A synergistic relationship of elevated low-density lipoprotein cholesterol levels and systolic blood pressure with coronary artery calcification.

We sought to evaluate this "response-to-injury" hypothesis of atherosclerosis by studying the interaction between systolic blood pressure (SBP) and LDL- cholesterol (LDL-C) in predicting the presence of coronary artery calcification (CAC) in asymptomatic men. We studied 526 men (46+/-7 years of age) referred for electron-beam tomography (EBT) exam. The prevalence of CAC was determined across LDL-C tertiles (low: <115 mg/dl; middle: 115-139 mg/dl; high: >or=140 mg/dl) within tertiles of SBP (low: <121 mmHg; middle: 121-130 mmHg; high: >or=131 mmHg). CAC was found in 220 (42%) men. There was no linear trend in the presence of CAC across LDL-C tertiles in the low (p=0.6 for trend) and middle (p=0.3 for trend) SBP tertile groups, respectively. In contrast, there was a significant trend for increasing CAC with increasing LDL-C (1st: 44%; 2nd: 49%; 3rd: 83%; p<0.0001 for trend) in the high SBP tertile group. In multivariate logistic analyses (adjusting for age, smoking, triglyceride levels, HDL-cholesterol levels, body mass index, and fasting glucose levels), the odds ratio for any CAC associated with increasing LDL-C was significantly higher in those with highest SBP levels, whereas no such relationship was observed among men with SBP in the lower two tertiles. An interaction term (LDL-C x SBP) incorporated in the multivariate analyses was statistically significant (p=0.038). The finding of an interaction between SBP and LDL-C relation to CAC in asymptomatic men support the response-to-injury model of atherogenesis.

High-normal fasting blood glucose in non-diabetic range is associated with increased coronary artery calcium burden in asymptomatic men.

OBJECTIVE: : The objective of the study is to evaluate whether high fasting blood glucose (FBG) in the non-diabetic range (<126 mg/dl) is associated with subclinical coronary atherosclerosis as determined by coronary artery calcium (CAC) independent of clustering of metabolic syndrome (MS) risk factors. METHODS & RESULTS: : Previously non-diabetic, 458 asymptomatic non-diabetic Brazilian men (mean age: 46+/-7 years, range: 29-65) underwent clinical consultation including FBG measurements and electron-beam tomography (EBT). The mean FBG of the study population was 88+/-10mg/dl. Overall, 190 (42%) of men had CAC>0. The prevalence of CAC was significantly higher among men with high-normal FBG (4th quartile: 94-125 mg/dl) versus normal FBG group (lower three quartiles: 66-93 mg/dl) (62% versus 35%, p<0.0001). In age adjusted analyses the odds ratio (OR) for any CAC among men with high-normal FBG versus normal FBG was 2.19 (95% CI: 1.33-3.58). On further adjustment for risk factors the relationship was slightly attenuated, however remained statistically significant (OR=1.78, 95% CI 1.05-3.00, p=0.03). In sub-stratified analyses high-normal FBG was associated with CAC among men without MS (OR: 1.99, 95% CI: 1.04-3.78) and with MS (OR: 2.12, 95% CI: 0.95-4.80). Similar relations with high-normal FBG were observed among individuals classified low risk (OR: 2.34, 95% CI: 1.14-4.83) as well intermediate high-risk men (OR: 1.95, 95% CI: 0.99-3.86) by Framingham risk score (FRS), respectively. CONCLUSIONS: : Fasting blood glucose in the upper normal range appears to be associated with the presence of CAC in apparently non-diabetic Brazilian men.

Association of increased cardiorespiratory fitness with low risk for clustering of metabolic syndrome components in asymptomatic men.

BACKGROUND: From a preventive aspect, it is especially important to investigate the lifestyle risk factors associated with cardiovascular disease (CVD). The purpose of this study was to determine the relationship of increasing metabolic syndrome (MS) components across increasing levels of estimated cardiorespiratory fitness (CRF) in asymptomatic young to middle-aged men. METHODS: We studied 449 consecutive asymptomatic men (47 +/- 7 years) who underwent a maximal treadmill exercise test according to the Bruce protocol. Cardiorespiratory fitness (CRF) was divided into tertiles based on metabolic equivalents (METs). The following MS components were studied: 1) waist circumference > 102 cm; 2) serum triglycerides > or = 150 mg/dL; 3) HDL cholesterol levels of < 40 mg/dL; 4) fasting blood glucose (FBG) > or = 110 mg/dL or 5) blood pressure > or = 130/85 mmHg or treated hypertension. Multinomial logistic regression was used to investigate the relationship between clustering of MS components and CRF as determined by metabolic equivalents (METs). We used polytomous logistic regression to determine the likelihood of clustering of increasing components of metabolic syndrome with intermediate (2nd tertile) and low (1st tertile) levels of CRF as compared to those with highest levels of CRF (3rd tertile). RESULTS: Overall in the study population, zero, 1, 2 and > or = 3 (i.e., metabolic syndrome) risk factors for MS were observed in 29% (n = 129), 26% (n = 118), 22% (n = 98) and 23% (n = 104) men, respectively. The mean METS achieved in the study population was 10 +/- 2 (range 4-20). Nearly half (49%) of individuals with the highest levels of CRF had no MS risk factors whereas only 18% of those with low CRF (METS < 9) had no MS risk factors. On the other end of the spectrum, the prevalence of MS (> or = 3 MS risk factors) increased significantly across decreasing levels of CRF (6, 22, 33% p < 0.0001 for trend). Multivariable polytomous logistic regression (adjusting for age, smoking, cholesterol-lowering therapy) demonstrated that individuals with low CRF (1st tertile of METS) compared to those with highest CRF had 3.1- (p = 0.001) and 11.8- (p < 0.0001) fold higher risk of having 2 and > or = 3 MS components, respectively. Similar results were observed when the analyses was repeated adjusting for Framingham risk score. CONCLUSIONS: Asymptomatic men with low levels of CRF have a greater likelihood for clustering of MS components and thus are at higher CVD risk. Further studies are needed to define the risk of cardiovascular disease in patients with intermediate levels of CRF and address which treatment strategies are most important given an individual's risk profile.

Relationship of subclinical coronary atherosclerosis and National Cholesterol Education Panel guidelines in asymptomatic Brazilian men.

BACKGROUND AND OBJECTIVE: Coronary heart disease (CHD) is the leading cause of death worldwide including Brazil. Improved precision in detecting early coronary disease may aid in more targeted preventive therapy. The National Cholesterol Education Program (NCEP) provides guidelines for determining the aggressiveness of primary prevention strategies including lipid lowering based on Framingham risk equation. Identification of subclinical atherosclerosis and coronary plaque burden is a step towards identifying high-risk individuals. This investigation was designed to determine how the updated NCEP guidelines classify asymptomatic individuals with presence of any as well as advanced CACS (coronary artery calcium score), a powerful intermediary for CHD events, in asymptomatic Brazilian men. METHODS AND RESULTS: Five hundred forty-six asymptomatic Brazilian men (mean age: 46+/-7 years) presented to a single electron beam tomography (EBT) facility in Sao Paulo. The study population was categorized into low risk (0-1 risk factors, n=166, 30%), intermediate risk (> or = 2 risk factors but < 10% risk of CHD over 10 years, n=150, 27%), moderately high risk (2 risk factors and 10-20% risk of hard CHD events in 10 years, n=147, 28%) and high-risk (> or = 2 risk factors and > 20% risk of hard CHD events in 10 years, n=83, 15%), respectively. In our study population, overall no CACS, mild CACS (1-99.9), moderate-severe CACS (> or = 100) were observed in 317 (58%), 160 (29%) and 69 (13%) men, respectively. Advanced calcification (CACS > or = 75th percentile for age) was present in 19% (n=104) men. Based on the LDL-C cutoffs recommended by the NCEP guidelines for initiation of lipid lowering, overall only 55% with CACS > or = 100 and 42% men with CACS > or = 75th percentile qualified for pharmacotherapy. As a result nearly half of individuals with CACS > or = 100 (45%) and CACS > or = 75th percentile (48%) missed eligibility for drug therapy. CONCLUSION: Our findings reveal the potential limitation of NCEP guidelines in identifying asymptomatic Brazilian men with significant coronary atherosclerosis who are potential candidates for aggressive primary prevention. Assessment of CACS may provide incremental value to global risk assessment in high-risk Brazilian men.

Increased level of cardiorespiratory fitness blunts the inflammatory response in metabolic syndrome.

OBJECTIVE: The presence of metabolic syndrome is associated with a higher degree of inflammation. We sought to assess whether the higher levels of cardiorespiratory fitness attenuate the levels of inflammation in people with metabolic syndrome. RESEARCH DESIGN AND METHODS: We studied 449 consecutive asymptomatic men (47+/-7 years) who underwent a maximal treadmill exercise test according to the Bruce protocol. Cardiorespiratory fitness was divided into tertiles based on metabolic equivalents (METs). White blood cells (WBC) (x10(9) cells/L) count was used as marker of inflammation. RESULTS: In our study population, 23% of the participants had the metabolic syndrome. The WBC count increased (p < 0.0001 for trend) with increasing number of risk factors for metabolic syndrome; however there was an inverse relationship (p < 0.0001 for trend) with increasing tertiles of fitness (6.47 cells x 10(9) cells/L for lowest tertile and 5.7 x 10(9) cells/L for highest tertile). Multiple linear regression analyses demonstrated that as compared to individuals with no MS risk factor, the WBC count remained significantly higher in men with metabolic syndrome in first tertile (regression coefficient: 1.2, 95% CI 0.4-2.0, p = 0.003) and second tertile (regression coefficient: 0.61, 95% CI 0.4-2.0, p = 0.02) of cardiorespiratory fitness, respectively. However, in the highest tertile of fitness no increase in level of WBC count was observed with increasing metabolic syndrome risk factors. CONCLUSION: Our findings suggest that in people with metabolic syndrome an increased level of physical fitness might exert its beneficial effect via attenuating inflammation.

Reabilitaçäo cardiovascular após infarto do miocárdio / Rehabilitation cardiovascular after miocardic infarct

As indicaçöes da reabilitaçäo cardiovascular, no momento atual, estäo mais amplas e englobam, além dos coronariopatas, os miocardiopatas de diferentes etiologias e graus de insuficiência cardíaca, os pós-operados de valvopatias, cardiopatias congênitas, pós-transplantes cardíacos e os indivíduos que apresentam fatores de risco para a doença coronária. A principal e mais frequente indicaçäo continua sendo, aos coronariopatas após infarto do miocárdio, cirurgia de revascularizaçäo miocárdica, angioplastia transluminal coronária e naqueles com insuficiência coronária crônica. A abordagem tem sido multifatorial, incluindo a atividade física regular, processos educacionais que englobam ensinamentos nutricionais visando ao controle de peso e dos lípides sanguíneos, aspectos psicológicos, especialmente em portadores de personalidades competitivas, aspectos sociais e vocacionais, com a finalidade de melhorar a qualidade de vida e quiçá alterar o curso natural da doença aterosclerótica, reduzindo sua morbimortalidade. Especificamente no que se refere ao paciente após infarto do miocárdio, as últimas décadas têm se caracterizado pela rápida mobilizaçäo física após o episódio agudo, com alta hospitalar mais precoce em pacientes näo complicados. O advento dos trombolíticos e da angioplastia primária nas primeiras horas do infarto do miocárdio, por seu turno, abreviou sobremaneira o tempo de internaçäo.