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School of Medicine
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Erin Michos, MD, MHS
Ciccarone Center Research
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- Meet the Authors
Prognostic value of cardiac troponins in chronic kidney disease patients without a suspected acute coronary syndrome: a systematic review.In chronic kidney disease patients without suspected acute coronary syndromes, troponin elevations were associated with worse prognosis.Published in: Annals of Internal MedicineRead on Pubmed
To facilitate the guideline-based implementation of treatment recommendations in the ambulatory setting and to encourage participation in the multiple preventive health efforts that exist, we have organized several recent guideline updates into a simple ABCDEF approach. We would remind clinicians that evidence-based medicine is meant to inform recommendations but that synthesis of patient-specific data and use of appropriate clinical judgment in each individual situation is ultimately preferred.Published in: Journal of the American Heart AssociationRead on Pubmed
Headed in the right direction but at risk for miscalculation: a critical appraisal of the 2013 ACC/AHA risk assessment guideline.The newly released 2013 ACC/AHA Guideline for Assessing Cardiovascular Risk was a major advance over prior guidelines, but the new risk equations do not appear to lead to significantly better discrimination than older models. Since the same risk factors are incorporated, using the new risk estimators may lead to inaccurate assessment of atherosclerotic cardiovascular risk in certain groups of patients. There also is likely an overestimation of risk when applied to modern populations. Future guidelines could provide clearer direction on which individuals would benefit from additional testing for more personalized preventive therapies.Published in: Journal of the American College of CardiologyRead on Pubmed
Niacin and statin combination therapy for atherosclerosis regression and prevention of cardiovascular disease events: Reconciling the AIM-HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global HealDespite substantial risk reductions targeting low-density lipoprotein cholesterol with statins, there remains significant residual risk as evidenced by incident and recurrent CVD events among statin-treated patients. Observational studies have shown that low levels of high-density lipoprotein cholesterol (HDL-C) are associated with increased CVD risk. It remains unclear whether strategies aimed at increasing HDL-C in addition to background statin therapy will further reduce risk.Published in: Journal of the American College of CardiologyRead on Pubmed
The premature termination of the ARBITER 6–HALTS trial, the small number of patients studied, and the limited duration of follow-up preclude us from conclusively declaring niacin the adjunctive agent of choice on the basis of the evidence. A decrease of 0.014 mm in the carotid intima–media thickness (IMT) over 14 months does not necessarily merit changes in our lipid-lowering guidelines at this time. However, for now, we would support the use of niacin as the preferred adjunctive agent to be used in combination with the maximal dose of a potent statin in persons who have low levels of HDL cholesterol and established cardiovascular disease. In summary, the ARBITER 6–HALTS results are provocative and are an important contribution to preventive cardiology research. However, the secondary choices for optimizing cholesterol-lowering therapy, constituting part of the “C” component of the “ABCDEs” of secondary prevention of cardiovascular disease, should not overshadow the importance of the rest of the ABCDEs: assessment of risk, antiplatelet therapy, blood-pressure management, cholesterol modification and cigarette-smoking cessation, dietary and weight modification, and exercise habits.Published in: New England Journal of MedicineRead on Pubmed
Clinical utility of rosuvastatin and other statins for cardiovascular risk reduction among the elderly.
Age is one of the strongest predictors of CVD risk. Treatment with statins can significantly reduce CVD events and mortality in both primary and secondary prevention. Yet despite the high CVD risk among the elderly, there is underutilization of statins in this population (ie, the treatment-risk paradox). Few studies have investigated the use of statins in the elderly, particularly for primary prevention and, as a result, guidelines for treating the elderly are limited. JUPITER is the largest primary prevention statin trial and enrolled a substantial number of elderly adults. Among the 5,695 JUPITER participants greater than or equal to 70 years of age, the absolute CVD risk reduction associated with rosuvastatin was actually greater than for younger participants. The implications of this JUPITER subanalysis and the broader role of statins among older adults is the subject of this review.
Clinical utility of statins for cardiovascular risk reduction in the among the elderly.
Age is one of the strongest predictors of cardiovascular disease (CVD) risk. Treatment with statins can significantly reduce CVD events and mortality in both primary and secondary prevention. Yet despite the high CVD risk among the elderly, there is underutilization of statins in this population (ie, the treatment-risk paradox). Few studies have investigated the use of statins in the elderly, particularly for primary prevention and, as a result, guidelines for treating the elderly are limited. This is likely due to: uncertainties of risk assessment in older individuals where the predictive value of individual risk factors is decreased; the need to balance the benefits of primary prevention with the risks of polypharmacy, health care costs, and adverse medication effects in a population with decreased life expectancy; the complexity of treating patients with many other comorbidities; and increasingly difficult social and economic concerns. As life expectancy increases and the total elderly population grows, these issues become increasingly important. JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) is the largest primary prevention statin trial to date and enrolled a substantial number of elderly adults. Among the 5695 JUPITER participants greater than or equal to 70 years of age, the absolute CVD risk reduction associated with rosuvastatin was actually greater than for younger participants. The implications of this JUPITER subanalysis and the broader role of statins among older adults is the subject of this review.
Relation of aortic valve calcium detected by cardiac computed tomography to all-cause mortality.
Aortic valve calcium (AVC) can be quantified on the same computed tomographic scan as CAC. Although CAC is an established predictor of cardiovascular events, limited evidence is available for an independent predictive value for AVC. We studied a cohort of 8,401 asymptomatic subjects (mean age 53 ± 10 years, 69% men), who were free of known coronary heart disease and were undergoing computed tomography for assessment of subclinical atherosclerosis. The patients were followed for a median of 5 years (range 1 to 7) for the occurrence of mortality from any cause. In conclusion, AVC was associated with increased all-cause mortality, independent of the traditional risk factors and the presence of CAC.
Should statin therapy be allocated on the basis of randomized trial evidence?
We questioned the utility of global risk assessment strategies based on the Framingham risk score for guiding statin therapy in light of current data that have become available from more recent and robust prospective randomized clinical trials since the publication of the National Cholesterol Education Program Adult Treatment Panel III guidelines. Moreover, the Adult Treatment Panel III guidelines do not support treatment of some patients who may benefit from statin therapy. In conclusion, we propose an alternative approach for incorporating more recent randomized trial data into future statin allocation algorithms and treatment guidelines.
Vitamin D in atherosclerosis, vascular disease, and endothelial function
Large-scale, well-conducted, placebo-controlled clinical trials testing the efficacy of vitamin D supplementation in delaying, slowing, or reversing the atherosclerotic disease process have not yet been conducted. Until the results of these studies are available, we believe it is premature to recommend vitamin D as a therapeutic option in atherosclerosis.
Rosuvastatin is similarly effective for primary prevention of cardiovascular disease in women as in men
Statins for the primary prevention of cardiovascular events in women with elevated high-sensitivity C-reactive protein or dyslipidemia: results from the Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) and meta-analysis of women from primary prevention trials.
Comparison of the Framingham Heart Study hypertension model with blood pressure alone in the prediction of risk of hypertension: the Multi-Ethnic Study of Atherosclerosis.
In this multi-ethnic cohort of U.S. adults, the Framingham Heart Study model was not substantially better than systolic blood pressure (SBP) alone for predicting hypertension.
Sex steroid hormone concentrations and risk of death in U.S. men.
Men with low free and bioavailable testosterone levels may have a higher risk of mortality within 9 years of hormone measurement. Future studies should be conducted to fully characterize the association of low free and bioavailable testosterone concentrations and mortality in men and to describe the mechanism underlying the association.
The JUPITER and AURORA clinical trials for rosuvastatin in special primary prevention populations: perspectives, outcomes, and consequences.
This review outlines the JUPITER and AURORA trials — which examined the effect of statins in two specific patient populations who currently do not meet the guidelines for statin treatment but are nonetheless at high cardiovascular risk — interprets the data and significance of the results, analyzes the drawbacks and impact of both trials, and delineates the potential for further clinical trials.
25-hydroxyvitamin D levels, race, and the progression of kidney disease.
Low 25-hydroxyvitamin D, or 25(OH)D, levels are associated with development of end stage renal disease (ESRD), even after adjustment for multiple risk factors. Low 25(OH)D levels may account for a substantial proportion of the increased risk for ESRD experienced by black individuals.