High Blood Cholesterol In Adults Research Articles

New options in the treatment of lipid disorders in HIV-infected patients.

Since the introduction of HAART, there was a remarkably change in the natural history of HIV disease, leading to a notable extension of life expectancy, although prolonged metabolic imbalances could significantly act on the longterm prognosis and outcome of HIV-infected persons, and there is an increasing concern about the cardiovascular risk in this population. Current recommendations suggest that HIV-infected perons undergo evaluation and treatment on the basis of the Third National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (NCEP ATP III) guidelines for dyslipidemia, with particular attention to potential drug interactions with antiretroviral agents and maintenance of virologic control of HIV infection. While a hypolipidemic diet and physical activity may certainly improve dyslipidemia, pharmacological treatment becomes indispensable when serum lipid are excessively high for a long time or the patient has a high cardiovascular risk, since the suspension or change of an effective antiretroviral therapy is not recommended. Moreover, the choice of a hypolipidemic drug is often a reason of concern, since expected drug-drug interactions (especially with antiretroviral agents), toxicity, intolerance, effects on concurrent HIV-related disease and decrease patient adherence to multiple pharmacological regimens must be carefully evaluated. Often the lipid goals of patients in this group are not achieved by the therapy recommended in the current lipid guidelines and in this article we describe other possibilities to treat lipid disorders in HIV-infected persons, like rosuvastatin, ezetimibe and fish oil.

Improving Weight Loss in Cardiac Rehabilitation

In the current issue of Circulation , Philip Ades and his associates at the University of Vermont College of Medicine have provided us with an innovative and important article demonstrating the feasibility and benefits of an enhanced exercise option in cardiac rehabilitation.1 In this study, 74 patients were randomized to a standard cardiac rehabilitation exercise program versus a high-calorie-expenditure exercise program. All patients were provided with 16 hours of group dietary counseling and given a dietary target deficit of 500 calories per day. One group was given a standard exercise program typically used in cardiac rehabilitation (25 to 40 minutes, 3 times per week) and the other an enhanced program targeting 45 to 60 minutes, 5 to 7 times per week, or a total caloric expenditure of 3000 to 3500 kcal/week. The length of the intervention was 5 months, though 1-year data collection was also performed. Patients were of course followed up closely to promote compliance. Article see p 2671 The primary outcome of the study was weight loss. Subjects in the high-calorie-expenditure exercise program lost more than twice as much total body weight (8.2±4 versus 3.7±5 kg) and fat mass (5.9±4 versus 2.8±3 kg). Waist circumference also decreased by a greater amount (7±5 versus 5±5 cm). The enhanced exercise program was also associated with a greater benefit on a number of coronary risk factors including insulin resistance, total/high-density lipoprotein cholesterol ratio, and metabolic syndrome. Most of the weight loss and the difference between the groups were retained at 1-year, though some weight regain occurred (1.3 kg for the enhanced exercise group and 0.9 kg for the standard exercise group). Guidelines for the secondary prevention of coronary heart disease2 and for management of specific coronary risk factors3–4 emphasize the importance of lifestyle change, including weight loss, but …

Hiperglicerolemia, una seudohipertrigliceridemia: A propósito de un niño de 6 años de edad

Recent recommendations from the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, considered that an increase in serum triglyceride levels is an independent risk factor for coronary heart disease. Most enzymatic methods used in routine laboratories do not involve a glycerol blank and determine both glycerol and triglycerides. Patients with glycerol-kinase deficiency or decreased ability to oxidize glycerol may be diagnosed with a pseudo-hypertriglyceridemia. We report a case of a child with a pseudo hypertriglyceridemia (falsely elevated triglycerides) due to a hyperglycerolemia.

Genome-wide association study of plasma lipoprotein(a) levels identifies multiple genes on chromosome 6q

Plasma lipoprotein(a) (Lp[a]) level is an independent risk factor of cardiovascular disease that is under strong genetic control. We conducted a genome-wide association study of plasma Lp(a) in 386 members of a founder population that adheres to a communal lifestyle, proscribes cigarette smoking, and prepares and eats meals communally. We identified associations with 77 single nucleotide polymorphisms (SNPs) spanning 12.5 Mb on chromosome 6q26-q27 that met criteria for genome-wide significance (P <or= 1.3 x 10(-7)) and were within or flanking nine genes, including LPA. We show that variation in at least six genes in addition to LPA are significantly associated with Lp(a) levels independent of each other and of the kringle IV repeat polymorphism in the LPA gene. One novel SNP in intron 37 of the LPA gene was also associated with Lp(a) levels and carotid artery disease number in unrelated Caucasians (P = 7.3 x 10(-12) and 0.024, respectively), also independent of kringle IV number. This study suggests a complex genetic architecture of Lp(a) levels that may involve multiple loci on chromosome 6q26-q27.

Obesity and metabolic syndrome in Brazilian patients with bipolar disorder.

We aimed to determine the prevalence of obesity and metabolic syndrome (O/MetS) in a sample of Brazilian outpatients with bipolar disorder. Eighty-four patients with bipolar disorder were evaluated. We used the definition of MetS established in the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, modified by the American Heart Association (AHA). Patients were classified as obese if their body mass index (BMI) was ≥ 30 kg/m2. We found that 28.6% of our sample met the AHA criteria for MetS and 35.7% were obese. The percentage of patients meeting each criterion of the AHA was as follows: 46% for abdominal obesity; 44% for hypertriglyceridemia or cholesterol-lowering medication use; 26% for low high-density lipoprotein cholesterol or being on a lipid-lowering medication; 45% for hypertension; and 20% for high fasting glucose or anti-diabetic medication use. The prevalence of obesity in our sample of outpatients with bipolar disorder was higher than that observed for the general population of Brazil. The rate of MetS was similar to that observed for the general population. Our data indicate the need for prevention, early detection and treatment of O/MetS in patients with bipolar disorder.

Prevalence of metabolic syndrome in Galicia (NW Spain) on four alternative definitions and association with insulin resistance

The present study evaluated the prevalence of the metabolic syndrome (MS) in a representative sample (no.=2860) of adults from the Spanish region of Galicia using the definitions of a) the World Health Organization; b) the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults; c) the European Group for Study of Insulin Resistance; and d) the International Diabetes Federation. In addition, we assess concordance among the different definitions, and the relationships of MS with insulin resistance (IR) as assessed by the homeostatic model assessment (HOMA-IR) index. Our results indicate a high prevalence of MS under all 4 definitions. MS prevalence was higher in men than women on all 4 definitions, and increased significantly with body mass index and age. IR was high among subjects with MS, and the HOMA index was a good discriminator of MS and non-MS on all 4 definitions, suggesting that HOMA index may be a useful predictive tool in clinical practice.

DO VASCULAR RISK FACTORS CORRELATE WITH PENILE DUPLEX PARAMETERS?

Eighty six consecutive patients referred to a Unit of penile Doppler ultrasound were evaluated for the presence of cardiovascular risk factors and MetS criteria as defined by the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults; Adult Treatment Panel III (ATP III, 2001). Body Mass Index (BMI) was calculated. Each patient underwent a penile duplex Doppler ultrasound study after injection of intracavernous prostaglandin E1 to assess penile blood flow parameters. The rates of arterial insufficiency, venooclusive dysfunction, mixed vascular disease and non vascular etiologies were evaluated along with peak systolic velocities. All the exams were performed by the same physician. Data are expressed as mean±SD, and statistical significance was assumed at P-level<0,05. Statistical analysis of clinical, laboratory, and penile duplex parameters was performed with SPSS® 14.0 software for Windows.

Prevalence of metabolic syndrome and its association with obesity indices in a Chinese population

To investigate the prevalence of metabolic syndrome in an urbanizing community in Qingpu, a suburb of Shanghai, and to determine which obesity indices, including body mass index, waist circumference (WC), and waist:hip (WHpR), and waist:height (WHtR) ratios, are most closely associated with metabolic syndrome. We conducted a cross-sectional health survey of 1634 individuals (age 15-87 years) in the Jinhulu community located in Qingpu. The National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP ATP III) criteria were used to define metabolic syndrome, with central obesity defined according to Asia-Pacific (APC) region criteria. The age-standardized prevalence of metabolic syndrome was 3.6% in men and 7.2% in women. Using the criterion of central obesity in the APC, the age-standardized prevalence of metabolic syndrome increased to 8.3% in men and 10.9% in women. Regardless of age, WHtR consistently showed a higher odd ratios (OR) after adjustment for confounding factors of 2.17 (95% confidence interval [CI] 1.12-4.20; P = 0.022) in subjects<52 years of age and 1.92 (95% CI 1.18-3.11; P = 0.008) in those ≥52 years of age. In men, the WHtR was the only significant predictor (OR 2.42; 95% CI 1.15-5.08; P = 0.02) of metabolic syndrome after adjustment, whereas in women WHtR (OR 1.87; 95% CI 1.37-2.85; P =0.0088) was slightly inferior to WHpR and WC. Metabolic syndrome is prevalent in an urbanizing rural area in Qingpu. Of the anthropometric parameters commonly used to identify metabolic syndrome, WHtR may be the best.

“Risky Business”

Nobody can go back and start a new beginning, but anyone can start today and make a new ending. — —Maria Robinson Although the Framingham Risk Score forms the bedrock of coronary heart disease (CHD) risk prediction, it has several limitations that have been well documented.1 The clinician is left to manage a significant proportion of patients who have “low to intermediate” estimated risk but accrue the majority of CHD events because they form the majority (≈65%) of the population. Article p 382 To address these deficiencies in the prediction of risk, several investigators have included other markers of risk such as biomarkers related to inflammation, genotypes, or imaging tests with traditional risk factors to improve CHD risk prediction. These analyses have resulted in the creation of novel risk-prediction schemes such as the Reynolds risk score, which added family history and high-sensitivity C-reactive protein (hs-CRP) to blood pressure, smoking, total and high-density lipoprotein cholesterol, and hemoglobin A1C to predict risk.2 However, whether algorithms have used biomarkers such as hs-CRP, imaging tests such as coronary calcium score or carotid intima-media thickness, or novel genotypes such as the single-nucleotide polymorphism on chromosome 9p21, the improvements in risk prediction have been modest. Other investigators have suggested that anybody who is not at very low risk should get an imaging test to further stratify risk.3 On the other hand, there have been efforts to identify the “lifetime risk” of CHD for individuals in various age groups. The concept of lifetime risk was highlighted in the National Cholesterol Education Program Adult Treatment Panel (ATP) III guidelines4 and is an important one, especially for individuals who are young to middle-aged. Traditional risk factors become manifest more often in the 4th and 5th decades of life when the estimated lifespan based on …

Classifying Africans with the Metabolic Syndrome

This study was aimed to compare prevalences of the metabolic syndrome in Africans using five definitions as proposed by the World Health Organization (WHO), the European Group for the Study of Insulin Resistance (EGIR), the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel (ATPIII)], the American College of Endocrinology (ACE), and the International Diabetes Federation (IDF). A further objective was to identify difficulties in classifying Africans with the metabolic syndrome and to suggest specific areas where criteria adjustments for identifying Africans should be made. A case-case-control cross-sectional study involved 102 urban African women. Except for microalbumin data, all data necessary for classification of the metabolic syndrome were collected, including fasting and 2-h glucose and insulin, anthropometric measurements, blood pressure, and lipids. The metabolic syndrome prevalences ranged from 5.4% (EGIR), 15.7% (ATPIII), >or=19.4% (WHO), 24.8% (IDF) to 25.5% (ACE). Only 2.9% (n=3) had a triglyceride level >or=1.69 mmol/l, but 58.8% (n=60) had a HDL-level <1.29 mmol/l, whereas 27% (n=26) were insulin resistant, 22.3% (n=21), had a blood pressure >or=140/90 or used hypertension medication. It seems as if the classification of hypertension, insulin resistance and hyperglycemia might have been adequate, but body composition and dyslipidemia criteria need adjustment for Africans. Since neither definition seems completely suitable for Africans it is suggested that clinical emphasis should rather be on treating any specific cardiovascular disease risk factor that is present, than on diagnosing a patient with the metabolic syndrome.

Prevalence of dyslipidaemia in apparently healthy professionals in Asaba, South South Nigeria.

Hypercholesterolaemia is a major risk factor for coronary heart disease (CHD) especially in industrialized societies. Coronary heart disease is becoming an increasing cause of death even in the developing world. To determine the prevalence of dyslipidaemia in apparently healthy professionals in a developing economy. One hundred apparently healthy professionals were recruited from several professions by stratified random sampling. This population was believed to be at higher risk of dyslipidaemia considering their more likely "western diet" lifestyle. Total cholesterol, LDL-cholesterol, HDL-cholesterol and Triglycerides were determined using standard cholesterol LDL precipitating reagents/kits. The mean age of the subjects was 41.59 +/- 8.22 years (range 29 to 58 years) with male to female ratio of 1:1.2. Mean total cholesterol was 180.69 +/- 36.248 mg/dl (4.67 +/- 0.94 mmol/L), LDL cholesterol 122.68 +/- 44.42 mg/dl (3.17 +/- 1.15 mmol/L), HDL-cholesterol 37.47 +/- 9.91 mg/dl (0.96 +/- 0.26 mmol/L) and Triglyceride 83.139 +/- 66.888 mg/dl (0.94 +/- 0.76 mmol/L). Using the Third Report of the NCEP Expert Panel on Detection. Evaluation and Treatment of high blood cholesterol in Adults (ATP III) definition and risk classification, 5% of the study population had hypercholesterolaemia, 23% elevated total serum cholesterol, 51% elevated LDL-cholesterol and 60% low HDL-cholesterol, with females recording better overall lipid profile. Dyslipidaemia was highly prevalent in the population studied, with low HDL-cholesterol being the most frequent lipid abnormality. Dyslipidaemia is becoming a serious health problem in the developing world also, even among the apparently healthy, and necessitates periodic lipid profile screening.

Depression: An Important Comorbidity With Metabolic Syndrome in a General Population

OBJECTIVE—There is a recognized association among depression, diabetes, and cardiovascular disease. The aim of this study was to examine in a sample representative of the general population whether depression, anxiety, and psychological distress are associated with metabolic syndrome and its components.RESEARCH DESIGN AND METHODS—Three cross-sectional surveys including clinical health measures were completed in rural regions of Australia during 2004–2006. A stratified random sample (n = 1,690, response rate 48%) of men and women aged 25–84 years was selected from the electoral roll. Metabolic syndrome was defined by the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, Adult Treatment Panel III (NCEP ATP III), and International Diabetes Federation (IDF) criteria. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale and psychological distress by the Kessler 10 measure.RESULTS—Metabolic syndrome was associated with depression but not psychological distress or anxiety. Participants with the metabolic syndrome had higher scores for depression (n = 409, mean score 3.41, 95% CI 3.12–3.70) than individuals without the metabolic syndrome (n = 936, mean 2.95, 95% CI 2.76–3.13). This association was also present in 338 participants with the metabolic syndrome and without diabetes (mean score 3.37, 95% CI 3.06–3.68). Large waist circumference and low HDL cholesterol showed significant and independent associations with depression.CONCLUSIONS—Our results show an association between metabolic syndrome and depression in a heterogeneous sample. The presence of depression in individuals with the metabolic syndrome has implications for clinical management.

Military Community: A Privileged Site for Clinical Research: Epidemiological Study of Metabolic Syndrome Risk Factors in the Military Environment

The metabolic syndrome is considered to be an important public health problem. The Epidemiological Study of Metabolic Syndrome Risk Factors in the Military Environment is a prospective epidemiological study that is designed to identify clinical and laboratory parameters of metabolic syndrome and cardiovascular risk factors with an initial 1-year cross-sectional study followed by a 10-year follow-up and patient care. One hundred eight-five (9%) of 2,045 military personnel subjects presented at least three of the five National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) criteria. They were significantly older (42.2 +/- 8.5 years) than the other subjects (37.3 +/- 8.7 years, p < 0.001), had a higher body mass index (BMI) (29.5 +/- 3.4 vs. 24.8 +/- 2.9, p < 0.001), and a greater body weight at age 20 (75.4 +/- 11 vs. 70.4 +/- 8.5 kg, p < 0.001). Smoking, little physical activity, and family histories of diabetes and arterial hypertension were more frequent in these subjects. Total plasma cholesterol and C-reactive protein were higher. Plasma insulin and BMI (r = 0.456, p < 0.0001) and plasma insulin and waist circumference (r = 0.446, p < 0.0001) were well correlated. Plasma insulin and homeostasis model assessment increased with the number of metabolic syndrome criteria. These results demonstrate a strong association with insulin resistance. Men with several risk factors require specific care especially for hypertension and dyslipidemia that will be evaluated during the follow-up period. Genotyping of subjects having metabolic syndrome vs. controls for genes, presumably involved should enlarge the area of exploration of this syndrome.

Single-pill amlodipine/atorvastatin helps patients of diverse ethnicity attain recommended goals for blood pressure and lipids (the Gemini-AALA study)

The Gemini-AALA (Australia, Asia, Latin America, Africa/Middle East) study evaluated the efficacy and safety of single-pill amlodipine/atorvastatin (Caduet) for the treatment of patients of diverse ethnicity with concomitant hypertension and dyslipidaemia. This was a 14-week, open-label study including patients from 27 countries across the Middle East, Asia-Pacific, Africa and Latin America. Eight dosage strengths of single-pill amlodipine/atorvastatin (5/10, 10/10, 5/20, 10/20, 5/40, 10/40, 5/80 and 10/80 mg) were titrated to improve blood pressure and lipid control. Blood pressure and lipid goals were determined according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP ATP III) guidelines, respectively (blood pressure, <140/90 or <130/80 mm Hg; low-density lipoprotein cholesterol (LDL-C), <4.1 to <2.6 mmol l(-1) (<160 to <100 mgdl(-1))). Overall, 1649 patients received study medication. Most patients (91.4%) had >or=1 cardiovascular risk factor (as defined by NCEP ATP III guidelines) in addition to hypertension/dyslipidaemia, and 61.7% had coronary heart disease/risk equivalent. At baseline, mean blood pressure was 146.6/88.3 mm Hg and LDL-C was 3.4 mmol l(-1) (130.2 mgdl(-1)). At week 14, 55.2% of patients reached both blood pressure and lipid goals, 61.3% reached blood pressure goal and 87.1% reached lipid goal (34.0% were at lipid goal at baseline). Mean blood pressure reduction was 20.2/11.4 mm Hg. For patients who were lipid-lowering drug naive at baseline, mean reduction in LDL-C was 41.0%. Treatment-related adverse events led to the discontinuation of 3.6% of patients. Single-pill amlodipine/atorvastatin therapy was well tolerated and effective for the reduction of blood pressure and lipids to recommended goals in patients from diverse ethnic backgrounds.

Dyslipidemia and Lipoprotein Profiles in Inflammatory Bowel Disease (IBD)

Purpose: Dyslipidemia (elevated total cholesterol, elevated low-density lipoproteins (LDL), elevated triglycerides (TG), decreased high-density lipoproteins (HDL) is a major risk factor for developing coronary artery disease (CAD). A characteristic lipoprotein profile with increased TG's and decreased HDL levels is commonly seen with systemic lupus erythematosis (SLE) and the levels correspond to the SLE disease activity. An increase in inflammatory cytokines (TNF-α, interleukin-1 and interferon-γ) decreases lipoprotein lipase (LPL) enzyme activity. As in SLE, high levels of circulating inflammatory cytokines are seen in IBD. However, the lipoprotein profile in IBD has not been studied. The aim of this study is to describe the prevalence of dyslipidemia and characterize the lipoprotein profiles in IBD patient population. Methods: Medical records of 784 patients diagnosed with IBD at an academic medical center between 2000–2007 were retrospectively reviewed for lipoprotein profiles, serum albumin levels, risk factors modifying LDL treatment levels, frequency of different combinations of lipoprotein values in abnormal range and anti-hyperlipidemic medication use. The lipoprotein values and risk factors are based on the Third National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) report. Only patients with documented IBD diagnosis and lipoprotein profiles are included in the study. Values are expressed as percentages. Results: 501 patients (186 males and 315 females) diagnosed with IBD (229 Crohn's disease (CD) and 272 ulcerative colitis (UC) qualified for the study. 283 patients without complete lipoprotein profile are excluded. Patients are grouped based on the gender and IBD disease type (CD v/s UC). Albumin levels are not significantly different. Lipoprotein profiles of IBD groups are shown in the Table 1. The percentage of dyslipidemia in IBD is about 19–48%. Interestingly 48% of male CD and male UC patients have HDL values below 40 mg/dL. Risk factors modifying LDL levels are as shown in Table 2. Smoking rate is significantly higher in the CD group. Anti-hyperlipidemia medication use is about 12–23%. Patients qualified per NCEP ATP-3 but not on treatment is about 15–27%. The frequency of different combinations of abnormal lipoprotein values are in Table 3. All four lipoprotein values in abnormal range is more commonly seen in female IBD group.Table 3: Frequency of different combinations of abnormal lipoprotein values (%).Table 2: Risk factors modifying LDL treatment goals (%)Table 1: Lipoprotein profiles of IBD patients (in percentages).Conclusion: To date, this is the only study describing dyslipidemia, characterizing lipoprotein profiles and their treatment trends in IBD patient population. More aggressive approach in profiling and treating dyslipidemia using NCEP-ATP III guidelines in IBD seems warranted.

Identifying the Vulnerable Patient with Rupture-Prone Plaque

Atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality in the United States, and the obesity epidemic combined with aging of the population seems destined to increase the burden of this disease. Traditional cardiovascular risk assessment accounts for <50% of the variability in risk in the United States. Therefore, better and more effective identification of persons at high cardiovascular risk is needed. Our understanding of atherosclerosis has shifted from a focal disease whose hallmark is symptoms caused by a severe stenosis to a systemic disease characterized by endothelial dysfunction (ED) and plaque inflammation, with the potential for rupture and thrombosis mainly in those with subcritical stenosis. Under the new paradigm, clinicians require updated strategies to better assess the quality of arterial plaque. Effective tools for primary and secondary prevention of heart attack and stroke include intensive lifestyle modification, blood pressure reduction, and lipid-modifying therapies. These interventions are now understood to decrease plaque inflammation and thereby promote plaque stability. Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) appears to be a specific marker of plaque inflammation that may play a direct role in the formation of rupture-prone plaque. In contrast, traditional risk factors, lipid measurement, and most vascular imaging modalities do not directly assess the acute ischemic potential in the arterial wall. Measuring Lp-PLA(2) levels in human serum or plasma is noninvasive and relatively inexpensive. Lp-PLA(2) may provide additional clinically relevant information that shows which patients have a high level of atherosclerotic disease activity as manifested by vascular inflammation, ED, and increased risk for progression toward rupture-prone plaque.

Metabolic Syndrome and Mortality in Older Adults

The utility of metabolic syndrome (MetS) for predicting mortality among older adults, the highest-risk population, is not well established. In addition, few studies have compared the predictive utility of MetS to that of its individual risk factors. We evaluated relationships of MetS (as defined by the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel III (ATPIII)], International Diabetes Foundation [IDF], and World Health Organization [WHO]) and individual MetS criteria with mortality between 1989 and 2004 among 4258 US adults 65 years or older and free of prevalent cardiovascular disease (CVD) in the Cardiovascular Health Study, a multicenter, population-based, prospective cohort. Total, CVD, and non-CVD mortality were evaluated. Cox proportional hazards models were used to estimate the mortality hazard ratio (relative risk [RR]) predicted by MetS. At baseline (mean age, 73 years), 31% of men and 38% of women had MetS (ATPIII). During 15 years of follow-up, 2116 deaths occurred. After multivariable adjustment, compared with persons without MetS, those with MetS had a 22% higher mortality (RR, 1.22; 95% confidence interval [CI], 1.11-1.34). Higher risk with MetS was confined to persons having elevated fasting glucose level (EFG) (defined as > or = 110 mg/dL [> or = 6.1 mmol/L] or treated diabetes mellitus) (RR, 1.41; 95% CI, 1.27-1.57) or hypertension (RR, 1.26; 95% CI, 1.15-1.39) as one of the criteria; persons having MetS without EFG (RR, 0.97; 95% CI, 0.85-1.11) or MetS without hypertension (RR, 0.92; 95% CI, 0.71-1.19) did not have higher risk. Evaluating MetS criteria individually, we found that only hypertension and EFG predicted higher mortality; persons having both hypertension and EFG had 82% higher mortality (RR, 1.82; 95% CI, 1.58-109). Substantially higher proportions of deaths were attributable to EFG and hypertension (population attributable risk fraction [PAR%], 22.2%) than to MetS (PAR%, 6.3%). Results were similar when we used WHO or IDF criteria, when we evaluated different cut points of each individual criterion, and when we evaluated CVD mortality. These findings suggest limited utility of MetS for predicting total or CVD mortality in older adults compared with assessment of fasting glucose and blood pressure alone.

Assessment of cardiovascular risk in shift healthcare workers

Shift work has been associated with an increased risk of cardiovascular disease (CVD); in particular, night work affects the circadian rhythm. The study examines the effectiveness of three screening methods and plasma hyperhomocysteinemia, an independent risk factor, in assessing the risk of CVD in 147 healthcare providers doing daytime or rotational shift work. The methods applied were: (i) the method proposed by the European Cardiovascular Indicators Surveillance Set (EUROCISS); (ii) the metabolic syndrome (MS) criteria of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATPIII) and (iii) the MS criteria of the International Diabetes Federation (IDF). EUROCISS was unable to distinguish between the CVD risk of daytime and rotational shift workers. Both the ATPIII and the IDF detected MS, which is strongly associated with CVD, but only the IDF evidenced a significantly greater prevalence of MS (P<0.05) among shift workers. Hyperhomocysteinemia was unable to discriminate the CVD risk between daytime and shift workers, as it was influenced by multiple confounding factors. The increased risk of CVD associated with shift work is related to the greater incidence of MS among these workers. In our study a high prevalence of MS was detected only with the IDF. The method is useful for CVD prevention and the promotion of health during any medical examination of shift workers.

The lipoprotein subfraction profile: heritability and identification of quantitative trait loci

The HDL and LDL subclass profile is an emerging cardiovascular risk factor. Yet, the biological and genetic mechanisms controlling the lipoprotein subclass distribution are unclear. Therefore, we aimed 1) to determine the heritability of the entire spectrum of LDL and HDL subclass features and 2) to identify gene loci influencing the lipoprotein subfraction pattern. Using NMR spectroscopy, we analyzed the lipoprotein subclass distribution in 1,275 coronary artery disease patients derived from the Regensburg Myocardial Infarction Family Study. We calculated heritabilities, performed a microsatellite genome scan, and calculated linkage. HDL and LDL subclass profiles showed heritabilities ranging from 23% to 67% (all P < 10(-3)) of traits using univariate calculation. After multivariate adjustment, we found heritabilities of 27-48% (all P < 0.05) for HDL and 21-44% for LDL traits. The linkage analysis revealed a significant logarithm of the odds (LOD) score (3.3) for HDL particle concentration on chromosome 18 and a highly suggestive signal for HDL particle size on chromosome 12 (2.9). After multivariate adjustment, we found a significant maximum LOD score of 3.7 for HDL size. Our study is the first to analyze heritability and linkage for the entire spectrum of LDL and HDL subclass features. Our findings may lead to the identification of genes controlling the lipoprotein subclass distribution.

The Metabolic Syndrome

See related article, pages 1078–1083. The metabolic syndrome is a clustering of metabolic abnormalities, which include insulin resistance or diabetes, obesity, hypertension, and dyslipidemia. Although the mechanisms of the underlying abnormalities remain to be clarified, the pathogenesis includes both genetic predisposition and modifiable risk factors such as sedentary lifestyle and dietary intake. Recent estimates suggest that approximately 24% of US adults have the metabolic syndrome.1 In several studies, the metabolic syndrome has been shown to increase the risk of cardiovascular diseases2; however, the strength of its association with stroke is weaker than that for coronary heart disease.3 In the guidelines for the primary prevention of stroke from the American Heart Association/American Stroke Association, the metabolic syndrome is listed as a less–well-documented risk factor.4 But, given the high prevalence of the metabolic syndrome, studying its association with stroke is certainly relevant for 2 reasons: first, to obtain a better etiologic understanding of the causes of stroke; second, to identify individuals at high risk for stroke. This translates into 2 distinct scientific questions: is the metabolic syndrome by itself a risk factor for stroke?; and can we predict which individuals are at increased risk for stroke based on information about the metabolic syndrome? To answer these questions from observational data, one needs 2 distinct model-building strategies that require differences in assumptions of biological associations and statistical considerations.5,6 In this issue of Stroke ,7 Wang and …