Exposure to Ionizing Radiation and Estimate of Secondary Cancers in the Era of High-Speed CT Scanning: Projections From the Medicare Population

PMID:

Developing an Action Plan for Patient Radiation Safety in Adult Cardiovascular Medicine: Proceedings From the Duke University Clinical Research Institute/American College of Cardiology Foundation/American Heart Association Think Tank Held on February 28, 2011

Technological advances and increased utilization of medical testing and procedures have prompted greater attention to ensuring the patient safety of radiation use in the practice of adult cardiovascular medicine. In response, representatives from cardiovascular imaging societies, private payers, government and nongovernmental agencies, industry, medical physicists, and patient representatives met to develop goals and strategies toward this end; this report provides an overview of the discussions. This expert “think tank” reached consensus on several broad directions including: the need for broad collaboration across a large number of diverse stakeholders; clarification of the relationship between medical radiation and stochastic events; required education of ordering and providing physicians, and creation of a culture of safety; development of infrastructure to support robust dose assessment and longitudinal tracking; continued close attention to patient selection by balancing the benefit of cardiovascular testing and procedures against carefully minimized radiation exposures; collation, dissemination, and implementation of best practices; and robust education, not only across the healthcare community, but also to patients, the public, and media. Finally, because patient radiation safety in cardiovascular imaging is complex, any proposed actions need to be carefully vetted (and monitored) for possible unintended consequences.

PMID:

Using Stress Testing to Guide Primary Prevention of Coronary Heart Disease Among Intermediate-Risk Patients A Cost-Effectiveness Analysis

OBJECTIVES: Noninvasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease, but it is unclear if such a strategy would be cost effective.

METHODS: We compared the status quo, in which the current national use of aspirin and statins was simulated, with 3 other strategies: (1) full implementation of Adult Treatment Panel III guidelines, (2) a treat-all strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only), and (3) a test-and-treat strategy in which all persons with an intermediate risk of coronary heart disease underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, coronary heart disease events, and quality-adjusted life years from 2011 to 2040 were projected.

RESULTS: Under a variety of assumptions, the treat-all strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other test-and-treat strategies, but it was less expensive than treat all only if statin cost exceeded $3.16/pill or if testing increased adherence from75%. However, stress electrocardiography could be cost effective in persons initially nonadherent to the treat-all strategy if it raised their adherence to 5% and cost saving if it raised their adherence to 13%.

CONCLUSIONS: When generic high-potency statins are available, noninvasive cardiac stress testing to target preventive medications is not cost effective unless it substantially improves adherence.

PMID: 22144567

Effect of Two Intensive Statin Regimens on Progression of Coronary Disease

OBJECTIVES: Statins reduce adverse cardiovascular outcomes and slow the progression of coronary atherosclerosis in proportion to their ability to reduce low-density lipoprotein (LDL) cholesterol. However, few studies have either assessed the ability of intensive statin treatments to achieve disease regression or compared alternative approaches to maximal statin administration.

METHODS: We performed serial intravascular ultrasonography in 1039 patients with coronary disease, at baseline and after 104 weeks of treatment with either atorvastatin, 80 mg daily, or rosuvastatin, 40 mg daily, to compare the effect of these two intensive statin regimens on the progression of coronary atherosclerosis, as well as to assess their safety and side-effect profiles.

RESULTS: After 104 weeks of therapy, the rosuvastatin group had lower levels of LDL cholesterol than the atorvastatin group (62.6 vs. 70.2 mg per deciliter [1.62 vs. 1.82 mmol per liter], P<0.001), and higher levels of high-density lipoprotein (HDL) cholesterol (50.4 vs. 48.6 mg per deciliter [1.30 vs. 1.26 mmol per liter], P=0.01). The primary efficacy end point, percent atheroma volume (PAV), decreased by 0.99% (95% confidence interval [CI], -1.19 to -0.63) with atorvastatin and by 1.22% (95% CI, -1.52 to -0.90) with rosuvastatin (P=0.17). The effect on the secondary efficacy end point, normalized total atheroma volume (TAV), was more favorable with rosuvastatin than with atorvastatin: -6.39 mm(3) (95% CI, -7.52 to -5.12), as compared with -4.42 mm(3) (95% CI, -5.98 to -3.26) (P=0.01). Both agents induced regression in the majority of patients: 63.2% with atorvastatin and 68.5% with rosuvastatin for PAV (P=0.07) and 64.7% and 71.3%, respectively, for TAV (P=0.02). Both agents had acceptable side-effect profiles, with a low incidence of laboratory abnormalities and cardiovascular events.

CONCLUSIONS: Maximal doses of rosuvastatin and atorvastatin resulted in significant regression of coronary atherosclerosis. Despite the lower level of LDL cholesterol and the higher level of HDL cholesterol achieved with rosuvastatin, a similar degree of regression of PAV was observed in the two treatment groups.

PMID: 22085316

Health at a Glance 2011: OECD Indicators

This sixth edition of Health at a Glance provides the latest comparable data on different aspects of the performance of health systems in OECD (Organization for Economic Cooperation and Development)countries. It provides striking evidence of large variations across countries in the costs, activities and results of health systems. For the first time, it also features a chapter on long-term care.

This edition presents data for all OECD member countries. Where possible, it also reports data for Brazil, China, India, Indonesia, the Russian Federation and South Africa, as major non-OECD economies.

This publication takes as it main basis OECD Health Data 2011, the most comprehensive set of statistics and indicators for comparing health systems across the 34 OECD member countries.

Download the publication.

http://www.oecd.org/document/11/0,3746,en_2649_33929_16502667_1_1_1_1,00.html

PMID:

Association of Coronary CT Angiography or Stress Testing With Subsequent Utilization and Spending Among Medicare Beneficiaries

OBJECTIVES: Coronary computed tomography angiography (CCTA) is a new noninvasive diagnostic test for coronary artery disease (CAD), but its association with subsequent clinical management has not been established. The objective here is to compare utilization and spending associated with functional (stress testing) and anatomical (CCTA) noninvasive cardiac testing in a Medicare population.

METHODS: Retrospective, observational cohort study using claims data from a 20% random sample of 2005-2008 Medicare fee-for-service beneficiaries 66 years or older with no claims for CAD in the preceding year, who received nonemergent, noninvasive testing for CAD (n = 282 830).The main outcome measure was cardiac catheterization, coronary revascularization, acute myocardial infarction, all-cause mortality, and total and CAD-related Medicare spending over 180 days of follow-up.

RESULTS: Compared with stress myocardial perfusion scintigraphy (MPS), CCTA was associated with an increased likelihood of subsequent cardiac catheterization (22.9% vs 12.1%; adjusted odds ratio [AOR], 2.19 [95% CI, 2.08 to 2.32]; P < .001), percutaneous coronary intervention (7.8% vs 3.4%; AOR, 2.49 [2.28 to 2.72]; P < .001), and coronary artery bypass graft surgery (3.7% vs 1.3%; AOR, 3.00 [2.63 to 3.41]; P < .001). CCTA was also associated with higher total health care spending ($4200 [$3193 to $5267]; P < .001), which was almost entirely attributable to payments for any claims for CAD ($4007 [$3256 to $4835]; P < .001). Compared with MPS, there was lower associated spending with stress echocardiography (−$4981 [−$4991 to −$4969]; P < .001) and exercise electrocardiography (−$7449 [−$7452 to −$7444]; P < .001). At 180 days, CCTA was associated with a similar likelihood of all-cause mortality (1.05% vs 1.28%; AOR, 1.11 [0.88 to 1.38]; P = .32) and a slightly lower likelihood of hospitalization for acute myocardial infarction (0.19% vs 0.43%; AOR, 0.60 [0.37 to 0.98]; P = .04).

CONCLUSIONS: Medicare beneficiaries who underwent CCTA in a nonacute setting were more likely to undergo subsequent invasive cardiac procedures and have higher CAD-related spending than patients who underwent stress testing.

PMID:

Outline of the Report on Cardiovascular Disease in China, 2010

The risk factors of cardiovascular disease (CVD) are increasing persistently in China. The
morbidity and mortality of CVD are still at a high level. The burden of CVD is aggravated, and
becomes an important issue of public health. The prevention and treatment of CVD should be
reinforced immediately.

1. Epidemiology of CVD

In general, the morbidity and mortality of CVD (heart disease and stroke) are elevating
continuously in Chinese population. It is estimated that the number of patients with CVD is 230 million, of which, 200 million are afflicted with hypertension, more than 7 million with stroke, 2 million with myocardial infarction, 4.2 million with heart failure, 5 million with pulmonary heart disease, 2.5 million with rheumatic heart disease, and 2 million with congenital heart disease. One out of 5 adults is suffered from CVD.

2. Mortality of CVD
The crude death rate of coronary heart disease (CHD) is 94.9 per 100 000 in urban citizens
and 71.27 per 100 000 in rural residents. The crude death rate of stroke is 126.3 per 100 000 in urban citizens and 152.1 per 100 000 in rural residents. About 3 million Chinese die of CVD annually, which accounts for 41% of all-cause death and is the leading cause of death. The acceleration of CVD death in rural residents is higher than that in urban citizens.

3. Risk Factors of CVD are Increasing Persistently
3.1 Hypertension
Hypertension is a principal risk factor of CVD in China. More than half of CVD is associated
with elevated blood pressure (BP). The prevalence of hypertension is increasing steadily. It was 18.8% in adults according to a National Survey in 2002, and reached approximately 25% in recent years according to investigation reports of some provinces and cities. It is supposed that 200 million Chinese are hypertensives, which means 1 of 5 adults is afflicted with hypertension. The major risk factors of hypertension are high-salt diet, overweight/obesity, over consumption of alcohol, and chronic intensive stress. Some study suggested that the prevalence of hypertension was increased by a factor of 3 in patients with obesity (body mass index [BMI] ≥28kg/m2) and by a factor of 2 in patients with overweight (BMI 24.0??27.9 kg/m2) in comparison with that in individuals with normal weight (BMI 24 kg/m2). The prevalence of hypertension is elevated by 72% in drinkers with alcohol intake ≥40g/d. A long-term follow-up study showed that 2.33 million CVD deaths were associated with elevated BP annually (2.10 million due to hypertension, and 0.22 million due to high normal BP), of which 1.27 million were premature CVD deaths (1.15 million due to hypertension, and 0.12 million due to high normal BP). The relationship between subtypes of hypertension and risk of CVD death. The risk of CVD death is 1.68 (95% confidence interval [CI] 1.58??1.78) in patients with isolated systolic hypertension, 1.45 (1.27??1.65) in isolated diastolic hypertension, and 2.53 (2.39??2.68) in combined systolic/diastolic hypertension, respectively. The risk of CVD death after antihypertensive treatment is 1.61 (1.28??2.08)
in patients with BP ??140/90 mmHg, and 2.88(2.60??3.09)in patients with BP??140/90 mmHg. The risk of CVD death is significantly reduced in patients with optmi al target BP.
Identification of high normal BP. The identification of high normal BP is higher in 2002 than that in 1991. It is reported that the risk in patients with high normal BP is increased by 56% for stroke, 44% for CHD, and 52% for all CVD. Close attention should be paid to the high normal BP in prevention of hypertension. Hypertension in children Identification of hypertension in children depends upon weight gain. The secondary hypertension accounts for half of the hypertension in children and should be taken into consideration.

3.2 Smoking
Smoking is an important risk factor of CVD in China. The prevalence of smoking in male
has reached a plateau, but that is slightly increased in young female. Active smokers are 350 million, and passive smokers are 540 million. Although the abstinence from smoking is improved a little in population older than the age of 15 years, the combat against cigarette is still arduous.

3.3 Dyslipidemia
The levels of plasma lipid in Chinese population are rising constantly in recent years, and that
in juveniles should be noted especially. According to a National Survey in 2002, the prevalence of dyslipidemia was 18.6% in adults, of which 2.9% was hypercholesterolemia (total cholesterol [TC] ≥5.72 mmol/L), 11.9% was hypertriglyceridemia (triglyceride [TG] ≥1.70 mmol/L), and 7.4% was low high-density lipoprotein cholesterol (HDL-C) level (HDL-C??1.04 mmol/L). It is estimated that dyslipidemia affects at least 200 million individuals, with hypercholesterolemia as the main risk factor of CVD (CHD).

3.4 Diabetes Mellitus
Diabetes mellitus is a common chronic disease and is also a potential risk factor of CVD.
The prevalence of diabetes mellitus is increasing rapidly in China with the change of lifestyle.
A survey was conducted by Chinese Diabetes Society in 14 provinces to investigate the prevalence of diabetes mellitus in residents ≥20 years old of central cities and their nearby countryside with the measurement of fast blood glucose and oral glucose tolerance test (OGTT). The age-standardized prevalence of diabetes mellitus was 9.7%, which was much higher than that in 2002. The prevalence of diabetes mellitus increases with age and BMI.
Prevention of diabetes mellitus A long-term follow-up study of diabetes prevention in Daqing
suggested that lifestyle modification in patients with impaired glucose tolerance could prevent or postpone the occurrence of diabetes mellitus.

3.5 Overweight/Obesity
Overweight/obesity is a pivotal risk factor of CVD. According to a survey in 2002, the
prevalence of overweight was 17.6% and that of obesity was 5.6%. It is estimated that the individuals with overweight and obesity may be as much as 240 million and 70 million, respectively. The prevalences of overweight/obesity in both children and adults are growing steadily, which is worthy of note.

3.6 Physical Inactivity
Physical inactivity is a risk factor of CVD. Lack of activity results in overweight/obesity,
hypertension, dyslipidemia, hyperglycemia and elevated risk of CVD. An investigation in 9 provinces and cities showed that the physical activity was reduced in young and middle-age residents. The physical activities in 2006 declined by 27.8% in male and 36.9% in female in comparison with those in 1997. A 2005 survey of physical health in college students with age of 19~22 years indicated that in comparison with that in 1985, the physical functionality decreased strikingly and the prevalence of overweight/obesity increased notably, which suggested that the physical activity of college students was going on a downward trend.

3.7 Diet and Nutrition
In general, the diet was improved remarkably in recent years, but some features of diet are still inadequate. The intake of grain reduced significantly, whereas the intake of fat increased dramatically. The daily intake of salt (15.9 g/d) is much greater than that of diet recommendation, which is less than 6g/d. The intake of vegetables and fruits is either insufficient.

3.8 Metabolic Syndrome
According to the Chinese National Nutrition and Health Survey in 2002, the prevalence of
metabolic syndrome in individuals with age 18 years was 6.6% diagnosed by CDS criteria and 13.8% by ATP III criteria.

4. Major Research on Prevention and Intervention of CVD
4.1 Coronary Artery Disease (CAD)
According to the Registry study, percutaneous coronary intervention (PCI) was increasing
rapidly in Mainland China. The number of PCIs was 182 312 in 2008, increased by a factor of 26% in comparison with that in 2007. In 2007, PCI could be performed independently in 870 hospitals. The number of hospitals where PCIs were completed greater than 100 annually was 299, which accounted for 34.4% of aforementioned hospitals. In 2008, 1.39 out of 10 000 individuals received PCI, which could be performed independently in 1061 hospitals. The average of PCIs was 172 for each hospital. The number of hospitals where PCIs were completed greater than 400 annually was 94 (8.86%). Effect of glucose level on the early mortality of acute myocardial infarction (AMI).The 30-day mortality of AMI increases with the glucose level from 4.5 mmol/L on hospitalization. The risk of mortality in patients with glucose level >11.0 mmol/L was increased by a factor of 3 in comparison with that in patients with glucose level of 4.5??5.5 mmol/L. But the mortality was also increased in patients with glucose level <4.5 mmol/L.Observational data from 52 medical centers in 6 cities of China indicated that a large proportion of out-patients received lipid modification, but the control rate was low. Research on secondary prevention of CHD in China suggested that the risk of cardiovascular events and mortality could be greatly reduced by treatment with Xuezhikang in hypertensive patientswith prior myocardial infarction.

4.2 Stroke
Stroke is a threatening disease for Chinese population. China is an epidemic area of stroke.
According to a survey on 340 000 death cases from 1999 to 2004 in Tianjin, cerebrovascular
disease, heart disease, and malignant tumor ranked the 3 leading cause of death. Analysis on the subtype of stroke indicated that the proportion of death from cerebral infarction increased gradually, while that of cerebral hemorrhage decreased. The standardized mortality of stroke displayed a declining trend. Secondary prevention of stroke (1) Post-stroke Antihypertensive Treatment Study (PATS) in China demonstrated that cerebrovascular disease could be prevented by treatment of hypertension with diuretics. The risk of recurrent stroke was reduced by 31% and that of cardiovascular events by 25%. Anti-hypertension is beneficial for secondary prevention of stroke.(2) Prospective registry study in 23 hospitals showed that the risk of all-cause death and recurrent cerebrovascular events could be reduced by antiplatelet therapy in adult patients with prior stroke in the last 1 to 6 months.

4.3 Chronic Kidney Disease
The prevalence of end-stage renal disease (ESRD): Investigation by Chinese Society of Blood
Purification in 27 provinces and cities showed that 65,074 patients with ESRD received hemodialysis or peritoneal dialysis. This number got up to 102,863 by the end of 2008. The major cause of death from ESRD is cardiovascular complications, stroke and infection.

4.4 Cardiac Surgery
The number of cardiac surgeries in China: The number of cardiac surgeries in Mainland China was 157,444 in 2009, which was increased by a factor of 8.7% in comparison with that in 2008. Of these surgeries, 128 358 was performed on-pump. Congenital heart disease: According to a survey in 2007, the prevalence of congenital heart disease was 8.2‰ in 84,062 newborn babies in Beijing. In the survived infants with congenital heart disease, 34.0% was afflicted with ventricular septal defect, 23.7% with patent ductus arteriosus, and
10.8 with atrial septal defect. Data from 18 hospitals demonstrated that 36, 072 patients with congenital heart disease had been treated with intervention therapy by the end of March in 2008. The incidence of complications was 1.97% ~ 4.45%, and the death rate was less than 0.11%.

4.5 Heart Failure
According to a survey from 20 towns and countrysides in 10 provinces and cities, the incidence of chronic heart failure in population aged 35 ~ 74 years was 0.9%. There were 4 million patients with heart failure in China. The prevalence was higher in female than in male, and higher in north than in south.

4.6 Peripheral Artery Disease (PAD)
The prevalence of PAD varies substantially among different samples of Chinese population. For example, it was 2.1% in Zhoushan fisherman, 6.0% in natural population above the age of 35 years in Beijing, 2%~4% in natural populations of multiple domestic regions, 16.4% in elderly population above the age of 60 years in Beijing, 19.4% in patients with diabetes mellitus, 22.5% in individuals with metabolic syndrome, and 27.5% in hypertensives. The prevalence of PAD increases with age, and is higher in female than in male.

4.7 Arrhythmia
20,000 patients underwent permanent cardiac pacemakers implantation in 2006.
The number of patients who were treated with radiofrequency ablation was 20 000 in 2006,
which demonstrated an upward trend. Radiofrequency ablation in treatment of atrial fibrillation develops rapidly. The incidence of sudden cardiac death (SCD) in China is 42 out of 100 000 persons. It is estimated that 540 000 SCDs occur annually.

5. Community-based Prevention and Treatment of CVD
Management of hypertension was started in 1969 in population of Capital Steel Corporation.
The incidence of stroke was reduced considerably by 50%. Various projects on the prevention and treatment of CVD were carried out thereafter. Detailed management of hypertension-associated disease was launched in Shanghai in 2006. Health management specialist bridged the communication between patients and doctors, and was in charge of the follow-up. After 1-year management, the control rate of blood pressure in management group was increased by 47% in comparison with that of reference group, while the plasma total cholesterol and BMI were lower.

6. Expenses for CVD
6.1 Number of Patients with CVD Discharged from Hospital
7.4 million patients with CVD (including cerebrovascular disease) were discharged from
hospital in 2008, which accounted for 10% of the total discharge, of which, the discharge of heart disease was 3.85 million (5.2%), and that of cerebrovascular disease 3.56 million (4.8%). The number of patients with heart disease discharged from hospital exceeded that of cerebrovascular disease. Most patients with CVD discharged from hospital in 2008 were those with ischemic heart disease (2.41 million) and cerebral infarction (2 million), which accounted for 32.5% and 27.1%, respectively. The other discharges were patients with hypertension (1.24 million), diabetes mellitus (1.24 million), cerebral hemorrhage (0.91 million), and rheumatic heart disease (0.2 million). The average increment of CVD discharge (8.28%) during 1980 ~ 2008 was more rapid than that of all diseases (5.27%). The average increment of discharge was ranked as diabetes mellitus (13.57%), cerebral infarction (11.19%), and hypertension (7.11%).

6.2 Expenses for CVD Hospitalization
The expense for hospitalization in 2008 was 2.45 billion RMB for AMI, 8.07 billion for
cerebral hemorrhage, and 12.7 billion for cerebral infarction. The annual increment of expenses for hospitalization since 2004 were 36.5%, 26.9%, and 31.1% for above specific disease, respectively. The expenses for every hospitalization was 12 566.2 RMB for AMI, 8488.5 for cerebral hemorrhage, and 6046.6 for cerebral infarction. The annual increment of expenses for every hospitalization since 2004 were 9.68%, 5.7%, and 2.69% for above specific disease, respectively.

6.3 Market of Medicines to Treat CVD
256,603 billion RMB was used to purchase various drugs in hospitals with more than 100
sickbeds in 2009, of which 30.39 billion was expended on medicines to treat CVD.

PMID:

Contribution of the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Epidemic to De Novo Presentations of Heart Disease in the Heart of Soweto Study Cohort

OBJECTIVES: The contemporary impact of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic on heart disease in South Africa (>5 million people affected) is unknown. The Heart of Soweto Study provides a unique opportunity to identify the contribution of cardiac manifestations of this epidemic to de novo presentations of heart disease in an urban African community in epidemiological transition.

METHODS: Chris Hani Baragwanath Hospital services the >1 million people living in Soweto, South Africa. A prospective, clinical registry captured data from all de novo cases of heart disease presenting to the Cardiology Unit during 2006-08. We describe all cases where HIV/AIDS was concurrently diagnosed.

RESULTS: Overall, 518 of 5328 de novo cases of heart disease were identified as HIV-positive (9.7%) with 54% of these prescribed highly active anti-retroviral therapies on presentation. Women (62%) and Africans (97%) predominated with women being significantly younger than men 38 ± 13 vs. 42 ± 13 years (P = 0.002). The most common primary diagnosis attributable to HIV/AIDS was HIV-related cardiomyopathy (196 cases, 38%); being prescribed more anti-retroviral therapy (127/196 vs. 147/322; odds ratio 2.85, 95% confidence interval 1.81-3.88) with higher viral loads [median 110 000 (inter-quartile range 26 000-510 000) vs. 19 000 (3200-87 000); P = 0.018] and a lower CD4 count [median 180 (71-315) vs. 211 (96-391); P = 0.019] than the rest. An additional 128 cases (25%) were diagnosed with pericarditis/pericardial effusion with a range of other concurrent diagnoses evident, including 42 cases (8.1%) of HIV-related pulmonary arterial hypertension. Only 14 of all 581 cases of coronary artery disease (CAD) (2.4%, mean age 41 ± 13 years) were confirmed HIV-positive.

CONCLUSIONS: Cardiac manifestations of HIV/AIDS identified within this cohort were relatively infrequent. While HIV-related cardiomyopathy and pericardial disease remain important targets for early detection and treatment in this setting, HIV-related cases of CAD remain at historically low levels.

PMID: 22048682

Cardiovascular Consequences of Famine in The Young

OBJECTIVES: The developmental origins hypothesis proposes that undernutrition during foetal life, infancy, or childhood is associated with an increased risk of cardiovascular disease in adulthood. As data on postnatal developmental programming are scarce, we investigated whether exposure to undernutrition during childhood, adolescence, or young adulthood is related to coronary heart disease (CHD) and stroke in adult life.

METHODS: We studied 7845 women from the Prospect-EPIC cohort who had been exposed at various degrees to the 1944-45 Dutch famine when they were aged between 0 and 21 years. We used Cox proportional hazard regression models to explore the effect of famine on the risk of CHD and stroke, overall and within exposure age categories (0-9, 10-17, ≥18 years). We adjusted for potential confounders, including age at famine exposure, smoking, and level of education as a proxy for socio-economic status.

RESULTS: Overall, stronger famine exposure was associated with higher CHD risk. Among those who experienced the famine between ages 10 and 17 years, CHDrisk was significantly higher among severely exposed women compared with unexposed women (HR 1.38; 95% CI 1.03-1.84), which only slightly attenuated after adjustment for confounding (HR 1.27; 95% CI 0.94-1.71). We observed a lower stroke risk among famine exposed women (HR 0.79; 95% CI 0.61-1.02). Adjustment for potential confounders produced similar results (HR 0.77; 95% CI 0.59-0.99).

CONCLUSIONS: Exposure to undernutrition during postnatal periods of development, including adolescence, may affect cardiovascular health in adult life.

PMID: 21868476

Optical Coherence Tomography: Has Its Time Come?

Cardiologists using intravascular ultrasound (IVUS) towards the end of the past millennium can recall the time when enthusiasm for a method that was initially seen purely as a powerful research tool began to be substituted by the awareness that intravascular imaging had the potential to revolutionise our understanding of the mechanisms of coronary interventions. Such a revolution occurred in Milan when Antonio Colombo and his group applied ultrasound to elucidate the mechanism of stent thrombosis, at that time common despite high levels of anticoagulation.

PMID: 21730261

Aortic Pulse Wave Velocity Is Associated With Measures of Subclinical Target Organ Damage

OBJECTIVES: Our goal was to evaluate the associations of central arterial stiffness, measured by aortic pulse wave velocity (aPWV), with subclinical target organ damage in the coronary, peripheral arterial, cerebral, and renal arterial beds. Arterial stiffness is associated with adverse cardiovascular outcomes. We hypothesized that aPWV is associated with subclinical measures of atherosclerosis—coronary artery calcification(CAC) and ankle-brachial index (ABI) and arteriolosclerosis—brain white matter hyperintensity (WMH) and urine albumin-creatinine ratio (UACR).

METHODS: Participants (n = 812; mean age 58 years; 58% women, 71% hypertensive) belonged to hypertensive sibships and had no history of myocardial infarction or stroke. aPWV was measured by applanation tonometry, CAC by electron beam computed tomography, ABI using a standard protocol, WMH volume by brain magnetic resonance, and UACR by standard methods. WMH was log-transformed, whereas CAC and UACR were log-transformed after adding 1 to reduce skewness. The associations of aPWV with CAC, ABI, WMH, and UACR were assessed by multivariable linear regression using generalized estimating equations to account for the presence of sibships. Covariates included in the models were age, sex, body mass index, history of smoking, hypertension and diabetes, total and high-density lipoprotein cholesterol, estimated glomerular filtration rate,use of aspirin and statins, and pulse pressure.

RESULTS: The mean ± SD aPWV was 9.8 ± 2.8 m/s. After adjustment for age, sex, conventional cardiovascular risk factors, and pulse pressure, higher aPWV (1 m/s increase) was significantly associated with higher log (CAC + 1) (β ± SE = 0.14± 0.04; p = 0.0003), lower ABI (β ± SE =–0.005 ± 0.002; p = 0.02), and greater log (WMH)(β ± SE = 0.03 ± 0.009; p = 0.002), but not with log (UACR + 1) (p = 0.66).

CONCLUSIONS: Higher aPWV was independently associated with greater burden of subclinical disease in coronary, lower extremity, and cerebral arterial beds, highlighting target organ damage as a potential mechanism underlying the association of arterial stiffness with adverse cardiovascular outcomes.

PMID:

Appropriateness of Percutaneous Coronary Intervention

OBJECTIVES: Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown. The objective is to assess the appropriateness of PCI in the United States.

METHODS: Design, Setting, and Patients Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non–ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication.

RESULTS: Of 500, 154 PCIs, 355 417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103, 245 [20.6%]; non–ST-segment elevation myocardial infarction, 105, 708 [21.1%]; high-risk unstable angina, 146, 464 [29.3%]), and 144 737 (28.9%) for nonacute indications. For acute indications, 350, 469 PCIs (98.6%) were classified as appropriate, 1,055 (0.3%) as uncertain, and 3,893 (1.1%) as inappropriate. For nonacute indications, 72, 911 PCIs (50.4%) were classified as appropriate, 54, 988 (38.0%) as uncertain, and 16, 838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%-16.7%).

CONCLUSIONS: In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals

PMID:

Prevalence of Cardiovascular Disease Risk Factor in the Chinese Population: The 2007-2008 China National Diabetes and Metabolic Disorders Study

OBJECTIVES: Cardiovascular disease (CVD) is now the most prevalent and debilitating disease affecting the Chinese population. The goal of the present manuscript was to analyse cardiovascular risk factors and the prevalence of non-fatal CVDs from data gathered from the 2007-2008 China National Diabetes and Metabolic Disorders Study.

METHODS: A nationally representative sample of 46, 239 adults, 20 years of age or older, was randomly recruited using a multistage stratified design method. Lifestyle factors, diagnosis of CVD, stroke, diabetes, and family history of each subject were collected, and an oral glucose tolerance test or a standard meal test was performed. Various non-fatal CVDs were reported by the subjects. SUDAAN software was used to perform all weighted statistical analyses, with P < 0.05 considered statistically significant.

RESULTS: The prevalence of coronary heart disease, stroke, and CVDs was 0.74, 1.07, and 1.78% in males; and 0.51, 0.60, and 1.10% in females, respectively. The presence of CVDs increased with age in both males and females. The prevalence of being overweight or obese, hypertension, dyslipidaemia, or hyperglycaemia was 36.67, 30.09, 67.43, and 26.69% in males; and 29.77, 24.79, 63.98, and 23.62% in females, respectively. In the total sample of 46 239 patients, the prevalence of one subject having 1, 2, 3, or ≥4 of the 5 defined risk factors (i.e. smoking, overweight or obese, hypertension, dyslipidaemia, or hyperglycaemia) was 31.17, 27.38, 17.76, and 10.19%, respectively. Following adjustment for gender and age, the odds ratio of CVDs for those who had 1, 2, 3, or ≥4 risk factors was 2.36, 4.24, 4.88, and 7.22, respectively, when compared with patients with no risk factors.

CONCLUSIONS: Morbidity attributed to the five defined cardiovascular risk factors was high in the Chinese population, with multiple risk factors present in the same individual. Therefore, reasonable prevention strategies should be designed to attenuate the rapid rise in cardiovascular morbidity.

PMID: 21719451

Radiology Health Services Research: From Imperative to Legislative Mandate

OBJECTIVES: In the era of health care reform, our value-added to patient care, its corresponding level of reimbursement, and the stature of radiology as a specialty will likely be grounded in the scientific evaluation methods of health services research.

CONCLUSIONS: We need to create more opportunities for training, provide resources and incentives for the brightest candidates to enter this field, and cultivate enriching environments for health services research in all academic radiology departments.

PMID: 21512077

Conflicts of Interest in Cardiovascular Clinical Practice Guidelines

PMID: 21444849