Higher Total Risk Research Articles

Correlation between mean platelet volume and total risk of cardiovascular disease

Introduction. The association between mean platelet volume (MPV) and single cardiovascular disease (CVD) risk factors has previously been tested. The aim of our study was to evaluate the association between MPV and total risk of CVD. Materials and Methods. In 216 consecutive outpatients referred for a cardiology assessment because of multiple CVD risk factors, total CVD risk was estimated according to the Framingham Risk Score (FRS) as low ( 20%). Additionally, FRS was adjusted for triglycerides (TG), body mass index (BMI) and a family history of CVD, important CVD risk factors which are not included in the FRS equation. Also, CVD risk was estimated according to terciles of MPV ( 9.1 fL, respectively). Correlation between high sensitivity C-reactive protein (hs-CRP) and FRS was used as confirmation that our study hypothesis was properly set. Results. MPV did not correlate with individual CVD risk factors or with FRS, either before, or after adjustment for additional CVD risk factors. Significant correlation between MPV and total CV risk was observed only in the adjusted high FRS group ; namely, for persons in tercile 3, CVD risk was doubled (OR 2.2 ; 95% CI 1.05-4.64 ; P =0.038). In comparison, there was a strong linear correlation between hs-CRP and unadjusted (r=0.203, P=0.004) and adjusted (r=0.383, P<0.001) FRS. Conclusion. Correlation between MPV and high total CVD risk suggests increased platelet activity primarily as a consequence and sign of atherosclerotic vascular damage. Linear correlation between hs-CRP with FRS confirms inflammation as an important mechanism of atherogenesis.

475 DIFFERENCES IN THE ROLE OF QUANTITATIVE HEPATITIS B SURFACE ANTIGEN BETWEEN HBEAG SEROPOSITIVE AND SERONEGATIVE INDIVIDUALS WITH CHRONIC HEPATITIS B

2004. They were tested for HBV-related seromarkers at study entry and regularly followed using high-resolution abdominal ultrasonography and serological examinations. The incidence of LC was detected by ultrasonography, computerized linkage with national health insurance profiles, and medical chart reviews. We allocated two-thirds participants (2,228) for model development and the other one-third (1,114) for model validation. The cumulative risk for LC by predictors were estimated by Kaplan-Meier methods. There were three models developed: model 1 included age, gender, ALT, HBeAg, and HBV DNA level; model 2 included quantitative HBsAg in addition; and model 3 further included HBV genotypes. The Cox’s proportional hazards models were utilized to estimate the regression coefficients of each predictor for LC and each coefficient was converted to an integer as a simple risk score. The area under receiver operating curve (AUROC) was used to evaluate the performance of each model. Results: The cumulative risk for LC were 9.8% for genotype B or B+C and 21.0% for genotype C (p < 0.001). Participants with elevated serum levels for HBsAg had an increased cumulative risk of 4.8% for <100 IU/mL, 8.8% for 100–999 IU/mL, and 16.2% for ≥1000 IU/mL (p < 0.001 for trend). Participants with higher total risk scores had an increasing predicted risk for LC. By applying the risk score system, participants in validation set could be categorized as low-, medium-, and high-risk for LC accurately (all p-values <0.001). The AUROCs ranged 0.75–0.80 for the three models. Conclusions: HBV genotypes and serum levels of HBV DNA and quantitative HBsAg had excellent long-term predictability of LC risk. They may be used to derive valid risk prediction models.

474 GENOMIC ANALYSIS OF THE HOST RESPONSE TO HEPATITIS B VIRUS INFECTION

2004. They were tested for HBV-related seromarkers at study entry and regularly followed using high-resolution abdominal ultrasonography and serological examinations. The incidence of LC was detected by ultrasonography, computerized linkage with national health insurance profiles, and medical chart reviews. We allocated two-thirds participants (2,228) for model development and the other one-third (1,114) for model validation. The cumulative risk for LC by predictors were estimated by Kaplan-Meier methods. There were three models developed: model 1 included age, gender, ALT, HBeAg, and HBV DNA level; model 2 included quantitative HBsAg in addition; and model 3 further included HBV genotypes. The Cox’s proportional hazards models were utilized to estimate the regression coefficients of each predictor for LC and each coefficient was converted to an integer as a simple risk score. The area under receiver operating curve (AUROC) was used to evaluate the performance of each model. Results: The cumulative risk for LC were 9.8% for genotype B or B+C and 21.0% for genotype C (p < 0.001). Participants with elevated serum levels for HBsAg had an increased cumulative risk of 4.8% for <100 IU/mL, 8.8% for 100–999 IU/mL, and 16.2% for ≥1000 IU/mL (p < 0.001 for trend). Participants with higher total risk scores had an increasing predicted risk for LC. By applying the risk score system, participants in validation set could be categorized as low-, medium-, and high-risk for LC accurately (all p-values <0.001). The AUROCs ranged 0.75–0.80 for the three models. Conclusions: HBV genotypes and serum levels of HBV DNA and quantitative HBsAg had excellent long-term predictability of LC risk. They may be used to derive valid risk prediction models.

Home blood pressure monitoring may make office measurements obsolete

he conventional measurement of blood pressure(BP) in the office or clinic has been the cornerstonefor hypertension management for decades. How-ever, because of the white-coat and the masked hyper-tension phenomena, out-of-office BP monitoring withambulatory or home measurements is often required [1].ExtensiveresearchonambulatoryBPmonitoringhasestab-lished its role as the most accurate tool for hypertensiondiagnosis [1–3].Onthecontrary,despitetheincreasinguseof home BP monitoring by hypertensive patients in thedaily management of their high BP condition, research inthisfield,inparticularwhenconsideringoutcometrials,hasbeen delayed as compared to ambulatory BP monitoring[4,5].

Potential impact of single-risk-factor versus total risk management for the prevention of cardiovascular events in Seychelles

To assess the prevalence of cardiovascular (CV) risk factors in Seychelles, a middle-income African country, and compare the cost-effectiveness of single-risk-factor management (treating individuals with arterial blood pressure ≥ 140/90 mmHg and/or total serum cholesterol ≥ 6.2 mmol/l) with that of management based on total CV risk (treating individuals with a total CV risk ≥ 10% or ≥ 20%). CV risk factor prevalence and a CV risk prediction chart for Africa were used to estimate the 10-year risk of suffering a fatal or non-fatal CV event among individuals aged 40-64 years. These figures were used to compare single-risk-factor management with total risk management in terms of the number of people requiring treatment to avert one CV event and the number of events potentially averted over 10 years. Treatment for patients with high total CV risk (≥ 20%) was assumed to consist of a fixed-dose combination of several drugs (polypill). Cost analyses were limited to medication. A total CV risk of ≥ 10% and ≥ 20% was found among 10.8% and 5.1% of individuals, respectively. With single-risk-factor management, 60% of adults would need to be treated and 157 cardiovascular events per 100000 population would be averted per year, as opposed to 5% of adults and 92 events with total CV risk management. Management based on high total CV risk optimizes the balance between the number requiring treatment and the number of CV events averted. Total CV risk management is much more cost-effective than single-risk-factor management. These findings are relevant for all countries, but especially for those economically and demographically similar to Seychelles.

The Association Between –Market Risk Disclosure Reporting And Firm Risk: The Impact Of SEC FRR No. 48

SEC FRR No. 48 requires that all firms report their market risk exposures using one or more of three alternative formats for disclosure: tabular format, sensitivity analysis, or Value at Risk (VaR). In this paper we examine how the method chosen affects a firm’s risk as measured by total risk, the cost of equity, and firm specific risk. We find that firms using VaR have higher total risk and firm specific risk than firms using sensitivity analysis. Conversely, firms employing tabular disclosure generally have lower but not statistically significant lower total risk, cost of equity, and firm specific risk than firms using sensitivity.

Performance of DJIA Stocks Using Fundamental Indexation

During the decade beginning on December 31, 1999, an equal-weighted portfolio of the Dow Jones Industrial Average (DJIA) stocks outperformed the market capitalization and priceweighted portfolios, with ending values of $1,020, $731, and $777 on the $1,000 originally invested, respectively. The net income and free cash flows-weighted portfolios performed the best with identical ending values of $1,082. The portfolio with the lowest standard deviation measure of total risk was weighted on net income (14.26%) and the portfolio with the highest total risk was weighted on total assets (27.78%). All portfolios had their worst performance in 2008, while the best performance varied across portfolios but were limited to the years 2003, 2006 and 2009.

Performance of Islamic and Conventional Exchange Traded Funds in Malaysia

ETFs have attracted many investors as one of the most innovative products of financial engineering. By virtue of the nascent nature of MyETF-DJIM Titan 25 and FBM 30ETF in Malaysia, comparative performance studies are essential during a financial crisis. MyETF is different from FBM 30ETF in terms of investment scope and Shari’ah governance structure. While MyETF has achieved its objective in tracking its index, FBM 30ETF has failed in this respect. Despite its higher total risk, MyETF performed better than its index. The same applies in the case of FBM 30ETF. Although MyETF has bigger net assets, economies of scale, and better diversification, the performances of the two funds are lacklustre and similar, with FBM 30ETF performing somewhat better. Notwithstanding their success to outperform their respective benchmarks, both ETFs had comparable negative performance, with decline in prices and NAV. The negative returns have caused abnormality in their measurements.

025 Lifestyle and health related quality of life changes in coronary and high CVD risk patients and their partners attending the MYACTION integrated vascular prevention programme in the community

Background Based on EUROACTION, we developed MYACTION, a novel community-based preventive cardiology programme for the UK NHS. It integrates preventive care of patients with CHD, traditionally managed in hospital programmes, with asymptomatic high risk individuals (eg, those at high total risk of developing CVD identified at Health Checks, or with diabetes) from primary care. It is family focussed and actively recruits the partners of all patients to the programme which includes a professional lifestyle intervention, and appropriate risk factor management, all undertaken in a community leisure facility. Methods Coronary patients (COR) from hospital and high risk individuals (HRI) with a CVD risk >20% over 10 years from primary care were invited with their partners to attend the programme. The initial assessment (IA) by cardiac specialist nurse, dietitian and physical activity specialist supported by a preventive cardiologist included measurements of dietary habits (Mediterranean diet score:MDS), physical activity (7-day physical activity recall), anthropometry, risk factors and HRQoL (Hospital Anxiety and Depression Scale, Dartmouth Coop and EQ-VAS). The 16-week programme included one to one lifestyle and risk factor management, educational workshops and supervised exercise sessions. All patients and partners had lifestyle and risk factor measurements made at IA and then at end of programme (EOP). Results Eighty-seven COR (61.3% of those referred) and 119 HRI (72.6%) attended with 93 partners (59.6%). 59 COR (67.8%), 85 HRI (71.4%) and 58 (63.0%) partners attended the EOP. 5 (25%) out of 20 COR, HRI and partners who were cigarette smokers had stopped smoking at EOP. Mean MDS improved significantly in COR +1.56, (95% CI 1.0 to 2.1), HRI + 1.3 (0.9 to 1.7) and partners + 1.4 (1.0 to 1.9). Proportions achieving physical activity guidelines improved significantly in COR + 47.2% (95% CI 31.8 to 62.5), HRI + 54.7% (40.9 to 68.4) and partners + 44.9% (28.9 to 60.9). Mean BMI and waist circumference were significantly reduced in COR: BMI −0.3 (−0.6 to −0.6) and waist −1.0 cm (−2.0 to −0); and HRI: BMI −0.7 (−0.8 to −0.2) and waist −2.4 cm (−3.4 to −1.5); and partners: BMI −0.4 (−0.8 to −0.1) and waist −1.9 (−2.8 to −1.1). Median anxiety scores were significantly reduced in COR: 6 (2.5,11) to 5 (2,8) but not in HRI and partners. Median depression scores were significantly reduced in COR: 3 (2,6.5) to 2 (1,5) and HRI: 3 (1,6) to 2 (1,5). Median total Dartmouth Coop scores were significantly reduced in COR: 21 (17,27) to 18 (15,23) and HRI: 18 (15,22) to 16 (13.5,20.5). EQ-VAS scores were significantly improved in COR: 70 (50,80) to 75 (68,80), in HRI: 72.5 (60,80) to 77 (70,88) and in partners: 75 (60,80) to 80 (70,90). Conclusions The MYACTION programme achieved real improvements in lifestyle, obesity management and in patient reported HRQoL outcomes. These results demonstrate that this novel programme is effective in reducing total CVD risk.

CEO Employment History and Firm Risk

We provide empirical evidence on the relation between CEO employment history and a firm’s choice of a new CEO, firm risk and a firm’s financing and investment policies. CEOs that have worked for more employers (mobile CEOs) match with employers that have higher total risk, are smaller and younger, have lower R&D intensity, offer compensation that is more sensitive to risk, have unsuccessful prior CEOs, and have smaller boards with fewer inside directors. Mobile CEOs increase operating performance volatility, idiosyncratic risk, financial leverage, and advertising, and decrease capital expenditures. Mobile CEOs increase (decrease) R&D investment in homogeneous (heterogeneous) industries. Our results suggest that CEO employment history reveals information on the unobservable risk tolerance of CEOs. Mobile CEOs appear to have a higher tolerance for risk and influence policies to conform to their preferences.

Digital Portfolio Theory: Portfolio Size, Versus Alpha, Beta, and Horizon Risk

Digital Portfolio Theory (DPT) permits investors to control their risk exposure with respect to multiple investment time horizons. DPT is a theoretical enhancement for estimating efficient portfolios that drops the normal distribution and zero autocorrelation assumptions of Modern Portfolio Theory (MPT) and allows effects of unconditional mean reversion risk at multiple horizons. The time horizon composition of single period risk creates hedging demands based on investor holding period and expectations without regard to changes in expected returns, changes in risk, or changes in state variables. DPT is a mean-variance-autocovariance portfolio optimization paradigm that allows investors to strategically control the risk that patterns occur but includes no information about what patterns other than their length. DPT incorporate more of the structure of the risk process contained in historical information compared to MPT, or CAPM representations. Academic financial research provides little specific portfolio recommendations suitable for long-term horizons. The MPT model assumes investors make decisions myopically in a single period framework. The Merton continuous-time model assumes investors make decisions dynamically based on intertemporal hedging over multiple periods. The DPT model assumes investor's make dynamic decisions based on longer holding periods in a static single period model. DPT analysis provides precise quantitative advice for short, intermediate, and long holding periods.Quadratic MPT does not permit users to specify the size in solution portfolios. An integer constraint added to linear DPT is useful to meet portfolio size requirements. This paper extends DPT to control portfolio size and empirically examines feasible size regions and in-sample optimal allocations for alternative levels of systematic, unsystematic and horizon length risk. The empirical test examines long only DPT solutions from a universe of 73 industries for a 16-year period that includes the October 1987 stock market crash. Optimal portfolios and feasible sizes are examined for three strategies; low versus high total risk, active versus passive, and short versus long horizon risk. Low-risk optimal portfolios and active optimal portfolios are smaller with fewer feasible size possibilities. Optimal industry allocations change with holding period and expectations. Long-term investors should hold smaller portfolios. The majority of allocations are not myopic; however a buy-and-hold strategy is appropriate for some sectors. Gold, oil, gas, and tobacco are included in solutions over multiple holding periods. This study contributes to the theory and practice of portfolio selection and optimization as well as to the question of holding period and horizon risk.

Hypertension Summer School 19-25 September, 2009 - Smolenice, Slovakia

The 2009 European Society of Hypertension Summer School on Hypertension was organized by the Slovak Society of Hypertension in Smolenice (Slovakia). The summer school covered many aspects of hypertension, including parts of the epidemiology, pathophysiology, clinical presentation and clinical course, associated clinical conditions, and treatment. This report summarizes the key points. Hypertension is a systemic disease, involving many organs. Hypertension is highly prevalent, but not adequately treated. To choose the optimal therapeutic approach, stratification of total cardiovascular risk, including the assessment of target organ damage, is crucial. Antihypertensive treatment needs to be prompt and aggressive in those hypertensive subjects with high total cardiovascular risk.

Treatment of hypertension in patients with peripheral arterial disease: An update

Hypertension is a known risk factor for cardiovascular events, and recent data have pointed to peripheral arterial disease (PAD) as another strong risk factor; together, they cause a surprisingly high total risk. This review deals with the clinical management of this dangerous association. The ankle-brachial index helps in the diagnosis of PAD and the estimation of risk. To control risk, lifestyle adaptation is essential. There is no consensus on a first choice of antihypertensive drug. Arguments favor angiotensin-converting enzyme inhibitors, but most patients require several antihypertensive drugs to reach goal pressure (140/90 mm Hg or lower). Moreover, to control the risk of PAD, antiplatelet drugs, antihypertensive drugs, and statins are recommended.

Left Ventricular Hypertrophy, Ischemic Heart Disease and the Incidence of Cardiovascular Events in Japanese High-Risk Hypertensive Patients

lthough blood pressure (BP) is the main variable determining cardiovascular (CV) risk in hypertensive patients, recent guidelines emphasize that management of hypertension should be related to quantification of the total CV risk. 1 This concept is based on the fact that, when concomitantly present, BP and other risk factors augment the risk and lead to a greater CV risk than the sum of the individual components. 2 Article p 1080 The most common clinical variables that should be used in stratification are risk factors, target organ damage, dia betes and established CV or renal disease. High total CV risk is a subgroup of patients with a previous diagnosis of CV disease, besides the subgroups of patients with diabetes mellitus and with severely elevated single risk factors. 1 In addition, it is widely accepted that subclinical organ damage plays a crucial role in determining the CV risk of hypertensive patients. Of these, there has been further confirmation of the adverse prognostic role of left ventricular hypertrophy (LVH), together with evidence that it is fairly common in hypertensive patients. 3 Accordingly, evaluation of cardiac complications, such as previous CV disease and the presence of LVH, is useful for detecting hypertensive subjects at increased risk of CV disease. However, whether each component cardiac complication has separate implications on the outcome of long-term CV events in hypertensive patients is not known with certainty. Ueshima et al, reporting in this issue of the Journal, 4 provide the interesting piece of information that each of 2 cardiac complications, LVH and ischemic heart disease (IHD), has a different effect on the incidence of future CV events in Japanese high-risk hypertensive patients. By using enrolled participants of the Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial, the authors evaluated 2,030 and 2,673 high-risk hypertensive patients with and without cardiac complications. The incidence of CV events, represented as a composite of sudden death, cerebrovascular, cardiac, renal and vascular events, was compared between patients with and without the complication of LVH and/or IHD in this post-hoc study. During 3.2 years of follow-up, the authors proved that cardiac complications as a whole are associated with the CV events rate, and further, both LVH and IHD are independent predictors for CV events. Moreover, the authors found that there are different effects on each event category of CV events between LVH and IHD. After adjustment for baseline characteristics, LVH is linked to cerebrovascular events, but not to CV death or other cardiac events, whereas IHD is associated with cardiac death, especially sudden death, and other cardiac events, but not with cerebrovascular events. Neither LVH nor IHD related to the onset of renal and vascular events. An extensive body of population studies has provided consistent evidence that LVH confers increased risk for CV events, including heart failure, myocardial infarction, sudden

Cardiovascular protection for all individuals at high risk: evidence-based best practice

Patients with cardiovascular risk factors are largely undertreated, for many reasons. Vulnerable individuals may not be aware of the risks they are facing or an individual's risk of cardiovascular disease may be underestimated, particularly among those at high risk. Furthermore, in individuals identified as being at high total cardiovascular risk, the full spectrum of therapeutic options may not be implemented or patients may not adhere to the treatment prescribed. We address these critical issues by summarizing the existing guidelines: our ultimate goal is to encourage the optimal management of individuals at high total cardiovascular risk according to evidence-based medicine, with the expectation that this will improve outcomes.

Ergonomic Assessment of Musculoskeletal Discomfort Among Commissary Foodservice Workers in Taiwan

This study was conducted to investigate the prevalence rate and potential risk factors associated with work-related musculoskeletal discomfort among commissary foodservice workers in Taiwan. Many workers reported numb or sore discomfort in their shoulders (41.1%), hands/wrists (38.2%), and lower backs (40.1%). But the three highest discomfort scores were for the elbow 3.00 (±1.05), finger/wrist 2.74 (±1.04), and upper back 2.74 (±0.92) according to the 5-point level scores. Several tasks had significant correlations: packing lunch box with forearm discomfort (odds ratio; OR = 1.9) and ankle/feet discomfort (OR = 2.5), moving object with forearm discomfort (OR = 2.6), and pre-preparing with lower back discomfort (OR = 2.0). The RULA (Rapid Upper-Limb Assessment) was used to evaluate working postures. The most frequent upper arm extension (flexion) was 20-45? or more, and the range for the lower arm was less than 60? or more than 100? of flexion. The participants' heads were in extension and their trunks had the highest degree of flexion. Moreover, their legs and feet were not balanced properly. RULA was determined from video recordings and presented as a useful technique. Results indicated that all four jobs (pre-prep/bussers, preparation/cooks and chefs, utility/dish washers, and service/packers) had frequent extension/flexion postures and posted high grand total risk scores (4.93-5.69).

The concept of doctor targets based on quality guidelines: focus on blood pressure

Clinicians are taught to diagnose and manage disease starting with the question does this patient have disease or not-yes or no. As a consequence, cardiovascular risk factors were viewed historically as being dichotomous. However, over the past decade, there has been a shift towards the concept of total cardiovascular risk as the primary determinant for making clinical decisions about treating individual risk factors. This change is reflected in the European guidelines, developed by the European Society of Cardiology in partnership with the European Society of Hypertension and the European Atherosclerosis Society, in a common approach to coronary and subsequently cardiovascular disease (CVD) prevention. Cardiovascular risk is strongly related to lifestyle, a high saturated fat diet, physical inactivity, and smoking tobacco. Thus, lifestyle changes are at the heart of guidelines. Patients with established CVD have declared themselves to be at high total risk of a further vascular event and, therefore, they require the most intensive intervention, including appropriate drug therapies, in order to achieve risk factor goals including a systolic blood pressure <140 mmHg and a diastolic blood pressure <90 mmHg. Similarly, patients with a high total cardiovascular risk, and patients with diabetes, can benefit from reducing blood pressure below 140/90 mmHg or even lower. Despite wide awareness of guidelines, recent European surveys show that one-quarter of the patients with elevated blood pressure were unaware of their hypertensive status. There is also a high prevalence of elevated blood pressure in patients with established coronary heart disease, half of whom require more intensive blood pressure management and, where appropriate, antihypertensive medication. The challenge for primary prevention in people at high risk of developing CVD is even greater.

Cardiovascular Risk Estimation by Professionally Active Cardiovascular Nurses: Results from the Basel 2005 Nurses Cohort∗

Nurses play a key role in the prevention of cardiovascular disease (CVD) and one would, therefore, expect them to have a heightened awareness of the need for systematic screening and their own CVD risk profile. The aim of this study was to examine personal awareness of CVD risk among a cohort of cardiovascular nurses attending a European conference. Of the 340 delegates attending the 5th annual Spring Meeting on Cardiovascular Nursing (Basel, Switzerland, 2005), 287 (83%) completed a self-report questionnaire to assess their own risk factors for CVD. Delegates were also asked to give an estimation of their absolute total risk of experiencing a fatal CVD event in the next 10 years. Level of agreement between self-reported CVD risk estimation and their actual risk according to the SCORE risk assessment system was compared by calculating weighted Kappa (kappa(w)). Overall, 109 responders (38%) self-reported having either pre-existing CVD (only 2%), one or more markedly raised CVD risk factors, a high total risk of fatal CVD (> or =5% in 10 years) or a strong family history of CVD. About half of this cohort (53%) did not know their own total cholesterol level. Less than half (45%) reported having a 10-year risk of fatal CVD of <1%, while 13% reported having a risk > or =5%. Based on the SCORE risk function, the estimated 10-year risk of a fatal CVD event was <1% for 96% of responders: only 2% had a > or =5% risk of such an event. Overall, less than half (46%) of this cohort's self-reported CVD risk corresponded with that calculated using the SCORE risk function (kappa(w)=0.27). Most cardiovascular nurses attending a European conference in 2005 poorly understood their own CVD risk profile, and the agreement between their self-reported 10-year risk of a fatal CVD and their CVD risk using SCORE was only fair. Given the specialist nature of this conference, our findings clearly demonstrate a need to improve overall nursing awareness of the role and importance of systematic CVD risk assessment.

Guidelines on cardiovascular disease prevention in clinical practice: the European perspective

To summarize the recommendations of the Third Joint European Society's Task Force on Cardiovascular Disease Prevention in Clinical Practice so that these may be made accessible to a wider audience. The relative importance of population and high-risk strategies for cardiovascular disease prevention is summarized. The guidelines stress the primacy of total risk assessment to guide management decisions. The hazards of decisions based on assessment of single risk factors is illustrated. Compared with earlier guidelines, the focus has changed from coronary heart disease to total cardiovascular disease prevention. A new system for predicting total cardiovascular disease mortality risk (Systematic Coronary Risk Evaluation) is presented. Explicit clinical priorities are defined. Total cardiovascular risk should be assessed before making management decisions. Individuals with established cardiovascular disease and those with high total cardiovascular risk gain most from preventive advice. This high-risk approach should be complemented by a population-based preventive strategy.

B-Type Natriuretic Peptide as an Alternative Way of Assessing Total Cardiovascular Risk in Patients With Diabetes Mellitus

Cardiovascular risk scores are available but are often not calculated in busy clinics for numerous practical reasons. B-type natriuretic peptide (BNP) may be an alternative way of identifying subjects who have a high total cardiovascular risk score. We compared BNP level with Framingham 10-year Risk Scores for coronary heart disease and stroke and New Zealand Cardiovascular Risk Scores in 231 patients who had type 2 diabetes and no preexisting coronary heart disease or stroke. There was a significant correlation between log BNP and 10-year risk for coronary heart disease and stroke, and there were significantly higher BNP levels in those who had high cardiovascular risk as assessed by the New Zealand Risk Score. BNP may be a useful way of measuring total cardiovascular risk, thus having the potential to better target the most aggressive primary preventive therapies toward the most needy.