Specific Cardiovascular Risk Factors Research Articles

Primary and Secondary Prevention of Cardiovascular Diseases: A Practical Evidence-Based Approach

Despite the fact that we possess highly effective tools for the primary and secondary prevention of myocardial infarction and other complications of atherosclerosis, coronary heart disease remains the most common cause of death in our society. Arterial inflammation and endothelial dysfunction play central roles in the pathogenesis of atherosclerosis and adverse cardiovascular (CV) events. Therapeutic lifestyle changes in conjunction with an aggressive multidrug regimen targeted toward the normalization of the major CV risk factors will neutralize the atherogenic milieu, reduce vascular inflammation, and markedly decrease the risk of adverse CV events and need for revascularization procedures. Specific CV risk factors and optimal therapies for primary and secondary prevention are discussed.

Modestly overweight women have vascular endothelial dysfunction.

Vascular endothelial dysfunction occurs early in the atherosclerotic process and is predictive of cardiovascular prognosis. However, the association between specific cardiovascular risk factors and endothelial dysfunction in women has not been well characterized. This study examined the relationship between endothelial dysfunction and cardiovascular risk factors (body mass index [BMI] >or= 25 kg/m(2), current smoking, age, diabetes, hypertension, hypercholesterolemia, and family history of early coronary heart disease) in a population of women that included those already being treated for risk factors. Endothelial function was assessed by brachial artery ultrasound flow-mediated vasodilation (FMD) in 185 consecutive women without a history of coronary heart disease. Women with hypertension, diabetes, or hyperlipidemia were allowed to continue on their usual therapy. There was an inverse linear association between age and FMD. Subjects who were active smokers had lower FMD compared with nonsmokers, and subjects with BMI >or= 25 kg/m(2) had lower FMD than subjects with BMI < 25 kg/m(2). FMD in overweight women (BMI >or= 25 and < 30 kg/m(2)) was similar to that of obese women (BMI >or= 30 kg/m(2)). Multivariate analysis demonstrated that body mass index, current smoking, and age were independent predictors of endothelial dysfunction in this population. Modestly elevated BMI, smoking, and age predict endothelial dysfunction in women, even in the presence of treatment for other atherosclerotic risk factors. These findings demonstrate the importance of modest elevation in BMI as a risk factor for impaired vascular health in women, and underscore the need for focusing further attention on lifestyle modification as a component of cardiovascular disease prevention.

Importance of Recognizing Occult Renal Disease in Hypertensive Patients

Occult renal disease (ORD) is a condition that characterizes the early stages of renal failure and which cannot be detected by routine monitoring. The aims of this study were to determine the prevalence of ORD in hypertensive patients attending cardiology outpatient clinics and to identify its relationship with specific cardiovascular risk factors or treatment. A cross-sectional, retrospective, multicenter observational study was carried out in 1214 hypertensive patients attending cardiology outpatient clinics. Data from 1190 patients (98%) were analyzed. In 11%, the glomerular filtration rate (GFR) was calculated by the attending cardiologist using the Modification of Diet in Renal Disease equation. Overall, 9.5% of patients were found to have ORD. Affected patients were more likely to be female, to be older, to have a history of dyslipidemia, diabetes, a sedentary lifestyle or atrial fibrillation or a long history of hypertension compared with those without ORD, but were less likely to have a history of dyslipidemia, diabetes or a sedentary lifestyle than those with renal failure. There was no significant difference in treatment. Moreover, ORD was observed in 2.9% (two of 68) of those aged under 50 years, in 3.3% (seven of 210) aged 50-60 years, in 9.3% (37 out of 398) aged 60-70 years and in 13.5% (70 out of 518) aged over 70 years. Almost 10% of hypertensive patients reviewed by a cardiologist had moderate renal dysfunction that had not been investigated. They represent an unrecognized population with an intermediate cardiovascular risk. Consequently, it is recommended that the GFR should be calculated, especially in women and older patients.

Prevalence of coronary artery calcification in patients undergoing assessment for orthotopic liver transplantation

Patients with advanced liver disease are at increased risk of cardiovascular events, especially following orthotopic liver transplantation (OLT). Coronary artery calcification (CAC) is a novel and independent predictor of cardiovascular risk, but its prevalence and utility in patients with cirrhosis are unknown. The aim of this study was to define the prevalence of CAC and its association with markers of disease severity and standard measures of cardiovascular risk in a large cohort of patients undergoing OLT assessment. A single-center, prospective, observational study of 147 consecutive patients undergoing assessment for OLT was performed. CAC scores were derived with the Agatston method from thoracic computed tomography scans and correlated with cardiovascular risk factors and measures of liver disease severity. There were 101 patients (66 males) with a mean age of 53.2 years; 46 patients were excluded because the CAC score was not reported. The median CAC score was 40 HU (range, 0-3533). Correlations were identified between the CAC score and age (r = 0.477; P < 0.001), male sex (r = 0.262; P = 0.008), family history of cardiovascular disease (r = 0.208; P = 0.036), Framingham risk score (r = 0.621; P < 0.001), Model for End-Stage Liver Disease score (r = 0.221; P = 0.027), systolic blood pressure (r = 0.285; P = 0.004), diastolic blood pressure (r = 0.267; P = 0.007), cytomegalovirus status (r = 0.278; P = 0.005), fasting glucose (r = 0.330; P = 0.001), number of coronary vessels involved (r = 0.899; P < 0.001), and components of the metabolic syndrome (r = 0.226; P = 0.026). After multivariate analysis, age, systolic blood pressure, fasting glucose, number of features of metabolic syndrome, and number of vessels involved remained significantly associated with CAC. In conclusion, this study identified a high prevalence of occult coronary artery disease in patients undergoing OLT assessment and identified a strong relationship between CAC scores and a limited number of specific cardiovascular risk factors. The usefulness of these factors in predicting perioperative and postoperative cardiovascular events in patients undergoing OLT requires prospective evaluation.

Diagnostic Uncertainty and Costs Associated With Current Emergency Department Evaluation of Low Risk Chest Pain

Of all stress tests done in low risk Emergency Department observation units (OU), a small, but significant number may be reported as positive or indeterminate. The objective of this study is to quantify the prevalence and costs associated with positive and indeterminate stress tests that result in negative cardiac catheterization. Retrospective observational cohort study over 9 months. All patients undergoing the chest pain protocol who got cardiac stress testing in the OU were eligible for inclusion. Cost data were derived from an institutional activity-based cost system utilizing actual costs. Chart review was completed on all patients with positive and indeterminate stress tests and a randomly chosen sample of those with negative stress tests. Of the 1194 patients who met the inclusion criteria, 1084 (90.8%) had a negative stress test. Sixty-two (5.2%) had a positive stress test, and 48 (4.0%) had an indeterminate stress test. Of all 59 patients who underwent catheterization, 41 (69.5%) were negative cardiac catheterizations. The prevalence among all OU stress test patients of positive or indeterminate stress tests with subsequent negative cardiac catheterization was 41/1194 (3.4%; 95% CI 2.5%-4.6%). The prevalence of significant coronary artery disease at cardiac catheterization was 18/1194 (1.5%; 95% CI 1.0%-2.4%). Patients with a positive or indeterminate stress test who had a negative catheterization incurred increased OU costs ($1385 vs. $1,039, P = 0.012), total costs ($7298 vs. $1562, P < 0.001) and length of inpatient stay (1.83 days vs. 0.00 days) when compared with those who had a negative stress test. The probability of going to the OU and having a positive or indeterminate stress test resulting in a subsequent negative catheterization was double the probability of having a stress test result in catheterization that detected significant coronary artery disease. These patients incurred 5 times the total cost when compared with those patients with negative stress testing. Further investigation is warranted to determine alternative risk stratification methods for these low risk chest pain patients with positive stress tests.

State of the science conference: Initiative to decrease cardiovascular risk and increase quality of care for patients living with HIV/AIDS: executive summary.

With successful antiretroviral therapy, patients infected with the human immunodeficiency virus (HIV) are living longer; however, recent reports suggest increased rates of coronary heart disease (CHD) among HIV-infected patients,1 and cardiovascular disease has become an important cause of morbidity and mortality in this population.2 Increased CHD rates in the HIV population may relate to traditional risk factors, including advancing age, higher smoking rates, dyslipidemia, insulin resistance, and impaired glucose tolerance. Cardiovascular disease may also be due to nontraditional factors, including changes in body composition with loss of subcutaneous fat and/or accumulation of visceral fat in some patients, inflammation, and direct effects of the virus on the vasculature, as well as to direct effects of specific antiretroviral drugs. Important questions remain as to the pathogenesis, detection, and treatment of cardiovascular disease and related risk factors in HIV-infected patients. These questions concern, among other things, the design of adequate trials to determine CHD incidence and the utility of existing CHD guidelines for screening, prevention, treatment, and risk stratification. To ascertain the state of the science with respect to these and related questions, a multidisciplinary conference with interested HIV specialists, cardiologists, endocrinologists, primary care physicians, National Institutes of Health representatives, and patient advocates was convened June 28–30, 2007, in Chicago, Ill, and chaired by Drs Steven Grinspoon and Robert Eckel. The discussions focused on 6 areas of interest, each with its own working group, including the following: (1) the contribution of metabolic and anthropometric abnormalities to cardiovascular disease risk factors (chaired by Drs Carl Grunfeld and Donald Kotler); (2) the epidemiological evidence for cardiovascular disease and its relationship to highly active antiretroviral therapy (HAART; chaired by Drs Judy Currier and Jens Lundgren); (3) the effects of HIV infection and antiretroviral therapy on the heart and vasculature (chaired by Drs Michael Dube …

Cardiorespiratory Fitness Is Related to Physical Inactivity, Metabolic Risk Factors, and Atherosclerotic Burden in Glucose-Intolerant Renal Transplant Recipients

The mechanisms of reduced cardiorespiratory fitness (CF) in renal transplant recipients (RTR) have not been studied closely. This study evaluated the relationships between CF and specific cardiovascular risk factors (metabolic syndrome [MS], physical inactivity, myocardial ischemia, and atherosclerotic burden) in glucose-intolerant RTR. Data were recorded on 71 glucose-intolerant RTR (mean age 55 yr; 55% male; median transplant duration 5.7 yr). MS was defined using National Cholesterol Education Programme Adult Treatment Panel III criteria. Resting and exercise stress echocardiography were performed, and myocardial ischemia was identified by new or worsening wall motion abnormalities. Cardiorespiratory fitness was determined using peak oxygen uptake (VO(2)) by expired gas analysis. Atherosclerotic burden was assessed by carotid intima-media thickness (IMT). Mean peak VO(2) was 19 +/- 7 ml/kg per min and was significantly lower than predicted peak VO(2) (29 +/- 6 ml/kg per min; P < 0.001). Patients with MS (63%) had reduced CF (17 +/- 6 versus 22 +/- 8 ml/kg per min; P = 0.001) and were more likely to be physically inactive (76 versus 48%; P = 0.02). CF was reduced in 14 patients with myocardial ischemia (15 +/- 3 versus 20 +/- 7 ml/kg per min; P = 0.05). CF was positively correlated with male gender, height, and physical activity and inversely correlated with number of MS risk factors and IMT (adjusted R(2) = 0.66). Carotid IMT added incremental value to clinical variables in determining VO(2) (adjusted R(2) = 0.65 versus 0.63; P = 0.04). Reduced CF is associated with physical inactivity, MS, and atherosclerotic burden in glucose-intolerant RTR. Further studies should address whether increasing exercise and modifying MS risk factors improve CF in RTR.

Gender differences in correlations among cardiovascular risk factors

Although the clustering of a few specific cardiovascular risk factors is known as the metabolic syndrome, sex-specific differences in correlations among risk factors have not been thoroughly examined. The analysis was undertaken to detect gender differences in correlations among cardio-vascular risk factors. Correlations among age, body mass index, systolic and diastolic blood pressures, and serum levels of fasting blood sugar (FBS), triglycerides (TG), high- and low-density lipoprotein cholesterol, high-sensitivity C-reactive protein (CRP), and uric acid were analyzed in apparently healthy Japanese men and women with TG<400 mg/dL and FBS<126 mg/dL. Among the 136 men and 136 women examined, the frequency of significant correlations was marginally higher in women than in men: 28/45 correlations versus 17/45 correlations, respectively (P=0.017). Of a total of 45 possible correlations, 5 were marginally or significantly stronger in women, whereas no correlations among these risk factors were marginally or significantly stronger in men (P=0.021). These gender differences were considerably attenuated after adjustment for age. However, a significant sex-specific difference was observed in the correlation between TG and rank transformation of CRP, even after adjustment for age (P<0.01). Correlations among cardiovascular risk factors were marginally stronger in women than in men. These results suggest that the existence of 1 additional risk factor may increase the risk of cardiovascular disease more steeply in women than in men.

Cardiovascular risk factors in patients with type 2 diabetes mellitus in Kenya: levels of control attained at the outpatient diabetic clinic of Kenyatta National Hospital, Nairobi

To determine the proportion of specific cardiovascular risk factors in ambulatory patients with type 2 diabetes and the levels of control achieved in them. Prospective, cross-sectional study over a six month period. Out-patient diabetic clinic of the Kenyatta National Hospital. Two hundred and eleven patients with type 2 diabetes. Sociodemographic attributes, duration of diabetes, levels of glycaemia, body weight, blood pressure, fasting lipids and modes of treatment. A total of 211 patients were enrolled, 57.3% were females. The mean (SD) age for women was 54.45 (9.44) and that of men was 55.8 (9.02) years. About 77% of the study population were on oral glucose-lowering agents with or without insulin but less than 30% achieved HbA1c < 7%; 15% were active cigarette smokers; about 50% were hypertensive with female predominance but 65% of them did not achieve desired blood pressure level inspite of treatment. Just over 50% had raised LDL-cholesterol and over 75% had raised total cholesterol but only three men were on statins without achieving desired targets. Body mass index above 30 kg/m2 as a measure obesity was found in 32% of females and 16% males. Most of the study patients admitted use of Aspirin at certain times in the course of their diabetes. The study showed that specific cardiovascular risk factors of hyperglycaemia, dyslipidaemia, hypertension and obesity were prevalent although not adequately controlled to targets. Statin use was extremely low in people who already needed them. Regular Aspirin use was infrequent because many patients did not quite understand its role in their diabetes treatment. It is recommended that a more pro-active approach in multifactorial address of cardiovascular risk factors be used in high-risk patients with type 2 diabetes to forestall future cardiovascular events.

Predictive Power of Cardiovascular Risk Factors for Detecting Peripheral Vascular Disease

Peripheral vascular disease (PVD) is underdiagnosed in primary care due to the absence of established criteria to warrant diagnostic testing. Our goal was to establish a risk factor hierarchy to enable earlier diagnosis of PVD. Data sets of 142 patients with abnormal ankle brachial indices (ABI) were randomly selected from our patient database to determine the prevalence of specific cardiovascular risk factors and demographic data. An ABI score < 0.90 is diagnostic of PVD. Patients were stratified into mild (0.75-0.89), moderate (0.50-0.74), and severe disease (< 0.50). Mean age was 69 +/- 9.9, ABI 0.65 +/- 0.16. Risk factor prevalence: diabetes, 42%; hypertension, 87%; tobacco use, 34%; hyperlipidemia, 53%; obesity, 24%; cardiovascular disease (CVD), 69%; stroke, 15%. Total risk factors per patient v = 3.2 +/- 1.3. Disease severity stratifications: mild, n = 46 (age v = 68.6 +/- 10.4, ABI v = 0.82 +/- 0.05); moderate, n = 72 (age v = 69.9 +/- 9.4, ABI v = 0.62 +/- 0.07); severe, n = 24 (age v = 67.5 +/- 10.9, ABI v = 0.40 +/- 0.06). Independent variable mean differences: hypertension-CVD (P = 0.0002); CVD-hyperlipidemia (P = 0.002); hyperlipidemia-diabetes (P = 0.0008); diabetes-tobacco use (P = 0.001); tobacco use-obesity (P = 0.0003); obesity-stroke (P = 0.05). Independent variable mean differences were significant across disease severity (P < 0.00001). Our study establishes the following hierarchy of cardiovascular risk factors as predictors of PVD: hypertension, cardiovascular disease, hyperlipidemia, diabetes, tobacco use, obesity, stroke.

Superior Mesenteric Artery Aneurysm in a Multi Aneurysmal Disorder Associated with a Distal Arteriovenous Fistula

IntroductionA superior mesenteric artery aneurysm (SMAA) is arare and most often isolated event that has variouscauses. This is, as far as we know, the first reportedcase of an SMAA, treated surgically by resection andreplacement, and associated with a distal arteriove-nous fistula responsible for arterial enlargement andmultiple arterial aneurysms.Case ReportA 60-year-old man with no specific cardiovascular riskfactors (coronary symptoms, valve disorder, or cardiacmedication) or past medical or surgical history wasadmitted to the cardiology unit with severe heartfailure, acute dyspnea and peripheral edema. Trans-thoracic echocardiography revealed right ventriculardilatation (70 mm in diastole) with functional tricus-pid regurgitation. The cardiac failure was treated andthe patient rapidly recovered. Whilst in hospital, alarge distal arteriovenous fistula was found in the leftankle. The patient reported that when he was 9 yearsold the left ankle was injured in a bicycle accident andbled profusely. The wound was compressed to stop thebleeding and the skin was directly sutured. The distalarteriovenous fistula related to the injury remainedundiagnosed at the time and developed over the next50 years. In a patient with no history of valve disordersor heart disease the arteriovenous fistula was pre-sumed responsible for a case of heart failure whichresponded rapidly to appropriate medication.Following successful cardiac management thepatient was transferred to the vascular surgery unitfor investigation and treatment of the distal arteriove-nous fistula. Angiography showed a distal arteriove-nous fistula between the left posterior tibial artery andvein. The distal arterial tree was normal. The angio-gram also showed arteriomegaly involving the entireleft arterial network with a popliteal aneurysmmeasuring 35 mm in diameter, and a dilated super-ficial femoral artery which measured 17 mm proxi-mally and 24 mm in the adductor hiatus (Fig. 1).Arteriomegaly was associated with multiple aneur-ysm formation including an aneurysm of the leftcommon iliac artery (35 mm), an abdominal aorticaneurysm (55 mm) and an aneurysm of the right renalartery (20 mm). Before managing the aneurysms wedecided to treat the arteriovenous fistula with doubleembolization (arterial and venous) under local anes-thetic. First, the posterior tibial artery adjacent to thearteriovenous fistula was embolized using three Cookcoils (MREY EMBOLIZATION COIL

Effect of a nutritional intervention promoting the Mediterranean food pattern on plasma lipids, lipoproteins and body weight in healthy French-Canadian women

The present study examined the effect of a nutritional intervention promoting the Mediterranean food pattern in uncontrolled ‘real life’ conditions among a group of 77 French-Canadian women. The principal objective was to document changes in the plasma lipid-lipoprotein profile and in body weight that occurred in response to the intervention. The 12-week nutritional intervention included two group sessions, three individual sessions and four 24-h recalls (phone interview) with a registered dietitian. A score based on the 11 components of the Mediterranean pyramid, ranging from 0 to 44 points, was established to evaluate the adhesion to the Mediterranean food pattern. The Mediterranean score increased from 21.1±3.6 at baseline to 28.6±4.4 after 6 weeks of intervention ( P<0.0001) with no further increase at week 12. Small but significant decreases in total cholesterol and apolipoprotein B (apoB) as well as in body mass index (BMI) were observed after 6 weeks of intervention. No significant change in plasma concentrations of high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and triglycerides (TG) were observed in response to the nutritional intervention. In conclusion, a nutritional intervention program promoting the Mediterranean food pattern was effective in modifying food habits of healthy women from the Québec City metropolitan area and resulted in small but significant effects on specific cardiovascular risk factors.

Effect of preoperative β-blockade on perioperative mortality in coronary surgery

Many preoperative factors can influence perioperative mortality in cardiac surgery. Because the perioperative use of beta-blocking agents may reduce perioperative cardiac complications in non-cardiac surgery, we considered the possibility that beta-blocking agents could improve survival in coronary surgery patients. In a retrospective study on 1586 patients undergoing coronary bypass surgery, the relative risk of 30-day mortality was determined in relation to preoperative risk factors and medication. Factors included patient characteristics, pre-existing illness, specific cardiovascular risk factors, cardiac status and urgency of surgery. Treatment with beta-blocking agents, calcium antagonists, angiotensin-converting enzyme inhibitors, nitrates, anti-arrhythmic agents, diuretics and antithrombotic agents was taken into account. Sex, age, chronic obstructive pulmonary disease, urgency and the preoperative use of diuretics and chronic beta-blocking therapy were found to be linked to mortality (P<0.05). Backward stepwise regression testing identified age, urgency and beta-blocking therapy as independent factors that could predict mortality. Increasing age and urgency of surgery are associated with greater mortality, whereas preoperative beta-blocking therapy is associated with less mortality. The characteristics of patients who received chronic beta-blockade did not differ significantly from those of patients who did not. The results suggest that chronic preoperative beta-blocker therapy reduces 30-day mortality in coronary surgery.

Classification of obesity and assessment of obesity-related health risks.

The barriers to the evaluation and treatment of obesity by health-care providers include a lack of awareness of obesity as an independent risk factor for morbidity and mortality and inadequate training in the medical management of obesity. However, the increased risk of medical disorders and emotional consequences associated with obesity make the disorder a priority for physicians to assess and treat. Obesity researchers have published and promoted the use of evidence-based, practical guidelines to educate physicians about how best to approach obesity as a medical disorder. The guidelines support classification and assessment of obesity as an important component of the patient's medical care. Assessment begins with classification by body mass index (BMI), with overweight and obesity defined as a BMI of 25 and 30 kg/m(2), respectively. Patients with high-risk combinations of BMI, waist circumference, and specific cardiovascular risk factors should begin a weight-loss program if no contraindications are present. Proper assessment also includes evaluation of complicating factors for obesity, such as sleep apnea and type 2 diabetes, psychosocial factors, and the use of medications that may contribute to obesity. Special attention should be paid to elements of the physical examination that often are performed incorrectly in obese patients, such as pelvic exams. Gathering this information will allow the clinician to tailor a weight-loss program to each patient individually. Although this represents the most challenging component of obesity care, resources are available to guide the clinician.

Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomised trial in general Practice

In addition to the treatment of specific cardiovascular risk factors, intervention which interferes with the general mechanisms of atherosclerosis could further reduce the incidence of cardiovascular events. We aimed to investigate in general practice the efficacy of antiplatelets and antioxidants in primary prevention of cardiovascular events in people with one or more major cardiovascular risk factors. We did a randomised controlled open 2x2 factorial trial to investigate low-dose aspirin (100 mg/day) and vitamin E (300 mg/day) in the prevention of cardiovascular events, in people with one or more of the following: hypertension, hypercholesterolaemia, diabetes, obesity, family history of premature myocardial infarction, or individuals who were elderly. 4495 people (2583 female, mean age 64.4 years) were included in the trial. After a mean follow-up of 3.6 years the trial was prematurely stopped on ethical grounds when newly available evidence from other trials on the benefit of aspirin in primary prevention was strictly consistent with the results of the second planned interim analysis. Aspirin lowered the frequency of all the endpoints, being significant for cardiovascular death (from 1.4 to 0.8%; relative risk 0.56 [95% CI 0.31-0.99]) and total cardiovascular events (from 8.2 to 6.3%; 0.77 [0.62-0.95]). Severe bleedings were more frequent in the aspirin group than the no-aspirin group (1.1% vs 0.3%; p<0.0008). Vitamin E showed no effect on any prespecified endpoint. Analyses were by intention-to-treat. In women and men at risk of having a cardiovascular event because of the presence of at least one major risk factor, low-dose aspirin given in addition to treatment of specific risk factors contributes an additional preventive effect, with an acceptable safety profile. The results on vitamin E's cardiovascular primary preventive efficacy are not conclusive per se, although our results are consistent with the negative results of other large published trials on secondary prevention.

Pet ownership may be a factor in improved health of the elderly.

The familiar adage "pets are good for your health" is an interesting but largely untested theory. A new model was developed, based on pet ownership leads to better self care, to show possible associations between pet ownership with eating, exercise, nutritional status, and specific cardiovascular risk factors. Seniors aged sixty and above were solicited mainly at senior congregate meals program sites in north-central Colorado (n = 127) to participate in this cross-sectional, observational study. Statistical analyses of questionnaire, anthropometric, physiological, and biochemical data were performed. Dog owners walked significantly longer than non-owners (p < 0.05), and pet owners had significantly lower serum triglycerides than non-owners (p < 0.01). Results suggest that pets may be good for your health.

Left ventricular diastolic function in young adults: The Coronary Artery Risk Development in Young Adults Study

Doppler transmitral flow velocities have been used to assess left ventricular diastolic function. Associations of transmitral velocities with specific physiologic variables and cardiovascular risk factors have not been reported previously in a large population-based study of young adults. We performed Doppler analysis of left ventricular inflow in 3492 black and white men and women (aged 23 to 35 years) in the year-5 examination of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. First third filling fraction, peak flow velocity in early diastole (PFVE), peak flow velocity in late diastole (PFVA), and the PFVA/PFVE ratio were measured. Women had higher PFVE and PFVA than had men (PFVE: 0.81 +/- 0.13 m/sec versus 0.76 +/- 0.13 m/sec; PFVA: 0.47 +/- 0.11 m/sec versus 0.43 +/- 0.10 m/sec; both p < 0.001). Gender-specific multiple regression analyses showed that age, heart rate, systolic blood pressure, left ventricular percent fractional shortening, and body weight were independently and positively related to PFVA (all p < 0.001) in men and women. Age, heart rate, and forced expiratory lung capacity in 1 second were inversely related to PFVE and first third filling fraction (both p < 0.01). Left ventricular percent fractional shortening was positively related to PFVE and first third filling fraction (p < 0.001). Age, heart rate, and body weight were positively correlated with the PFVA/PFVE ratio (all p < 0.001). Height had weak negative associations with PFVA and PFVE in women only. These results suggest that, in young adults, Doppler measures of left ventricular diastolic filling are related to age, sex, body weight, blood pressure, heart rate, left ventricular systolic function, and lung function.

Medical Complications in Total Laryngectomy: Incidence and Risk Factors

The prevention and management of medical complications are important components in the surgical treatment of head and neck malignancies. We retrospectively evaluated the postoperative medical complications in 414 patients who underwent total laryngectomy between 1973 and 1987. The mortality rate was 1.2% (five deaths); while major, nonfatal medical complications occurred in 6.3% (24 of 384 patients)--seven strokes, three myocardial infarctions, two pulmonary emboli, and 12 respiratory failures requiring mechanical ventilation. Elderly patients did not experience more frequent or more severe medical complications, and the overall pattern of complications was different from that of other surgical specialties. Only specific cardiovascular and pulmonary risk factors were associated with these complications. We conclude that medical complications are a significant cause of morbidity in total laryngectomy; a focused preanesthetic risk factor analysis by a medical team familiar with head and neck cancer patients assures prompt identification and management of these complications.

Management of hypercholesterolemia: Approach to diet and drug therapy

The benefit of lowering elevated plasma low-density lipoprotein cholesterol levels and preventing coronary artery disease is now well documented. The guidelines formulated by the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults provide a rational approach to lipid level management. Once an elevation in low-density lipoprotein cholesterol level has been confirmed in an accurate and precise laboratory, the initial step in therapy remains regulation of diet. Pharmacologic intervention is recommended only if patients do not achieve desirable low-density lipoprotein cholesterol levels after an adequate period receiving regulated diet. The guidelines provide a mix of specific low-density lipoprotein level cutoff points and additional cardiovascular risk factors on which to base decisions in regard to drug therapy. The initial approach should be monotherapy with either a bile acid binding resin or nicotinic acid, with selection based on a variety of factors, including patient age, sex, and the severity and exact type of lipid disorder. Should difficulties or inadequate control occur with either of these agents, the hydroxy-methylglutaryl-coenzyme A reductase inhibitors should be utilized, since their ability to reduce low-density lipoprotein cholesterol levels is significantly greater than that of the other available agents. If inadequate control is obtained with monotherapy, combination therapy is recommended. Optimal combinations of drugs and dosages have yet to be fully assessed and will ultimately depend on patient acceptance, efficacy, side effects, and cost effectiveness. Severely affected subjects may require triple-drug therapy. Other agents, such as fibric acid derivatives and probucol, have only a limited role when elevated low-density lipoprotein cholesterol level is the only abnormality. In patients with combined hyperlipidemias, especially when the very low-density lipoprotein level is significantly increased, the fibrates may even be used for initial therapy.

A multivariate model for assessing eating patterns and their relationship to cardiovascular risk factors: the Bogalusa Heart Study

Eating patterns were studied in 1275 adolescents and young adults (aged 12-24 y). Factor analysis of 64 foods consumed weekly revealed 17 eating-pattern factors, accounting for 57% of the item variance. Factor I (12 food items from either the seafood or meat group) accounted for 8% of the variance, factor II (snacks), 5%, and factors III (fats and pasta) and IV (beef and chicken), 4% each. Remaining factors accounted for from 1.9% to 3.9%. The factors were effective in discriminating eating patterns across race and gender. Significant age effects were also noted for 10 of the 17 factors. Eating patterns for persons in the upper or lower quartiles differed consistently for specific cardiovascular (CV) risk factors. Use of this statistical model to identify differences in eating patterns by race, gender, and CV risk factors during maturation can assist health professionals in targeting food sources for changing eating behavior.