Growing importance of valvular heart disease in the elderly

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Ethnic differences in cardiovascular risk in rheumatic disease: Focus on Asians

Rheumatic diseases are associated with high cardiovascular morbidity and mortality. Considerable differences exist in the frequency of cardiovascular disease (CVD) risk factors and events among people of different ethnic origins, but little is known of the ethnic variations in the relative distribution of CVD risk factors and the degree of atherosclerosis in patients with rheumatic diseases. Understanding this variation will provide insight into the underlying pathogenesis of CVD in patients with rheumatic diseases, and aid in future studies of the detection and management of this complication. In general, although Asian patients seem to have fewer background CVD risk factors and are less affected by metabolic syndrome (MetS) than their non-Asian counterparts, those with rheumatic disease are equally as susceptible to CVD. Furthermore, it seems that systemic inflammation and mechanisms that do not involve conventional CVD risk factors and MetS have an important role in the development of atherosclerosis in patients with rheumatic diseases. Here we examine the frequency of conventional CVD risk factors and the prevalence of MetS in both Asian and non-Asian patients with selected rheumatic diseases. We also discuss the burden of CVD, as evaluated using various surrogate markers in these patients, and their overall CVD mortality rate. © 2011 Macmillan Publishers Limited. All rights reserved.postprin

PR prolongation strongly predicts new-onset myocardial infarction, ischaemic stroke, heart failure, and cardiovascular death in coronary patients or risk equivalent: a 5-year clinical-patholophysiological study

Oral PresentationOBJECTIVES: To investigate the role of PR prolongation in new-onset adverse cardiovascular (CV) events in high-risk CV patients, and the underlying pathophysiological mechanisms in terms of vascular phenotypes. METHODS: We prospectively followed up 597 high-risk CV out-patients (mean age 66±11 years; male 67%; coronary disease 55%, stroke 22%, diabetes 52%) for new-onset ischaemic stroke, myocardial infarction (MI), congestive heart failure (CHF), and CV death. Vascular phenotypes were asses…published_or_final_versio

Perioperative antithrombotic management in joint replacement surgeries

Objectives To determine optimal perioperative antithrombotic management for patients with cardiac diseases undergoing joint replacement surgeries. Data sources MEDLINE and PubMed database search up to January 2013. Study selection Those dealing with perioperative antithrombotic management of patients undergoing orthopaedic operations, especially joint replacement, and also those undergoing general surgery. Various combinations of the following key words were used in our search: 'antiplatelet', 'antithrombotic', 'anticoagulant', 'coronary stent', 'perioperative', 'venous thromboembolism', 'cardiovascular', 'surgery', 'orthopaedic', 'knee replacement', 'hip replacement', 'joint replacement', and 'arthroplasty'. Data extraction Literature review, original articles, and best practice guidelines. Data synthesis Patients should be stratified according to their risk of developing arterial thromboembolism in order to decide the most appropriate perioperative antiplatelet or anticoagulant regimen for them. After recent coronary stenting, including bare-metal stents implanted within 6 weeks and drug-eluting stents implanted within 6 months, surgery should be deferred. For venous thromboembolism prophylaxis in patients already on aspirin, the dosage should be adjusted as necessary or additional low-molecular-weight heparin administered. Conclusion The perioperative management of patients with cardiac diseases in receipt of antithrombotic agents is based upon a delicate balance between the perceived risk of arterial thromboembolism and the perceived risk of perioperative bleeding. One must exercise good judgement in deciding the most appropriate perioperative antithrombotic regimen. Venous thromboembolism is also a common problem after joint replacement surgeries. For patients already on aspirin, optimal venous thromboembolism prophylaxis is still being debated.published_or_final_versio

Prognostic implications of surrogate markers of atherosclerosis in low-to-intermediate risk patients with type 2 diabetes

Poster PresentationINTRODUCTION: Type 2 diabetes mellitus (T2DM) patients are at increased risk of developing cardiovascular events. Unfortunately traditional risk assessment scores, including the Framingham Risk Score (FRS), have only modest accuracy in cardiovascular risk prediction in these patients. METHODS: We sought to determine the prognostic values of different non-invasive markers of atherosclerosis, including brachial artery endothelial function, carotid artery atheroma burden, ankle-brachial index, arterial stiffness and computed tomography coronary artery calcium score (CACS) in 151 T2DM Chinese patients who were identified low-intermediate risk from the FRS recalib…published_or_final_versio

Impact of glycaemic control on circulating endothelial progenitor cells and arterial stiffness in patients with type 2 diabetes mellitus

Topics: Basic science, translational and clinical researchPoster PresentationThis journal supplement contains abstracts from the 17th MRC; Dept. of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong KongINTRODUCTION: Patients with type 2 diabetes mellitus (DM) have increased risk of endothelial dysfunction and arterial stiffness. Levels of circulating endothelial progenitor cells (EPCs) are also reduced in hyperglycaemic states. However, the relationships between glycaemic control, levels of EPCs and arterial stiffness are unknown. METHODS: We measured circulating EPCs and …published_or_final_versionThe 17th Medical Research Conference (MRC), Department of Medicine, University of Hong Kong, Hong Kong, 14 January 2012. In Hong Kong Medical Journal, 2012, v. 18 suppl. 1, p. 63, abstract no. 10

Development and Validation of the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) for Primary Care Patients with Type 2 Diabetes

Objectives: To develop and evaluate the psychometric properties of a Chinese questionnaire which assesses the barriers and enablers to commencing insulin in primary care patients with poorly controlled Type 2 diabetes. Research Design and Method: Questionnaire items were identified using literature review. Content validation was performed and items were further refined using an expert panel. Following translation, back translation and cognitive debriefing, the translated Chinese questionnaire was piloted on target patients. Exploratory factor analysis and item-scale correlations were performed to test the construct validity of the subscales and items. Internal reliability was tested by Cronbach's alpha. Results: Twenty-seven identified items underwent content validation, translation and cognitive debriefing. The translated questionnaire was piloted on 303 insulin naïve (never taken insulin) Type 2 diabetes patients recruited from 10 government-funded primary care clinics across Hong Kong. Sufficient variability in the dataset for factor analysis was confirmed by Bartlett's Test of Sphericity (P 0.4 and Eigenvalues >1. Total variance for the 10 factors was 66.22%. Kaiser-Meyer-Olkin measure was 0.725. Cronbach's alpha coefficients for the first four factors were ≥0.6 identifying four subscales to which 13 items correlated. Remaining sub-scales and items with poor internal reliability were deleted. The final 13-item instrument had a four scale structure addressing: 'Self-image and stigmatization'; 'Factors promoting self-efficacy; 'Fear of pain or needles'; and 'Time and family support'. Conclusion: The Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) appears to be a reliable and valid measure for assessing barriers to starting insulin. This short instrument is easy to administer and may be used by healthcare providers and researchers as an assessment tool for Chinese diabetic primary care patients, including the elderly, who are unwilling to start insulin. © 2013 Fu et al.published_or_final_versio

Worsened arterial stiffness in high-risk cardiovascular patients with high habitual carbohydrate intake: a cross-sectional vascular function study

BACKGROUND: Previous studies suggested that high dietary carbohydrate intake is associated with increased cardiovascular risk through raised triglyceride and decreased high-density lipoprotein-cholesterol levels. However, the relation between carbohydrate intake and arterial stiffness has not been established. The purpose of this study was to examine this relation among high-risk cardiovascular patients. METHODS: We studied the relation between dietary macronutrient intake and arterial stiffness in 364 patients with documented cardiovascular diseases or risk equivalent (coronary artery diseases 62%, ischemic stroke 13%, diabetes mellitus 55%) and in 93 age-and-sex matched control subjects. Dietary macronutrient intake was assessed using a validated food-frequency questionnaire (FFQ) for Chinese. Heart-ankle pulse wave velocity (PWV) was measured non-invasively with a Vascular Profiling System (VP2000, Colin Corp. USA). A dietary pattern with >/=60% total energy intake derived from carbohydrates was defined as a high-carbohydrate diet according to the Dietary Reference Intakes (DRI) for Chinese. RESULTS: Subjects who consumed a high-carbohydrate diet had significantly higher mean PWV than those who did not consume a high-carbohydrate diet (P = 0.039). After adjustment for potential confounders, high-carbohydrate diet was associated with significantly increased PWV [B = 73.50 (10.81 to 136.19), P = 0.022]. However, there was no significant association between high-carbohydrate diet and PWV in controls (P = 0.634). CONCLUSIONS: High-carbohydrate diet is associated with increased arterial stiffness in patients with established cardiovascular disease or risk equivalent.published_or_final_versio

Incremental predictive value of vascular assessments combined with the Framingham Risk Score for prediction of coronary events in subjects of low-intermediate risk

Background: In patients with low-intermediate risk, the use of the Framingham Risk Score (FRS) may not allow accurate prediction of the occurrence of coronary events. Objective: To determine whether non-invasive vascular sonographic assessments add value to the FRS for prediction of coronary events. Methods: Brachial artery flow-mediated dilatation (FMD), carotid intima-media thickness (IMT) and the presence of carotid plaque in 70 male subjects (mean (SD) age 62 (9) years) with a low-intermediate FRS who presented with a recent coronary event were evaluated and compared with those in 35 male controls matched for age (mean age 60 (9) years). Results: Patients with a recent coronary event had a significantly higher FRS than controls. They had a significantly lower FMD (3.56 (2.41)% vs 5.18 (2.69)%, p = 0.003) and significantly higher prevalence of carotid plaque (67% vs 40%, p = 0.008), but there was no significant difference in mean maximum IMT between the two groups (1.01 (0.28) vs 0.96 (0.14) mm, p = 0.32). Multivariate analysis revealed that FMD ≤ 4.75% was an independent predictor of an acute coronary event. Of the three vascular markers, FMD ≤ 4.75% and presence of carotid plaque provided the best diagnostic accuracy for a coronary event, with area under the curve (AUC) of 0.70 and 0.64 (p = 0.001 and p = 0.033), respectively, based on receiver operating characteristic curve analysis. Furthermore, incorporating carotid plaque or FMD ≤ 4.75% into the FRS (AUC = 0.72 and AUC = 0.78) provided incremental benefit in risk stratification over FRS alone (AUC = 0.66) (p = 0.008 and p = 0.007, for comparison of difference in two receiver operating characteristic curves). Conclusions: Incorporating a measure of FMD or carotid plaque burden with FRS significantly increases the accuracy of predicting coronary events in subjects of low-intermediate risk and hence should be considered as additional investigations to improve coronary risk assessment.published_or_final_versio

Atherosclerosis in patients with rheumatoid arthritis

Both Rheumatoid Arthritis (RA) and atherosclerosis are complex polygenic diseases. Previous studies have demonstrated that patients with RA are associated with up to 60% increased risk of cardiovascular disease related death. Nonetheless, the increased cardiovascular morbidity and mortality in patients with RA cannot be entirely explained by traditional risk factors, and likely to be multifactorial. The present article reviews the data supporting the association of RA with cardiovascular risk factors, possible mechanism for developing atherosclerosis and evaluates the potential strategies that may prevent premature atherosclerosis in these patients.published_or_final_versio