Screening For Subclinical Disease Research Articles

Screening in Frail Older People: An Ounce of Prevention or a Pound of Trouble?

Screening for subclinical disease has provided benefit to many asymptomatic patients, especially those who are relatively young and otherwise healthy. However, frail older people do not always profit from such maneuvers, for several reasons. First, older individuals usually have less physiological reserve and greater comorbidity and resultant polypharmacy than their younger counterparts. As such, they may tolerate the invasive interventions called for after a positive screening test less easily. In addition, shorter natural life expectancy shifts the focus to quality of life improvement after screening tests rather than simply offering a promise of "more years." Lack of education and cognitive decline may also interfere with the older person's ability to give truly informed consent to these maneuvers. Thus, on the whole, in this rapidly growing subpopulation, screening programs may tilt the balance toward the likelihood of causing more harm than good. For many frail older patients, an individualized approach to screening is recommended, adjusted to comorbidity, life expectancy, and patient preference. One size does not fit all.

Carotid Intima-Media Thickness: Knowledge and Application to Everyday Practice

Heart disease is the primary cause of death in the United States. Fortunately, intervention measures can reduce the risk of cardiovascular disease (CVD) after a patient has been accurately assessed. Atherosclerotic disease, one of the driving forces behind CVD, is not always detected by traditional risk assessment. Carotid intima-media thickness (CIMT), as measured by B-mode ultrasound, is a surrogate marker for atherosclerosis and can be used to detect an accelerated disease process and subclinical disease. Advantages of CIMT are that it is noninvasive, relatively inexpensive, and can be repeatedly performed with no adverse effects on the patient. Carotid intima-media thickness is associated with CVD and is an independent predictor of stroke and myocardial infarction. Therefore, CIMT is valuable for clarifying CVD risk, particularly for patients with intermediate risk by conventional risk assessment. Screening for subclinical disease even in low-risk patients may have benefit, especially for those with a family history of premature CVD or those with any of the National Cholesterol Education Program risk factors. The detection of subclinical atherosclerosis allows the physician to implement prevention efforts prior to a devastating CVD event and to investigate possible reasons for increased arterial thickening, such as an occult underlying insulin-resistant condition or residual lipid risk markers. Treatment with several types of drugs has been demonstrated to halt the progression or even reduce CIMT. Carotid intima-media thickness is currently limited by the lack of standardized protocols that may affect reproducibility from measure to measure. Efforts to draft a standardized protocol are underway by the Society of Atherosclerosis Imaging and Prevention that will address this issue. Carotid intima-media thickness provides a valuable tool for physicians to clarify the CVD risk of their patients. Practical implications of CIMT for everyday clinical practice are addressed.

Circulating biomarkers in cardiovascular disease.

According to the Merriam-Webster Online Dictionary, a biomarker is ‘a distinctive biological or biologically derived indicator (as a metabolite) of a process, event, or condition (as aging, disease, or oil formation)’ [1]. A biomarker can be structural, such as mammography or a coronary calcium scan, or functional, such as glomerular filtration rate or blood pressure, but the term biomarker is most commonly used for describing measureable serological or circulating biological entities, such as proteins or metabolites. The purposes of measuring a biomarker vary, but include help in identification of individuals at increased risk for disease, screening for subclinical disease in asymptomatic individuals, diagnosis of existing disease in symptomatic patients, monitoring of treatment results in patients on therapy, or prognostication of recurrence or sequelae of disease. The purpose of this special issue of ‘Disease Markers’ is to give a comprehensive overview of the current state of knowledge regarding circulating biomarkers in cardiovascular disease. The main focus of the eight articles is the use of biomarkers in risk stratification of healthy individuals or early detection of subclinical disease, but some of the contributions also discuss other uses of biomarkers, such as prognostication in individuals with prevalent disease. In cardiovascular medicine, there is a long history of using biomarkers

Review: Cardiovascular risk assessment in the metabolic syndrome, screening for subclinical disease, and implications for treatment

he metabolic syndrome is a clustering of risk factors known to promote or increase the risk for development of cardiovascular disease. Approximately 25—35% of the adult population of developed countries are characterised with metabolic syndrome by different definitions. Metabolic syndrome, even in the absence of diabetes, is associated with an increased risk of cardiovascular disease and total mortality, and is related to an increased risk for the development of diabetes. Initial evaluation of coronary heart disease risk involves global risk estimation using Framingham or other algorithms for risk prediction. Given the absence of key metabolic syndrome risk factors (namely obesity, elevated triglycerides, and impaired fasting glucose) in these algorithms, elevations in these factors need to be considered in individual patient risk evaluation. Further, consideration of screening for novel risk factors such as C-reactive protein, as well as subclinical atherosclerosis (from carotid ultrasound, computed tomography, or ankle-brachial index), can further refine the estimation of future cardiovascular disease risk. The presence of subclinical atherosclerosis or elevated levels of C-reactive protein can potentially modify recommended treatment goals for lipid and other cardiovascular risk factors. The American Heart Association and US National Heart Lung and Blood Institute have recently released revised guidelines for the diagnosis and clinical management of metabolic syndrome. This article examines global assessment of cardiovascular risk in persons with metabolic syndrome, the role of screening for subclinical disease in risk assessment, as well as treatment strategies and their implications for reducing cardiovascular risk in those with metabolic syndrome.

Atherosclerotic Vascular Disease Conference: Writing Group IV: imaging.

The goals of the imaging writing group were to define the role of imaging and to recommend important programmatic research and advocacy initiatives in atherosclerotic peripheral vascular disease for the American Heart Association. It should be noted that this is not a practice guideline initiative; therefore, the writing group purposely avoided recommending imaging modalities for specific circulatory beds. This report discusses the following imaging modalities: duplex ultrasound, MRI and MR angiography (MRA), CT imaging and angiography (CTA), and digital intra-arterial angiography. The requirements for proficiency in all of these modalities include physician oversight, quality assurance programs, and standardization for acquisition of images, interpretation of the study, postprocessing procedures, workstations, and reporting. The roles of imaging for each modality such as screening for subclinical disease, diagnosis, and treatment planning as an adjunct to invasive therapies (interventional MR and CT) and follow-up and monitoring are reviewed.