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By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
CAC: A kinder, Gentler Way to Predict Cardiovascular Risk
In 2007, the ACCF/AHA published a consensus statement in the Journal of the American College of Cardiology endorsing a role for coronary artery calcium scoring (CAC) in cardiovascular risk stratification. Because the CAC process is relatively inexpensive, brief, highly reproducibly, non-invasive and supported by multiple large data sets, it holds great appeal.
Detrano, et al studied an ethnically diverse population (n=6,722) comprised of white (38.6%), black (27.6%), Hispanic (21.9%) and Chinese (11.9%) adults over the age of 45. Subjects, who had no known cardiovascular disease at study enrollment, underwent CAC at baseline and were followed for a median of 3.8 years.
During the followup period, 162 major coronary events occurred. Compared to persons without increased CAC scores, the relative risk for coronary events was more than 7-fold higher in persons with elevated CAC scores. There was no discernible difference in the association of CAC score with coronary events between the different ethnic groups. The authors note that the predictive capacity of CAC goes beyond that of traditional risk factors. CAC is not yet universally available, but merits consideration by clinicians. Experts suggest that the greatest utility of CAC is in individuals calculated to be at intermediate coronary risk by traditional scoring, such as Framingham.
Detrano R, et al. N Engl J Med. 2008;358:1336-1345.
Was Mae West Right? CV Risk Reduction: Too Much of A Good Thing is Wonderful
The concept that global cardiovascular risk reduction (ie, concomitant lipid, BP, glucose, diet, and exercise interventions) is the most sensible path for success in persons identified as vasculopaths has few detractors. On the other hand, how much of a good thing gets to be too much of a good thing? Despite the counsel of Mae West, increasing intensity of pharmacotherapy is typically associated with increased cost, risk, and complexity, and should be documented to provide meaningful incremental benefit because of the associated increased burdens.
The SANDS trial (Stop Atherosclerosis in Native Diabetics Study) enrolled American Indian type 2 diabetics (n=499) and randomized them to aggressive LDL control (<70 mg/dL) and BP control (<115 mmHG SBP) vs standard therapy (LDL<100, SBP <130). The primary endpoint was progression of carotid artery intimal medial thickness. Clinical events were a secondary endpoint. Carotid IMT was measured at baseline, 18, and 36 months.
There was a statistically significant difference in carotid IMT favoring the intensive intervention group. Left ventricular mass also decreased more with aggressive intervention. Although there was a trend towards fewer CVD events, this difference did not achieve statistical significance, perhaps attributed to the unusually low number of events in the trial as a whole. These data are supportive of aggressive risk factor reduction in diabetics.
Howard BV, et al. JAMA. 2008;299(14):1678-1689.
The mean age of attainment of menopause in American women51 yearshas not meaningfully changed over more than a century. During late reproductive life, pregnancy has more adverse consequences than in younger women. The therapeutic abortion rate of post-40 women is higher than any other age group except adolescents. Hence, midlife contraceptive decisions might be weighed differently than at other periods of reproductive life.
Kaunitz reviews multiple factors that impact contraceptive decisions after age 40. DVT risk after age 39 is more than 4-fold greater than in adolescent women, exaggerated further in obese women, in whom progestin-only oral contraceptives might logically be preferred. Older women who smoke should not be prescribed oral contraceptives, and Kaunitz recommends similar restrictions for midlife women with hypertension or diabetes.
Data on risk for breast cancer in association with oral contraceptives is largely reassuring, although data sets usually contain few women over age 45 to study. Oral contraceptives improve bone mineral density, and are associated with reduced risk for ovarian, endometrial, and colon cancer.
No method of discontinuation of contraception has proven ideal in all women. Kaunitz suggests continuing oral contraceptives, if well tolerated, into the early-mid 50s, after which pregnancy risk upon discontinuation is very low. Women who continue to menstruate after that point may use barrier methods. The ideal candidate for midlife oral contraceptives is the lean, slender, nonsmoker.
Kaunitz AM. N Engl J Med. 2008;358:12:1262-1270.