Primary prevention of cardiovascular disease: a call to action

Knowledge about cardiovascular diseases in a first-level healthcare center in Lima, Peru

BACKGROUND

Motivation for the study. In Peru, the knowledge level of patients about their cardiovascular health is unknown at the first level of care, which receives 85% of the population, and where primary disease prevention activities are carried out.

BACKGROUND

Main findings. More than 70% of people had an inadequate level of knowledge about their own cardiovascular health.

BACKGROUND

Implications. Our results highlight the need to improve the education of people on cardiovascular health issues at the first level of care, taking into account that these diseases are increasingly frequent in the population.

BACKGROUND

This study aimed to determine the level of knowledge about cardiovascular diseases in people in a primary healthcare center (PHCC). A descriptive and cross-sectional study was carried out by surveying people who attended a PHCC in Lima, Peru. A score less than 6 was considered inadequate knowledge. A total of 400 people were surveyed, 66.3% were women and the mean age was 46.8 ± 16.2 years. The average score was 4.52 +/- 1.85. We found that 71% of those surveyed had an inadequate level of knowledge, regardless of age, gender or education level. Our findings show that the level of knowledge about risk factors and cardiovascular disease was inadequate in the primary care population. It is necessary to achieve proper specific education in cardiovascular risk factors in order to reduce the impact of these diseases.

The Impact of Statin Therapy on Cardiovascular Outcomes in Patients With Diabetes: A Systematic Review

Cardiovascular disease (CVD) is the primary cause of death all over the world, especially due to myocardial ischemia caused by atherosclerosis that blocks cardiac arteries and leads to arrhythmia and other cardiac diseases. Meanwhile, diabetes mellitus (DM) and elevated cholesterol level are the risk factors for cardiovascular (CV) disease. This noncommunicable disease has become a main concern for us as cardiovascular disease develops in a slow manner without any symptoms in the early stage. Early prevention and intervention have a major impact on improving the outcome of cardiovascular health in diabetic patients. Controlling cholesterol level by administering statin has shown some beneficial impacts in reducing the risk of cardiovascular disease in patients with DM. This study used a systematic literature review (SLR) approach to give an overview of the current literature and to analyze the effects of statin therapy on cardiovascular outcomes in patients with DM. The literature search was conducted in PubMed and Google Scholar databases. The total number of articles included in the present review is six, obtained from reputable journals published between 2013 and 2023, and we only focused on reviewing six articles for in-depth analysis. The evidence we collected showed a positive outcome in terms of cardiovascular health in persons with DM after statin therapy. However, there are several risk factors that interfere with the effectiveness of statin in diabetic patients.

HEAD-MIP-(HEAlth Dialogues for patients with Mental Illness in Primary care)-a feasibility study

BACKGROUND

Patients with mental illness have an increased risk of cardiovascular morbidity and mortality compared to the rest of the population, which is partly related to unhealthy lifestyle habits. To individualise lifestyle counselling in primary care, the Swedish-developed Health Dialogue (HD) can be used as an educative tool at recurrent measurement points with the goal to improve non-healthy lifestyle habits. HD has not been aimed specifically at patients with mental illness, and the effect of a systematic approach with repeated HDs in patients with mental illness in primary care has not been previously studied. The aim of this pilot study was to assess the feasibility of the study design for a larger-scale cohort study using repeated HDs focused on the improvement of lifestyle habits in patients seeking primary care due to anxiety, depression, sleeping problems or stress-related symptoms.

METHODS

Patients were recruited after a visit to a Primary Health Care Center due to mental illness between October 2019 until November 2021 and received a Health Dialogue, including an assessment of cardiovascular risk factors through a Health Curve. Specific feasibility objectives measured were dropout rate, time to follow-up, and risk improvement rate for different lifestyle changes.

RESULTS

A total of 64 patients were recruited and 29 (45%) attended a second HD, with a mean follow-up time of 15 months. All participants had at least one elevated cardiovascular risk level on the Health Curve for the assessed lifestyles. Risk level improvement rate was good except for tobacco use.

CONCLUSION

Despite a higher dropout rate than expected, we suggest that the proposed methodology for a full cohort study within general practice of patients with mental illness in primary care is both acceptable to practice and feasible.

TRIAL REGISTRATION

NCT05181254 . Registered January 6th, 2022. Retrospectively registered.

Structured assessment of modifiable lifestyle habits among patients with mental illnesses in primary care

Patients with mental illness have an increased risk of cardiovascular morbidity. The Swedish-developed Health Dialogue is a pedagogical tool to individualize lifestyle counselling, used in specific age-groups to improve lifestyle habits and decrease mortality, but not tested specifically for patients with mental illness. Patients > 18 years old seeking primary care due to symptoms related to mental illness and diagnosed with depression, sleeping disorders, stress and anxiety, were included. A nurse-led health dialogue was conducted, focusing on lifestyle habits, anthropometric measurements, and blood samples, resulting in tailored advice regarding the individual's risk profile. All 64 participants had lifestyle areas with increased risk level. Approximately 20% had elevated fasting glucose, blood pressure or cholesterol levels, and over 40% had highest risk level in Waist-Hip-Ratio. 30% were overweight, or physical inactive. The results suggest the need of a larger cohort study with long-term follow up, to establish potentially positive effects on wellbeing, and decreased cardiovascular risk in patients with mental illness.Clinical trial registration: The study was registered at ClinicalTrials.gov January 6th, 2022, registration number NCT05181254.

Genetic and Non-genetic Determinants of Cardiovascular Disease in South Asians

South Asians (SAs), people from the Indian subcontinent (e.g., India, Pakistan, Bangladesh, Sri Lanka, and Nepal) have a higher prevalence of cardiovascular disease (CVD) and suffer from a greater risk of CVD-associated mortality compared to other global populations. These problems are compounded by the alterations in lifestyles due to urbanization and changing cultural, social, economic, and political environments. Current methods of CV risk prediction are based on white populations that under-estimate the CVD risk in SAs. Prospective studies are required to obtain actual CVD morbidity/mortality rates so that comparisons between predicted CVD risk can be made with actual events. Overwhelming data support a strong influence of genetic factors. Genome-Wide Association Studies (GWAS) serve as a starting point for future genetic and functional studies since the mechanisms of action by which these associated loci influence CVD is still unclear. It is difficult to predict the potential implication of these findings in clinical settings. This review provides a systematic assessment of the risk factors, genetics, and environmental causes of CV health disparity in SAs, and highlights progress made in clinical and genomics discoveries in the rapidly evolving field, which has the potential to show clinical relevance in the near future.

Self-Assembling Peptides as an Emerging Platform for the Treatment of Metabolic Syndrome

Metabolic syndrome comprises a cluster of comorbidities that represent a major risk of developing chronic diseases, such as type II diabetes, cardiovascular diseases, and stroke. Alarmingly, metabolic syndrome reaches epidemic proportions worldwide. Today, lifestyle changes and multiple drug-based therapies represent the gold standard to address metabolic syndrome. However, such approaches face two major limitations: complicated drug therapeutic regimes, which in most cases could lead to patient incompliance, and limited drug efficacy. This has encouraged scientists to search for novel routes to deal with metabolic syndrome and related diseases. Within such approaches, self-assembled peptide formulations have emerged as a promising alternative for treating metabolic syndrome. In particular, self-assembled peptide hydrogels, either as acellular or cell-load three-dimensional scaffoldings have reached significant relevance in the biomedical field to prevent and restore euglycemia, as well as for controlling cardiovascular diseases and obesity. This has been possible thanks to the physicochemical tunability of peptides, which are developed from a chemical toolbox of versatile amino acids enabling flexibility of designing a wide range of self-assembled/co-assembled nanostructures forming biocompatible viscoelastic hydrogels. Peptide hydrogels can be combined with several biological entities, such as extracellular matrix proteins, drugs or cells, forming functional biologics with therapeutic ability for treatment of metabolic syndrome-comorbidities. Additionally, self-assembly peptides combine safety, tolerability, and effectivity attributes; by this presenting a promising platform for the development of novel pharmaceuticals capable of addressing unmet therapeutic needs for diabetes, cardiovascular disorders and obesity. In this review, recent advances in developing self-assembly peptide nanostructures tailored for improving treatment of metabolic syndrome and related diseases will be discussed from basic research to preclinical research studies. Challenges facing the development of approved medicinal products based on self-assembling peptide nanomaterials will be discussed in light of regulatory requirement for clinical authorization.

The efficacy of 'static' training interventions for improving indices of cardiorespiratory fitness in premenopausal females

PURPOSE

Cardiovascular disease (CVD) is the leading cause of death worldwide. Many risk factors for CVD can be modified pharmacologically; however, uptake of medications is low, especially in asymptomatic people. Exercise is also effective at reducing CVD risk, but adoption is poor with time-commitment and cost cited as key reasons for this. Repeated remote ischaemic preconditioning (RIPC) and isometric handgrip (IHG) training are both inexpensive, time-efficient interventions which have shown some promise in reducing blood pressure (BP) and improving markers of cardiovascular health and fitness. However, few studies have investigated the effectiveness of these interventions in premenopausal women.

METHOD

Thirty healthy females were recruited to twelve supervised sessions of either RIPC or IHG over 4 weeks, or acted as non-intervention controls (CON). BP measurements, flow-mediated dilatation (FMD) and cardiopulmonary exercise tests (CPET) were performed at baseline and after the intervention period.

RESULTS

IHG and RIPC were both well-tolerated with 100% adherence to all sessions. A statistically significant reduction in both systolic (- 7.2 mmHg) and diastolic (- 6 mmHg) BP was demonstrated following IHG, with no change following RIPC. No statistically significant improvements were observed in FMD or CPET parameters in any group.

CONCLUSIONS

IHG is an inexpensive and well-tolerated intervention which may improve BP; a key risk factor for CVD. Conversely, our single arm RIPC protocol, despite being similarly well-tolerated, did not elicit improvements in any cardiorespiratory parameters in our chosen population.

Possible roles of platelet-derived microparticles in atherosclerosis

Platelets and platelet-derived microparticles (PMPs) play important roles in cardiovascular diseases, especially atherosclerosis. Continued research has revealed that PMPs have numerous functions in atherosclerosis, not only in thrombosis formation, but also by induction of inflammation. PMPs also induce formation of foam cells. Recent evidence strongly indicates a significant role of PMPs in atherosclerosis. Here, current research on the function of PMPs in atherosclerosis is reviewed.

Measurement of body composition as a surrogate evaluation of energy balance in obese patients

In clinical practice obesity is primarily diagnosed through the body mass index. In order to characterize patients affected by obesity the use of traditional anthropometric measures appears misleading. Beyond the body mass index, there are overwhelming evidences towards the relevance of a more detailed description of the individual phenotype by characterizing the main body components as free-fat mass, muscle mass, and fat mass. Among the numerous techniques actually available, bioelectrical impedance analysis seems to be the most suitable in a clinical setting because it is simple, inexpensive, noninvasive, and highly reproducible. To date, there is no consensus concerning the use of one preferred equation for the resting energy expenditure in overweight and/or obese population. Energy restriction alone is an effective strategy to achieve an early and significant weight loss, however it results in a reduction of both fat and lean mass therefore promoting or aggravating an unfavourable body composition (as sarcobesity) in terms of mortality and comorbidities. Therefore the implementation of daily levels of physical activity should be simultaneously promoted. The major role of muscle mass in the energy balance has been recently established by the rising prevalence of the combination of two condition as sarcopenia and obesity. Physical exercise stimulates energy expenditure, thereby directly improving energy balance, and also promotes adaptations such as fiber type, mitochondrial biogenesis, improvement of insulin resistance, and release of myokines, which may influence different tissues, including muscle.

Adolescent and adult African Americans have similar metabolic dyslipidemia

BACKGROUND

African Americans (AAs) have lower triglyceride (TG) and higher high-density lipoprotein cholesterol (HDL-C) than other ethnic groups; yet, they also have higher risk for developing diabetes mellitus despite the strong relationship of dyslipidemia with insulin resistance. No studies directly compare adolescents and adults with regard to relationships among dyslipidemia, high-sensitivity C-reactive protein (hs-CRP), and insulin resistance. Here, we compare AA adolescents to adults with regard to the relationships of adiposity-related lipid risk markers (TG-to-HDL ratio and non-HDL-C) with body mass index (BMI), waist circumference (WC), homeostasis model of insulin resistance (HOMA), and hs-CRP.

METHODS

Two cohorts of healthy AA were recruited from the same urban community. Participants in each cohort were stratified by TG-to-HDL ratio (based on adult tertiles) and non-HDL-C levels. BMI, WC, HOMA, and hs-CRP were compared in adolescents and adults in the low-, middle-, and high-lipid strata.

RESULTS

Prevalence of TG-to-HDL ratio greater than 2.028 (high group) was 16% (44 of 283) in adolescents and 33% (161 of 484) in adults; prevalence of non-HDL-C above 145 and 160, respectively, was 8% (22 of 283) in adolescents and 12% (60 of 484) in adults. Values of hs-CRP were lower, and HOMA values were higher in adolescents (both P < .01). As both TG-to-HDL ratio and non-HDL-C strata increased, BMI, WC, HOMA, and hs-CRP increased in both adolescents and adults. In the high TG-to-HDL ratio and non-HDL-C groups, BMI and WC were similar in adolescents vs adults (BMI, 34 kg/m(2) vs 32 kg/m(2); WC, 101 cm vs 101 cm). After adjusting for non-HDL-C and other covariates, a 2-fold increase in TG-to-HDL ratio was associated with increases of 10.4% in hs-CRP (95% CI, 1.1%-20.5%) and 24.2% in HOMA (95% CI, 16.4%-32.6%). Non-HDL-C was not significant in models having TG-to-HDL ratio.

CONCLUSION

The elevated TG-to-HDL ratio is associated with similar inflammation and metabolic risk relationships in adolescent and adult AAs.

Plant sterols from foods in inflammation and risk of cardiovascular disease: a real threat?

High dietary intakes of cholesterol together with sedentary habits have been identified as major contributors to atherosclerosis. The latter has long been considered a cholesterol storage disease; however, today atherosclerosis is considered a more complex disease in which both innate and adaptive immune-inflammatory mechanisms as well as bacteria play a major role, in addition to interactions between the arterial wall and blood components. This scenario has promoted nutritional recommendations to enrich different type of foods with plant sterols (PS) because of their cholesterol-lowering effects. In addition to cholesterol, PS can also be oxidized during food processing or storage, and the oxidized derivatives, known as phytosterol oxidation products (POPs), can make an important contribution to the negative effects of both cholesterol and cholesterol oxidation oxides (COPs) in relation to inflammatory disease onset and the development of atherosclerosis. Most current research efforts have focused on COPs, and evaluations of the particular role and physiopathological implications of specific POPs have been only inferential. Appreciation of the inflammatory role described for both COPs and POPs derived from foods also provides additional reasons for safety studies after long-term consumption of PS. The balance and relevance for health of all these effects deserves further studies in humans. This review summarizes current knowledge about the presence of sterol oxidation products (SOPs) in foods and their potential role in inflammatory process and cardiovascular disease.

Factors influencing left ventricular hypertrophy in children and adolescents with or without family history of premature myocardial infarction

BACKGROUND

Cardiovascular diseases are the highest ranking cause of mortality. The prevalence of cardiovascular diseases is increasing among people in developed and developing countries. Since left ventricular hypertrophy is one of the risk factors leading to extremely dangerous heart diseases and even sudden death at early ages, investigating its contributing factors can be beneficial. The purpose of this study was to determine factors contributing to left ventricular hypertrophy in students aged 7-18 years in Isfahan. Statistical population of this case-control study was the 7-18 year old students in Isfahan, who were studied in two groups of children with premature myocardial infarction in their parents and the control group.

MATERIALS AND METHODS

After determining the sample size of 138 people, a two-part questionnaire was designed and demographic characteristics and anthropometric measures were recorded in students' profiles. The obtained information was analyzed using SPSS15 software and logistic regression model and the results were reported at P < 0.05.

RESULT

The results showed that among the studied variables, gender, age, body mass index, and blood pressure were associated with the left ventricular hypertrophy.

CONCLUSION

Considering the results and previous studies in this field, it was observed that left ventricular hypertrophy exists at early ages, which is very dangerous and can lead to heart diseases at early ages. Factors such as being overweight, having high blood pressure, and being male cause left ventricular hypertrophy and lead to undiagnosable heart diseases.

Coronary artery calcium score: Re-evaluation of its predictive value for coronary artery disease

Coronary artery disease is the leading cause of death in advanced countries and its prevalence is increasing among the developing countries. Cardiac computed tomography (CT) has been increasingly used in the diagnosis of coronary artery disease due to its rapid improvements in multislice CT scanners over the last decade, and this less-invasive technique has become a potentially effective alternative to invasive coronary angiography. Quantifying the amount of coronary artery calcium with cardiac CT has been widely accepted as a reliable non-invasive technique for predicting risk of future cardiovascular events. However, the main question that remains uncertain is whether routine, widespread coronary artery calcium scoring in an individual patient will result in an overall improvement in quality of care and clinical outcomes. In this commentary, we discuss a current issue of the clinical value of coronary artery calcium scoring with regard to its value of predicting adverse cardiac events. We also discuss the applications of coronary artery calcium scores in patients with different risk groups.

Mipomersen: a safe and effective antisense therapy adjunct to statins in patients with hypercholesterolemia

Mipomersen is an antisense oligonucleotide inhibitor of apolipoprotein (apo) B-100 currently in phase 3 of development for the treatment of hyperlipidemia in patients with a high risk for cardiovascular disease. The drug acts by inhibiting the production of apoB-100, which is the structural core for all atherogenic lipids, including low-density lipoprotein cholesterol (LDL-C). The agent has been shown to produce significant reductions in LDL-C from baseline values compared with placebos. Clinical trials have demonstrated that mipomersen reduces LDL-C up to 44% in patients with familial hypercholesterolemia and patients with significantly elevated LDL despite taking maximum doses of statins. Unlike other medications that target apoB-100, such as microsomal triglyceride transfer proteins, mipomersen does not cause hepatic steatosis or intestinal steatosis and does not affect dietary fat absorption. Adverse side effects encountered with mipomersen include flu-like symptoms, injection site reactions, and elevated liver transaminases. If future studies continue to show such promising results, mipomersen would likely be a viable additional lipid-lowering therapy for patients who are at high cardiovascular risk, intolerant to statins, and/or not at target lipid levels despite maximum doses of statin therapy. Clinical outcome studies looking at cardiovascular disease end points still need to be done.

Microparticles, Vascular Function, and Atherothrombosis

Membrane-shed submicron microparticles (MPs) are released after cell activation or apoptosis. High levels of MPs circulate in the blood of patients with atherothrombotic diseases, where they could serve as a useful biomarker of vascular injury and a potential predictor of cardiovascular mortality and major adverse cardiovascular events. Atherosclerotic lesions also accumulate large numbers of MPs of leukocyte, smooth muscle cell, endothelial, and erythrocyte origin. A large body of evidence supports the role of MPs at different steps of atherosclerosis development, progression, and complications. Circulating MPs impair the atheroprotective function of the vascular endothelium, at least partly, by decreased nitric oxide synthesis. Plaque MPs favor local inflammation by augmenting the expression of adhesion molecule, such as intercellular adhesion molecule -1 at the surface of endothelial cell, and monocyte recruitment within the lesion. In addition, plaque MPs stimulate angiogenesis, a key event in the transition from stable to unstable lesions. MPs also may promote local cell apoptosis, leading to the release and accumulation of new MPs, and thus creating a vicious circle. Furthermore, highly thrombogenic plaque MPs could increase thrombus formation at the time of rupture, together with circulating MPs released in this context by activated platelets and leukocytes. Finally, MPs also could participate in repairing the consequences of arterial occlusion and tissue ischemia by promoting postischemic neovascularization.

Longitudinal genome-wide association of cardiovascular disease risk factors in the Bogalusa heart study

Cardiovascular disease (CVD) is the leading cause of death worldwide. Recent genome-wide association (GWA) studies have pinpointed many loci associated with CVD risk factors in adults. It is unclear, however, if these loci predict trait levels at all ages, if they are associated with how a trait develops over time, or if they could be used to screen individuals who are pre-symptomatic to provide the opportunity for preventive measures before disease onset. We completed a genome-wide association study on participants in the longitudinal Bogalusa Heart Study (BHS) and have characterized the association between genetic factors and the development of CVD risk factors from childhood to adulthood. We report 7 genome-wide significant associations involving CVD risk factors, two of which have been previously reported. Top regions were tested for replication in the Young Finns Study (YF) and two associations strongly replicated: rs247616 in CETP with HDL levels (combined P = 9.7×10⁻²⁴), and rs445925 at APOE with LDL levels (combined P = 8.7×10⁻¹⁹). We show that SNPs previously identified in adult cross-sectional studies tend to show age-independent effects in the BHS with effect sizes consistent with previous reports. Previously identified variants were associated with adult trait levels above and beyond those seen in childhood; however, variants with time-dependent effects were also promising predictors. This is the first GWA study to evaluate the role of common genetic variants in the development of CVD risk factors in children as they advance through adulthood and highlights the utility of using longitudinal studies to identify genetic predictors of adult traits in children.

We have studied the association between genetic factors on a whole genome level and cardiovascular disease (CVD) risk factors in a population of individuals studied from childhood through adulthood. The longitudinal study design has enabled the investigation of genetic variation influencing trait values over time. We have identified DNA variants that are associated with CVD trait values consistently over time, and a second set of variants that are associated with CVD trait values in a time-dependent manner. We also show that variants previously identified in adult populations have consistent effects within our population and that these effects are usually similar across childhood through adulthood. The discovery of time-dependent variants that influence CVD trait values over time can potentially be used to screen young individuals who are pre-symptomatic and provide the opportunity for preventive measures decades before disease onset.

Pharmacotherapy for end-stage coronary artery disease

IMPORTANCE OF THE FIELD

Coronary artery disease remains the leading cause of mortality in the industrialized world. Despite advances in surgical and catheter-based interventions, a select number of patients remain with no options for invasive therapy. The goal of this review is to discuss the current status of pharmacotherapeutic interventions to treat end-stage coronary artery disease.

AREAS COVERED IN THIS REVIEW

Literature review on the topic of therapeutic angiogenesis from 1980 to 2009.

WHAT THE READER WILL GAIN

Insight into current therapeutic strategies employed to manage end-stage coronary artery disease.

TAKE HOME MESSAGE

A promising approach focuses on augmenting the endogenous angiogenic response to chronic myocardial ischemia via the use of growth factors.

Cytokine network and T cell immunity in atherosclerosis

Atherosclerosis is a chronic inflammatory disease of the arterial wall where both innate and adaptive immune responses contribute to disease initiation and progression. Recent studies established that subtypes of T cells, regulatory T cells (Tregs), actively involved in the maintenance of immunological tolerance, inhibit the development and progression of atherosclerosis. Here, we review the current knowledge on the Treg response and the major cytokines involved in its modulation in the context of atherosclerosis.

Annexin A5: an imaging biomarker of cardiovascular risk

Apoptosis, a form of programmed cell death (PCD), plays an important role in the initiation and progression of a number of cardiovascular disease, such as heart failure, myocardial infarction, and atherosclerosis. One of the most prominent characteristics of apoptosis is the externalisation of phosphatidylserine (PS), a plasma cell membrane phospholipid, which in healthy cells only is present on the inner leaflet of the plasma cell membrane. Annexin A5, a 35 kD plasma protein, has strong affinity for PS in the nano-molar range. Through the coupling of Annexin A5 to contrast agents, visualization of apoptotic cell death in vivo in animal models and in patients has become feasible. These imaging studies have provided novel insight into the extent and kinetics of apoptosis in cardiovascular disease. Furthermore, Annexin A5 imaging has proven to be a suitable imaging biomarker for the evaluation of cell death modifying compounds and plaque stabilizing strategies. Recent insight in PS biology has shown that PS externalisation not only occurs in apoptosis, but is also observed in activated macrophages and stressed cells. In addition, it has been shown that Annexin A5 not only binds to exteriorized PS, but is also internalized through an Annexin A5 specific mechanism. These latter findings indicate that Annexin A5 imaging is not exclusively valuable for apoptosis detection, but can also be used to visualize inflammation and cell stress. This will open novel opportunities for imaging and drug delivery strategies. In this review we will discuss the introduction of Annexin A5 in preclinical and clinical imaging studies and provide an outlook on novel opportunities of Annexin A5 based targeting of PS.

Reduced antioxidant capacity and diet-induced atherosclerosis in uncoupling protein-2-deficient mice

Vascular dysfunction in response to reactive oxygen species (ROS) plays an important role in the development and progression of atherosclerotic lesions. In most cells, mitochondria are the major source of cellular ROS during aerobic respiration. Under most conditions the rates of ROS formation and elimination are balanced through mechanisms that sense relative ROS levels. However, a chronic imbalance in redox homeostasis is believed to contribute to various chronic diseases, including atherosclerosis. Uncoupling protein-2 (UCP2) is a mitochondrial inner membrane protein shown to be a negative regulator of macrophage ROS production. In response to a cholesterol-containing atherogenic diet, C57BL/6J mice significantly increased expression of UCP2 in the aorta, while mice lacking UCP2, in the absence of any other genetic modification, displayed significant endothelial dysfunction following the atherogenic diet. Compared with wild-type mice, Ucp2(-/-) mice had decreased endothelial nitric oxide synthase, an increase in vascular cell adhesion molecule-1 expression, increased ROS production, and an impaired ability to increase total antioxidant capacity. These changes in Ucp2(-/-) mice were associated with increased aortic macrophage infiltration and more numerous and larger atherosclerotic lesions. These data establish that in the vasculature UCP2 functions as an adaptive antioxidant defense to protect against the development of atherosclerosis in response to a fat and cholesterol diet.

Efetividade de um programa de exercícios no condicionamento físico, perfil metabólico e pressão arterial de pacientes hipertensos

HISTÓRICO E OBJETIVO: Tem sido mostrado que exercícios aeróbios são úteis na redução da pressão arterial. Contudo, a efetividade de um programa de exercícios ainda é controversa e não foi bem analisada em populações de baixa renda. O objetivo do presente estudo foi estabelecer um programa de condicionamento físico individualizado - Projeto Hipertensão - focado em pessoas hipertensas, pacientes da Unidade Básica de Saúde (UBS) e, logo após, investigar os efeitos deste programa no condicionamento físico, perfil metabólico e níveis de pressão. MÉTODOS: Dezesseis mulheres hipertensas (56 ± 3 anos) sob tratamento farmacológico regular foram submetidas a 4 meses de um programa de exercícios aeróbios e de alongamento (3 sessões/semana, 90 min/sessão, 60% de VO2max.) Diversas variáveis físicas e metabólicas foram comparadas antes e depois de 4 meses de treinamento. RESULTADOS: O treinamento diminuiu significativamente a pressão arterial sistólica (PAS, -6%); melhorou o condicionamento cardiorrespiratório (+42% do VO2max), flexibilidade (+11%) e conteúdo de glicose plasmática (-4%). IMC e % de gordura não tiveram modificação. Além de modificar o perfil metabólico, observou-se que o treinamento apresentou correlações significativas entre os valores iniciais individuais de nível de colesterol total (CT), lipoproteína de alta densidade (HDL-C) e lipoproteína de baixa densidade (LDL-C) e suas respostas após exercício. CONCLUSÕES: O estudo mostra que programas de exercício podem ser personalizados para pacientes hipertensos da UBS e confirma a efetividade do exercício na PA, condicionamento físico, flexibilidade e perfil lipídico em pacientes hipertensos. A redução expressiva de PA em sujeitos hipertensos sugere que esta intervenção de exercícios deve ser enfatizada em outros centros que assistam populações de baixa renda.

Cranberry Juice Increases Antioxidant Status Without Affecting Cholesterol Homeostasis in Orchidectomized Rats

Oxidative stress and hypogonadism are linked to the increased incidence of cardiovascular disease in males. The objective of this research was to delineate whether drinking cranberry juice for 4 months affects antioxidant capacity and lipid profile in orchidectomized rats. Thirty-two 1-year-old male rats were randomized to two groups: a sham-control group (n = 8) and an orchidectomized group (n = 24). The orchidectomized group was divided into three groups of eight and assigned to one of the following treatments: orchidectomy, orchidectomy plus 27% cranberry juice, and orchidectomy plus 45% cranberry juice. At 120 days after initiation of the study, all rats were killed, blood was collected, and plasma was harvested for total antioxidant status, malondialdehyde, nitrate + nitrite, and superoxide dismutase (SOD) activity in liver, and concentrations of cholesterol and triglyceride in liver and in plasma. Orchidectomy depressed (P < .05) plasma antioxidant capacity and SOD activity, elevated (P < .05) nitrate + nitrite and malondialdehyde in plasma, and increased (P < .05) triglyceride and cholesterol values in liver and in plasma. Cranberry juice increased (P < .05) plasma antioxidant capacity and SOD activity and reduced (P < .05) nitrate + nitrite and malondialdehyde concentrations. Drinking cranberry juice did not affect cholesterol concentrations in liver and in plasma. Triglyceride concentration in plasma of orchidectomized rats that were drinking cranberry juice increased (P < .05), but its concentration in liver decreased (P < .05) to the level of shams. The protective effect of cranberry juice from oxidative damage may be mediated by a decrease in nitrate + nitrite and dose-dependent decrease in peroxidation.

Using technology to enhance prevention services for children in primary care

Primary care is the principal setting for implementation of prevention services for children and their families. However, aspects of primary care practice and lack of patient adherence to therapeutic regimens that ultimately lead to lifestyle and behavior changes are barriers to the delivery of prevention services. The authors of this paper present descriptive information about how a web-based computer application is being used to assist physicians in a major medical center overcome some of these impediments. This information is presented in the hopes of generating discussion about the utility of computer based support for prevention services in primary care settings. Additional steps to optimize the care of patients are also described.

Citrus juice modulates antioxidant enzymes and lipid profiles in orchidectomized rats

Oxidative stress and hypogonadism are two factors linked to the increased incidence of cardiovascular disease in males. Eating fruits and vegetables is known to reduce the incidences of oxidative stress. The objective of this research was to delineate whether drinking daily squeezed orange juice (OJ) or grapefruit juice (GJ) modulates oxidative stress and antioxidant enzymes while impacting cardiovascular risk factors in hypogonad male rats. In the present study, 36 1-year-old male rats were equally divided among the following four treatments: sham (control), orchidectomized (ORX), ORX + OJ, and ORX + GJ. After 60 days of drinking OJ or GJ, antioxidant capacity, cholesterol, and triglycerides in serum and superoxide dismutase (SOD), catalase (CAT), cholesterol, and triglycerides in liver were evaluated. Serum antioxidant capacity and SOD and CAT activities decreased (P < .05), while serum cholesterol and liver triglycerides increased (P < .05) in the ORX group compared with the sham group. In contrast to the ORX group, drinking OJ was ineffective while drinking GJ decreased (P < .05) cholesterol concentration in liver and in serum. Nevertheless, OJ and GJ decreased (P < .05) triglyceride concentration in liver and increased (P < .05) serum antioxidant capacity and SOD and CAT activities compared with the ORX group. In conclusion, drinking OJ or GJ prevented oxidative stress by enhancing total antioxidant capacity and elevating liver antioxidant enzymes while modulating cardiovascular risk factors.

Identification of the metabolic syndrome and imaging of subclinical coronary artery disease: early markers of cardiovascular risk

The metabolic syndrome and imaging of subclinical coronary artery disease are novel approaches to identify cardiovascular risk at an early disease stage before the onset of complications. The metabolic syndrome is defined as a combination of major and emerging cardiovascular risk factors that are related to underlying insulin resistance. These risk factors accelerate atherosclerotic disease progression and increase the risk for future cardiovascular events. Atherosclerosis imaging visualizes the presence of subclinical disease burden many years before the onset of symptoms. The early identification of asymptomatic persons with increased cardiovascular risk provides the opportunity to prevent of future disease complications. The relationship between the metabolic syndrome and sublinical disease burden is incompletely understood. Although further evaluation of the potential role for the emerging biomarkers and imaging techniques in the setting of the metabolic syndrome is needed, it is obvious that cardiovascular nurses need to develop a heightened awareness of patients at risk for future events.

Influence of different lipid-lowering strategies on plaque volume and plaque composition in patients with coronary artery disease: role of intravascular ultrasound imaging

Lipid-lowering therapy has a significant impact on the prognosis and clinical course of coronary artery disease (CAD). Slowdown of plaque progression and plaque stabilization are the major cardiac goals of any lipid-lowering strategy. Until now, intravascular ultrasound imaging (IVUS) has been the only in vivo imaging modality which allows serial analysis of plaque burden and plaque composition on a volumetric basis. Several serial IVUS studies have shown that chronic statin therapy could decrease or even halt plaque growth. Moreover, aggressive lipid-lowering therapy using statins changes plaque composition over time. There is evidence that changes in plaque composition might explain the positive prognostic impact of statin therapy in patients with CAD. Beyond clinical endpoint studies, serial volumetric IVUS studies will become the standard to prove the efficacy of new lipid-lowering strategies in the future.

Modelling the decline in coronary heart disease deaths in England and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention

OBJECTIVE

To investigate whether population based primary prevention (risk factor reduction in apparently healthy people) might be more powerful than current government initiatives favouring risk factor reduction in patients with coronary heart disease (CHD) (secondary prevention).

DESIGN, SETTING, AND PARTICIPANTS

The IMPACT model was used to synthesise data for England and Wales describing CHD patient numbers, uptake of specific treatments, trends in major cardiovascular risk factors, and the mortality benefits of these specific risk factor changes in healthy people and in CHD patients.

RESULTS

Between 1981 and 2000, CHD mortality rates fell by 54%, resulting in 68,230 fewer deaths in 2000. Overall smoking prevalence declined by 35% between 1981 and 2000, resulting in approximately 29,715 (minimum estimate 20 035, maximum estimate 44,675) fewer deaths attributable to smoking cessation: approximately 5035 in known CHD patients and approximately 24,680 in healthy people. Population total cholesterol concentrations fell by 4.2%, resulting in approximately 5770 fewer deaths attributable to dietary changes (1205 in CHD patients and 4565 in healthy people) plus 2135 fewer deaths attributable to statin treatment (1990 in CHD patients, 145 in people without CHD). Mean population blood pressure fell by 7.7%, resulting in approximately 5870 fewer deaths attributable to secular falls in blood pressure (520 in CHD patients and 5345 in healthy people) plus approximately 1890 fewer deaths attributable to antihypertensive treatments in people without CHD. Approximately 45,370 fewer deaths were thus attributable to reductions in the three major risk factors in the population: some 36 625 (81%) in people without recognised CHD and 8745 (19%) in CHD patients.

CONCLUSIONS

Compared with secondary prevention, primary prevention achieved a fourfold larger reduction in deaths. Future CHD policies should prioritise population-wide tobacco control and healthier diets.

Non-invasive coronary angiography with multi-detector computed tomography: comparison to conventional X-ray angiography

Selective coronary angiography introduced clinical coronary imaging in the late 1950s. The angiographic identification of high-grade coronary lesions in patients with acute and chronic symptomatic coronary artery disease (CAD) led to the development of surgical and percutaneous coronary revascularization. However, the fact that CAD remains the major cause of death in North America and Europe demonstrates the need for novel, complementary diagnostic strategies. These are driven by the need to characterize both increasingly advanced disease stages but also early, asymptomatic disease development. Complex revascularization techniques for patients with advanced disease stages will initiate a growing demand for 3-dimensional coronary imaging and integration of imaging modalities with new mechanical therapeutic devices. An emerging focus is atherosclerosis imaging with the goal to identify subclinical disease stages as the basis for pharmacological intervention aimed at disease stabilization or reversal. Non-invasive coronary imaging with coronary multidetector computed tomographic angiography (MDCTA) allows both assessment of luminal stenosis and subclinical disease of the arterial wall. Its complementary role in the assessment of early and advanced stages of CAD is increasingly recognized.

Issues in minority health: atherosclerosis and coronary heart disease in African Americans

Cardiovascular disease (in particular, CHD) is the leading cause of death in the United States for Americans of both sexes and of all racial and ethnic backgrounds. African Americans have the highest overall CHD mortality rate and the highest out-of-hospital coronary death rate of any ethnic group in the United States, particularly at younger ages. Contributors to the earlier onset of CHD and excess CHD deaths among African Americans include a high prevalence of coronary risk factors, patient delays in seeking medical care, and disparities in health care. The clinical spectrum of acute and chronic CHD in African Americans is the same as in whites; however, African Americans have a higher risk of sudden cardiac death and present clinically more often with unstable angina and non-ST-segment elevation myocardial infarction than whites. Although generally not difficult, the accurate diagnosis and risk assessment for CHD in African Americans may at times present special challenges. The high prevalence of hypertension and type 2 diabetes mellitus may contribute to discordance between symptomatology and the severity of coronary artery disease, and some noninvasive tests appear to have a lower predictive value for disease. The high prevalence of modifiable risk factors provides great opportunities for the prevention of CHD in African Americans. Patients at high risk should be targeted for intensive risk reduction measures, early recognition/diagnosis of ischemic syndromes, and appropriate referral for coronary interventions and cardiac surgical procedures. African Americans who have ACSs receive less aggressive treatment than their white counterparts but they should not. Use of evidence-based therapies for management of patients who have ACSs and better understanding of various available treatment strategies are of utmost importance. Reducing and ultimately eliminating disparities in cardiovascular care and outcomes require comprehensive programs of education and advocacy(Box 4) with the goals of (1) increasing provider and public awareness of the disparities in treatment; (2) decreasing patient delays in seeking medical care for acute myocardial infarction and other cardiac disorders; (3) more timely and appropriate therapy for ACSs; (4) improved access to preventive, diagnostic, and interventional cardiovascular therapies; (5) more effective implementation of evidence-based treatment guidelines; and (6) improved physician-patient communications.

Atherosclerosis imaging: intravascular ultrasound

Most acute coronary syndromes result from the rupture or erosion of high-risk plaques. Clinical imaging studies have shown that atherosclerotic plaque formation and rupture are widespread processes that are often asymptomatic. The rationale for atherosclerosis imaging is the in-vivo identification of high-risk lesions, which may subsequently lead to prevention of future cardiovascular events. Although intravascular ultrasound (IVUS) imaging studies demonstrated that echolucent appearance of the plaque and expansive (positive) remodelling are associated with unstable clinical presentation, these characteristics were not adequate for accurate plaque characterisation. Recent technical developments in ultrasound equipment and analytical methods, utilising several characteristics of the digitised ultrasound signal with radiofrequency analysis and elastography, promise accurate tissue characterisation. Other imaging modalities, including optical coherence tomography, also contribute to a more precise characterisation of the composition of atherosclerotic plaques. A non-imaging approach is the focal assessment of temperature differences using sensitive intravascular thermography catheters, presumably reflecting focal inflammatory changes of vulnerable lesions. Although the histological characteristics of the atheroma are critically important in the sequence of events leading to acute coronary syndromes, the clinical relevance of identifying these characteristics is not yet clear. There is increasing evidence that identifying and treating individual culprit lesions may not be enough to prevent the ischaemic cardiac events in most patients, because the acute coronary syndrome is not a disease of a single site or a few discrete segments, but rather a systemic disease that involves the entire coronary tree. In addition to detection and quantitation of early coronary atherosclerosis and disease activity, accurate and reproducible methods could help to identify high-risk patients and allow serial monitoring during various therapeutic interventions. Serial IVUS imaging makes it possible to visualise the vessel wall that harbours the atheroma at different time points. Typically, serial IVUS allows the assessment of the percentage change in atheroma volume, with considerable statistical power to detect small changes. Using this methodology, aggressive lipid lowering by a high-dose statin agent has been shown to stop the progression of atherosclerosis, and a new mutant high-density lipoprotein complex was found to be effective in regressing atheroma burden. Although intravascular ultrasound is very accurate for quantification of atheroma burden, widespread application and accurate and reproducible non-invasive imaging modalities are needed for large-scale risk assessment algorithms. Cardiovascular computed tomography is at the forefront of the non-invasive imaging modalities. Future prospective imaging studies will be necessary to identify focal or systemic characteristics of high-risk lesions and to demonstrate the relationship between plaque burden, biochemical markers and clinical events.

An apolipoprotein B antisense oligonucleotide lowers LDL cholesterol in hyperlipidemic mice without causing hepatic steatosis

High levels of plasma apolipoprotein B-100 (apoB-100), the principal apolipoprotein of LDL, are associated with cardiovascular disease. We hypothesized that suppression of apoB-100 mRNA by an antisense oligonucleotide (ASO) would reduce LDL cholesterol (LDL-C). Because most of the plasma apoB is made in the liver, and antisense drugs distribute to that organ, we tested the effects of a mouse-specific apoB-100 ASO in several mouse models of hyperlipidemia, including C57BL/6 mice fed a high-fat diet, Apoe-deficient mice, and Ldlr-deficient mice. The lead apoB-100 antisense compound, ISIS 147764, reduced apoB-100 mRNA levels in the liver and serum apoB-100 levels in a dose- and time-dependent manner. Consistent with those findings, total cholesterol and LDL-C decreased by 25-55% and 40-88%, respectively. Unlike small-molecule inhibitors of microsomal triglyceride transfer protein, ISIS 147764 did not produce hepatic or intestinal steatosis and did not affect dietary fat absorption or elevate plasma transaminase levels. These findings, as well as those derived from interim phase I data with a human apoB-100 antisense drug, suggest that antisense inhibition of this target may be a safe and effective approach for the treatment of humans with hyperlipidemia.

Heart healthy equals prostate healthy equals statins: the next cancer chemoprevention trial. Part II

PURPOSE OF REVIEW

Specific ongoing observations from diverse medical studies do not serve to belittle the impact of prostate or other cancers, but the overall impact of cardiovascular disease (CVD) in individuals at high-risk or in individuals that have been diagnosed with common cancers needs to be addressed by future research. CVD has been the number one cause of death in men and women since the year 1990. Serum cholesterol levels are some of the most accurate long-term predictors of all-cause mortality. CVD has been the number one cause of death in the largest dietary supplement cancer chemoprevention trials.

RECENT FINDINGS

The potential for utilizing a cancer chemoprevention agent that may simultaneously reduce the risk of CVD and cancer is not only attractive, but several agents are available immediately that may demonstrate this unique impact. For example, recently statin drugs, low-dose aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), and even fish oil supplements may be utilized in the next major cancer chemoprevention trial.

SUMMARY

Heart healthy agents and interventions seem to also exhibit the ability to be prostate healthy. In addition, their low cost and potential to reduce all-cause mortality may also ensure good compliance. Statins and other heart healthy agents should be considered to be the next most ideal interventions to be utilized in the next major chemoprevention trial, especially now because several popular past dietary supplements and drugs have demonstrated the potential for notable side effects and an inability to impact the risk of CVD.

Coronary atherosclerosis in diabetic subjects: clinical significance, anatomic characteristics, and identification with in vivo imaging

Diabetes mellitus is an endocrine disorder that promotes the development and progression of atherosclerotic coronary disease. As a consequence, cardiovascular disease is the most important cause of morbidity and mortality in diabetics. Early identification and treatment of asymptomatic stages provides the opportunity to prevent cardiovascular end organ complications. Modem clinical imaging modalities allow the assessment of early atherosclerotic changes in coronary arteries; however, prospective evidence that atherosclerosis imaging impacts on clinical outcome is not yet available and future studies are necessary.

Why a statin and/or another proven heart healthy agent should be utilized in the next major cancer chemoprevention trial: Part I

The recent removal of refecoxib (a cyclo-oxygenase II inhibitor), a drug involved in a large prostate cancer chemoprevention trial, and the completion of recruitment for the SELECT cancer chemoprevention trial utilizing selenium and vitamin E should lead researchers to ponder a similar question in cancer chemoprevention. The question of "What agent should be utilized and what clinical trial should designed and conducted next for cancer chemoprevention?" Part I and II of this manuscript attempts to argue that statins or cholesterol-lowering drugs or heart healthy agents are the ideal next choice for a large chemoprevention trial for numerous reasons including: (1) Cardiovascular disease (CVD) has been the number one cause of death in men and women every year in the US since 1900; (2) CVD has been the number one cause of death in the major cancer chemoprevention trials; (3) CVD has been the number one or two cause of death of men and women postdiagnosis of breast, colorectal, and prostate cancer; and (4) the recent potential relationship between certain cancers and dyslipidemia needs to be investigated. What other chemoprevention agent can also boast that in the worst case scenario the number one cause of death in men and women would probably be reduced in this future cancer chemoprevention trial of statins?! The list continues to grow of cancer chemoprevention trials that will probably be either a complete hit or miss. In other words, they will or have reduced the disease of interest with virtually no potential role for reducing the number one cause of death in men and women. The time seems more than overdue for a statin and/or another cholesterol lowering or heart healthy cancer chemoprevention trial.

Pharmacologic strategies for the prevention of atherosclerotic plaque progression

Despite improved treatment options, coronary artery disease remains the leading cause of death in men and women in industrialized societies. Reduction of atherosclerotic disease will require the development and evaluation of new classes of pharmacologic agents capable of modifying the development and progression of the atherosclerotic disease process. The direct observation of coronary plaque burden and morphology with in vivo imaging modalities has been evaluated as an end point in serial pharmacologic intervention trials. This review will describe the use of intravascular ultrasound for such studies, summarize results from recent trials and outline potential future pharmacologic targets.

Prostate cancer and coronary heart disease: correlation or coincidence?

A few past clinical and recent case-control studies of statin use, for example, in patients with and without prostate cancer have not demonstrated its potential for reducing or preventing the risk for this disease, and the potential for benefit may have been a confounding coincidence. Data from larger continuing and future studies will be needed to resolve this issue, but the recent data on cholesterol or dyslipidemia and risk increase or reduction with treatment are interesting, especially because of other potential improvements with therapy in nonprostate cancers. In addition, the finding that some available cancer treatments improve some parameters of the lipid profile is fascinating, and some cancer drugs are being used in a specific cardiovascular disease treatment setting to improve outcome. Even if CHD, dyslipidemia, and the treatment of these conditions has no role in preventing prostate cancer or its progression, what has been lost? CVD is still the leading cause of death of men, and a heart-healthy program for the patient concerned about prostate disease would reduce this primary cause of death. Patients would take a step forward in improving all-cause mortality. Recent data from surveys, however, continue to demonstrate that men have an inadequate understanding of cholesterol and heart disease. Crisis creates opportunity, and individuals working in urology have ample reasons not only to discuss the overall benefits of reducing lipid markers, but to improve cholesterol and CHD awareness as much as health professionals working in other fields of medicine. The marriage between general preventive medicine and urology seems to be inevitable, and in the authors' opinion, this merger will provide the foundation for novel research that could affect patients' lives dramatically.

Assessing Coronary Plaque Burden and Plaque Vulnerability:Atherosclerosis Imaging With IVUS and Emerging Noninvasive Modalities

Despite significantly improved preventive and therapeutic options, coronary artery disease remains the major cause of mortality in North America. A large number of acute coronary events, including acute myocardial infarction and sudden cardiac death, occur in patients without prior symptoms because these events are initiated by sudden rupture of mildly stenotic but vulnerable lesions. Recent results demonstrate a high prevalence of such plaques many years before clinical events occur. Because these lesions are mildly stenotic before the event, the angiographic evaluation of the lumen is not sufficient for their detection. Therefore, direct observation of coronary plaque burden and plaque vulnerability with in vivo tomographic imaging modalities is increasingly utilized. Intravascular ultrasound is the most established invasive method with a long clinical track record. More recently, noninvasive modalities including computed tomography and magnetic resonance imaging are emerging.