A Comparative Review of Established Diets for Prevention of Cardiovascular Disease and Newer Dietary Strategies.

As part of a population-based approach to combating obesity, the American Heart Association has published specific dietary guidelines for the management of obesity and cardiovascular disease prevention. These guidelines give a primary view of healthy dietary changes and goals which may reduce cardiovascular risk. The American Heart Association guideline on Cardiovascular Prevention focuses on the benefits of a Plant-Based Diet and the Mediterranean diet. In addition to these recommendations, several other diets exist with variable long-term cardiovascular outcomes. In recent years, the ketogenic and intermittent fasting diets have been emerging and have garnered their own respective followings as weight loss strategies, and we will include them in our discussion of the potential long-term benefits related to cardiovascular risks. As the guidelines emphasize, all of the diets we will cover throughout this review must be discussed at the level of the individual patient with their primary care provider, and cannot be exercised without informed consent regarding the potential outcomes. Further research is required, and caution is advised before prescribing any of these diets to patients in the long-term, due to the potential to exacerbate cardiovascular risk factors.

Coronary artery calcium scoring for individualized cardiovascular risk estimation in important patient subpopulations after the 2019 AHA/ACC primary prevention guidelines.

The 2018 and 2019 American Heart Association and American College of Cardiology (AHA/ACC) guidelines for primary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend consideration of so-called "risk-enhancing factors" in borderline to intermediate risk individuals. These include high-risk race/ethnicity (e.g. South Asian origin), chronic kidney disease, a family history of premature ASCVD, the metabolic syndrome, chronic inflammatory disorders (e.g. rheumatoid arthritis [RA], psoriasis, or chronic human immunodeficiency virus [HIV]), and conditions specific to women, among others. Studies suggest, however, that risk may be highly heterogeneous within these subgroups. The AHA/ACC guidelines also recommend consideration of coronary artery calcium (CAC) scoring for further risk assessment in borderline to intermediate risk individuals in whom management is uncertain. Although the combination of risk enhancing factors and CAC burden (together with Pooled Cohort estimates) may lead to more accurate ASCVD risk assessment, few publications have closely examined the interplay between risk enhancing factors and CAC scoring for personalized risk estimation. Our aim is to review the relevant literature in this area. Although further research is clearly needed, CAC assessment seems a highly valuable option to inform individualized ASCVD risk management in these important, often highly heterogeneous patient subgroups.

Breast Arterial Calcium: A Game Changer in Women's Cardiovascular Health?

In 2018, cardiovascular disease (CVD) was the leading cause of death among women, and current CVD prevention paradigms may not be sufficient in this group. In that context, it has recently been proposed that detection of calcification in breast arteries may help improve CVD risk screening and assessment in apparently healthy women. This review provides an overview of breast arterial anatomy; and the epidemiology, pathophysiology, and measurement of breast artery calcium (BAC); and discusses the features of the BAC-CVD link. The potential clinical applications that BAC may offer for CVD prevention in the context of current clinical practice guidelines and recommendations are also discussed. Finally, current gaps in evidence gaps are outlined, and future directions in the field are explored with a focus on the implementation of BAC mammography as a CVD risk-screening tool in routine clinical practice.

Coronary Artery Calcium Scoring: Is It Time for a Change in Methodology?

Quantification of coronary artery calcium (CAC) has been shown to be reliable, reproducible, and predictive of cardiovascular risk. Formal CAC scoring was introduced in 1990, with early scoring algorithms notable for their simplicity and elegance. Yet, with little evidence available on how to best build a score, and without a conceptual model guiding score development, these scores were, to a large degree, arbitrary. In this review, we describe the traditional approaches for clinical CAC scoring, noting their strengths, weaknesses, and limitations. We then discuss a conceptual model for developing an improved CAC score, reviewing the evidence supporting approaches most likely to lead to meaningful score improvement (for example, accounting for CAC density and regional distribution). After discussing the potential implementation of an improved score in clinical practice, we follow with a discussion of the future of CAC scoring, asking the central question: do we really need a new CAC score?

Improving the CAC Score by Addition of Regional Measures of Calcium Distribution: Multi-Ethnic Study of Atherosclerosis.

OBJECTIVES: The aim of this study was to investigate whether inclusion of simple measures of calcified plaque distribution might improve the ability of the traditional Agatston coronary artery calcium (CAC) score to predict cardiovascular events. BACKGROUND: Agatston CAC scoring does not include information on the location and distributional pattern of detectable calcified plaque. METHODS: We studied 3,262 (50%) individuals with baseline CAC >0 from MESA (Multi-Ethnic Study of Atherosclerosis). Multivessel CAC was defined by the number of coronary vessels with CAC (scored 1 to 4, including the left main). The "diffusivity index" was calculated as: 1 - (CAC in most affected vessel/total CAC), and was used to group participants into concentrated and diffuse CAC patterns. Multivariable Cox proportional hazards regression, area under the curve, and net reclassification improvement analyses were performed for both coronary heart disease (CHD) and cardiovascular disease (CVD) events to assess whether measures of regional CAC distribution add to the traditional Agatston CAC score. RESULTS: Mean age of the population was 66 ± 10 years, with 42% women. Median follow-up was 10.0 (9.5 to 10.7) years and there were 368 CHD and 493 CVD events during follow-up. Considerable heterogeneity existed between CAC score group and number of vessels with CAC (p < 0.01). Addition of number of vessels with CAC significantly improved capacity to predict CHD and CVD events in survival analysis (hazard ratio: 1.9 to 3.5 for 4-vessel vs. 1-vessel CAC), area under the curve analysis (C-statistic improvement of 0.01 to 0.033), and net reclassification improvement analysis (category-less net reclassification improvement 0.10 to 0.45). Although a diffuse CAC pattern was associated with worse outcomes in participants with ≥2 vessels with CAC (hazard ratio: 1.33 to 1.41; p < 0.05), adding this variable to the Agatston CAC score and number of vessels with CAC did not further improve global risk prediction. CONCLUSIONS: The number of coronary arteries with calcified plaque, indicating increasingly "diffuse" multivessel subclinical atherosclerosis, adds significantly to the traditional Agatston CAC score for the prediction of CHD and CVD events.

Usefulness of regional distribution of coronary artery calcium to improve the prediction of all-cause mortality.

Although the traditional Agatston coronary artery calcium (CAC) score is a powerful predictor of mortality, it is unknown if the regional distribution of CAC further improves cardiovascular risk prediction. We retrospectively studied 23,058 patients referred for Agatston CAC scoring, of whom 61% had CAC (n=14,084). CAC distribution was defined as the number of vessels with CAC (0 to 4, including left main). For multivessel CAC, "diffuse" CAC was defined by decreasing percentage of CAC in the single most affected vessel and by ≤75% total Agatston CAC score in the most calcified vessel. All-cause mortality was ascertained through the social security death index. The mean age was 55±11 years, with 69% men. There were 584 deaths (2.5%) over 6.6±1.7 years. Considerable heterogeneity existed between the Agatston CAC score group and the number of vessels with CAC. In each CAC group, increasing number of vessels with CAC was associated with an increased mortality rate. After adjusting for age, gender, Agatston CAC score, and cardiovascular risk factors, increasing number of vessels with CAC was associated with higher mortality risk compared with single-vessel CAC (2-vessel: HR 1.61 [95% CI 1.14 to 2.25], 3-vessel: 1.99 [1.44 to 2.77], and 4-vessel: 2.22 [1.53 to 3.23]). "Diffuse" CAC was associated with a higher mortality rate in the CAC 101 to 400 and >400 groups. Left main CAC was associated with increased mortality risk. In conclusion, increasing number of vessels with CAC and left main CAC predict increased all-cause mortality and improve the prognostic power of the traditional Agatston CAC score.

Improving the relationship between coronary artery calcium score and coronary plaque burden: addition of regional measures of coronary artery calcium distribution.

BACKGROUND: The Agatston coronary artery calcium (CAC) score predicts cardiovascular events through its association with overall burden of coronary atherosclerosis. It is unclear whether adding regional measures of CAC distribution to the Agatston score improves this association. METHODS: We studied 920 consecutive patients (mean age 57 ± 12, 53% female), referred for 64-slice Coronary CT angiography (CCTA) who had concomitant CAC scoring. Total atherosclerosis burden was quantified as the segment involvement score (SIS), which describes the number of coronary segments with plaque on CCTA. We studied the heterogeneity between CAC group (0, 1-100, 101-400, >400) and the number of vessels with CAC (0-4), and related this to SIS on CCTA. In patients with multi-vessel disease, we examined the relationship of concentrated vs. diffuse CAC (> or ≤75% total CAC in one vessel) with SIS. RESULTS: When CAC was intermediate (1-400), considerable heterogeneity was noted between CAC group and the number of vessels with CAC (CAC 1-100: 53% 1-vessel, 29% 2-vessel, 16% 3-vessel, 2% 4-vessel; CAC 101-400: 9% 1-vessel, 28% 2-vessel, 43% 3-vessel, 20% 4-vessel). Within each CAC group, increase in the number of vessels with CAC was significantly associated with increased SIS. In multi-vessel disease, a higher SIS was associated with diffuse versus concentrated CAC (CAC 1-100: 3.8 vs. 2.8, CAC 101-400: 5.5 vs. 4.3 [both p < 0.01]). These associations persisted after adjustment for age, gender, and the absolute Agatston CAC score (p < 0.01). CONCLUSION: Addition of measures of regional CAC distribution improves the association of the Agatston CAC score with total plaque burden.

Impact of troponin testing in noncardiac admissions.

BACKGROUND: There is little data to support Troponin I (TNI) use in the management of noncardiac patients. We studied the use of TNI in patients on our gastroenterology service, to determine whether there was a change in management as a result of TNI testing. METHODOLOGY: Patients admitted from September 2011 to June 2012 to our gastroenterology service who had TNI performed were included. Data collected included symptoms, cardiovascular risk factors, medical treatment, and testing. RESULTS: Sixty-three of 295 patients had a positive TNI. The mean length of stay was significantly longer with a positive troponin (180 vs. 108 hours, P<0.001). Age, hypertension, diabetes, coronary artery disease, and chronic kidney disease were associated with a positive TNI. Cardiac consultation and echocardiography were performed in a higher proportion of TNI positive patients (P<0.0001). There were no statistically significant changes in treatment with clopidogrel, beta-blockers, angiotensin converting enzyme inhibitors, or statins between both groups. CONCLUSIONS: TNI testing in patients admitted to the gastroenterology service was associated with increased length of stay and echocardiography, without any change in management. This study supports adherence to national guidelines for the use of TNI, to reduce TNI testing and length of hospital stay.

Association of coronary artery calcium and coronary heart disease events in young and elderly participants in the multi-ethnic study of atherosclerosis: a secondary analysis of a prospective, population-based cohort.

OBJECTIVE: To evaluate the association of coronary artery calcium (CAC) and coronary heart disease (CHD) events among young and elderly individuals. PARTICIPANTS AND METHODS: This is a secondary analysis of data from a prospective, multiethnic, population-based cohort study designed to study subclinical atherosclerosis. A total of 6809 persons 45 through 84 years old without known cardiovascular disease at baseline were enrolled from July 2000 through September 2002. All participants had CAC scoring performed and were followed up for a median of 8.5 years. The main outcome measures studied were CHD events, defined as myocardial infarction, definite angina or probable angina followed by revascularization, resuscitated cardiac arrest, or death attributable to CHD. RESULTS: Comparing individuals with a CAC score of 0 with those with a CAC score greater than 100, there was an increased incidence of CHD events from 1 to 21 per 1000 person-years and 2 to 23 per 1000 person-years in the 45- through 54-year-old and 75- through 84-year-old groups, respectively. Compared with a CAC score of 0, CAC scores of 1 through 100 and greater than 100 impart an increased multivariable-adjusted CHD event risk in the 45- through 54-year-old and 75- through 84-year-old groups (hazard ratio [HR], 2.3; 95% CI, 0.9-5.8; for those 45-54 years old with CAC scores of 1-100; HR, 12.4; 95% CI, 5.1-30.0; for those 45-54 years old with CAC scores >100: HR, 5.4; 95% CI, 1.2-23.8; for those 75-84 years old with CAC scores of 1-100; and HR, 12.1; 95% CI, 2.9-50.2; for those 75-84 years old with CAC scores >100). CONCLUSION: Increased CAC imparts an increased CHD risk in younger and elderly individuals. CAC is highly predictive of CHD event risk across all age groups, suggesting that once CAC is known chronologic age has less importance. The utility of CAC scoring as a risk-stratification tool extends to both younger and elderly patients.

All-cause mortality in asymptomatic persons with extensive Agatston scores above 1000.

BACKGROUND: Risk assessment in the extensive calcified plaque phenotype has been limited by small sample size. OBJECTIVE: We studied all-cause mortality rates among asymptomatic patients with markedly elevated Agatston scores > 1000. METHODS: We studied a clinical cohort of 44,052 asymptomatic patients referred for coronary calcium scans. Mean follow-up was 5.6 years (range, 1-13 years). All-cause mortality rates were calculated after stratifying by Agatston score (0, 1-1000, 1001-1500, 1500-2000, and >2000). A multivariable Cox regression model adjusting for self-reported traditional risk factors was created to assess the relative mortality hazard of Agatston scores 1001 to 1500, 1501 to 2000, and >2000. With the use of post-estimation modeling, we assessed for the presence of an upper threshold of risk with high Agatston scores. RESULTS: A total of 1593 patients (4% of total population) had Agatston score > 1000. There was a continuous graded decrease in estimated 10-year survival across increasing Agatston score, continuing when Agatston score > 1000 (Agatston score 1001-1500, 78%; Agatston score 1501-2000, 74%; Agatston score > 2000, 51%). After multivariable adjustment, Agatston scores 1001 to 1500, 1501 to 2000, and >2000 were associated with an 8.05-, 7.45-, and 13.26-fold greater mortality risk, respectively, than for Agatston score of 0. Compared with Agatston score 1001 to 1500, Agatston score 1501 to 2000 had a similar all-cause mortality risk, whereas Agatston score > 2000 had an increased relative risk (Agatston score 1501-2000: hazard ratio [HR], 1.01 [95% CI, 0.67-1.51]; Agatston score > 2000: HR, 1.79 [95% CI, 1.30-2.46]). Graphical assessment of the predicted survival model suggests no upper threshold for risk associated with calcified plaque in coronary arteries. CONCLUSION: Increasing calcified plaque in coronary arteries continues to predict a graded decrease in survival among patients with extensive Agatston score > 1000 with no apparent upper threshold.

Ethnic and sex differences in fatty liver on cardiac computed tomography: the multi-ethnic study of atherosclerosis.

OBJECTIVE: To describe ethnic and sex differences in the prevalence and determinants of fatty liver in a multiethnic cohort. PATIENTS AND METHODS: We studied participants of the Multi-Ethnic Study of Atherosclerosis who underwent baseline noncontrast cardiac computed tomography between July 17, 2000, and August 29, 2002, and had adequate hepatic and splenic imaging for fatty liver determination (n=4088). Fatty liver was defined as a liver/spleen attenuation ratio of less than 1. We compared the prevalence and severity of fatty liver, in 4 ethnicities (white, Asian, African American, and Hispanic), and the factors associated with fatty liver in each ethnicity, stratifying by obesity and metabolic syndrome. Multivariable ordinal logistic regression was used to determine the effect of cardiometabolic risk factors on the prevalence of fatty liver in different ethnicities. RESULTS: The prevalence of fatty liver varied significantly by ethnicity (African American, 11%; white, 15%; Asian, 20%; and Hispanic, 27%; P<.001). Although African Americans had the highest prevalence of obesity, a smaller percentage of obese African Americans received a diagnosis of fatty liver than did other ethnicities (African American, 17%; white, 31%; Asian, 37%; and Hispanic 39%; P<.001). Hispanics had the highest prevalence of fatty liver, including the obese and metabolic syndrome population. An increase in insulin resistance predicted a 2-fold increased prevalence of fatty liver in all ethnicities after multivariable adjustment. CONCLUSION: African Americans have a lower prevalence and Hispanics have a higher prevalence of fatty liver than do other ethnicities. There are distinct ethnic variations in the prevalence of fatty liver even in patients with the metabolic syndrome or obesity, suggesting that genetic factors may play a substantial role in the phenotypic expression of fatty liver.

Relation of uric acid to serum levels of high-sensitivity C-reactive protein, triglycerides, and high-density lipoprotein cholesterol and to hepatic steatosis.

Increased uric acid (UA) is strongly linked to cardiovascular disease. However, the independent role of UA is still debated because it is associated with several cardiovascular risk factors including obesity and metabolic syndrome. This study assessed the association of UA with increased high-sensitivity C-reactive protein (hs-CRP), increased ratio of triglyceride to high-density lipoprotein cholesterol (TG/HDL), sonographically detected hepatic steatosis, and their clustering in the presence and absence of obesity and metabolic syndrome. We evaluated 3,518 employed subjects without clinical cardiovascular disease from November 2008 through July 2010. Prevalence of hs-CRP ≥3 mg/L was 19%, that of TG/HDL ≥3 was 44%, and that of hepatic steatosis was 43%. In multivariable logistic regression after adjusting for traditional cardiovascular risk factors and confounders, highest versus lowest UA quartile was associated with hs-CRP ≥3 mg/L (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.01 to 2.28, p = 0.04), TG/HDL ≥3 (OR 3.29, 95% CI 2.36 to 4.60, p <0.001), and hepatic steatosis (OR 3.10, 95% CI 2.22 to 4.32, p <0.001) independently of obesity and metabolic syndrome. Association of UA with hs-CRP ≥3 mg/L became nonsignificant in analyses stratified by obesity. Ascending UA quartiles compared to the lowest UA quartile demonstrated a graded increase in the odds of having 2 or 3 of these risk conditions and a successive decrease in the odds of having none. In conclusion, high UA levels were associated with increased TG/HDL and hepatic steatosis independently of metabolic syndrome and obesity and with increased hs-CRP independently of metabolic syndrome.

Utility of coronary artery calcium scoring in the evaluation of patients with chest pain.

Although coronary artery calcium (CAC) scoring has an established role in risk-stratifying asymptomatic patients at intermediate risk of coronary heart disease (CHD), its utility in the evaluation of patients with chest pain is uncertain. We conducted a literature review of articles investigating the utility of: (1) CAC scoring in elective patients with indeterminate chest pain symptoms, (2) CAC as a "gatekeeper" in the triage of patients presenting to the emergency department (ED) with chest pain, and (3) the cost-effectiveness of the use of CAC scoring in the ED. We also evaluated the predictive accuracy of the absence of CAC in a pooled analysis of applicable studies. Only studies evaluating patients classified as low or intermediate risk were included. Low to intermediate risk was established by Framingham risk scores, Thrombolysis in Myocardial Infarction scores, Diamond-Forrester classification, or by the absence of typical angina symptoms, ischemic electrocardiogram, positive cardiac biomarkers, or a prior history of CHD. In our pooled analysis, the presence of any CAC resulted in a high sensitivity (range 70%-100%) for predicting the presence of obstructive coronary disease among symptomatic patients subsequently referred for coronary angiography. More importantly, a CAC score of 0 in low- and intermediate-risk ED populations with chest pain had a high negative predictive value (99.4%) for CHD events over an average follow-up of 21 months. CAC scoring also seems cost-effective in this population. Although further research is needed, carefully selected ED patients with a normal electrocardiogram, normal cardiac biomarkers, and CAC = 0 may be considered for early discharge without further testing.

Coronary artery calcium for the prediction of mortality in young adults <45 years old and elderly adults >75 years old.

AIMS: To determine if coronary artery calcium (CAC) scoring is independently predictive of mortality in young adults and in the elderly population and if a young person with high CAC has a higher mortality risk than an older person with less CAC. METHODS AND RESULTS: We studied a cohort of 44 052 asymptomatic patients referred for CAC scans for cardiovascular risk stratification. All-cause mortality rates (MRs) were calculated after stratifying by age groups (<45, 45-54, 55-64, 65-74, and ≥75) and CAC score (0, 1-100, 100-400, and >400). Multivariable Cox regression models were constructed to assess the independent value of CAC for predicting all-cause mortality in the <45- and ≥75-year-old age groups. The MR increased in both the <45- and ≥75-year-old age groups with an increasing CAC group. After multivariable adjustment, increasing CAC remained independently predictive of increased mortality compared with CAC = 0 [<45 age group, hazard ratio (95% confidence interval): CAC = 1-100, 2.3 (1.2-4.2); CAC = 100-400, 7.4 (3.3-16.6); CAC > 400, 34.6 (15.5-77.4); ≥75 age group: CAC = 1-100, 7.0 (2.4-20.8); CAC = 100-400, 9.2 (3.2-26.5); CAC > 400, 16.1 (5.8-45.1)]. Persons <45 years old with CAC = 100-400 and CAC > 400 had 2- and 10-fold increased MRs, respectively, compared with persons ≥75 with no CAC. Individuals ≥75 years old with CAC = 0 had a 5.6-year survival rate of 98%, similar to those in other age groups with CAC = 0 (5.6-year survival, 99%). CONCLUSION: The value of CAC for predicting mortality extends to both elderly patients and those <45 years old. Elderly persons with no CAC have a lower MR than younger persons with high CAC.

Differences in coronary plaque composition with aging measured by coronary computed tomography angiography.

BACKGROUND: Little is known about the independent impact of aging on coronary plaque morphology and composition in the era of cardiac computed tomography angiography (CCTA). METHODS: We studied 1015 consecutive asymptomatic South Korean subjects (49 ± 10 years, 64% men) who underwent 64-slice CCTA during routine health evaluation. Coronary plaque characteristics were analyzed on a per-segment basis according to the modified AHA classification. Plaques with >50% calcified tissue were classified as calcified (CAP), plaques with <50% calcified tissue were classified as mixed (MCAP), and plaques without calcium were classified as non-calcified (NCAP). Multiple regression analysis was employed to describe the cross-sectional association between age tertile and plaque type burden (≥ 2 affected segments) after adjustment for other cardiovascular risk factors. RESULTS: The prevalence of coronary plaque increased with age, (1st tertile: 7.5%, 3rd tertile: 38.5% [p<0.001]). The relative contribution of NCAP to overall plaque burden decreased with age from nearly 50% in the first tertile to approximately 20% in the third, while there was a reciprocal increase in both MCAP and CAP subtypes. In multivariable analysis, patients in the oldest tertile had a 2.5-fold increase in burden of NCAP, yet a nearly 40-fold increase in MCAP and 16-fold increase in CAP compared to the youngest tertile. In conclusion, CCTA is an effective method for measuring age-related differences in the burden of individual coronary plaque subtypes. Future research is needed to determine whether the increase in mixed and calcified plaques seen with aging produce an independent contribution to the age-related increase in cardiovascular risk.

A practical approach to the metabolic syndrome: review of current concepts and management.

PURPOSE OF REVIEW: Novel research over the past 2 years has necessitated an update of our 'ABCDE' approach to the metabolic syndrome. RECENT FINDINGS: Clinical trials investigating the role of aspirin in primary prevention have led to an adjustment in the indication for aspirin in metabolic syndrome patients at intermediate risk of a cardiovascular event. There has been renewed enthusiasm for the use of niacin as second-line treatment for atherogenic dyslipidemia, with fibrates reserved for those with severe residual dyslipidemia. In light of the noteworthy findings of the Justification for the Use of statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin trial, the 'C' category representing 'cholesterol' has been expanded to include the use of high-sensitivity C-reactive protein for guiding statin use and perhaps monitoring statin therapy. Recent evidence confirms that diet and exercise continue to be the cornerstone of any metabolic syndrome treatment strategy. SUMMARY: The revised 'ABCDE' approach incorporates the most recent influential studies into a simple yet thorough algorithm for management of the metabolic syndrome.

Microbial quality of "doubles" sold in Trinidad

A cross-sectional study was conducted to determine the prevalence and characteristics of Escherichia coli, Staphylococcus aureus, Bacillus spp. and Salmonella spp. in "bara", "channa", condiments/spices and ready-to-eat "doubles" sold by vendors in the St. George and Caroni counties of Trinidad. Of 196 samples of each of "bara", "channa", condiments/spices and ready-to-eat "doubles" examined, E. coli was detected in 0 (0.0 per cent), 14 (7.1 per cent), 96 (49.0 per cent) and 67 (34.2 per cent), respectively; Staphylococci were isolated from 104 (53.1 per cent), 71 (36.2 per cent), 129 (65.8 per cent) and 123 (62.8 per cent) samples, respectively; and Bacillus spp. were recovered from 22 (11.2 per cent), 85 (43.4 per cent), 100 (51.0 per cent) and 88 (44.9 per cent) samples, respectively. Salmonella spp. were not isolated from any sample. Of the 177 isolates of E. coli recovered from all sources, 9 (5.1 per cent), 7 (4.0 per cent) and 47 (26.6 per cent) were mucoid, haemolytic and non-sorbitol fermenters (NSF), respectively, but none agglutinated with O157 antiserum. Of 427 staphylococcal isolates, 130 (30.4 per cent) were confirmed as S. aureus of which 20 (15.4 per cent) were haemolytic and 84 (64.6 per cent) pigmented, while 17 (20.7 per cent) of 82 strains of S. aureus tested produced enterotoxins. Ready-to-eat "doubles", a popular food in Trinidad, therefore pose a potential health risk to consumers due to the high level of contamination with bacteria.