Arterial calcification at multiple sites: sex-specific cardiovascular risk profiles and mortality risk-the Rotterdam Study.

BACKGROUND: Evidence has pointed towards differences in the burden of arteriosclerosis according to its location and sex. Yet there is a scarcity of population-based data on aggregated sex-specific cardiovascular risk profiles, instead of single risk factors, and mortality risk according to the location of arteriosclerosis. We assessed sex-specific cardiovascular risk profiles and mortality risk associated with arteriosclerosis. METHODS: From the population-based Rotterdam Study, 2357 participants (mean age 69 years, 53% women) underwent non-contrast computed tomography to quantify calcification, as a proxy for arteriosclerosis, in the coronary arteries (CAC), aortic arch (AAC), extracranial (ECAC) and intracranial carotid arteries (ICAC), vertebrobasilar arteries (VBAC), and aortic valve (AVC). Principal component analysis (PCA) of eight distinct cardiovascular risk factors was performed, separately for women and men, to derive risk profiles based on the shared variance between factors. We used sex-stratified multivariable logistic regression to examine the associations between PCA-derived risk profiles and severe calcification at different locations. We investigated the associations of severe calcification with mortality risk using sex-stratified multivariable Cox regression. RESULTS: PCA identified three cardiovascular risk profiles in both sexes: (1) anthropometry, glucose, and HDL cholesterol; (2) blood pressure; and (3) smoking and total cholesterol. In women, the strongest associations were found for profile 2 with severe ECAC and ICAC (adjusted OR [95% CI] 1.32 [1.14-1.53]) and for profile 3 with severe at all locations, except AVC. In men, the strongest associations were found for profile 2 with VBAC (1.31 [1.12-1.52]) and profile 3 with severe AAC (1.28 [1.09-1.51]). ECAC and AVC in women and CAC in men showed the strongest, independent associations with cardiovascular mortality (HR [95% CI] 2.11 [1.22-3.66], 2.05 [1.21-3.49], 2.24 [1.21-3.78], respectively). CONCLUSIONS: Our findings further underline the existence of sex- and location-specific differences in the etiology and consequences of arteriosclerosis. Future research should unravel which distinct pathological processes underlie differences in risk profiles for arteriosclerosis.

Atherothrombotic disease, traditional risk factors, and 4-year mortality in a Latin American population: the REACH Registry.

BACKGROUND: Atherothrombosis is becoming the leading cause of chronic morbidity in developing countries. This epidemiological transition will represent an unbearable socioeconomic burden in the near future. We investigated factors associated with 4-year all-cause mortality in a Latin American population at high risk. HYPOTHESIS: Largely modifiable risk factors as well as polyvascular disease are the main predictors of 4-year all-cause and cardiovascular mortality in this Latin American cohort. METHODS: We analyzed 1816 Latin American stable outpatients (62.3% men, mean age 67 years) with symptomatic atherothrombosis (87.1%) or with multiple risk factors only (12.9%), in the Reduction of Atherothrombosis for Continued Health registry. RESULTS: Of patients with symptomatic atherothrombosis, 57.3% had coronary artery disease, 32% cerebrovascular disease, and 11.7% peripheral artery disease at baseline (9.1% polyvascular). The main risk factors were hypertension (76%), hypercholesterolemia (60%), and smoking (52.3%) in patients with established atherothrombosis; and hypertension (89.7%), diabetes (80.8%), and hypercholesterolemia (73.9%) in those with risk factors only. Four-year all-cause mortality steeply increased with none (6.8%), 1 (9.2%), 2 (15.5%), and 3 (29.2%) symptomatic arterial disease locations. In patients with only 1 location, cardiovascular mortality was significantly higher with peripheral artery disease (11.3%) than with cerebrovascular disease (6%) or coronary artery disease (5.1%). Significant baseline predictors of 4-year all-cause mortality were congestive heart failure (hazard ratio [HR]: 3.81), body mass index <20 (HR: 2.32), hypertension (HR: 1.84), polyvascular disease (HR: 1.69), and age ≥ 65 years (HR: 1.47), whereas statin use (HR: 0.49) and body mass index ≥ 30 (HR: 0.58) were associated with a reduced risk. CONCLUSIONS: Hypertension was the main modifiable risk factor for atherothrombosis and all-cause mortality in this Latin American cohort. Nearly one-third of the population with 3 symptomatic vascular-disease locations died at 4-year follow-up.

Is lowering phosphate exposure the key to preventing arterial stiffening with age?

Cardiovascular disease remains the leading cause of death world wide. Although atheroma is clearly important, the role of arteriosclerotic vascular disease is often overlooked. Arteriosclerosis causes increased arterial stiffness, with consequent systolic hypertension and left ventricular hypertrophy. Serum phosphate is increasingly being recognised as a cardiovascular risk factor and has been implicated in the development of arteriosclerosis and arterial calcification. Its determinants are unclear, but both diet and minor reductions in renal function may be important. Diets in affluent populations are high in phosphate because of increased consumption of animal protein and the use of phosphate-containing preservatives. This viewpoint suggests that the consumption of a phosphate-rich diet, exacerbated by the high prevalence of chronic kidney disease found in ageing populations, accelerates the development of arteriosclerosis. It is hypothesised that reducing phosphate intake will attenuate the progression of arterial stiffness with major beneficial effects upon cardiovascular mortality and morbidity.

Japan Arteriosclerosis Longitudinal Study-Existing Cohorts Combine (JALS-ECC): rationale, design, and population characteristics.

BACKGROUND: The Japan Arteriosclerosis Longitudinal Study-Existing Cohorts Combine (JALS-ECC) is a pooled study based on individual participant data from existing prospective cohort studies in Japan. Its purpose was to consider associations between risk factors and cardiovascular disease (CVD) outcomes, as well as differences between subgroups, defined by age, gender or geographical region, which could not be detected in the smaller samples. METHODS AND RESULTS: Individual records for 66,691 participants in 21 cohort studies were pooled, accounting for a total of 575,628 person-years. From this data, there were 409 deaths attributed to stroke and 169 deaths attributed to coronary heart disease (CHD). Total stroke and CHD events were 1,478 and 178, respectively. Of the 1,424 total stroke events with a reported stroke subtype, 975 were classified as ischemic, 267 as hemorrhagic, and 178 as subarachnoid hemorrhage. CONCLUSION: The JALS-ECC collected data from existing cohort studies covering a diverse Japanese population, which has provided information about the effects of modifiable factors on the risks of the CVD. Such information should provide a reliable basis for establishing prevention strategies.

[Screening in cardiovascular diseases]. / Screening bei Herz- und Gefässkrankheiten.

Cardiovascular disease still ranks number one in the mortality statistics in the industrialized world. In Germany the five most common causes of death are all associated with arteriosclerotic changes of the arterial vasculature. As the treatment often extends over long periods and it can be impossible for patients to work, peripheral arterial occlusive disease (PAOD) constitutes a not inconsiderable economic factor. Thus, screening for arteriosclerotic disease seems to be reasonable, because the potential for influencing arteriosclerotic changes is known to be higher in an early stage of the disease even before symptoms become apparent. Not every case can be cured, but progression can frequently be slowed down. The need for invasive procedures, some of them associated with ionizing radiation, limited the use of imaging of the arterial vasculature for a long time. Noninvasive clinical examinations such as the "ankle brachial index" (ABI) can indicate the presence of PAOD, though exact localization of the pathologic changes is not possible except with imaging methods. In contrast to these, MRI is a noninvasive imaging modality that does not involve ionizing radiation but offers high spatial resolution arterial imaging.

Does it matter how you lower blood pressure in patients with uncomplicated hypertension? Weighing the evidence.

Arterial hypertension is one of the most important preventable causes of death worldwide; therefore, adequate treatment of high blood pressure should be mandatory in each hypertensive patient. Hypertension is now defined on the basis of systolic and diastolic blood pressure levels and classified into stages on the basis of the degree of elevation. Normal blood pressure is widely considered as being less than 120/80 mm Hg. The presence of risk factors such as elevated blood cholesterol, smoking, diabetes, and obesity greatly increases the risk for hypertension-related morbid events. The physiologic link between vascular health and arterial pressure makes it difficult to separate the adverse effects of pressure and vascular functional and structural alterations in determining the adverse complications of hypertension. Several landmark trials in hypertension treatment have been published in the past few years, providing more evidence-based medicine data regarding optimal treatment of hypertension to reduce cardiovascular morbidity and mortality. Maintaining vascular health within the scope of global risk reduction in a personalized manner will be the cornerstone of modern cardiovascular disease prevention rather than waiting until arterial hypertension develops.

Influence and interaction of diabetes and lipoprotein (a) serum levels on mortality of patients with peripheral artery disease.

BACKGROUND: Diabetes mellitus is a risk factor for early complications and mortality in patients with peripheral artery disease. Lipoprotein (a) [Lp(a)] is also suggested to be a marker of increased cardiovascular risk. We investigated the association and interaction between diabetes mellitus, lipoprotein(a) and mortality in high risk patients with peripheral artery disease (PAD). METHODS: We studied 700 consecutive patients [median age 73 years, interquartile range (IQR) 62-80, 393 male (56%)] with PAD from a registry database. Atherothrombotic risk factors (diabetes, smoking, hyperlipidaemia, arterial hypertension) and Lp(a) serum levels were recorded. We used stratified multivariate Cox proportional hazard analyses to assess the mortality risk at a given patient's age with respect to the presence of diabetes and Lp(a) serum levels (in tertiles). RESULTS: Patients with Lp(a) levels above 36 mg dL(-1) (highest tertile) and insulin-dependent type II diabetes had a 3.01-fold increased adjusted risk for death (95% confidence interval 1.28-6.64, P = 0.011) compared to patients without diabetes or patients with non-insulin-dependent type II diabetes. In patients with Lp(a) serum levels below 36 mg dL(-1) (lower and middle tertile), diabetes mellitus was not associated with an increased risk for death. CONCLUSION: Insulin-dependent type II diabetes mellitus seems to be associated with an increased risk for mortality in PAD patients with Lp(a) serum levels above 36 mg dL(-1). PAD patients with non-insulin-dependent type II diabetes, and patients with diabetes and Lp(a) levels below 36 mg dL(-1) showed survival rates comparable to PAD patients without diabetes.

Carga de mortalidad asociada a la inactividad física en Bogotá / Burden of mortality associated to physical inactivity in Bogota, Colombia

La carga de mortalidad asociada a la inactividad física (IF) no ha sido estimada para los grandes centros urbanos de países en desarrollo. Objetivo Calcular la carga de mortalidad por seis enfermedades crónicas no transmisibles (ECNT) asociadas a la IF y estimar el número de muertes potencialmente prevenibles si se reduce la prevalencia de IF en la ciudad. Métodos La prevalencia de IF obtenida mediante encuestas poblacionales representativas se combinó con datos sobre la mortalidad en adultos mayores de 45 años durante el año 2002. La mortalidad por ECNT atribuible a la IF y la mortalidad prevenible asociada a reducciones del 30 por ciento en la prevalencia de IF se estimaron mediante cálculos del riesgo atribuible poblacional (RAP). Resultados Una prevalencia de exposición a la IF del 53,2 por ciento se asoció con un RAP de 19,3 por ciento para enfermedad coronaria, 24,2 por ciento para accidentes cerebro vasculares, 13,8 por ciento para hipertensión, 21 por ciento para Diabetes Mellitus, 17,9 por ciento para cáncer de colon y 14,2 por ciento para cáncer de seno. Un 7,6 por ciento de la mortalidad total y un 20,1 por ciento de la mortalidad por ECNT pueden ser atribuibles a la IF. Un 5 por ciento de la mortalidad por ECNT podría evitarse si la prevalencia de IF se reduce en un 30 por ciento. Conclusiones Una proporción considerable de la mortalidad ocasionada por las ECNT más frecuentes puede atribuirse a los efectos de la IF. Estrategias para la disminución de la IF pueden conllevar a reducciones progresivas de la carga de mortalidad por ECNT en la ciudad.

Estimates of the burden of mortality associated to physical inactivity (PI) have not been quantified for large urban centers located in developing countries. Objectives To estimate the burden of mortality due to six chronic diseases (CDZ) associated to PI and the number of potentially preventable deaths associated to reductions in the prevalence of PI. Methods PI exposure prevalence obtained via population surveys was linked to mortality data registered during 2002 among adult (> 45 y) Bogotá residents. The strength of association between PI and disease-specific mortality was obtained from the literature. Population attributable risk (PAR) was used to calculate the CDZ mortality attributable to PI and to estimate the number of potentially preventable deaths associated to a 30 percent reduction in the prevalence of PI. Results A 53,2 percent PI exposure prevalence was associated to a PAR of 19,3 percent for coronary artery disease, 24,2 percent for stroke, 13,8 percent for arterial hypertension, 21 percent for Diabetes Mellitus, 17,9 percent for colon cancer and 14,2 percent for breast cancer. An estimated 7,6 percent of all-cause mortality and 20,1 percent of CDZ mortality could be attributed to PI. An estimated 5 percent of the CDZ mortality could be prevented if PI prevalence is reduced by 30 percent. Conclusion Conservative estimates indicate that a considerable proportion of deaths due to highly prevalent CDZ could be attributed to PI. Strategies to reduce the prevalence of PI in Bogotá could lead to progressive reductions in the burden of CDZ mortality.

[Burden of mortality associated to physical inactivity in Bogota, Colombia]. / Carga de mortalidad asociada a la inactividad física en Bogotá.

UNLABELLED: Estimates of the burden of mortality associated to physical inactivity (PI) have not been quantified for large urban centers located in developing countries. OBJECTIVES: To estimate the burden of mortality due to six chronic diseases (CDZ) associated to PI and the number of potentially preventable deaths associated to reductions in the prevalence of PI. METHODS: PI exposure prevalence obtained via population surveys was linked to mortality data registered during 2002 among adult (> 45 y) Bogotá residents. The strength of association between PI and disease-specific mortality was obtained from the literature. Population attributable risk (PAR) was used to calculate the CDZ mortality attributable to PI and to estimate the number of potentially preventable deaths associated to a 30 % reduction in the prevalence of PI. RESULTS: A 53,2 % PI exposure prevalence was associated to a PAR of 19,3 % for coronary artery disease, 24,2 % for stroke, 13,8 % for arterial hypertension, 21 % for Diabetes Mellitus, 17,9 % for colon cancer and 14,2 % for breast cancer. An estimated 7,6 % of all-cause mortality and 20,1 % of CDZ mortality could be attributed to PI. An estimated 5% of the CDZ mortality could be prevented if PI prevalence is reduced by 30 %. CONCLUSION: Conservative estimates indicate that a considerable proportion of deaths due to highly prevalent CDZ could be attributed to PI. Strategies to reduce the prevalence of PI in Bogotá could lead to progressive reductions in the burden of CDZ mortality.

Factores de riesgo aterogénico en una población de adultos mayores / Atherogenic risk factors in an elderly population

La aterosclerosis constituye la primera causa de muerte y también de morbilidad en ingresos hospitalarios en el ámbito mundial donde las infecciones no ocupan este lugar tan preponderante. En Cuba, sus más frecuentes y dañinas consecuencias orgánicas constituyen también la primera causa de muerte. Se realizó una investigación descriptiva en 108 adultos mayores de un total de 427 pacientes de ambos sexos durante el año 2003 para identificar factores de riesgo aterogénicos. Se utilizó el modelo de recolección del dato primario para obtener información sobre la edad, peso al nacer, antecedentes patológicos personales y familiares, consumo de cigarrillos, tensión arterial sistólica y diastólica, concentración del colesterol del suero y de su fracción de alta densidad y el grado de actividad física. Se encontró que el 26,9 por ciento de la muestra eran fumadores activos, el 33,3 por ciento tenían sobrepeso, el 15,7 eran obesos, el 81,4, hipertensos y de ellos el 50 por ciento eran pacientes nuevos. Un alto porcentaje no practicaba ejercicios físicos. Se apreció que 78 pacientes tenían hipercolesterolemia y en 46, la concentración de la lipoproteína de alta densidad estaba disminuida. En la población de adultos mayores estudiada se identificaron, en porcentajes apreciables, factores de riesgo aterogénicos que pueden ser modificados en aras de tener una mejor salud y calidad de vida(AU)

The aterosclerosis constitutes the first cause of death and also of morbilidad in hospital revenues in the world environment where the infections don't occupy this place so preponderant. In Cuba, their most frequent and harmful organic consequences also constitute the first cause of death. He/she was carried out a descriptive investigation in 108 adults bigger than a total of 427 patients of both sexes during the year 2003 to identify factors of risk aterogénicos. The pattern of gathering of the primary fact was used to obtain information on the age, weight when being born, personal and family pathological antecedents, consumption of cigarettes, systolic arterial tension and diastólica, concentration of the cholesterol of the serum and of its fraction of high density and the degree of physical activity. It was found that 26,9 percent of the sample was smoking active, 33,3 percent had overweight, the 15,7 were obese, the 81,4, hipertensos and of them 50 percent was patient new. A high percentage didn't practice physical exercises. It was appreciated that 78 patients had hipercolesterolemia and in 46, the concentration of the lipoproteína of high density was diminished. In the studied bigger population of adults they were identified, in appreciable percentages, factors of risk aterogénicos that can be modified for the sake of having a better health and quality of life(AU)

The influence of ascending aortic atherosclerosis on the long-term survival after CABG.

OBJECTIVE: Ascending aortic atherosclerosis is a risk factor for perioperative morbidity and mortality in coronary surgery. It was the aim of our study to determine the role of atherosclerosis of the ascending aorta and other factors for the survival rate during long-term follow-up after CABG. METHODS: From 500 out of 580 CABG patients (aged 67 (33-85) years, 77% male), who underwent intraoperative epiaortic ultrasound for assessment of ascending aortic wall thickness, a complete follow up regarding long-term survival was achieved. The median follow-up time was 55 (1-78) months. RESULTS: 53/500 (11%) patients died within the follow-up period, and the cumulative survival rate was 95, 90, and 84% after 1, 3, and 5 years, respectively (including hospital deaths). A significantly lower long-term survival was present in patients with: an age of 70 years or more (P<0.001), COPD (P=0.005), preoperative elevated serum creatinine of >1.2mg/dl (P=0.007), preoperative LVEF <40% (P=0.033), ascending aortic wall thickness of 4mm or more (P=0.001), carotid artery disease (P<0.001), peripheral vascular disease (P<0.001), and acute operation (P=0.009). Multivariate analysis revealed carotid artery disease, LVEF <40%, peripheral vascular disease, and advanced age to be independent risk factors. CONCLUSION: Patients with ascending aortic atherosclerosis are at risk for a decreased long-term survival after CABG. Besides, preoperative elevated serum creatinine, COPD, carotid artery disease, LVEF <40%, peripheral vascular disease, and advanced age are risk factors for a decreased long-term survival after CABG.

Long-term predictors of survival for the Seven Countries Study cohort from Crete: from 1960 to 2000.

BACKGROUND: In 1960, all male inhabitants of a series of villages in rural Crete, born between 1900 and 1919, were invited to participate in the Seven Countries Study. Analysis of 25-year mortality data from the 16 cohorts of participants indicated that the cohort from Crete had the lowest age-standardised all-cause and coronary heart disease death rates. METHODS: At baseline, 686 Cretan men (98% of those invited) participated in health examinations. Mortality data were collected over 40 years. Time-fixed and updated covariate survival analysis techniques were applied to assess eight cardiovascular disease risk factors as long-term predictors of all-cause and cardiovascular disease mortality. RESULTS: The median survival time was 32 years. All-cause and cardiovascular mortality rates were 26 and 11 per 1000 person-years, respectively. Age (relative risk 1.11, 95% CI 1.09-1.13), diastolic blood pressure (relative risk 1.02, 95% CI 1.01-1.03), and smoking (relative risk 1.37, 95% CI 1.14-1.64) were positively associated and forced expiratory volume (relative risk 0.50, 95% CI 0.36-0.68) was negatively associated with all-cause mortality. Age (relative risk 1.13, 95% CI 1.09-1.16), diastolic blood pressure (relative risk 1.01, 95% CI 1.001-1.03), and forced expiratory volume (relative risk 0.53, 95% CI 0.32-0.89) were independent predictors of cardiovascular mortality. Serum cholesterol concentration and body mass index were not independently associated with death risk. CONCLUSIONS: The Cretan cohort displays favourable 40-year survival. Even so, long-term predictors of the hazard of both all-cause and cardiovascular disease mortality are present.

Prevalence of valve calcium and association of valve calcium with coronary artery disease, atherosclerotic vascular disease, and all-cause mortality in 137 patients undergoing hemodialysis for chronic renal failure.

Of 137 patients (mean age 63 years) who underwent hemodialysis for chronic renal failure, 65 (47%) had mitral valve calcium, mitral annular calcium, or aortic valve calcium. Thirty-eight of 65 patients (59%) who had valve calcium died at 3.5-year follow-up versus 21 of 72 patients (29%) who did not have valve calcium and who died at 4.3-year follow-up (p = 0.0005).

Percutaneous and open renal revascularizations have equivalent long-term functional outcomes.

Atherosclerotic renal artery stenosis is a significant cause of poorly controlled hypertension and progressive renal dysfunction leading to ischemic nephropathy and other end-organ damage. The optimal treatment of renovascular disease contributing to hypertension and renal dysfunction is not known. This study compares the anatomic and functional outcomes of both open and endovascular therapy for chronic, symptomatic atherosclerotic renal artery disease. We performed a retrospective analysis of records from patients who underwent renal arterial interventions, endovascular or open bypass, between January 1984 and January 2004. Principal indications for intervention were hypertension (51%), chronic renal insufficiency (13%), and hypertension and elevated creatinine (36%). A total of 247 patients (109 males; mean age 69 +/- 10, range 44-89 years) underwent 314 interventions (109 open procedures; 205 angioplasties, 71% with stent placement). There was a significant difference in 30-day mortality (4% vs. <1%; p < 0.005) between the open and endoluminal groups, but not at 1, 3, or 5 years. Patients in the open group had a higher primary patency rate at 5 years (83 +/- 5% vs. 76 +/- 6%; p = 0.03), but patients in the endoluminal group had a higher assisted primary patency rate at 5 years (92 +/- 5% vs. 84 +/- 5; p = 0.03). There was no significant difference between both treatment groups in cumulative freedom from presenting symptom or in freedom from dialysis and renal-related death. Patients who presented with hypertension were more likely to have shown improvement in their blood pressure with endoluminal intervention at 1, 3, and 5 (59 +/- 6% endoluminal vs. 83 +/- 5% open; p = 0.01) years. From these results we conclude that open repair and endoluminal repair of atherosclerotic renal artery stenosis have similar immediate and long-term functional and anatomic outcomes. Patients who present with hypertension may have greater benefit with an endoluminal repair.

Outcomes of patients with atherosclerotic upper extremity tissue loss.

Severe ischemia of the upper extremity causing tissue necrosis occurs much less frequently than in the lower extremity. The clinical outcome of patients diagnosed with digital nonhealing ulcer or gangrene is largely unknown. A retrospective review of patients with upper extremity tissue loss was performed. Patients with ischemia from embolic disease, steal syndromes, and vasospastic or connective tissue disorders were excluded. Thirteen patients with upper extremity ischemic gangrene and/or nonhealing ulcers were treated from January 1995 to June 2002. Comorbid conditions included diabetes mellitus in 10 patients and renal failure in 11 patients. Five patients developed bilateral upper extremity ischemia during the period of evaluation, while 8 had unilateral involvement. Nine patients had dry gangrene of a digit, 5 had nonhealing ulcers, and 1 patient developed wet gangrene from an ischemic ulcer. All 13 patients received local wound care and medical treatment with anticoagulants, calcium channel blockers, or antiplatelet agents. Ischemic lesions healed in 3 of the 5 patients with conservative management. Surgical intervention was performed on 6 patients with dry gangrene, and the patient with wet gangrene underwent amputation of the hand (53.8%). Two patients underwent sympathectomy without improvement. In the remaining 3 patients, tissue loss remained stable. Seven patients died within 2 years of presentation with upper extremity ischemia, with a survival at 24 months of only 14% by lifetable analysis. The local outcome of severe upper extremity ischemia is generally favorable, with good response to either medical management or digit amputation. However, the life expectancy of the patients with upper extremity ischemia from true atherosclerotic disease is dismal. Therefore, surgical intervention should be reserved for infection control or pain relief only.

Heterogeneity of cardiovascular risk among smokers is related to degree of carbon monoxide exposure.

BACKGROUND: Between smokers matched for daily tobacco consumption there are marked variations of the cardiovascular risk. This follow up of the population based cohort "Men born in 1914" from Malmö, Sweden, explored whether this is accounted for by the levels of carbon monoxide (CO). METHODS: Three hundred and sixty-five men without history of cardiovascular disease (CVD) were followed over 27 years. Leg artery disease was defined as a systolic ankle-arm pressure ratio (ABPI) below 0.9 in either leg. Incidence of myocardial infarction (MI), stroke and deaths is based on linkage with regional and national registers. The distribution of CO in blood and expired air, respectively, was divided into quartiles. RESULTS: There was a significant inverse relation between ABPI and CO in blood and expired air. Incidence of CVD events and deaths increased progressively with degree of CO exposure. Men with CO in the top quartile had significantly increased risks of CVD events (RR: 2.2; 95% CI: 1.00-4.6) and cardiovascular deaths (RR: 3.2, CI: 1.2-8.3), adjusted for daily tobacco consumption and other potential confounders. CONCLUSIONS: In smokers, the prevalence of leg atherosclerosis and incidence of cardiovascular disease is related to the amount of carbon monoxide in blood or expired air.

Vascular complications of the intra-aortic balloon counterpulsation.

From September 1994 to December 2002, 6,274 cardiosurgery operations were performed at the Department of Cardiac Surgery, University Hospital, Hradec Kralove, Czech Republic. Intra-aortic balloon counterpulsation (IABP) was applied in 192 cases (3.1%). From this group of 192 counterpulsated patients 103 were successfully treated (53.6%); 89 counterpulsated patients (46.4%) died from the surgical procedure (30-day mortality rate). In 5 cases (2.6%) from the group of 192, the IABP was introduced before the operation. Ischemic changes of the limb were observed in 11 cases (5.7%). Significant bleeding occurred at the site of puncture in 6 cases (3.1%). Dissection of the femoral and iliac arteries was found in 2 patients (1.0%), perforation of the iliac artery in 1 case (0.5%). In 2 cases (1.0%) the balloon was led into the venous system. In case report No. 1 an introduction of the balloon under a sclerotic plaque of the descending aorta and iliac artery is described. In case report No. 2 a placement of the balloon in the venous bloodstream is reported.

Management of peripheral vascular disease.

The management of patients with peripheral arterial occlusive disease (PAD) has to be planned in the context of natural history, epidemiology, and apparent risk factors that predict deterioration. The ankle-brachial index to date has proved to be the most effective, accurate, and practical method of PAD detection. Given that PAD is a powerful indicator of systemic atherosclerosis and (independent of symptoms) is associated with an increased risk of myocardial infarction and stroke, as well as a six times greater likelihood of death, the prevalence and demographic distribution of measurable PAD becomes particularly relevant. Reliable information on interventions to confer symptom relief is much weaker and reflects discrepancies between published reports from centers of excellence and the experience of patients routinely treated in communities around the world. The impact of newer treatment modalities, such as complex endovascular procedures and therapeutic angiogenesis, has been a subject of recent controversy.

[Major impact of arteriosclerosis on cardiovascular morbidity and mortality]. / Impactul major al rigiditatii arteriale (arteriosclerozei) asupra morbiditatii si mortalitatii cardiovasculare.

Arterial stiffness (arteriosclerosis) is a diffuse process affecting the media of large arteries, strongly linked to the process of ageing, but influenced by several other major factors like hypertension and vascular calcifications. Arteriosclerosis has been recognized in recent years as a novel non-traditional cardiovascular risk factor both for renal and non-renal general population. Two of arterial stiffness parameters, pulse wave velocity and the augmentation index--determined by applanation tonometry, are strongly correlated with cardiovascular morbidity and mortality, as well as with the general mortality. Arterial stiffness, due to several factors related to the uremic milieu, is more pronounced in patients with end-stage renal disease compared with patients without renal dysfunction. The authors are briefly reviewing the most recent literature regarding the impact of arterial stiffness on cardiovascular outcome. Identifying the factors associated with reduced arterial compliance may positively influence cardiovascular outcome in the general population, and particularly in renal patients, plagued by a high burden of cardiovascular disease.