Prevalence of coronary artery disease in a general population without suspicion of coronary artery disease: angiographic analysis of subjects aged 40 to 70 years referred for catheter ablation therapy

Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs

Sexual health has a fundamental role in overall health and well-being, and a healthy and dynamic sex life can make an important contribution to a good quality of life. Sexual dysfunction, and especially erectile dysfunction (ED) in men, is highly prevalent in patients with cardiovascular disease (CVD). CVD and ED have shared risk factors and pathophysiological links, such as endothelial dysfunction, inflammation and low plasma testosterone levels. ED has been shown to be an independent and early harbinger of future CVD events, providing an important window to initiate preventive measures. Therefore, screening and diagnosing ED is essential for the primary and secondary prevention of CVD because the assessment of ED offers an easy and low-cost prognostic tool that is an alternative to other investigational cardiovascular biomarkers. Moreover, ED is a major contributing factor to the discontinuation of, or poor adherence to, cardiovascular therapy. Cardiovascular drugs have divergent effects on erectile function, with diuretics and β-blockers having the worst profiles, and renin-angiotensin-aldosterone system inhibitors and nebivolol having the best profiles. Pharmacological treatment of ED has an equivocal effect on the risk of CVD, suggesting a complex interaction between ED and drugs for CVD. In this Review, we discuss how sexual function could be incorporated into the patient history taken by physicians treating individuals with CVD, not merely as part of the diagnostic work-up but as a means to pursue tangible and essential benefits in quality of life and cardiovascular outcomes.

Low risk patients with acute atrial fibrillation and elevated high-sensitivity troponin do not have increased incidence of pathological stress tests

OBJECTIVES

Many patients with atrial fibrillation (AF) or atrial flutter (AFL) and rapid ventricular response (RVR) have elevated high-sensitivity troponin T (hsTnT) values. Elevated hsTnT is an independent risk marker for cardiovascular events and mortality. The aim was to examine if AF/AFL patients with RVR and elevated hsTnT have an increased incidence of pathological cardiac stress tests, indicating need of further evaluation for coronary artery disease (CAD). Design: We prospectively included 90 AF/AFL patients without known heart failure and CAD presenting with AF/AFL and RVR. Half of the patients had elevated hsTnT (cases) and half had levels below the 99th percentile (controls). All patients were discharged in sinus rhythm. After approximately one week in sinus rhythm a new hsTnT was analysed and the patients performed a bicycle exercise stress test within the 30 day follow-up. The primary endpoint was a pathological stress test confirmed by a pathological SPECT myocardial perfusion imaging or a coronary angiography. Results: None of the controls reached the primary endpoint. Two patients (4%) out of the 45 cases reached the primary endpoint (p = .49 vs controls), but only one was found to have significant CAD at subsequent coronary angiography. Conclusion: Patients with paroxysmal AF/AFL, without a history of CAD and heart failure, who present with a RVR and minor hsTnT elevations were not found to have an increased incidence of pathological stress tests compared to patients with hsTnT values below the 99th percentile.

An Overview of FGF-23 as a Novel Candidate Biomarker of Cardiovascular Risk

Fibroblast growth factor-23 (FGF)-23 is a phosphaturic hormone involved in mineral bone metabolism that helps control phosphate homeostasis and reduces 1,25-dihydroxyvitamin D synthesis. Recent data have highlighted the relevant direct FGF-23 effects on the myocardium, and high plasma levels of FGF-23 have been associated with adverse cardiovascular outcomes in humans, such as heart failure and arrhythmias. Therefore, FGF-23 has emerged as a novel biomarker of cardiovascular risk in the last decade. Indeed, experimental data suggest FGF-23 as a direct mediator of cardiac hypertrophy development, cardiac fibrosis and cardiac dysfunction via specific myocardial FGF receptor (FGFR) activation. Therefore, the FGF-23/FGFR pathway might be a suitable therapeutic target for reducing the deleterious effects of FGF-23 on the cardiovascular system. More research is needed to fully understand the intracellular FGF-23-dependent mechanisms, clarify the downstream pathways and identify which could be the most appropriate targets for better therapeutic intervention. This review updates the current knowledge on both clinical and experimental studies and highlights the evidence linking FGF-23 to cardiovascular events. The aim of this review is to establish the specific role of FGF-23 in the heart, its detrimental effects on cardiac tissue and the possible new therapeutic opportunities to block these effects.

Energy Metabolism in the Failing Right Ventricle: Limitations of Oxygen Delivery and the Creatine Kinase System

Pulmonary arterial hypertension (PAH) results in hypertrophic remodeling of the right ventricle (RV) to overcome increased pulmonary pressure. This increases the O2 consumption of the myocardium, and without a concomitant increase in energy generation, a mismatch with demand may occur. Eventually, RV function can no longer be sustained, and RV failure occurs. Beta-adrenergic blockers (BB) are thought to improve survival in left heart failure, in part by reducing energy expenditure and hypertrophy, however they are not currently a therapy for PAH. The monocrotaline (MCT) rat model of PAH was used to investigate the consequence of RV failure on myocardial oxygenation and mitochondrial function. A second group of MCT rats was treated daily with the beta-1 blocker metoprolol (MCT + BB). Histology confirmed reduced capillary density and increased capillary supply area without indications of capillary rarefaction in MCT rats. A computer model of O2 flux was applied to the experimentally recorded capillary locations and predicted a reduction in mean tissue PO2 in MCT rats. The fraction of hypoxic tissue (defined as PO2 < 0.5 mmHg) was reduced following beta-1 blocker (BB) treatment. The functionality of the creatine kinase (CK) energy shuttle was measured in permeabilized RV myocytes by sequential ADP titrations in the presence and absence of creatine. Creatine significantly decreased the KmADP in cells from saline-injected control (CON) rats, but not MCT rats. The difference in KmADP with or without creatine was not different in MCT + BB cells compared to CON or MCT cells. Improved myocardial energetics could contribute to improved survival of PAH with chronic BB treatment.

Temporal changes in the pattern of invasive angiography use and its outcome in suspected coronary artery disease: implications for patient management and healthcare resources utilization

INTRODUCTION

Invasive coronary angiography (CAG), the 'gold standard' in coronary artery disease (CAD) diagnosis, requires hospitalization, is not risk-free, and engages considerable healthcare resources.

AIM

To assess recent (throught out 10 years) evolution of 'significant' (≥ 50% stenosis(es)) CAD prevalence in subjects undergoing CAG for CAD diagnosis in a high-volume tertiary referral center.

MATERIAL AND METHODS

Anonymized medical records were compared for the last vs. the first 2-years of the decade (June 2007 to May 2018). Referrals for suspected CAD were 2067 of 4522 hospitalizations (45.7%) and 1755 of 5196 (33.8%) respectively (p < 0.001).

RESULTS

The median patient age (64 vs. 68 years) and the prevalence of heart failure (24.1% vs. 42.2%) increased significantly (p < 0.001). The CAG atherosclerotic lesions, for all stenosis categories (< 50%; ≥ 50%; ≥ 70%; occlusion(s)), were significantly more prevalent in men. The proportion of subjects with any atherosclerosis on CAG increased (80.7% vs. 77.6%, p = 0.015). However, in the absence of any gross change in, for instance, the fraction of women (40.4% vs. 41.8%), the proportion of CAGs with significant CAD (lesion(s) ≥ 50%) decreased from 55.2% in 2007/2008 to below 1 in every 2 angiograms (48.9%) in 2017/2018 (p < 0.001). This unexpected finding occurred consistently across nearly all CAG referral categories.

CONCLUSIONS

Despite more advanced age and a higher proportion of subjects with 'any' coronary atherosclerosis on CAG, the likelihood of a 'negative' angiogram (lesion(s) < 50%; no further evaluation/intervention) has increased significantly over the last decade. The exact nature of this phenomenon requires further investigation, particularly as a reverse trend would be expected with the growing role (and current high penetration) of contemporary non-invasive diagnostic tools to rule out significant CAD.

Implication of Inflammation and Epigenetic Readers in Coronary Artery Remodeling in Patients With Pulmonary Arterial Hypertension

Objective—

Pulmonary arterial hypertension (PAH) is a vascular disease not restricted to the lungs. Many signaling pathways described in PAH are also of importance in other vascular remodeling diseases, such as coronary artery disease (CAD). Intriguingly, CAD is 4× more prevalent in PAH compared with the global population, suggesting a link between these 2 diseases. Both PAH and CAD are associated with sustained inflammation and smooth muscle cell proliferation/apoptosis imbalance and we demonstrated in PAH that this phenotype is, in part, because of the miR-223/DNA damage/Poly[ADP-ribose] polymerase 1/miR-204 axis activation and subsequent bromodomain protein 4 (BRD4) overexpression. Interestingly, BRD4 is also a trigger for calcification and remodeling processes, both of which are important in CAD. Thus, we hypothesize that BRD4 activation in PAH influences the development of CAD.

Approach and Results—

PAH was associated with significant remodeling of the coronary arteries in both human and experimental models of the disease. As observed in PAH distal pulmonary arteries, coronary arteries of patients with PAH also exhibited increased DNA damage, inflammation, and BRD4 overexpression. In vitro, using human coronary artery smooth muscle cells from PAH, CAD and non-PAH–non-CAD patients, we showed that both PAH and CAD smooth muscle cells exhibited increased proliferation and suppressed apoptosis in a BRD4-dependent manner. In vivo, improvement of PAH by BRD4 inhibitor was associated with a reduction in coronary remodeling and interleukin-6 expression.

Conclusions—

Overall, this study demonstrates that increased BRD4 expression in coronary arteries of patient with PAH contributes to vascular remodeling and comorbidity development.

Prediction of Coronary Artery Disease Extent and Severity Using Pulse Wave Velocity

Background

Pulse-wave velocity (PWV) measures aortic stiffness. It is an independent predictor of cardiovascular events and mortality, yet there is paucity in the literature on its association with the severity and extent of coronary artery disease (CAD).

Methods

To examine the utility of PWV in predicting CAD burden in men and women the PWV was determined in 344 patients (Men = 266, Women = 78) presenting for invasive coronary angiography for the assessment of suspected CAD. Pearson correlations and multivariate analysis were used to evaluate the relationship between these coronary scores, PWV and traditional cardiovascular risk factors.

Results

Compared to men, women with chest pain had lower mean Extent scores (19.2 vs. 35.6; p = 0.0001) and Gensini scores (23.6 vs. 41.9; p = 0.0001). PWV was similar between men and women (12.35 ± 3.74 vs. 12.43 ± 4.58; p = 0.88) and correlated with Extent score (r = 0.21, p = 0.0001) but not Gensini or vessel score (r = 0.03, p = 0.64 and r = 0.06, p = 0.26, respectively). PWV was associated with Extent score in men (B = 2.25 ± 0.78, p = 0.004 for men and B = 1.50 ± 0.88, p = 0.09 for women). It was not a predictor of Gensini score (B = -0.10, P = 0.90).

Conclusion

PWV correlates with the extent of CAD, as measured by the ‘Extent’ score in men more than women. However, it does not correlate with the severity of obstructive CAD in either gender.

Gender differences in the severity and extent of coronary artery disease

Objective

To investigate whether women presenting with suspected angina would show less severe coronary artery disease in than men as determined by the extent score.

Methods

We examined 994 participants of the Australian Heart Eye Study presenting for coronary angiography in the investigation of chest pain from June 2009 to February 2012. People were excluded if there was a history of coronary artery bypass surgery, previous stenting procedure or incomplete angiogram scoring. An extent and vessel score was calculated using invasive coronary angiography. Normal coronary arteries were defined as having no luminal irregularity (Extent score = 0). Obstructive coronary artery disease was defined as a luminal narrowing of greater than 50%.

Results

Women compared to men without infarction had a lower burden of CAD with up to 50% having normal coronary arteries in the 30–44 year group and 40% in the 45–59 year group. Compared to men, women with chest pain had lower mean extent scores (19.6 vs 36.8; P < 0.0001) and lower vessel scores (0.7 v 1.3; P < 0.0001). Although the mean extent score was lower in women than men with myocardial infarction, this was not statistically significant (34.8 vs 41.6 respectively; P = 0.18).

Conclusion

There is a marked difference in coronary artery disease severity and burden between females and males presenting for the investigation of suspected angina. Women are more likely to have normal coronary arteries or less severe disease than age-matched men, particularly if they do not present with myocardial infarction.

Advances in the Care of Adults With Congenital Heart Disease

The significant decline in mortality among children and adolescents with congenital heart disease (CHD) is associated with an increasing prevalence of CHD in adults, particularly those with moderate to severe defects. As a significant percentage of adolescents and young adults are lost to follow-up in the transition from pediatric to adult care, they may present for elective procedures with substantial CHD-associated morbidity. In addition to the specific cardiac defect, the procedures performed, and the current pathophysiological status, several factors should be considered when managing the adult with CHD. These include the type of setting (adult vs pediatric institution); surgeon (pediatric vs adult cardiac surgeon); coexisting diseases associated with CHD, such as coronary artery disease, hepatic dysfunction, renal dysfunction, cerebrovascular accidents, myopathy, and coagulation disorders; acquired diseases of aging; pregnancy; and psychosocial functioning. The current status of the management of common and important congenital cardiac defects is also described.

Heart failure in adult congenital heart disease

OPINION STATEMENT

Adult congenital heart disease (ACHD) patients represent a special population in modern cardiology: though their numbers are growing, and they represent a high-resource utilization subgroup, a robust evidence-base of randomized trials is lacking. Much of the standard therapy is adapted from the treatment of ischemic and idiopathic left ventricle systolic failure, with a small, but growing body of evidence on medical therapy in select ACHD diagnoses. At our institution, for instance, there is a long tradition of using angiotensin antagonists in patients with a systemic right ventricle to prevent deleterious remodeling. The effects of beta-blockers on functional class in ACHD are yet unproven, but there is promising data on pulmonary vasodilators. Control of coronary risk factors and aerobic exercise should be considered for all. Prevention of arrhythmias is important, and multi-site pacing is an emerging therapy. New prognostic tools including natriuretic peptides and CPET are increasingly used to guide earlier initiation of these therapies.

Prevalence and prediction of coronary artery disease in patients with liver cirrhosis: a registry-based matched case-control study

BACKGROUND

There is conflict regarding the prevalence of coronary artery disease (CAD) in patients with liver cirrhosis. This study aimed to investigate the prevalence of silent CAD in comparison with the general population, and to identify the relevant risk factors in patients with liver cirrhosis.

METHODS AND RESULTS

This retrospective study included 1045 prospectively registered consecutive patients with liver cirrhosis without any history of chest pain or CAD, who underwent computerized coronary angiography as a pretransplant workup. These were matched with 6283 controls with healthy livers, based on propensity scores according to established cardiovascular risk factors. Obstructive CAD was defined as ≥50% luminal narrowing in any artery. A matched analysis of 853 pairs showed that the proportion of subjects with obstructive CAD did not differ significantly between the cirrhotic and control groups (7.2% versus 7.9%, P=0.646), in agreement with the outcome of multivariate analysis for its predictors, with an adjusted odds ratio for liver cirrhosis of 1.06 (P=0.690). Nonobstructive CAD was more prevalent in the matched cirrhotic cases (30.6% versus 23.4%, P=0.001). In the pooled cirrhotic cohort, older age, male sex, hypertension, diabetes mellitus, and alcoholic cirrhosis were independently associated with obstructive CAD (adjusted odds ratios, 1.07, 2.74, 1.69, 2.37, and 2.17, respectively; P<0.05 for all), whereas liver function and coagulation parameters were not.

CONCLUSIONS

Asymptomatic cirrhotic patients and nonhepatic subjects are similar in terms of the prevalence of occult obstructive CAD. Traditional cardiovascular risk factors are related to critical coronary stenosis in cirrhotic patients, and thus may be helpful indicators for more careful preoperative evaluation of coronary risk.

Angiographic prevalence and pattern of coronary artery disease in women

BACKGROUND

There are not many studies describing the prevalence and pattern of "coronary artery disease" (CAD) in women undergoing "coronary angiography" (CAG). Hence, uncertainty thrives with regard to the angiographic prevalence and pattern of CAD in women.

OBJECTIVE

Our objective was to study the prevalence and pattern of CAD among women undergoing CAG.

METHODS

Data of 500 women who underwent CAG for suspected CAD over 3 years were retrospectively analyzed. They were classified into young group (age < 55 years) and elderly group (age ≥ 55 years). Angiographic profile of "left main disease" (LMD) was also studied.

RESULTS

There was greater prevalence of obstructive CAD especially double vessel disease and triple vessel disease in elderly group while normal coronaries were more prevalent in young group. There was equal distribution of non-significant lesions and intermediate lesions between the two groups. The prevalence of LMD is 3.4%, obstructive CAD is 45.4%, and multivessel disease is 28%. The prevalence of LMD and multivessel disease is 31.4%. The pattern of involvement of coronary arteries was same between the two groups; left anterior descending artery is the most commonly affected vessel. Chronic total occlusion mostly involved right coronary artery. Bifurcation lesion involving distal left main coronary artery is the most prevalent pattern of LMD.

CONCLUSION

There has been a change with regard to clinical presentation and onset of risk factors for CAD at young age, but the load of atherosclerotic burden and pattern of involvement of coronary arteries have not changed in women.

Differential behavior between S100A9 and adiponectin in coronary artery disease. Plasma or epicardial fat

AIMS

S100A9 is a new inflammatory marker associated with obesity and cardiovascular disease. Because epicardial adipose tissue (EAT) is an inflammatory source in coronary artery disease (CAD), our aim was to evaluate the S100A9 levels in plasma and EAT and its association with CAD.

MAIN METHODS

Blood, EAT and/or subcutaneous adipose tissue (SAT) biopsies were obtained from 89 patients undergoing elective cardiac surgery. Plasma S100A9 and adiponectin were analyzed by enzyme-linked immunosorbent assay (ELISA) and mRNA expression in both fat pads and were measured by real-time polymerase chain reaction (PCR).

KEY FINDINGS

Our results have shown higher levels of plasma S100A9 in patients with CAD than those without (29 [10-50] vs. 17 [3-28] ng/mL; p=0.007). They were dependent on the number of injured-coronaries (p=0.002) with tendency toward negative association with plasma adiponectin (p=0.139). Although EAT expressed higher levels than SAT and their levels were higher in CAD patients, this last difference did not reach statistical significance. However, there was a positive correlation between neutrophils and EAT S100A9 expression (p=0.007) that may reveal an increase of neutrophil filtration on this fat pad.

SIGNIFICANCE

Plasma S100A9 levels are increased in chronic CAD. The absence of differences regarding EAT S100A9 expression levels indicates a differential inflammatory process between fat tissues and blood in CAD process.

Pseudoxanthoma elasticum: cardiac findings in patients and Abcc6-deficient mouse model

Background

Pseudoxanthoma elasticum (PXE), caused by mutations in the ABCC6 gene, is a rare multiorgan disease characterized by the mineralization and fragmentation of elastic fibers in connective tissue. Cardiac complications reportedly associated with PXE are mainly based on case reports.

Methods

A cohort of 67 PXE patients was prospectively assessed. Patients underwent physical examination, electrocardiogram, transthoracic echocardiography, cardiac magnetic resonance imaging (CMR), treadmill testing, and perfusion myocardial scintigraphy (SPECT). Additionally, the hearts of a PXE mouse models (Abcc6^−/−) and wild-type controls (WT) were analyzed.

Results

Three patients had a history of proven coronary artery disease. In total, 40 patients underwent exercise treadmill tests, and 28 SPECT. The treadmill tests were all negative. SPECT showed mild perfusion abnormalities in two patients. Mean left ventricular (LV) dimension and function values were within the normal range. LV hypertrophy was found in 7 (10.4%) patients, though the hypertrophy etiology was unknown for 3 of those patients. Echocardiography revealed frequent but insignificant mitral and tricuspid valvulopathies. Mitral valve prolapse was present in 3 patients (4.5%). Two patients exhibited significant aortic stenosis (3.0%). While none of the functional and histological parameters diverged significantly between the Abcc6^−/− and WT mice groups at age of 6 and 12 months, the 24-month-old Abcc6^−/− mice developed cardiac hypertrophy without contractile dysfunction.

Conclusions

Despite sporadic cases, PXE does not appear to be associated with frequent cardiac complications. However, the development of cardiac hypertrophy in the 24-month-old Abcc6^−/− mice suggests that old PXE patients might be prone to developing late cardiopathy.

Prevalence and impact of coronary artery disease in patients with pulmonary arterial hypertension

The occurrence and impact of coronary artery disease (CAD) among patients with pulmonary arterial hypertension (PAH) are unknown. We aimed to determine the prevalence, clinical correlates, and effect of CAD in patients with PAH. We reviewed the medical records of consecutive patients diagnosed with PAH at a university-based referral center for pulmonary vascular disease from January 1990 to May 2010. The patients systematically underwent right heart catheterization and coronary angiography as a part of their evaluation. The patients with PAH with CAD (defined as ≥50% stenosis in ≥1 major epicardial coronary artery) were compared to patients without CAD. Among the 162 patients with PAH, the prevalence of CAD was 28.4%. The presence of CAD was associated with older age (66.6 ± 11.5 vs 49.2 ± 14.0 years, p <0.001), systemic hypertension, and dyslipidemia. The patients with PAH and CAD had a lower mean pulmonary arterial pressure (44.6 ± 11.1 vs 49.2 ± 14.0 mm Hg; p = 0.02) than patients without CAD. During a median follow-up of 36 months, 73 patients died. The presence of CAD was a predictor of all-cause mortality on univariate analysis (hazard ratio 1.97, 95% confidence interval 1.21 to 3.20) but not on multivariate analysis, which identified older age (hazard ratio 1.03, 95% confidence interval 1.01 to 1.05) and right atrial pressure (hazard ratio 1.08, 95% confidence interval 1.03 to 1.14) as the only independent predictors. In conclusion, our study has demonstrated that CAD is common among patients with PAH. CAD prevalence increases with age, dyslipidemia, and hypertension, but we did not detect an independent prognostic effect of CAD on mortality.

Increasing frequency and burden of cerebral artery atherosclerosis in Korean stroke patients

PURPOSE

Koreans have been undergoing rapid lifestyle changes that may have an effect on patterns of cerebral artery atherosclerosis. This study was aimed at determining the frequency and distribution of atherosclerosis in the cerebral arteries and associated temporal changes over the past eight-year period among Korean stroke patients.

MATERIALS AND METHODS

By using stroke registry data registered between April 1999 and March 2007, we investigated the presence, severity, and location of cerebral artery atherosclerosis as determined by angiographic findings. Their annual patterns and association with vascular risk factors were investigated.

RESULTS

Of 1,955 patients, 1,517 patients (77.6%) demonstrated atherosclerosis in one or more arteries. A significantly increasing trend of atherosclerosis was observed during the past eight years, which was ascribed to an increase of combined extracranial (EC) and intracranial (IC) atherosclerosis. The number of atherosclerotic arteries increased as the number of risk factors increased. In the multivariate analysis, the year and vascular risk factors were independent predictors of the presence of atherosclerosis.

CONCLUSION

We found that the atherosclerotic burden has been increasing for the past eight years in Korean stroke patients, particularly the combined EC and IC subtype. Lifestyle changes and increase in vascular risk factors may be contributing factors.

Effects of chronic obstructive pulmonary disease on coronary atherosclerosis

The chronic systemic inflammation and oxidative stress are important features in chronic obstructive pulmonary disease (COPD). Atherosclerosis is accepted as an inflammatory disease. Both local and systemic inflammation and oxidative stress negatively affect the atherosclerotic process. Metabolic alterations, systemic inflammation, and neurohormonal activation frequently occur in patients with COPD. However, the impact of COPD on intensity and severity of atherosclerosis and morphology of stenotic lesions in patients with established coronary artery disease by coronary angiography is unknown. Eighty-eight patients who were diagnosed with COPD disease were enrolled in the study. Eighty-two patients without any pulmonary disease were included in the control group. Coronary angiography and blood gases analysis were performed in all patients. Gensini score and Extent score were used to evaluate the intensity and severity of atherosclerosis. Lesion morphologies were defined in all patients. The mean number of affected coronary arteries was 2.5 +/- 0.6 in the COPD group and 2.1 +/- 0.7 in the control group (P = 0.004). The mean Extent score was 37 +/- 16 in the COPD group and 23 +/- 11 in the control group (P = 0.001). The Gensini score in the COPD group was significantly higher than that in the control group (respectively 10.9 +/- 6.3 vs 6.6 +/- 4.1, P = 0.01). The number of critical lesions, and type B and C lesions were higher in the COPD group. Multivariate analysis demonstrated that COPD was independently predictive for Gensini score (odds ratio 1.371; 95% confidence interval 1.682-9.228; P = 0.002) and Extent score (odds ratio 1.648; 95% confidence interval 2.023-13.339; P = 0.001). Severity and intensity of atherosclerosis increases in COPD and atherosclerotic lesions have worse morphological properties in COPD.

Burden of coronary artery disease in adults with congenital heart disease and its relation to congenital and traditional heart risk factors

As adult patients with congenital heart disease (CHD) grow older, the risk of developing coronary artery disease (CAD) increases. We sought to estimate the prevalence of CAD in adult patients with CHD, the safety of coronary angiography in this setting, and the potential relation of CAD to clinical and hemodynamic parameters. Two hundred fifty adult patients with CHD (mean age 51 +/- 15 years; 53% men) underwent selective coronary angiography in our center for reasons other than suspected CAD. Clinical and hemodynamic data were retrieved retrospectively from medical records and echocardiographic and angiographic databases, respectively. Significant CAD using quantitative coronary angiography was found in 9.2% of adult patients with CHD. No patient with cyanosis or age <40 years had significant CAD. Systolic and diastolic systemic ventricular dimensions were significantly higher in patients with CAD, even after adjustment for age (odds ratio [OR] for 10-mm increase 2.59, 95% confidence interval [CI] 1.29 to 5.21, p = 0.007; OR 2.31, 95% CI 1.24 to 4.31, p = 0.008, respectively). Systemic arterial hypertension and hyperlipidemia were strong predictors of CAD (OR 4.54, 95% CI 1.82 to 12.0, p = 0.001; OR 9.08, 95% CI 3.56 to 24.54, p <0.0001, respectively), whereas no relation to chest pain was found. Only 1 major adverse event was recorded during coronary angiography. In conclusion, the prevalence of significant CAD in a hospital adult CHD cohort was similar to that in the general population. This study supported the performance of selective coronary angiography in patients >40 years referred for cardiac surgery, with low risk of major complications. Traditional cardiovascular risk factors for CAD also applied to adult patients with CHD, in whom primary prevention of CAD was as important as in the general population.

Sex-related differences in the angiographic results of 14,500 cases referred for suspected coronary artery disease

OBJECTIVE

To investigate sex differences of angiographic results in patients undergoing coronary angiography for suspected coronary artery disease (CAD).

METHODS

We retrospectively assessed the coronary angiograms of 2840 women and 11,610 men from 1984 to 2003. We examined sex differences regarding the extent and topography of significant stenoses (SS) (i.e. > or =50% of the luminal diameter), the age of presentation, and the variation of the annual frequency of the angiographic findings across the study period.

RESULTS

SS were recorded in 1817 women and 9984 men (64 vs. 86%, P<0.001). Women were more likely to present with nonsignificant stenoses (i.e. <50% of the luminal diameter) or angiographically normal coronaries (P<0.001). In patients with SS, women had a higher chance to present with one-vessel (P<0.001) or peripheral branches (P<0.05) disease, whereas men were more likely to have two-vessel disease (P<0.005). Compared with men, women were less likely to exhibit SS in the right coronary artery (P<0.001), left circumflex (P<0.01), intermediate artery (P<0.01) and first obtuse marginal branch (P<0.01). No significant sex differences were recorded in the frequency of SS in the left anterior descending artery. In patients aged from 31 to 60 years, SS were more common in men, whereas in patients 61-80 years of age SS were more common in women. The annual frequency of SS in women gradually increased throughout the study period.

CONCLUSION

SS were less common in women, were found later in life, and were less likely to involve the right coronary artery, left circumflex, intermediate artery and first obtuse marginal branch than in men.

Acute myocardial infarction and underlying stenosis severity

OBJECTIVES

The objective of this study was to investigate the underlying stenosis severity of the culprit lesion in acute myocardial infarction.

BACKGROUND

It is widely believed that myocardial infarction often occurs in angiographically mild luminal stenosis. This, however, is in contradiction with experience from interventional practice in primary PCI.

METHODS

We performed quantitative coronary angiography (QCA) in 250 consecutive patients referred for acute percutaneous coronary intervention (PCI) because of acute myocardial infarction (AMI). Fundamental for analysis was that a realistic estimate of underlying luminal narrowing before the infarction could be made angiographically that QCA could be performed and that one of two criteria was met: (1) spontaneous reflow allowing assessment of the lumen proximal and distal to the culprit lesion, or (2) coronary artery closed at arrival but reflow after uncomplicated wiring allowing assessment of the lumen proximal and distal to the culprit lesion.

RESULTS

Of 250 consecutive patients (mean age 61.7 +/- 12.7 years, 48 women) referred for acute PCI, 156 patients (62%) fulfilled at least one of the above criteria for reliable QCA. In 151 of these patients (96%) the severity of the underlying stenosis was >50% and in 103 (66%) it was >70%. There were no differences in stenosis severity between the left anterior descending [LAD, (72 +/- 13)%, n = 57], left circumflex [Cx, (74 +/- 10)%, n = 20], and right coronary artery territory [RCA, (74 +/- 12)%, n = 76] (ANOVA, P = 0.76). There were no differences in stenosis severity between women [(73 +/- 13)%, n = 36] and men [(75 +/- 11)%, n = 120; P = 0.35].

CONCLUSION

In contrast to what is often believed, the majority of myocardial infarctions occurs in significant stenosis.

Cardiovascular disease and type 2 diabetes mellitus: a multifaceted symbiosis

Chronic hyperglycaemia (e.g. type 2 diabetes mellitus (T2DM) and prediabetes) in humans is associated with an increased risk of cardiovascular (CV) complications, and, vice versa, the presence of CV complications (e.g. myocardial infarction, stroke or intermittent claudication) among patients heightens the risk of T2DM or prediabetes. In both cases (i.e. chronic hyperglycaemia and CV complications), significant diagnostic and treatment challenges resulting from a broad range of factors may serve as barriers to reducing the deleterious societal impact of T2DM and prediabetes. These challenges often include clinicians: failing to intervene early and aggressively enough among patients with T2DM to achieve CV risk factor control; failing to efficaciously identify T2DM patients with already established CV complications; and failing proactively to assess individuals at high risk for T2DM. This review discusses the apparent symbiosis between CV disease and T2DM, with a focus on identifying patients with established T2DM or at risk for T2DM; traditional and novel risk factors and markers for CV disease in T2DM; challenges related to diagnosing CV disease in T2DM; and organization of T2DM care in order to prevent CV complications. These are issues that require attention because identifying patients at high risk for T2DM can halt or reduce their further glycaemic deterioration if addressed properly, and because novel markers and non-invasive tests could be applied in patients with T2DM as a means of detecting and possibly treating unrecognized CV disease in time. Furthermore, several approaches for T2DM care can be effective in controlling the CV risk factors contributing to CV complications.

Inflammation, Metabolic Syndrome, Erectile Dysfunction, and Coronary Artery Disease: Common Links

OBJECTIVE

Erectile dysfunction (ED) may be the early clinical manifestation of a generalized vascular disease and carries an independent risk for cardiovascular events. Low-grade subclinical inflammation affects endothelial function and is involved in all stages of the atherosclerotic process. This review identifies potential pathophysiologic links among low-grade inflammation, ED, metabolic syndrome, and coronary artery disease (CAD) and presents the clinical implications in terms of ED diagnosis, assessment of patient risk, and therapy.

METHODS

A comprehensive evaluation was performed for available published data in full-length papers that were identified in MedLine up to July 2007.

RESULTS

Studies support an association between metabolic syndrome, ED, and increased inflammatory state. Increased circulating levels of inflammatory and endothelial-prothrombotic compounds are related to the presence and severity of ED. Specific inflammatory biomarkers and their combination appear to have the potential to aid ED diagnosis or exclusion. ED and CAD may confer a similar unfavorable impact on the inflammatory and prothrombotic state, whereas ED adds an incremental activation on top of CAD; these findings have important implications for cardiovascular risk. Lifestyle and risk factor modification, as well as pharmacologic therapy, are associated with anti-inflammatory effects.

CONCLUSIONS

Low-grade systemic inflammation could be an important element of the association between metabolic syndrome, ED, and CAD. Its individualized assessment may be a valuable tool for ED diagnosis, risk assessment, and rationalized therapeutic approach especially in patients with ED who have metabolic syndrome and carry an intermediate risk for future cardiovascular events.

Inflammation and coronary angiography in asymptomatic type 2 diabetic subjects

OBJECTIVE

Coronary artery disease (CAD) is prevalent in patients with type 2 diabetes mellitus (T2DM) and because it is often asymptomatic and extensive in comparison with CAD in subjects without diabetes, it represents a diagnostic challenge. The objective of the study was to investigate the prevalence of CAD in asymptomatic T2DM patients utilizing angiography and to investigate its association with cardiovascular (CV) risk factors, the metabolic syndrome and markers of inflammation.

MATERIAL AND METHODS

Eighty-two patients with T2DM without symptoms of CAD, and with >or=1 CV risk factor (hypertension, dyslipidaemia, premature familial CAD, smoking or microalbuminuria) underwent a diagnostic stress test and coronary angiography irrespective of stress test results. Stenosis detected in the main coronary arteries >or=50% of lumen diameter was categorized as one-, two- or three-vessel disease. Inflammatory markers were analysed in fasting samples.

RESULTS

Fifteen men and two women had significant CAD (21%) (1-vessel disease, n=10; 2- or 3-vessel disease, n=7). Patients with 2- or 3-vessel disease were significantly older and had a longer duration of diabetes, but the prevalence of other traditional CV risk factors or the metabolic syndrome was similar among those with 1-vessel and those with 2- or 3-vessel disease. Sensitivity for CAD of the stress test was low (0.35). The mean level of the pro-inflammatory marker interleukin-6 was elevated in patients with 2- to 3-vessel CAD as compared to patients with no or 1-vessel CAD (p<0.05).

CONCLUSIONS

Significant CAD was found in 21% of asymptomatic patients with T2DM with >or=1 CV risk factor. Inflammatory markers may be helpful in identifying patients that are likely to have significant CAD, but larger studies are warranted.

Statins and stroke prevention

Over the past decade, statins have been proven to significantly decrease coronary events in primary and secondary prevention of coronary artery disease. Recent clinical trials have indicated that statins significantly reduce stroke risk in patients with vascular disease. The Cholesterol Treatment Trialists' Collaborators in a meta-analysis including 90,056 patients found that the use of statins determined a significant 17% proportional reduction in the incidence of first-ever stroke of any type per 1 mmol/l low-density lipoprotein (LDL) cholesterol reduction. During an average of 5 years of treatment, the reduction in the overall incidence of stroke was about one sixth per 1 mmol/l LDL cholesterol decrease meaning that 8 fewer participants have any stroke per 1,000 among those with preexisting coronary artery disease at baseline, compared with 5 fewer per 1,000 among the participants with no such history. It is not known whether these findings might be due to the cholesterol reduction effect of statins or to pleiotropic effects of statins, such as improved endothelial function, decreased platelet aggregability, and reduced vascular inflammation. In secondary prevention of stroke, the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study found that treatment with atorvastatin reduced the risk of recurrent cerebrovascular events in patients with recent stroke or transient ischemic attack but no history of heart disease. Combining the results of patients with no history of heart disease from the SPARCL study and Heart Protection Study in a mini meta-analysis, compared with placebo, statins were associated with a barely nonsignificant difference in recurrent stroke (OR = 0.87, 95% CI = 0.75-1.01, p = 0.07) and a significant difference in the occurrence of major vascular events (OR = 0.78, 95% CI = 0.68-0.88, p = 0.0001) at final follow-up.

Doppler evaluation of erectile dysfunction – Part 1

Erectile dysfunction (ED) is the consistent inability to achieve and maintain an erection sufficient for satisfactory sexual activity. Erectile dysfunction affects as many as 30 million men in America, with an increasing prevalence with age. Erectile dysfunction is secondary to organic, psychogenic and combined causes. The first part of this review article describes the guidelines for evaluation and treatment plans for men with ED. It also describes the normal sonographic anatomy of the penis, sonographic technique for evaluation of ED and the normal phases of erection.

Improved prediction of early-onset coronary artery disease using APOE ε4, BChE-K, PPARγ2 Pro12 and ENOS T-786C in a polygenic model

OBJECTIVES

Coronary artery disease (CAD) is often polygenic due to multiple mutations that contribute small effects to susceptibility. Since most prior studies only evaluated the contribution of single candidate genes, we therefore looked at a combination of genes in predicting early-onset CAD [apolipoprotein E (APOE) epsilon4, butyrylcholinesterase (BChE) K, peroxisome proliferator-activated receptor gamma2 (PPARgamma2) Pro12Ala and endothelial nitric oxide synthase (ENOS) T-786C].

DESIGN AND METHODS

We examined the frequencies, individually and in combination, of all four alleles among patients with early-onset CAD (n = 150; <50 years), late-onset CAD (n = 150; >65 years) and healthy controls (n = 150, age range 47-93 years). Differences in the proportion of subjects in each group with the given gene combination were assessed and likelihood ratios (LR) were calculated using logistic regression to combine the results of multiple genes.

RESULTS

Early-onset CAD patients had increased, but non-significant, frequencies of PPARgamma2 Pro12/Pro12 (P = 0.39) and ENOS T-786C (P = 0.72), while BChE-K was only significantly higher in early-onset CAD patients compared to controls (P = 0.03). There were significantly more APOE epsilon4 alleles alone (P = 0.02) or in combination with BChE-K (P = 0.02) among early-onset CAD patients compared to late-onset CAD ones or controls. When combined, there was a higher prevalence of all four alleles in early-onset CAD (early-onset CAD patients: 10.7%, late-onset CAD patients: 3.3% and controls: 2.7%, P = 0.01). LR for early-onset CAD for a single allele was relatively small (1.08 for PPARgamma2 to 1.70 for APOE epsilon4). This increased to 2.78 (1.44-5.37) when combining all four alleles, therefore increasing the pre-test probability of CAD from 5% to a post-test probability of 12.7%.

CONCLUSIONS

While any single mutation causes only a mildly increased LR (none > 1.7), in combination, the likelihood of early-onset CAD increased to 2.78 with four mutations. The genetics of early-onset CAD appear to be multifactorial, requiring polygenic models to elucidate risk.

Adherence to guidelines in the clinical care for adults with congenital heart disease: The Euro Heart Survey on Adult Congenital Heart Disease

AIMS

To investigate the role of guidelines in structuring the clinical care for adult patients with congenital heart disease (CHD), and to assess adherence to the guidelines in Europe.

METHODS AND RESULTS

A selected number of current guidelines were chosen pertaining to operative procedures, investigations, and the use of medication ('interventions'). The source for this analysis was the database of the Euro Heart Survey on adult CHD, which contains retrospectively collected data on 4110 patients followed-up for a median of 5.1 years. For each guideline investigated, patients were selected from the database for whom the particular guideline was relevant. The selected cases were classified according to two criteria: was there an indication for the particular intervention and did the intervention take place? In this manner, cases of 'undue treatment' and 'insufficient treatment' were identified. Adherence to guidelines was found to be good in the case of operative procedures and prophylactic drug treatment. However, regarding diagnostic procedures there had been adherence to guidelines in only slightly more than half of the cases.

CONCLUSION

Guidelines have an important role in the actual clinical care of adults with CHD. However, large outcome studies are needed to develop more precise guidelines.

When is diabetes mellitus a relative or absolute contraindication to liver transplantation?

1. Diabetes mellitus is common in patients with cirrhosis; patients with DM undergoing liver transplantation often have many other co-morbid illnesses including obesity, coronary artery disease (CAD), autonomic neuropathy, gastroparesis, and nephropathy. 2. Long-term survival of patients with diabetes mellitus (DM) is significantly lower and morbidity higher when compared to non-diabetics mainly because of cardiovascular complications, infections, and renal failure. 3. Obesity, CAD, and renal failure are confounding factors that result in poor patient survival. 4. Patients with DM should undergo careful cardiovascular diagnostic work up, including routine coronary arteriogram, and necessary interventions before liver transplantation. This is especially important in those over 50 years old, and in those with retinopathy, nephropathy, and neuropathy. 5. Patients with coronary artery disease that is not amenable to surgery or stents, and those with impaired left ventricular function, should not be considered for liver transplantation. Other relative or absolute contraindications are those with proteinura and renal failure who are not candidates for combined liver/kidney transplantation, those with severe gastroparesis, especially when it is associated with diabetic autonomic neuropathy, and those with two or more risk factors such as CAD, morbid obesity, and renal failure. 6. Future studies should focus on risk stratification of patients with DM undergoing liver transplantation and better interventions to reduce the risk of diabetic complications before and after liver transplantation.

Prevalence of asymptomatic coronary artery disease in men with vasculogenic erectile dysfunction: a prospective angiographic study

OBJECTIVES

Erectile dysfunction (ED) shares common risk factors with coronary artery disease (CAD). It has been suggested that ED may be considered a clinical manifestation of a generalized vascular disease affecting also the penile arteries. The aim of this prospective study was to evaluate angiographically the incidence of asymptomatic CAD in men with ED of vascular origin.

METHODS

Fifty consecutive asymptomatic men, aged 41-74 years, with non-psychogenic and non-hormonal ED were comprehensively evaluated using medical history and examination, exercise treadmill test and stress echocardiography. Patients who had positive one or both of the two non-invasive procedures were referred for coronary arteriography in order to document CAD and evaluate the severity of the disease.

RESULTS

The mean time interval between the onset of ED and cardiological assessment was 25 months (range 1-66). Smoking (32 patients/64%), hypertension (31 patients/62%) and hyperlipidemia (26 patients/52%) were the most common risk factors. Moreover, 35 men (70%) had two or more risk factors. Twelve patients (24%) with ED had positive one or both of the two non-invasive procedures and one patient presented with acute myocardial infarction before he completed the non-invasive investigation. Coronary arteriography performed in ten patients (in nine with positive one or both of the two non-invasive procedures [while the other three refused], and in the patient with acute myocardial infarction) demonstrated that one patient had three-vessel disease, two patients had two-vessel disease and six patients had single-vessel disease.

CONCLUSIONS

A considerable proportion (9/47 or 19%) of patients with ED of vascular origin has angiographically documented silent CAD. These findings support the strategy that patients with ED should undergo further cardiovascular evaluation.

Cyanotic congenital heart disease and coronary artery atherogenesis

Hypoxemic erythrocytotic residents of high altitudes lack coronary atherosclerosis and have low cholesterol levels. It was postulated that hypoxemic erythrocytotic adults with cyanotic congenital heart disease (CCHD) might be analogous. The incidence of coronary atherosclerosis in this patient population has not been established, and hypocholesterolemia has not previously been recognized. Accordingly, 279 patients were divided into 4 groups: group A: 143 cyanotic patients not operated on (54 men and 89 women, aged 18 to 69 years); group B: 47 cyanotic patients (28 men and 19 women rendered acyanotic by operation at age 22 to 69 years); group C: 41 acyanotic patients not operated on (22 men and 19 women, aged 22 to 75 years); and group D: 48 patients acyanotic before and after operation (24 men and 24 women, aged 21 to 70 years). Coronary arteries were studied angiographically in 59 patients and at necropsy in 5 subjects aged 37 to 56 years. Total cholesterol was <160 mg/dl in 58% of group A, 52% of group B, 10% of group C, and 12% of group D (p <0.000001, chi-square analysis). Angiograms disclosed dilated coronary arteries without obstruction. Necropsy disclosed ectatic coronary arteries with structural abnormalities of the media. In conclusion, this study provides the first quantitative and qualitative data on antiatherogenic changes in lipoproteins in adults with CCHD. The coronary arteries are atheroma free because hypocholesterolemia acts in concert with the antiatherogenic properties of upregulated nitric oxide, hyperbilirubinemia, hypoxemia, and low platelet counts. The persistence of hypocholesterolemia after the surgical elimination of cyanosis suggests a genetic determinant.

LCAT-dependent conversion rate is a determinant of plasma prebeta1-HDL concentration in healthy Japanese

BACKGROUND

Prebeta1-HDL acts as a primary acceptor of cellular cholesterol. Prebeta1-HDL is converted into alpha-migrating high-density lipoprotein (HDL) by lecithin/cholesterol acyltransferase (LCAT). We examined whether the LCAT-dependent conversion rate of prebeta1-HDL is a determinant of the plasma prebeta1-HDL concentration in healthy Japanese.

METHODS

We measured the conversion half time (CHT(prebeta1)), the time required for 50% of baseline prebeta1-HDL to be changed into alpha-migrating HDL by LCAT, in 100 healthy Japanese (47 men, 53 women, 22-88 years).

RESULTS

Prebeta1-HDL concentration, as determined by immunoassay, was significantly lower in younger women (<50 years, n=24) than in older women (>or=50 years, n=29) (16.8+/-3.3 vs. 21.7+/-8.0 mg/l apolipoprotein AI (apoAI), p<0.01). There was no significant difference in prebeta1-HDL concentration between younger (n=24) and older (n=23) men (21.2+/-6.8 vs. 22.5+/-6.6 mg/l apoAI). The mean CHT(prebeta1) for all subjects was 47.4+/-13.0 min, and was not influenced by gender or age. Prebeta1-HDL concentration was positively correlated with CHT(prebeta1) in both men and women, suggesting that high prebeta1-HDL levels may reflect delayed conversion of prebeta1-HDL.

CONCLUSION

LCAT-dependent conversion rate is a determinant of plasma prebeta1-HDL concentration in healthy Japanese. We speculate that prebeta1-HDL concentration may be used as a metabolic marker for HDL maturation.

Coronary artery disease is common in nonuremic, asymptomatic type 1 diabetic islet transplant candidates

OBJECTIVE

Coronary artery disease (CAD) is the most common cause of death in patients with type 1 diabetes. Asymptomatic CAD is common in uremic diabetic patients, but its prevalence in nonuremic type 1 diabetic patients is unknown. The prevalence of CAD was determined by coronary angiography and the performance of noninvasive cardiac investigation evaluated in type 1 diabetic islet transplant (ITX) candidates with preserved renal function.

RESEARCH DESIGN AND METHODS

A total of 60 consecutive type 1 diabetic ITX candidates (average age 46 years [mean 24-64], 23 men, and 47% ever smokers) underwent coronary angiography, electrocardiographic stress testing (EST), and myocardial perfusion imaging (MPI) in a prospective cohort study. CAD was indicated on angiography by the presence of stenoses >50%. Models to predict CAD were examined by logistic regression.

RESULTS

Most subjects (53 of 60) had no history or symptoms of CAD; 23 (43%) of these asymptomatic subjects had stenoses >50%. CAD was associated with age, duration of diabetes, hypertension, and smoking. Although specific, EST and MPI were not sensitive as predictors of CAD on angiography (specificity 0.97 and 0.93, sensitivity 0.17 and 0.04, respectively) but helped identify two of three subjects requiring revascularization. EST and MPI did not enhance logistic regression models. A clinical algorithm to identify low-risk subjects who may not require angiography was highly sensitive but was applicable only to a minority (n = 8, sensitivity 1.0, specificity 0.27, negative predictive value 1.0).

CONCLUSIONS

Nonuremic type 1 diabetic patients with hypoglycemic unawareness and/or metabolic lability referred for ITX are at high risk for asymptomatic CAD despite negative noninvasive investigations. Aggressive management of cardiovascular risk factors and further investigation into optimal cardiac risk stratification in type 1 diabetes are warranted.

Cholesterol-independent effects of statins and new therapeutic targets: ischemic stroke and dementia

The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or "statins", are used as cholesterol-lowering agents worldwide. Statins inhibit cholesterol biosynthesis, leading to enhanced uptake of low-density lipoprotein (LDL) from the circulation via LDL receptors. This strong cholesterol-lowering action contributes to the beneficial effects of statins. For example, large clinical trials have demonstrated that statins significantly reduce cardiovascular risk. Recent research has shown that statins have other multiple actions involved in endothelial function, cell proliferation, inflammatory response, immunological reactions, platelet function, and lipid oxidation. These "pleiotropic actions" of statins probably provide a significant contribution to the reduction of cardiovascular events. This review summarizes the pleiotropic actions of statins in both basic and clinical studies. It also considers the potential for statin therapy in the treatment of stroke and dementia.

Screening Coronary Arteriography in the Primary Prevention of Coronary Artery Disease

Recent studies indicate an expansion of the population eligible for primary prevention of coronary artery disease with lipid-lowering therapy. This change has led to the unnecessary treatment of many individuals and an overall decreased effectiveness of medication with potentially significant side effects. If instead, the asymptomatic population is screened for the presence of early coronary artery disease (CAD), lipid lowering can be targeted to those who can truly benefit. The prevalence of asymptomatic CAD in men older than 50 years of age approaches 20% and arteriography is currently the best available test to identify these men. The approximate complication rate of arteriography in such a population (1 or 2 per 10,000) approaches that of other screening tests. Although insufficient data exists for formal cost analysis, approximations indicate significant savings for arteriographically targeted treatment of at-risk asymptomatic individuals. The authors show that coronary arteriography is a potentially safe and cost-effective method of screening an asymptomatic adult population for presence of early CAD, allowing for the targeting of lipid lowering to those who can benefit most from this therapy.

Oxidized LDL autoantibodies are related to apolipoprotein E phenotype, independently of postprandial change in plasma triglycerides and LDL size, among patients with angiographically verified coronary artery disease and healthy controls

OBJECTIVE

Oxidized low-density lipoprotein (LDL) autoantibodies (oxLDLab), apolipoprotein E (apoE) phenotype, postprandial triglyceride changes and LDL size are suggested to be risk factors for coronary artery disease (CAD). Our aim was to study the interaction between these new risk factors among patients with CAD and healthy controls.

METHODS

oxLDLab from 31 men with angiographically verified CAD and 31 healthy men were analyzed by enzyme-linked immunosorbent assay. Isoelectric focusing and immunoblotting were used for apoE phenotyping. Triglyceride level was measured after 12 h of fasting and 3, 5 and 7 h after a high-fat meal. Nondenaturing gradient gel electrophoresis was used to separate LDL particles according to size.

RESULTS

oxLD- Lab levels increased according to apoE phenotype in the following order: E2 < E3 < E4 (p = 0.004, ANOVA). The postprandial response of triglycerides, the size of LDL particles and the concentration of LDL and high-density lipoprotein (HDL) cholesterol did not differ between apoE phenotypes, and the use of these variables as covariates did not change the statistically significant difference in oxLDLab levels between apoE phenotypes (p = 0.01, ANCOVA). oxLDLab levels did not differ between the patient and control groups.

CONCLUSION

We found an association between apoE allele epsilon2 and decreased levels of oxLDLab, which was independent of the postprandial response of triglycerides, the size of LDL particles and plasma LDL and HDL cholesterol levels. The mechanism by which apoE affects oxidation of LDL remains unknown.

Silent coronary atheromatosis in type 1 diabetic patients and its relation to long-term glycemic control

Type 1 diabetic patients have a pronounced risk of premature coronary artery disease and death. We sought to evaluate the prevalence of silent coronary atheromatosis and to evaluate the relation between coronary atheromatosis and glycemic control. Coronary atheromatosis was evaluated in type 1 diabetic patients with no symptoms of coronary artery disease by exercise electrocardiogram (ECG) in 39 patients and quantitative coronary angiography and by intravascular ultrasound (IVUS) examinations in 29 patients. The findings from the IVUS examinations were related to mean HbA(1c) collected prospectively over 18 years. Abnormal exercise ECGs were found in 15% of patients, and angiographic diameter stenosis of >50% in one or more of the main coronary arteries was found in 34% of patients. All patients examined with intracoronary ultrasound had developed atherosclerotic plaques with an increased intimal thickness (>0.5 mm) in one or more of the coronary arteries. Coronary artery plaque formation, as judged by ultrasound, was significantly related to mean HbA(1c) during 18 years (P < 0.05) after adjustment for total cholesterol and age. This study demonstrates a high prevalence of silent coronary atheromatosis in type 1 diabetic patients with no symptoms of coronary heart disease. Long-term glycemic control was shown to be associated with coronary atheromatosis.