Risk Of Future Cardiovascular Events Research Articles

Levels of Circulating Progenitor Cells, Cardiovascular Outcomes and Death: A Meta-Analysis of Prospective Observational Studies.

Circulating progenitor cells (CPCs), including endothelial progenitor cells (EPCs) are biologically related to many aspects of cardiovascular disease, as they promote angiogenesis and vascular repair. We herein aimed to meta-analyze studies reporting the prognostic role of the CPC/EPC measure on cardiovascular outcomes and death. We screened the English-language literature for longitudinal studies reporting the association between baseline CPC/EPC levels, future cardiovascular events, and death. We retrieved 28 studies, 21 of which contained poolable data and entered the meta-analysis, for a total of 4155 patients, mostly with a high baseline cardiovascular risk. Sixty percent of the studies met at least 11 of 16 items of quality assessment. Overall, reduced CPC/EPC levels were associated with a ≈2-fold increased risk of future cardiovascular events and cardiovascular death. The most predictive phenotype was CD34(+)CD133(+): low versus high levels predicted cardiovascular events, restenosis after endovascular intervention, cardiovascular death, and all-cause mortality. Heterogeneity among studies and according to the CPC/EPC phenotype was generally high. Excluding studies for which the risk estimate had to be extrapolated or limiting the analyses to higher quality studies still indicated a significant risk for future cardiovascular events and death in patients with low versus high progenitor cell counts. This meta-analysis shows that a reduction in the levels of circulating cells putatively provided with vasculoregenerative properties represents a risk factor for adverse cardiovascular outcomes and death.

Aortic augmentation index in endurance athletes: a role for cardiorespiratory fitness.

Endurance exercise improves cardiovascular health and reduces mortality risk. Augmentation index (AIx) reflects adverse loading exerted on the heart and large arteries and predicts future cardiovascular disease. The purpose of this study was to establish whether endurance athletes possess lower AIx and aortic blood pressure compared to healthy controls, and to determine the association between AIx and cardiorespiratory fitness. Forty-six endurance athletes and 43 healthy controls underwent central BP and AIx measurements by non-invasive applanation tonometry before a maximal exercise test. Peak oxygen uptake ([Formula: see text]) was assessed by pulmonary analysis. Relative to controls, athletes had significantly lower brachial diastolic blood pressure (BP, -4.8mmHg, p<0.01), central systolic BP (-3.5mmHg, p=0.07), and AIx at a heart rate of 75 beatsmin(-1) (AIx@75, -11.9%, p<0.001). No AIx@75 differences were observed between athletes and controls when adjusted for age and [Formula: see text] [athletes vs controls mean (%)±SE: -6.9±2.2 vs -5.7±2.3, p=0.76]. Relative to men with low [Formula: see text], those with moderate and high [Formula: see text] had lower age-adjusted AIx@75 (p<0.001). In women, those with high [Formula: see text] had lower AIx@75 than those with low and moderate [Formula: see text] (p<0.01). The lower AIx@75 in endurance athletes is partly mediated by [Formula: see text]. While an inverse relationship between AIx@75 and [Formula: see text] was found in men, women with the highest [Formula: see text] possessed lowest AIx@75 compared to females with moderate or poor cardiorespiratory fitness. We recommend aerobic training aimed at achieving a minimum [Formula: see text] of 45mlkg(-1)min(-1) to decrease the risk of future cardiovascular events and all-cause mortality.

Coronary Heart Disease, Diabetes, and Sexuality in Men.

Erectile dysfunction (ED) has been well recognized as a marker of increased cardiovascular risk for more than 15 years, especially in younger men. Early detection of ED represents an opportunity to intervene to decrease the risk of future cardiovascular events and limit the progression of ED severity. Evidence suggests there is a window of opportunity of 3 to 5 years from the onset of ED to subsequent cardiovascular events. This opportunity is usually missed if the onus is placed on the patient to seek care for his sexual problems. Unfortunately, these clear messages have not been incorporated into routine cardiovascular care. The reasons for these disparities within specialties are discussed in this article, in addition to management algorithms. Lifestyle modification is usually recommended as the first-line treatment to correct ED and lessen cardiovascular risk, but evidence suggests that this might be effective only in men without established cardiovascular comorbidities. In men with type 2 diabetes mellitus and established cardiovascular disease, lifestyle modification alone is unlikely to be effective. Cardiovascular medications are often associated with sexual dysfunction but changes in medication are more likely to be beneficial in men with milder recent-onset ED. A balanced view must be taken related to medication adverse events, taking into account optimal management of established cardiovascular disease. Testosterone deficiency has been associated with different metabolic disorders, especially metabolic syndrome and type 2 diabetes mellitus. Testosterone deficiency syndrome has been associated with an independent burden on sexual function globally and increased cardiovascular and all-cause mortality. Testosterone replacement therapy has been shown to improve multiple aspects of sexual function and, in some studies, has been associated with a decrease in mortality, especially in men with type 2 diabetes mellitus. Recent studies have suggested that phosphodiesterase type 5 inhibitors, the first-line medications to treat ED, could decrease cardiovascular and all-cause mortality, through multiple mechanisms, predominantly related to improved endothelial function.

Cardiovascular events after ischemic stroke in young adults: A prospective follow-up study.

To study the long-term risk of recurrent cardiac, arterial, and venous events in young stroke patients, and whether these risks differed between etiologic subgroups. The study population comprised 970 patients aged 15-49 years from the Helsinki Young Stroke Registry (HYSR) who had an ischemic stroke in 1994-2007. We obtained follow-up data until 2012 from the Finnish Care Register and Statistics Finland. Cumulative 15-year risks were analyzed with life tables, whereas relative risks and corresponding confidence intervals (CI) were based on hazard ratios (HR) from Cox regression analyses. There were 283 (29.2%) patients with a cardiovascular event during the median follow-up of 10.1 years (range 0.1-18.0). Cumulative 15-year risk for venous events was 3.9%. Cumulative 15-year incidence rate for composite vascular events was 34.0 (95% CI 30.1-38.2) per 1,000 person-years. When adjusted for age and sex, patients with an index stroke caused by high-risk sources of cardioembolism had the highest HR for any subsequent cardiovascular events (3.7; 95% CI 2.6-5.4), whereas the large-artery atherosclerosis group had the highest HR (2.7; 95% CI 1.6-4.6) for recurrent stroke compared with patients with stroke of undetermined etiology. The risk for future cardiovascular events after ischemic stroke in young adults remains high for years after the index stroke, in particular when the index stroke is caused by high-risk sources of cardioembolism or large-artery atherosclerosis.

Combined Oral Contraceptives Increase High-Sensitivity C-Reactive Protein but Not Haptoglobin in Female Athletes.

No studies have examined the effects of oral hormonal contraception on chronic low-grade inflammation as assessed by stratified levels of high-sensitivity C-reactive protein (hsCRP) in athletes. We explored the impact of combined oral contraceptives (OCs) on serum hsCRP, haptoglobin, triglycerides and cholesterol in white female athletes. Italian sportswomen (n=205; mean age 24±5.3years; body mass index 21±2.2kgm-2; sport activity 8.7±3.65hweek-1) were analyzed according to OC use. Progressive hsCRP levels were evaluated in OC users (n=53) compared to non-OC users (n=152). Levels of hsCRP from 3.0 to <10.0mgL-1 (at high risk of future cardiovascular events) were found in 26.4% (14/53) of OC users and only in 2.6% (4/153) of non-OC users (OR=13.3, 95% CI 4.14-42.6, P<0.001). Risky hsCRP levels ≥1.0mgL-1 were found in 62.3% of OC users versus 13.2% non-OC users (OR=10.9, 95% CI 5.26-22.5, P<0.001). Protective hsCRP levels (<0.5mgL-1) were found in 17.0% of OC users and in 64.5% of non-OC users (OR=0.11, 95% CI 0.05-0.25, P<0.001). OC use increased serum triglycerides (P<0.001), total cholesterol (P=0.027) and HDL cholesterol (P=0.018), whereas haptoglobin was unaffected. Hours of exerciseweek-1 had a mild inverse association with hsCRP (P=0.048) in non-OC users only. OC use markedly elevated chronic low-grade inflammation in athletes, which could predispose to a higher inflammatory response to physical stress and elevate cardiovascular risk. Physical activity without OC use seemed to favor low hsCRP. Further research is needed to extend our results and to elucidate the potential effects on athletic performance of chronically elevated hsCRP. Our findings would be useful for sport physicians interpreting blood tests in athletes.

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

BackgroundPatients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease.MethodsIn this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction.ResultsBy 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003).ConclusionsIn this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.)

CORONARY CALCIUM SCANS AND RADIATION EXPOSURE IN THE SOCIETY FOR HEART ATTACK PREVENTION AND ERADICATION COHORT

Coronary artery calcium (CAC) scoring is used in asymptomatic patients to improve their clinically predicted risk for future cardiovascular events. Exposure to radiation has been a valid concern to this patient population. Current CT protocols seek to reduce radiation exposure without diminishing

PD47-08 CORONARY ARTERY CALCIUM SCORE AND ASSOCIATION WITH RECURRENT NEPHROLITHIASIS: THE MULTI-ETHNIC STUDY OF ATHEROSCLEROSIS

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II1 Apr 2016PD47-08 CORONARY ARTERY CALCIUM SCORE AND ASSOCIATION WITH RECURRENT NEPHROLITHIASIS: THE MULTI-ETHNIC STUDY OF ATHEROSCLEROSIS Ryan Hsi, Andrew Spieker, Marshall Stoller, David Jacobs, Alex Reiner, Robyn McClelland, Arnold Kahn, Thomas Chi, Moyses Mzklo, and Mathew Sorensen Ryan HsiRyan Hsi More articles by this author , Andrew SpiekerAndrew Spieker More articles by this author , Marshall StollerMarshall Stoller More articles by this author , David JacobsDavid Jacobs More articles by this author , Alex ReinerAlex Reiner More articles by this author , Robyn McClellandRobyn McClelland More articles by this author , Arnold KahnArnold Kahn More articles by this author , Thomas ChiThomas Chi More articles by this author , Moyses MzkloMoyses Mzklo More articles by this author , and Mathew SorensenMathew Sorensen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2696AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Kidney stone disease is linked to systemic conditions including hypertension, obesity, diabetes mellitus, and coronary heart disease. Therefore, biologic pathways that result in coronary artery calcification may also lead to the development of nephrolithiasis. Subclinical coronary artery calcification (CAC) is an established predictor of cardiovascular events. CAC is quantified noninvasively by computed tomography, and the calculated CAC score reflects the presence and extent of atherosclerotic disease. While a history of kidney stones has been linked to subclinical carotid atherosclerosis, no study has examined its relationship with CAC. We studied the association between kidney stone history and prevalent CAC from the MESA study. METHODS The Multi-Ethnic Study of Atherosclerosis is a multi-site cohort study of participants aged 45-84 without known cardiovascular disease at baseline (2000-2002). At follow up in 2010-2012, 3,282 participants underwent computed tomography to determine CAC and had kidney stone history assessed by self-report. CAC scores were categorized as none, mild (<100), moderate (101-400), or severe (>400). A cross-sectional analysis was performed adjusting for demographic and dietary factors related to kidney stones. RESULTS Prevalence of kidney stone disease history was approximately 9%, mean age was 69.5±9.3 years, 39% of participants were Caucasian, 47% were men, and 69% had detectable (CAC score >0). Of the stone formers, 129 (44.6%) reported a history of 2 or more stones in the past. Mean±SD CAC score among non-stone formers and stone formers was 279±595 and 380±602, respectively. No difference in CAC score was seen between single stone formers and non-stone formers. Recurrent kidney stone formation was associated with moderate or severe CAC on multivariable logistic regression (versus none or mild CAC) (OR 1.80, 95% CI 1.22-2.67). When CAC scores were separated into none, mild, moderate, and severe CAC, recurrent stone formation was associated with higher CAC score category on multivariable ordinal logistic regression (OR per category 1.44, 95% CI 1.04- 2.01). CONCLUSIONS Recurrent kidney stone formation is associated with subclinical coronary atherosclerosis. This association appeared stronger with CAC severity than with CAC presence. The clinical significance of these findings is that a recurrent stone former, who has no prior cardiac history and is otherwise asymptomatic, may have higher levels of coronary calcification and be at risk for future cardiovascular events. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1173 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Ryan Hsi More articles by this author Andrew Spieker More articles by this author Marshall Stoller More articles by this author David Jacobs More articles by this author Alex Reiner More articles by this author Robyn McClelland More articles by this author Arnold Kahn More articles by this author Thomas Chi More articles by this author Moyses Mzklo More articles by this author Mathew Sorensen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Inaccurate risk perceptions contribute to treatment gaps in secondary prevention of cardiovascular disease.

All patients with cardiovascular disease (CVD) are at high risk of recurrent events. Despite strong evidence, large treatment gaps exist in CVD secondary prevention. We hypothesise that patients' self-perception and general practitioner's (GP) assessment of future cardiovascular (CV) risk may influence secondary prevention behaviours. To examine in patients with known CVD the perceived risk of future CV events and its relationship with use of secondary prevention medications and risk factor control. We examined patient and practitioner's perceived risk and its relationship with the uptake of secondary prevention recommendations in adults with CVD participating in the Australian Hypertension and Absolute Risk Study. Among the 1453 participants, only 11% reported having a high absolute risk and 29% reported high relative risk of recurrent events. The GP categorised only 30% as having a 5-year risk ≥15%. After adjusting for covariates, hospitalisation within the preceding 12 months was the only significant predictor of patients' accurate risk perception. Conventional CV risk factors were predictive of the GP's risk estimates. Patients who accurately understood their risk reported higher smoking cessation rates (7 vs 3%, P = 0.003) and greater use of antiplatelet, blood pressure lowering therapy and statins (P ≤ 0.01). However, there was no relationship between GP's risk perception and secondary prevention treatments. Both patients and GP have optimistic bias and underestimate the risk of future CV events. Patients' accurate self-perception, but not GP risk perception, was associated with improved secondary preventative behaviours. This suggests that helping patients to understand their risk may influence their motivation towards secondary prevention. Providing support to GP or programmes to help patients better understand their risks could have potential benefit on secondary prevention behaviours.

Circulating Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Predicts Future Risk of Cardiovascular Events Independently of Established Risk Factors.

The secreted protein proprotein convertase subtilisin/kexin type 9 (PCSK9) is a promising new target for lowering plasma low-density lipoprotein cholesterol and preventing cardiovascular disease (CVD). The relationship between circulating PCSK9 and incident CVD in the general population is unknown. We investigated whether serum PCSK9 concentration is associated with incident CVD in a prospective cohort study of 4232 men and women 60 years of age at the time of recruitment. Incident CVD was recorded by matching to national registries. After 15 years of follow-up, a total of 491 incident events (fatal and nonfatal myocardial infarctions, unstable angina, deaths from coronary heart disease, fatal and nonfatal ischemic strokes) were recorded. Cox proportional hazards model was used to calculate hazard ratios with 95% confidence intervals. Baseline serum PCSK9 concentration predicted incident CVD; concentration in quartile 4 compared with quartile 1 was associated with a hazard ratio of 1.69 (95% confidence interval, 1.30-2.19) after adjustment for sex. Further adjustment for low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, lipoprotein(a), triglycerides, hypertension, diabetes mellitus, smoking, overweight, obesity, physical inactivity, and statin use resulted in a decrease in the hazard ratio to 1.48 (95% confidence interval, 1.12-1.95). Serum PCSK9 concentration is associated with future risk of CVD even after adjustments for established CVD risk factors. Further studies are needed to confirm this observation.

The Role of the Myocardial Microvasculature in Mental Stress-Induced Myocardial Ischemia.

There is increasing evidence that mental stress can manifest as physical diseases. One such condition is mental stress-induced myocardial ischemia (MSIMI); a silent, transient, myocardial ischemic response to stressful conditions. We propose that the cardiac microvasculature may be an important site for the interplay between mental stress and MSIMI. This study is a review of the literature discussing the prevalence and emerging mechanisms underlying MSIMI. We identified several aspects underlying MSIMI, including psychological, genetic, and physiological causes. Several sources suggested that dysfunctional cardiac microvasculature might be a contributing factor in the development of stress-induced myocardial ischemia. The literature also suggested that although MSIMI has distinct features and pathophysiology, its occurrence might indicate an increased future risk of cardiovascular events. We found that dysfunctional cardiac microvasculature may be the key point of interaction between mental stress and transient myocardial ischemia and that the development of MSIMI might be a "silent" indicator for future cardiac events.

Capsule Commentary on Rana et al., Diabetes and Prior Coronary Heart Disease Are Not Necessarily Risk Equivalent for Future Coronary Heart Disease Events.

T he prevalence of diabetes mellitus (DM) has risen dramatically over the past decades as obesity rates have increased in the United States. Recent estimates suggest that approximately 9 % of the U.S. population, or over 29 million Americans, have DM, with the great majority having Type 2 DM. While cardiovascular disease is known to be the leading cause of death among those with diabetes, there has been controversy as to whether prevalent diabetes portends the same risk for future cardiovascular events as prevalent coronary heart disease (CHD). Delineating diabetes as a CHD equivalent or a CHD risk factor is critical to improving the accuracy of cardiovascular risk prediction and in developing tailored risk reduction strategies. Rana and colleagues analyzed electronic health record data from the Kaiser Permanente Northern California health care system, which includes over 1.5 million members. This study demonstrated that the risk of a CHD event over a 10-year follow-up period was significantly lower for those with diabetes alone as compared to those with prior CHD; these findings appear to refute previous data showing that prevalent diabetes is a CHD equivalent. Most interestingly, those with diabetes for the longest duration, or for ten or more years in the cohort, had a similar risk of CHD events as those with CHD alone. The findings are robust, given that much of the prior data examining diabetes as a CHD risk equivalent comes from metaanalyses with inherent methodologic limitations, and this study was done in a large, ethnically and racially diverse population from a real-world setting. Additionally, sex-stratified analyses of CHD event rates in this population help to identify whether CHD risk based on prevalent diabetes differs betweenmen andwomen. One area for future work with this study cohort would be to evaluate differences in CHD event rates across racial and ethnic groups among those with diabetes and/or CHD as compared to those without either disease. Overall, these findings support the use of outcomes data from diverse patient populations for creating and refining cardiovascular risk prediction models, as was used in the creation of the 2013 ACC/AHA cardiovascular risk estimator. The author has no conflict with any of the material in this manuscript. Funding support for the author is provided by the Division of Intramural Research of the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health (NIH). The views expressed in this manuscript are those of the author and do not necessarily represent the views of the National Heart, Lung, andBlood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services.

Using electronic health records to predict costs and outcomes in stable coronary artery disease

ObjectivesTo use electronic health records (EHR) to predict lifetime costs and health outcomes of patients with stable coronary artery disease (stable-CAD) stratified by their risk of future cardiovascular events, and...

Influence of Bariatric Surgery on Carotid Intima-Media Thickness

Background: Carotid intima media thickness (CIMT) is used as a surrogate measure of coronary artery disease. The aim of this research was to evaluate the effects of laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric plication (LGP), and its associated weight loss, on CIMT. Materials and Methods: This prospectively designed study enrolled 48 consecutive obese subjects who underwent either LSG or LGP between January 2013 and June 2014. Patient demographic data (age, sex, height, and weight), body–index (BMI), and metabolic parameters (lipid profile) were measured before and 3 and 6 months after surgery. The degree of liver steatosis was also determined ultrasonographically at the same time. Results: LSG was performed in 25 patients (LSG group) and LGP in 23 patients (LGP group). Both groups were similar in terms of age, sex, BMI, and CIMT preoperatively. In both groups, biochemical parameters improved significantly at 3 and 6 months after surgery. Mean CIMT decreased significantly in both groups. Conclusion: In addition to the improvement in lipid profiles of obese patients after either LGP or LSG, CIMT decreases after bariatric surgery. This decrease is proportional to the decrease in BMI and cholesterol levels. The risk of future cardiovascular events in obese subjects undergoing bariatric surgery may be decreased.

Biomarkers of inflammation and risk of cardiovascular events in anticoagulated patients with atrial fibrillation

ObjectiveAtrial fibrillation (AF) is a risk factor for stroke and mortality and the prothrombotic state has been linked to inflammation. In this study we evaluated the relationship between inflammatory biomarkers...

Relation Between Change in Renal Function and Cardiovascular Outcomes in Atorvastatin-Treated Patients (from the Treating to New Targets [TNT] Study)

Statins may have nephroprotective as well as cardioprotective effects in patients with cardiovascular disease. In the Treating to New Targets (TNT) study (NCT00327691), patients with coronary heart disease (CHD) were randomized to atorvastatin 10 or 80 mg/day and followed for 4.9 years. The relation between intrastudy change in estimated glomerular filtration rate (eGFR) from baseline and the risk of major cardiovascular events (MCVEs, defined as CHD death, nonfatal non-procedure-related myocardial infarction, resuscitated cardiac arrest, or fatal or nonfatal stroke) was assessed among 9,500 patients stratified by renal function: improving (change in eGFR more than +2 ml/min/1.73 m(2)), stable (-2 to +2 ml/min/1.73 m(2)), and worsening (less than -2 ml/min/1.73 m(2)). Compared with patients with worsening renal function (1,479 patients, 15.6%), the rate of MCVEs was 28% lower in patients with stable renal function (2,241 patients, 23.6%) (hazard ratio [HR] 0.72; 95% confidence interval [CI] 0.60 to 0.87; p = 0.0005) and 64% lower in patients with improving renal function (5,780 patients, 60.8%; HR 0.36; 95% CI 0.30 to 0.43; p <0.0001). For each 1 ml/min/1.73 m(2) increase in eGFR, the absolute reduction in the rate of MCVEs was 2.7% (HR 0.973; 95% CI 0.967 to 0.980; p <0.0001). An absolute MCVE rate reduction per 1 ml/min/1.73 m(2) increase in eGFR of 2.0% was reported with atorvastatin 10 mg and 3.3% with atorvastatin 80 mg. In conclusion, intrastudy stabilization or increase in eGFR in atorvastatin-treated patients with CHD from the TNT study was associated with a reduced rate of MCVEs. Statin-treated CHD patients with progressive renal impairment are at high risk for future cardiovascular events.

Cardiovascular risk factors in young adult survivors of childhood malignancies.

138 Background: Survivors of childhood cancer are at increased risk of early cardiovascular (CV) diseases related to previous cancer therapy, chronic stress and unhealthy behaviors, as well as traditional cardiovascular risk factors. The aim of the study was to assess the prevalence of cardiovascular risk factors in young adult survivors of childhood malignancies. Methods: Medical records of 155 adult childhood cancer survivors were analyzed to extract data on cancer treatment, demographical characteristics, family history, smoking, blood pressure (BP), lipids, fasting glucose, creatinine measured during a routine visit in our follow-up clinic for adult childhood cancer survivors. Results: The prevalence of traditional CV risk factors was high, with 55% of patients presenting with prehypertension (office systolic BP 120-139 mmHg or diastolic 80-89 mmHg) and 15,4% with hypertension (BP ≥ 140 mmHg and/or ≥ 90 mmHg or being on antihypertensive drugs). The prevalence of overweight and obesity was 23,5% and 3,7%, respectively. A classic “atherogenic lipid profile” (28% patients with elevated total cholesterol and 27% with elevated LDL cholesterol) was more common than a dyslipidemic pattern (elevated triglycerides 11% and reduced HDL cholesterol 7,8%). Two or more CV risk factors were found in 50% of patients and only 16% did not have any of traditional risk factors. Conclusions: Major CV risk factors are common in very young adults with cancer history in the childhood and may substantially increase risk for future CV events in this population. These finding support the need for screening of adult survivors of childhood malignancy for early detection and treatment of modifiable risk factors. [Table: see text]

Preeclampsia and Vascular Function: A Window to Future Cardiovascular Disease Risk.

Preeclampsia affects ∼3%-7% of all pregnancies and is the third leading cause of maternal mortality globally. Growing evidence indicates that preeclampsia results from vascular dysfunction, which also increases the risk for future cardiovascular events. Until recently, preeclampsia was considered a disorder limited to pregnancy, which fully resolved with the delivery of the placenta; however, it is now clear that women with a history of preeclampsia have approximately double the risk of future cardiovascular events compared to women with normotensive pregnancies. The aims of this review were to describe the hemodynamic and vascular changes that occur in normal and preeclamptic pregnancies, to review noninvasive methods to test vascular function, and to discuss the associated increased cardiovascular disease risk related to preeclampsia.

The Role of Beta-Blockers in the Treatment of Hypertension.

Two major guide-line committees (JNC-8 and NICE UK) have dropped beta-blockers as first-line therapy in the treatment of hypertension. Also, recent meta-analyses (that do not take age into account) have concluded that beta-blockers are inappropriate first-line agents in the treatment of hypertension. This review seeks to shed some light on the "rights and wrongs" of such actions and conclusions. Because the pathophysiology of primary/essential hypertension differs in elderly and younger subjects, the latter being closely linked to obesity and increased sympathetic nerve activity, the author sought to clarify the efficacy of beta-blockers in the younger/middle-aged group in reducing the risk of death, and cardiovascular end-points. Four searches were undertaken, utilising PubMed up to 31st Dec 2015. One search was under the terms "hypertension AND obesity AND sympathetic nerve activity". A second was "hypertension AND plasma noradrenaline/norepinephrine AND survival". A third was "beta-blockers or adrenergic beta-antagonists AND hypertension AND age AND stroke or myocardial infarction or death". A fourth was "meta-analysis of beta-blockers AND hypertension AND age AND death, stroke, myocardial infarction" RESULTS: Diastolic (with or without systolic) hypertension, in contrast to isolated systolic hypertension, occurs primarily in younger subjects, and is linked to overweight/obesity and increased sympathetic nerve activity. In younger/middle-aged hypertensive subjects, high plasma norepinephrine levels are linked (independent of blood pressure) to an increased risk of future cardiovascular events and death. High resting heart rates (a surrogate for high sympathetic nerve activity) likewise predict premature all-cause death, coronary heart disease and cardiovascular events in younger hypertensive subjects. In this younger/middle-aged hypertensive group, antihypertensive agents that increase sympathetic nerve activity (diuretics, dihydropyridine calcium blockers, and angiotensin receptor blockers (ARBs)) do not decrease (and may increase) the risk of myocardial infarction, and are therefore inappropriate first-line agents in this age-group. By contrast, in younger/middle-aged hypertensive subjects (less than 60years old), meta-analysis has shown that beta-blockers are significantly superior to randomised placebo, and at least as effective as randomised comparator agents, in reducing death/stroke/myocardial infarction. In this younger/middle-aged hypertensive group beta-blockers have been shown (vs randomised placebo or diuretics) to reduce the risk of myocardial infarction by 35-50 %, and stroke by 50-55 % (vs placebo), in non-smoker men. Atenolol was at least as effective as ACE-inhibition (captopril) in reducing all 7 cardiovascular endpoints (including stroke which was reduced by 50 %), vs less tight control of blood pressure, in obese hypertensive subjects with type-2 diabetes (UKPDS study); and after 20 years follow-up, atenolol was significantly (23 %) superior to the ACE-inhibitor in reducing the risk of all-cause death (beta-blockers have anti-cancer properties, which maybe relevant). Primary/essential hypertension in younger/middle-age is underpinned by high sympathetic nerve activity. In this age-group high resting heart rates and high plasma norepinephrine levels (independent of blood pressure) are linked to premature cardiovascular events and death. Thus, anti-hypertensive agents that increase sympathetic nerve activity ie diuretics, dihydropyridine calcium blockers, and ARBs, are inappropriate first-line choices in this younger age-group. Beta-blockers perform well vs randomised placebo and other antihypertensive agents regarding reduced risk of death/stroke/myocardial infarction in younger (<60years) hypertensive subjects, and are a reasonable first-line choice of therapy (certainly in men). These facts should be reflected in the recommendations of guideline committees around the world.

Objective criteria for septal fibrosis in non-ischemic dilated cardiomyopathy: validation for the prediction of future cardiovascular events

BackgroundExpert subjective reporting of mid-wall septal fibrosis on late gadolinium enhancement (LGE) images has been shown to predict major cardiovascular outcomes in patients with non-ischemic dilated cardiomyopathy (NIDCM). This study aims to establish objective criteria for non-experts to report clinically relevant septal fibrosis and compare its performance by such readers versus experts for the prediction of cardiovascular events.MethodsLGE cardiovascular magnetic resonance (CMR) was performed in 118 consecutive patients with NIDCM (mean age 57 ± 14, 42 % female) and the presence of septal fibrosis scored by expert readers. CMR-naive readers performed signal threshold-based LGE quantification by referencing mean values of remote tissue and applying these to a pre-defined anatomic region to measure septal fibrosis. All patients were followed for the primary composite outcome of cardiac mortality or appropriate implantable cardioverter-defibrillator (ICD) therapy.ResultsThe mean LVEF was 32 ± 12 %. At a median follow-up of 1.9 years, 20 patients (17 %) experienced a primary composite outcome. Expert visual scoring identified 55 patients with septal fibrosis. Non-expert septal fibrosis quantification was highly reproducible and identified mean septal fibrosis burden for three measured thresholds as follows; 5SD: 2.9 ± 3.6 %, 3SD: 6.9 ± 6.3 %, and 2SD: 11.1 ± 7.5 % of the left ventricular (LV) mass, respectively. By ROC analysis, optimal thresholds for prediction of the primary outcome were; 5SD: 2.74 % (HR 8.7, p < 0.001), 3SD: 6.63 % (HR 5.7, p = 0.001) and 2SD: 10.15 % (HR 6.1, p = 0.001). By comparison, expert visual scoring provided a HR of 5.3 (p = 0.001). In adjusted analysis, objective quantification by a novice reader (>5SD threshold) was the strongest independent predictor of the primary outcome (HR 8.7) and provided improved risk reclassification beyond LVEF alone (NRI 0.54, 95 % CI 0.16–0.92, p = 0.005).ConclusionsNovice readers were able to achieve superior risk prediction for future cardiovascular events versus experts using objective criteria for septal fibrosis in patients with NIDCM. Patients with a septal fibrosis burden >2.74 % of the LV mass (>5SD threshold) were at a 9-fold higher risk of cardiac death or appropriate ICD therapy versus those not meeting this criteria. As such, this study validates reproducible criteria applicable to all levels of expertise to identify NIDCM patients at high risk of future cardiovascular events.