Coronary Risk Score Research Articles

Changes in management of elderly patients with myocardial infarction

Despite being at higher risk for mortality, elderly patients (>/=75 years) admitted for acute myocardial infarction (MI) often receive fewer effective therapies, because of contraindications or higher risk of drug-induced adverse events. The aim of this study was to assess the changes in the use of effective treatments between 2001 and 2006 in elderly patients, and the relation with 1-month mortality. Prospective, multicentre registry, considering two periods: 6 months between October 2000 and March 2001 (cohort 1) and 12 months between October 2005 and October 2006 (cohort 2). Demographic and clinical characteristics at admission, in-hospital treatment (reperfusion or early invasive therapy, oral antiplatelets, anticoagulants, angiotensin-converting enzyme (ACE)-inhibitors, beta-blockers, and statins), and 1-month survival were compared between the two cohorts, after adjustment on a propensity score (for being admitted in 2001). Eight hundred and sixty-eight elderly patients were included, 280 in cohort 1 and 588 in cohort 2. When compared with cohort 1, patients from cohort 2 presented with comparable characteristics, except for the Global Registry of Acute Coronary Events risk score and we observed a significant increase in the use of aspirin, clopidogrel, reperfusion therapy, ACE-inhibitors, and statins in cohort 2. One-month mortality was significantly lower in cohort 2 (13.6% in cohort 1 vs. 7.1% in cohort 2, P = 0.001), mainly driven by a decrease in the mortality among patients with ST-segment elevation MI (23.3% in cohort 1 vs. 9.2% in cohort 2, P < 0.001). Adjustment on the propensity score did not alter these results. By multivariable analysis, the three-fold higher mortality in patients from cohort 1 was offset when the rate of use of treatments was considered in the model, suggesting that the treatment intensity was related to lower mortality. Between 2001 and 2006, a significant increase in the use of guidelines-recommended treatments (GRTs) was observed, associated with lower 30-day mortality, in elderly patients. These data confirm that high-risk patients, such as the elderly, benefit from an increase in the use of GRTs.

Type-D Personality and Cortisol in Survivors of Acute Coronary Syndrome

To test the hypothesis that Type-D personality is associated with elevated cortisol levels in patients 4 months after an acute coronary syndrome (ACS). Salivary cortisol profiles were measured at home in 70 coronary heart disease patients (Mean age = 60.90 years, SD = 10.7, 17% female) 4 months after hospitalization for ACS. Eight saliva samples were taken over the course of 1 day. Thirty eight percent of the ACS patients were defined as Type-D. Cortisol profiles showed a typical diurnal pattern, with low levels in the evening, high levels early in the day. Type-D was not related to the cortisol awakening response, but cortisol output the day was higher in Type-D (mean = 4443.3, SD = 2334.1 nmol/l) than non Type-D patients (mean = 3252.0, SD = 1810.2 nmol/l) after adjustment for age, gender, hypertension, Global Registry of Acute Coronary Events risk score, recurrence of cardiac symptoms, previous myocardial infarction, body mass index and concurrent depressed mood (p = .044). Type-D personality accounted for 6% over the variance in cortisol output over the day, after covariates had been taken into account. Type-D personality may be associated with prolonged disruption of the hypothalamic-pituitary-adrenal axis function in survivors of acute cardiac events and may contribute to biological responses influencing future cardiac morbidity.

Bleeding and outcome in acute coronary syndrome: Insights from continuous electrocardiogram monitoring in the Integrilin and Enoxaparin Randomized Assessment of Acute Coronary Syndrome Treatment (INTERACT) trial

Bleeding is associated with adverse outcome in acute coronary syndromes. However, the precise pathophysiologic mechanisms have not been elucidated. We sought to determine the relationship between bleeding and myocardial ischemia detected by concurrent continuous electrocardiogram (ECG) monitoring and their independent long-term prognostic significance. The INTERACT trial was a randomized controlled trial of enoxaparin versus unfractionated heparin in patients with high-risk non-ST-elevation acute coronary syndromes. Continuous ECG monitoring, performed after enrollment up to 96 hours, was analyzed by an automated algorithm and reviewed by a blinded cardiologist. We centrally adjudicated all bleeding and clinical events in a blinded fashion and calculated the Global Registry of Acute Coronary Events risk score (a validated predictor of mortality) for each patient. Of the 746 patients enrolled, 34 (4.6%) developed major bleeding within 96 hours. After a median follow-up of 2.4 years, patients with bleeding had a higher risk of death (28.4% vs 7.3%, P < .001) and death/myocardial infarction (38.0% vs 12.9%, P < .001) compared with those without bleeding. Overall, 619 patients survived the first 96 hours with complete data on continuous ECG monitoring. Bleeding was associated with the simultaneous presence of ST-segment shifts on continuous ECG monitoring (P = .03). After adjusting for Global Registry of Acute Coronary Events risk score and myocardial ischemia detected by continuous ECG monitoring, major bleeding remained an independent predictor of death (adjusted hazard ratio = 3.48, 95% confidence interval 1.51-8.03, P = .003) and death/myocardial infarction (adjusted hazard ratio = 2.85, 95% confidence interval 1.40-5.78, P = .004). Bleeding is a powerful independent predictor of poor long-term outcome, even after adjusting for other associated prognostic factors such as advanced age and renal dysfunction. Although bleeding is associated with concurrent myocardial ischemia, its adverse prognostic impact may be mediated by complex pathophysiologic mechanisms rather than myocardial ischemia alone. Our findings suggest that future investigations should focus on other biologically plausible mechanisms.

Evaluation of a workplace health program to reduce coronary risk factors

PurposeThe purpose of this paper is to docoment a randomized controlled trial, with follow‐up at three and six months, to determine the impact of a coronary risk factor modification program for employees.Design/methodology/approachIntervention participants received a 12‐week health promotion program involving exercise, education seminars, nutritional analysis and smoking cessation counselling. Outcome measures included differences in coronary risk factors of control and intervention participants between baseline and three and six‐month follow‐up visits.FindingsThe participants included 566 individuals employed in the Halifax area, Nova Scotia, Canada. They were between 19 and 66 years old with at least two modifiable coronary risk factors. There were statistically significant differences at three months in coronary risk score improvement, smoking cessation, physical activity level increases, body mass index reductions and serum cholesterol. At six months, improvements remained significant except for cholesterol. Reduction in blood pressure was not significantly different. Intervention participants compared to control participants showed significant differences in both cardiac and stroke risk at three and six‐month visits.Practical implicationsThis study demonstrates that employees had a significant coronary disease risk reduction as a result of a relatively short health promotion intervention. Benefits three months post‐intervention were not sustained to the same extent as during the intervention. This underscores the need for long‐term commitment with lifestyle changes and raises the issue of the need for a comprehensive approach that also addresses environmental factors.Originality/valueThis paper contributes to the current research base on this topic as there are few well‐designed studies to reduce coronary risk factors for employees.

New and emerging risk factors for CVD

Morphological and immunocytochemical studies have elucidated the complex processes involved in atherogenesis. The notion of plaque instability has emerged from this work and underscored the importance of inflammation in determining clinical complications associated with atherosclerosis, such as acute coronary syndrome. Cells of the immune system have been detected within atherosclerotic lesions and auto-antibodies directed against modified LDL and heat-shock proteins have been identified in the blood of individuals with atherosclerosis. The use of risk 'engines', e.g. the Framingham coronary risk score, has facilitated the identification of individuals at high risk, but the constituent classical risk factors used in these algorithms do not adequately differentiate individuals at moderate risk. As age is a major component of the equations used in these algorithms they are not particularly useful in young adults, and their applicability to non-Caucasian populations has been questioned. Biomarkers of early disease and plaque instability have therefore both been sought. Although some of these markers have been shown individually to be associated with a significant hazard ratio, no substantial improvement in discrimination has been demonstrated when they are incorporated into a risk 'engine'. The latter has generally been assessed by receiver operator characteristic curve analysis, although this approach has been criticised. Other modalities, including imaging and functional assessments of vascular function, are now being developed for clinical use.

Increased Serum CXCL16 Level Is a Marker for Acute Coronary Syndromes

CXCL16 is a transmembrane molecule combining scavenger receptor functions with the properties of an inflammatory chemokine. Accumulating evidence suggests that CXCL16 is involved in atherosclerosis; however, the role of circulating soluble CXCL16 in human coronary artery disease remains unclear. ELISA was used to examine the concentration of serum-soluble CXCL16 in 26 stable angina pectoris patients (SAP), 29 acute coronary syndrome (ACS) patients and 21 control patients. In patients with ACS, serum level of CXCL16 was significantly increased compared to control and SAP patients (p <0.001 vs. control; p = 0.041 vs. SAP patients); serum levels of CXCL16 in patients with SAP were higher than in control patients although no statistical significance was found (p = 0.059). No significant association was found between serum CXCL16 and acute-phase reactants, TNF-alpha, or serum lipid parameters. In ACS patients, increased level of serum CXCL16 was not linked to either the severity of coronary stenosis or TIMI risk score, which is an early risk evaluation system for ACS. Increased level of serum-soluble CXCL16 was independently associated with ACS.

C-reactive protein in risk prediction of cardiovascular outcomes: Tehran Lipid and Glucose Study

Background The main aim of this study was to evaluate the additional utility of C-reactive protein (CRP) over traditional cardiovascular risk factors in risk prediction of cardiovascular outcomes. Methods In a nested case-control study, 207 cardiovascular events among participants over 30 years of the Tehran Lipid and Glucose Study (TLGS) were documented during 3 years of follow-up. Those cases that were free of cardiovascular disease at baseline (126 subjects) were matched to 259 controls for age and sex. High sensitivity CRP and traditional cardiovascular risk factors were measured at baseline. Results Modest correlation was found between CRP and body mass index ( r = 0.34), waist-to-hip ratio ( r = 0.22), total cholesterol ( r = 0.24) and calculated 10-year Framingham coronary risk score (FRS) ( r = 0.27) (all P values < 0.001). The age and sex adjusted relative risk of cardiovascular events for subjects in the highest quartile of the population distribution of CRP compared with the lowest quartile was 2.6 (95% CI = 1.4–5.1, P = 0.006). After additional adjustment for traditional cardiovascular risk factors the odds ratio decreased to non-significant levels (0.8, 95% CI = 0.3–1.9). Addition of CRP did not improve the area under receiver operating characteristic curve of risk functions that was based on traditional cardiovascular risk factors or FRS. Conclusion It seems that for short-term prediction of cardiovascular disease outcomes in the Iranian population, measurement of CRP has no additional value when traditional cardiovascular risk factors are known.

Assessing risk of myocardial infarction and stroke: new data from the Prospective Cardiovascular Münster (PROCAM) study‡

Based on the data of the Prospective Cardiovascular Münster (PROCAM) study, a prospective study of men and women at work in the north-west of Germany, we aimed (i) to develop a refined scoring scheme for calculating the risk of acute coronary events among adult and elderly men and women; and (ii) to generate a new scoring scheme for calculating the risk of ischaemic stroke or transient ischaemic attack (TIA). The coronary risk score was derived from a Weibull function using data from 18 460 men and 8515 women who were recruited before 1996 and had a mean follow-up period of 12+/-6 years. The stroke score was derived using a Cox proportional hazards model using data of 5905 men and 2225 women aged 35-65 years with at least 10 years of unbroken follow-up. The coronary risk score was based on 511 major coronary events, 462 (168 fatal, 294 non-fatal) in men and 49 (18 fatal, 31 non-fatal) in women and included the risk factors LDL cholesterol, HDL cholesterol, systolic blood pressure, smoking status, triglycerides and diabetes mellitus status. It was accurate in both sexes over an age range from 20 to 75 years with an area under the receiver-operating characteristics (ROC) curve of 0.82. The stroke score was based on 85 cerebral ischaemic events (21 TIAs, 64 ischaemic strokes) and included the risk factors age, sex, diabetes mellitus status, smoking status and systolic blood pressure. It had an area under the ROC curve of 0.78 and identified a high-risk group comprising only 4% of the study population that contained 31% of all cerebral ischaemic events. Both new PROCAM risk scores provide simple and effective ways to assess the risk of acute coronary events and ischaemic stroke in the general population and will improve the ability of physicians to target measures in an effort to prevent these potentially devastating conditions.

Hypertension and Coronary Artery Disease: A Summary of the American Heart Association Scientific Statement

The American Heart Association scientific statement on the treatment of hypertension in the prevention and management of ischemic heart disease was published recently. The main recommendations were as follows: (1) For most adults with hypertension, the blood pressure (BP) goal is <140/90 mm Hg but should be <130/80 [corrected] mm Hg in patients with diabetes mellitus, chronic kidney disease, known coronary artery disease (CAD), CAD equivalents (carotid artery disease, abdominal aortic aneurism, and peripheral vascular disease), or 10-year Framingham risk score of >/=10%. For those with left ventricular dysfunction, the recommended BP target is <120/80 mm Hg. (2) For primary CAD prevention, any effective antihypertensive drug or combination is indicated, but preference is given to angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazide diuretics. (3) For the management of hypertension in patients with established CAD (stable or unstable angina, non-ST-segment elevation myocardial infarction, ST-segment elevation myocardial infarction), beta-blockers and ACE inhibitors (or ARBs) are the basis of treatment. If further BP lowering is needed, a thiazide diuretic and/or a dihydropyridine CCB (not verapamil or diltiazem) can be added. If a beta-blocker is contraindicated or not tolerated, diltiazem or verapamil can be substituted. (4) If there is left ventricular dysfunction, recommended therapy consists of an ACE inhibitor or ARB, a beta-blocker, and either a thiazide or loop diuretic. In patients with more severe heart failure, an aldosterone antagonist and hydralazine/isosorbide dinitrate (in black patients) should be considered.

Management Patterns in Relation to Risk Stratification Among Patients With Non–ST Elevation Acute Coronary Syndromes

Randomized clinical trials have established the efficacy of an early invasive management strategy for high-risk non-ST elevation acute coronary syndromes (ACSs). We examined the use of in-hospital cardiac catheterization and medications in relation to risk across the broad spectrum of non-ST elevation ACSs. We evaluated 4414 patients with non-ST elevation ACSs in the prospective, multicenter, Canadian ACS 1 (September 1, 1999-June 30, 2001) and ACS 2 (October 1, 2002-December 31, 2003) Registries. Patients were stratified into low-, intermediate-, and high-risk groups based on tertiles of the calculated Global Registry of Acute Coronary Events risk score (a validated predictor of in-hospital mortality). Although in-hospital mortality rates were similar, the in-hospital use of cardiac catheterization increased significantly over time (38.8% in the ACS 1 Registry vs 63.5% in the ACS 2 Registry; P<.001). The rates of cardiac catheterization in the low-, intermediate-, and high-risk groups were 48.0%, 41.1%, and 27.3% in the ACS 1 Registry, and 73.8%, 66.9%, and 49.7% in the ACS 2 Registry, respectively (P<.001 for trend for both). After adjusting for other confounders, intermediate-risk (adjusted odds ratio, 0.75; 95% confidence interval, 0.63-0.90; P<.001) and high-risk (adjusted odds ratio, 0.35; 95% confidence interval, 0.28-0.45; P<.001) patients remained less likely to undergo cardiac catheterization compared with low-risk patients. Furthermore, there existed a similar inverse relationship between risk and the use of in-hospital revascularization and medications. Despite temporal increases in the use of cardiac catheterization and revascularization in the management of non-ST elevation ACSs, evidence-based invasive and pharmacological therapies remain paradoxically targeted toward low-risk patients. Strategies to eliminate this treatment-risk paradox must be implemented to fully realize the benefits and optimize the cost-effectiveness of invasive management.

The impact of cardiovascular risk factors on subclinical left main coronary artery disease: An intravascular ultrasound study

The impact of cardiovascular risk factors on subclinical but measurable left main coronary artery (LMCA) atherosclerosis is not well known. We analyzed 150 consecutive patients with first-time coronary artery disease presentation undergoing intervention of a left anterior descending coronary artery or left circumflex lesion with motorized intravascular ultrasound transducer pullback that included a nonstenotic LMCA. Framingham, PROCAM, and European SCORE risk assessments were determined in 107 patients <65 years of age (because the Framingham, PROCAM, and European SCORE studies excluded patients >65 years old). Intravascular ultrasound measurements were compared in patients with <10% vs 10% to 20% risk of events. Plaque volumes were greater in patients with higher risk scores: P = .007 in patients with 10% to 20% PROCAM risk, P = .063 in patients with 10% to 20% Framingham risk, and P = .059 in patients with 10% to 20% SCORE risk (P = .059). The mean arc of LMCA calcium (12 degrees +/- 25 degrees overall) correlated with plaque volume (51 +/- 28 mm3, r = 0.30, P = .0001) and with the number of coronary risk factors (P = .048) and ranged from 0.28 degrees +/- 0.74 degrees in patients with 0 to 1 risk factors to 9.95 degrees +/- 21.55 degrees in patients with 2 to 4 risk factors to 19.38 degrees +/- 32.51 degrees in patients with 5 to 7 risk factors. Regression analysis showed obesity and age were the most important factors contributing to LMCA calcium. Intravascular ultrasound measurable atherosclerosis in nonstenotic LMCA correlates with conventional primary coronary risk scores. Left main coronary artery calcium correlates both with LMCA plaque volume and risk factors. Thus, subclinical LMCA atherosclerosis may be a marker for events that are predicted by commonly used primary risk-assessment algorithms.

Coronary Risk Status of Police Officers Compared to Age-Matched Males

Police work is a sedentary occupation with an occasional need to respond to high physical demands. An adequate level of fitness is a hiring requirement for new police personnel. However, few departments mandate minimal fitness standards after initial employment despite heart disease being the most common cause of death for police officers. PURPOSE: The purpose of this study was to compare the coronary risk profile scores of police officers (PO) to age matched males (AM) from the general population. Coronary risk profile was assessed using criteria developed by the Cooper Clinic in Dallas, TX. Male police officers were compared to age-matched males in our Cardiovascular Risk Assessment Program database. RESULTS: Subjects were grouped in 10 year age increments (20–29, 30–39, 40–49, 50–59). After age 20–29 there was a higher coronary risk score in police officers compared to age matched males. CONCLUSION: The risk of developing coronary artery disease is higher in police officers when compared to age-matched males in the general population. Based on these data it appears that officers would benefit from mandated fitness programs designed to improve cardiovascular risk status.Figure

Subclinical Coronary Artery Atherosclerosis in Patients With Erectile Dysfunction

OBJECTIVES The purpose of our study was to assess the prevalence and extent of coronary artery atherosclerosis in asymptomatic patients with vascular erectile dysfunction (ED). BACKGROUND An association between ED and ischemic heart disease has been suggested, but it is unknown if it represents a marker of subclinical coronary atherosclerosis. METHODS We studied 70 consecutive patients with vascular ED, evaluated by penile Doppler, and 73 control subjects with no history of coronary artery disease. We measured traditional coronary risk factors, circulating levels of C-reactive protein (CRP), endothelial function by ultrasound of brachial artery, and coronary artery calcification by multi-slice computed tomography. RESULTS The patients and the control group were similar for age, race, and coronary risk score. Patients with ED had significantly higher high-sensitivity C-reactive protein levels (2.62 vs. 1.03 mg/l, p < 0.001). Flow-mediated dilation of the brachial artery was more impaired in patients with ED than in controls (2.36 vs. 3.92, p < 0.001). Coronary artery calcification was more frequent in individuals with ED than in control subjects (p = 0.01). Multiple logistic regression analysis showed that patients with ED had an overall odds ratio of 3.68 for having calcium score above the 75th percentile, compared to the controls. CONCLUSIONS Coronary atherosclerosis is more severe in patients with vascular ED; ED predicts the presence and extent of subclinical atherosclerosis independent of traditional risk factors for cardiovascular disease. Thus, ED may be considered an additional, early warning sign of coronary atherosclerosis.

Framingham Score in Congenital Hemophilia Patients (HP) with Cardiovascular Disease (CVD).

CVD risk factors of age, hypertension, high cholesterol (HC), smoking, diabetes are expressed in the Framingham coronary risk score. Previous data suggest that hemophilia may protect against CVD. However, CVD risk factors may place HP at risk as they age. HIV infected patients are a rapidly developing group with CVD. No data address the effect of established risk factors on CVD prevalence in HP. We report an extensive analysis of a single hemophilia treatment center (HTC) database for CVD risk factors and prevalence in HP. Framingham coronary risk scores were calculated for HP patients with documented CVD events, using age at time of event to calculate risk. HTC population ≥40 yrs, used as denominator, comprised 156 with FVIII deficiency (63 severe, 16 moderate, 77 mild);109 with FIX deficiency (24 severe, 53 moderate, 31 mild). Forty-eight HP had HIV infection, 113 had hepatitis C, and 25 had HIV/hepatitis C coinfection. Twenty-one HP, 10 with viral infection, ranging 49 to75 years, experienced 23 CVD events. They included 11 FVIII (0 severe, 1 moderate, 10 mild),10 FIX (2 severe,6 moderate, 2 mild). CVD events included 13 myocardial infarction (MI); 5 cerebrovascular accidents (CVA); 1 patient with carotid stenosis and 4 HP with coronary artery disease on catheterization. Two patients each had both MI and CVA. Four patients underwent coronary artery bypass graft surgery. Of 8 patients on antiplatelet therapy, 2 had major bleeds (CNS and GI bleed); one had a minor bleed (epistaxis). Of these 21 HP with CVD, one patient had HIV disease; 8 had hepatitis C, 1 had co-infection with HIV and hepatitis C. One patient was on Vioxx® at the time of his CVD event.Six are deceased, all due to CVD. Overall, CVD affected 7.9% of HP aged >40 years in this population. Of all HP with viral infection in this HTC population, 40% experienced CVD. Ten-year CVD risk per Framingham model at time of event ranged from 10% to 37% (mean 20.1%; median 16%). All HP patients with CVD met the definition of high coronary risk per AHA guidelines with 10-year risk of CVD>10%. Management of established CVD in HP is difficult due to need for invasive procedures and bleeding risk with antiplatelet therapy. Primary prevention of CVD is thus crucial. Aggressive risk factor modification is indicated in all HP with 10-year risk score >10% for primary prevention of CVD. To our knowledge, this is the first application of the well validated Framingham score in the HP population.We conclude that the easily calculable Framingham score should be assessed in all HP over age 40, especially those with viral infections, and incorporated into the comprehensive care model.

High cardiovascular risk in young Saudi males: Cardiovascular risk factors, diet and inflammatory markers

Background The relationship between coronary risk score (CRS), individual coronary risk factors and the serum inflammatory markers, high sensitivity C-reactive protein (hsCRP), ceruloplasmin (Cp), and soluble intercellular adhesion molecule-1 (sICAM-1) was studied in 140 Saudi males without clinically evident coronary heart disease (CHD). Methods One hundred forty subjects without clinically evident CHD were categorized into age tertiles. Demographic data together with an estimate of CRS using Framingham and PROCAM algorithms were obtained, and serum lipid profile, glucose, hsCRP, sICAM-1, and Cp were measured. Macronutrient intake was assessed by a questionnaire. The relationship between CRS, biochemical markers and diet was assessed by univariate and multivariate analysis. Results There was no significant difference in median hsCRP, sICAM-1 or Cp between the age groups. Serum Cp was positively associated with age ( r = 0.224, p < 0.01) and FRS score ( r = 0.174, p < 0.05). Serum sICAM-1 was negatively associated with PROCAM score ( r = − 0.183, p < 0.05). sICAM-1 was positively associated with HDL cholesterol ( r = 0.36, p < 0.0001) among non-diabetics and negatively associated ( r = − 0.397, p < 0.05) among diabetic subjects. Age and dietary intake of saturated fatty acids together explained 7.9% of the variation in serum Cp level in a stepwise multiple regression model. Similarly 6.5% of the variation in serum sICAM-1 level was explained by the total cholesterol / HDL-C ratio. The youngest tertile of the group (< 30 y) had the highest dietary intake of energy, fat and saturated fatty acids ( p < 0.05), and also had a high prevalence of obesity, smoking and sedentary lifestyle. Conclusion We have demonstrated that there is a high prevalence of coronary risk factors and poor dietary intake within a Saudi male population, and that dietary factors are associated with serum sICAM-1 and ceruloplasmin but not hsCRP concentrations in this group.

Subclinical Coronary Artery Atherosclerosis in Patients With Erectile Dysfunction

The purpose of our study was to assess the prevalence and extent of coronary artery atherosclerosis in asymptomatic patients with vascular erectile dysfunction (ED). An association between ED and ischemic heart disease has been suggested, but it is unknown if it represents a marker of subclinical coronary atherosclerosis. We studied 70 consecutive patients with vascular ED, evaluated by penile Doppler, and 73 control subjects with no history of coronary artery disease. We measured traditional coronary risk factors, circulating levels of C-reactive protein (CRP), endothelial function by ultrasound of brachial artery, and coronary artery calcification by multi-slice computed tomography. The patients and the control group were similar for age, race, and coronary risk score. Patients with ED had significantly higher high-sensitivity C-reactive protein levels (2.62 vs. 1.03 mg/l, p < 0.001). Flow-mediated dilation of the brachial artery was more impaired in patients with ED than in controls (2.36 vs. 3.92, p < 0.001). Coronary artery calcification was more frequent in individuals with ED than in control subjects (p = 0.01). Multiple logistic regression analysis showed that patients with ED had an overall odds ratio of 3.68 for having calcium score above the 75th percentile, compared to the controls. Coronary atherosclerosis is more severe in patients with vascular ED; ED predicts the presence and extent of subclinical atherosclerosis independent of traditional risk factors for cardiovascular disease. Thus, ED may be considered an additional, early warning sign of coronary atherosclerosis.

In-Hospital Revascularization and One-Year Outcome of Acute Coronary Syndrome Patients Stratified by the GRACE Risk Score

In the prospective, multicenter Canadian Acute Coronary Syndromes Registry, in-hospital revascularization was independently associated with better 1-year survival only among patients with high-risk non-ST-elevation acute coronary syndromes stratified by the Global Registry of Acute Coronary Events risk score; similar benefits were not observed in the low- and intermediate-risk groups. The Global Registry of Acute Coronary Events risk score appears to be a useful risk stratification tool that identifies high-risk patients for whom more aggressive treatment is warranted.

Use of a Coronary Risk Score (the TIM I Risk Score) in a Non–Selected Patient Population Assessed for Chest Pain at an Emergency Department

Stratification algorithms for acute coronary syndrome enable the identification of high-risk patients who will benefit from more aggressive treatment. The TIMI Risk Score (TRS) has been shown to be useful in intermediate- and high-risk patients. However, little is known about its value in non-selected patients. Our aim was to assess the efficacy of the TRS for risk stratification in a non-selected population with chest pain. We evaluated 1254 consecutive patients (age, 54 [19] years; 57% male) attending an emergency department for chest pain. Overall, 343 (27%) were admitted and 911 (73%) were discharged. All cardiac events during 6-month follow-up were recorded. Of the 911 discharged patients, 45 (5.3%) were admitted during follow-up: 9 (1.1%) underwent revascularization, 5 (0.6%) had a myocardial infarction (MI), and 2 (0.2%) died from cardiovascular disease. Patients with a high TRS had a significantly higher risk of reaching the composite endpoint of death, MI, or revascularization (relative risk per unit of TRS increase, 3.63; 95% CI, 2.20-6.00; P < .001). Of the patients who were initially admitted, 22 (6.4%) underwent revascularization, 4 (1.2%) had an MI, and 14 died (4.1%) from cardiovascular disease during follow-up. The relative risk of the composite endpoint per unit of TRS increase was 1.72 (95% CI, 1.32-2.24; P < .001). The TIMI risk score is useful for stratifying cardiovascular event risk in non-selected patients with chest pain. The score can identify high-risk patients who will benefit from hospital admission and early aggressive treatment.

Frontiers in Cardiovascular Magnetic Resonance

Cardiovascular magnetic resonance (MR) is emerging as a multipurpose imaging modality for the assessment of cardiovascular disease in general and ischemic heart disease in particular. Currently, the pace of innovation is rapid, and the modality is changing from one that is used primarily as a research tool to one that is increasingly used in routine clinical practice. The process of innovation includes not only improvements in scanner hardware, such as coil and gradient technology, and the development of new contrast agents but also the development of novel pulse sequences. The concept of the pulse sequence, in which programming changes at the scanner can lead to fundamental changes in activating tissue, is unique to MR and gives this modality the potential to assess a vast number of biological parameters. Cardiovascular MR promises to play an important clinical and investigational role in both vascular and cardiac systems. Current and potential future applications of cardiovascular MR will be discussed with a particular focus on ischemic heart disease. Multidetector-row computed tomography, another promising and complementary noninvasive imaging technology, will be discussed briefly in relation to cardiovascular MR for the assessment of atherothrombotic disease. ### Nomenclature and Evolving Imaging Assessment Atherothrombosis is a systemic or multiterritory arterial disease that primarily affects the large- and medium systemic arteries, including the aorta and the carotid, coronary, and peripheral arteries. Although the epicardial coronary arteries appear to be the most susceptible to atherothrombosis,1,2 intramyocardial arteries are relatively resistant. The concept of multiterritory atherothrombosis has been addressed in 2 large studies of symptomatic patients that showed that at entry into the studies, 3% to 8% had symptomatic atherothrombotic disease in all 3 main arterial districts and 23% to 32% had disease in 2 districts.3,4 From a structural point of view, the 4 main components of the atherothrombotic plaques are as follows: (1) fibrocellular, …

Benign hereditary leukopenia-neutropenia does not result from lack of low grade inflammation. A new look in the era of microinflammation

The purpose of this study was to determine whether benign hereditary leukopenia-neutropenia in Yemenites may be reflective of an absent or a lesser degree of chronic low grade inflammation that has been documented to exist in most apparently healthy subjects. The white blood cell count (WBCC), fibrinogen as well as high sensitivity C-reactive protein (hs-CRP) concentrations were determined in a group of apparently healthy individuals during their routine health screening program. These inflammatory biomarkers in a group of 82 Yemenite Jews were compared to those measured in a group of 1817 individuals whose parents immigrated to Israel from Central and East Europe, from countries surrounding the Mediterranean Sea as well as the Middle East. The two study groups were matched for possible confounding factors that may have an influence on the intensity of the microinflammatory response including age, gender, body mass index, components of the metabolic syndrome and the Ten Year Calculated Coronary Heart Disease Framingham Risk Score. The expected reduced WBCC was noted in the group of Yemenite Jews (6.99 ± 1.64 versus 5.88 ± 2.06 × 10 3/μL cells, P = 0.001). However, they had significantly enhanced concentrations of hs-CRP, the respective values being 2.1 ± 2 versus 1.4 ± 2.4 mg/L in men ( P = 0.002) and 2.5 ± 2.2 versus 1.4 ± 2.9 in women ( P < 0.0005). An increased concentration of fibrinogen was found in the Yemenite Jews, although the difference was not statistically significant in men. Thus, the leukopenia-neutropenia in Yemenite Jews is probably not an expression of an absent or lesser degree of chronic low grade inflammation. These findings shed more light on the potential mechanisms that are responsible for the low WBCC in this particular ethnic group.