Occurrence Of Major Cardiovascular Events Research Articles

Relationship between pulmonary hypertension, peripheral vascular calcification, and major cardiovascular events in dialysis patients

BackgroundPulmonary hypertension (PHT) is a recently recognized complication of chronic kidney disease. In this study, we investigated the association between PHT, peripheral vascular calcifications (VCs), and major cardiovascular events. MethodsIn this retrospective study, we included 172 end-stage renal disease (ESRD) patients undergoing dialysis [hemodialysis (HD)=84, peritoneal dialysis=88]. PHT was defined as an estimated pulmonary artery systolic pressure>37mmHg using echocardiography. The Simple Vascular Calcification Score (SVCS) was measured using plain radiographic films of the hands and pelvis. ResultsThe prevalence of PHT was significantly higher in HD patients (51.2% vs. 22.7%). Dialysis patients with PHT had a significantly higher prevalence of severe VCs (SVCS≥3). In multivariate analysis, the presence of severe VCs [odds ratio (OR), 2.68], mitral valve disease (OR, 7.79), HD (OR, 3.35), and larger left atrial diameter (OR, 11.39) were independent risk factors for PHT. In addition to the presence of anemia, severe VCs, or older age, the presence of PHT was an independent predictor of major cardiovascular events in ESRD patients. ConclusionThe prevalence of PHT was higher in HD patients and was associated with higher rates of major cardiovascular events. Severe VCs are thought to be an independent risk factor for predicting PHT in ESRD patients. Therefore, in dialysis patients with PHT, careful attention should be paid to the presence of VCs and the occurrence of major cardiovascular events.

A2-4: Declining Rates of Major Cardiovascular Events in Adults With and Without Diabetes: 2005-2011

Background/Aims A major goal of diabetes care is the prevention of major cardiovascular events (CVE). Its success can be measured by quantifying trends over time in major CVE in adults with and without diabetes. To quantify trends in occurrence of major CVE in adults with and without diabetes who received care at 11 U.S. managed care organizations from 2005 to 2011.

Ankle-brachial index in coronary artery disease

Dear Editor, We have read the article “Ankle-brachial index as a predictor of coronary disease events in elderly patients submitted to coronary angiography” by Eduardo D. E. Papa et al. (1). These authors aimed to evaluate the value of the ankle-brachial index (ABI) as a marker of cardiovascular events in elderly patients and to evaluate the relationship between the ABI and the extent of coronary artery disease (CAD), as documented by coronary angiography. They demonstrated that in elderly patients with documented coronary disease, a low ABI (<0.9) was associated with the severity and extent of CAD. Additionally, at late follow-up appointments, a low index was correlated with an increase in the occurrence of major cardiovascular events. This study was interesting and relatively well presented. However, there are certain essential points that must be further discussed. An abnormal ABI is not only a valuable diagnostic tool for peripheral arterial disease but also a predictor of generalized atherosclerosis (2). However, although the ABI provides several benefits (i.e., it is relatively simple, noninvasive and inexpensive) and is more than 90% sensitive and specific compared with angiography, it has certain limitations. Approximately 10% of the population lacks the dorsalis pedis or posterior tibial artery, meaning that their ABI cannot be accurately measured. Additionally, the ABI is not precise in noncompressible pedal arteries, which may be found in diabetic and elderly patients (3). In addition, certain medications, such as antihypertensive treatments, antiplatelet drug therapies and statins, may influence ABI parameters (4). For this reason, the results might have been different if the authors had mentioned these factors in their study. Furthermore, the extent of CAD was evaluated by calculating the number of vessels involved; CAD was uniarterial when there was an isolated lesion in one coronary artery and multiarterial when lesions were present in two or more vessels. Previously, the extent of CAD was evaluated based on many other calculations. However, the syntax score (SS) has been accepted as the true method for grading coronary complexity based on visual angiographic assessment. The addition of clinical risk factors to the SS has been shown to potentially further augment its utility for objective evaluation of patients with severe CAD (5). ABI deterioration is indeed associated with higher mortality in CAD patients, as presented in this study. However, it should be kept in mind that although the ABI is the easiest, most inexpensive, most reliable, least invasive and most widely available marker among the tested tools and can predict the mortality rate, further studies should discuss ABI-related factors (6).

Low Vitamin D as a Risk Factor for the Development of Myalgia in Patients Taking High-Dose Simvastatin: A Retrospective Review

BackgroundStatins are the treatment of choice for dyslipidemia, primarily lowering elevated LDL-C levels and reducing the occurrence of major cardiovascular events. In June 2011, the Food and Drug Administration issued a warning regarding the use of high-dose simvastatin 80 mg and its risk of myopathy. ObjectiveThe incidence of myalgia, myopathy, and rhabdomyolysis was analyzed in a veteran population prescribed simvastatin 80 mg. Risk factors for myalgia were examined and compared with the results of recently published studies. MethodsThis was a retrospective medical record review of 450 patients who were prescribed simvastatin 80 mg at the Veterans Affairs Western New York Healthcare System between August 1, 2006, and July 31, 2011. Records were examined for evidence of myalgia, myopathy (incipient or definite), and rhabdomyolysis. Variables that may have contributed to the development of myalgia were also collected and analyzed. ResultsMyalgia was reported by 50 patients (11.1%), whereas rhabdomyolysis developed in 1 patient (0.22%). No patient fit the criteria for myopathy (incipient or definite). Myalgia was statistically more likely to occur in younger patients, patients with a history of myalgia, and patients with low vitamin D levels. The mean (SD) vitamin D level in patients experiencing myalgia was 26.2 (12.9) versus 36.3 (11.8) ng/mL. The 25-hydroxyvitamin D level in those who reported myalgia was approximately 10 ng/mL lower compared with those who tolerated simvastatin 80 mg (P = 0.0003). There was no statistically significant association between length of therapy and development of myalgia. ConclusionA lower incidence of adverse muscle events with high-dose simvastatin 80 mg was found in patients with higher vitamin D levels, suggesting that correction of 25-hydroxyvitamin D levels before statin therapy initiation may mitigate one risk factor in the development of statin-related myalgia. Vitamin D insufficiency appears to be a risk factor for the development of myalgia.

Atherogenic dyslipidemia and residual cardiovascular risk in statin-treated patients.

Treatment with statins reduces the rate of cardiovascular events in high-risk patients, but residual risk persists. At least part of that risk may be attributable to atherogenic dyslipidemia characterized by low high-density lipoprotein cholesterol (≤40 mg/dL) and high triglycerides (triglycerides≥150 mg/dL). We studied subjects with stroke or transient ischemic attack in the Prevention of Cerebrovascular and Cardiovascular Events of Ischemic Origin With Terutroban in Patients With a History of Ischemic Stroke or Transient Ischemic Attack (PERFORM; n=19,100) and Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL; n=4731) trials who were treated with a statin and who had high-density lipoprotein cholesterol and triglycerides measurements 3 months after randomization (n=10,498 and 2900, respectively). The primary outcome measure for this exploratory analysis was the occurrence of major cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death). We also performed a time-varying analysis to account for all available high-density lipoprotein cholesterol and triglyceride measurements. A total of 10% of subjects in PERFORM and 9% in SPARCL had atherogenic dyslipidemia after ≥3 months on start statin therapy. After a follow-up of 2.3 years (PERFORM) and 4.9 years (SPARCL), a major cardiovascular event occurred in 1123 and 485 patients in the 2 trials, respectively. The risk of major cardiovascular events was higher in subjects with versus those without atherogenic dyslipidemia in both PERFORM (hazard ratio, 1.36; 95% confidence interval, 1.14-1.63) and SPARCL (hazard ratio, 1.40; 95% confidence interval, 1.06-1.85). The association was attenuated after multivariable adjustment (hazard ratio, 1.23; 95% confidence interval, 1.03-1.48 in PERFORM and hazard ratio, 1.24; 95% confidence interval, 0.93-1.65 in SPARCL). Time-varying analysis confirmed these findings. The presence of atherogenic dyslipidemia was associated with higher residual cardiovascular risk in PERFORM and SPARCL subjects with stroke or transient ischemic attack receiving statin therapy. Specific therapeutic interventions should now be trialed to address this residual risk.

Abstract 9337: Zofenopril is Cost Effective for Treatment of Patients With Left Ventricular Systolic Dysfunction After Acute Myocardial Infarction: A Post- Hoc Analysis of the SMILE-4 Study

Background and objective: in the Survival of Myocardial Infarction Long-term Evaluation 4 Study (SMILE-4) zofenopril associated with ASA was superior to ramipril plus ASA in reducing the occurrence of major cardiovascular events, in patients with left ventricular dysfunction (LVD) following acute myocardial infarction (AMI). The present post-hoc analysis was performed to evaluate cost-effectiveness of zofenopril compared to ramipril. Methods: a total of 771 patients with LVD and AMI were randomized double-blind to zofenopril 60 mg/day (n=389) or ramipril 10 mg/day (n=382) plus ASA 100 mg/day and followed-up for 1 year. The primary study end-point was 1-year combined occurrence of death or hospitalization for cardiovascular causes. The economic analysis was based on the evaluation of cost of medications and hospitalizations and was applied to the intention-to-treat population (n=716). Cost data were drawn from the National Health Service databases of the European countries participating into the study. The incremental cost-effectiveness ratio (ICER) was used to quantify the cost per event prevented with zofenopril vs. ramipril. Results: zofenopril significantly (p=0.028) reduced the risk of the primary study end-point by 30% as compared to ramipril (95% confidence interval: 49%, 4%). The number needed to treat to prevent a major cardiovascular event with zofenopril was 13 less than with ramipril. The cost of drug therapies was higher with zofenopril (328.78 Euros per patient per year, n=365) than with ramipril (165.12 Euros per patient per year, n=351). The cost related to the occurrence of major cardiovascular events requiring hospitalization, averaged 4983.64 Euros for zofenopril and 4850.01 Euros for ramipril. The ICER of zofenopril vs. ramipril was 2125.45 Euros per event prevented (worst- and best-case scenario in the sensitivity analysis: 3590.09 and 3243.96 Euros, respectively). Conclusions: zofenopril is a viable and cost-effective treatment for managing patients with LVD after AMI.

Zofenopril is a cost-effective treatment for patients with left ventricular systolic dysfunction following acute myocardial infarction: a pharmacoeconomic analysis of the SMILE-4 study

Objective: The Survival of Myocardial Infarction Long-term Evaluation 4 Study (SMILE-4) showed the superiority of Zofenopril (Z) associated with Acetylsalicylic Acid (ASA) as respect to Ramipril (R) plus ASA in reducing the occurrence of major cardiovascular events, in patients with left ventricular dysfunction (LVD) following Acute Myocardial Infarction (AMI). The objective of this retrospective analysis was the evaluation of cost-effectiveness of Z compared to R. Methods: 771 patients with LVD and AMI were randomized, double-blind to Z 60 mg/day (n=389) or R 10 mg/day (n=382) plus ASA 100 mg/day and followed-up for 1 year. The primary study end-point was 1-year combined occurrence of death or hospitalization for cardiovascular causes. The economic analysis was based on the evaluation of cost of medications and hospitalizations and was applied to the intention-to-treat population (n=716). Cost data were drawn from the database of the Italian National Health Service. The Incremental Cost-Effectiveness Ratio (ICER) was used to quantify the cost per event prevented with Z vs. R. Results: Z significantly (p=0.028) reduced the risk of the primary study end-point by 30% as compared to ramipril (95% confidence interval: 49%, 4%). The number needed to treat to prevent a major cardiovascular event with Z was 13 less than with R. The cost of drug therapies was higher with Z (313.90 Euros per patient per year, n=365) than with R (160.60 Euros per patient per year, n=351). The cost related to the occurrence of major cardiovascular events requiring hospitalization, averaged 3195.47 Euros for Z and 3071.37 Euros for R. The ICER of Z vs. R was 1990.88 Euros per event prevented. Conclusions: Z is a viable and cost-effective treatment for managing patients with LVD after AMI.

Risk stratification in patients with stable angina pectoris - adenosine perfusion cardiac magnetic resonance serves as an excellent tool concerning long-term prediction of severe clinical endpoints

Purpose: Objective was to assess the hypothesis that cardiac magnetic resonance (CMR) myocardial perfusion imaging is able to provide prognostic value regarding the prediction of major cardiovascular events in patients presenting with stable angina pectoris. Therefore, a large, consecutive and thereby unselected cohort of patients who underwent stress CMR has been followed up to clarify the incremental prognostic benefit over other conventional risk factors. Methods: From 2003 to 2007 consecutive patients with stable angina pectoris who were referred for adenosine perfusion CMR were enrolled unless they exhibited the predefined exclusion criteria. Myocardial perfusion imaging by adenosine-stress and late gadolinium enhancement were assessed in a 1.5 T whole-body CMR-scanner. Follow-up information concerning the combined endpoint cardiac death, non-fatal myocardial infarction and stroke was gotten from the patient, the general practitioner or the treating hospital, respectively. Results: 1,229 consecutive patients were enrolled in our study. During the mean follow-up period of 4.2±2.1 years, 88 primary endpoints could be observed. Patients with a reversible perfusion deficit held significantly more cardiac deaths (p<0.0001) and non-fatal myocardial infarction (p=0.001) than patients without. Performing univariate and multivariate testing, we were able to demonstrate that the presence of a reversible perfusion deficit has to be considered as the strongest independent predictor for an adverse event with a 3-fold increased risk (Hazard ratio 2.99). Moreover, the absence of a perfusion deficit has shown to exhibit a high negative predictive value. Conclusion: In patients with stable angina pectoris, the presence of a reversible perfusion deficit diagnosed by adenosine perfusion CMR goes along with a significant higher risk concerning the occurrence of major cardiovascular events. We could demonstrate that the presence of a reversible perfusion deficit is a strong and independent variable that provides incremental information over other conventional risk factors.

Cost-effectiveness of zofenopril in patients with left ventricular systolic dysfunction after acute myocardial infarction: a post hoc analysis of SMILE-4

BackgroundIn SMILE-4 (the Survival of Myocardial Infarction Long-term Evaluation 4 study), zofenopril + acetylsalicylic acid (ASA) was superior to ramipril + ASA in reducing the occurrence of major cardiovascular events in patients with left ventricular dysfunction following acute myocardial infarction. The present post hoc analysis was performed to compare the cost-effectiveness of zofenopril and ramipril.MethodsIn total, 771 patients with left ventricular dysfunction and acute myocardial infarction were randomized in a double-blind manner to receive zofenopril 60 mg/day (n = 389) or ramipril 10 mg/day (n = 382) + ASA 100 mg/day and were followed up for one year. The primary study endpoint was the one-year combined occurrence of death or hospitalization for cardiovascular causes. The economic analysis was based on evaluation of cost of medications and hospitalizations and was applied to the intention-to-treat population (n = 716). Cost data were drawn from the National Health Service databases of the European countries participating in the study. The incremental cost-effectiveness ratio was used to quantify the cost per event prevented with zofenopril versus ramipril.ResultsZofenopril significantly (P = 0.028) reduced the risk of the primary study endpoint by 30% as compared with ramipril (95% confidence interval, 4%–49%). The number needed to treat to prevent a major cardiovascular event with zofenopril was 13 less than with ramipril. The cost of drug therapies was higher with zofenopril (328.78 Euros per patient per year, n = 365) than with ramipril (165.12 Euros per patient per year, n = 351). The cost related to the occurrence of major cardiovascular events requiring hospitalization averaged 4983.64 Euros for zofenopril and 4850.01 Euros for ramipril. The incremental cost-effectiveness ratio for zofenopril versus ramipril was 2125.45 Euros per event prevented (worst and best case scenario in the sensitivity analysis was 3590.09 and 3243.96 Euros, respectively).ConclusionZofenopril is a viable and cost-effective treatment for managing patients with left ventricular dysfunction after acute myocardial infarction.

Echocardiography to predict adverse cardiac and vascular events in patients with severe chronic kidney disease (stage 4): A prospective study

Cardiovascular disease is the primary cause of mortality and morbidity among patients with chronic kidney disease. To investigate whether echocardiography can predict the occurrence of major cardiovascular events in patients with severe chronic kidney disease. Patients with stable stage 4 chronic kidney disease (estimated glomerular filtration rate 15-29 mL/min/1.73 m(2)) and followed in the nephrology department were included. Clinical, biological, electrocardiographic and echocardiographic data were recorded. Endpoint was defined as fatal or non-fatal cardiovascular event (acute coronary syndrome, acute heart failure, stroke, sustained ventricular arrhythmias, arterial thrombotic events and death). We included 71 patients (46 men); mean age 72±14 years. Mean glomerular filtration rate was 21.9±4.8 mL/min/1.73 m(2). Over a mean follow-up of 258±30 days, 18 (25%) patients reached endpoint (death in 7/18). Male sex, blood urea, atrial fibrillation, Sokolow index, left atrial size, pulmonary arterial pressure, indexed left ventricular mass and protodiastolic peak velocity of transmitral Doppler flow were significantly higher whereas left ventricular ejection fraction was significantly lower in these patients. By multivariable analysis, blood urea and left ventricular ejection fraction remained predictive of major cardiovascular event with odds ratios of 1.10 (95% confidence interval 1.02-1.18) and 0.93 (95% confidence interval 0.89-0.97), respectively. The negative predictive value was 95% when left ventricular ejection fraction was>50% with blood urea<15 mmol/L. Patients with stage 4 chronic kidney disease are at high risk of major cardiovascular events and death. Echocardiographic evaluation is effective in identifying patients at highest risk of adverse cardiac events.

Benefits of Early Hypertension Control on Cardiovascular Outcomes in Patients With Diabetes

OBJECTIVETo assess the impact of early hypertension (HT) control on occurrence of subsequent major cardiovascular events in those with diabetes and recent-onset HT.RESEARCH DESIGN AND METHODSStudy subjects were 15,665 adults with diabetes but no diagnosed coronary or cerebrovascular disease at baseline who met standard criteria for new-onset HT. Poisson regression models assessed whether adequate blood pressure control within 1 year of HT onset predicts subsequent occurrence of major cardiovascular events with and without adjustment for baseline Framingham Risk Score (FRS) and other covariates.RESULTSMean age was 51.5 years, and mean blood pressure at HT onset was 136.8/80.8 mmHg. In the year after HT onset, mean blood pressure decreased to 131.4/78.0 mmHg and was <130/80 mmHg in 32.9% of subjects and <140/90 mmHg in 80.2%. Over a mean follow-up of 3.2 years, age-adjusted rates of major cardiovascular events in those with mean 1-year blood pressure measurements of <130/80, 130–139/80–89, and ≥140/90 mmHg were 5.10, 4.27, and 6.94 events/1,000 person-years, respectively (P = 0.004). In FRS-adjusted models, rates of major cardiovascular events were significantly higher in those with mean blood pressure ≥140/90 mmHg in the first year after HT onset (rate ratio 1.30 [95% CI 1.01–1.169]; P = 0.04).CONCLUSIONSFailure to adequately control BP within 1 year of HT onset significantly increased the likelihood of major cardiovascular events within 3 years. Prompt control of new-onset HT in patients with diabetes may provide important short-term clinical benefits.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Impact of cytochrome P450 2C19*2 polymorphism on the clinical cardiovascular events after stent implantation in patients receiving clopidogrel of a southern Tunisian region

Introduction: The concept of clopidogrel resistance, first described in biology is being strengthened by recent data from clinical epidemiology. The cardiologists have been sensitized to this concept because of its possible involvement in the occurrence of coronary stent thrombosis. Purpose of the study: The purpose of this study was to investigate the genetic variant of the gene CYP 2C19 inour population and to assess the involvement of this genetic profile in the occurrence of major cardiovascular events (MACE) during the follow-up period. Methods: Our prospective study was conducted between May 2009 and September 2010 including 100 patients admitted to the cardiology department for percutaneous coronary stenting. The patients were divided into 2 groups: those with at least one CYP2C19*2 allele (*2 carriers) and non-carriers. Results: The mean age of our patients was 56.7 years ± 10, 5. No remarkable differences in the baseline characteristics were noted between the two groups. The prevalence of CYP2C19*2 allele in our population was 11.5%. Hospital mortality was estimated at 3%. No statistically significant differences were noted between the two groups regarding the occurrence of intra hospital MACE. The mean follow up was 7.5 ± 4.87 months for the entire study population. The rate of MACE during the follow-up of patients receiving clopidogrel was 8.2% throughout the study population: 5.3% in the *2 non-carriers versus 18.2% in the *2 carriers with a statistically significant difference (p = 0.075) at the risk of error of 10%. Concerning the occurrence of stent thrombosis, there was no significant statistical difference between the two study groups. Conclusion: From these results it is suggested that CYP2C19*2 polymorphism is associated with increase in the occurrence of MACE among Tunisian patients receiving clopidogrel. A larger study is needed to assess the role of genotyping in the evaluation of the phenomenon of clopidogrel resistance.

Clinical Significance of Histological Features of Thrombi in Patients with Myocardial Infarction

BackgroundPercutaneous Coronary Intervention (PCI) is the most common strategy for the treatment of Acute ST segment elevation Myocardial Infarction (STEMI), and thromboaspiration has been increasingly utilized for removal of occlusive thrombi.ObjectivesTo analyze the influence of histopathological features of coronary thrombi in clinical outcomes of patients with STEMI, and the association of these variables with clinical, angiographic, and laboratory features and medications used in hospitalization.MethodsProspective cohort study. All patients were monitored during hospitalization and thirty days after the event. Aspirated thrombi were preserved in formalin and subsequently stained with hematoxylin-eosin and embedded in paraffin. Thrombi were classified as recent and old. The primary outcome was the occurrence of major cardiovascular events within thirty days.ResultsDuring the study period, 1,149 patients were evaluated with STEMI, and 331 patients underwent thrombi aspiration, leaving 199 patients available for analysis. It was identified recent thrombi in 116 patients (58%) and old thrombi in 83 patients (42%). Recent thrombi have greater infiltration of red blood cells than old thrombi (p = 0.02), but there were no statistically significant differences between other clinical, angiographic, laboratory, and histopathological features and medications in both group of patients. The rates of clinical outcomes were similar in both groups.ConclusionsRecent thrombi were identified in 58% of patients with STEMI and it was observed an association with infiltration of red blood cells. There was no association between histopathological features of thrombi and clinical variables and cardiovascular outcomes.

NOS3 894G>T Polymorphism is Associated With Progression of Kidney Disease and Cardiovascular Morbidity in Type 2 Diabetic Patients: NOS3 as a Modifier Gene for Diabetic Nephropathy?

Background/Aims: We have previously associated SNP 894G>T in the NOS3 gene with diabetic nephropathy (DN) using multi-locus analysis. Variant 894G>T has been widely studied as a DN susceptibility factor with contradictory results. In the present study we genotyped 894G>T in the cohort of prospectively followed type 2 diabetics with the aim to investigate its possible role in the progression of DN and development of morbidity and mortality associated with diabetes. Methods: 311 subjects with defined stage of DN were enrolled in the study and followed up for a median of 38 months. We considered three end-points: progression of DN, major cardiovascular event and all-cause mortality. Results: Considering baseline GFR, age at enrolment and diabetes duration as confounders, Cox regression analysis identified 894GT genotype as a risk factor for DN progression (HR = 1.843 [95% CI 1.088 - 3.119], P = 0.023) and 894TT genotype as a risk factor for major cardiovascular event (HR = 2.515 [95% CI 1.060 - 5.965], P = 0.036). Conclusion: We ascertained the significant effect of the NOS3 894G>T variant on DN progression and occurrence of major cardiovascular event in T2DM subjects. Based on these results NOS3 can be considered a modifier gene for DN.

Ankle-brachial index as a predictor of coronary disease events in elderly patients submitted to coronary angiography

OBJECTIVES:To correlate the importance of the ankle-brachial index in terms of cardiovascular morbimortality and the extent of coronary arterial disease amongst elderly patients without clinical manifestations of lower limb peripheral arterial disease.METHODS:We analyzed prospective data from 100 patients over 65 years of age with coronary arterial disease, as confirmed by coronary angiography, and with over 70% stenosis of at least one sub-epicardial coronary artery. We measured the ankle-brachial index immediately after coronary angiography, and a value of <0.9 was used to diagnose peripheral arterial disease.RESULTS:The patients' average age was 77.4 years. The most prevalent risk factor was hypertension (96%), and the median late follow-up appointment was 28.9 months. The ankle-brachial index was <0.9 in 47% of the patients, and a low index was more prevalent in patients with multiarterial coronary disease compared to patients with uniarterial disease in the same group. Using a bivariate analysis, only an ankle-brachial index of <0.9 was a strong predictive factor for cardiovascular events, thereby increasing all-cause deaths and fatal and non-fatal acute myocardial infarctions two- to three-fold.CONCLUSION:In elderly patients with documented coronary disease, a low ankle-brachial index (<0.9) was associated with the severity and extent of coronary arterial disease, and in late follow-up appointments, a low index was correlated with an increase in the occurrence of major cardiovascular events.

Ustekinumab y seguridad cardiovascular

Patients with psoriasis have an increased risk of cardiovascular events, and there is evidence of a correlation between the immune processes that occur in psoriasis and those seen in other chronic inflammatory disorders such as atheromatous disease. The occurrence of major cardiovascular events in patients with plaque psoriasis being treated with ustekinumab caused alarm among some researchers, but a thorough analysis of the findings to date has confirmed the cardiovascular safety of this agent.

Preanalytic conditions of the C-reactive protein are of paramount importance to use as a predictor of cardiovascular disease in clinical practice

We read the article by Wu et al. [1] about of the intra-individual variability of high-sensitivity C-reactive protein (hsCRP) in a cohort of Chinese adults. They recruited a large population (44,140 males and 12,078 females) inwhich blood samples were obtained during morning. The authors conclude that the age and gender are factors that influenced the hsCRP level. However, in the present article we saw an additional potential limitation of the study: they have not determined the hsCRP along a 24-hour period to eliminate the possible influence of circadian rhythms. Many epidemiological studies have demonstrated that hsCRP, a biomarker of inflammation, is an important prognostic factor for the future occurrence of major cardiovascular events, both in patients with known cardiovascular disease and apparently in healthy subjects [2,3]. The 2009 National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines included and endorsed the use of hsCRP as a novel means by which to identify individuals who are at risk for vascular disease [4]. Circulating biomarkers are subject to variability arising from sampling procedures andbiologic variation, and this variabilitymust be determined and adjusted for in the interpretation of laboratory results. Diurnal variation may be an important source of heterogeneity or bias, and standardization for sampling time may be important in populationbased studies, as well as, in using these variables for additional coronary heart disease risk prediction in individuals [5–8]. The available data on diurnal variations of hsCRP levels in healthy subjects are few and controversial. We have demonstrated absence of diurnal variation of hsCRP levels, when blood samples were collected at 9:00 AM (light period) and 2:00 AM (dark period) from 70 healthy subjects [9]. Previously, Meier-Ewert and colleagues found no diurnal variation in hsCRP samples that were taken hourly from 13 healthy subjects [10]. In other study of hsCRP, D-dimer, tissue plasminogen activator, and von Willebrand factor in a middle-aged population showed diurnal variation as high as 34% in hsCRP, with maximum hsCRP levels observed at 3:00 PM. However, that study was limited in that hsCRP was measured between 9:00 AM and 10:00 PM [11]. Moreover, recently Koc and colleagues [12] demonstrated a variation of 86% of hsCRP in 30 subjects who had normal coronary arteries at 6hour intervals over 24-hour period. Wu et al. have discussed in their manuscript that the age and environmental variables, such as lipid levels, blood pressure, obesity and diabetesmellitus can contribute to the variation of hsCRP [1,13]. However, with the items mentioned above, we believe that the diurnal variation should be taken into account as a control variable in multivariate regression models. In summary, hsCRP represents the most extensively studiedproinflammatorymolecule, but additional effort is requiredon the part of the investigators to manage standardization of methodology and to determine cost-effective timing and frequency of measurements. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology (Shewan and Coats 2010;144:1–2).

Valor prognóstico da troponina I de alta sensibilidade versus troponina T nas síndromes coronarianas agudas

Despite superior diagnostic accuracy of high-sensitivity cardiac troponins, their prognostic value has not been validated against conventional cardiac troponins. To test the prognostic value of high-sensitivity cardiac troponin I (hs-cTnI), compared with conventional cardiac troponin T (cTnT) in the setting of non-ST elevation acute coronary syndromes. At hospital admission, a plasma sample was collected from 103 consecutive patients with unstable angina or non-ST elevation acute myocardial infarction. In this sample, troponin was measured both by hs-cTnI and cTnT methods. Their prognostic value was compared as to the occurrence of major cardiovascular events, defined as a combination of death, nonfatal acute myocardial infarction or refractory unstable angina during hospitalization. During median hospitalization of 8 days (interquartile range = 5 - 11), the incidence of cardiovascular events was 10% (5 deaths, 3 non-fatal myocardial infarctions and 2 non-fatal refractory anginas). High-sensitivity troponin I significantly predicted cardiovascular events, with a C-statistics of 0.73 (95% CI = 0.59 - 0.87), similarly to cTnT (0.70; 95% CI = 0.55 - 0.84) - P = 0.75. The definition of positive cardiac marker that provided the best prognostic accuracy was hs-cTnI > 0.055 µg/L and cTnT > 0.010 µg/L, with equal sensitivity of 90% and specificity of 52% for both assays. Positive hs-cTnI was associated with 17% incidence of events, compared with 2% in patients with negative hs-cTnI (P = 0.02). High-sensitivity troponin I predicts cardiovascular events similarly to conventional troponin T in the setting of non-ST-elevation ACS.

A cost-utility analysis of hypertension treatment in Greece

To assess the cost-utility of hypertension treatment versus a hypothetical 'no-treatment' strategy in Greece. A six-state Markov model simulated the occurrence of major cardiovascular events for hypertensive patients over a 20-year period. Baseline population consisted of a cohort of 1453 patients (46.92% men) that were followed up for a 1-year period, during which health-resource use and clinical characteristics of hypertension were documented. Age, sex and smoking status - specific transition probabilities in the model - were estimated via the HellenicSCORE and Framingham risk equations. The analysis followed a third-party payer perspective. Incremental cost-effectiveness ratios (ICERs) of treatment versus no treatment were 3539&OV0556;/quality-adjusted life year (QALY), 3986&OV0556;/QALY, 3957&OV0556;/QALY and 5485&OV0556;/QALY gained for men smokers, men nonsmokers, women smokers and women nonsmokers, respectively. ICERs became more favorable with an increase in the years of treatment and advanced age of treatment initiation across all study groups. The probabilistic sensitivity analysis showed that the base-case scenario results were cost-effective for an implicit 30 000&OV0556;/QALY threshold at 97.4, 95.2, 94.8, and 86% of the 10 000 Monte Carlo simulations for men smokers, men nonsmokers, women smokers and women nonsmokers, respectively. In the case of hypertension, one of the most prevalent and modifiable diseases/risk factors, that is accompanied by large-scale costs, the above analysis demonstrates that treatment is a highly cost-effective intervention that should be further supported at the patient and the system level.