Multiple Cardiovascular Risk Research Articles

Lipoprotein(a) hyperlipidemia as cardiovascular risk factor: pathophysiological aspects.

Lipoprotein (a) [Lp(a)] is a modified LDL particle with an additional apolipoprotein [apo(a)] protein covalently attached by a thioester bond. Multiple isoforms of apo(a) exist that are genetically determined by differences in the number of Kringle-IV type-2 repeats encoded by the LPA gene. Elevated plasma Lp(a) is an independent risk factor for cardiovascular disease.The phenotypic diversity of familial Lp(a) hyperlipidemia [Lp(a)-HLP] and familial hypercholesterolemia [FH], as defined risks with genetic background, and their frequent co-incidence with additional cardiovascular risk factors require a critical revision of the current diagnostic and therapeutic recommendations established for isolated familial Lp(a)-HLP or FH in combination with elevated Lp(a) levels.Lp(a) assays still suffer from poor standardization, comparability and particle variation. Further evaluation of the current biomarkers and establishment of novel comorbidity biomarkers are necessary for extended risk assessment of cardiovascular disease in FH or Lp(a)-HLP and to better understand the pathophysiology and to improve patient stratification of the Lp(a) syndrome complex.Lp(a) promotes vascular remodeling, increased lesion progression and intima media thickening through induction of M1-macrophages, antiangiogenic effects (e.g. vasa vasorum) with secretion of the antiangiogenic chemokine CXCL10 (IP10) and CXCR3 mediated activation of Th1- and NK-cells.In addition inhibition of serine proteases causing disturbances of thrombosis/ hemostasis/ fibrinolysis, TGFb-activation and acute phase response (e.g. CRP, anti-PL antibodies) are major features of Lp(a) pathology. Anti-PL antibodies (EO6 epitope) also bind to oxidized Lp(a).Lipoprotein apheresis is used to reduce circulating lipoproteins in patients with severe FH and/or Lp(a)-HLP, particularly with multiple cardiovascular risks who are intolerant or insufficiently responsive to lipid-lowering drugs.

Simvastatin/fenofibrate combination in the treatment of dyslipidemia: current evidence

Simvastatin/fenofibrate combination in the treatment of dyslipidemia: current evidence Jose G Jimenez-Montero,1 Gregory Haft2 1Post Graduate Studies, University of Medical Sciences, San José, Costa Rica; 2Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA Background: It has been demonstrated that statins can reduce major cardiovascular complications throughout a broad range of patients with dyslipidemia and multiple cardiovascular risk. Despite the impact of statin therapy on cardiovascular morbidity and mortality, a residual cardiovascular risk remains following lowering of low-density lipoprotein cholesterol. In many patients, optimization of the lipid profile cannot be achieved with statin therapy. Therefore, pharmacologic interventions with non-statin therapy can be used. Aims: The objective of this review was to analyze current clinical evidence of the effects of simvastatin/fenofibrate combination therapy. Methods: We searched and analyzed the evidence up to June 2014, regarding the effects of statin/fibrate combination therapy for reducing cardiovascular complications. Results: Forty-nine studies reporting the efficacy and safety of statin/fibrate combination therapy were analyzed. Of the forty-nine, 19 analyzed the simvastatin/fenofibrate combination therapy. This therapy was demonstrated to be safe and superior to the statin monotherapy in modifying atherogenic dyslipidemia, including lipoprotein subclasses. Nevertheless, in randomized clinical trials cardiovascular endpoints were not significantly different when fenofibrate was added to a standard low-density lipoprotein cholesterol reducing therapy. Of note, in the subgroup analysis, positive results were observed in patients with high triglycerides and low high-density lipoproteins. The inclusion of heterogeneous populations in these studies may explain the mixed results of cardiovascular outcomes seen in randomized clinical trials. Conclusion: Future clinical studies that rigorously address the effects of simvastatin/fenofibrate in patients with triglycerides >2.25 mmol/L and high density lipoprotein cholesterol <0.90 mmol/L, will provide a more accurate conclusion regarding the use of simvastatin/fenofibrate combination therapy. For now, emphasis must be put on non-pharmacological interventions that effectively induce weight loss and strict glycemic control in diabetics. The initiation of simvastatin/fenofibrate combination therapy among patients with residual cardiovascular risk should be employed at the physician's discretion, as this strategy lacks hard cardiovascular end points. Keywords: dyslipidemia, atherosclerotic cardiovascular disease, residual risk, simvastatin fenofibrate combination therapy

Cardiovascular risk factors contribute to disparities in graft outcomes in African American renal transplant recipients: A retrospective analysis

Data examining cardiovascular (CV) risk factors in renal transplant recipients (RTRs) and their contribution to the disparity in graft survival between African American (AA) patients and non-AAs is limited. A single-center, retrospective analysis of 1003 adult RTRs from January 1, 2000 to May 1, 2008 to inspect the impact of race on post-transplant CV events, treatment of CV risk factors and their independent influence on graft outcomes was performed. AAs experienced a higher incidence of late graft loss, with 1- and 5-year graft survival rates of 93% and 76% vs 95% and 84% in the non-AA group, respectively. AA patients had a higher prevalence of hypertension (HTN) and diabetes mellitus (DM) and demonstrated reduced control of DM post-transplant (AA 74% vs non-AA 82%, p = 0.053). Multivariate analysis for graft survival indicated acute rejection, delayed graft function (DGF) and incidence of CV events were significant risk factors for graft failure, while the use of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) and 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors were protective. In conclusion, after controlling for CV risk factors and events, race did not have an independent effect on outcomes, suggesting CV risk factors and events contribute to this disparity. Clinical summary. AAs experienced a higher rate of graft failure and CV events; after adjusting for multiple immunological and CV risk factors, race no longer remained an independent risk factor for post-transplant CV events or graft failure; although disparities in post-transplant outcomes remain, race alone does not account for the disparity; the racial disparity is due to the higher incidence of DGF and acute rejection, as well as traditional CV risk factors, including HTN and DM.

Roux-en-Y Esophagojejunostomy Reduces Serum and Aortic Inflammatory Biomarkers in Type 2 Diabetic Rats

Recent studies have shown the reduction in serum inflammatory biomarkers by bariatric surgery. However, few studies have reported its effects on local vascular inflammation. We have investigated the effects of Roux-en-Y esophagojejunostomy on both serum and aortic tissue inflammation biomarkers in type 2 diabetic rats. Sprague-Dawley rats were divided into five groups: diabetic RYEJ, diabetic RYEJ sham, diabetic food restriction, diabetic rats, and non-diabetic control (n = 6/group). At 4weeks after surgery, serum leptin, interleukin-6, C-reactive protein, interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), chemerin, and adiponectin were measured. Aortic expression of c-Jun NH2-terminal kinase and p38 mitogen-activated protein kinases was examined with immunohistochemistry; aortic expression of IL-1β, TNF-α, intercellular adhesion molecule-1, and vascular adhesion molecule-1 was assessed with western blotting. Hyperinsulinemic-euglycemic clamps with tracer infusion were completed to assess insulin sensitivity. Roux-en-Y esophagojejunostomy significantly decreased serum inflammatory parameters and increased the concentration of the anti-inflammatory mediator adiponectin. The aortic inflammatory protein expression was markedly decreased in the diabetic RYEJ group as compared with that of the diabetic group (P < 0.05). Additionally, Roux-en-Y esophagojejunostomy improved insulin sensitivity and dyslipidemia and decreased body weight and total body fat. Roux-en-Y esophagojejunostomy reduces the systemic and local vascular inflammation. The improvements in systemic and vascular inflammation are not wholly dependent on the magnitude of weight loss. Moreover, Roux-en-Y esophagojejunostomy alleviates insulin resistance and improves the features of metabolic syndrome, leading to a reduction in multiple cardiovascular risks.

The Relationship Between Artery Stiffness and Left Ventricular Diastolic Function in Patients With Multiple Cardiovascular Risks

To evaluate the relationship between artery stiffness and left ventricular diastolic function. A total of 79 patients with multiple cardiovascular risks were recruited and divided into two groups according to the value of E/Em: diastolic dysfunctional group (E/Em≧10, n=25) and control group (E/Em<10, n=54). The arterial stiffness parameters of carotid artery and endothelium-independent dilation (EID) of brachial artery were evaluated by ET for two groups. The arterial stiffness parameters of carotid artery and EID of brachial artery in diastolic dysfunctional group were higher than that in controls (p > 0.05), and were associated to diastolic function parameters of left ventricular (p < 0.05). The arterial stiffness is closely related to the diastolic function of left ventricular, and maybe an important factor to impact on it. The increased arterial stiffness is useful in predicting left ventricular diastolic dysfunction in patients with multiple cardiovascular risks.

Abstract 59: The Effects of Dapagliflozin on Cardiovascular Risk Factors in Patients with Type 2 Diabetes Mellitus

Background: Patients with type 2 diabetes mellitus (T2DM) often have multiple cardiovascular (CV) risk factors and, thus, an increased CV risk. Dapagliflozin (DAPA), a selective SGLT2 inhibitor currently under evaluation for the treatment of T2DM, reduces hyperglycemia by promoting renal glucose excretion, independently of insulin secretion or action. Methods: Using prospective exploratory analysis, the effects of DAPA on CV risk factors, including body weight, waist circumference, blood pressure (BP), plasma lipids, uric acid, estimated glomerular filtration rate (eGFR), and hypoglycemia were evaluated in four phase 3 studies. Patients were randomized to DAPA 2.5, 5, or 10 mg or placebo (PBO) once daily for 24 weeks as monotherapy in drug-naïve patients (Study 1, NCT00528372 , N=485 [main cohort n=274]), as add-on to metformin (Study 2, NCT00528879 , N=546), as add-on to glimepiride (Study 3, NCT00680745 , N=596), or as add-on to insulin (Study 4, NCT0067323, N=808). Non-protocol antidiabetic and weight-reducing drugs were prohibited; other background medications were not controlled. Mean changes from baseline to week 24 adjusted for baseline values were analyzed. Results: DAPA significantly reduced glycated hemoglobin in all studies (Table). Weight loss with DAPA was greater than with PBO in all 4 studies, with statistically significant differences in Studies 2, 3, and 4 ( P &lt;0.0001). There were numerical decreases in waist circumference with DAPA in all 4 studies. DAPA reduced systolic BP and to a lesser extent, diastolic BP in all studies. Patients treated with DAPA showed inconsistent changes in triglycerides or LDL-cholesterol, whereas there were consistent increases in HDL-cholesterol. Decreases in serum uric acid were observed with DAPA in all studies. No clinically meaningful changes in eGFR were observed. Hypoglycemic events were infrequent and occurred in a similar proportion of patients in PBO and DAPA groups in Studies 1 and 2, but were more frequent with DAPA than with PBO in Studies 3 and 4, when added to sulfonylurea or insulin therapy. Conclusions: DAPA has favorable effects on important CV risk factors in patients with T2DM.

Outcomes from the REACH Registry for Australian general practice patients with or at high risk of atherothrombosis

To report on 1-year cardiovascular (CV) event rates in patients with established cardiovascular disease (CVD) or with multiple cardiovascular risk factors. Prospective cohort study of 2873patients at high risk of atherothrombosis based on the presence of multiple risk factors and overt coronary artery disease (CAD), cerebrovascular disease (CerVD) or peripheral arterial disease (PAD) presenting to 273Australian general practitioners; this study was conducted as part of the international REACH Registry. One-year rates of cardiovascular death, myocardial infarction, stroke, and hospitalisation for cardiovascular procedures. The cardiovascular death rate at 1year was 1.4%. The combined cardiovascular death, non-fatal MI, stroke and hospitalisation rate for vascular disease affecting one location at 1year was 11%. Even for patients with no overt disease, but with multiple risk factors, the 1-year combined event rate was 4.2%. The highest combined event rate was in patients with PAD (21.0%), and in patients with atherothrombotic disease identified in all three locations (coronary arteries, cerebrovascular system and peripheral arteries) at 39%. The rate of clinical events in community-based patients with stable atherothrombotic disease increases dramatically with the severity of disease and the number of vascular beds involved. Where disease was evident in all three locations, and for patients with PAD alone, the 1-year risk of cardiovascular events was substantially increased. Poor adherence to statin therapy in the secondary preventive setting is a major treatment gap that needs to be closed; the influences of obesity and diabetes warrant further investigation.

Integrating Evidence and Individual Preferences Using a Web-Based Multi-Criteria Decision Analytic Tool

Annalisa© (AL) is a web-based decision-support template grounded in multi-criteria decision analysis (MCDA). It uses a simple expected value algorithm to calculate a score for each option by taking into account the individual's preferences for different criteria (as importance weights) and the evidence of the performance of each option on each criterion. Given the uncertainty surrounding the trade offs between benefits and harms for prostate cancer screening, this topic was chosen as the vehicle to introduce this new decision-support template. The aim of the study was to introduce a new decision-support template, AL, and to develop and pilot a decision-support tool for prostate cancer screening using it. A decision-support tool for prostate cancer screening (ALProst) was implemented in the AL template. ALProst incorporated evidence on both the benefits and the potential harms of prostate cancer screening (the 'attributes') from published randomized controlled trials (RCTs). Individual weights for each attribute were elicited during interviews. By combining the individual's preferences and the evidence, the best option for the user was identified on the basis of quantified scores. A convenience sample of computer-proficient primary-care physicians (general practitioners [GPs] in Australia) from the Sydney Metropolitan area (Australia) were invited to complete a face-to-face interview involving the decision-support tool. Preference for undergoing prostate-specific antigen testing for prostate cancer, both personally and for their patients, was sought prior to seeing the tool. After gaining hands-on experience with using the tool, GPs were asked to comment on the merits of the template and the tool. Preference for presenting the benefits of prostate cancer screening as the relative or absolute risk reduction in prostate cancer-specific mortality was also sought. Of 60 GPs approached, ten (six men and four women) completed an interview (16.7% response rate). Most GPs agreed/strongly agreed with positive statements about the ease with which they could use AL (seven GPs), and understand the information in, and format of, AL (nine and eight, respectively). Eight agreed/strongly agreed that ALProst would be a useful tool for discussing prostate cancer screening with their patients. GPs were also asked to nominate difficult clinical decisions that they, and their patients, have had to make; responses included cancer screening (including prostate cancer); treating patients with multiple illnesses/diseases; managing multiple cardiovascular disease risk factors; and managing patients who are receiving multiple medications. The common element was the need to consider multiple factors in making these complex decisions. AL is distinguishable from most other decision-support templates available today by its underlying conceptual framework, MCDA, and its power to combine individual preferences with evidence to derive the best option for the user quantitatively. It therefore becomes potentially useful for all decisions at all levels in the healthcare system. Moreover, it will provide a universal graphic 'language' that can overcome the burden to patients of encountering a plethora of widely varying decision aids for different conditions during their lifetime.

Gender differences in cardiovascular risks of obese adolescents in the bronx

Objective: The associations between the degree of obesity and cardiovascular disease (CVD) risks and the impact of gender differences with regard to these risk factors are not well understood. The aim of our study was to examine the gender−specific differences in CVD risk factors in inner−city minority youths.Methods: A total of 269 adolescents (109 males and 160 females) were included in this retrospective study. Data on multiple metabolic variables were collected. Evaluation of abnormalities in these parameters was based on standard criteria. Pearson correlations were calculated to examine the relationship between body mass index (BMI) z−score and obesity−related parameters. Chi−square and Fisher’s tests were used to compare the frequencies of single or multiple cardiovascular risks in the two gender groups.Results: In the male group, BMI z−scores showed significant positive correlations with insulin resistance and diastolic blood pressure. In the female group, BMI z−scores showed significant positive correlations with insulin resistance and systolic blood pressure. In both genders, the prevalence of CVD risks was high, but a similar risk pattern was established in both sexes, with dyslipidemia being the highest, hypertension the second, and impaired glucose tolerance (IGT) being the least outstanding. The most important finding in this study was that the male group had a significantly higher prevalence of systolic hypertension.Conclusion: Male inner−city minority adolescents show a high prevalence of CVD risks associated with obesity. Appropriate risk stratification is critical to developing and implementing both therapeutic and preventive interventions.Conflict of interest:None declared.

Familial hypercholesterolemia and lipoprotein(a) hyperlipidemia as independent and combined cardiovascular risk factors

Abstract The phenotypic diversity of familial hypercholesterolemia (FH) and lipoprotein(a) hyperlipidemia (Lp(a)-HLP), as defined risks for coronary artery disease with genetic background, and their frequent co-incidence with additional cardiovascular risk factors require a critical revisiting of the current diagnostic and screening criteria as well as therapeutic recommendations established for FH or isolated Lp(a)-HLP, since there is no clear guidance for patient stratification and disease management for combined cases. Further evaluation of the recent biomarkers and establishment of novel biomarkers are necessary for extended risk assessment of cardiovascular disease in FH or Lp(a)-HLP and to better understand the pathophysiology of these syndrome complexes. Lipoprotein apheresis is used as long-term treatment to reduce circulating lipoproteins in patients with severe FH and/or Lp(a)-HLP, particularly with multiple cardiovascular risks who are intolerant or insufficiently responsive to lipid-lowering drugs. Recent sophisticated analyses of molecular lipid species (lipidome) extended with transcriptomic and/or proteomic approaches may provide further lipid biomarkers for disease management of FH and/or Lp(a)-HLP, and relevant data for optimization of apheresis treatment. This review summarizes current studies investigating FH and Lp(a)-HLP as independent and combined cardiovascular risk factors, and some promising biomarker candidates for these entities.

2009 Canadian Hypertension Education Program recommendations: The scientific summary – an annual update

The present report highlights the key messages of the 2009 Canadian Hypertension Education Program (CHEP) recommendations for the management of hypertension and the supporting clinical evidence. In 2009, the CHEP emphasizes the need to improve the control of hypertension in people with diabetes. Intensive reduction in blood pressure (to less than 130/80 mmHg) in people with diabetes leads to significant reductions in mortality rates, disability rates and overall health care system costs, and may lead to improved quality of life. The CHEP recommendations continue to emphasize the important role of patient self-efficacy by promoting lifestyle changes to prevent and control hypertension, and encouraging home measurement of blood pressure. Unfortunately, most Canadians make only minor changes in lifestyle after a diagnosis of hypertension. Routine blood pressure measurement at all appropriate visits, and screening for and management of all cardiovascular risks are key to blood pressure management. Many young hypertensive Canadians with multiple cardiovascular risks are not treated with antihypertensive drugs. This is despite the evidence that individuals with multiple cardiovascular risks and hypertension should be strongly considered for antihypertensive drug therapy regardless of age. In 2009, the CHEP specifically recommends not to combine an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker in people with uncomplicated hypertension, diabetes (without micro- or macroalbuminuria), chronic kidney disease (without nephropathy [micro- or overt proteinuria]) or ischemic heart disease (without heart failure).

Non-ST Elevation Myocardial Infraction after High Dose Intravenous Immunoglobulin Infusion

Intravenous immunoglobulins (IVIgs) are used for several indications, including autoimmune conditions. IVIg treatment is associated with several possible adverse reactions including induction of a hypercoagulable state. We report a 76-year-old woman treated with IVIg for myasthenia gravis, which developed chest pain and weakness following IVIg infusion. The symptoms were associated with ST segment depression in V4–6 and elevated troponin levels. The patient was diagnosed with non-ST elevation myocardial infarction (NSTEMI). The patient had no significant risk factor besides age and a cardiac perfusion scan was interpreted as normal (the patient refused to undergo cardiac catheterization). This case is compatible with IVIg-induced hypercoagulability resulting in NSTEMI. Cardiac evaluation should therefore be considered prior to initiation of IVIg treatment especially in patients with multiple cardiovascular risks.

Multiple Biomarkers and Cardiovascular Risk

Multiple Biomarkers and Cardiovascular Risk

Abstract 3644: Moderate Alcohol Consumption Is Associated With Improved Endothelial Function

Background and Purpose: Moderate alcohol intake is protective against coronary artery disease. Endothelial dysfunction contributes to atherosclerosis and the pathogenesis of cardiovascular disease. Effects of alcohol consumption on endothelial function may be relevant to these cardiovascular outcomes, but very few human studies have examined the effect of alcohol consumption on endothelial function assessed by flow-mediated dilation (FMD) of the brachial artery. Methods: In the population-based Northern Manhattan Study (NOMAS), we performed a cross-sectional analysis of lifetime alcohol intake and brachial artery FMD during reactive hyperemia using high-resolution B-mode ultrasound images among 883 stroke free participants (mean age 66.7 years, women 56.6%, Hispanic 67.5%, black 17.5%, and white 14.9%). Results: The mean brachial FMD was 5.68% and the median was 5.52%. Reported lifetime alcohol consumption was as follows:147 (16.7%) non-drinkers (&lt;1drink/month), 616 (69.8%) &gt;1drink/mo to 2drinks/day, 59 (6.7%) &gt;2 to 5drinks/day, 60(6.8%) &gt;5drinks/day. Compared to non-drinkers, those who drank &gt;1 drink/mo to 2 drinks/day were more likely to have FMD above the median (5.5%) of FMD (unadjusted OR 1.7, 95% CI 1.2–2.5, p=0.004). In multivariate analysis, the relationship between moderate alcohol consumption and FMD remained significant after adjusting for multiple traditional cardiovascular risk factors, including age, body mass index, hypertension, diabetes and smoking (adjusted OR 1.5, 95%CI 1.1–2.2, p=0.02). No beneficial effect on FMD was seen for those who drank more than 2 drinks/day. Conclusion: Consumption of up to 2 alcoholic beverages per day independently was associated with improved FMD compared to nondrinkers in this multiethnic population compared to non-drinkers. The effect on FMD may represent an important mechanism in explaining the protective effect of alcohol intake on cardiovascular disease.

Young Overweight Girls Have Multiple Cardiovascular Risks

Young Overweight Girls Have Multiple Cardiovascular Risks

Cardiovascular Risk Reduction

A case on cardiovascular risk reduction is presented. Multiple cardiovascular risks (dyslipidemia, hypertension, and diabetes) are addressed. Management of the metabolic syndrome and appropriate testing for the newer cardiovascular marker, C-reactive protein, are also discussed. The case emphasizes the importance of patient education about chronic disease states, which are often asymptomatic.

Mo-P1:88 Impact evaluation on the intervention of multiple cardiovascular disease risk factors in clinical settings

Mo-P1:88 Impact evaluation on the intervention of multiple cardiovascular disease risk factors in clinical settings

Commentary on pretransplantation: identifying risk factors

O ur definitions of high-risk transplantation continue to evolve. Patient death with a functioning allograft is now the most common cause of late transplant failure. Thus we are increasingly aware of the potential contribution of metabolic complications to these end points and are devoting greater attention to risk reduction after transplantation. However, with broadening definitions of which patients are suitable recipients, it is also increasingly apparent that pretransplant variables play a major role in posttransplant outcomes. As can be seen in their somewhat ominous report, Kim and colleagues documented dramatically increased coronary disease and platelet reactivity in asymptomatic young adults who experienced endstage renal disease (ESRD) and transplantation as children. We must be aware that in most patients with advanced chronic kidney disease, multiple potent cardiovascular risk factors (including hypertension, anemia, glucose intolerance, altered calcium and phosphorus metabolism, hyperlipidemia, and so on) have been operative for years. Given the epidemic of obesity in the United States, it should not be surprising that we are now performing more transplantations in overweight patients than ever before. In the second study, deMattos and coworkers from the University of Oregon monitored 608 patients for 5 years. Their results remind us that, although many of these patients fared well over time, the risk of mortality is higher with increasing body mass index. Obesity at the time of transplantation was a major risk factor for nonfatal cardiac events and development of posttransplant diabetes mellitus (PTDM). As they state, a longer follow-up period will help determine whether pretransplant obesity is related to graft loss. Likewise, in a cohort of cyclosporine-treated patients, the Ohio State University study of Pesavento and associates evaluated pretransplant records of 79 patients and found evidence of pre-existing glucose intolerance in more than half of those with subsequent development of PTDM. There was also a strong correlation between PTDM and pretransplant obesity. These findings are consistent with a recent publication by Woodward and colleagues1 that indicated our previous understanding of pre-existing glucose intolerance and new-onset diabetes after transplantation was incomplete and may contribute to miscalculation of the true risk of PTDM. To put it simply, many patients that we now identify as having PTDM already had diabetes, masked perhaps by renal insufficiency and its effects on glucose and insulin metabolism. Multiple variables are at play in determining the risk of glucose intolerance after transplantation, not just calcineurin-inhibitors and corticosteroids. These 3 reports indicate that our concern for reducing posttransplant cardiovascular risk must begin well before transplantation. Implementation of DOQI (National Kidney Foundation Kidney Disease Outcomes Quality Initiative) guidelines in the chronic kidney disease and ESRD populations should prove beneficial in this regard.2 Additionally, better awareness of pre-existing risk at the time of transplantation may enable more effective approaches afterward in terms of lifestyle modifications, aggressive risk reduction, and more informed immunosuppressant choices.

Impact of multiple cardiovascular disease risk factors on brachial artery distensibility in young adults: The Bogalusa heart study

Impact of multiple cardiovascular disease risk factors on brachial artery distensibility in young adults: The Bogalusa heart study

Effects of weight loss on multiple cardiovascular disease risk factor reduction: one-year of treatment with Orlistat.

Effects of weight loss on multiple cardiovascular disease risk factor reduction: one-year of treatment with Orlistat.