Evaluation of the cardiovascular health study (CHS) instrument and the Vulnerable Elders Survey-13 (VES-13) in elderly cancer patients. Are we still missing the right screening tool?

BACKGROUND: A geriatric screening tool would be valuable to identify elderly cancer patients who might benefit from a comprehensive geriatric assessment (CGA). This study evaluated the accuracy of the cardiovascular health study (CHS) instrument in predicting abnormality in CGA. The vulnerable elders' survey-13 (VES-13) was also evaluated. PATIENTS AND METHODS: Patients aged ≥ 70 years with solid tumors underwent a CGA after being screened with the CHS and VES-13. Analyses were conducted for the overall population and according to the disease status (early or advanced) and type of early cancer (breast or gastrointestinal, GI). RESULTS: Of 259 patients, 75% were impaired according to the CHS and 47% according to the VES-13. CGA impairment was reported in 171 patients (66%). In the overall population, overall accuracy, sensitivity and specificity of CHS in identifying CGA impairments were 74%, 87% and 49%, respectively. The corresponding figures for the VES-13 were 68%, 62% and 81%. Sensitivity and specificity of CHS in predicting CGA impairments in subgroups were early 81% and 55%, advanced 98% and 29%; early breast 78% and 69%, early GI 87.5% and 19%. CONCLUSIONS: The CHS compared favourably with VES-13 for sensitivity. However, the great variability in specificity observed with the CHS within subgroups limits its applicability in the global population.

Sequestration of aggregated LDL by macrophages studied with freeze-etch electron microscopy.

The detailed morphology of macrophages involved in the uptake and intracellular processing of low density lipoprotein (LDL) and, ultimately, formation of macrophage-derived foam cells of atherosclerotic lesions has long fascinated investigators. This study examined localization of LDL in subcellular compartments of macrophage-derived intimal foam cells in cardiac valves isolated from rabbits by diet-induced hypercholesterolemia and, as an in vitro model of formation of foam cells, in cultured human monocyte-macrophages incubated for 2;-120 h with aggregated LDL produced by vortexing or phospholipase C lipolysis. The quasi-three-dimensional morphology of macrophages involved in endocytosis was preserved by ultrarapid freezing and freeze-etch microscopy in conjunction with thin-section electron microscopy. This approach produced unique images of subcellular compartments in human monocyte-macrophages involved in the uptake and processing of aggregated LDL with a clarity not previously reported. Three-dimensional ultrastructural analyses revealed a complex network of coated and uncoated vesicles, surface-connected saclike compartments, and endosomal/lysosomal compartments including the labyrinth of vesicular/tubular lysosomes all enmeshed in the microtubular, microfilament cytoskeletal network. These dynamic views of subcellular structures at the high resolution of the electron microscope provide an additional framework to better understand how lipoprotein particles are transported into, and processed within, macrophages during foam cell formation in atherogenesis.

Genetic control of HDL levels and composition in an interspecific mouse cross (CAST/Ei x C57BL/6J).

Strain CAST/Ei (CAST) mice exhibit unusually low levels of high density lipoproteins (HDL) as compared with most other strains of mice, including C57BL/6J (B6). This appears to be due in part to a functional deficiency of lecithin:cholesterol acyltransferase (LCAT). LCAT mRNA expression in CAST mice is normal, but the mice exhibit several characteristics consistent with functional deficiency. First, the activity and mass of LCAT in plasma and in HDL of CAST mice were reduced significantly. Second, the HDL of CAST mice were relatively poor in phospholipids and cholesteryl esters, but rich in free cholesterol and apolipoprotein A-I (apoA-I). Third, the adrenals of CAST mice were depleted of cholesteryl esters, a phenotype similar to that observed in LCAT- and acyl-CoA:cholesterol acyltransferase-deficient mice. Fourth, in common with LCAT-deficient mice, CAST mice contained triglyceride-rich lipoproteins with "panhandle"-like protrusions. To examine the genetic bases of these differences, we studied HDL lipid levels in an intercross between strain CAST and the common laboratory strain B6 on a low fat, chow diet as well as a high fat, atherogenic diet. HDL levels exhibited complex inheritance, as 12 quantitative trait loci with significant or suggestive likelihood of observed data scores were identified. Several of the loci occurred over plausible candidate genes and these were investigated. The results indicate that the functional LCAT deficiency is unlikely to be due to variations of the LCAT gene. Our results suggest that novel genes are likely to be important in the control of HDL metabolism, and they provide evidence of genetic factors influencing the interaction of LCAT with HDL.

Determinants of exercise tolerance after acute myocardial infarction in older persons.

OBJECTIVES: Exercise tolerance is reduced with advancing age. Identification of potentially reversible determinants of the age-related decrement in exercise tolerance, which remain largely unexplored in older subjects and in patients recovering from a recent myocardial infarction (MI), may have useful therapeutic implications. The objective of this study was to identify the independent determinants of exercise tolerance in older patients with a recent MI. DESIGN, SETTING, AND PARTICIPANTS: Data is from baseline assessment of 265 post-MI patients (age range 45-85 years) enrolled in the Cardiac Rehabilitation in Advanced Age randomized, controlled trial. Patients with major comorbidities or severe MI complications were excluded from the trial. Exercise tolerance was determined from symptom-limited exercise testing and expressed as total work capacity (TWC, kg.m) or peak oxygen consumption (VO2peak, mL/kg/min). The associations between both TWC and VO2peak and baseline demographic, social, clinical, and neuropsychological variables and an index of health-related quality of life were determined with univariate and multivariate analysis. RESULTS: With univariate analysis, TWC decreased by 1285 kg.m per decade of increasing age between 45 and 85 years of age. With multivariate analysis, TWC decreased by 922 kg.m per decade. Increasing age (P < .001), female gender (P < .001), a small body surface area (P < .001), a low level of usual physical exercise before MI (P < .002), and the presence of post-MI depressive symptoms (P < .024) were independently associated with a lower TWC. The same factors, in addition to a small arm muscle area (P < .002), were also independently associated with a lower VO2peak. CONCLUSIONS: Age per se accounts for approximately 70% of the age-related decay in TWC or VO2peak. However, the inclusion of modifiable factors such as physical exercise and depression in the prediction model reinforces the importance of a multidimensional approach to the evaluation and treatment of older patients with a recent MI.

Ultrastructure of early lipid accumulation in ApoE-deficient mice.

Apolipoprotein (apo) E-deficient mice develop severe hypercholesterolemia and have lesions that progress from fatty streaks to fibrous plaques distributed in lesion-prone areas throughout the aorta. Lesions develop in apoE-deficient mice on a regular chow diet and will occur faster on a diet higher in cholesterol. Examination of the aortas from these mice on a chow diet by high-resolution, freeze-etch electron microscopy demonstrated lipid retention in the intima by 3 weeks of age. Lipid was retained in the matrix as individual particles between 33 and 48 nm in diameter, aligned along the collagen fibrils and in aggregates consisting of lipid particles with average diameters of 33 and 68 nm. Larger particles seemed to have formed from fusion of smaller particles. Lipid retention was more widespread in 5- and 9-week-old mice. Monocyte attachment to endothelial cells was observed by electron microscopy at 5 weeks of age. The appearance of the intimal lipid was similar to that previously described in rabbit models and suggests that lipid interaction with matrix filaments and subsequent aggregation of lipid particles are critical first steps in the process of foam cell formation.

Aims, design and enrollment rate of the Cardiac Rehabilitation in Advanced Age (CR-AGE) randomized, controlled trial.

Data regarding the efficacy of cardiac rehabilitation after acute myocardial infarction in advanced age are limited, and are derived from either controlled but non randomized trials, or observational studies. Several aspects of cardiac rehabilitation after myocardial infarction in advanced age, including its effectiveness on exercise tolerance and health-related quality of life, as well as the feasibility of rehabilitation programs, need clarification. The objectives of this randomized, controlled trial, Cardiac Rehabilitation in Advanced Age (CR-AGE), are to examine the effects of an 8-week comprehensive cardiac rehabilitation intervention, comparing 1) supervised outpatient, hospital-based cardiac rehabilitation, 2) home-based cardiac rehabilitation, and 3) usual care in each of three groups of post-myocardial infarction patients, 45-65, 66-75, and 76-85 years of age. The primary objective of the trial is to evaluate the change in physical fitness in each age group assessed by total work capacity at the end of the intervention, and during follow-up over both the medium- (6 months) and the long-term (1 and 2 years). Secondary objectives of the trial include an examination of the feasibility of cardiac rehabilitation in older patients, as well as the determination of the following: exercise complication rates; changes in peak oxygen consumption; changes in other outcome measures, such as health-related quality of life, prevalence of anxiety and depressive symptoms, fluid intelligence, body composition and mass index; incidence of new cardiac and non-cardiac events; and utilization rates of health care services. Enrollment in the CR-AGE trial is expected to be completed within the first half of 1998.

Subcellular distribution of ankyrin in developing rabbit heart--relationship to the Na+-Ca2+ exchanger.

Ankyrins are a multigene family of proteins that function as adapters between the cytoskeleton and trans-membrane proteins, such as ion channels. Previous studies have shown the linkage between ankyrin and ionic transport proteins such as Na+-K+ ATPase, voltage-dependent Na+ channels and Ca2+ channels. In the present study, we have investigated the subcellular distribution of ankyrin and its relationship to the Na+-Ca2+ exchange protein in immature and adult rabbit ventricular myocytes. Isolated single cardiomyocytes from neonatal, juvenile and adult rabbit hearts were examined by immunofluorescence labeling techniques, using antibodies against ankyrin and the Na+-Ca2+ exchanger. We found that in neonatal rabbit cardiac myocytes, ankyrin labeling was mainly present at the Z disk, whereas the Na+-Ca2+ exchanger was only present on the peripheral sarcolemma. At 2 weeks of age, ankyrin labeling was still predominantly observed at the level of the Z disks as well as in the partially developed T-tubules. In the adult cells, however, ankyrin and the Na+-Ca2+ exchanger seem to be co-localized within T-tubules and at the costamere region of the peripheral sarcolemma. Immunogold labeling studies at the higher resolution electron microscopic level using cyrosection tissues of rabbit heart at different ages confirm these findings. These results indicate that the distribution pattern of ankyrin and the Na+-Ca2+ exchanger changes with development in rabbit ventricular myocytes.

Insulin-like growth factor II induces DNA synthesis in fetal ventricular myocytes in vitro.

Insulin-like growth factor II (IGF2) belongs to a family of growth factors that includes insulin and insulin-like growth factor I (IGF1). Although the accumulating evidence indicates that IGF1 is involved in regulating proliferation of ventricular myocytes, the role of IGF2 is less clear. To gain more insight into the functions of IGF2, rat ventricular expression of IGF2 mRNA at four developmental stages was examined by Northern analysis. An abundant IGF2 mRNA of approximately 3.8 kb was detected in fetal ventricles. It was dramatically decreased in neonatal ventricles and became undetectable in juvenile and adult ventricles. Similar expression patterns of the mRNA encoding IGF1 receptor and IGF2 receptor were observed. Since the results of Northern analysis strongly suggest the importance of IGF2 in regulating proliferation of fetal rat ventricular myocytes, the effects of an exogenous IGF2 on DNA synthesis in cultured rat ventricular myocytes were determined. DNA synthesis, which was monitored by measuring 5-bromo-2'-deoxyuridine (BrdU) and [3H]thymidine incorporation, was increased by twofold to threefold in IGF2-stimulated fetal ventricular myocytes, whereas no change in BrdU or [3H]thymidine incorporation was observed in neonatal ventricular myocytes. Instead, IGF2 seemed to induce hypertrophy in neonatal ventricular myocytes. An antisense oligonucleotide against rat IGF2 mRNA was able to significantly reduce BrdU incorporation, and this effect was quantitatively reversed by the addition of exogenous IGF2. Reversion by exogenous IGF2 was abolished by a monoclonal antibody against IGF1 receptor. In conclusion, our results suggest that IGF2 directly regulates proliferation of fetal rat ventricular myocytes in a paracrine/autocrine fashion.

Distribution of the Na+/Ca2+ exchange protein in developing rabbit myocytes.

The Na+/Ca2+ exchanger is a major pathway for transmembrane flux of Ca2+ in cardiac cells. Immunolabeling in adult rabbit myocytes showed localization of the Na+/Ca2+ exchanger to the peripheral sarcolemma and especially in the T tubules. Previous studies have also demonstrated higher Na+/Ca2+ exchanger activity in fetal and newborn rabbit hearts in which the T tubular system is not completely developed. Indirect immunofluorescent studies were performed to localize the Na+/Ca2+ exchanger in isolated myocytes from immature (5, 11, 17, and 30 days) and adult rabbits. Cells were incubated with a monoclonal antibody to the exchanger followed by fluorescein-labeled goat anti-mouse antibody. It is found that at 5 days of age the immunofluorescent labeling was very intense and confined to the peripheral sarcolemma. After 11 days of age, localization of labeling followed the development of the T tubules. The exchanger appeared in the T tubules as soon as they were formed. The Na+/Ca2+ exchange protein is abundantly localized to the peripheral sarcolemma before and during the development of T tubule system.

Subcellular distribution of dystrophin in isolated adult and neonatal cardiac myocytes.

The subcellular localization of dystrophin was examined in adult rabbit and rat cardiac myocytes with immunofluorescence and at higher resolution with immunogold. The aim was to resolve the conflicting reports on the presence of dystrophin in the transverse tubules (T tubules) of cardiac muscle and to determine its distribution in neonatal myocytes before and during the development of the T tubules. Dystrophin was localized to the peripheral sarcolemma and the T-tubular membrane and was absent from the intercalated disk membranes. In addition, dystrophin localization was followed with immunofluorescence in developing rabbit myocytes at 4 days, 1 wk, and 1 mo after birth. At 4 days of age, T tubules are absent and dystrophin was localized only in the peripheral sarcolemma. Dystrophin was present in the developing T tubules at 1 wk and 1 mo. These results imply that dystrophin is expressed in the T tubules as soon as they develop and confirm the different distribution of dystrophin in the T tubules of cardiac and skeletal muscle.

An ultrastructural study of lipoprotein accumulation in cardiac valves of the rabbit.

Heart valves are composed chiefly of extracellular matrix surrounded by an endothelial cell monolayer and as a result are an excellent model of the intima. Heart valves from rabbits fed a high-cholesterol diet accumulate lipids within the matrix and over time develop fatty streaks similar to those seen in the aorta. In this study we demonstrate that the heart valves (atrioventricular and aortic) can be isolated and used as an in vitro preparation to control and follow low-density lipoprotein (LDL) uptake and deposition. Using thin-section and freeze-etch microscopy we found that LDL rapidly associates with collagen within the extracellular matrix. As it accumulates along the collagen fibers the LDL appears to undergo structural changes in size and surface topography. This association of LDL with collagen may be a key step in lipid aggregation in the intima.

Distribution of the Na(+)-Ca2+ exchange protein in mammalian cardiac myocytes: an immunofluorescence and immunocolloidal gold-labeling study.

The present study reports on the location of the Na(+)-Ca2+ exchanger in cardiac sarcolemma with immunofluorescence and immunoelectron microscopy. Both polyclonal and monoclonal antibodies to the Na(+)-Ca2+ exchanger were used. The mAb was produced from a hybridoma cell line generated by the fusion of mouse myeloma NS-1 cells with spleen cells from a mouse repeatedly immunized with isolated reconstituted canine cardiac Na(+)-Ca2+ exchanger (Philipson, K. D. S. Longoni, and R. Ward. 1988. Biochim. Biophys. Acta. 945:298-306). The polyclonal antibody has been described previously and reacts with three proteins (70, 120, 160 kD) in cardiac sarcolemma associated with the Na(+)-Ca2+ exchanger (Nicoll, D. A., S. Longoni, and K. D. Philipson. 1990. Science (Wash. DC). 250:562-565). Both the monoclonal and the polyclonal antibodies appear to react with extracellular facing epitopes in the cardiac sarcolemma. Immunofluorescence studies showed labeling of the transverse tubular membrane and patchy labeling of the peripheral sarcolemma. The immunofluorescent labeling clearly delineates the highly interconnected T-tubular system of guinea pig myocytes. This localization of the exchanger to the sarcolemma, with an apparent high density in the transverse tubules, was also seen with immunoelectron microscopy. It is of great interest that the Na(+)-Ca2+ exchanger, as the main efflux route for Ca2+ in heart cells, would be abundantly located in sarcolemma closest to the release of Ca2+.

Lipid accumulation in rabbit aortic intima 2 hours after bolus infusion of low density lipoprotein. A deep-etch and immunolocalization study of ultrarapidly frozen tissue.

The intima from aortas of normal New Zealand White rabbits was studied 2 hours after infusion of 320 mg human low density lipoprotein (LDL), resulting in a plasma concentration of at least five times and maximally 20 times the values found in normal rabbit serum. The following techniques were used: 1) ultrarapid freezing without chemical fixation, followed by freeze-etching; 2) immunofluorescence microscopy; and 3) postembedding immunogold-labeling electron microscopy. In the latter two methods MB47, a murine monoclonal antibody against human apolipoprotein B, was used as the primary antibody. Control rabbits were infused with the same volume of buffer only. Rotary-shadowed replicas of samples from the LDL-injected rabbits showed the deposition of lipidlike particles in the subendothelial-intimal space that were the size of the injected LDL (23 nm). In focal areas of the intima, groups of 23-nm-sized lipidlike particles and larger lipidlike structures were found enmeshed in the extracellular matrix. Control replicas were essentially free of lipid deposition. Immunofluorescence microscopy of frozen aortic cross sections showed an overall increase in apolipoprotein B in the intima of the LDL-injected rabbits. The presence of apolipoprotein B in the intima was also confirmed by immunoelectron microscopy. These in vivo results show that clustering of LDL-sized particles occurs in the intima within 2 hours of excessive LDL uptake. It also demonstrates the interaction of these LDL-sized particles with the filaments of the extracellular matrix. The clustering of the LDL-sized particles supports the possibility that LDL self-aggregation may occur in vivo and that components of the extracellular matrix are involved in this process.

Membrane structure in ultrarapidly frozen, unpretreated, freeze-fractured myocardium.

Ultrarapid freezing has been applied to monitor the structure of the freeze-fractured myocardial sarcolemma. Our two goals were to demonstrate that large areas of membrane can be preserved free of visible ice crystal damage and, thus, be amenable to quantitative analysis and to compare the structure of directly frozen myocardial membranes with conventionally prepared tissue. The E face was most affected by lack of chemical pretreatment. First, our laboratory reported an increase in E face particle density from 379 +/- 30/micron 2 in conventional fixed tissue to 489 +/- 18/micron 2 in unpretreated tissue. Discrete arrays of 12-15 nm particles on the E face were a striking feature of the unfixed sarcolemma. However, P face intramembrane particle (IMP) density remained unchanged from previous estimates in fixed tissue. Specialized regions of the sarcolemma were enhanced in ultrarapidly frozen tissue. Particle domains of the adherens junctions were very prominent in forming a cap alongside the gap junctions. Both the P and E faces of the gap junctions were highly ordered into hexagonal arrays. Caveolae in the membrane were infrequent in both P and E faces.

Ultrastructure and function of isolated myocytes after calcium depletion and repletion.

We describe a system in which the contractile response of a single isolated Ca-tolerant rat myocyte can be monitored while stimulated in Ca-free (37 degrees C) and then Ca-containing medium. This same cell is then processed for ultrastructural analysis. We find unattached isolated Ca-tolerant myocytes can withstand Ca depletion and repletion. They respond to stimulation after Ca repletion with healthy twitches and are structurally intact. The cell surface of the isolated myocyte appears similar to that seen in the intact myocytes even after 15 min in Ca-free solution. This is in marked contrast to myocardial cells in tissue where Ca depletion causes separation of the layers of the glycocalyx. When the cell is attached to a fine pipette so that some of the sarcolemma is under stress, the sequence of Ca depletion and repletion drives the cell into hypercontracture and loss of structural integrity that is characteristic of the Ca paradox.