Management Of Atherosclerotic Risk Factors Research Articles

Coronary Artery Spasm: New Insights.

Coronary artery spasm (CAS) defined by a severe reversible diffuse or focal vasoconstriction is the most common diagnosis among INOCA (ischemia with no obstructive coronary artery disease) patients irrespective to racial, genetic, and geographic variations. However, the prevalence of CAS tends to decrease in correlation with the increasing use of medicines such as calcium channel blockers, angiotensin converting enzyme inhibitor, and statins, the controlling management of atherosclerotic risk factors, and the decreased habitude to perform a functional reactivity test in highly active cardiac catheterization centers. A wide spectrum of clinical manifestations from silent disease to sudden cardiac death was attributed to this complex entity with unclear pathophysiology. Multiple mechanisms such as the autonomic nervous system, endothelial dysfunction, chronic inflammation, oxidative stress, and smooth muscle hypercontractility are involved. Regardless of the limited benefits proffered by the newly emerged cardiac imaging modalities, the provocative test remains the cornerstone diagnostic tool for CAS. It allows to reproduce CAS and to evaluate reactivity to nitrates. Different invasive and noninvasive therapeutic approaches are approved for the management of CAS. Long-acting nondihydropyridine calcium channel blockers are recommended for first line therapy. Invasive strategies such as PCI (percutaneous coronary intervention) and CABG (coronary artery bypass graft) have shown benefits in CAS with significant atherosclerotic lesions. Combination therapies are proposed for refractory cases.

Association between Prescription and Control Status of Dyslipidemia and Hypertension among Japanese Patients with Diabetes.

Aims: The proper management of atherosclerotic risk factors (ARFs) and attainment of target levels (TLs) for ARFs are crucial in preventing atherosclerotic cardiovascular disease (ASCVD). In this study, utilizing data from the “Specific Health Check and Guidance in Japan,” which was conducted from 2008 to 2011, we examined TL attainment status of low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) and prescription status of dyslipidemia and hypertension in patients with diabetes undergoing medical treatment, and analyzed the factors that affected prescription status.Methods: Subjects receiving medical treatment for diabetes were selected from the database. Subjects were classified by prescription status for dyslipidemia and hypertension, and TL attainment status was assessed for each ARF.Results: The percentage of subjects who did not attain TLs and were not under medication was higher for LDL-C than for BP. The un-prescribed rates among non-TL-attained subjects were 60%–75% for LDL-C, and around 30%–40% for BP. The un-prescribed rates to those who were qualified for prescription therapy were also higher for LDL-C than for BP. Logistic regression analyses revealed that the subjects who were prescribed for dyslipidemia had the following characteristics compared with the un-prescribed non-TL-attained subjects: older age, higher body mass index, lower estimated glomerular filtration rate, previous heart or cerebrovascular disease, and higher medication rate for other ARFs.Conclusions: The present study revealed that, in Japan, the adequate prescription rate for dyslipidemia was lower than that for hypertension in patients with diabetes, suggesting the proper prescription therapy for dyslipidemia should be pursued to further prevent ASCVD.

Abstract TMP120: Treatment Rate of Atherosclerotic Risk Factor Among Young Adults Compared to Older Adults

Background: The aggressive management of atherosclerotic risk factors (ARF) has been accredited with the declining incidence of stroke in older adults. The goal of this study was to look at treatment patterns of ARF in young adults compared to older adults. Methods: A commercial claims database was used, containing enrollees between ages 15 to 45 for young adults and ≥ 55 for older adults from 2001 to 2014. Diagnosis for ARF including hypertension, diabetes and hyperlipidemia were established based on 2 outpatient or 1 inpatient claim. Hospitalization with the primary diagnosis of stroke were identified. Of patients with an ARF diagnosis, we looked for the presence of any medication claims including oral antihypertensive, antihyperlipidemics, and antidiabetics (including injectables) based on the Generic Product Identifier (GPI) codes. Results: Included in the analysis were 3,770,474 young adults with mean age 28 and 1,552,351 older adults with mean age 60. From 2001 to 2014, the overall prevalence of hypertension, diabetes and hyperlipidemia were 7.68%, 2.65%, and 7.85% respectively in young adults, compared to 47.8%, 18.0% and 46.6% respectively in older adults. Treatment rate of hypertension, diabetes and hyperlipidemia improved faster annually in older adults (1.9%, 1.7%, 1.8% respectively) than young adults (0.96 %, 0.99%, 0.61%, respectively, p<0.01). For young and older adults with stroke, overall treatment rates for hypertension and dyslipidemia were higher than those without stroke (p 0.028 to <0.0001). However, diabetes was treated at a lower rate in those with stroke for both young (61.9% vs. 66.3%, p=0.001) and older adults (57.9% vs. 61.3%, p < 0.001). Conclusion: Proportion of treatment for ARF in older adults improved at a faster rate than young adults. Overall treatment rates of diabetes was higher in young adults likely due to proportionally more cases of type 1 diabetes. Hyperlipidemia was treated at a much lower rate in young adults than older adults.

Impact of clinical pharmacists on atherosclerotic risk factor management in an integrated heart and vascular clinic.

Impact of clinical pharmacists on atherosclerotic risk factor management in an integrated heart and vascular clinic.

Medical Management of Atherosclerotic Risk Factors in Vascular Surgery Patients

There is an epidemic of cardiovascular disease in the United States, which is responsible for approximately one death every 40 seconds in the United States. Whereas the overall mortality attributable to cardiovascular disease is decreasing, the overall prevalence of atherosclerotic risk factors is increasing. Optimal management of atherosclerotic risk factors can have profound effects on morbidity and mortality after vascular surgical procedures. This review covers risk factors for the development of atherosclerosis; the evaluation of patients with vascular disease; management of tobacco abuse, hypertension, hyperlipidemia, diabetes mellitus, and antiplatelet agents; and perioperative medical management concerns in vascular surgery. Tables highlight investigational biomarkers for atherosclerosis, behavioral modification recommendations to be used to improve smoking cessation, Eighth Joint National Committee guidelines for blood pressure management, definitions of high- and moderate-intensity statin therapy, and potential future areas of research. Algorithms lay out the effects of cigarette smoke, the proposed mechanism of statin pleiotropy as it pertains to the vasculature, and the proposed mechanisms of the role of hyperglycemia in atherogenesis. This review contains 3 figures, 6 tables, and 79 references.

English

INTRODUCTION: Peripheral arterial disease (PAD) is a condition characterized by atherosclerotic occlusive disease of the lower extremities. While PAD is a major risk factor for lower- extremity amputation, it is also accompanied by a high likelihood for symptomatic cardiovascular and cerebrovascular disease. Atherosclerosis accounts for more than 90% of cases of PAD, and uncommon vascular syndromes account for the remaining 10%. The femoral and popliteal arteries are affected in 80% to 90% of symptomatic PAD patients, the tibial and peroneal arteries in 40% to 50%, and the aortoiliac arteries in 30%.Although 65-75% of patients with PAD are asymptomatic, the classic presenting symptom is usually described as muscle cramps, fatigue or pain in the lower legs induced by exercise and rapidly relieved by rest; often the symptom location indicates the level of arterial involvement. RISK FACTORS: Diabetes and smoking are the strongest risk factors for PAD. Other well-known risk factors are advanced age, hypertension, and hyperlipidemia. DIAGNOSIS: PAD can be easily and accurately diagnosed by calculating the ankle-brachial index (ABI).The ABI is defined as the ratio of the systolic blood pressure in the ankle divided by the systolic blood pressure at the arm. The tools required to perform the ABI measurement include a hand-held 5-10 MHz Doppler probe and a blood pressure cuff. MANAGEMENT: Most patients' symptoms improve with optimal medical treatment and invasive intervention is often not required. Smoking cessation and exercise are considered the two most important treatments for PAD. CONCLUSION: Symptomatic PAD often impairs a patient's quality of life and untreated disease can lead to limb loss. Aggressive management of atherosclerotic risk factors, a structured exercise program, use of antiplatelet agents and when indicated percutaneous or surgical revascularizations are the keys for successful

Serial assessment of arterial stiffness by cardio-ankle vascular index for prediction of future cardiovascular events in patients with coronary artery disease.

Arterial stiffness is a significant predictor of cardiovascular disease (CVD), the risk of which is modified by medications for atherosclerotic risk factors and life-style changes. Cardio-ankle vascular index (CAVI) provides noninvasive, objective information on arterial stiffness, independent of blood pressure. This study aimed to investigate changes in CAVI after management of atherosclerotic risk factors, and the impact of these changes on future CVD outcomes in patients with coronary artery disease (CAD). The study consisted of 211 CAD patients (65 ± 10 years, 118 men) with impaired CAVI. CAVI examination was repeated 6 months later. Impaired CAVI was defined as greater than the mean plus 1 s.d. of the age- and gender-specific normal CAVI values, according to results obtained in 5188 healthy subjects. All patients were followed for > 1 year or until the occurrence of a CVD event. Of the 211 patients, CAVI improved in 106 (50%) patients after 6 months, but remained high in 105 (50%) patients. During follow-up (2.9 ± 1.0 years), CVD events occurred in 28 (13%) patients. Persistently impaired CAVI was an independent predictor of future CVD events (P = 0.01), independent of baseline CAVI. CVD outcomes were worse in patients with persistently impaired CAVI than in those with improved CAVI (P < 0.001). Among patients with a normalized CAVI after treatment (n = 22) only one suffered a CVD event. This study was the first to demonstrate that persistent impairment of arterial stiffness was an independent risk factor of future CVD events. Serial measurements of CAVI provide important prognostic information regarding patients with CAD in clinical practice.

Serial assessment of arterial stiffness by cardio-ankle vascular index for prediction of future cardiovascular events in patients with coronary artery disease

Purpose: Arterial stiffness is a significant predictor of cardiovascular disease (CVD), which is modified by medications for atherosclerotic risk factors and life-style changes. Cardio-ankle vascular index (CAVI) provides noninvasive, objective information on arterial stiffness, independent of blood pressure. This study aimed to investigate changes in CAVI after management of atherosclerotic risk factors and their impact on future CVD outcome in patients with coronary artery disease (CAD). Methods: The study consisted of 211 CAD patients (65±10 years, 118 men) with impaired CAVI. CAVI examination was repeated 6 months later. Impaired CAVI was defined as > the mean plus 1 SD of the age- and gender-specific normal CAVI values, according to the results in 5,188 healthy subjects. All patients were followed for more than 1 year or until the occurrence of CVD event. Results: Of the 211 patients, CAVI improved 6 months later in 106 (50%) patients, but remained high in 105 (50%) patients. During follow-up (2.9±1.0 years), CVD events occurred in 28 (13%) patients. Persistently impaired CAVI was an independent predictor of future CVD events (p=0.003), independent of baseline CAVI. The CVD outcome was worse in patients with persistently impaired CAVI than in those with improved CAVI (p<0.001) (Figure). Patients with normalized CAVI after treatment (n=22) had only 1 CVD event. ![Figure][1] Kaplan-Meier curves for CVD events Conclusions: This study demonstrated for the first time that persistent impairment of arterial stiffness was an independent risk factor of future CVD events. Serial measurement of CAVI provides important prognostic information on patients with CAD in clinical practice. [1]: pending:yes

Glomerular filtration rate is related to carotid intima-media thickness in middle-aged adults

Severe renal dysfunction is associated with increased cardiovascular risk. The aim of this study was to investigate the association between renal function and carotid intima-media thickness (cIMT) in a middle-aged population-based cohort. A total of 247 males and 258 females aged 40-62 years participated in this cross-sectional study. Renal function was assessed with estimated glomerular filtration rate (eGFR) and carotid atherosclerosis with ultrasonography as the mean IMT of the far carotid wall. The mean eGFR values were 90.2 (SD 16.8) ml/min/1.73 m(2) for men and 78.0 (SD 14.0) ml/min/1.73 m(2) for women, and the mean cIMT values were 0.92 (SD 0.21) mm for men and 0.82 (SD 0.12) mm for women. The mean cIMT was highest in the tertile with the lowest eGFR in both sexes (P = 0.013 for males and P = 0.031 for females). In males, the eGFR tertile was significantly associated with cIMT (P = 0.026) in a model adjusted for traditional risk factors. Renal function was also significantly associated with cIMT in a subset of 149 postmenopausal women (P = 0.008). Even a minor deterioration in renal function was independently associated with increased cIMT in the middle-aged male population and in the postmenopausal women. This finding underlines the importance of early detection of subjects with mildly decreased kidney function and the aggressive management of atherosclerotic risk factors in this population.

Risk Factor Treatment in Veteran Women at Risk for Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death in women. Aggressive management of atherosclerotic risk factors can prevent or delay the onset of CVD. Treatment of modifiable risk factors provides an important opportunity to reduce the burden of CVD in women and decrease future adverse event rates. The aims of this study were to assess current treatment of atherosclerotic risk factors in women found to be at moderate or high-risk for CVD and to examine levels of CVD knowledge and awareness among women found to be at moderate or high-risk for CVD METHODS: In a cross-sectional study, we screened ambulatory female veterans aged 40 to 85 y for the prevalence of peripheral vascular disease (PVD) and associated atherosclerotic risk factors, and administered a survey to assess the participants' knowledge and awareness of CVD, risk factors, and consequences. Medical records, pharmacy data, and clinician encounter notes were reviewed for documented evidence of CVD risk factors, comorbidities, and corresponding treatment. From a total cohort of 162 women, 108 (66.7%) were categorized as having an increased risk of cardiovascular disease based on a modification of the Framingham cardiovascular risk score, which took into account the presence of carotid intimal-medial thickness (cIMT) > 1.0 mm or ankle-brachial index <or= 0.9, as determined by a voluntary, one time, noninvasive screening. In no category of CVD risk factor were 100% of the women receiving adequate medical or behavioral management. Especially surprising to us were the low levels of treatment for women with heart disease, smoking, and previous history of peripheral artery disease (PAD). Over half of the women who were postmenopausal or who have had hysterectomy at the time of this study continued to use hormone replacement therapy (HRT) despite warnings about its role in coronary artery disease (CAD), stroke, and PAD. One-third of moderate- to high-risk women had evidence of increased cIMT, which is a known surrogate marker of subclinical heart disease. Knowledge and awareness scores were low, regardless of risk factor level and respectable levels of education. Our findings show a high prevalence of CVD risk factors and low knowledge levels among ambulatory veteran women. There is a need for improvement in recognition and aggressive management of CVD risk factors, including the use of noninvasive studies as surrogate markers for early diagnosis. Continued efforts to educate women and providers about CVD risk factors, heart-healthy behaviors, screening, and treatment are vital to improve the current state of women's health and decrease future adverse cardiac event rates.

Association of glucose metabolism, smoking and cardiovascular risk factors with incident peripheral arterial disease: The DESIR study

Aims We determined the 6-year incidence of peripheral arterial disease (PAD) in a French population and assessed the association of glucose metabolism, smoking, cardiovascular risk factors and physical activity with incident PAD. Methods Participants from the French Data from a Epidemiological Study on the Insulin Resistance Syndrome (DESIR) were studied. Participants analysed were 30–65 years (at baseline) and had complete data ( n = 3805) after 6 years of follow-up. Diabetes was diagnosed according to the 1999 WHO criteria on the basis of fasting plasma glucose results or previous diagnosis of diabetes mellitus. The ankle brachial pressure index (ABPI) and a claudication question were used to classify PAD. Results The 6-year incidence of PAD (defined by ABPI < 0.9 and or claudication present) among those with normal fasting glucose (NFG) and free of PAD at baseline was 5.1%. Among those with impaired fasting glucose (IFG) at baseline the incidence of PAD was 4.9% and among those with diabetes mellitus at baseline the incidence of PAD was 9.8%. The incidence of PAD among those who maintained NFG over 6 years was 4.7% and among those who progressed to diabetes over 6 years was 10.2%. Those who progressed from NFG or IFG to diabetes over 6 years were twice as likely to develop PAD compared to those who maintained NFG over 6 years, after adjustment for age and sex (OR (95% CI), 2.22 (1.12–4.42)). Independent risk factors for incident PAD using baseline population characteristics were diabetes (OR (95% CI) 2.11 (1.25–3.55)), systolic BP 122–135 mmHg 1.06 (0.70–1.60), >135 mmHg 1.54 (1.04–2.27) and current smoking 1.60 (1.10–2.34) after multivariate adjustment for age, sex, cholesterol, triglycerides and waist circumference. Conclusions This French study shows that those who progress to diabetes are twice as likely to develop PAD, compared to those who maintain NFG. Peripheral arterial disease is a treatable condition and more aggressive management of atherosclerotic risk factors could reduce the numbers of people who develop PAD.

Peripheral Arterial Procedures and Postinterventional Prophylaxis

In patients with peripheral arterial disease (PAD), prophylaxis is indicated after any vascular intervention to prevent acute thrombotic occlusion, as well as recurrent stenosis due to intimal hyperplasia or progressive arteriosclerosis. In contrast to coronary and carotid interventions, there is no standardized regime established or even recommended after peripheral arterial interventions. Coronary interventions are performed by cardiologists only, while peripheral interventions are conducted by radiologists, cardiologists, angiologists, and vascular surgeons. However, radiologists and vascular surgeons are not trained in the management of atherosclerotic risk factors. In this editorial, I discuss the lack of a specific prophylaxis protocol after transcatheter interventions and bypass surgery. Issues to be considered are whether postinterventional prophylaxis depends on the type of transluminal or surgical procedure and whether such a regime can be the same in each patient. Finally, the need for a comprehensive concept is examined, including the management of atherosclerotic risk factors.

Suboptimal Intensity of Risk Factor Modification in Peripheral Arterial Disease (PAD)

Conclusion: There is suboptimal medical management of atherosclerotic risk factors in patients with peripheral arterial disease (PAD). Summary: The PARTNERS study (PAD Awareness, Risk and Treatment) indicated that PAD was under recognized in primary care practice and only 60% of patients with PAD were receiving lipid lowering therapy (JAMA 2001;286:1317-24). This study sought to determine if practice guidelines for patients with cardiovascular disease, developed after publication of PARTNERS, have effected current community management of PAD. The authors recruited via a media campaign conducted in a large northern California urban area patients with leg pain that limited their walking. Respondents were screened by telephone and, if eligible, offered PAD assessment. Eligibility criteria included age ≥50 years with symptomatic PAD. PAD was defined as exertional leg pain with an ankle brachial index ≤0.9. For patients with diabetes, PAD was defined as a toe pressure of <30 mmHg. Patients must have been able to walk for 2 minutes or 50 feet on an exercise treadmill and have been on a stable medication regimen. Patients with rest pain, ulceration or gangrene were excluded. Also excluded were patients with recent myocardial infarction, Type I diabetes, and active malignancy. Treatment and risk factor profiles were determined by self reported medical history and current medication lists. Patients were evaluated as to whether or not they met current treatment guidelines for lipids, hypertension, and diabetes. With respect to lipids, an LDL cholesterol <100 mg/dl was considered to have met therapeutic guidelines. Hypertension was defined as a systolic blood pressure >140 mmHg and a diastolic blood pressure >90 mmHg. Hemoglobin A1c levels (HgbA1c) ≥7% indicated suboptimal glycemic control. There were 101 subjects in this study. Dyslipidemia was recognized in 56.4%. In dyslipidemic subjects there was suboptimal therapy in 52.6%. In addition, 20.8% of the sample were previously unrecognized cases. A history of hypertension was reported in 54.5% of the study sample. Management of systolic blood pressure was sub-optimal in 74.5% of hypertensive subjects. Systolic hypertension had been previously unrecognized in 13.9% of the study subjects. Hypertensive patients were found a 81% utilization rate of antihypertensive medication. Patients on mono versus triple therapy for hypertension exhibited no significant differences in systolic or diastolic blood pressures. Diabetes was reported in 26.7% of the patients. HgbA1c was 7.9 ± 1.9 mg/dl. Glycemic control was felt to be suboptimal in 57% of patients (mean HgbA1c = 8.7 ± 1.8 mg/dl). Sixty-two percent of the study population was on anti-platelet therapy. Anticoagulation therapy was employed in 15%. About 35% of subjects (n = 36) were not taking anticoagulant or anti-platelet therapy. No patients appeared to have had a contraindication to anti-platelet therapy. Comment: The study is small and therefore subject to Type II statistical error. Nevertheless, the results are similar to PARTNERS and indicate suboptimal management of risk factors in patients with PAD. It is clear one publication, the PARTNERS publication, has not had a dramatic impact on primary care practice with respect to management of PAD. Meaningful changes in management of PAD risk factors will only occur after intensive promulgation of treatment goals for patients with PAD.