Subsequent Vascular Events Research Articles

Cardiovascular Risk Factors and Carotid Intima-Media Thickness in Asymptomatic Children

Atherosclerosis, beginning in childhood, is dependent on several risk factors and may be predictive of coronary artery disease in adulthood. The risk factors for subclinical atherosclerosis are similar to those for clinical disease. Carotid intima-media thickness is a measure of subclinical atherosclerosis and a predictor of subsequent vascular events. This study aimed to examine the relationships of carotid intima-media thickness with known risk factors in asymptomatic children. Family history of cardiovascular disease was collected, together with anthropometric, demographic, and clinical data. Body mass index z-scores were calculated. Serum glucose, lipid fractions, fibrinogen, and C-reactive protein were determined. High-resolution ultrasonography was used to assess intima-media thickness. Associations and relationships of risk factors with composite intima-media thickness were explored. The study enrolled 93 children (44 girls) ranging in age from 49 to 169 months. The boys had a thicker intima-media (0.46 +/- 0.06 mm) than the girls (0.43 +/- 0.06 mm; p = 0.028). The unadjusted triglyceride levels were significantly higher in the overweight and obese children (p = 0.010). Body mass index and overweight/obesity were positively related to intima-media thickness (r = 0.259; p = 0.012 and r (s) = 0.230; p = 0.027, respectively), whereas family history of cardiovascular disease was unrelated. Only gender and overweight/obesity were related to intima-media thickness in a multiple linear regression model (R (2) = 0.125; p = 0.002). Male gender and overweight/obesity were associated with increased intima-media thickness, whereas family history of cardiovascular disease was unrelated.

Interventions in the management of serum lipids for preventing stroke recurrence.

Studies have shown that interventions which reduce total and low-density lipoprotein cholesterol levels also reduce coronary heart disease (CHD) and stroke events in those with a history of CHD. However, it is uncertain whether treatment to alter cholesterol levels can prevent recurrence of either stroke or subsequent cardiovascular events and whether differences in outcomes exist between classes of lipid-lowering therapy. This is an update of a Cochrane review first published in 2002. To investigate the effect of altering serum lipids pharmacologically for preventing subsequent cardiovascular disease and stroke recurrence in patients with a history of stroke. We searched the Cochrane Stroke Group Trials Register (last searched December 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2008), MEDLINE (1966 to December 2008) and EMBASE (1980 to December 2008). We contacted pharmaceutical companies known to produce a lipid-lowering agent for information on relevant publications or unpublished work. Unconfounded randomised trials of participants aged 18 years and over with a history of stroke or transient ischaemic attack (TIA). Two review authors independently selected trials, assessed quality and extracted data. We included eight studies involving approximately 10,000 participants. The active interventions were pravastatin, atorvastatin, simvastatin, clofibrate, and conjugated oestrogen. Fixed-effect analysis showed no overall effect on stroke recurrence but statin therapy alone had a marginal benefit in reducing subsequent cerebrovascular events in those with a previous history of stroke or TIA (odds ratio (OR) 0.88, 95% confidence interval (CI) 0.77 to 1.00). There was no evidence that such intervention reduced all-cause mortality or sudden death (OR 1.00, 95% CI 0.83 to 1.20). Three statin trials showed a reduction in subsequent serious vascular events (OR 0.74, 95% CI 0.67 to 0.82). There is evidence that statin therapy in patients with a history of ischaemic stroke or TIA significantly reduces subsequent major coronary events but only marginally reduces the risk of stroke recurrence. There is no clear evidence of beneficial effect from statins in those with previous haemorrhagic stroke and it is unclear whether statins should be started immediately post stroke or later. In view of this and the evidence of the benefit of statin therapy in those with a history of CHD, patients with ischaemic stroke or TIA, with or without a history of established CHD, should receive statins.

Patent Foramen Ovale, Cardiac Valve Thickening, and Antiphospholipid Antibodies as Risk Factors for Subsequent Vascular Events

We sought to estimate risk of recurrent stroke/TIA/death in the subgroup of the Patent Foramen Ovale in the Cryptogenic Stroke Study (PICSS) cohort with patent foramen ovale (PFO) and antiphospholipid antibodies (aPL) and to estimate risk of recurrent stroke/TIA/death in aPL-positive patients who have thickened left-side heart valves (VaT). PFO is associated with cryptogenic ischemic stroke. Also, the presence of aPL is associated with ischemic cerebrovascular disease. Combined data from 2 major substudies of the Warfarin Aspirin Recurrent Stroke Trial (WARSS) were evaluated. PICSS subjects were included if they were enrolled in the Antiphospholipid Antibodies and Stroke Study (APASS) and underwent a baseline aPL test (lupus anticoagulant, anticardiolipin antibodies, or both) within 1 month of the stroke. All patients in PICSS underwent transesophageal echocardiography for PFO as well as VaT, which was performed blinded to aPL status and treatment arm (325 mg/day aspirin or adjusted dose warfarin; target international normalized ratio, 1.4-2.8). The primary outcome event was the 2-year risk of recurrent stroke/TIA/death and was evaluated using Cox proportional hazards model. Because there was no treatment effect, warfarin and aspirin groups were combined to increase power. For the combined end point, power to detect HR of 2 was 47.8% for the PFO and aPL-positive group, and 75.3% for the valve thickening and aPL-positive group, assuming 2-sided type I error of 0.05. Five hundred twenty-five subjects were tested for the combined presence of PFO and aPL and were available for evaluation. The primary outcome event rate was 23.9% (HR, 1.39; 95% CI, 0.75-2.59) in the PFO-positive/aPL-positive group, compared to 13.9% (HR, 0.83; 95% CI, 0.44-1.56) in the PFO-positive/aPL-negative group, and 19.9% (HR, 1.16; 95% CI, 0.68-1.90) in the PFO-negative/aPL-positive group. Five hundred forty-five subjects tested for combined presence of aPL and left-side cardiac VaT were available for evaluation. The primary event rate was 22.6% (HR, 1.65; 95% CI, 0.88-3.09) in the VaT-positive/aPL-positive group, compared to 19.4% (HR, 1.50; 95% CI, 0.82-2.75) in the VaT-positive/aPL-negative group, and 20.2% (HR, 1.63; 95% CI, 0.81-3.25) in the VaT-negative/aPL-positive group. The combined presence of aPL either with a PFO or with left-side cardiac VaT did not significantly increase risk of subsequent cerebrovascular events in this PICCS/APASS cohort of patients.

Elevated C-reactive protein levels predict worsening prognosis in Chinese patients with first-onset stroke

The role of high sensitivity C-reactive protein (hsCRP) in predicting prognosis after stroke in the Asian population has not been investigated.We hypothesized that elevated levels of hsCRP were associated with worsening prognosis after stroke in Chinese patients. Two hundred and ninety consecutive patients with first-onset stroke and 290 age- and gender-matched control subjects without any cerebrovascular disease were enrolled for study. Plasma hsCRP level was detected and subsequent vascular events and death were recorded in both groups over a 5-year period. Compared to control group, patients presenting with stroke had higher plasma hsCRP level (3.3 ± 3.8 vs 1.3 ± 2.2 mg/L, P<0.01). Furthermore, in the group of patients with stroke, the mean plasma hsCRP level was higher in patients who developed subsequent vascular diseases or died as compared with the patients without further complications (4.4 ± 4.3 vs 2.7 ± 3.3 mg/L, P<0.01). Compared to the lowest tertile of hsCRP level, the relative risk for vascular events or death in stroke patients was 2.91 in the highest tertile of hsCRP (95% CI, 1.54–5.50, P = 0.001). This increase in relative risk for vascular events or death in stroke patients continued after adjustment for age, sex and other cardiovascular risk factors such as hypertension and diabetes (OR: 2.771, 95% CI: 1.367-5.617, P = 0.005). These findings indicate that increased hsCRP level is associated with worsening prognosis after stroke in Chinese patients and suggests that inflammation is correlated with stroke outcome.

Association between hormone replacement therapy and subsequent arterial and venous vascular events: a meta-analysis

A new systematic review regarding this contested women's health issue is certainly welcome.1 However, the inclusion of several trials evaluating the effects of menopausal hormone therapies (MHTs) on coronary heart disease (CHD), myocardial infarction, cerebrovascular events, and venous thrombo-embolism events ( Figure 3 )1 is debatable. …

Prothrombotic gene variation and new vascular events after cerebral ischemia of arterial origin.

Several genetic variants involved in hemostasis have been associated with ischemic stroke or myocardial infarction (MI). Stroke patients who carry a prothrombotic genotype may also be at increased risk for subsequent vascular events. We included 887 patients with non-disabling cerebral ischemia of arterial origin, who were referred to the University Medical Center Utrecht in the Netherlands between 1995 and 2005 and followed them for the occurrence of ischemic stroke, MI or death. The primary outcome was a composite of death from all vascular causes, non-fatal ischemic stroke, non-fatal MI, whichever happened first. We selected 22 prothrombotic variants in 14 genes that were previously associated with ischemic stroke or MI or had evidence of functionality. During a 4.6-year mean follow-up period new vascular events occurred in 135 patients (annual event rate 3.3%). None of the 22 variants was associated with the occurrence of new vascular events. Eight additional analyses with secondary outcomes or among subgroups revealed four associations that were likely to be false positive after accounting for multiple testing. In this cohort, prothrombotic genetic variants do not affect the risk of new vascular events after cerebral ischemia of arterial origin. This study does not support the use of prothrombotic genetic variants to identify stroke patients at increased risk for new vascular events or to guide antithrombotic treatment.

170: Does Sex Influence the Risk for Subsequent Events Following an Acute Ischemic Stroke?

To assess whether sex influences the likelihood of a subsequent vascular event (acute ischemic stroke (AIS), transient ischemic attack (TIA), and myocardial infarction (MI)) in the year following an acute ischemic stroke.

Risk Factor Control in Symptomatic Intracranial Stenosis

These authors asked whether risk-factor control influences occurrence of subsequent vascular events in patients with symptomatic intracranial stenosis.

Metabolic syndrome and the risk of new vascular events and all-cause mortality in patients with coronary artery disease, cerebrovascular disease, peripheral arterial disease or abdominal aortic aneurysm

To investigate the vascular risk associated with Metabolic Syndrome (MetS) according to different clinical criteria with subsequent vascular events and all-cause mortality in patients with coronary artery disease, cerebrovascular disease, peripheral artery disease or abdominal aortic aneurysm and to examine whether patients with MetS at treatment goals for systolic blood pressure (SBP) or low density lipoprotein-cholesterol (LDL-c) level are still at elevated risk. Prospective study of 3196 patients with a history or recent diagnosis of clinically manifest vascular disease. During a median follow-up of 3.2 years (interquartile range 1.4-5.4 years), 331 patients died and 373 patients experienced a first vascular event. National Cholesterol Education Program (NCEP) and revised NCEP (NCEP-R)-defined MetS were related to increased risk of vascular events [HR - hazard ratio 1.50 (95% CI - confidence interval 1.22-1.84) and 1.50 (1.22-1.87)] and all-cause mortality [HR 1.49(1.20-1.84) and 1.43 (1.14-1.78)]. Results were similar in the 2472 patients without type 2 diabetes (DM2) and localization of vascular disease; SBP-category (<140 or > or =140 mmHg) or LDL-category (<2.5 or > or =2.5 mmol/L) did not affect this relation. In patients with various manifestations of atherosclerosis, presence of NCEP and NCEP-R-defined MetS is associated with increased risk of cardiovascular events and all-cause mortality, independently of the presence of DM2. This risk is significantly higher than the risk associated with International Diabetes Federation-defined MetS. Also in patients at treatment goals for SBP (<140 mmHg) or LDL-c (<2.5 mmol/L) according to current guidelines, presence of NCEP-R-defined MetS points to a higher vascular risk.

Study of Patients Having Splenectomy Due to Trauma for Long Term Infectious and Vascular Complications.

Splenectomy, commonly performed for hematologic conditions, is followed by an increased risk of septicemia and arterial and deep venous thrombosis and pulmonary arterial hypertension. Most recent studies of post-splenectomy vascular complications focus primarily on patients with sickle cell disease, thalassemia, or hereditary stomatocytosis. However, the incidence and pathophysiology of complications in these patients is confounded by persistent hemolysis. Therefore, study of long term post-splenectomy infectious and vascular complications in patients without hemolysis or other serious medical conditions is indicated. Patients having splenectomy for trauma are often young and otherwise healthy so might be good candidates for investigation of post-splenectomy sequelae. To determine the feasibility of conducting a study of infectious and vascular complications following splenectomy for trauma, we retrospectively studied such patients admitted to Parkland Memorial Hospital, a 950 bed public hospital and the site of the Dallas metropolitan area's primary trauma center. Using appropriate ICD-9 and CPT codes, three separate databases (hospital medical records, trauma registry, and professional billing compilation) were reviewed in order to identify patients ≥ age 18 yr. having total splenectomy for trauma during the past 15 years and to determine whether follow-up data were available in the records regarding subsequent vascular events or surrogate laboratory markers suggesting an increased risk of thrombosis. Between 1992 and 2006, 855 individuals had splenectomy, including 643 (75%) following trauma. The annual number of patients having splenectomy due to trauma did not decline during this period. A comprehensive chart review was performed on the 77 patients having splenectomy for trauma during 2003 and 2004. Records were unavailable in four patients, and 20 died of their injuries shortly after admission. Follow-up records of the remaining 53 patients - 26 (49%) of whom appeared to be discharged in good condition without serious sequelae - were reviewed to attempt to gather data regarding clinical features and laboratory test results. Post hospitalization follow-up occurred in only 9 (17%) of these 53 patients. Six had serious post-trauma complications (e.g., paraplegia); only three seen in follow-up more than six months following splenectomy appeared well. We conclude that complete splenectomy following trauma remains a common procedure. Retrospective review of these patients' records does not permit evaluation of post-splenectomy complications. However, many patients were discharged shortly following splenectomy without other serious injuries. These patients could potentially be studied prospectively to assess the frequency, timing, and pathophysiology of infection, thrombosis, pulmonary arterial hypertension, and other complications of the post-splenectomy state without the confounder of hemolytic anemia.

Presence of calcified carotid plaque predicts vascular events: The Northern Manhattan Study

Objective The prognostic implications of carotid plaque calcification (CPC) relative to subsequent vascular events are unclear. Our aim was to determine the association between CPC and risk of vascular events in a prospective multi-ethnic cohort. Methods CPC was assessed among 1118 stroke-free subjects (mean age 68 ± 8 years; 59% women; 59% Hispanic, 22% black, 19% white) from the Northern Manhattan Study using high-resolution B-mode ultrasound. CPC was defined by presence of any acoustic shadowing associated with carotid plaque, producing a reduction in echo amplitude due to intervening structures with high attenuation. Using Cox proportional hazards models, hazard ratios (HR) were estimated for the combined vascular outcome, defined as ischemic stroke (IS), myocardial infarction (MI) or vascular death (VD). Results Carotid plaque was present in 637 (57%) subjects. CPC was present in 225 subjects (20% of total cohort; 35% of those with plaque). During a mean follow-up time of 2.7 years, the combined vascular outcome occurred among 52 subjects (20 IS, 22 MI, and 24 VD). Adjusting for demographics, major vascular risk factors, and carotid intima media thickness, those with CPC (in comparison to those without plaque) had a significantly increased risk of the combined vascular outcome (HR 2.5, 95% CI 1.0–5.8). Conclusions In this population-based cohort, the presence of calcified carotid plaque, as assessed by high-resolution B-mode ultrasound, was an independent predictor of vascular events. It may serve as a simple and non-invasive marker of increased atherosclerotic risk and further aid in vascular risk stratification.

The Economics of Thrombolysis

See related article, pages 1952–1955. Stroke leads to significant long-term disability with important ongoing human and economic costs. Although the clinical and economic benefits of thrombolysis have been demonstrated in previous analyses,1 efficacious large volume stroke care requires systematic organization and commitment on the part of healthcare payers. Canada benefits from a universal single-payer system which faces increasing cost pressures attributable to an ageing population and increasing costs of healthcare technology. The Organization for Economic Cooperation and Development (OECD) estimates that healthcare spending could double as a proportion of GDP in this country by 2050.2 The Canadian Institutes of Health Information note that Canadian jurisdictions spent 38.7% of all expenditures on health care in 2005 to 2006.3 Development and maintenance of stroke care systems will require well executed economic analyses to influence policy makers. In this regard, stroke is an ideal condition to treat from an economic perspective because its incidence is strongly age-linked …

Subsequent Vascular Event Following an Acute Ischemic Stroke

Subsequent Vascular Event Following an Acute Ischemic Stroke

Asymptomatic Carotid Artery Stenosis and the Risk of New Vascular Events in Patients With Manifest Arterial Disease

The frequency of asymptomatic carotid artery stenosis (CAS) increases with age from 0.5% in individuals below 50 years of age to 5% to 10% in individuals over 65 years of age in the general population. Its prognostic value has been examined in the general population but less often in patients with clinical manifestations of arterial disease other than retinal or cerebral ischemia. We examined the relationship between asymptomatic CAS and the risk of subsequent events in this specific group of patients. This study involved 2684 consecutive patients with clinical manifestations of arterial disease or type 2 diabetes mellitus, but without a history of cerebral ischemia, enrolled in the SMART study (Second Manifestations of ARTerial disease). The degree of asymptomatic CAS was assessed with Duplex scanning and defined on the basis of the blood flow velocity patterns at baseline in both carotid arteries. None of the patients underwent carotid endarterectomy or endovascular intervention. During the follow-up period, vascular events (vascular death, ischemic stroke, and myocardial infarction) were documented in detail. Data were analyzed with Cox proportional hazards regression and adjusted for age, gender, and classic vascular risk factors. Asymptomatic CAS of 50% or greater was present in 221 (8%) patients. During a mean follow up of 3.6 years (SD=2.3), a first vascular event occurred in 253 patients (9%). The cumulative incidence rate for the composite of subsequent vascular events after 5 years was 12.3% (95% CI=10.7 to 13.9), for cerebral infarction 2.2% (95% CI=1.4 to 2.8), and for myocardial infarction 8.0% (95% CI=6.6 to 9.4). Adjusted for age and gender, asymptomatic CAS of 50% or greater was related to a higher risk of subsequent vascular events (hazard ratio=1.5, 95% CI=1.1 to 2.1), in particular of vascular death (hazard ratio=1.8, 95% CI=1.2 to 2.6). After additional adjustment for vascular risk factors, the hazard ratios remained essentially the same. Asymptomatic carotid artery stenosis is an independent predictor of vascular events, especially vascular death, in patients with clinical manifestations of arterial disease or type 2 diabetes but without a history of cerebral ischemia.

Large-Artery Stenosis Predicts Subsequent Vascular Events in Patients with Transient Ischemic Attack

Background and purposeWe investigated subsequent vascular events in patients with transient ischemic attack (TIA) and determined the predictors of such events among vascular risk factors including large-artery disease, TIA-symptom duration, and acute ischemic lesions on diffusion-weighted imaging (DWI).MethodsWe identified 98 consecutive patients with TIA who visited a tertiary university hospital and underwent DWI and brain magnetic resonance angiography within 48 hours of symptom onset. We reviewed the medical records to assess the clinical characteristics of TIA, demographics, and the subsequent vascular events including acute ischemic stroke, TIA, and myocardial infarction.ResultsLarge-artery disease was detected in 55 patients (56%). Ten patients (10%) experienced TIA symptoms for longer than 1 hour, and acute infarctions on DWI were identified in 30 patients (31%). During the mean follow-up period of 19 months, seven patients (7%) had an acute ischemic stroke and 20 patients (20%) had TIA. Retinal artery occlusion in two patients, spinal cord infarction in one patient, and peripheral vascular claudication in one patient were also recorded. Cox proportional-hazards multivariate analysis revealed that large-artery disease was an independent predictor of subsequent cerebral ischemia (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.1-7.1; p=0.02) and subsequent vascular events (HR, 2.9; 95% CI, 1.2-6.7; p=0.01).ConclusionsIn patients with TIA, large-artery disease is an independent predictor of subsequent vascular events. Acute infarction on DWI and a symptom duration of more than 1 hour are not significantly correlated with a higher risk of subsequent vascular events. These findings suggest that the underlying vascular status is more important than symptom duration or acute ischemic lesion on DWI.

Evolving Perspectives on Clopidogrel in the Treatment of Ischemic Stroke

Antiplatelet therapy is indicated for the treatment of ischemic stroke or transient ischemic attack (TIA). Aspirin reduces subsequent occlusive vascular events, including recurrent stroke, by about 25%. In such patients, clopidogrel has been evaluated in an effort to further reduce risk. In the Management of Atherothrombosis with Clopidogrel in High-risk Patients trial, the combination of clopidogrel plus aspirin was compared with clopidogrel alone, and the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance trial tested the addition of clopidogrel to aspirin. Combination therapy with aspirin plus clopidogrel provided no significant incremental benefit compared with aspirin or clopidogrel alone. In addition, combination therapy increased the risk of serious bleeding. On the basis of the current totality of evidence for long-term treatment of survivors of ischemic stroke or TIA, clopidogrel is an effective alternative for patients who are intolerant to aspirin.

Silent Ischemic Lesion Recurrence on Magnetic Resonance Imaging Predicts Subsequent Clinical Vascular Events

Previous studies identified a high frequency of silent ischemic lesion recurrence on magnetic resonance imaging (MRI) after an index stroke. To investigate whether ischemic lesion recurrence on MRI predicts subsequent clinical events. Retrospective cohort study. General community hospital. Patients We recruited 120 patients who experienced an acute ischemic stroke (IS) and who underwent initial MRI within 24 hours of onset and subsequent MRI on day 5. Of those patients, 68 underwent follow-up MRI up to 90 days after onset. Early silent lesion recurrence was defined as new asymptomatic ischemic lesions on 5-day MRI, and late silent lesion recurrence was defined as those on 30- or 90-day MRI. Patients were followed up for recurrent vascular events by interviews. Among the 104 patients (86.7%) who had available clinical outcome data, 35 (33.7%) had early silent lesion recurrence; 15 (22.1%) of 68 patients had late silent lesion recurrence. Of the patients, 8 experienced a recurrent IS, 3 experienced a transient ischemic attack, and 3 had vascular deaths during a mean +/- SD follow-up of 19.3 +/- 9.0 months. For recurrent IS as a clinical end point, late silent lesion recurrence independently predicted recurrent IS (odds ratio, 6.55; 95% confidence interval, 1.09-39.55) by the Cox proportional hazards model. For combined clinical end points, early (odds ratio, 3.19; 95% confidence interval, 1.02-10.00) and late (odds ratio, 8.09; 95% confidence interval, 1.29-50.91) silent lesion recurrences independently predicted clinical recurrent IS, transient ischemic attack, or vascular deaths. These data suggest that silent ischemic lesion recurrence on MRI may be a potential surrogate marker of clinical recurrence.

Differential risks of subsequent vascular events for transient ischaemic attack and minor ischaemic stroke

Using a prospective hospital-based registry, 146 patients with transient ischaemic attack (TIA) were compared with 376 patients with minor first-ever ischaemic stroke with respect to the 3-month risk of subsequent vascular events, in order to clarify the distinctions between the disease entities. All patients were enrolled within 48 h of onset. The risk factor distribution for the two groups was comparable, except that the TIA patients had more previous TIAs. Large artery atherosclerosis (34%) and small vessel occlusion (32%) were the main aetiologies in the TIA group, whereas small vessel occlusion (49%) was the major cause in the stroke group. The 3-month risk of combined endpoints of stroke, myocardial infarction, and vascular death for TIA patients was higher than that for the minor stroke group (15.1% vs. 3.2%; hazard ratio 4.6, 95% confidence interval 2.3–9.3 in multivariate analysis). Large artery atherosclerosis and male sex were the other significant predictors. TIA may demand more urgent management than minor stroke. The fact that aetiology is a predictor, highlights the need for rapid diagnostic tests to establish pathogenesis.

Characteristics and six-month outcomes in a cohort of 8288 diabetic and non-diabetic patients with previous history of acute coronary syndrome or stroke: the French PREVENIR 3 survey

To evaluate the cardiovascular prognosis of 1845 Diabetic Patients (DP) and 6443 Non-Diabetic Patients (NDP) in secondary prevention. Patients were recruited prospectively if they had had a previous history of ischemic stroke or acute coronary syndrome (ACS) i.e. Myocardial Infarction (MI) or Unstable Angina (UA) within a period of five years preceding inclusion. For each patient, the number of hospitalizations and vital status were recorded each month over a 6-month period (mean follow-up: 4.8 months). 306 patients (9.5/100--person years; 95% CI, 8.5 to 10.6) had undergone at least one subsequent event (hospitalization for ACS, ischemic stroke, or cardiovascular death). A majority of these events were non-fatal ACS (n=248). The cumulative incidence rate of subsequent events was higher in DP: 12.6/100- person years (10.0 to 15.2) than in NDP: 8.6/100--person years (7.5 to 9.8). DP were significantly at higher risk of subsequent cardiovascular events (OR: 1.34; P=0.025) after adjustment for confounding factors. 93% of coronary DP and NDP underwent a recurrent event affecting the same location. When the index episode was a stroke, 71% of DP had a subsequent stroke vs. 47% of NDP. in secondary prevention, the risk of mortality and subsequent vascular events is independently higher in French DP than in NDP. The locations affected by each type of subsequent cardiovascular event seemed correlated to the baseline diagnosis, whatever the diabetic status, even when the frequency of subsequent strokes increased (not significantly) in DP when compared to NDP.

Can the Central Sympathetic Blockade Profile be Advantageous in the Management of Patients with Metabolic Syndrome?

Metabolic syndrome, the association of obesity, hypertension and hyperlipidaemia in conjunction with impaired glucose tolerance or frank diabetes, is a rising global pattern and has been subjected to a useful consensus re-definition in recent months. Its origins are fixed in changing dietary and activity patterns across the developed world but also increasingly affecting all developing economies. The obvious sequelae of this spiraling pattern are increases of atherosclerotic vascular disease and subsequent occlusive vascular events, morbidity and premature mortality for affected patients. Given its emerging importance we should consider carefully the role of the sympathetic nervous system in the overlapping management of the pathophysiology of obesity and hypertensive vascular disease; the recognition of the metabolic syndrome and its definition in practice; and whether new trial results pertinent to managing hypertension in the overweight patient with metabolic syndrome using the central imidazoline antagonist drug, moxonidine, might prompt reconsideration of this established strategy for lowering blood pressure.