved coronary vascular function, compared with patients consuming a flavenol-free control chocolate. Dark chocolate has been shown to have cardiovascular benefits in other studies too.
For dark chocolate to have any health benefit flavenols have to be present in the chocolate. However, some chocolate manufacturers take out the flavenols from the darkened cocoa solids; this means that the chocolate has no health benefit.
Manufacturers often do not label their products with information about flavenols . So, before you go out to buy dark chocolate beware of the catch, states the Editorial.
Dark chocolate is rich in calories, so in order to gain any health benefit from flavenol-rich dark chocolate, you would have to reduce your intake of other foods to balance the calories. The editorial warns, "The devil in the dark chocolate is the fat, sugar, and calories it contains."
The Editorial concludes: "Of course some would say that, in terms of food intake, the best and simplest health message would be to stay away from the chocolate and eat a healthy, balanced diet, low in sugar, salt, and fat, and full of fresh fruit and vegetables." "The devil in the dark chocolate"
The Lancet Volume 370, Number 9605, 22 December 2007 page 2070
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Wednesday, January 2, 2008
Coffee Consumption and Risk of Cardiovascular Events After Acute Myocardial Infarction
Coffee Consumption and Risk of Cardiovascular Events After Acute Myocardial Infarction
Results From the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico)-Prevenzione Trial
Circulation. 2007;116:2944-2951
Background— The relation between coffee consumption and cardiovascular disease has been studied extensively, but results are still debated. In addition, little evidence is available on patients with established coronary heart disease.
Methods and Results— Prospectively ascertained information among 11 231 Italian patients (9584 males and 1647 females) with recent (3 months) myocardial infarction enrolled in the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico)-Prevenzione trial was used. Usual dietary habits were assessed at baseline and updated at 0.5 and 1.5 years. Coffee consumption was categorized as never/almost never, <2>4 cups per day. Medication use and fasting glucose were assessed at 0.5, 1, 1.5, 2.5, and 3.5 years. Risk was evaluated with Cox proportional hazards with time-varying covariates. The main outcome measure was the cumulative incidence of cardiovascular events (cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke). A total of 1167 cardiovascular events occurred during 36 961 person-years of follow-up. After multivariable adjustment for potential confounders in the time-dependent analysis, the relative risk of cardiovascular events across categories of coffee consumption was 1.02 (95% CI 0.87 to 1.20) for <2>4 cups per day compared with abstainers (P for trend=0.18). Ultimately, coffee consumption did not change the risk of coronary heart disease events, stroke, and sudden death.
Conclusions— No association between moderate coffee intake and cardiovascular events was observed in post–myocardial infarction patients
Results From the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico)-Prevenzione Trial
Circulation. 2007;116:2944-2951
Background— The relation between coffee consumption and cardiovascular disease has been studied extensively, but results are still debated. In addition, little evidence is available on patients with established coronary heart disease.
Methods and Results— Prospectively ascertained information among 11 231 Italian patients (9584 males and 1647 females) with recent (3 months) myocardial infarction enrolled in the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico)-Prevenzione trial was used. Usual dietary habits were assessed at baseline and updated at 0.5 and 1.5 years. Coffee consumption was categorized as never/almost never, <2>4 cups per day. Medication use and fasting glucose were assessed at 0.5, 1, 1.5, 2.5, and 3.5 years. Risk was evaluated with Cox proportional hazards with time-varying covariates. The main outcome measure was the cumulative incidence of cardiovascular events (cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke). A total of 1167 cardiovascular events occurred during 36 961 person-years of follow-up. After multivariable adjustment for potential confounders in the time-dependent analysis, the relative risk of cardiovascular events across categories of coffee consumption was 1.02 (95% CI 0.87 to 1.20) for <2>4 cups per day compared with abstainers (P for trend=0.18). Ultimately, coffee consumption did not change the risk of coronary heart disease events, stroke, and sudden death.
Conclusions— No association between moderate coffee intake and cardiovascular events was observed in post–myocardial infarction patients
Tuesday, January 1, 2008
Restless Legs Syndrome Doubles Risk Of Stroke And Heart Disease
Restless Legs Syndrome Doubles Risk Of Stroke And Heart Disease, Study Shows
ScienceDaily (Jan. 1, 2008) — People with restless legs syndrome (RLS) are twice as likely to have a stroke or heart disease compared to people without RLS, and the risk is greatest in those with the most frequent and severe symptoms, according to new research.
The study, the largest of its kind enrolling both men and women, involved 3,433 people with an average age of 68 who were enrolled in the Sleep Heart Health Study. Participants were diagnosed with RLS by detailed questionnaire and asked if they had been diagnosed with a variety of systemic diseases including cardiovascular disease and cerebrovascular disease. Of the participants, nearly seven percent of women and three percent of men had RLS.
The study found people with RLS were more than twice as likely to have cardiovascular disease or cerebrovascular disease. The results remained the same after adjusting for age, sex, race, body mass index, diabetes, high blood pressure, high blood pressure medication, HDL/LDL cholesterol levels, and smoking.
"The association of RLS with heart disease and stroke was strongest in those people who had RLS symptoms at least 16 times per month," said study author John W. Winkelman, MD, PhD, with Harvard Medical School in Boston. "There was also an increased risk among people who said their RLS symptoms were severe compared to those with less bothersome symptoms."
Winkelman says although this study does not show that RLS causes cardiovascular and cerebrovascular disease, a number of potential mechanics for such a process exist. "In particular, most people with RLS have as many as 200 to 300 periodic leg movements per night of sleep and these leg movements are associated with substantial acute increases in both blood pressure and heart rate, which may, over the long term, produce cardiovascular or cerebrovascular disease.
Winkelman says there are limitations to the study, including that the diagnosis of RLS was self-reported by questionnaire rather than by clinical interview.
This research was published in the January 1, 2008, issue of Neurology®, the medical journal of the American Academy of Neurology.
ScienceDaily (Jan. 1, 2008) — People with restless legs syndrome (RLS) are twice as likely to have a stroke or heart disease compared to people without RLS, and the risk is greatest in those with the most frequent and severe symptoms, according to new research.
The study, the largest of its kind enrolling both men and women, involved 3,433 people with an average age of 68 who were enrolled in the Sleep Heart Health Study. Participants were diagnosed with RLS by detailed questionnaire and asked if they had been diagnosed with a variety of systemic diseases including cardiovascular disease and cerebrovascular disease. Of the participants, nearly seven percent of women and three percent of men had RLS.
The study found people with RLS were more than twice as likely to have cardiovascular disease or cerebrovascular disease. The results remained the same after adjusting for age, sex, race, body mass index, diabetes, high blood pressure, high blood pressure medication, HDL/LDL cholesterol levels, and smoking.
"The association of RLS with heart disease and stroke was strongest in those people who had RLS symptoms at least 16 times per month," said study author John W. Winkelman, MD, PhD, with Harvard Medical School in Boston. "There was also an increased risk among people who said their RLS symptoms were severe compared to those with less bothersome symptoms."
Winkelman says although this study does not show that RLS causes cardiovascular and cerebrovascular disease, a number of potential mechanics for such a process exist. "In particular, most people with RLS have as many as 200 to 300 periodic leg movements per night of sleep and these leg movements are associated with substantial acute increases in both blood pressure and heart rate, which may, over the long term, produce cardiovascular or cerebrovascular disease.
Winkelman says there are limitations to the study, including that the diagnosis of RLS was self-reported by questionnaire rather than by clinical interview.
This research was published in the January 1, 2008, issue of Neurology®, the medical journal of the American Academy of Neurology.
Saturday, December 29, 2007
Exercise-induced blood pressure increases predict survival
Exercise-induced blood pressure increases predict survival
24 December 2007
MedWire News: An increase in systolic blood pressure (SBP) during exercise stress testing appears to be associated with improved survival in men, researchers report.
Data suggest that exercise-induced increases in SBP are prognostic for cardiovascular (CV) mortality, independent of age, resting blood pressure, and common cardiac risk factors.
To determine whether SPB measured during exercise stress testing adds prognostic information to CV mortality, Manish Gupta, from Lenox Hill Hospital in New York City, USA, and colleagues evaluated SBP responses in 6213 consecutive men referred for exercise stress testing for clinical reasons.
Patients were grouped according to whether their median change in exercise induced SPB was ≤43 mmHg or ≥44 mmHg, representing low and normal increases in SPB, respectively.
The results demonstrated that patients with increases in baseline SBP ≥44 mmHg had significantly lower mortality than patients with increases in baseline SBP ≤43 mmHg, at 8.2% versus 13.7%, respectively. This difference in improved survival remained after controlling for age, exercise capacity, ST abnormalities, history of myocardial infarction or congestive heart failure, hypertension, and use of a beta blocker.
The researchers also found that the survival benefit was incremental, with patients in the highest quartile of increased SBP (≥76 mmHg) having significantly lower CV mortality than patients in the lowest quartile (≤42 mmHg), at 7.3% versus 16.7%, respectively. Importantly, a history of hypertension was independently and significantly associated with a higher SPB response to exercise.
The team concludes in the American Journal of Cardiology that an increase in SPB with exercise stress test predicts cardiovascular mortality independent of age, exercise capacity, and ST-segment abnormalities.
They add that "an increase in systolic BP≥ 44 mmHg from baseline [is] associated with survival even in patients with a history of hypertension," and emphasize that the findings are applicable only to men because exercise testing results have been shown to differ between genders.
Source: Am J Cardiol 2007; 100: 1609-1613
24 December 2007
MedWire News: An increase in systolic blood pressure (SBP) during exercise stress testing appears to be associated with improved survival in men, researchers report.
Data suggest that exercise-induced increases in SBP are prognostic for cardiovascular (CV) mortality, independent of age, resting blood pressure, and common cardiac risk factors.
To determine whether SPB measured during exercise stress testing adds prognostic information to CV mortality, Manish Gupta, from Lenox Hill Hospital in New York City, USA, and colleagues evaluated SBP responses in 6213 consecutive men referred for exercise stress testing for clinical reasons.
Patients were grouped according to whether their median change in exercise induced SPB was ≤43 mmHg or ≥44 mmHg, representing low and normal increases in SPB, respectively.
The results demonstrated that patients with increases in baseline SBP ≥44 mmHg had significantly lower mortality than patients with increases in baseline SBP ≤43 mmHg, at 8.2% versus 13.7%, respectively. This difference in improved survival remained after controlling for age, exercise capacity, ST abnormalities, history of myocardial infarction or congestive heart failure, hypertension, and use of a beta blocker.
The researchers also found that the survival benefit was incremental, with patients in the highest quartile of increased SBP (≥76 mmHg) having significantly lower CV mortality than patients in the lowest quartile (≤42 mmHg), at 7.3% versus 16.7%, respectively. Importantly, a history of hypertension was independently and significantly associated with a higher SPB response to exercise.
The team concludes in the American Journal of Cardiology that an increase in SPB with exercise stress test predicts cardiovascular mortality independent of age, exercise capacity, and ST-segment abnormalities.
They add that "an increase in systolic BP≥ 44 mmHg from baseline [is] associated with survival even in patients with a history of hypertension," and emphasize that the findings are applicable only to men because exercise testing results have been shown to differ between genders.
Source: Am J Cardiol 2007; 100: 1609-1613
Tuesday, December 25, 2007
Health outcomes of bereavement.
Health outcomes of bereavement.
Lancet. 2007 Dec 8;370(9603):1960-73.
Stroebe M, Schut H, Stroebe W.
Research Institute for Psychology and Health, Utrecht University, Utrecht, Netherlands. M.S.Stroebe@UU.NL
In this Review, we look at the relation between bereavement and physical and mental health.
Although grief is not a disease and most people adjust without professional psychological intervention, bereavement is associated with excess risk of mortality, particularly in the early weeks and months after loss. It is related to decrements in physical health, indicated by presence of symptoms and illnesses, and use of medical services. Furthermore, bereaved individuals report diverse psychological reactions. For a few people, mental disorders or complications in the grieving process ensue. We summarise research on risk factors that increase vulnerability of some bereaved individuals. Diverse factors (circumstances of death, intrapersonal and interpersonal variables, ways of coping) are likely to co-determine excesses in ill-health. We also assess the effectiveness of psychological intervention programmes.
Intervention should be targeted at high-risk people and those with complicated grief or bereavement-related depression and stress disorders.
Lancet. 2007 Dec 8;370(9603):1960-73.
Stroebe M, Schut H, Stroebe W.
Research Institute for Psychology and Health, Utrecht University, Utrecht, Netherlands. M.S.Stroebe@UU.NL
In this Review, we look at the relation between bereavement and physical and mental health.
Although grief is not a disease and most people adjust without professional psychological intervention, bereavement is associated with excess risk of mortality, particularly in the early weeks and months after loss. It is related to decrements in physical health, indicated by presence of symptoms and illnesses, and use of medical services. Furthermore, bereaved individuals report diverse psychological reactions. For a few people, mental disorders or complications in the grieving process ensue. We summarise research on risk factors that increase vulnerability of some bereaved individuals. Diverse factors (circumstances of death, intrapersonal and interpersonal variables, ways of coping) are likely to co-determine excesses in ill-health. We also assess the effectiveness of psychological intervention programmes.
Intervention should be targeted at high-risk people and those with complicated grief or bereavement-related depression and stress disorders.
Wednesday, December 12, 2007
Thiazolidinediones and Cardiovascular Outcomes in Older Patients With Diabetes
Thiazolidinediones and Cardiovascular Outcomes in Older Patients With Diabetes
Lorraine L. Lipscombe, MD, MSc; Tara Gomes, MHSc; Linda E. Lévesque, BScPhm, MSc; Janet E. Hux, MD, MSc; David N. Juurlink, BPhm, MD, PhD; David A. Alter, MD, PhD
JAMA. 2007;298(22):2634-2643.
Context Thiazolidinediones (TZDs), used to treat type 2 diabetes, are associated with an excess risk of congestive heart failure and possibly acute myocardial infarction. However, the association between TZD use and cardiovascular events has not been adequately evaluated on a population level.
Objective To explore the association between TZD therapy and congestive heart failure, acute myocardial infarction, and mortality compared with treatment with other oral hypoglycemic agents.
Design, Setting, and Patients Nested case-control analysis of a retrospective cohort study using health care databases in Ontario. We included diabetes patients aged 66 years or older treated with at least 1 oral hypoglycemic agent between 2002 and 2005 (N = 159 026) and followed them up until March 31, 2006.
Main Outcome Measures The primary outcome consisted of an emergency department visit or hospitalization for congestive heart failure; secondary outcomes were an emergency department visit or hospitalization for acute myocardial infarction and all-cause mortality. The risks of these events were compared between persons treated with TZDs (rosiglitazone and pioglitazone) and other oral hypoglycemic agent combinations, after matching and adjusting for prognostic factors.
Results During a median follow-up of 3.8 years, 12 491 patients (7.9%) had a hospital visit for congestive heart failure, 12 578 (7.9%) had a visit for acute myocardial infarction, and 30 265 (19%) died. Current treatment with TZD monotherapy was associated with a significantly increased risk of congestive heart failure (78 cases; adjusted rate ratio [RR], 1.60; 95% confidence interval [CI], 1.21-2.10; P < .001), acute myocardial infarction (65 cases; RR, 1.40; 95% CI, 1.05-1.86; P = .02), and death (102 cases; RR, 1.29; 95% CI, 1.02-1.62; P = .03) compared with other oral hypoglycemic agent combination therapies (3478 congestive heart failure cases, 3695 acute myocardial infarction cases, and 5529 deaths). The increased risk of congestive heart failure, acute myocardial infarction, and mortality associated with TZD use appeared limited to rosiglitazone.
Conclusion In this population-based study of older patients with diabetes, TZD treatment, primarily with rosiglitazone, was associated with an increased risk of congestive heart failure, acute myocardial infarction, and mortality when compared with other combination oral hypoglycemic agent treatments.
Lorraine L. Lipscombe, MD, MSc; Tara Gomes, MHSc; Linda E. Lévesque, BScPhm, MSc; Janet E. Hux, MD, MSc; David N. Juurlink, BPhm, MD, PhD; David A. Alter, MD, PhD
JAMA. 2007;298(22):2634-2643.
Context Thiazolidinediones (TZDs), used to treat type 2 diabetes, are associated with an excess risk of congestive heart failure and possibly acute myocardial infarction. However, the association between TZD use and cardiovascular events has not been adequately evaluated on a population level.
Objective To explore the association between TZD therapy and congestive heart failure, acute myocardial infarction, and mortality compared with treatment with other oral hypoglycemic agents.
Design, Setting, and Patients Nested case-control analysis of a retrospective cohort study using health care databases in Ontario. We included diabetes patients aged 66 years or older treated with at least 1 oral hypoglycemic agent between 2002 and 2005 (N = 159 026) and followed them up until March 31, 2006.
Main Outcome Measures The primary outcome consisted of an emergency department visit or hospitalization for congestive heart failure; secondary outcomes were an emergency department visit or hospitalization for acute myocardial infarction and all-cause mortality. The risks of these events were compared between persons treated with TZDs (rosiglitazone and pioglitazone) and other oral hypoglycemic agent combinations, after matching and adjusting for prognostic factors.
Results During a median follow-up of 3.8 years, 12 491 patients (7.9%) had a hospital visit for congestive heart failure, 12 578 (7.9%) had a visit for acute myocardial infarction, and 30 265 (19%) died. Current treatment with TZD monotherapy was associated with a significantly increased risk of congestive heart failure (78 cases; adjusted rate ratio [RR], 1.60; 95% confidence interval [CI], 1.21-2.10; P < .001), acute myocardial infarction (65 cases; RR, 1.40; 95% CI, 1.05-1.86; P = .02), and death (102 cases; RR, 1.29; 95% CI, 1.02-1.62; P = .03) compared with other oral hypoglycemic agent combination therapies (3478 congestive heart failure cases, 3695 acute myocardial infarction cases, and 5529 deaths). The increased risk of congestive heart failure, acute myocardial infarction, and mortality associated with TZD use appeared limited to rosiglitazone.
Conclusion In this population-based study of older patients with diabetes, TZD treatment, primarily with rosiglitazone, was associated with an increased risk of congestive heart failure, acute myocardial infarction, and mortality when compared with other combination oral hypoglycemic agent treatments.
Tuesday, December 11, 2007
Inadequate Control of Hypertension in US Adults With Cardiovascular Disease Comorbidities in 2003-2004
Inadequate Control of Hypertension in US Adults With Cardiovascular Disease Comorbidities in 2003-2004
Nathan D. Wong, PhD; Victor A. Lopez, BS; Gilbert L'Italien, PhD; Roland Chen, MD; Sue Ellen J. Kline, PhD; Stanley S. Franklin, MD
Arch Intern Med. 2007;167(22):2431-2436.
Background Cardiovascular risks associated with hypertension (HTN) and the importance of its control are well established; however, the prevalence and adequacy of its treatment and control in persons with cardiovascular comorbidities (CVCs) are uncertain.
Methods To examine the prevalence, treatment, and control of HTN among US adults with and without CVCs, we analyzed data from adults at least 18 years of age (n = 4646, N [projected sample size] = 192.4 million) in the National Health and Nutrition Examination Survey 2003-2004, a nationally representative cross-sectional survey of the noninstitutionalized civilian US population. Prevalence, treatment, and control rates of HTN in patients with CVCs vs those without, including coronary artery disease, congestive heart failure, stroke, chronic kidney disease, peripheral artery disease, and diabetes mellitus, and distance to blood pressure goal in those whose HTN was not controlled were the main outcomes.
Results The overall prevalence rate of HTN was 31.4% (n = 1671, N = 60.5 million), ranging from 23.1% in those without CVCs to 51.8% to 81.8% in those with CVCs (P < .01). Despite HTN treatment rates for diabetes mellitus, stroke, heart failure, and coronary artery disease that are higher (83.4%-89.3%) than the rates of those without these conditions (66.5%) (P < .01), control rates for treatment remained poor (23.2%-49.3%) (P < .001 to P = .048). Isolated systolic HTN was the most common hypertensive subtype in those with CVCs ( 63.5%) with systolic blood pressure averaging at least 20 mm Hg from goal. Conclusions Nearly three-fourths of adults with CVCs have HTN. Poor control rates of systolic HTN remain a principal problem that further compromises their already high cardiovascular disease risk.
Nathan D. Wong, PhD; Victor A. Lopez, BS; Gilbert L'Italien, PhD; Roland Chen, MD; Sue Ellen J. Kline, PhD; Stanley S. Franklin, MD
Arch Intern Med. 2007;167(22):2431-2436.
Background Cardiovascular risks associated with hypertension (HTN) and the importance of its control are well established; however, the prevalence and adequacy of its treatment and control in persons with cardiovascular comorbidities (CVCs) are uncertain.
Methods To examine the prevalence, treatment, and control of HTN among US adults with and without CVCs, we analyzed data from adults at least 18 years of age (n = 4646, N [projected sample size] = 192.4 million) in the National Health and Nutrition Examination Survey 2003-2004, a nationally representative cross-sectional survey of the noninstitutionalized civilian US population. Prevalence, treatment, and control rates of HTN in patients with CVCs vs those without, including coronary artery disease, congestive heart failure, stroke, chronic kidney disease, peripheral artery disease, and diabetes mellitus, and distance to blood pressure goal in those whose HTN was not controlled were the main outcomes.
Results The overall prevalence rate of HTN was 31.4% (n = 1671, N = 60.5 million), ranging from 23.1% in those without CVCs to 51.8% to 81.8% in those with CVCs (P < .01). Despite HTN treatment rates for diabetes mellitus, stroke, heart failure, and coronary artery disease that are higher (83.4%-89.3%) than the rates of those without these conditions (66.5%) (P < .01), control rates for treatment remained poor (23.2%-49.3%) (P < .001 to P = .048). Isolated systolic HTN was the most common hypertensive subtype in those with CVCs ( 63.5%) with systolic blood pressure averaging at least 20 mm Hg from goal. Conclusions Nearly three-fourths of adults with CVCs have HTN. Poor control rates of systolic HTN remain a principal problem that further compromises their already high cardiovascular disease risk.
"Body fat distribution and risk of coronary heart disease in men and women in the European Prospective Investigation into Cancer and Nutrition in Norfolk cohort: a population-based prospective study"
Circulation: Journal of the American Heart AssociationSource reference:
Canoy D, et al Circulation 2007; DOI: 10.1161/CIRCULATIONAHA.106.673756.
Background—Body fat distribution has been cross-sectionally associated with atherosclerotic disease risk factors, but the prospective relation with coronary heart disease remains uncertain.
Methods and Results—We examined the prospective relation between fat distribution indices and coronary heart disease among 24 508 men and women 45 to 79 years of age using proportional hazards regression. During a mean 9.1 years of follow-up, 1708 men and 892 women developed coronary heart disease. The risk for developing subsequent coronary heart disease increased continuously across the range of waist-hip ratio. Hazard ratios (95% CI) of the top versus bottom fifth of waist-hip ratio were 1.55 (1.28 to 1.73) in men and 1.91 (1.44 to 2.54) in women after adjustment for body mass index and other coronary heart disease risk factors. Hazard ratios increased with waist circumference, but risk estimates for waist circumference without hip circumference adjustment were lower by 10% to 18%. After adjustment for waist circumference, body mass index, and coronary heart disease risk factors, hazard ratios for 1-SD increase in hip circumference were 0.80 (95% CI, 0.74 to 0.87) in men and 0.80 (95% CI, 0.69 to 0.93) in women. Hazard ratios for body mass index were greatly attenuated when we adjusted for waist-hip ratio or waist circumference and other covariates.
Conclusions—Indices of abdominal obesity were more consistently and strongly predictive of coronary heart disease than body mass index. These simple and inexpensive measurements could be used to assess obesity-related coronary heart disease risk in relatively healthy men and women.
Circulation: Journal of the American Heart AssociationSource reference:
Canoy D, et al Circulation 2007; DOI: 10.1161/CIRCULATIONAHA.106.673756.
Background—Body fat distribution has been cross-sectionally associated with atherosclerotic disease risk factors, but the prospective relation with coronary heart disease remains uncertain.
Methods and Results—We examined the prospective relation between fat distribution indices and coronary heart disease among 24 508 men and women 45 to 79 years of age using proportional hazards regression. During a mean 9.1 years of follow-up, 1708 men and 892 women developed coronary heart disease. The risk for developing subsequent coronary heart disease increased continuously across the range of waist-hip ratio. Hazard ratios (95% CI) of the top versus bottom fifth of waist-hip ratio were 1.55 (1.28 to 1.73) in men and 1.91 (1.44 to 2.54) in women after adjustment for body mass index and other coronary heart disease risk factors. Hazard ratios increased with waist circumference, but risk estimates for waist circumference without hip circumference adjustment were lower by 10% to 18%. After adjustment for waist circumference, body mass index, and coronary heart disease risk factors, hazard ratios for 1-SD increase in hip circumference were 0.80 (95% CI, 0.74 to 0.87) in men and 0.80 (95% CI, 0.69 to 0.93) in women. Hazard ratios for body mass index were greatly attenuated when we adjusted for waist-hip ratio or waist circumference and other covariates.
Conclusions—Indices of abdominal obesity were more consistently and strongly predictive of coronary heart disease than body mass index. These simple and inexpensive measurements could be used to assess obesity-related coronary heart disease risk in relatively healthy men and women.
Friday, November 30, 2007
Cholesterol seen tied to heart disease, not stroke
Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55 000 vascular deaths
The Lancet 2007; 370:1829-1839
Summary
Background
Age, sex, and blood pressure could modify the associations of total cholesterol (and its main two fractions, HDL and LDL cholesterol) with vascular mortality. This meta-analysis combined prospective studies of vascular mortality that recorded both blood pressure and total cholesterol at baseline, to determine the joint relevance of these two risk factors.
Methods
Information was obtained from 61 prospective observational studies, mostly in western Europe or North America, consisting of almost 900 000 adults without previous disease and with baseline measurements of total cholesterol and blood pressure. During nearly 12 million person years at risk between the ages of 40 and 89 years, there were more than 55 000 vascular deaths (34 000 ischaemic heart disease [IHD], 12 000 stroke, 10 000 other). Information about HDL cholesterol was available for 150 000 participants, among whom there were 5000 vascular deaths (3000 IHD, 1000 stroke, 1000 other). Reported associations are with usual cholesterol levels (ie, corrected for the regression dilution bias).
Findings
1 mmol/L lower total cholesterol was associated with about a half (hazard ratio 0·44 [95% CI 0·42–0·48]), a third (0·66 [0·65–0·68]), and a sixth (0·83 [0·81–0·85]) lower IHD mortality in both sexes at ages 40–49, 50–69, and 70–89 years, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. The proportional risk reduction decreased with increasing blood pressure, since the absolute effects of cholesterol and blood pressure were approximately additive. Of various simple indices involving HDL cholesterol, the ratio total/HDL cholesterol was the strongest predictor of IHD mortality (40% more informative than non-HDL cholesterol and more than twice as informative as total cholesterol). Total cholesterol was weakly positively related to ischaemic and total stroke mortality in early middle age (40–59 years), but this finding could be largely or wholly accounted for by the association of cholesterol with blood pressure. Moreover, a positive relation was seen only in middle age and only in those with below-average blood pressure; at older ages (70–89 years) and, particularly, for those with systolic blood pressure over about 145 mm Hg, total cholesterol was negatively related to haemorrhagic and total stroke mortality. The results for other vascular mortality were intermediate between those for IHD and stroke.
Interpretation
Total cholesterol was positively associated with IHD mortality in both middle and old age and at all blood pressure levels. The absence of an independent positive association of cholesterol with stroke mortality, especially at older ages or higher blood pressures, is unexplained, and invites further research. Nevertheless, there is conclusive evidence from randomised trials that statins substantially reduce not only coronary event rates but also total stroke rates in patients with a wide range of ages and blood pressures.
The Lancet 2007; 370:1829-1839
Summary
Background
Age, sex, and blood pressure could modify the associations of total cholesterol (and its main two fractions, HDL and LDL cholesterol) with vascular mortality. This meta-analysis combined prospective studies of vascular mortality that recorded both blood pressure and total cholesterol at baseline, to determine the joint relevance of these two risk factors.
Methods
Information was obtained from 61 prospective observational studies, mostly in western Europe or North America, consisting of almost 900 000 adults without previous disease and with baseline measurements of total cholesterol and blood pressure. During nearly 12 million person years at risk between the ages of 40 and 89 years, there were more than 55 000 vascular deaths (34 000 ischaemic heart disease [IHD], 12 000 stroke, 10 000 other). Information about HDL cholesterol was available for 150 000 participants, among whom there were 5000 vascular deaths (3000 IHD, 1000 stroke, 1000 other). Reported associations are with usual cholesterol levels (ie, corrected for the regression dilution bias).
Findings
1 mmol/L lower total cholesterol was associated with about a half (hazard ratio 0·44 [95% CI 0·42–0·48]), a third (0·66 [0·65–0·68]), and a sixth (0·83 [0·81–0·85]) lower IHD mortality in both sexes at ages 40–49, 50–69, and 70–89 years, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. The proportional risk reduction decreased with increasing blood pressure, since the absolute effects of cholesterol and blood pressure were approximately additive. Of various simple indices involving HDL cholesterol, the ratio total/HDL cholesterol was the strongest predictor of IHD mortality (40% more informative than non-HDL cholesterol and more than twice as informative as total cholesterol). Total cholesterol was weakly positively related to ischaemic and total stroke mortality in early middle age (40–59 years), but this finding could be largely or wholly accounted for by the association of cholesterol with blood pressure. Moreover, a positive relation was seen only in middle age and only in those with below-average blood pressure; at older ages (70–89 years) and, particularly, for those with systolic blood pressure over about 145 mm Hg, total cholesterol was negatively related to haemorrhagic and total stroke mortality. The results for other vascular mortality were intermediate between those for IHD and stroke.
Interpretation
Total cholesterol was positively associated with IHD mortality in both middle and old age and at all blood pressure levels. The absence of an independent positive association of cholesterol with stroke mortality, especially at older ages or higher blood pressures, is unexplained, and invites further research. Nevertheless, there is conclusive evidence from randomised trials that statins substantially reduce not only coronary event rates but also total stroke rates in patients with a wide range of ages and blood pressures.
Thursday, November 22, 2007
Inflammation key factor in low socioeconomic status link with CVD
Inflammation key factor in low socioeconomic status link with CVD
By Caroline Price
22 November 2007
Circulation 2007; 116: 2383-2390
MedWire News: Low socioeconomic status is linked to increased levels of serum inflammatory markers, which may explain why it is associated with higher rates of cardiovascular disease (CVD), according to a report in the journal Circulation.
The study of over 6000 men and women revealed that lower income was associated with higher concentrations of interleukin (IL)-6, and C-reactive protein (CRP) in several race and ethnic groups.
"This study helps to explain some of the puzzle as to why poor people have more heart disease," commented Nalini Ranjit (University of Michigan, Ann Arbor, USA), who led the study group.
The researchers reviewed data on 6814 US adults aged 45 to 84 years in the Multi-Ethnic Study of Atherosclerosis (MESA). They conducted race- and ethnicity-stratified analyses to estimate the associations of household income and education with IL-6 and CRP before and after adjustment for factors such as infection and medication use, psychosocial factors, behaviors, adiposity, and diabetes.
Household income was inversely associated with levels of the markers in all race/ethnic groups. Each standard-deviation decrease in income, the equivalent of around US$40,000 (€27,000), was associated with between 6% and 9% higher IL-6 and CRP levels, with the greatest increase in risk among White individuals.
By contrast, the association between education and income was inconsistent across race/ethnic groups. Each standard-deviation decrease in education level was associated with 6-14% higher levels of IL-6 and CRP in White and Black groups, whereas no association was seen for Chinese and Hispanic populations.
"When we adjusted the model for other possible confounding markers such as infection, there was no significant effect on the findings," Ranijit noted. "But when you look at body mass index, it shrinks the effect of income or education on IL-6 and CRP, meaning the associations are mediated by adiposity."
Other factors contributing to the observed associations included a generalized attitude of cynical distrust, which explained some of the link between education and IL-6 levels in all groups, and smoking, which partly accounted for this association in Black and White populations.
"Our results suggest that persons of lower socioeconomic position have greater inflammatory burden that those of high socioeconomic position as a result of the cumulative effects of multiple behavioral psychosocial and metabolic characteristics," the authors write.
"If the role of inflammation in causing multiple chronic diseases is confirmed, inflammation may represent a common element through which low socioeconomic position is related to CVD and other chronic diseases of aging."
Free abstract
By Caroline Price
22 November 2007
Circulation 2007; 116: 2383-2390
MedWire News: Low socioeconomic status is linked to increased levels of serum inflammatory markers, which may explain why it is associated with higher rates of cardiovascular disease (CVD), according to a report in the journal Circulation.
The study of over 6000 men and women revealed that lower income was associated with higher concentrations of interleukin (IL)-6, and C-reactive protein (CRP) in several race and ethnic groups.
"This study helps to explain some of the puzzle as to why poor people have more heart disease," commented Nalini Ranjit (University of Michigan, Ann Arbor, USA), who led the study group.
The researchers reviewed data on 6814 US adults aged 45 to 84 years in the Multi-Ethnic Study of Atherosclerosis (MESA). They conducted race- and ethnicity-stratified analyses to estimate the associations of household income and education with IL-6 and CRP before and after adjustment for factors such as infection and medication use, psychosocial factors, behaviors, adiposity, and diabetes.
Household income was inversely associated with levels of the markers in all race/ethnic groups. Each standard-deviation decrease in income, the equivalent of around US$40,000 (€27,000), was associated with between 6% and 9% higher IL-6 and CRP levels, with the greatest increase in risk among White individuals.
By contrast, the association between education and income was inconsistent across race/ethnic groups. Each standard-deviation decrease in education level was associated with 6-14% higher levels of IL-6 and CRP in White and Black groups, whereas no association was seen for Chinese and Hispanic populations.
"When we adjusted the model for other possible confounding markers such as infection, there was no significant effect on the findings," Ranijit noted. "But when you look at body mass index, it shrinks the effect of income or education on IL-6 and CRP, meaning the associations are mediated by adiposity."
Other factors contributing to the observed associations included a generalized attitude of cynical distrust, which explained some of the link between education and IL-6 levels in all groups, and smoking, which partly accounted for this association in Black and White populations.
"Our results suggest that persons of lower socioeconomic position have greater inflammatory burden that those of high socioeconomic position as a result of the cumulative effects of multiple behavioral psychosocial and metabolic characteristics," the authors write.
"If the role of inflammation in causing multiple chronic diseases is confirmed, inflammation may represent a common element through which low socioeconomic position is related to CVD and other chronic diseases of aging."
Free abstract
Ozone modifies heart disease risk associated with high temperature
Ozone modifies heart disease risk associated with high temperature
By Caroline Price
22 November 2007
Occup Environ Med 2007; Advance online publication
MedWire News: High ozone levels in the atmosphere exacerbate the increase in cardiovascular (CV) mortality due to hot weather, study findings reveal.
"Concentrations of air pollutants, particularly ozone, are correlated with temperature.
Therefore, temperature and air pollution may interact to affect morbidity and mortality," explain C Ren (University of California, Irvine, USA) and colleagues.
Having previously demonstrated that air particulate matter modifies the association between temperature and morbidity and mortality, the researchers specifically examined the effect of ozone on this relationship.
They analyzed data from the US National Morbidity, Mortality, and Air Pollution Study for 95 different geographical regions, containing nearly 100 million people, between June and September each year for the period 1987-2000.
As reported in the journal Occupational and Environmental Medicine, ozone levels ranged from a daily average of 36.74 to 142.85 parts per billion and average daily temperatures ranged from 20°C to around 42°C.
A total of 4 million myocardial infarctions or strokes occurred, and plotting daily deaths against temperature fluctuations during 1 day revealed that ozone was a common factor.
In general, ozone positively modified the associations between temperature and CV mortality, ie, the increase in CV risk with rising temperature was greater the higher the ozone level.
For all 95 communities, a 10°C increase in average maximum temperature on the current day was associated with an increase in CV mortality on the same day of 1.17%, 4.35%, 4.31%, and 8.31% across quartiles of ozone levels, from the lowest to the highest.
Corresponding increases in CV mortality after a 1-day lag across ozone quartiles were 0.80%, 3.73%, 4.35%, and 8.62%.
The authors reason that exposure to ozone may affect the airways and autonomic nervous system, making people more susceptible to temperature fluctuations.
They say that public health warnings should alert people to stay indoors and avoid exposure on days with high temperature and high ozone.
Rising temperatures and the impact of ozone are likely to become increasingly important as the world heats up as a result of global warming, they add.
Journal
By Caroline Price
22 November 2007
Occup Environ Med 2007; Advance online publication
MedWire News: High ozone levels in the atmosphere exacerbate the increase in cardiovascular (CV) mortality due to hot weather, study findings reveal.
"Concentrations of air pollutants, particularly ozone, are correlated with temperature.
Therefore, temperature and air pollution may interact to affect morbidity and mortality," explain C Ren (University of California, Irvine, USA) and colleagues.
Having previously demonstrated that air particulate matter modifies the association between temperature and morbidity and mortality, the researchers specifically examined the effect of ozone on this relationship.
They analyzed data from the US National Morbidity, Mortality, and Air Pollution Study for 95 different geographical regions, containing nearly 100 million people, between June and September each year for the period 1987-2000.
As reported in the journal Occupational and Environmental Medicine, ozone levels ranged from a daily average of 36.74 to 142.85 parts per billion and average daily temperatures ranged from 20°C to around 42°C.
A total of 4 million myocardial infarctions or strokes occurred, and plotting daily deaths against temperature fluctuations during 1 day revealed that ozone was a common factor.
In general, ozone positively modified the associations between temperature and CV mortality, ie, the increase in CV risk with rising temperature was greater the higher the ozone level.
For all 95 communities, a 10°C increase in average maximum temperature on the current day was associated with an increase in CV mortality on the same day of 1.17%, 4.35%, 4.31%, and 8.31% across quartiles of ozone levels, from the lowest to the highest.
Corresponding increases in CV mortality after a 1-day lag across ozone quartiles were 0.80%, 3.73%, 4.35%, and 8.62%.
The authors reason that exposure to ozone may affect the airways and autonomic nervous system, making people more susceptible to temperature fluctuations.
They say that public health warnings should alert people to stay indoors and avoid exposure on days with high temperature and high ozone.
Rising temperatures and the impact of ozone are likely to become increasingly important as the world heats up as a result of global warming, they add.
Journal
Friday, November 16, 2007
Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
Obesity Paradox in Patients with Hypertension and Coronary Artery Disease
The American Journal of Medicine
Volume 120, Issue 10, October 2007, Pages 863-870
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66 ± 9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to <25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P <.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P <.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5 ± 21.9 mm Hg/−9.8 ± 12.4 mm Hg vs −20.7 ± 23.1 mm Hg /−10.6 ± 12.5 mm Hg, P <.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
The American Journal of Medicine
Volume 120, Issue 10, October 2007, Pages 863-870
Abstract
Purpose
An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.
Methods
A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66 ± 9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2 (overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.
Results
With patients of normal weight (BMI 20 to <25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P <.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P <.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5 ± 21.9 mm Hg/−9.8 ± 12.4 mm Hg vs −20.7 ± 23.1 mm Hg /−10.6 ± 12.5 mm Hg, P <.001).
Conclusion
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.
Tuesday, November 13, 2007
AHA - 2007: Oral contraceptives increase risk of plaques
Oral contraceptives increase risk of plaques
Orlando, FL - A team of Belgian researchers has made the surprise discovery that women who have used oral contraceptives (OCs) for some time appear to be at increased risk of atherosclerosis in the carotid and femoral arteries. They also found that those taking the pill had three times higher C-reactive protein (CRP) levels than those not using it.
Dr Ernest Rietzschel (Ghent University, Belgium) reported the findings at the American Heart Association (AHA) 2007 Scientific Sessions last week. He told heartwire: "This is the first time that this has been documented. It was an accidental finding. We were stunned by the large elevations in CRP that you see in women taking the pill, so we then performed a safety analysis to see whether there was a link between past pill use and atherosclerosis measured by echo in both the carotid and femoral arteries. Our null hypothesis was that we would see no effect, but in hindsight that was probably naive."
He stressed, however, that this research should not mean that women should cease using oral contraceptives: "I'm certainly not advocating stopping use of the pill," he noted. First, the findings need to be replicated, "that's really important," he said, "and then we need more research. It's staggering that for a drug that is being used by 80% of women, there is so little information about the long-term safety. That's really incredible."
OCs an important factor in global atherosclerotic burden
Rietzschel and colleagues started out by assessing novel risk factors for atherosclerosis in women participating in the Asklepios study, a blinded sample of men and women volunteers aged 35 to 55 years in the Belgian population who were free from overt cardiovascular disease. Rietzschel said that there has been one prior report of increased CRP in OC users, from the Cardiovascular Risk in Young Finns study.
Of 1301 women (mean age 45.7 years) in Asklepios, 27.4% were taking OCs and 10.0% were taking hormone replacement therapy (HRT). Past OC use was much higher, however, with 81% of women having taken it for at least one year, with a median exposure of 13 years.
After multivariate adjustment, women who were not taking OCs or HRT had high-sensitivity CRP of 1.0 mg/L compared with 1.2 for those currently taking HRT and 3.3 for women currently taking OCs. Effects on other inflammatory markers, such as interleukin-6, were far less pronounced, the researchers note.
"Contraceptive therapy is a major cause of CRP rise. The magnitude of CRP rise (threefold) far exceeds other population-prevalent noninfectious stimuli and is much larger than the CRP rise for HRT. Future research should take into account this effect when reporting CRP data in women, aim to qualify its biological significance, and assess the potential of CRP as a tool to select those women at high thrombotic risk under hormonal therapy," Rietzschel et al say.
This finding spurred Rietzschel and his team to look at past OC use, "something we might not have considered a plausible candidate for atherosclerosis," he explained to heartwire. After multivariate adjustment, they found the odds ratios (OR) per 10 years of OC exposure were 1.17 for carotid plaque and 1.28 for femoral plaque. They also looked at prevalence of bilateral disease as a more stringent phenotype of atherosclerosis and found ORs per 10 years of OC exposure of 1.42 for carotid plaque and 1.34 for femoral plaque.
"Use of contraceptive therapy is very common and is associated with an unexpected increase in the prevalence of carotid and femoral atherosclerosis in otherwise young, apparently healthy women. Our data suggest a 20% to 30% increased prevalence of plaque in the carotid and femoral arteries per 10 years of OC exposure. In the light of widespread and usually prolonged OC use, these results suggest OC use could be an important factor in the global atherosclerotic burden," the scientists observe.
A unique opportunity to intervene
While Rietzschel stresses that women should not stop taking the pill on the basis of this research, he says, "Perhaps women should be wary of taking the pill for longer than they need to. At a certain point, don't prolong it out of habit."
Women seeking oral contraception also present a unique opportunity for doctors to give advice on the prevention of cardiovascular disease at an early age, he notes. "Young women have an idea that they won't succumb to cardiovascular disease, which is entirely wrong, because more women die of cardiovascular disease than men. Maybe this is a good time to start talking with young women. Okay, you want to take the pill, but think about the long-term implications. You should stop smoking, check your weight, and be more physically active. Also, we know the pill has effects on blood pressure and lipid profiles, so these should be checked."
The pharmaceutical industry must also contribute, Rietzschel says: "We would like to ask them to develop safer pills." He says he has been approached by some OC manufacturers following his presentation last week but declined to say which ones.
At this time, it is also impossible to say whether any specific type of pill is more hazardous than any other, he noted. "We know that estrogen has a beneficial effect on lipid profiles and it is probably the progestin component of the pill that has adverse effects on lipids, but with regard to the blood-pressure rises seen, it's not clear what raises BP."
Orlando, FL - A team of Belgian researchers has made the surprise discovery that women who have used oral contraceptives (OCs) for some time appear to be at increased risk of atherosclerosis in the carotid and femoral arteries. They also found that those taking the pill had three times higher C-reactive protein (CRP) levels than those not using it.
Dr Ernest Rietzschel (Ghent University, Belgium) reported the findings at the American Heart Association (AHA) 2007 Scientific Sessions last week. He told heartwire: "This is the first time that this has been documented. It was an accidental finding. We were stunned by the large elevations in CRP that you see in women taking the pill, so we then performed a safety analysis to see whether there was a link between past pill use and atherosclerosis measured by echo in both the carotid and femoral arteries. Our null hypothesis was that we would see no effect, but in hindsight that was probably naive."
He stressed, however, that this research should not mean that women should cease using oral contraceptives: "I'm certainly not advocating stopping use of the pill," he noted. First, the findings need to be replicated, "that's really important," he said, "and then we need more research. It's staggering that for a drug that is being used by 80% of women, there is so little information about the long-term safety. That's really incredible."
OCs an important factor in global atherosclerotic burden
Rietzschel and colleagues started out by assessing novel risk factors for atherosclerosis in women participating in the Asklepios study, a blinded sample of men and women volunteers aged 35 to 55 years in the Belgian population who were free from overt cardiovascular disease. Rietzschel said that there has been one prior report of increased CRP in OC users, from the Cardiovascular Risk in Young Finns study.
Of 1301 women (mean age 45.7 years) in Asklepios, 27.4% were taking OCs and 10.0% were taking hormone replacement therapy (HRT). Past OC use was much higher, however, with 81% of women having taken it for at least one year, with a median exposure of 13 years.
After multivariate adjustment, women who were not taking OCs or HRT had high-sensitivity CRP of 1.0 mg/L compared with 1.2 for those currently taking HRT and 3.3 for women currently taking OCs. Effects on other inflammatory markers, such as interleukin-6, were far less pronounced, the researchers note.
"Contraceptive therapy is a major cause of CRP rise. The magnitude of CRP rise (threefold) far exceeds other population-prevalent noninfectious stimuli and is much larger than the CRP rise for HRT. Future research should take into account this effect when reporting CRP data in women, aim to qualify its biological significance, and assess the potential of CRP as a tool to select those women at high thrombotic risk under hormonal therapy," Rietzschel et al say.
This finding spurred Rietzschel and his team to look at past OC use, "something we might not have considered a plausible candidate for atherosclerosis," he explained to heartwire. After multivariate adjustment, they found the odds ratios (OR) per 10 years of OC exposure were 1.17 for carotid plaque and 1.28 for femoral plaque. They also looked at prevalence of bilateral disease as a more stringent phenotype of atherosclerosis and found ORs per 10 years of OC exposure of 1.42 for carotid plaque and 1.34 for femoral plaque.
"Use of contraceptive therapy is very common and is associated with an unexpected increase in the prevalence of carotid and femoral atherosclerosis in otherwise young, apparently healthy women. Our data suggest a 20% to 30% increased prevalence of plaque in the carotid and femoral arteries per 10 years of OC exposure. In the light of widespread and usually prolonged OC use, these results suggest OC use could be an important factor in the global atherosclerotic burden," the scientists observe.
A unique opportunity to intervene
While Rietzschel stresses that women should not stop taking the pill on the basis of this research, he says, "Perhaps women should be wary of taking the pill for longer than they need to. At a certain point, don't prolong it out of habit."
Women seeking oral contraception also present a unique opportunity for doctors to give advice on the prevention of cardiovascular disease at an early age, he notes. "Young women have an idea that they won't succumb to cardiovascular disease, which is entirely wrong, because more women die of cardiovascular disease than men. Maybe this is a good time to start talking with young women. Okay, you want to take the pill, but think about the long-term implications. You should stop smoking, check your weight, and be more physically active. Also, we know the pill has effects on blood pressure and lipid profiles, so these should be checked."
The pharmaceutical industry must also contribute, Rietzschel says: "We would like to ask them to develop safer pills." He says he has been approached by some OC manufacturers following his presentation last week but declined to say which ones.
At this time, it is also impossible to say whether any specific type of pill is more hazardous than any other, he noted. "We know that estrogen has a beneficial effect on lipid profiles and it is probably the progestin component of the pill that has adverse effects on lipids, but with regard to the blood-pressure rises seen, it's not clear what raises BP."
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