Manifestations Of Atherosclerotic Cardiovascular Disease Research Articles

Place of the Advanced Practice Registered Nurse (APRN) within the vascular team: A qualitative study of vascular medicine physicians and nurses caring for patients with Peripheral Artery Disease (PAD)

APRNs treat and diagnose diseases, counsel the public about health problems, manage chronic diseases, and participate in continuing education. In the cardiovascular field, PAD, one of the manifestations of atherosclerotic cardiovascular disease, is archetypal in combining multiple cardiovascular risk factors (hypertension, hyperlipidemia, diabetes mellitus smoking). Patients with PAD should benefit from APRN care, but to date there is little published on the place of APRN in vascular medicine worldwide, and none in France. As the status of APRN in France has only been enacted by law in 2018, we aim to investigate physicians and nurses working with patients suffering from PAD, to gather their opinions and draw the cooperation outlines these practitioners could have with an APRN. Multicentre exploratory qualitative study by semi-directive interview conducted until data saturation and thematic analysis carried out with healthcare practitioners taking care of patients with PAD: 10 physicians working either in private practice setting or hospital setting or both, and 8 nurses in a vascular unit for hospitalized patients. Three main themes emerged from responders’ verbatims: a specific organization of vascular medicine with its inherent challenges, particularly regarding patients with PAD (specific psychosocial profile of patients, lack of therapeutic education, time, knowledge of non-specialist physicians, tedious follow-up outside hospitals, complex care trajectory, and lack of medical-surgical collaboration). Second, a role for APRN, particularly in consultation as part of patient follow-up, with expected benefits for the patient and the care team. The expected benefits include a smoother care pathway and increased capacity for cardiovascular education and prevention, especially during consultations (Fig. 1). Third, there are certain pitfalls that need to be clarified to integrate these new practitioners into the vascular teams already in place. In particular, the need to inform the vascular medicine teams about this new profession, and the indispensable presence of the conditions necessary for the development of a relationship of trust. APRN could be the missing link in a vascular team by creating a continuum in the care of patients with PAD, ensuring clinical assessment, nursing supervision, adverse event screening, and renewing drug prescriptions with the necessary adjustments, while ensuring an essential part of therapeutic education personalized to each PAD patient.

Place of the Advanced Practice Registered Nurse within the vascular team: a qualitative study of vascular medicine physicians and nurses caring for patients with peripheral artery disease

Abstract Introduction Advanced Practice Registered Nurses (APRNs) treat and diagnose diseases, counsel the public about health problems, manage chronic diseases, and participate in continuing education. In the cardiovascular field, Peripheral Arterial Disease (PAD), one of the manifestations of atherosclerotic cardiovascular disease, is archetypal in combining multiple cardiovascular risk factors (hypertension, hyperlipidemia, diabetes mellitus smoking). Vascular medicine faces the challenge of improving their care and quality of life, but some goals cannot be achieved with all patients. Patients with PAD should benefit from APRN care, but to date there is little published on the place of APRN in vascular medicine worldwide, and none in France. Objective It appeared important to us to assess the perception of their role by physicians and nurses in vascular medicine. As the status of APRN in France has only been enacted by law in 2018, we aim to investigate physicians and nurses working with patients suffering from PAD, to gather their opinions and draw the cooperation outlines these practitioners could have with an APRN. Methods Multicentre exploratory qualitative study by semi-directive interview conducted until data saturation and thematic analysis carried out with healthcare practitioners taking care of patients with PAD: 10 physicians working either in private practice setting or hospital setting or both, and 8 nurses in a vascular unit for hopsitalised patients. Results Three main themes emerged from responders' verbatims: a specific organization of vascular medicine with its inherent challenges, particularly regarding patients with PAD (specific psychosocial profile of patients, lack of therapeutic education, time, knowledge of non-specialist physicians, tedious follow-up outside hospitals, complex care trajectory, and lack of medical-surgical collaboration). Second, a role for APRN, particularly in consultation as part of patient follow-up, with expected benefits for the patient and the care team. The APRN is wanted to fill part of this gap. The expected benefits include a smoother care pathway and increased capacity for cardiovascular education and prevention, especially during consultations. Third, there are certain pitfalls that need to be clarified to integrate these new practitioners into the vascular teams already in place. In particular, the need to inform the vascular medicine teams about this new profession, and the indispensable presence of the conditions necessary for the development of a relationship of trust. Conclusion APRN could be the missing link in a Vascular team by creating a continuum in the care of patients with PAD, ensuring clinical assessment, nursing supervision, adverse event screening, and renewing drug prescriptions with the necessary adjustments, while ensuring an essential part of therapeutic education personalized to each PAD patient. Funding Acknowledgement Type of funding sources: None.

Reduced Heart Failure and Mortality in Patients Receiving Statin Therapy Before Initial Acute Coronary Syndrome

BackgroundThere is uncertainty regarding the impact of statins on the risk of atherosclerotic cardiovascular disease (ASCVD) and its major complication, acute heart failure (AHF). ObjectivesThe aim of this study was to investigate whether previous statin therapy translates into lower AHF events and improved survival from AHF among patients presenting with an acute coronary syndrome (ACS) as a first manifestation of ASCVD. MethodsData were drawn from the International Survey of Acute Coronary Syndromes Archives. The study participants consisted of 14,542 Caucasian patients presenting with ACS without previous ASCVD events. Statin users before the index event were compared with nonusers by using inverse probability weighting models. Estimates were compared by test of interaction on the log scale. Main outcome measures were the incidence of AHF according to Killip class and the rate of 30-day all-cause mortality in patients presenting with AHF. ResultsPrevious statin therapy was associated with a significantly decreased rate of AHF on admission (4.3% absolute risk reduction; risk ratio [RR]: 0.72; 95% CI: 0.62-0.83) regardless of younger (40-75 years) or older age (interaction P = 0.27) and sex (interaction P = 0.22). Moreover, previous statin therapy predicted a lower risk of 30-day mortality in the subset of patients presenting with AHF on admission (5.2 % absolute risk reduction; RR: 0.71; 95% CI: 0.50-0.99). ConclusionsAmong adults presenting with ACS as a first manifestation of ASCVD, previous statin therapy is associated with a reduced risk of AHF and improved survival from AHF. (International Survey of Acute Coronary Syndromes [ISACS] Archives; NCT04008173)

Association Between Metabolic Syndrome and Peripheral Arterial Disease in Elderly Patients with Type 2 Diabetes

BackgroundPeripheral artery disease (PAD) is a manifestation of atherosclerotic cardiovascular disease (ASCVD) and significantly increases the risk of myocardial infarction and stroke. As most patients with PAD are asymptomatic, this condition is largely neglected in clinical practice. Type 2 diabetes (T2DM) patients have higher prevalence of PAD. Therefore, early detection and intervention of diabetic PAD are very important. Metabolic syndrome (MetS) is a group of interrelated metabolic risk factors, a predictor of poor prognosis in elderly patients with ASCVD. Recently, many of the metabolic risk factors as well as the overall concept of MetS itself have sparked a great deal of debate regarding their precise roles in PAD.ObjectiveTo evaluate the relationship between metabolic syndrome (MetS) and peripheral arterial disease (PAD) in elderly patients with type 2 diabetes (T2DM).MethodsTwo hundred and eighty-one elderly T2DM patients admitted to Beijing Tongren Hospital from October 2016 to December 2017 were divided into PAD group (n=136) and non-PAD (NPAD) group (n=145). Their medical records, physical examination parameters and laboratory testing parameters were later recorded and analyzed by multivariate logistic regression analysis.ResultsNo significant difference was detected in general clinical data and laboratory testing parameters between the two groups (P>0.05). The incidence of MetS was significantly higher in PAD group than in NPAD group (88.2% vs 70.3%, P=0.001). Multivariate logistic regression analysis showed that the risk of PAD was 1.762-fold higher in MetS patients after adjustment for age, sex, history of smoking and alcohol consumption, WC, SBP, serum TC and HbA1c level, eGFR and duration of DM (95% CI: 1.205–6.330, P=0.016).ConclusionMetS closely correlates with PAD in elderly T2DM patients, though no significant difference has been detected in their metabolic indicators.

Gestational Diabetes History and Glucose Tolerance After Pregnancy Associated With Coronary Artery Calcium in Women During Midlife: The CARDIA Study.

Gestational diabetes (GD) leads to earlier onset and heightened risk of type 2 diabetes, a strong risk factor for cardiovascular disease (CVD). However, it is unclear whether attaining normoglycemia can ameliorate the excess CVD risk associated with GD history. This study sought to evaluate GD history and glucose tolerance after pregnancy associated with coronary artery calcification (CAC) in women, a manifestation of atherosclerotic CVD and a predictor of CVD clinical events. Data were obtained from the CARDIA study (Coronary Artery Risk Development in Young Adults), a US multicenter, community-based prospective cohort of young Black (50%) and White adults aged 18 to 30 years at baseline (1985-1986). The sample included 1133 women without diabetes at baseline, who had ≥1 singleton births (n=2066) during follow-up, glucose tolerance testing at baseline and up to 5 times during 25 years (1986-2011), GD status, and CAC measurements obtained from 1 or more follow up examinations at years 15, 20, and 25 (2001-2011). CAC was measured by noncontrast cardiac computed tomography; dichotomized as Any CAC (score>0) or No CAC (score=0). Complementary log-log models for interval-censored data estimated adjusted hazard ratios of CAC and 95% confidence intervals for GD history and subsequent glucose tolerance groups (normoglycemia, prediabetes, or incident diabetes) on average 14.7 years after the last birth adjusted for prepregnancy and follow-up covariates. Of 1133 women, 139 (12.3%) reported GD and were 47.6 years of age (4.8 SD) at follow-up. CAC was present in 25% (34/139) of women with GD and 15% (149/994) of women with no GD. In comparison with no GD/normoglycemia, adjusted hazard ratios (95% CIs) were 1.54 (1.06-2.24) for no GD/prediabetes and 2.17 (1.30-3.62) for no GD/incident diabetes, and 2.34 (1.34-4.09), 2.13 (1.09-4.17), and 2.02 (0.98-4.19) for GD/normoglycemia, GD/prediabetes, and GD/incident diabetes, respectively (overall P=0.003). Women without previous GD showed a graded increase in the risk of CAC associated with worsening glucose tolerance. Women with a history of GD had a 2-fold higher risk of CAC across all subsequent levels of glucose tolerance. Midlife atherosclerotic CVD risk among women with previous GD is not diminished by attaining normoglycemia.

Bempedoic Acid a Small Molecule Drug Process and Synthesis, Innovation And /Or Advantages, Development Status And /Or Regulatory Status

The current standard of care for patients with hypercholesterolaemia is primarily statins which can reduce LDL-C. However, some patients, particularly those with heterozygous familial hypercholesterolaemia, coronary heart disease (CHD), CHD-risk equivalents, and other clinical manifestations of atherosclerotic cardiovascular disease [1] (ASCVD), require additional LDL cholesterol lowering on top of what can be achieved with maximum tolerated statin therapy.

Socioeconomic status predicts second cardiovascular event in 29,226 survivors of a first myocardial infarction.

Background Risk assessment post-myocardial infarction needs improvement, and risk factors derived from general populations apply differently in secondary prevention. The prediction of subsequent cardiovascular events post-myocardial infarction by socioeconomic status has previously been poorly studied. Design Swedish nationwide cohort study. Methods A total of 29,226 men and women (27%), 40-76 years of age, registered at the standardised one year revisit after a first myocardial infarction in the secondary prevention quality registry of SWEDEHEART 2006-2014. Personal-level data on socioeconomic status measured by disposable income and educational level, marital status, and the primary endpoint, first recurrent event of atherosclerotic cardiovascular disease, defined as non-fatal myocardial infarction or coronary heart disease death or fatal or non-fatal stroke were obtained from linked national registries. Results During the mean 4.1-year follow-up, 2284 (7.8%) first recurrent manifestations of atherosclerotic cardiovascular disease occurred. Both socioeconomic status indicators and marital status were associated with the primary endpoint in multivariable Cox regression models. In a comprehensively adjusted model, including secondary preventive treatment, the hazard ratio for the highest versus lowest quintile of disposable income was 0.73 (95% confidence interval 0.62-0.83). The association between disposable income and first recurrent manifestation of atherosclerotic cardiovascular disease was stronger in men as was the risk associated with being unmarried (tests for interaction P < 0.05). Conclusions Among one year survivors of a first myocardial infarction, first recurrent manifestation of atherosclerotic cardiovascular disease was predicted by disposable income, level of education and marital status. The association between disposable income and first recurrent manifestation of atherosclerotic cardiovascular disease was independent of secondary preventive treatment but further study on causal pathways is needed.

Epicardial fat thickness is associated with aortic intima-media thickness in patients without clinical manifestation of atherosclerotic cardiovascular disease.

Although the relationship between epicardial fat thickness (EFTh) and coronary atherosclerosis is well established, this relation in the early periods of atherosclerosis has not been fully demonstrated. On the other hand, thoracic aortic intima-media thickness (IMT) rather than carotid IMT was reported as an earlier marker of preclinical atherosclerosis. We aimed to assess the relationship between thoracic aortic IMT and EFTh in patients undergoing transesophageal echocardiography (TEE) examination for different indications. We included 104 patients (mean age 38±11.4years), who underwent TEE for various indications. The patients were divided into two groups according to the median thoracic aortic IMT values (IMT normal group<10mm and IMT abnormal group≥10mm). EFTh was obtained using two-dimensional transthoracic echocardiography on the right ventricular free wall during systole and diastole. The highest EFTh values (3.3±0.96mm vs. 4.51±0.66mm, P<.001) were observed in the abnormal aortic IMT group. Multivariate linear regression analysis showed that aortic IMT was independently correlate with EFTh (β=0.423, P<.001). Moreover, EFTh was found to be associated with history of transient ischemic attack (r=.403, P<.001) and abnormal IMT (r=.643, P<.001) in bivariate analysis. Epicardial fat thickness is independently related to the extent of subclinical thoracic aortic atherosclerosis. Increase in EFTh may be crucial marker for initial atherosclerosis.

Prevalence, Presenting Complaints, Risk Factors and Comorbidity of Acute Coronary Syndrome at Orotta National Referral Hospital Intensive Care Unit Eritrea: Retrospective Study

Coronary Heart Disease (CHD) being one of the major manifestations of atherosclerotic cardiovascular disease, it ranks a third for all deaths above the age of 35 in developed countries. It is the principal cause of mortality globally for greater than 4.5 million people in the developing world with a relative lack of preventive measures implemented. Eighty percent of deaths due to Cardiovascular Diseases (CVD) occur in developing countries. CHD rates are expected to increase in developing countries mainly South East Asia, Sub-Saharan Africa, Latin America, and the Middle East; from 9 million in 1990 to 19 million by 2020. This Retrospective study was carried out to assess the Prevalence, Presenting Complaints, Risk factors and Comorbidity of Acute Coronary Syndrome (ACS) at Orotta National Referral Hospital Intensive Care Unit, Asmara, Eritrea. Hospital based Retrospective record review study of ten years was done on clinical cards of patients. The study results revealed an overall prevalence of 8.5 percent. ACS was observed to increase with an increasing age, being higher in 164 patients (55%) who are in the age group greater than sixty. Majority (86.6%) of admissions were reported as from zoba Maekel. It was observed to increase in males than females with 3.66 to 1 ratio of male to female. Chest pain was documented as a chief complaint (85.23%). The average length of hospital stay until discharged or death was found to be 11 days. Comorbidity between Hypertension, Diabetes and ACS was documented as 55.4 percent showing a significant association (P Value= 0.001). The study results also revealed a significant association between sex and, NSTEMI and STEMI at a P- value = 0.003, but no any association was found among NSTEMI and STEMI, and age, smoking, cholesterol level, Diabetes and Hypertension. In conclusion, this study revealed that ACS is increasing in Eritrea as any other developed and developing countries. The association between sex and, NSTEMI and STEMI which may be attributed to modifiable behavioral risk factors that are gender related. Therefore, the study recommends to Clinicians to ask and record, family history of premature CHD death, duration of Diabetes, Hypertension and other chronic cardio-pulmonary diseases, all diagnostic investigations and specific medications that are used for the management of the disease and good outcome.

Mean platelet volume is associated with aortic intima-media thickness in patients without clinical manifestation of atherosclerotic cardiovascular disease.

Objective:Mean platelet volume (MPV) plays a pivotal role in the pathophysiology of atherosclerotic disease. Thoracic aortic intima-media thickness (IMT) was reported as an earlier marker of preclinical atherosclerosis than carotid IMT. However, the relationship between MPV and aortic IMT was not investigated. We aimed to assess the relationship between thoracic aortic IMT and MPV in patients undergoing transesophageal echocardiography (TEE) examination for different indications.Methods:We studied 190 patients (mean age 37.0±12.5 years) who underwent TEE for different indications. The patients who have known atherosclerotic disease were excluded from study. The patients were divided into 2 groups according to the median thoracic aortic IMT values (IMTlow group <13 mm and IMThigh group ≤13 mm). Platelet count and MPV were analyzed with an automated hematology analyzer. A multiple stepwise linear regression analysis was performed to identify the independent associations of thoracic aortic IMT.Results:The highest MPV values were observed in the IMThigh group compared with the IMTlow group (9.5±10 fL vs. 10.9±1.2 fL, p<0.001). Also, the IMThigh group had higher age, hs-CRP and uric acid levels (p<0.05 for all). Multiple linear regression analysis showed that aortic IMT was independently related with age (β=0.340, p<0.001), uric acid (β=0.111, p=0.041), hs-CRP (β=0.200, p<0.001), and MPV (β=0.482, p<0.001).Conclusion:MPV is independently related to the extent of subclinical thoracic aortic atherosclerosis. Increases in MPV may be a crucial biochemical marker for initial atherosclerosis.

Aortic Distensibility and Aortic Intima-Media Thickness in Patients without Clinical Manifestation of Atherosclerotic Cardiovascular Disease

Background: There is growing evidence that aortic distensibility (AD) is a subclinical marker of early atherosclerosis. Aortic intima-media thickness (IMT) was an earlier marker than carotid IMT of preclinical atherosclerosis. In this study, we aimed to assess the relationship between thoracic aortic IMT and AD. Methods: We studied 192 patients (mean age: 45.5 ± 8.4 years) who underwent transesophageal echocardiography (TEE) for various indications. Four different grades were determined according to IMT of thoracic aorta (Grade 1 < 1 mm; 1 mm ≤ Grade 2 < 3 mm; 3 mm ≤ Grade 3 < 5 mm; 5 mm ≤ Grade 4). AD was calculated from the echocardiographically derived ascending aorta diameters and hemodynamic pressure measurements in all patients. High sensitive C-reactive protein (hsCRP) and other biochemical markers were measured using an automated chemistry analyzer. Results: TEE evaluation characterized thoracic aortic intimal morphology as grade 1 in 71 patients (37%), grade 2 in 57 patients (29.7%), grade 3 in 34 patients (17.7%), and grade 4 in 30 (15.6%) patients. The lowest AD level was observed in grade 4 group compared with grade 1 and grade 2 groups (P < 0.001, P = 0.009, respectively). AD level of grade 3 group was lower than grade 1 and grade 2 group (P < 0.001, P = 0.021, respectively). In multiple linear regression analysis, AD was independently associated with age (β = −0.138, P = 0.029), hsCRP (β = −0.209, P = 0.001), and aortic IMT (β = −0.432, P < 0.001). Conclusion: AD is independently associated with age, thoracic aortic IMT, and hsCRP. Impaired elasticity index of the aorta might be an independent predictor for the severity of thoracic atherosclerosis.

Aortic Distensibility and Aortic Intima‐Media Thickness in Patients without Clinical Manifestation of Atherosclerotic Cardiovascular Disease

There is growing evidence that aortic distensibility (AD) is a subclinical marker of early atherosclerosis. Aortic intima-media thickness (IMT) was an earlier marker than carotid IMT of preclinical atherosclerosis. In this study, we aimed to assess the relationship between thoracic aortic IMT and AD. We studied 192 patients (mean age: 45.5 ± 8.4 years) who underwent transesophageal echocardiography (TEE) for various indications. Four different grades were determined according to IMT of thoracic aorta (Grade 1 < 1 mm; 1 mm ≤ Grade 2 < 3 mm; 3 mm ≤ Grade 3 < 5 mm; 5 mm ≤ Grade 4). AD was calculated from the echocardiographically derived ascending aorta diameters and hemodynamic pressure measurements in all patients. High sensitive C-reactive protein (hsCRP) and other biochemical markers were measured using an automated chemistry analyzer. TEE evaluation characterized thoracic aortic intimal morphology as grade 1 in 71 patients (37%), grade 2 in 57 patients (29.7%), grade 3 in 34 patients (17.7%), and grade 4 in 30 (15.6%) patients. The lowest AD level was observed in grade 4 group compared with grade 1 and grade 2 groups (P < 0.001, P = 0.009, respectively). AD level of grade 3 group was lower than grade 1 and grade 2 group (P < 0.001, P = 0.021, respectively). In multiple linear regression analysis, AD was independently associated with age (β = -0.138, P = 0.029), hsCRP (β = -0.209, P = 0.001), and aortic IMT (β = -0.432, P < 0.001). AD is independently associated with age, thoracic aortic IMT, and hsCRP. Impaired elasticity index of the aorta might be an independent predictor for the severity of thoracic atherosclerosis.

Translational Medicine in Atherosclerosis: From Human Genetics to New Biology to Novel Therapeutics

Despite advances over the last few decades, atherosclerotic cardiovascular disease (ASCVD) remains a major public health issue worldwide. New therapies for the prevention and treatment of ASCVD are still needed. The investigation of monogenic disorders, such as those associated with extremes of plasma lipids, have yielded new therapeutic targets and spurred the development of new therapeutic approaches. Unbiased genome-wide studies have identified a large number of novel genetic loci associated with different manifestations of ASCVD (eg. myocardial infarction and obstructive CAD) as well as risk factor traits (eg. plasma lipids). These discoveries are beginning to result in new insights into biology and physiology relevant to the development of ASCVD. For example, a locus on chromosome 1p13 was found to be significantly associated with MI, as well as noted to be one the strongest loci in the genome associated with LDL cholesterol. The causal gene at this locus, SORT1, encodes a protein sortilin that through action in the liver has important effects on LDL metabolism. Several other loci associated with plasma lipid traits have yielded new insights into the regulation of lipoprotein metabolism. Similarly, loci associated with MI and CAD are putting new molecules on the map that causally influence the development of atherosclerosis or plaque disruption. Just as the study of monogenic disorders has yielded new therapeutic targets, it is expected that translation of the new biology unfolding as a result of genome-wide studies of ASCVD and its risk factors will ultimately yield novel therapies for the treatment of atherosclerotic disease.

Abstract 530: Is Severe Hypertriglyceridemia (&gt; 1000 mg/dl) a Risk Factor for Atherosclerosis ?

Severe Hypertriglyceridemia (SHTG) is believed to be a rare condition difficult to treat, but associated with a relatively low risk of morbidity, except for pancreatitis. In particular, SHTG is not believe to be a risk factor of atherosclerosis . Therefore, we performed a morbidity survey of SHTG patients being followed up for at least 2 years in the lipid clinics of the German Working Group. Evaluation of co-morbid conditions was based on patient chart review. The data of 893 SHTG cases (689 males (m), 204 females (f)) were compiled. As an admission criterion to the study SHTG patients had to have a documented TG &gt; 1000 mg/dl prior to follow-up in the respective lipid clinics. Mean age was 50 ± 12 years, mean BMI was 28.7 ± 4.5. Upon admission to the lipid clinics mean TG was 2800 mg/dl (1000 – 16 000 mg/dl) and mean TC was 480 mg/dl (162–15920 mg/dl). Even after long term treatment in the lipid clinics mean TG and TC were still highly elevated (1190mg/dl and 322mg/dl, respectively). Regarding co-morbid conditions the following prevalence data were obtained: episodes of pancreatitis 24% (21% m,35%f), gallstones 21% (17% m, 32% f),hypertension 70%, diabetes 51 %, hyperuricemia 72 %. The prevalence of clinical manifestations of CVD was as follows : CHD by angiography 24% (27% m , 16 % f), MI 14 % (16% m, 5% f) , angina 21% (23% m, 17% f), PVD 15 % (14% m, 17% f), cerebrovascular disease 20 % (19% m, 24% f ). A total of 36 % of all SHTG patients (37% m, 33% f) showed at least one clinical manifestation of atherosclerotic cardiovascular disease. After excluding other risk factors 19% of remaining SHTG cases (20% m, 16 % f) still had clinical CVD. In conclusion, we were able to demonstrate a significant CVD burden in both male and female SHTG patients. SHTG itself seems to be an independent CVD risk factor.

Population-based study of carotid endarterectomy in Western Australia.

Previous studies reported an increase in the rates of operation following the publication of major trials that demonstrated the benefit of carotid endarterectomy in reducing stroke. The aim of this study was to determine whether carotid endarterectomy rates have continued to rise despite the reducing trend in most manifestations of atherosclerotic cardiovascular disease. Record linkage was used to select patients who had a carotid endarterectomy during the interval from 1988 to 2001. Incidence rates were age-standardized and trends were examined with Poisson regression. The rate increased by 13.8 per cent per year between 1988 and 1998; however, from 1999 onwards the rate of carotid surgery fell by 15.8 per cent per year. In octogenarians, the rate increased steadily from 0.9 to 5.1 per 100,000 person-years between 1992 and 2000. The proportion of octogenarians also increased significantly from 0.9 per cent in 1988-1990 to 19.5 per cent in 2000-2001 (chi2=60.11, 4 d.f., P<0.001). For the first time a recent decline has been observed in the rate of carotid endarterectomy, most likely owing to a combination of the deceasing incidence of atherosclerosis and more widespread use of effective drugs in the treatment of cardiovascular disease. The rate and proportion of operations in patients aged 80 years or older has increased steadily.

Cardiovascular risk in hypertension: implications of the Sheffield Table for lipid-lowering strategy.

To determine the actual use of 'statin' therapy for primary and secondary prevention and the potential effect of using the Sheffield Table for primary prevention of coronary heart disease upon 'statin' use in a consultant-run Hypertension and Cardiovascular Risk Clinic. Prospective audit of the current use of cholesterol-lowering therapy and the effect of implementing the criteria used in the Sheffield Table and the Scandinavian Simvastatin Study for cholesterol lowering in 'at risk' patients upon statin use in a consultant-led cardiovascular risk clinic. The Aberdeen Hypertension Clinic. A total of 1500 patients were reviewed of which 416 (27.7%) had experienced at least one clinical manifestation of atherosclerotic cardiovascular disease (CVD) and 392 (94%) of these had a total cholesterol measured of whom 298 (76%) had a total cholesterol >5.5 mmol/l. Only 11.2% of eligible patients were actually receiving lipid-lowering treatment for secondary prevention. A total of 1084 patients with no prior cardiovascular disease were identified, 97 (8.9%) were excluded because of age. Using the Sheffield Table, 92 (9.4%) of these patients were eligible for statin therapy and only six of the 92 patients were actually receiving treatment. The results of this study reveal that even in a consultant-led cardiovascular prevention clinic there is a significant discrepancy between optimal evidence-based management and the actual delivery of clinical care. Seventy-two per cent and 9.3% of patients attending the clinic were eligible for statin treatment for secondary and primary prevention, respectively. However, only 11.2% of patients suitable for secondary prevention and 6.5% of patients suitable for primary prevention were actually receiving appropriate lipid-lowering therapy. Considering the proven benefit of this form of medical intervention the results of this study are of real importance to practising clinicians and patients alike.

Pediatric preventive cardiology clinics.

Atherosclerotic cardiovascular disease is the leading cause of death in the adult population in our society. Cardiac diseases due to diphtheria, rubella, and rheumatic fever are currently extremely rare in comparison with the incidence in previous generations. 1 This is, to a great extent, due to successful practice of preventive medicine in the offices of pediatricians. Although the clinical manifestations of atherosclerotic cardiovascular disease seem to be in the distant future for children, there is good evidence that the pathological process begins in childhood. 1-6 Furthermore, there is no question that behavioral aspects of a coronary disease–prone life-style have their roots in childhood. 5,7 Efforts directed at the prevention of adult atherosclerotic cardiovascular disease are being increasingly incorporated into the practice of pediatrics. Pediatric preventive cardiology clinics have developed in the recent past for several reasons. The incorporation of preventive cardiology efforts in pediatric practice leads to the identification of