Prior Cardiovascular Events Research Articles

Non-stenotic echolucent ultrasound-assessed femoral artery plaques are predictive for future cardiovascular events in middle-aged men

Objectives: The aim of the present study was to examine the relationship between plaque occurrence, plaque size and plaque echogenicity, assessed by B-mode ultrasound, in the femoral artery and the development of clinical cardiovascular disease. Background: The relationship between carotid atherosclerosis assessed by B-mode ultrasound and cardiovascular disease has been thoroughly investigated. In comparison, the femoral arteries have received much less attention. Methods: The femoral artery was examined by high-resolution B-mode ultrasound in 391, 58-year-old men identified by screening in the city of Göteborg, Sweden. Assessment of plaque occurrence, plaque size (no, small, or moderate/large) and plaque characteristics in terms of echogenicity (no, echogenic or echolucent) were performed. Results: Subjects with a plaque present in the femoral artery at study baseline had a three-fold increase in odds ratio (OR 3.04, 95%, CI 1.24–7.42) for having a cardiovascular event during 6.6 years of follow-up compared to subjects without plaque. After adjustment for cardiovascular risk factors (LDL, triglycerides, systolic blood pressure and smoking) there was a borderline significant association between plaque occurrence and cardiovascular disease (OR = 2.64, p = 0.055). Plaque size could be demonstrated to be associated with cardiovascular events ( p = 0.012, for trend). The results also showed that in this group of men, the risk of having a cardiovascular event was to a large extent confined to those with an echolucent plaque at baseline. However, no significant difference in risk prediction was seen between echogenic and echolucent plaques, respectively. Conclusions: This is the first study to show that the presence of non-stenotic plaques in the femoral artery in middle-aged men without prior cardiovascular events has a predictive value for future cardiovascular events. The relationship was attenuated by adjustment for traditional cardiovascular risk factors. Data also indicates that plaque echolucency predicts increased risk.

Global Cardiovascular Risk

Atherosclerosis is a multifactorial disease. This is supported by a large body of clinical and experimental data collected during the last 30 years, either in observational or in interventional clinical trials. During these years, a large number of risk factors and clinical conditions, closely related to the development of atherosclerosis, have been identified. The most relevant risk factors for cardiovascular disease are hyperlipidaemia, arterial hypertension, diabetes mellitus, cigarette smoking and family history.Cardiovascular risk factors interact with each other in a complex, and not fully elucidated fashion, contributing to the definition of a 'global cardiovascular risk profile'. Thus, the cardiovascular risk profile must be evaluated (through algorithms or risk charts) for each individual. Patients presenting with multiple cardiovascular risk factors have a higher risk of developing a major cardiovascular event, and in these patients a strict control of risk factors leads to an effective prevention of cardiovascular disease.In this latter regard, hypercholesterolemia deserves a 'dynamic' role. The most recent guidelines for the management of patients with hyperlipidaemia underscore the need for a more strict metabolic control in patients with prior cardiovascular events (secondary prevention), and also in patients with no evidence of cardiovascular disease (primary prevention), in which the concomitant presence of multiple risk factors or diabetes confers a high risk (e.g. patients with previous myocardial infarction or stroke).

Predictors of “lost-to-follow-up” status in the convince trial

The Controlled ONset Verapamil INvestigation of Cardiovascular Endpoints (CONVINCE) Trial randomized 16,602 hypertensive volunteers from 15 countries to initial antihypertensive therapy with either Controlled-Onset, Extended Release (COER)-verapamil or “Standard of Care” (SOC), a physician-directed choice of atenolol or hydrochlorothiazide (HCTZ). The primary outcome (PO) was the first occurrence of myocardial infarction, stroke, or cardiovascular disease-related death. Median follow-up was 3 years. Substantial efforts were made at the end of the study to ascertain the PO status of every volunteer, but were unsuccessful for 1113 volunteers. A Cox model was developed to identify characteristics associated with an increased risk of having unknown PO status; all risk factors were entered simultaneously into the model. The results were: Other baseline parameters, including SOC choice (atenolol v. HCTZ), gender, diabetes, left ventricular hypertrophy, dyslipidemia, obesity, and vascular disease, were not significant predictors of having unknown PO status at the end of the study. As in prior international hypertension trials, volunteers from the USA were significantly more likely to become lost. Those who were lost were more commonly minorities, older, tobacco users, and had higher baseline systolic BPs as well as prior cardiovascular events. These data indicate that, in CONVINCE, higher risk volunteers were more likely to become lost-to-follow-up. This should increase the number of unreported events beyond that expected if volunteers became lost at random. (See Table)

Compliance with National Cholesterol Education Program dietary and lifestyle guidelines among older women with self-reported hypercholesterolemia: The Women’s Health Initiative

PurposeDietary therapy remains the first line of treatment for patients with high blood cholesterol levels. Among free-living persons, compliance with National Cholesterol Education Program (NCEP) dietary recommendations is uncertain. Subjects and methodsWe performed a cross-sectional, baseline analysis of 91,627 postmenopausal women enrolled in the Women’s Health Initiative Observational Study. Among women with self-reported hypercholesterolemia, we ascertained factors associated with compliance with National Cholesterol Education Program dietary recommendations, defined for the Step II diet as ≤30% of total calories from fat, <7% of calories from saturated fat, and daily dietary cholesterol <200 mg. ResultsOf the 13,777 participants who reported having high cholesterol levels requiring drug therapy, only 20% reported total fat, saturated fat, and dietary cholesterol consumption consistent with Step II dietary goals. Factors associated with Step II dietary compliance included having a college degree (odds ratio [OR] = 1.26; 95% confidence interval [CI]: 1.14 to 1.40), a prior cardiovascular event (OR = 1.48; 95% CI: 1.28 to 1.70), and consumption of five or more daily servings of fruits or vegetables (OR = 3.0; 95% CI: 2.7 to 3.3). Being married, smoking, a sedentary lifestyle, and a higher body mass index were all associated with reduced compliance (all P <0.0001). In the subsample in which plasma lipid levels were measured, dietary compliance was associated with higher levels of low-density lipoprotein cholesterol (P = 0.02). ConclusionSince the inception of the NCEP in 1985, health care providers, public health programs, and patients have not successfully implemented the dietary recommendations.

The Importance of Health Insurance as a Determinant of Cancer Screening: Evidence from the Women's Health Initiative

Background. Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort.Methods. Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years.Results. Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening.Conclusions. In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.

Control of blood pressure and lifestyle-related risk factors in elderly Japanese hypertensive subjects.

The aim of this study was to analyze the treatment of elderly hypertensive patients by Japanese physicians specializing in hypertension. We enrolled 939 patients with hypertension who were treated in the outpatient clinics of 11 hospitals in 1995; 793 of these patients (388 men and 405 women; mean age, 66.6+/-9.0 years) received follow-up examinations in 1996, and the data on these patients was used for the present analysis. Blood pressure (BP), body mass index, lifestyle, and laboratory data were analyzed in all patients. The average BP was 143+/-16/81+/-10 mmHg in 1995 and 142+/-15/80+/-10 mmHg in 1996. The patients whose baseline BP was at the level of Grade 2 or 3 in the WHO-ISH classification (n=117) were characterized by a higher women-to-men ratio, higher age, a higher serum total cholesterol concentration, and higher QRS voltage. In these patients, from 1995 to 1996, the average BP significantly decreased, whereas fasting plasma glucose, serum total cholesterol and serum creatinine concentrations showed only negligible changes. In 220 patients (28%), BP was <140/<90 mmHg at both the initial and the follow-up examinations, whereas 351 patients (44%) were hypertensive in both 1995 and 1996. Thirty-three percent of the patients were smokers. More smokers than nonsmokers had had prior cardiovascular events, diabetes mellitus, or overt proteinuria. In conclusion, the average BP level among the patients treated by Japanese physicians specializing in hypertension was somewhat higher than that recommended by WHO-ISH Guidelines (1999). Patient education to control lifestyle-related risk factors, particularly to stop smoking, should be emphasized.

Platelet inhibitors and antioxidant vitamins in cardiovascular disease

Considerable research attention has focused on the possible roles of platelet inhibition, principally using aspirin, and antioxidant vitamins in reducing the risks of cardiovascular disease. Data from large-scale randomized trials indicate that aspirin reduces subsequent vascular events among patients with prior myocardial infarction, stroke, transient ischemic attacks, or unstable angina, as well as among patients with acute evolving myocardial infarction. In primary prevention trials, the Physicians' Health Study showed a clear benefit in decreasing risk of a first myocardial infarction in men; the data on stroke and total number of deaths from vascular causes are inadequate. The Women's Health Study, a trial now under way among apparently healthy women, will provide direct evidence on the balance of risks and benefits of aspirin in primary prevention. Antioxidant vitamins are hypothesized to decrease cardiovascular disease risk by several mechanisms, including inhibition of oxidation of low-density lipoprotein cholesterol and decreasing uptake into the coronary endothelium. Promising results have emerged from observational studies, which show that people with high intakes of antioxidant vitamins through diet or supplements have lowered risks of cardiovascular disease; however, unknown or unmeasured factors associated with high antioxidant vitamin intake may explain all or part of the observed associations. Randomized trials to provide reliable data are now ongoing among apparently healthy men and women, as well as among survivors of prior cardiovascular disease events.