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Ciccarone Articles

Ciccarone Center Research

Year

2009

Landmark Article

  • 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.
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The HALTS trial — halting atherosclerosis or halted too early?
By: Blumenthal RS, Michos ED.
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.
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Update on peripheral arterial disease and claudication rehabilitation.
By: Salameh MJ, Ratchford EV
Peripheral arterial disease is often under diagnosed and under treated due to a general lack of awareness on the part of the patient and the practitioner. The evidence-base is growing for the optimal medical management of the patient with peripheral arterial disease; in parallel, endovascular revascularization options continue to improve. Comprehensive care of the peripheral arterial disease patient focuses on the ultimate goals of improving quality of life and reducing cardiovascular morbidity and mortality.
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Lipoprotein(a) measurement and determining risk of myocardial infarction.
By: Jones SR, Blumenthal RS.
There are few outcome data to support treatment decisions in patients with increased levels of lipoprotein(a). The only conventional drug therapy shown to reduce lipoprotein(a) levels is nicotinic acid, but risk reduction may not follow changes in lipoprotein(a) serum levels. Statins have little or no effect on lipoprotein(a) levels, but their use has been based on clinical and quantitative coronary angiography data showing loss of incremental risk attributable to lipoprotein(a) at low levels of LDL-C. Trials evaluating risk assessment strategies incorporating lipoprotein(a) and treatment strategies aimed at lowering levels of apolipoprotein B and lipoprotein(a) levels in primary and secondary prevention are needed to form the basis for incorporation of lipoprotein(a) into prevention guidelines.
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Association of traditional cardiovascular risk factors with coronary plaque sub-types assessed by 64-slice computed tomography angiography in a large cohort of asymptomatic subjects.
By: Rivera JJ, Nasir K, Cox PR, Choi E, Yoon Y, Cho I, Chun EJ, Choi SI, Blumenthal RS, Chang HJ.
Age and gender are overall the strongest predictors of atherosclerosis as assessed by CCTA in this large asymptomatic Korean population and these two risk factors are not particularly associated with a specific coronary plaque sub-type. Smoking is a strong predictor of NCAP, which has been suggested by previous reports as a more vulnerable lesion. Whether a specific plaque sub-type is associated with a worse prognosis is yet to be determined by future prospective studies.
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Assessment of subclinical coronary atherosclerosis in asymptomatic patients with type 2 diabetes mellitus with single photon emission computed tomography and coronary computed tomography angiography.
By: Choi EK, Chun EJ, Choi SI, Chang SA, Choi SH, Lim S, Rivera JJ, Nasir K, Blumenthal RS, Jang HC, Chang HJ.
We evaluated the characteristics of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus (DM) using single photon emission computed tomography (SPECT) and coronary computed tomographic angiography (CCTA). In conclusion, a significant percentage of patients with DM and normal eletrocardiographic findings, no peripheral arterial disease, and normal findings on SPECT have evidence of occult CAD on CCTA. Furthermore, a small percentage had had a cardiac event by mid-term follow-up.
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Favorable cardiovascular risk factor profile is associated with reduced prevalence of coronary artery calcification and inflammation in asymptomatic nondiabetic white men.
By: Michos ED, Santos RD, Narla V, Pandey S, Meneghelo R, Carvalho JA, Budoff MJ, Blumenthal RS, Nasir K.
In age-adjusted analysis, each lower cardiovascular risk factor (CVRF) profile was associated with lower odds of prevalent coronary artery calcium and elevated white blood cell count. Our study supports the notion that a favorable cardiovascular disease (CVD) profile is associated with less underlying atherosclerosis and inflammation and further highlights the importance of primary prevention of CVRFs.
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ACCF/AHA/ACP 2009 competence and training statement: a curriculum on prevention of cardiovascular disease: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Competence and...
By: Bairey Merz CN, Alberts MJ, Balady GJ, Ballantyne CM, Berra K, Black HR, Blumenthal RS, Davidson MH, Fazio SB, Ferdinand KC, Fine LJ, Fonseca V, Franklin BA, McBride PE, Mensah GA, Merli GJ, O’Gara PT, Thompson PD, Underberg JA.

The prevention of cardiovascular morbidity and mortality is a shared responsibility among all health professionals involved in the care of people at risk of developing CVD. This document is directed at those individuals seeking expertise at a leadership level in this field, and includes opportunities for formal training and alternative routes to competence and maintenance of competence in prevention of CVD and educational resources for acquisition and maintenance of competence in the prevention of CVD. To address the expanding fund of knowledge in the area and to ensure that an adequately trained force of preventive cardiovascular leaders will be available to primary care providers, as well as to provide a pool of providers with expertise in running rehabilitation and other programs designed to address the ongoing issue of adherence, the formulation of clinical competency criteria for the cardiovascular preventive specialist is needed. Cardiovascular preventive specialists will have varying areas of expertise and will not necessarily achieve all of the outlined areas of competencies. These clinical competency criteria in the area of specialty treatment and prevention of CVD are needed, given the current setting of a rapidly growing field of knowledge, ranging from molecular and cellular mechanisms to clinical outcomes, in order to translate this into improved patient care.

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Engraftment, differentiation, and functional benefits of autologous cardiosphere-derived cells in porcine ischemic cardiomyopathy.
By: Johnston PV, Sasano T, Mills K, Evers R, Lee ST, Smith RR, Lardo AC, Lai S, Steenbergen C, Gerstenblith G, Lange R, Marbán E.

Cardiosphere-derived cells (CDCs) isolated from human endomyocardial biopsies reduce infarct size and improve cardiac function in mice. Safety and efficacy testing in large animals is necessary for clinical translation. Intracoronary delivery of CDCs in a preclinical model of postinfarct left ventricular dysfunction results in formation of new cardiac tissue, reduces relative infarct size, attenuates adverse remodeling, and improves hemodynamics. The evidence of efficacy without obvious safety concerns at 8 weeks of follow-up motivates human studies in patients after myocardial infarction and in chronic ischemic cardiomyopathy.

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Carotid bruit for detection of hemodynamically significant carotid stenosis: the Northern Manhattan Study.
By: Ratchford EV, Jin Z, Di Tullio MR, Salameh MJ, Homma S, Gan R, Boden-Albala B, Sacco RL, Rundek T.
In this ethnically diverse cohort, the prevalence of carotid bruits and hemodynamically significant carotid stenosis was low. Sensitivity and positive predictive value were also low, and the 44% false-negative rate suggests that auscultation is not sufficient to exclude carotid stenosis. While the presence of a bruit may still warrant further evaluation with carotid duplex, ultrasonography may be considered in high-risk asymptomatic patients, irrespective of findings on auscultation.
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Exposure to low-dose ionizing radiation from medical imaging procedures.
By: Fazel R, Krumholz HM, Wang Y, Ross JS, Ting HH, Shah ND, Nasir K, Einstein AJ, Nallamothu BK.

Imaging procedures are an important source of exposure to ionizing radiation in the United States and can result in high cumulative effective doses of radiation.

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