Healthcare disparities in vascular surgery: A critical review.

Health disparities in vascular surgical care have existed for decades. Persons categorized as Black undergo a nearly twofold greater risk-adjusted rate of leg amputations. Persons categorized as Black, Latinx, and women have hemodialysis initiated via autogenous fistula less often than male persons categorized as White. Persons categorized as Black, Latino, Latina, or Latinx, and women are less likely to undergo carotid endarterectomy for symptomatic carotid stenosis and repair of abdominal aortic aneurysms. New approaches are needed to address these disparities. We suggest surgeons use data to identify groups that would most benefit from medical care and then partner with community organizations or individuals to create lasting health benefits. Surgeons alone cannot rectify the structural inequalities present in American society. However, all surgeons should contribute to ensuring that all people have access to high-quality vascular surgical care.

Spontaneous Coronary Artery Dissection: Clinical Characteristics, Management, and Outcomes in a Racially and Ethnically Diverse Community-Based Cohort.

CONTEXT: Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome, which predominantly affects healthy women; however, few data define this vulnerable population. OBJECTIVE: To identify demographic and clinical characteristics of patients with SCAD and determine outcomes in a community-based cohort. DESIGN: Retrospective cohort study of patients with SCAD at Kaiser Permanente Northern California during a 10-year period. We compared 111 SCAD cases with 333 healthy, matched controls. MAIN OUTCOME MEASURES: Predisposing factors, treatment modalities, and inhospital and late outcomes. RESULTS: Patients with SCAD had a mean age (standard deviation) of 48.1 (11) years; 92.8% were women, and 49.5% were nonwhite. Of women, 9% were peripartum. Fibromuscular dysplasia was identified in 21.8% of femoral angiograms obtained. With conditional logistic regression, only pregnancy and hyperlipidemia were associated with SCAD compared with controls. Fifty-five patients (49.5%) were successfully treated without revascularization; of the 54 who had urgent percutaneous coronary intervention, 2 required coronary artery bypass grafting for SCAD extension. During a median follow-up of 2.6 years, major adverse cardiovascular events occurred in 8.1% of patients. Pregnancy-related SCAD was not associated with worsened outcomes. However, Emergency Department visits or hospitalizations because of recurrent chest pain occurred frequently for 54% of patients with SCAD. CONCLUSION: The study cohort is comparable to published SCAD cohorts, but notable for a racially and ethnically diverse population. Compared with the controls, only pregnancy and hyperlipidemia were associated with SCAD. For the SCAD cases, major adverse cardiovascular events occurred in 8.1%, and race did not influence outcomes.

Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention.

BACKGROUND: Although many studies have demonstrated racial disparities after major vascular surgery, few have identified the reasons for these disparities, and those that did often lacked clinical granularity. Therefore, our aim was to evaluate differences in initial vascular intervention between black and white patients. METHODS: We identified black and white patients' initial carotid, abdominal aortic aneurysm (AAA), and infrainguinal peripheral artery disease (PAD) interventions in the Vascular Quality Initiative (VQI) registry from 2009 to 2014. We excluded nonblack or nonwhite patients as well as those with Hispanic ethnicity, asymptomatic PAD, or a history of prior ipsilateral interventions. We compared baseline characteristics and disease severity at time of intervention on a national and regional level. RESULTS: We identified 76,372 patients (9% black), including 35,265 carotid (5% black), 17,346 AAA (5% black), and 23,761 PAD interventions (18% black). For all operations, black patients were younger, more likely female, and had more insulin-dependent diabetes, hypertension, congestive heart failure, renal dysfunction, and dialysis dependence. Black patients were less likely to be on a statin before AAA (62% vs 69%; P < .001) or PAD intervention (61% vs 67%; P < .001) and also less likely to be discharged on an antiplatelet and statin regimen after these procedures (AAA, 60% vs 64% [P = .01]; PAD, 64% vs 67% [P < .001]). Black patients presented with more severe disease, including higher proportions of symptomatic carotid disease (36% vs 31%; P < .001), symptomatic or ruptured AAA (27% vs 16%; P < .001), and chronic limb-threatening ischemia (73% vs 62%; P < .001). Black patients more often presented with concurrent iliac artery aneurysms at the time of AAA repair (elective open AAA repair, 46% vs 26% [P < .001]; elective endovascular aneurysm repair, 38% vs 23% [P < .001]). CONCLUSIONS: Black patients present with more advanced disease at the time of initial major vascular operation. Efforts to control risk factors, identify and treat arterial disease in a timely fashion, and optimize medical management among black patients may provide opportunity to improve current disparities.

Fibroblast Growth Factor 23 and Cause-Specific Mortality in the General Population: The Northern Manhattan Study.

CONTEXT: An elevated fibroblast growth factor (FGF) 23 is an independent risk factor for cardiovascular disease and mortality in patients with kidney disease. The relationship between FGF23 and cause-specific mortality in the general population is unknown. OBJECTIVE: To investigate the association of elevated FGF23 with the risk of cause-specific mortality in a racially and ethnically diverse urban general population. DESIGN, SETTING, PARTICIPANTS: The Northern Manhattan Study is a population-based prospective cohort study. Residents who were > 39 years old and had no history of stroke were enrolled between 1993 and 2001. Participants with available blood samples for baseline FGF23 testing were included in the current study (n = 2525). MAIN OUTCOME MEASURES: Cause-specific death events. RESULTS: A total of 1198 deaths (474 vascular, 612 nonvascular, 112 unknown cause) occurred during a median follow-up of 14 years. Compared to participants in the lowest FGF23 quintile, those in the highest quintile had a 2.07-fold higher risk (95% confidence interval [CI], 1.45, 2.94) of vascular death and a 1.64-fold higher risk (95% CI, 1.22, 2.20) of nonvascular death in fully adjusted models. Higher FGF23 was independently associated with increased risk of mortality due to cancer, but only in Hispanic participants (hazard ratio per 1 unit increase in ln FGF23 of 1.87; 95% CI, 1.40, 2.50; P for interaction = .01). CONCLUSIONS: Elevated FGF23 was independently associated with increased risk of vascular and nonvascular mortality in a diverse general population and with increased risk of cancer death specifically in Hispanic individuals.

Associations between inflammation and cognitive function in African Americans and European Americans.

OBJECTIVES: To examine associations between specific inflammatory biomarkers and cognitive function in African Americans (AAs) and European Americans (EAs) with prevalent vascular risk factors. DESIGN: Cross-sectional analysis using generalized estimating equations to account for familial clustering; standardized ß-coefficients, adjusted for age, sex, and education are reported. SETTING: Community cohort study in Jackson, Mississippi, and Rochester, Minnesota. PARTICIPANTS: Genetic Epidemiology Network of Arteriopathy (GENOA)-Genetics of Microangiopathic Brain Injury (GMBI) Study participants. MEASUREMENTS: Associations between inflammation (high-sensitivity C-reactive protein (CRP), interleukin (IL)-6, soluble tumor necrosis factor (TNF) receptor 1 and 2 (sTNFR1, sTNFR2)) and cognitive function (global, processing speed, language, memory, and executive function) were examined in AAs and EAs (N = 1,965; aged 26-95, 64% women, 52% AA, 75% with hypertension). RESULTS: In AAs, higher sTNFR2 was associated with poorer cognition in all domains (global: -0.11, P = .009; processing speed: -0.11, P < .001; language: -0.08, P = .002; memory: -0.09, P = .008; executive function: -0.07, P = .03); sTNFR1 was associated with slower processing speed (-0.08, P < .001) and poorer executive function (-0.08, P = .008); higher CRP was associated with slower processing speed (-0.04, P = .024), and higher IL6 was associated with poorer executive function (-0.07, P = .02). In EA, only higher sTNFR1 was associated with slower processing speed (-0.05, P = .007). Associations were not found between cognition and sTNFR2, CRP, or IL6 in EA. CONCLUSION: In a population with high vascular risk, adverse associations between inflammation and cognitive function were especially apparent in AAs, primarily involving markers of TNFα activity.

Analysis of 27 cases of large vascular lesions in 161 cases of Behcet's disease: clinical manifestations and treatment outcome.

Very little is known about the features of Behcet's disease (BD) with vascular lesions, especially in Chinese population. This study reports the incidence, pattern, and clinical features of vascular lesions in BD patients in China. A total of 161 patients with BD were screened, and 27 patients with vessel involvement were identified. The clinical and laboratory data of the 27 BD patients with vessel involvements were retrospectively analyzed. Of 161 enrolled patients with BD, 27 had large blood vessel damage (16.77 %), with 24 males and 3 females, indicating clear prevalence in males. The average age of onset was 26.2 years old. Seven patients involved arteries only, 15 had vein damage, and 5 showed damage to both arteries and veins. Although vein lesions were more prevalent, arterial lesions were not rare (44.4 % of the vessel-affected BD patients) and could be life-threatening. All 27 patients received various treatments such as steroids, immunosuppressants, anticoagulants, and surgery, and most responded well as evidenced by resumed blood circulation and complete resolution. In conclusion, this study shows features of vessel that involved BD similar to those reported in literatures. Comprehensive treatments lead to significant improvement in BD patients.

Serum adiponectin in relation to race-ethnicity and vascular risk factors in the Northern Manhattan Study.

BACKGROUND: Population-based data on serum adiponectin levels, an adipocytokine secreted from adipose tissue, are lacking, particularly across race-ethnic groups. Studies have suggested an inverse association between adiponectin and vascular risk factors, but data are limited and inconsistent. We examined the cross-sectional association between adiponectin, vascular risk factors and race-ethnicity in the population-based Northern Manhattan Study (NOMAS). METHODS: Blood samples, anthropomorphics, and vascular risk factors were collected at baseline. Multivariable linear regression analysis was conducted with log-transformed adiponectin as the dependent variable. RESULTS: Adiponectin was measured among 2900 participants (age 69±10 years, body mass index (BMI) 28.0±5.6, 37% male, 21% white, 53% Hispanic, 24% black). The mean adiponectin was 11.4±6.2 µg/mL (median=9.8, range=2.1-53.3). After multivariable adjustment, adiponectin levels were greatest among whites, followed by Hispanics, and lowest among blacks. Lower adiponectin levels were observed in participants with the following characteristics: Male, former smoking, hypertension, diabetes, homeostasis model assessment of insulin resistance (HOMA-IR), metabolic syndrome, moderate alcohol use, elevated waist circumference, BMI, estimated glomerular filtration rate (eGFR), triglycerides, low-density lipoprotein cholesterol (LDL-C), lower high-density lipoprotein cholesterol (HDL-C), and younger age. Obesity was a stronger risk factor for decreased adiponectin among blacks than among whites or Hispanics. The associations for several vascular risk factors, including hypertension, triglycerides, and low HDL-C, with low adiponectin were stronger among individuals who were not obese than among those who were obese. CONCLUSIONS: Adiponectin levels were lower among blacks and Hispanics and among those with various vascular risk factors, and greater with older age. The association between BMI and adiponectin varied across race-ethnic groups. Investigation of whether differences in body fat distribution may explain race-ethnic differences in adiponectin is needed.

The relationship between carotid intima-media thickness and endogenous androgens in young women with polycystic ovary syndrome in Taiwan.

Polycystic ovary syndrome (PCOS) is a common and complex female endocrinopathy that is associated with multiple vascular risk factors. Our objective was to investigate the relationship between carotid intima-media thickness (CIMT) and endogenous androgens in young Taiwanese-Chinese women with PCOS. We measured CIMT with B-mode ultrasound in 42 young PCOS patients and 43 controls. Atherosclerosis-associated profiles and endocrinological parameters were also measured. The results showed that although Taiwanese-Chinese PCOS patients tend to possess more risk factors for atherosclerosis than controls, there was no evidence to support that they have a greater CIMT at this age. Furthermore, androstenedione appears to be inversely associated with CIMT.

Methods used in cross-cultural comparisons of vasomotor symptoms and their determinants.

Methodological differences among studies of vasomotor symptoms limit rigorous comparison or systematic review. Vasomotor symptoms generally include hot flushes and night sweats although other associated symptoms exist. Prevalence rates vary between and within populations, but different studies collect data on frequency, bothersomeness, and/or severity using different outcome measures and scales, making comparisons difficult. We reviewed only cross-cultural studies of menopausal symptoms that explicitly examined symptoms in general populations of women in different countries or different ethnic groups in the same country. This resulted in the inclusion of nine studies: Australian/Japanese Midlife Women's Health Study (AJMWHS), Decisions At Menopause Study (DAMeS), Four Major Ethnic Groups (FMEG), Hilo Women's Health Survey (HWHS), Mid-Aged Health in Women from the Indian Subcontinent (MAHWIS), Penn Ovarian Aging Study (POAS), Study of Women's Health Across the Nation (SWAN), Women's Health in Midlife National Study (WHiMNS), and Women's International Study of Health and Sexuality (WISHeS). These studies highlight the methodological challenges involved in conducting multi-population studies, particularly when languages differ, but also highlight the importance of performing multivariate and factor analyses. Significant cultural differences in one or more vasomotor symptoms were observed in 8 of 9 studies, and symptoms were influenced by the following determinants: menopausal status, hormones (and variance), age (or actually, the square of age, age(2)), BMI, depression, anxiety, poor physical health, perceived stress, lifestyle factors (hormone therapy use, smoking and exposure to passive smoke), and acculturation (in immigrant populations). Recommendations are made to improve methodological rigor and facilitate comparisons in future cross-cultural menopause studies.

Differential endothelial cell gene expression by African Americans versus Caucasian Americans: a possible contribution to health disparity in vascular disease and cancer.

BACKGROUND: Health disparities and the high prevalence of cardiovascular disease continue to be perplexing worldwide health challenges. This study addresses the possibility that genetic differences affecting the biology of the vascular endothelium could be a factor contributing to the increased burden of cardiovascular disease and cancer among African Americans (AA) compared to Caucasian Americans (CA). METHODS: From self-identified, healthy, 20 to 29-year-old AA (n = 21) and CA (n = 17), we established cultures of blood outgrowth endothelial cells (BOEC) and applied microarray profiling. BOEC have never been exposed to in vivo influences, and their gene expression reflects culture conditions (meticulously controlled) and donor genetics. Significance Analysis of Microarray identified differential expression of single genes. Gene Set Enrichment Analysis examined expression of pre-determined gene sets that survey nine biological systems relevant to endothelial biology. RESULTS: At the highly stringent threshold of False Discovery Rate (FDR) = 0, 31 single genes were differentially expressed in AA. PSPH exhibited the greatest fold-change (AA > CA), but this was entirely accounted for by a homolog (PSPHL) hidden within the PSPH probe set. Among other significantly different genes were: for AA > CA, SOS1, AMFR, FGFR3; and for AA < CA, ARVCF, BIN3, EIF4B. Many more (221 transcripts for 204 genes) were differentially expressed at the less stringent threshold of FDR <.05. Using the biological systems approach, we identified shear response biology as being significantly different for AA versus CA, showing an apparent tonic increase of expression (AA > CA) for 46/157 genes within that system. CONCLUSIONS: Many of the genes implicated here have substantial roles in endothelial biology. Shear stress response, a critical regulator of endothelial function and vascular homeostasis, may be different between AA and CA. These results potentially have direct implications for the role of endothelial cells in vascular disease (hypertension, stroke) and cancer (via angiogenesis). Also, they are consistent with our over-arching hypothesis that genetic influences stemming from ancestral continent-of-origin could impact upon endothelial cell biology and thereby contribute to disparity of vascular-related disease burden among AA. The method used here could be productively employed to bridge the gap between information from structural genomics (for example, disease association) and cell function and pathophysiology.

Bisphosphonate Use and Prevalence of Valvular and Vascular Calcification in Women MESA (The Multi-Ethnic Study of Atherosclerosis).

OBJECTIVES: the aim of this study was to determine whether nitrogen-containing bisphosphonate (NCBP) therapy is associated with the prevalence of cardiovascular calcification. BACKGROUND: cardiovascular calcification correlates with atherosclerotic disease burden. Experimental data suggest that NCBP might limit cardiovascular calcification, which has implications for disease prevention. METHODS: the relationship of NCBP use to the prevalence of aortic valve, aortic valve ring, mitral annulus, thoracic aorta, and coronary artery calcification (AVC, AVRC, MAC, TAC, and CAC, respectively) detected by computed tomography was assessed in 3,710 women within the MESA (Multi-Ethnic Study of Atherosclerosis) with regression modeling. RESULTS: Analyses were age-stratified, because of a significant interaction between age and NCBP use (interaction p values: AVC p < 0.0001; AVRC p < 0.0001; MAC p = 0.002; TAC p < 0.0001; CAC p = 0.046). After adjusting for age; body mass index; demographic data; diabetes; smoking; blood pressure; cholesterol levels; and statin, hormone replacement, and renin-angiotensin inhibitor therapy, NCBP use was associated with a lower prevalence of cardiovascular calcification in women ≥ 65 years of age (prevalence ratio: AVC 0.68 [95% confidence interval (CI): 0.41 to 1.13]; AVRC 0.65 [95% CI: 0.51 to 0.84]; MAC 0.54 [95% CI: 0.33 to 0.93]; TAC 0.69 [95% CI: 0.54 to 0.88]; CAC 0.89 [95% CI: 0.78 to 1.02]), whereas calcification was more prevalent in NCBP users among the 2,181 women <65 years of age (AVC 4.00 [95% CI: 2.33 to 6.89]; AVRC 1.92 [95% CI: 1.42 to 2.61]; MAC 2.35 [95% CI: 1.12 to 4.84]; TAC 2.17 [95% CI: 1.49 to 3.15]; CAC 1.23 [95% CI: 0.97 to 1.57]). CONCLUSIONS: among women in the diverse MESA cohort, NCBPs were associated with decreased prevalence of cardiovascular calcification in older subjects but more prevalent cardiovascular calcification in younger ones. Further study is warranted to clarify these age-dependent NCBP effects.

Rationale, design, and baseline data of the Japanese Primary Prevention Project (JPPP)-a randomized, open-label, controlled trial of aspirin versus no aspirin in patients with multiple risk factors for vascular events.

BACKGROUND: Prevention of atherosclerotic disease has become an important public health priority in Japan due to the aging of the population and changes in diet and lifestyle factors. METHODS: The Japanese Primary Prevention Project (JPPP) is a multicenter, open-label, randomized, parallel-group trial that is evaluating primary prevention with low-dose aspirin in Japanese patients aged 60 to 85 years with hypertension, dyslipidemia, or diabetes mellitus. The study cohort will be followed for a mean of 4 years. The primary end point is a composite of death from cardiovascular causes (including fatal myocardial infarction [MI], fatal stroke, and other cardiovascular death), nonfatal stroke (ischemic or hemorrhagic), and nonfatal MI. Key secondary end points include a composite of cardiovascular death, nonfatal stroke, nonfatal MI, transient ischemic attack, angina pectoris, or arteriosclerotic disease requiring surgery or intervention; each component of the primary end point; noncerebrovascular and noncardiovascular death; and extracranial hemorrhage requiring transfusion or hospitalization. End point assessment is done by a central adjudication committee that is blinded to treatment assignments. RESULTS: Enrollment began in March 2005 and was completed in June 2007. A total of 14,466 patients were randomly allocated to receive enteric-coated aspirin, 100 mg/d, or no aspirin. At randomization, the study cohort had a mean (SD) age of 70.6 (6.2) years; 57.8% were women, 85.0% had hypertension, 71.7% had dyslipidemia, and 33.9% had diabetes. In the study cohort, 80.4% of patients had > or =3 risk factors. CONCLUSION: The JPPP is the largest primary prevention trial of aspirin in a Japanese population that is investigating whether the benefit of aspirin in reducing risk of vascular events outweighs any bleeding risk in elderly patients with multiple risk factors.

Uninsured South Florida vascular surgery patients are less likely to receive optimal medical management than their insured counterparts.

OBJECTIVE: Vascular disease is the most prevalent condition in patients aged >60 years, leading to increasing complications associated with their comorbid conditions. Poor medical compliance could be one reason why the rate of complications may be higher in this patient population, particularly the uninsured. This study was conducted to better assess rates of medication compliance in vascular surgical patients. METHODS: Consecutive patients seen in vascular clinics at a busy tertiary academic center were prospectively studied. Physicians and physician assistants used a standardized questionnaire to collect patient data and evaluated patients for coexisting medical conditions and medication use. Optimal medical therapy was defined according to the 2006 American Heart Association (AHA)/American College of Cardiology (ACC) "Guidelines for Secondary Prevention for Atherosclerotic Vascular Disease." Data were analyzed using multivariate regression. RESULTS: During the 4-month study period, 180 consecutive patients (47% men) were seen in vascular surgery clinics. Most patients (79%) were nonsmokers and only 21% admitted to smoking. Comorbid conditions surveyed included hypertension in 141, diabetes mellitus in 56, coronary artery disease in 24, hypercholesterolemia in 89, and chronic renal failure in 13; of these, 61% were insured and 39% had no insurance. Overall, only 31% of all patients were receiving adequate medical therapy for their comorbid conditions, and about 66% were receiving suboptimal medical treatment for their vascular disease. Uninsured patients were less likely (19%) than insured patients (39%) to receive optimal medical therapy (P = .012). Lack of insurance was a predictor of suboptimal medical therapy for hypertension (odds ratio [OR], 3.13; 95% confidence interval [CI], 1.20-8.16; P = .016), hypercholesterolemia (OR, 5.1; 95% CI, 1.87-13.88; P = .001), peripheral arterial disease (OR, 13.32; 95% CI, 2.84-62.54, P < .001), and any disease overall (OR, 2.43; 95% CI, 1.21-4.88, P = .012). Overall, men and women were equally likely (68%) to receive suboptimal medical therapy; however, women were significantly more likely to be undertreated for coronary artery disease (OR, 0.022; 95% CI, 0.0017-0.293; P < .001). CONCLUSIONS: Compliance with optimal medical therapy for secondary risk factor management amongst our vascular surgery patients is low. Uninsured patients are less likely to receive optimal medical therapy than their insured counterparts. This survey provides sobering statistics regarding medical compliance in our population. This issue deserves further study and may indirectly affect outcomes in minority groups that are disproportionately represented in our uninsured patients.

Don't all veins look alike? Comprehensively attending to diversity within the vascular surgical specialty.

Prior research has established diversity as a topic of empirical analysis in the vascular surgery literature. Building on the work of previously published articles on diversity in the Journal of Vascular Surgery and elsewhere, this article engages in a broad discussion of diversity in two interrelated arenas: educational/workplace diversity and culturally competent care. Interdisciplinary review of the literature indicates that diversity is often thought of as an end-state to be accomplished. A more fruitful way to encompass the changing aspects of diversity work is to think of diversity as a set of processes that can be adjusted based on a set of interrelated goals that matter differently to different groups. In considering diversity as a process, an approach to diversity emerges that considers both independent effects of gender and race/ethnicity as well as interactive effects between the two variables to address future trends in medical education. Such trends are diagnosed and multiple courses of intervention are offered as reasonable options for future efforts. A comprehensive definition of diversity will be established in order to encompass two different arenas in which diversity concerns arise: educational diversity and culturally competent patient care. Second, a discussion of the rationales for attention to diversity among vascular surgeons will provide different avenues into a conversation about diversity in the profession. In so doing, three successful efforts will be briefly discussed: the Ohio State University's MED-Path program, the Keck School of Medicine's chair-centered approach to diversity in residency training, and the American Association of Orthopedic Surgeons' (AAOS) approach to culturally competent care.

Changing demographics in patients with vascular disease.

The United States population with vascular disease has changed dramatically during the past 2 decades, with large increases in the proportion of Hispanic, African American, and other minority patients. Not only has the number of these patients increased, but the types and distribution of vascular disease in minority populations is also different from that encountered in non-Hispanic whites. Although genetic makeup accounts for some of these differences, access to vascular care is also an important determinant, with many minority patients presenting late in the course of the disease process. These factors create significant challenges for the vascular specialists caring for these patients. The vascular surgery workforce is composed of >90% white men and does not currently represent the changes in the population of patients with vascular disease. In addition, women with vascular disease comprise up to 50% of many vascular surgery practices. In many parts of the country, Hispanics and African Americans outnumber non-Hispanic whites with vascular disease. Yet, women and minority physicians are still significantly under-represented in the field of vascular surgery. This year's E. Stanley Crawford Critical Issues Forum at the Society for Vascular Surgery meeting addressed the disconnect between the vascular surgery workforce and the patients whom we serve. This article reviews the projected demographic changes in the population of the United States, which supports the need for training a vascular surgery workforce that is more diverse. This article also reviews the current status of minority and female representation in medical schools, surgical training programs, and vascular surgery programs in the United States.

Atherosclerotic vascular disease and risk factors in Turkey: from past to present.

The prevalence of atherosclerotic vascular disease is unexpectedly high in Turkey despite its young population, with a median age of 29. The mean total cholesterol is lower than in Western European countries; however, smoking is very prevalent, the incidence of metabolic syndrome high and obesity, diabetes and hypertension are becoming a major problem, especially in women. Having these risk factors as well as lower HDL levels leads to high cardiovascular morbidity and mortality at younger ages. This problem is expected to become worse with increasing industrialisation, adaptation to Western diets, a sedentary lifestyle and increasing obesity. A National Heart Health Policy has been developed to overcome this epidemic and combat the risk factors and reduce the burden of atherosclerotic vascular disease.

Homocysteine, migration and early vascular impairment in people of African descent.

OBJECTIVES: A gradient of increased vascular risk with migration exists across the African diaspora. We investigated the hypothesis that differences in homocysteine/folic acid status contribute to this increased risk. DESIGN: Community cohort study of 73 Afro-Caribbeans in the United Kingdom and 151 matched Afro-Caribbeans in Jamaica with no conventional vascular risk factors. METHODS: Subjects were compared for baseline characteristics, vascular risk profile, homocysteine (tHcy), folate and B(12) concentrations. Endothelium-dependent vasodilatation was assessed by measuring the absolute change from baseline in the reflection index (RI) of the digital volume pulse during intravenous infusion of albuterol (5 microg/min, Delta RI(ALB)) and glyceryltrinitrate (GTN) (5 microg/min, Delta RI(GTN)). Carotid intima media thickness (CIMT) was measured ultrasonographically in the distal 1 cm of the common carotid artery. RESULTS: UK Afro-Caribbeans had higher tHcy (mean difference 2.3 (95% confidence interval 1.3 to 3.4) micromol/l) and lower folate (mean difference 3.2 (95% CI 1.8 to 4.7) microg/l) levels. Delta RI(ALB) was 5.1 (95% CI 2.5 to 7.6) percentage points lower and CIMT 0.124 (95% CI 0.075 to 0.173) mm greater in UK Afro-Caribbeans. Higher tHcy and lower folate concentrations correlated with impaired Delta RI(ALB) and increased CIMT. A 1 microg/l increase in folate concentration was associated with 0.3 (95% CI 0.1 to 0.5) percentage point increase in Delta RI(ALB) and 0.002 (95% CI 0.001 to 0.006) mm decrease in CIMT, independent of blood pressure, smoking and vascular risk profile. CONCLUSIONS: Lower folate concentrations in UK compared with West Indian African-Caribbeans may contribute to the higher stroke risk seen in UK African-Caribbean people.

Disparities in the treatment and outcomes of vascular disease in Hispanic patients.

BACKGROUND: The Hispanic population represents the fastest growing minority in the United States. As the population grows and ages, the vascular surgery community will be providing increasing amounts of care to this diverse group. To appropriately administer preventive and therapeutic care, it is important to understand the incidence, risk factors, and natural history of vascular disease in Hispanic patients. METHODS: We analyzed hospital discharge databases from New York and Florida to determine the rate of lower extremity revascularization (LER), carotid revascularization (CR), and abdominal aortic aneurysm (AAA) repair in Hispanics relative to the general population. The rates of common comorbidities, the indications for the procedures, and outcomes during the same hospitalization as the index procedure were determined. Multivariate logistic regression analysis was used to determine the differences between Hispanics and white non-Hispanics with respect to rate of procedure, symptoms at presentation, and outcome after procedure. Demographic variables and length of stay were also analyzed. RESULTS: The rate of LER, CR, and AAA repair was significantly lower in Hispanic patients than in white non-Hispanics. Despite this lower rate of intervention, Hispanics were significantly more likely than whites to present with limb-threatening lower extremity ischemia (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.91 to 2.29), symptomatic carotid artery disease (OR, 1.57; 95% CI, 1.4 to 1.75), and ruptured AAA (OR, 1.26; 95% CI, 1.04-1.52) than white non-Hispanics These differences were maintained after controlling for the presence of diabetes mellitus and other comorbidities. Hispanic patients had higher rates of amputation during the same hospitalization after LER (6.2% vs 3.4%, P < .0001) and higher mortality after elective AAA repair (5% vs 3.4%, P = .0032). Length of stay after LER, CR, and AAA repair was longer for Hispanic patients than white non-Hispanics. CONCLUSION: Significant disparities in the rate of utilization of three common vascular surgical procedures exist between Hispanic patients and the general population. In addition, Hispanics appear to present with more advanced disease and have worse outcomes in some cases. Reasons for these disparities must be determined to improve these results in the fastest growing segment of our society.

Risk factors for chronic venous disease: the San Diego Population Study.

BACKGROUND: The etiology of chronic venous disease in the lower limbs is unclear, and very limited data are available on potential risk factors from representative population studies. METHODS: Participants in the San Diego Population Study, a free-living adult population randomly selected from age, sex, and ethnic strata, were systematically assessed for risk factors for venous disease. Categorization of normal, moderate, and severe disease was determined hierarchically through clinical examination and ultrasonography imaging by trained vascular technologists, who also performed anthropometric measures. An interviewer administered a questionnaire and an examination assessed potential risk factors for venous disease suggested by previous reports. RESULTS: In multivariable models, moderate venous disease was independently related to age, a family history of venous disease, previous hernia surgery, and normotension in both sexes. In men, current walking, the absence of cardiovascular disease, and not moving after sitting were also predictive. Additional predictors in women were weight, number of births, oophorectomy, flat feet, and not sitting. For severe disease, age, family history of venous disease, waist circumference, and flat feet were predictive in both sexes. In men, occupation as a laborer, cigarette smoking, and normotension were also independently associated with severe venous disease. Additional significant and independent predictors in women were hours standing, history of leg injury, number of births, and cardiovascular disease, but African American ethnicity was protective. Multiple other postulated risk factors for venous disease were not significant in multivariable analysis in this population. CONCLUSIONS: Although some risk factors for venous disease such as age, family history of venous disease, and findings suggestive of ligamentous laxity (hernia surgery, flat feet) are immutable, others can be modified, such as weight, physical activity, and cigarette smoking. Overall, these data provide modest support for the potential of behavioral risk-factor modification to prevent chronic venous disease.