Improving risk factor modification: A global approach

Serum uric acid as a prognostic marker in the setting of advanced vascular disease: a prospective study in the elderly

Background

Many epidemiological studies analyze the relationship between hyperuricemia and cardiovascular outcomes. This observational prospective study investigates the association of serum uric acid (SUA) levels with adverse cardiovascular events and deaths in an elderly population affected by advanced atherosclerosis.

Methods

Two hundred and seventy six elderly patients affected by advanced atherosclerosis (217 males and 59 females; aged 71.2 ± 7.8 years) were included. All patients were assessed for history of cardiovascular disease, cancer, obesity and traditional risk factors. Patients were followed for approximately 31 ± 11 months. Major events were recorded during follow-up, defined as myocardial infarction, cerebral ischemia, myocardial and/or peripheral revascularization and death.

Results

Mean SUA level was 5.47 ± 1.43 mg/dL; then we further divided the population in two groups, according to the median value (5.36 mg/dL). During a median follow up of 31 months (5 to 49 months), 66 cardiovascular events, 9 fatal cardiovascular events and 14 cancer-related deaths have occurred. The patients with increased SUA level presented a higher significant incidence of total cardiovascular events (HR: 1.867, P = 0.014, 95% CI: 1.134–3.074). The same patients showed a significant increased risk of cancer-related death (HR: 4.335, P = 0.025, 95% CI: 1.204–15.606).

Conclusions

Increased SUA levels are independently and significantly associated with risk of cardiovascular events and cancer related death in a population of mainly elderly patients affected by peripheral vasculopathy.

Primary Prevention of Cardiovascular Disease

Cardiovascular disease (CVD) is a spectrum of disorders that includes stroke, coronary heart disease (CHD) and peripheral vascular disease (PVD). CVD is the UK's biggest cause of death, with over 191 000 deaths a year. The extent to which CVD affects the health of the population and the financial burden this places on the National Health Service (NHS) makes it an important modifiable disease. Preventing CVD is now a significant role of the general practice team.

An essential role for diet in exercise-mediated protection against dyslipidemia, inflammation and atherosclerosis in ApoE⁻/⁻ mice

BACKGROUND

Diet and exercise promote cardiovascular health but their relative contributions to atherosclerosis are not fully known. The transition from a sedentary to active lifestyle requires increased caloric intake to achieve energy balance. Using atherosclerosis-prone ApoE-null mice we sought to determine whether the benefits of exercise for arterial disease are dependent on the food source of the additional calories.

METHODS AND RESULTS

Mice were fed a high-fat diet (HF) for 4.5 months to initiate atherosclerosis after which time half were continued on HF while the other half were switched to a high protein/fish oil diet (HP). Half of each group underwent voluntary running. Food intake, running distance, body weight, lipids, inflammation markers, and atherosclerotic plaque were quantified. Two-way ANOVA tests were used to assess differences and interactions between groups. Exercised mice ran approximately 6-km per day with no difference between groups. Both groups increased food intake during exercise and there was a significant main effect of exercise F((1,44) = 9.86, p<0.01) without interaction. Diet or exercise produced significant independent effects on body weight (diet: F(1,52) = 6.85, p = 0.012; exercise: F(1,52) = 9.52, p<0.01) with no significant interaction. The combination of HP diet and exercise produced a greater decrease in total cholesterol (F(1, 46) = 7.9, p<0.01) and LDL (F(1, 46) = 7.33, p<0.01) with a large effect on the size of the interaction. HP diet and exercise independently reduced TGL and VLDL (p<0.05 and 0.001 respectively). Interleukin 6 and C-reactive protein were highest in the HF-sedentary group and were significantly reduced by exercise only in this group. Plaque accumulation in the aortic arch, a marker of cardiovascular events was reduced by the HP diet and the effect was significantly potentiated by exercise only in this group resulting in significant plaque regression (F1, 49 = 4.77, p<0.05).

CONCLUSION

In this model exercise is beneficial to combat dyslipidemia and protect from atherosclerosis only when combined with diet.

Changes in lipid and carnitine concentrations following repeated fasting-refeeding in mice

The purpose of this study was to evaluate the effects of repeated fasting and refeeding on lipid metabolism. Thirty male ICR mice, aged 6 weeks, were fed an AIN-93 control diet during the experimental period. The mice were divided into 5 groups: Non fasting group (ad libitum-fed, NF), fasting for 3 days (F), fasting for 3 days and then refeeding for 4 days repeated once (FRF1), fasting for 3 days and then refeeding for 4 days repeated twice (FRF2), and fasting for 3 days and then refeeding for 4 days repeated three times (FRF3). Rates of body weight gain, epididymal fat weight, and serum TG were significantly decreased in the F, FRF1, FRF2, and FRF3 groups, compared to the NF group. LDL-cholesterol was significantly higher in the FRF3 group than the NF and F groups, but HDL-cholesterol and HDL/TC were significantly lower in the FRF3 group than in the NF and F groups. Serum total carnitine was significantly lower in the FRF1, FRF2, FRF3 groups than the NF and F groups. However, rates of serum and hepatic acyl-carnitine concentration were significantly lower in FRF1, FRF2, and FRF3 than in NF and F. Repeated fasting-refeeding resulted in visible reductions of body weight and fat mass, but it caused ill-effects with lipid and carnitine metabolism in the body.

Barriers to cardiovascular disease risk scoring and primary prevention in Europe

The prevalence and burden of cardiovascular disease (CVD) is high, and it remains the leading cause of death worldwide. Unfortunately, many individuals who are at high risk for CVD are not recognized and/or treated. Therefore, programs are available to ensure individuals at risk for CVD are identified through appropriate risk classification and offered optimal preventative interventions. The use of algorithms to determine a global risk score may help to achieve these goals. Such global risk-scoring algorithms takes into account the synergistic effects between individual risk factors, placing increases in individual risk factors into context relative to the overall disease, allowing for a continuum of disease risk to be expressed, and identifying patients most likely to derive benefit from an intervention. The predictive value of risk scoring such as using the Framingham equation is reasonable, analogous to cervical screening, with area under the receiver operated characteristic curve a little over 70%. However, limitations do exist, and as they are identified adjustments can be made to the global risk-scoring algorithms. Limitations include patient-specific issues, such as variations in lifetime risk level, ethnicity or socio-economic strata, and algorithm-specific issues, such as discrepancies between different algorithms arising from varying risk factors evaluated. The use of currently developed algorithms is low in general practice, in part, because of the belief that the assessment may oversimplify the risk and/or lead to medication overuse. Additional hindrances to the use of risk scoring include government or local health policy, patient compliance issues and lack of time. A thorough, easy-to-use, and standardized tool for risk estimation would allow for improvements in the primary prevention of CVD.