Short- and Midterm Adherence to Platelet P2Y12 Receptor Inhibitors After Percutaneous Coronary Intervention With Drug-Eluting Stents.

INTRODUCTION/OBJECTIVES: In patients who have undergone recent percutaneous coronary intervention (PCI), poor adhesion to antiplatelet agents may increase the risk of stent thrombosis and death. We aimed to investigate the adherence to different P2Y12 receptor inhibitors after PCI with drug-eluting stent in stable and unstable patients and to evaluate the factors associated with low adherence. METHOD: In a prospective study conducted between 2014 and 2018, the 8-item Morisky scale was applied at 30 days and 6 months post-PCI to measure P2Y12 receptor inhibitors adherence. Also, we describe the characteristics of patients using different platelet receptor P2Y12 inhibitors. Regression models were used to identify predictors of poor adherence. RESULTS: A total of 214 patients were included (65 ± 12 years, 81% man, 61% acute coronary syndromes). Patients in the clopidogrel group were older than those in the prasugrel (68 ± 12 vs 59 ± 11 years, P < .01, respectively) or ticagrelor group (68 ± 12 vs 62 ± 12 years, P < .01). Patients with low/moderate adherence at 30 days and 6 months represented, respectively, 19.8% and 27.5% of our sample. Current smokers and preexisting cardiovascular disease at presentation were associated with lower adherence at 30 days. CONCLUSIONS: We found substantial rates of moderate and low adherence to P2Y12 receptor inhibitors early after PCI. Current smokers and preexisting cardiovascular disease at presentation were associated with a lower likelihood of adherence. These results highlight the need of monitoring adherence to medical treatment after PCI.

Association between clinical factors and self-underestimation of cardiovascular risk in subjects submitted to a routine health evaluation.

BACKGROUND: The perception of cardiovascular (CV) risk is essential for adoption of healthy behaviors. However, subjects underestimate their own risk. HYPOTHESIS: Clinical characteristics might be associated with self-underestimation of CV risk. METHODS: This is a retrospective, cross-sectional study of individuals submitted to routine health evaluation between 2006 and 2012, with calculated lifetime risk score (LRS) indicating intermediate or high risk for CV disease (CVD). Self-perception of risk was compared with LRS. Logistic regression analysis was performed to test the association between clinical characteristics and subjective underestimation of CV risk. RESULTS: Data from 5863 subjects (age 49.4 ± 7.1 years; 19.9% female) were collected for analysis. The LRS indicated an intermediate risk for CVD in 45.7% and a high risk in 54.3% of individuals. The self-perception of CV risk was underestimated compared with the LRS in 4918 (83.9%) subjects. In the adjusted logistic regression model, age (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.10-1.47 per 10 years, P = 0.001), smoking (OR: 1.99, 95% CI: 1.40-2.83, P < 0.001), dyslipidemia (OR: 1.21, 95% CI: 1.01-1.46, P = 0.045), physical activity (OR: 1.66, 95% CI: 1.36-2.02, P < 0.001), and use of antihypertensive (OR: 1.49, 95% CI: 1.15-1.92, P = 0.002) and lipid-lowering medications (OR: 2.13, 95% CI: 1.56-2.91, P < 0.001) were associated with higher chance of risk underestimation, whereas higher body mass index (OR: 0.92, 95% CI: 0.90-0.94, P < 0.001), depressive symptoms (OR: 0.46, 95% CI: 0.37-0.57, P < 0.001), and stress (OR: 0.41, 95% CI: 0.33-0.50, P < 0.001) decreased the chance. CONCLUSIONS: Among individuals submitted to routine medical evaluation, aging, smoking, dyslipidemia, physical activity, and use of antihypertensive and lipid-lowering medications were associated with higher chance of CV risk underestimation. Subjects with these characteristics may benefit from a more careful risk orientation.

Persistent Depressive Symptoms are Independent Predictors of Low-Grade Inflammation Onset Among Healthy Individuals / Sintomas Depressivos Persistentes são Preditores Independentes de Início de Inflamação de Baixo Grau em Indivíduos Saudáveis

Abstract Background: Depressive symptoms are independently associated with an increased risk of cardiovascular disease (CVD) among individuals with non-diagnosed CVD. The mechanisms underlying this association, however, remain unclear. Inflammation has been indicated as a possible mechanistic link between depression and CVD. Objectives: This study evaluated the association between persistent depressive symptoms and the onset of low-grade inflammation. Methods: From a database of 1,508 young (mean age: 41 years) individuals with no CVD diagnosis who underwent at least two routine health evaluations, 134 had persistent depressive symptoms (Beck Depression Inventory - BDI ≥ 10, BDI+) and 1,374 had negative symptoms at both time points (BDI-). All participants had been submitted to repeated clinical and laboratory evaluations at a regular follow-up with an average of 26 months from baseline. Low-grade inflammation was defined as plasma high-sensitivity C-Reactive Protein (CRP) concentrations > 3 mg/L. The outcome was the incidence of low-grade inflammation evaluated by the time of the second clinical evaluation. Results: The incidence of low-grade inflammation was more frequently observed in the BDI+ group compared to the BDI- group (20.9% vs. 11.4%; p = 0.001). After adjusting for sex, age, waist circumference, body mass index, levels of physical activity, smoking, and prevalence of metabolic syndrome, persistent depressive symptoms remained an independent predictor of low-grade inflammation onset (OR = 1.76; 95% CI: 1.03-3.02; p = 0.04). Conclusions: Persistent depressive symptoms were independently associated with low-grade inflammation onset among healthy individuals.

Resumo Fundamento: Sintomas depressivos estão associados de forma independente ao risco aumentado de doença cardiovascular (DCV) em indivíduos com DCV não diagnosticada. Os mecanismos subjacentes a essa associação, entretanto, não estão claros. Inflamação tem sido indicada como um possível elo mecanicista entre depressão e DCV. Objetivos: Este estudo avaliou a associação entre sintomas depressivos persistentes e o início de inflamação de baixo grau. Métodos: De um banco de dados de 1.508 indivíduos jovens (idade média: 41 anos) sem diagnóstico de DCV submetidos a pelo menos duas avaliações de saúde de rotina, 134 tinham sintomas depressivos persistentes (Inventário de Depressão de Beck - BDI ≥10, BDI+) e 1.374 não apresentavam sintomas em nenhuma das ocasiões (BDI-). Todos os participantes foram submetidos a repetidas avaliações clínicas e laboratoriais em seguimento regular, cuja média foi de 26 meses desde a condição basal. Definiu-se inflamação de baixo grau como concentração plasmática de proteína C reativa (PCR) ultrassensível > 3 mg/L. O desfecho foi a incidência de inflamação de baixo grau por ocasião da segunda avaliação clínica. Resultados: A incidência de inflamação de baixo grau foi maior no grupo BDI+ em comparação ao grupo BDI- (20,9% vs. 11,4%; p = 0,001). Após ajuste para sexo, idade, circunferência abdominal, índice de massa corporal, níveis de atividade física, tabagismo e prevalência de síndrome metabólica, os sintomas depressivos persistentes continuaram sendo um preditor independente de início de inflamação de baixo grau (OR = 1,76; IC 95%: 1,03-3,02; p = 0,04). Conclusões: Sintomas depressivos persistentes foram independentemente associados com início de inflamação de baixo grau em indivíduos saudáveis.

High frequency of silent brain infarcts associated with cognitive deficits in an economically disadvantaged population

OBJECTIVE: Using magnetic resonance imaging, we aimed to assess the presence of silent brain vascular lesions in a sample of apparently healthy elderly individuals who were recruited from an economically disadvantaged urban region (São Paulo, Brazil). We also wished to investigate whether the findings were associated with worse cognitive performance. METHODS: A sample of 250 elderly subjects (66-75 years) without dementia or neuropsychiatric disorders were recruited from predefined census sectors of an economically disadvantaged area of Sao Paulo and received structural magnetic resonance imaging scans and cognitive testing. A high proportion of individuals had very low levels of education (4 years or less, n=185; 21 with no formal education). RESULTS: The prevalence of at least one silent vascular-related cortical or subcortical lesion was 22.8% (95% confidence interval, 17.7-28.5), and the basal ganglia was the most frequently affected site (63.14% of cases). The subgroup with brain infarcts presented significantly lower levels of education than the subgroup with no brain lesions as well as significantly worse current performance in cognitive test domains, including memory and attention (p<0.002). CONCLUSIONS: Silent brain infarcts were present at a substantially high frequency in our elderly sample from an economically disadvantaged urban region and were significantly more prevalent in subjects with lower levels of education. Covert cerebrovascular disease significantly contributes to cognitive deficits, and in the absence of magnetic resonance imaging data, this cognitive impairment may be considered simply related to ageing. Emphatic attention should be paid to potentially deleterious effects of vascular brain lesions in poorly educated elderly individuals from economically disadvantaged environments.

Persistent Depressive Symptoms are Independent Predictors of Low-Grade Inflammation Onset Among Healthy Individuals.

Background: Depressive symptoms are independently associated with an increased risk of cardiovascular disease (CVD) among individuals with non-diagnosed CVD. The mechanisms underlying this association, however, remain unclear. Inflammation has been indicated as a possible mechanistic link between depression and CVD. Objectives: This study evaluated the association between persistent depressive symptoms and the onset of low-grade inflammation. Methods: From a database of 1,508 young (mean age: 41 years) individuals with no CVD diagnosis who underwent at least two routine health evaluations, 134 had persistent depressive symptoms (Beck Depression Inventory - BDI ≥ 10, BDI+) and 1,374 had negative symptoms at both time points (BDI-). All participants had been submitted to repeated clinical and laboratory evaluations at a regular follow-up with an average of 26 months from baseline. Low-grade inflammation was defined as plasma high-sensitivity C-Reactive Protein (CRP) concentrations > 3 mg/L. The outcome was the incidence of low-grade inflammation evaluated by the time of the second clinical evaluation. Results: The incidence of low-grade inflammation was more frequently observed in the BDI+ group compared to the BDI- group (20.9% vs. 11.4%; p = 0.001). After adjusting for sex, age, waist circumference, body mass index, levels of physical activity, smoking, and prevalence of metabolic syndrome, persistent depressive symptoms remained an independent predictor of low-grade inflammation onset (OR = 1.76; 95% CI: 1.03-3.02; p = 0.04). Conclusions: Persistent depressive symptoms were independently associated with low-grade inflammation onset among healthy individuals.

Fundamento: Sintomas depressivos estão associados de forma independente ao risco aumentado de doença cardiovascular (DCV) em indivíduos com DCV não diagnosticada. Os mecanismos subjacentes a essa associação, entretanto, não estão claros. Inflamação tem sido indicada como um possível elo mecanicista entre depressão e DCV. Objetivos: Este estudo avaliou a associação entre sintomas depressivos persistentes e o início de inflamação de baixo grau. Métodos: De um banco de dados de 1.508 indivíduos jovens (idade média: 41 anos) sem diagnóstico de DCV submetidos a pelo menos duas avaliações de saúde de rotina, 134 tinham sintomas depressivos persistentes (Inventário de Depressão de Beck - BDI ≥10, BDI+) e 1.374 não apresentavam sintomas em nenhuma das ocasiões (BDI-). Todos os participantes foram submetidos a repetidas avaliações clínicas e laboratoriais em seguimento regular, cuja média foi de 26 meses desde a condição basal. Definiu-se inflamação de baixo grau como concentração plasmática de proteína C reativa (PCR) ultrassensível > 3 mg/L. O desfecho foi a incidência de inflamação de baixo grau por ocasião da segunda avaliação clínica. Resultados: A incidência de inflamação de baixo grau foi maior no grupo BDI+ em comparação ao grupo BDI- (20,9% vs. 11,4%; p = 0,001). Após ajuste para sexo, idade, circunferência abdominal, índice de massa corporal, níveis de atividade física, tabagismo e prevalência de síndrome metabólica, os sintomas depressivos persistentes continuaram sendo um preditor independente de início de inflamação de baixo grau (OR = 1,76; IC 95%: 1,03-3,02; p = 0,04). Conclusões: Sintomas depressivos persistentes foram independentemente associados com início de inflamação de baixo grau em indivíduos saudáveis.

Acute management of unstable angina and non-ST segment elevation myocardial infarction / Tratamento atual da síndrome coronária aguda sem supradesnivelamento do segmento ST

Non-ST segment elevation coronary syndrome usually results from instability of an atherosclerotic plaque, with subsequent activation of platelets and several coagulation factors. Its treatment aims to reduce the ischemic pain, limiting myocardial damage and decreasing mortality. Several antiplatelet and anticoagulation agents have been proven useful, and new drugs have been added to the therapeutic armamentarium in the search for higher anti-ischemic efficacy and lower bleeding rates. Despite the advances, the mortality, infarction and readmission rates remain high.

A síndrome coronária sem supradesnivelamento do ST geralmente resulta da instabilização de uma placa aterosclerótica, com subsequente ativação plaquetária e de diversos fatores de coagulação. O tratamento visa aliviar a dor isquêmica, limitar o dano miocárdico e diminuir a mortalidade. Diversos agentes antiagregantes e anticoagulantes provaram sua utilidade, e novas drogas passaram a compor o arsenal terapêutico, buscando maior eficácia anti-isquêmica e menores índices de sangramento. Apesar dos avanços, as taxas de mortalidade, infarto e reinternação ainda permanecem elevadas.

Depression as a Clinical Determinant of Dependence and Low Quality of Life in Elderly Patients with Cardiovascular Disease / Depressão como Determinante Clínico de Dependência e Baixa Qualidade de Vida em Idosos Cardiopatas

Background: The aging process promotes a progressive increase in chronic-degenerative diseases. The effect of these diseases on the functional capacity has been well recognized. Another health parameter concerns “quality of life related to health”. Among the elderly population, cardiovascular diseases stand out due to the epidemiological and clinical impact. Usually, these diseases have been associated with others. This set of problems may compromise both independence and quality of life in elderly patients who seek cardiologic treatment. These health parameters have not been well contemplated by cardiologists. Objective: Evaluating, among the elderly population with cardiovascular disease, which are the most relevant clinical determinants regarding dependence and quality of life. Methods: This group was randomly and consecutively selected and four questionnaires were applied: HAQ, SF-36, PRIME-MD e Mini Mental State. Results: The study included 1,020 elderly patients, 63.3% women. The group had been between 60 and 97 years-old (mean: 75.56 ± 6.62 years-old). 61.4% were independent or mild dependence. The quality of life total score was high (HAQ: 88.66 ± 2.68). 87.8% of patients had a SF-36 total score > 66. In the multivariate analysis, the association between diagnoses and high degrees of dependence was significant only for previous stroke (p = 0.014), obesity (p < 0.001), lack of physical activity (p = 0.016), osteoarthritis (p < 0.001), cognitive impairment (p < 0.001), and major depression (p < 0.001). Analyzing the quality of life, major depression and physical illness for depression was significantly associated with all domains of the SF-36. Conclusion: Among an elderly outpatient cardiology population, dependence and quality of life clinical determinants are not cardiovascular comorbidities, especially the depression. .

Fundamento: Com o envelhecimento, a prevalência de doenças crônico-degenerativas sofreu aumento progressivo. A repercussão dessas doenças sobre a capacidade funcional foi reconhecida. Outro parâmetro de saúde é a “qualidade de vida relacionada à saúde”. Na população idosa, as doenças cardiovasculares destacam-se pelo impacto epidemiológico e clínico. Elas, geralmente, vêm associadas a outras afecções. Esse conjunto de problemas pode comprometer a independência e a qualidade de vida do idoso que busca tratamento cardiológico. Objetivo: Avaliar, em uma população de idosos cardiopatas, quais são os determinantes clínicos mais relevantes de dependência e de qualidade de vida. Métodos: O grupo foi selecionado aleatória e consecutivamente, sendo aplicados quatro questionários: HAQ, SF-36, PRIME‑MD e Mini Exame do Estado Mental. Resultados: Incluiu-se 1020 idosos, 63,3% mulheres. O grupo tinha em média 75,56 ± 6,62 anos. 61,4% mostrou-se independente ou com dependência leve. O escore de qualidade de vida foi elevado (HAQ: 88,66 ± 2,68). 87,8% dos pacientes apresentou escore total do SF-36 ≥ 66. À análise multivariada, a associação entre os diagnósticos e graus elevados de dependência foi significante apenas para acidente vascular cerebral prévio (p = 0,014), obesidade (p < 0,001), sedentarismo (p = 0,016), osteoartrite (p < 0,001), déficit cognitivo (p < 0,001), e depressão maior (p < 0,001). Ao analisarmos a qualidade de vida, a depressão maior e a depressão por doença física associou-se significativamente com todos os domínios do SF-36. Conclusão: Em uma população de idosos cardiopatas, os determinantes clínicos mais relevantes de prejuízos para dependência e qualidade de vida foram as comorbidades não cardiovasculares, particularmente a depressão. .

Desafios e soluções para a falta de aderência a orientações e tratamentos / Challenges and solutions for lack of adherence to guidelines and treatment

A falta de aderência às orientações e tratamentos dos pacientes com doenças cardiovasculares é extremamente prevalente e se associa a maior morbidade, mortalidade e custos em saúde. Controle pressórico inadequado nos hipertensos, maior mortalidade nos pacientes que realizaram angioplastia e necessidade de reinternação em pacientes com insuficiência cardíaca são algumas das consequências associadas à má aderência. Diversos fatores estão implicados, como complexidade do regime terapêutico, custos, efeitos adversos, falta de acesso ao sistema de saúde, comunicação inadequada, baixos níveis de conhecimento em saúde e presença de depressão ou déficit cognitivo. Não existe padrão ouro para mensurar os níveis de aderência e foram utilizados autorrelatos, contagem de comprimidos, embalagens eletrônicas, renovação de receitas em sistemas fechados de farmácia e níveis séricos de medicação. Para melhora deste cenário, precisamos implementar efetivamente os conhecimentos existentes e desenvolver novas estratégias de intervenção. Diminuição do custo d drogas, simplificação de esquemas posológicos, comunicação adequada e estratégias comportamentais que incorporam o uso de medicações e comportamentos mais saudáveis no dia-a-dia dos pacientes obtiveram sucesso em estudos clínicos.

The lack of adherence to guidelines and treatment of patients with cardiovascular disease in highly prevalente and is associated with increased morbidity, mortality and healthcare costs. Inadequate blood pressure control in hypertensive patients, increased mortality in patients undergoing angioplasty and need for re-hospitalization in patients with heart failure are some of the consequences associated with poor adherence. Several factors are implicated as therapeutic regimen complexity, cost, adverse effects, lack of access to health care, inadequate communication, low levels of knowledge about health and presence of depression or cognitive impairment. There is no gold standard for measuring levels of adherence. Therefore self-reports, pill counts, electronic packaging, prescription refills in closed pharmacy system and sérum levels of medications were used for measuring levels of adherence. To improve this scenario, we need to effectively implemente existing knowledge and developed new strategies for intervention. Decreased drug cost, simplified dosing regimens, proper communication and behavioral strategies that incorporated the use of medications and healthy behaviors in the daily lives of patients were successful in clinical trials.

Dimensão digital, promoção de saúde e prevenção cardiovascular / Digital dimension, health promotion and cardiovascular prevention

Vivemos um momento de transição radical na área da saúde. Com novos modelos de saúde, a atenção é entregue por equipes, avaliada pelos resultados e adquirida como pacotes. Nesta nova configuração, mídias digitais e sociais tornam-se uma fonte cada vez mais importante de valor. As pessoa estão sendo capacitadas a participar mais ativamente de sua própria saúde, fornecendo novas ferramentas para gerenciar as condições crônicas e aliviar a carga sobre os sobrecarregados sistemas de saúde. A saúde é prestada, tradicionalmente, em três espaços: domicílios, clínicas e hospitais. As mídias digitais criaram o quarto espaço, o espaço digital, que inclui: canal digital para saúde, inovação digital e iniciativas digitais de impacto social. No canal digital para saúde, os profissionais de saúde estão implantando mídia digital e social no sistema de saúde tradicional para, por exemplo, consulta de acompanhamento por e-mail e acesso on-line para os resultados de laboratório. Na área de inovação digital para consumidores, mídia digital e social oferecem maneiras novas e melhores para pacientes e cuidadores gerirem doença e saúde e compartilharem experiências com comunidade on-line. Nas iniciativas digitais de impacto social, as organizações dos setores público e privado usam inovações digitais para facilitar comunicações interativas, a fim de prevenir a doença e promover a saúde. Concluindo, o uso das estratégias digitais na área da saúde está cada vez mais presente e, certamente, contribui e contribuirá para a melhoria da prática clínica, porém, ainda se sugere a necessidade de novos estudos bem planejados e de qualidade sobre este novo método.

We are living a moment of a radical transition in the health area. Health care is proportioned by a team, evaluated by results and acquired like packets. In this new way of health care the digital and social media become na important source of value. People are being capable of taking part actively of their own health, providing tools to manage chronic conditions in order to relieve "overburdened" health system. The health traditionally contains three spaces: homes, ambulatories and hospitals. The digital media created the fourth space, the digital space that includes: digital channel for health, digital innovation and digital initiatives of social impact. In the digital channel for health, the health professional are implanting digital and social media in the traditional health system to make the follow up of patients by e-mail, or to have online access of laboratory results. In the digital innovation for consumers social and digital media provide new and better ways for patients and caregivers to manage disease and health and share experiences with online community. In the digital initiatives of social impact, the private and public organizations to prevent disease and promote health. Concluding, the use of digital strategies in the health area is more and more presente and certainly contributes and will contribute to improve clinical practice, however we suggest the need of well-planned new studies for the use of this strategy.

Predictors of the risk of falls among elderly with chronic atrial fibrillation

OBJECTIVES: Though elderly persons with chronic atrial fibrillation have more comorbidities that could limit indications for the chronic use of anticoagulants, few studies have focused on the risk of falls within this particular group. To evaluate the predictors of the risk of falls among elderly with chronic atrial fibrillation, a cross-sectional, observational study was performed. METHODS: From 295 consecutive patients aged 60 years or older with a history of atrial fibrillation who were enrolled within the last 2 years in the cardiogeriatrics outpatient clinic of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, 107 took part in this study. Their age was 77.9±6.4 years, and 62 were female. They were divided into two groups: a) no history of falls in the previous year and b) a history of one or more falls in the previous year. Data regarding the history of falls and social, demographic, anthropometric, and clinical information were collected. Multidimensional assessment instruments and questionnaires were applied. RESULTS: At least one fall was reported in 55 patients (51.4%). Among them, 27 (49.1%) presented recurrent falls, with body lesions in 90.4% and fractures in 9.1% of the cases. Multivariate logistic regression showed that selfreported difficulty maintaining balance, use of amiodarone, and diabetes were independent variables associated with the risk of falls, with a sensitivity of 92.9% and a specificity of 44.9%. CONCLUSION: In a group of elderly patients with chronic atrial fibrillation who were relatively independent and able to attend an outpatient clinic, the occurrence of falls with recurrence and clinical consequences was high. Difficulty maintaining balance, the use of amiodarone and a diagnosis of diabetes mellitus were independent predictors of the risk for falls. Thus, simple clinical data predicted falls better than objective functional tests.

Simultaneous transfer of cholesterol, triglycerides, and phospholipids to high-density lipoprotein in aging subjects with or without coronary artery disease

OBJECTIVE: To verify whether the capacity of high-density lipoprotein (HDL) to simultaneously receive nonesterified cholesterol, triglycerides, cholesteryl esters, and phospholipids changes with aging and the presence of coronary artery disease. DESIGN: Cross-sectional study with biochemical analyses. SUBJECTS: Eleven elderly patients with coronary artery disease (74±5 years) were compared with the following groups of non-coronary artery disease subjects (referred to as "healthy"): 25 young (25±5 years), 25 middle-aged (42± years), and 25 elderly subjects (75±8 years). METHODS: Plasma samples were incubated with a nanoemulsion labeled with radioactive lipids; the transfer of the lipids from the nanoemulsion to the HDL was measured in chemically precipitated HDL. HDL size and paraoxonase-1 activity were also determined. RESULTS: The transfer of cholesteryl esters and phospholipids to high-density lipoprotein was significantly greater (p<0.001) in healthy elderly subjects than in the middle-aged and younger subjects. Non-esterified cholesterol and triglyceride transfer was not different among these three groups. The HDL size was significantly greater (p<0.001) in healthy elderly subjects than in the middle-aged and younger subjects. The paraoxonase-1 activity was similar among the groups. Compared with healthy elderly subjects, coronary artery disease elderly subjects had significantly less (p<0.05) transfer of non-esterified cholesterol, triglycerides, and cholesteryl esters to the HDL and a significantly smaller (p<0.05) HDL size. CONCLUSION: Because lipid transfer is enhanced in healthy elderly subjects but not in those with coronary artery disease, increasing lipid transfer to HDL may be a protective mechanism against the disease.

Cardiac disorders as risk factors for Alzheimer's disease.

Vascular risk factors can play an important role in determining the onset of non-genetic Alzheimer's disease (AD). Most cases of AD are sporadic and late-onset, and a complex interaction between genetic predisposition and vascular risk factors has been proposed. Vascular risk factors for AD include stroke, hypertension, diabetes, homocysteine, smoking, hypercholesterolemia, heart failure and atrial fibrillation; it is possible that these can trigger cerebrovascular dysfunction and AD pathology. Explanations for these associations include the coincidence of common disorders in the elderly where vascular and cerebrovascular disease can precipitate AD, implying that the onset of dementia disease is determined by a synergistic combination of risk factors. In this paper we review the role of cardiovascular risk factors in the pathogenesis of AD and discuss the associated brain mechanisms that can underlie the onset of AD. Cardiovascular diseases are a promising avenue of AD research because they are potentially modifiable in early adult life and provide a new perspective for the prevention of dementia.

The role of invasive therapies in elderly patients with acute myocardial infarction.

INTRODUCTION: In elderly patients with acute myocardial infarction, very little is known about the role of surgical myocardial revascularization and percutaneous coronary intervention (invasive therapies--IT), especially in the context of long-term outcomes after hospital discharge. METHODS: We analyzed 1588 patients with MI who had been included prospectively in a databank and followed for up to 7.5 years. In this population, 548 patients were >70 years old (elderly group--EG), and 1040 were <70 years of age (younger group--YG); 1088 underwent IT during hospitalization, and the remaining 500 were treated medically (conservative therapy--CT). Patients were monitored either by visit or by phone at least once a year. A standard questionnaire was administered to all patients. The impact of IT was analyzed with both non-adjusted and adjusted models. RESULTS: By the end of the follow-up period, the survival rates for the IT and CT groups were, respectively, 71.9% versus 47.2% in the global population (hazard ratio=0.55, P<0.001), 81.5% versus 66.6% in the YG (hazard ratio=0.68, P=0.018) and 48.8% versus 20.3% in the EG (hazard ratio=0.58, P<0.001). In the adjusted models, the hazard ratios were 0.62 (P<0.001) in the global population, 0.74 in the YG (P=0.073) and 0.64 (P=0.001) in the EG. CONCLUSION: Long-term follow-up of patients with myocardial infarction revealed that IT during the in-hospital phase was at least as effective in elderly patients as in younger patients.