The influence of assessment and modification of cardiovascular risk on atherosclerosis progression and relation to the markers of arterial wall damage

This paper reviews the 1997−2008 experience gained by the Preventive Cardiology unit since its establishment in the department of Cardiovascular diseases of Vilnius University. We summarize the results of managing 1624 patients with coronary heart disease, 977 subjects with different cardiovascular risk (metabolic syndrome, diabetes, dyslipidaemia, arterial hypertension, healthy controls), evaluated 236 subjects from 67 families in the genetic project. A survey on the lifestyle, risk factors and use of cardioprotective drug therapies in patients with coronary heart disease from 22 European countries has showed major patient management differencies between Lithuania and other countries. The large proportion of patients in Lithuania do not achieve the targets for cardiovascular disease prevention, especially in lipid management. There is still considerable potential in Lithuania to raise standarts of cardiovascular prevention. We analyzed the prevalence of conventional risk factors among our patients with coronary heart disease and showed that they are more common than described in the literature. Our data revealed that 98% of coronary patients had at least one of four conventional risk factors. Two-thirds (66,5%) of younger patients (<55 years) with coronary heart disease had two and more risk factors. We have found statistically significant correlation between atherosclerosis progression rate in the coronary arteries and risk factors: elevated blood pressure, blood glucose, homocystein, lipoprotein (a), low density lipoprotein cholesterol. Central obesity and any type of glycaemic disorder seem to be core components of the metabolic syndrome. Waist cimcumference are significantly correlated with the insuline resistance indexes in our patients. Other findings indicate that the immunological and inflammatory factors (adhesion molecules, cytokines, etc.) are significantly higher in acute coronary group compared with the normal levels in healthy subjects, so those factors could be markers of atherosclerosis and the severity of coronary heart disease. We have analyzed efficacy and safety of different antiatherosclerotic and cardioprotective drugs. Our findings demonstrate that calcium channel blocker improves flow-mediated dilatation in the brachial artery in patients with coronary vasospasm. This improvement was accompanied by the improvement of angina characteristics. There were no allelic variants associated with the susceptibility to atherosclerosis identified in our first genetic study. Further studies are warranted including more families. The first experience with arterial dysfunctional and wall structural markers have shown that carotid intimal-medial thickness, presence of plaques, flow mediated dilatation of brachial artery, aortic stiffness parameters are related to traditional cardiovascular risk factors and can help to predict cardiovascular risk

Evaluation of arterial hypertension control and treatment in daily practice of family physicians

The objective of this study was to evaluate the percentage of patients with primary arterial hypertension treated with antihypertensive drug(s), who achieved target arterial blood pressure (ABP), and to compare the characteristics of patients with controlled and uncontrolled ABP, their current treatment, and treatment modifications. Material and methods. A total of 429 18–80-year-old patients with primary arterial hypertension treated for ≥1 year participated in this study. General practitioners collected data on patients’ demographic and clinical characteristics, current treatment for primary arterial hypertension, and treatment modifications. Results. According to physicians, 45.4% of patients achieved target ABP levels. Adequately controlled ABP was documented more often in the group of low and moderate cardiovascular risk than in high- and very high-risk group (n=141, 62.9% versus n=54, 26.3%; P&lt;0.0001). Based on ABP measurements, 160 (37.3%) patients had ABP of &lt;140/90 mm Hg. The majority of patients were treated with a combination of two (n=153, 35.7%) to three (n=144, 33.6%) antihypertensive drugs. Patients with uncontrolled ABP more frequently than patients with controlled ABP were given combination therapy. Treatment was not modified in 37.8% (n=162) of patients, more commonly in those with controlled ABP. Conclusions. The level of hypertension control in study population was far from optimal, especially in the group of patients at high- and very high-risk where target ABP was lower. Almost 12% of patients with uncontrolled ABP were still undergoing monotherapy, whereas 16% of patients were not recommended any modifications of antihypertensive treatment despite their ABP was not controlled

Association Between Erectile Dysfunction and Asymptomatic Cardiovascular Damage in Middle-Aged Men

Background and Objective. It has been proposed that the same cardiovascular risk (CV) factors predispose middle-aged men to the development of both coronary artery disease and erectile dysfunction (ED). Moreover, several recently published studies have identified ED as a possible early marker of CV disease. The aim of this particular study was to evaluate the association between ED and early asymptomatic heart and vascular damage in middle-aged men with CV risk factors. Material and Methods. In this case-control study, the International Index of Erectile Function (IIEF) questionnaire was employed to assess the erectile function of the study participants and to allocate them either into the ED group (N=21; mean IIEF score, 18.15 [SD, 2.54]; mean age, 48.2 years [SD, 4.4]) or the control group (N=24; mean IIEF score, 23.45 [SD, 0.99]; mean age, 46.8 years [SD, 3.1]). Additionally, pulse wave velocity, augmentation index, pulse pressure, carotid intima media thickness (IMT), and atherosclerotic plaque count were determined, and echocardiography was performed in every subject. Results. The mean IMT and left ventricular mass index (LVMI) of both carotid arteries in the ED group were significantly higher when compared with controls (598.57 vs. 535.54 mm·10–3, P=0.03, and 107.26 vs. 98.67 g/m2, P=0.04, respectively). Using multiple regression analysis, an independent association between the IIEF score and the LVMI was found (P=0.002). No significant differences in the results of pulse wave velocity, atherosclerotic plaque count, and other laboratory tests were found between the 2 study groups. Conclusions. The study suggests that ED is associated with a higher LVMI and may be an early marker of CV disease

Selective apheresis of low-density lipoproteins in a child

The case of rear complicated homozygous hypercholesterolemia treated by a direct adsorption of lipoprotein apheresis procedure is presented in this article. In total, 30 sessions of direct adsorption of lipoprotein apheresis were performed on a 14–16-year-old patient from June 2004 to December 2006. Blood flow rate was 30–70 mL/min. Central and ulnar veins were punctured. Lipid levels were measured before and after lipid apheresis during each session throughout the study period. The mean decrease in total cholesterol level was 26.4–71.2% compared to baseline, low-density lipoprotein cholesterol – 31.9–72.2%, lipoprotein (a) – 56.6–90.9%, apolipoprotein B – 26.4–60.0%. Clinical procedures were completely uneventful. The last 26 sessions were performed in a day unit

Retrospective analysis of complications and survival in patients with acute inferior myocardial infarction accompanied by right ventricular myocardial infarction

Right ventricular myocardial infarction (RVMI) accompanies about 30–50% of inferior wall myocardial infarction. RVMI is associated with higher rates of cardiogenic shock, atrioventricular block, atrial fibrillation, increased mortality rates. The topic requires a scientific update, as only a few studies have been made on RVMI during the past decade. We aimed to analyse the impact of RVMI on inferior myocardial infarction. Design and methods: Retrospective study included 310 patients with documented inferior myocardial infarction (with and without RVMI) between January 2013 and January 2014. Data on baseline characteristics, mortality, in-hospital complications: cardiogenic shock and rhythm and conduction disorders was collected. Results: In 102 (32.9%) patients with inferiormyocardial infarction, RVMI was present and 208 (67.1%) cases were without RVMI involvement. RVMI patients had higher rate of rhythm and conduction disturbances than patients without RVMI involvement: atrioventricular block (OR 3.8, 95% CI 2.0–7.1, p < 0.001), atrial fibrillation (OR 1.6, 95% CI 0.9–2.9, p = 0.001), also higher incidence of cardiogenic shock (OR 2.6, 95% CI 1.7–3.9, p < 0.001). Mortality rates after 24 months were higher in RVMI group (OR 1.8, 95% CI 1.2–3.8, p = 0.034). No significant difference was found on in-hospital mortality. Conclusions: Right ventricular involvement complicates the long-term mortality and outcomes after inferior myocardial infarction. It is related to a higher incidence of in-hospital complications, especially I–III degree AV block and atrial fibrillation. However, influence on long-term mortality needs further investigation

Prevalence of conventional risk factors in patients with coronary heart disease

Extensive clinical and statistical studies have identified risk factors that increase the incidence of coronary heart disease. It is commonly suggested that more than 50% of patients with coronary heart disease lack any of the conventional risk factors. Objective. To determine the prevalence of four conventional risk factors among patients with coronary heart disease. Material and methods. We analyzed data of 606 patients with coronary heart disease (myocardial infarction, unstable and stable angina pectoris) hospitalized in the Clinics of Santariškės, Vilnius University Hospital, in 1997–2005. Results. Among patients with coronary heart disease, at least one of four conventional risk factors was present in 98% of patients. Hypertension was present in 47.7% of patients, diabetes – in 12.9%, dyslipidemia – 90.1%, and smoking – in 24.1% of patients. In younger patients (&lt;55 years), only 2.3% of patients lacked any of four conventional risk factors. Two-thirds (66.5%) of younger patients with coronary heart disease had two and more risk factors. Conclusions. Considering the fact that patients with coronary heart disease often lack conventional risk factors, currently more attention is given to nontraditional risk factors as well as genetic causes of coronary heart disease. Nevertheless, the present study revealed that 98% of patients with coronary heart disease had at least one of four conventional risk factors. Among younger patients (younger than 55 years), conventional risk factors are identified very frequently. Thus, it can be concluded that in order to reduce the epidemic of coronary heart disease, much greater emphasis should be given to identify and to improve prevention of four conventional risk factors as well as the lifestyle of the patient

Autosomal recessive hypercholesterolemia: Case report.

INTRODUCTION: Autosomal recessive hypercholesterolemia (ARH; OMIM #603813) is a very rare monogenic disorder affecting less than 1 in 1000,000 people and is characterized by very high levels of low-density lipoprotein cholesterol (LDL-C), leading to aggressive and premature atherosclerotic cardiovascular disease if left untreated. Lowering of LDL-C is the main target of the treatment. We report on a 29-year-old male patient born in nonconsanguineous Lithuanian family homo(hemi-)zygous for LDLRAP1 gene variant causing ARH. This variant is not present in population databases and, to our knowledge, has not been reported in scientific literature before. METHODS AND RESULTS: The earliest clinical sign, noticed at the age of 5 years, was painful and enlarging nodules on Achilles tendons. At the age of 10 years, xanthomas of the metacarpal joint area on both hands emerged. The first lipid panel was performed at the age of 12 years. In accordance with Dutch Lipid Clinic Network diagnostic criteria for familial hypercholesterolemia (FH), definite FH (type IIA hyperlipoproteinemia) was diagnosed and the treatment with cholestyramine 4 grams per day was initiated. As the patient was 15 years old, direct adsorption of low-density lipoprotein apheresis was started and repeated monthly. At the age of 20 years, along with lipoprotein apheresis, 10 mg of rosuvastatin daily intake was prescribed. At the age of 28 years, the dose of rosuvastatin was increased to 40 mg per day, and 10 mg of ezetimibe daily intake was added. At the age of 28 years, homozygous LDLRAP1 gene variant NM_015627.2:c.488A.C, NP_056442.2:p.(Gln163Pro) causing autosomal recessive hypercholesterolemia was determined by genetic testing. CONCLUSIONS: This case report implies that ARH, being an extremely rare disorder, is a severe disease. As there is limited routine testing, including genetic testing, patients suffering from both this disease and FH may remain undiagnosed. Cascade screening and genetic counseling differ for ARH as compared with FH, as the carrier of a pathogenic variant in the LDLRAP1 gene does not have marked total cholesterol and LDL-C elevations. However, genetic testing of the proband and their relatives is essential to evaluate the risk of development of FH and to provide prognosis as well as adequate, timely treatment. To improve the quality of life of patients with FH and prolong their life expectancy, national registries of FH and wider laboratory and genetic testing are undoubtedly necessary. A national FH screening program was set up in Lithuania, which helps to identify, monitor, and treat subjects with FH

Relationship of arterial wall parameters to cardiovascular risk factors and cardiovascular risk assessed by SCORE system

Tuberculosis is one of the biggest global health problems. One-third of the world’s population (2 billion) is latently infected with tuberculosis. The tuberculin skin test is commonly used to diagnose tuberculosis infection. This test has poor specificity and sensitivity, cross-reactivity with bacille Calmette-Guérin vaccination and many environmental mycobacteria, and poor sensitivity (only 75–90% in active tuberculosis). Mycobacterium tuberculosis activates a strong T cell-mediated immune response. That is why, a better marker for tuberculosis infection could be the presence of mycobacteria specific interferon-γ-secreting T cells. These cells can be identified in blood or any other sample, which contains T cells. The test specificity is 99.9% (in low-risk control groups), and the sensitivity is 97.2% (in subjects with culture-confirmed active disease). New in vitro diagnostic test of tuberculosis, based on tuberculosis-induced immunological mechanisms, seems to be more specific and useful as previous methods

High-Sensitivity Cardiac Troponin Impact on the Differential Diagnosis of Non-ST Segment Elevation Coronary Syndromes&mdash;Is It Helping?

Background and Objectives: Increased levels of high-sensitivity cardiac troponin (hs-cTn) are the main criteria that differentiate non-ST segment elevation myocardial infarction (NSTEMI) from unstable angina (UA). How are these implemented in clinical practices? This study aims to detect cases of misdiagnosed UA instead of NSTEMI. Materials and Methods: We analysed discharge summaries of 840 patients admitted to Vilnius University Hospital Santaros Klinikos with the diagnosis of UA in 2017&ndash;2018. We retrospectively checked symptoms, levels of hs-cTn, coronary angiography and electrocardiogram changes with an aim to differentiate UA and type 1 NSTEMI, according to the Fourth Universal Definition of Myocardial Infarction. We excluded patients with missing hs-cTn levels or coronary angiography. Results: We found that 46.71% (n = 334) of patients met the diagnostic criteria of UA according to the Fourth Universal Definition, whereas 19.16% of patients (n = 137) could have been diagnosed with type 1 NSTEMI instead of UA. In the group of patients who could be reclassified to type 1 NSTEMI, the median level of hs-cTn was 184.32 [226.15] ng/L on admission. The median of the lowest level during the hospitalization was 114.0 [207.4] ng/L. Median highest&mdash;304.0 [257.6] ng/L. Myocardial infarction with non-obstructive coronary arteries could have been diagnosed in 3.36% (n = 24) of patients. Conclusions: Only less than half of patients met the diagnostic UA criteria. Almost one-fifth of patients with a diagnosis of UA could be reclassified to type 1 NSTEMI

Prevalence of Cardiovascular Risk Factors in Middle-Aged Lithuanian Men Based on Body Mass Index and Waist Circumference Group Results from the 2006&ndash;2016 Lithuanian High Cardiovascular Risk Prevention Program

Background and aims: This study aimed to estimate the prevalence of cardiovascular risk factors in middle-aged Lithuanian men categorized according to body mass index and waist circumference results. Methods and results: The data were from the Lithuanian High Cardiovascular Risk primary prevention program between 2009 and 2016. This community-based cross-sectional study comprised 38,412 men aged 40 to 54 years old. We compared the prevalence of arterial hypertension, dyslipidaemia, diabetes mellitus, smoking, and metabolic syndrome in body mass index (BMI) and waist circumference (WC) groups. Regarding the allometric anthropometrics for WC, A Body Shape Indices (ABSIs) were analyzed with respect to mortality risk and smoking status. The most prevalent risk factor in men was dyslipidaemia, followed by arterial hypertension and smoking (86.96%, 47.94%, and 40.52%, respectively). All risk factors except for smoking were more prevalent in men with overweight or obesity as measured by BMI compared to men with normal weight. Similarly, smoking was the only cardiovascular risk factor that was more prevalent among subjects with normal WC compared to those with increased WC or abdominal obesity. Elevated ABSI, which is associated with higher mortality risk, was more prevalent in smokers. Conclusion: The most prevalent cardiovascular risk factor among middle-aged Lithuanian men was dyslipidaemia, with a surprisingly high prevalence in all BMI and WC groups. Smoking was the only risk factor most prevalent in subjects with low or normal weight according to BMI. It was also more prevalent in the normal WC group compared to the increased WC or abdominal obesity groups, but ABSI values associated with higher mortality were more prevalent among smokers than non-smokers