Understanding Of Cardiovascular Disease Research Articles

Reducing the Cardiovascular Disease Burden

Better understanding of cardiovascular disease (CVD) presentation and pathophysiology has led to the development of remarkable advances in the prevention and treatment of CVD and stroke, and recent data have shown a fall in trends of mortality from CVD.1 Nevertheless, CVD has remained the leading cause of mortality and morbidity at the beginning of the third millennium, accounting for 1 in every 3 deaths in the United States.2,3 More than 2 million Americans suffer from CVD or stroke each year.2 According to US 2008 mortality data, 1 person dies of cardiovascular disease every 39 seconds.3 Besides being a major cause of demise and disability, CVD is associated with enormous costs. If the current trends for cardiovascular disease continue, nearly 40% of the US population will experience some form of CVD, with estimated direct and indirect costs exceeding $1 trillion annually.4 The Million Hearts Initiative (MHI) is an ambitious national campaign that aims to reduce the incidence of CVD and stroke. Led by the Department of Health and Human Services, in collaboration with multiple governmental and private sector organizations, MHI will foster nationwide efforts to target major cardiovascular risk factors including hypertension, dyslipidemia, smoking, and obesity, as well as encouraging the implementation of preventive measures such as prescription of aspirin to patients at risk of CVD or stroke. Efforts will also be made to work with the food industry for reduction of trans fat moieties from food products. Similarly, MHI aims to reduce the salt intake of Americans, by a variety of strategies, including educational initiatives and pushing for extensive disclosure of sodium content on food packaging. By addressing such key risk factors, MHI aims to prevent 1 million myocardial infarctions and strokes over the next 5 years.2,5 Table 1 summarizes …

Public knowledge and awareness of cardiovascular disease and its risk factors: a cross-sectional study of 1000 Jordanians

To assess the level of the current knowledge and understanding of cardiovascular disease (CVD) among Jordan's general public, their behaviour towards CVD and the factors associated with different CVD knowledge levels. The data in the present study were collected using an interview-administered questionnaire. One thousand members of the general public were interviewed face to face. CVD knowledge was computed as a continuous variable. The present study reports limited public knowledge and awareness of CVD. Participants were more likely to have better CVD knowledge scores if they were non-smokers, always or often paid attention to their diet, reported having an 'about right' weight, occupied a very high socioeconomic level, held a university degree and had positive family history of CVD. Participants indicated that the community pharmacists had to play a role in helping patients manage their prescribed medicines; however, they did not recognise the community pharmacists' role in other areas of CVD prevention and management. The present study reports that the general public in Jordan has limited knowledge and awareness of CVD. In planning to positively impact CVD prevention and management, community pharmacists must develop and promote effective and accessible services.

2012 Theme Issue on Cardiovascular Disease

OVER THE PAST CENTURY AS THE WEST TRANSItioned from an agrarian to an industrial economy, the nature of the dominant diseases afflicting humans changed from communicable to chronic conditions. During this epidemiologic transition, cardiovascular disease has ascended from an uncommon problem to its current position as the number one cause of death and disability worldwide. This transformation of human disease is continuing as regional economies develop and the global population ages. In many highincome countries the onset of some cardiovascular events is being delayed from middle to older age and more people are living longer with various forms of cardiovascular disease. In middleand lower-income countries the ascendancy of cardiovascular disease has been more rapid than in the West. Although some progress has been made in parts of the world in reversing trends in certain cardiovascular risk factors, major risk factors such as obesity are still on the rise globally. The emergence of this cardiovascular disease epidemic has led to amazing advances in understanding of its pathophysiology and improvements in treatment. Health care systems have evolved to deal with acute manifestations of chronic diseases, such as myocardial infarction and stroke, improving survival and lessening disability. Secondary preventive strategies such as -blockers and angiotensin-converting enzyme inhibitors have improved long-term management. Preventive and public health measures (eg, diet modification and exercise) have reduced the rates of incident myocardial infarction and stroke in the West. However, the challenges to deal with this global burden of risk factors and cardiovascular disease remain substantial. In November, as clinicians and scientists gather to exchange information and ideas about virtually all aspects of cardiovascular disease at the American Heart Association’s Scientific Sessions, JAMA will publish a theme issue on cardiovascular disease. We at JAMA view this as an opportunity to share with our worldwide readers, listeners, and viewers important new findings on understanding of cardiovascular disease as well as of major challenges and future directions in its prevention, treatment, and longer-term management. As we plan for this theme issue, authors are invited to submit manuscripts on any topic related to cardiovascular disease for consideration for this JAMA theme issue. A high priority will be given to manuscripts reporting results of major late-breaking clinical trials and other high-impact studies that will be presented at the American Heart Association’s Scientific Sessions. These will be considered for simultaneous release at the time of the presentation. We are interested in high-quality clinically relevant original research that includes multicenter randomized trials and large-scale observational epidemiological studies. We also welcome scholarly work addressing how to expedite the adoption of effective cardiac therapies into clinical settings. Manuscripts on comparative effectiveness, application of cardiovascular disease treatments in clinical settings, prevention, and novel work that expands understanding of the mechanistic underpinnings of cardiovascular disease will be considered. The effect of cardiovascular disease around the globe is also important to our readers. Interested authors should consult the Instructions for Authors for guidelines on preparation and submission of manuscripts. All submitted manuscripts will undergo JAMA’s usual rigorous editorial review and evaluation. Manuscripts received by July 1, 2012, will have the best chance for inclusion in the 2012 JAMA theme issue on cardiovascular disease. We encourage authors who anticipate presentation of late-breaking studies to communicate with editorial staff as early as possible.

Auto‐antibodies: diagnostic tools in acute myocardial infarction?

Auto‐antibodies: diagnostic tools in acute myocardial infarction?

Thrombin Receptor Activation Work Wins 2011 Lucian Award

For more than 30 years, the Lucian Award for Research in Circulatory Disease has recognized the contribution of an investigator or team whose work has had a significant impact on our understanding of cardiovascular disease. Designed to promote innovative research and a collaborative spirit, the 35th Lucian Award was awarded last summer at McGill University in Montreal, Quebec. ### The Lucian Award Created in 1965 by a $2 million bequest of Olga Leibovici in honor of her two brothers, Louis and Artur Lucian, the Lucian Award is a $60,000 CDN prize that was first awarded in 1978. The terms of the bequest state that McGill University or its representative will use part of the income from the original $2 million endowment to create the Louis and Artur Lucian Award. “Very specifically, it should be given to the best work recently published related to diseases of the cardiovascular system,” explains Jacques Genest MD, FRCP(C), Professor, Faculty of Medicine at McGill University, and Scientific Director, Center for Innovative Medicine at the Research Institute at the McGill University Health Center, and current Chair of the Lucian Selection committee. “As such, this award has had a huge influence over the course of the last nearly 40 years.” Each year the Lucian Award jury, which is composed of a mix of past Lucien Award recipients and former graduates or current faculty of McGill University, meets to review the approximately 20 to 30 applications received each year. “It was a very tough choice this year. We had truly outstanding applicants,” says Dr Genest. This year's winner is Shaun Coughlin, MD, PhD, of the University of California, San Francisco Cardiovascular Research Institute, whose laboratory studies signaling mechanisms involved in cardiovascular biology and disease. Dr Coughlin was awarded the prize for his work on how proteases regulate cellular behaviors and the importance …

SLEEP DURATION DOES NOT PREDICT MAJOR ADVERSE CARDIAC EVENTS IN THE SWEDISH NATIONAL MARCH COHORT STUDY

Introduction and Objectives: Experimental research suggests that sleep deprivation may alter physiological factors associated with an increased risk for cardiovascular diseases (CVDs). Prior observational studies examining the effects of sleep duration have focused on narrowly defined CVD outcomes, such as myocardial infarction or stroke only. A more comprehensive measure of CVDs is lacking. Therefore, we examined the relationship between sleep duration and Major Adverse Cardiac Events (MACE).Materials and Methods: In 1997, 39,047 Swedish residents (women: 64%, age: 18-94 years) were enrolled in the National March cohort study and asked to self-report their habitual sleep duration in a questionnaire. They were followed-up over approximately 7 years to study incidents of MACE. Events were defined as death from all CVDs, nonfatal myocardial infarction, stroke, or heart failure. The relationship between sleep duration and MACE was analyzed using Cox proportional hazards models.Results: A total of 1,730 events were observed during a median follow-up period of 7.25 years. We found 665 nonfatal myocardial infarctions, 641 nonfatal strokes, 212 nonfatal heart failures, and 198 deaths from all CVDs. Age- and sex-adjusted hazard ratios (95% confidence intervals) of MACE (with 7 hours of sleep/day as the reference group) for individuals reporting ≤5, 6, and ≥ 8 hours of sleep were 1.24 (1.05-1.47), 1.03 (0.91-1.16), and 1.09 (0.97-1.23), respectively. Adjusting for BMI and physical activity did not change the hazard ratios. When adjusting for additional confounders, e.g., depressive symptoms, sleep apnea, and smoking, the association between ≤5h of sleep and MACE was attenuated (HR: 1.22, 95% CI: 0.98-1.52).Conclusion: Sleep duration was not associated with the risk of Major Adverse Cardiac Events. Sleep duration, however, may not in itself explain the effects of inadequate sleep on cardiovascular diseases. Yet, it may serve as an essential component in the understanding of cardiovascular diseases. Copyright © 2011 Elsevier B.V. All rights reserved.

Cardiovascular Disease in US Firefighters

Cardiovascular disease (CVD) is the leading cause of on-duty death among firefighters (45% of on-duty fatalities) and a major cause of morbidity. CVD in the fire service also has adverse public safety implications as well as significant cost impacts on government agencies. Over the last decade, our understanding of CVD among firefighters has significantly improved and provides insight into potential preventive strategies. The physiology of cardiovascular arousal and other changes that occur in association with acute firefighting activities have been well-characterized. However, despite the strenuous nature of emergency duty, firefighters' prevalence of low fitness, obesity, and other CVD risk factors are high. Unique statistical approaches have documented that on-duty CVD events do not occur at random in the fire service. They are more frequent at certain times of day, certain periods of the year, and are overwhelmingly more frequent during strenuous duties compared with nonemergency situations. Moreover, as expected on-duty CVD events occur almost exclusively among susceptible firefighters with underlying CVD. These findings suggest that preventive measures with proven benefits be applied aggressively to firefighters. Furthermore, all fire departments should have entry-level medical evaluations, institute periodic medical and fitness evaluations, and require rigorous return to work evaluations after any significant illness. Finally, on the basis of the overwhelming evidence supporting markedly higher relative risks of on-duty death and disability among firefighters with established coronary heart disease, most firefighters with clinically significant coronary heart disease should be restricted from participating in strenuous emergency duties.

Improving Stroke Prevention in the French West Indies

We sought to evaluate lay knowledge and understanding of cardiovascular diseases in the French West Indies. In 2007, a cross-sectional study of 1005 randomly selected men and women (54%) age 25 to 74 years from Guadeloupe and stratified by sex, age, and region was established to ascertain the population's knowledge and awareness of chronic diseases. Questions were asked about the respondent's knowledge of cardiovascular risk factors as well as their opinions and beliefs about measures to prevent these diseases. Knowledge about stroke prevention in this sample was lower than for heart disease, with 69% of women and 65% of men reporting that precautions can be taken to avoid a stroke versus 84% and 77%, respectively, for heart disease. "Avoid stress" was the most commonly cited stroke prevention measure, with 35% of women and 27% of men reporting it. The first spontaneous item cited for heart disease prevention was "physical exercise or sport," reported by 47% of women and 45% of men. We hypothesize that knowledge of stroke and stroke risk factors is poor in Guadeloupe or that it reflects culturally adapted health promotion messages from doctors. Knowledge and awareness were found to be lower for stroke than for heart diseases. Changes in health promotion strategies are required in the French West Indies to improve the population's overall awareness of these diseases and to narrow the gap between knowledge and practice.

Expression and regulation of a low‐density lipoprotein receptor exon 12 splice variant

As low-density lipoprotein receptor (LDLR) contributes to cholesterol and amyloid beta homeostasis, insights into LDLR regulation may facilitate our understanding of cardiovascular disease and Alzheimer's disease. Previously, we identified LDLR isoforms that lacked exon 12 or exons 11-12 and that are predicted to encode soluble, dominant negative, LDLR. Moreover, these isoforms were associated with rs688, an exon 12 polymorphism that was associated with LDL-cholesterol and Alzheimer's disease risk. In this study, we present evidence that although the truncated LDLR isoforms are translated in vitro, they represent < 0.1% of CSF proteins. As these LDLR isoforms likely represent a loss of mRNA-encoding functional LDLR, we then focused upon identifying intron-exon boundary and exonic splicing enhancer elements critical to splicing. Exon 12 inclusion is enhanced by altering the 5' splice site in intron 12 towards a consensus splice donor sequence, consistent with its being a weak 5' splice site. Additionally, of the nine evolutionarily conserved putative splicing enhancer regions within exon 12, two regions that flank rs688 were critical to exon 12 inclusion. Overall, these results suggest that LDLR splice variants represent a loss of mRNA encoding functional LDLR and provide insights into the regulatory elements critical for LDLR exon 12 splicing.

Toward Metabolomic Signatures of Cardiovascular Disease

Small biochemicals are the end result of all the regulatory complexity present in a cell, tissue, or organism, including transcriptional regulation, translational regulation, and posttranslational modifications. Metabolic changes are thus the most proximal reporters of the body’s response to a disease process or drug therapy. In 1971, Robinson and coworkers1 conceived the core idea that information-rich data reflecting the functional status of a complex biological system resides in the quantitative and qualitative pattern of metabolites in body fluids. In the same year, Horning and Horning2 first used the term metabolic profiling to describe the output of a gas chromatogram from a patient sample. This new approach to the quantitative metabolic profiling of large numbers of small molecules in biofluids was ultimately termed “metabonomics” by Nicholson et al3 and “metabolomics” by others. Article see p 207 Two core technologies are used to perform metabolic profiling: nuclear magnetic resonance and tandem mass spectrometry (MS/MS), as previously reviewed in Circulation: Cardiovascular Genetics. 4 Nuclear magnetic resonance requires relatively little sample preparation and is nondestructive, allowing for subsequent structural analyses. However, the method tends to have low sensitivity and can detect only highly abundant analytes. Tandem mass spectrometry (MS/MS), coupled with liquid chromatography, on the other hand, has much higher sensitivity for small molecules and is also applicable to a wide range of biological fluids (including serum, plasma, and urine). Recent advances in MS technology now enable researchers to determine analyte masses with such high precision and accuracy that metabolites can be identified unambiguously even in complex fluids. These technologies can be used to characterize biological samples either in a targeted manner or in a pattern discovery manner. In the former, the investigator targets a predefined …

Knowledge of Cardiovascular Health Among Chinese, Korean and Vietnamese Immigrants to the US

Cardiovascular disease (CVD) is the leading cause of death among Asian Americans, the majority of whom are foreign-born. However, CVD and risk factor data is sparse for specific Asian immigrant populations. To assess knowledge and understanding of CVD and risk factors within Chinese, Korean and Vietnamese immigrant populations, we conducted eight focus groups of 77 participants between 36 and 84 years old. Participants correctly identified signs and symptoms for heart attacks while knowledge about stroke was incomplete. While poor diet, lack of exercise, older age, and high cholesterol were frequently discussed as risk factors, mechanisms perceived as contributing to heart disease were influenced primarily by non-Western paradigms. Non-Western remedies were discussed in detail among Chinese and Vietnamese participants. All participants desired more information, and identified barriers to effective communication with healthcare providers. A deeper understanding of beliefs and barriers faced by Asian immigrants can help guide health promotion efforts.

Perceptions and predictions of cardiovascular disease of Alabama women in a rural county

Purpose The aim of this project was to gain a better understanding of cardiovascular disease (CVD) as a women's health issue among Alabama women in a rural county. Research Questions 1. What are the risks and perceptions of CVD of Alabama women in a rural county? 2. What demographic and study variables predict CVD? Methods One hundred twelve women participated in this descriptive, prospective study. Findings Thirty percent identified CVD as the greatest health problem facing women and the leading cause of death in women. Ninety percent believed that they had a 41% or greater chance of developing CVD. The variables in the study explained 60% of the participant's coronary heart disease risk prediction scores. Conclusions The understanding gained in this study will be used to find ways to increase the awareness of CVD and to design interventions that improve the cardiovascular health of women in a rural area of Alabama.

Myocardial Biomarkers for Prediction of Cardiovascular Disease

The identification of those persons in the population who have the highest risk of future cardiovascular events is important for targeting intensive preventive efforts. This can be reliably done using a handful of long since established risk factors. The unmet need for new molecular biomarkers for prediction of cardiovascular events in the general population is therefore low. In order for a new biomarker to be used clinically for risk prediction, a statistically significant association of levels of the biomarker to adverse outcome is not enough, but the biomarker should also be demonstrated to add discriminative capacity beyond established risk factors. In contrast to the limited value of new biomarkers for risk prediction, their usefulness for unraveling the pathophysiology of cardiovascular disease is large. The myocardium is the source of a vast number of interesting biomarkers, of which a few may be useful for risk prediction in the general population. Two of these, troponin-I and the N-terminal fragment of brain natriuretic peptide, have passed tests of added discriminatory value. Numerous other biomarkers produced by cardiomyocytes or non-cardiomyocytes in the myocardium are promising, and if they are not proven useful for risk prediction, they will unquestionably enhance our understanding of cardiovascular disease.

Myocardial biomarkers for prediction of cardiovascular disease.

The identification of those persons in the population who have the highest risk of future cardiovascular events is important for targeting intensive preventive efforts. This can be reliably done using a handful of long since established risk factors. The unmet need for new molecular biomarkers for prediction of cardiovascular events in the general population is therefore low. In order for a new biomarker to be used clinically for risk prediction, a statistically significant association of levels of the biomarker to adverse outcome is not enough, but the biomarker should also be demonstrated to add discriminative capacity beyond established risk factors. In contrast to the limited value of new biomarkers for risk prediction, their usefulness for unraveling the pathophysiology of cardiovascular disease is large. The myocardium is the source of a vast number of interesting biomarkers, of which a few may be useful for risk prediction in the general population. Two of these, troponin-I and the N-terminal fragment of brain natriuretic peptide, have passed tests of added discriminatory value. Numerous other biomarkers produced by cardiomyocytes or non-cardiomyocytes in the myocardium are promising, and if they are not proven useful for risk prediction, they will unquestionably enhance our understanding of cardiovascular disease.

New cardiovascular risk determinants do exist and are clinically useful

Can we improve our understanding of cardiovascular disease (CVD) causality and prediction? Intuitively, we can. Recent publications, however, could be misinterpreted as suggesting the opposite. First, the Interheart study, which concluded that nine conventional risk factors explain >90% of premature myocardial infarction, is at risk for being interpreted as saying that other, 'new' cardiovascular risk factors can only cause a small remaining fraction of disease of at most 10%. Secondly, papers addressing the predictive value of new risk factors or markers of early CVD risk have concluded that risk prediction does not improve by adding these variables to risk models. In this paper, we will explain that searching for 'new causes' of CVD is still highly relevant, and that improvement of risk prediction is often assessed using inappropriate statistical methodology.

Asymmetric dimethylarginine and impaired cardiovascular healing

Asymmetric dimethylarginine (ADMA) typically accumulates in the plasma of patients with chronic renal failure. Moreover, its plasma levels are raised in the presence of virtually all of the traditional cardiovascular risk factors. ADMA inhibits the three isoforms of nitric oxide (NO) synthase, thereby blunting the known cardioprotective effects of NO. Through its NO inhibitor actions, ADMA also exerts pro-apoptotic effects and suppresses progenitor cell mobilization, differentiation and function. Among patients with ischemic heart disease, low progenitor cell bioavailability and kidney dysfunction are emerging as strong predictors of death and recurrent cardiovascular events. We propose that patients with ischemic heart disease, kidney dysfunction, and high risk factor burden exhibit adverse cardiovascular outcomes, at least in part, through ADMA-mediated NO depression, enhanced apoptotic signalling, and reduced progenitor cell bioavailability, with consequent blunting of cardiovascular healing. Further research into the mechanisms that regulate the NO/ADMA balance may advance our understanding of cardiovascular diseases.

Isoform-specific functions of protein kinase C: the platelet paradigm

Platelets are central to haemostasis and thrombosis. Many key steps in platelet activation and aggregation are regulated by members of the PKC (protein kinase C) family. Multiple isoforms of PKC are expressed in platelets, and evidence is emerging that different isoforms play distinct roles in the platelet activation process. This may, in part, be regulated by isoform-specific interactions between PKC family members and other intracellular signalling molecules, such as tyrosine kinases, or the actin cytoskeleton regulator, VASP (vasodilator-stimulated phosphoprotein). The contributions of individual PKC isoforms can be addressed directly in platelets from knockout mouse models, which are providing key insights into the physiological function of PKC isoform diversity and can be a valuable complimentary approach to more commonly used pharmacological analyses. Using knockout mouse models, recent reports have demonstrated the importance of PKCbeta and PKCtheta in integrin-dependent platelet spreading, and also a novel role for PKCdelta in regulating filopodial formation, highlighting the utility of such models to investigate the functions of specific PKC isoforms in a physiological process that is significant to our understanding of cardiovascular disease.

Clinical evidence for anti-inflammatory effects of antiplatelet therapy in patients with atherothrombotic disease

Recent advances in our understanding of cardiovascular disease have revealed that atherothrombotic events, such as myocardial infarction and ischemic stroke, are the end result of a complex inflammatory response to multifaceted vascular pathology. As well as initiating thrombus formation at the site of a ruptured atherosclerotic plaque, platelets play a key role in vascular inflammation, through release of their own pro-inflammatory mediators and interactions with other relevant cell types (endothelial cells, leukocytes, and smooth muscle cells). An increasing body of literature shows that inflammatory biomarkers can be used to predict atherothrombotic risk and that antiplatelet therapy may reduce the levels of these markers. Acetylsalicylic acid (ASA) has been attributed with reducing levels of the transcription factor nuclear factor kappaB (NF-kappaB), C-reactive protein, and soluble CD40 ligand, although the evidence relating to the latter two markers is conflicting. There is also substantial evidence that therapy with clopidogrel, a specific antagonist of the platelet P2Y12 ADP-receptor, also leads to reductions in serum levels of CD40 ligand, C-reactive protein, P-selectin, and platelet-leukocyte aggregate formation. Beneficial effects of clopidogrel on inflammatory markers have been demonstrated across the spectrum of atherothrombotic disease (acute coronary syndrome patients, patients undergoing percutaneous coronary intervention (PCI), acute ischemic stroke patients, and those with peripheral arterial disease). Oral glycoprotein (GP) IIb/IIIa receptor antagonists, at doses that achieve moderate levels of receptor blockade, may paradoxically be associated with platelet-mediated pro-inflammatory effects. A similar phenomenon has been observed with intravenous GP IIb/IIIa antagonists in vitro, but most often at low doses, and data from clinical studies suggest that these agents may actually attenuate release of inflammatory mediators when administered at doses producing more complete receptor blockade.

ACE Inhibition in Hypertension

Ongoing developments in our understanding of cardiovascular disease, together with the introduction of new drugs to treat these conditions, has led to much debate over the optimal management of hypertension. The ALLHAT study showed no major differences in cardiovascular outcome among three major classes of antihypertensive drugs. Indeed, large meta-analyses have substantiated this view, and most experts would agree that BP reduction matters more than the choice of antihypertensive agent. However, recently published data from the ASCOT-BPLA trial for hypertensive patients at moderate risk of cardiac events have caused some experts to re-evaluate this view. The recent Blood Pressure Lowering Treatment Trialists' Collaboration publication confirmed this change. In the ASCOT-BPLA trial, antihypertensive therapy based on amlodipine+perindopril significantly reduced total and cardiovascular mortality as well as other clinically relevant outcomes in comparison with a traditional strategy based on atenolol and a thiazide diuretic, despite both regimens producing nonsignificantly different reductions in brachial BP. These findings suggest that amlodipine/perindopril may exert a beneficial effect by acting on other parameters such as central BP or BP variability. ACE inhibitors have been shown to have antiatherosclerotic and antithrombogenic effects, to improve endothelial dysfunction, and to prevent cardiac remodeling in patients with coronary heart disease. In this regard, perindopril, which has relatively high affinity for ACE and true 24-hour duration of action, is one of the most extensively studied ACE inhibitors. More recent data suggest that ACE inhibitors reduce arterial stiffness, an independent risk factor for cardiovascular events, and have a beneficial effect on central aortic BP, thus providing a possible explanation for the findings of ASCOT-BPLA and confirming that ACE inhibitors are an appropriate first choice for patients with hypertension.

Efficient anisotropic adaptive discretization of the cardiovascular system

We present an anisotropic adaptive discretization method and demonstrate how computational efficiency can be increased when applying it to the simulation of cardiovascular flow. We further propose a new adaptive approach which controls the mesh adaptation procedure to maintain structured and graded elements near the wall resulting in a more accurate wall shear stress computation. To perform mesh adaptation for hemodynamic flows, a single mesh metric field is constructed for the whole cardiac cycle. Two alternative approaches are applied, one in which a metric field is constructed based on the average flow whereas in the other approach the metric field is obtained by intersecting metric fields computed at specified instants in the cycle. We apply the method to the case of a 3D branching vessel model. The efficiency of our approach is measured by analyzing the wall shear stress, a challenging but important quantity in the understanding of cardiovascular disease. The general anisotropic adaptivity based on metric intersection achieves over an order of magnitude reduction in terms of degrees of freedom when compared to uniform refinement for a given level of accuracy.