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Journal of the American College of Cardiology
- Read on Pubmed
Headed in the right direction but at risk for miscalculation: a critical appraisal of the 2013 ACC/AHA risk assessment guideline.Read on Pubmed
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.
Baseline subclinical atherosclerosis burden and distribution are associated with frequency and mode of future coronary revascularization: multi-ethnic study of atherosclerosis.Read on Pubmed
There was a strong association between the baseline burden and regional distribution of CAC and the risk and type of future coronary revascularization among asymptomatic subjects.
High-sensitivity C-reactive protein and cardiovascular disease: A resolute belief or an elusive link?Read on Pubmed
Although high-sensitivity C-reactive protein (hsCRP) is involved in the immunologic process that triggers vascular remodeling and plaque deposition and is associated with increased cardiovascular disease (CVD) risk, definitive randomized evidence for its role as a causative factor in atherothrombosis is lacking. This article reviews four distinct points from the literature to better understand the current state and application of hsCRP in clinical practice, and we highlight recommendations from societies and important considerations when using hsCRP to guide treatment decisions in the primary prevention setting.
Mortality rates in smokers and nonsmokers in the presence or absence of coronary artery calcification.Read on Pubmed
The aim of this study was to further explore the interplay between smoking status, coronary artery calcium (CAC), and all-cause mortality. Smoking is a risk factor for death across the entire spectrum of subclinical coronary atherosclerosis. Smokers with any CAC had significantly higher mortality than smokers without CAC, a finding with implications for smokers undergoing lung cancer CT-based screening. However, the absence of CAC might not be as useful a "negative risk factor" in active smokers, because this group has mortality rates similar to nonsmokers with mild-to-moderate atherosclerosis.
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 HealRead on Pubmed
Despite 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.
Caveat emptor: the coronary calcium warranty.
It would be beneficial for clinicians to have the “warranty period” of a zero coronary calcium score stratified by baseline risk group (<10% and 10% to 20%). It may even be prudent to stratify further, as some have advocated for CAC testing in an expanded intermediate-risk group of 6% to 20% (e.g., <6%, 6% to 10%, and 10% to 20%). The investigators may have been overly prudent to suggest that “caution should be applied to interpreting our results among patients who are not receiving lipid-lowering therapy.” Although they express concern that the 756 patients on statin therapy (72%) may have had retarded CAC progression, randomized trials to date have not shown that statin therapy can achieve this. CAC = 0 has enormous potential for ruling out important coronary artery disease in asymptomatic patients. The duration and application of the “warranty period” remains an important topic for further research.
Zero coronary calcium and Bayes’ theorem.
It is important to note that the conclusion in the editorial that the Gottlieb et al. paper presents a “starkly contrasting picture” to a prior systematic review is based on a statistical error.Once again, Bayes’ theorem is critical. Although CAC = 0 may not definitively exclude important coronary artery disease (CAD) in patients referred for coronary angiography, there may be potential applications in lower-risk patients presenting with atypical chest pain features.
What is the prognostic value of a zero calcium score? Ask Bayes!
The role of calcium scoring (CS), if any, appears to be in the reclassification of asymptomatic patients at intermediate risk for CAD by traditional risk factor models. This has led to a Class IIb recommendation by the American Heart Association for the use of CS in these patients. Further research is ongoing to study the effect of such reclassification.
Screening for cardiovascular risk in asymptomatic patients.
We describe 6 risk algorithms (Framingham Risk Score for coronary heart disease events and for cardiovascular events, Adult Treatment Panel III, SCORE [Systematic Coronary Risk Evaluation] project, Reynolds Risk Score, ASSIGN [Assessing Cardiovascular Risk to Scottish Intercollegiate Guidelines Network/SIGN to Assign Preventative Treatment], and QRISK [QRESEARCH Cardiovascular Risk Algorithm]) for outcomes, population derived/validated, receiver-operating characteristic, variables included, and limitations. Areas of uncertainty include 10-year versus lifetime risk, prediction of CVD or coronary heart disease end points, nonlaboratory-based risk scores, age at which to start, race and sex differences, and whether a risk score should guide therapy. We believe that the best high-risk approach to CVD evaluation and prevention lies in routine testing for cardiovascular risk factors and risk score assessment. We recommend that health care providers discuss the global cardiovascular risk and lifetime cardiovascular risk score assessment with each patient.
A randomized, double-blind, placebo-controlled, dose-escalation study of intravenous adult human mesenchymal stem cells (prochymal) after acute myocardial infarction.
Bone marrow-derived hMSCs may ameliorate consequences of MI, and have the advantages of preparation ease, allogeneic use due to immunoprivilege, capacity to home to injured tissue, and extensive pre-clinical support.
Intravenous allogeneic hMSCs are safe in patients after acute MI. This trial provides pivotal safety and provisional efficacy data for an allogeneic bone marrow-derived stem cell in post-infarction patients. (Safety Study of Adult Mesenchymal Stem Cells [MSC] to Treat Acute Myocardial Infarction; NCT00114452).
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...
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.