Looking Beyond Low-density Lipoprotein Cholesterol
Participants at the 12th Preventive Cardiovascular Nurses Association (PCNA) Symposium in Denver last April had the opportunity to "Check their Lipid Numbers" during several morning screening sessions. More than 160 nurses participated in the Nuclear Magnetic Resonance (NMR) LipoProfile testing. This test uses NMR spectroscopy to provide direct measurement of the number of low-density lipoprotein particles (LDL-P), size of LDL-P, direct measurement of high-density lipoprotein (HDL) and very low-density lipoprotein (VLDL) subclasses, along with traditional cholesterol values. This NMR profile identifies "disconnected" patients whose cardiovascular disease risk is elevated because of increased number of LDL particles, despite acceptable LDL cholesterol values. Patients with diabetes or metabolic syndrome are among those most likely to show this "disconnect." Previous clinical trials have noted that over one third of patients with "optimal" LDL cholesterol levels have elevated number of LDL particles, placing them at increased level of coronary heart disease risk. How did our sample of nurses fare?
Although LDL particle number is the most important parameter based on NMR spectroscopy, some studies show that particle size is also an important determinant of cardiovascular disease risk. Individuals with pattern B (small particle size) are considered at higher risk. Our sample found a few nurses with pattern B despite LDL cholesterols less than 70 mg/dL. Three nurses were identified with metabolic syndrome based on calculations of small LDL particle size, low HDL-P, and high VLDL-P.
Pattern B (small):
18-20.5 nm = 17 nurses;
Pattern A (large):
20.6-23 nm = 143 nurses.
The biggest "disconnect" was observed in 6 individuals with LDL particle numbers between 1,000 and 1,700 who had LDL cholesterols in the 60s. This is important information because LDL particles are incorporated into arterial walls and form the basis for plaque development and growth, not only the cholesterol contained within those particles. Clinicians who obtain NMR LipoProfiles may identify patients eligible for lipid-lowering therapy who would not be identified based on standard lipid profiles.
LipoScience will offer NMR LipoProfile testing in Minneapolis at the 2007 PCNA Symposium in April.
New Research Findings Reported at American Heart Association Scientific Sessions 2006
High Consumption of Fish, Dairy Products, and Cereal Associated with Low Prevalence of Metabolic Syndrome
Bongard and colleagues reported on the relationship of fish, dairy product, and cereal intakes with metabolic syndrome in the MONItoring CArdiovascular Disease (MONICA) Study. Participants included 912 French men aged 45 to 64 years who completed a 3 consecutive day food record and waist circumference, blood pressure, and fasting blood lipid and glucose measurement. Metabolic syndrome was assessed according to the definition of National Cholesterol Education Program (Adult Treatment Panel III). The prevalence of metabolic syndrome was 24% in the whole sample. When the intakes of fish, dairy products, and cereals were below the median value in the sample, the prevalence was 29%, 28%, and 28%, respectively, and significantly lower (P = .001) when the intakes were above the median (18%, 19%, and 19%). When the 3 intakes were all above the median, the prevalence was 13%, as compared with 38% when they were all below. The authors concluded that dietary behaviors characterized by a high consumption of fish, dairy products, and cereals are associated with a lower probability to present with a metabolic syndrome, independently of the level of other environmental factors. The combination of these food intakes tends to be more favorable than the consumption of each one separately.
Dietary Change-induced Weight Loss Produces Rise in Homocysteine Levels: Modification by Folic Acid and Vitamin B Supplementation
Gundry and Ehrman followed serum homocysteine levels in 300 consecutive patients with metabolic syndrome and/or coronary artery disease who enrolled in a lifestyle modification program that included a weight loss goal. Group A (n = 200) took a regular multivitamin during initial weight loss, and group B (n = 100) received 2,000 [mu]g folic acid and 1 B-100 tablet/day. In group A, homocysteine levels rose significantly from 9.7 +/- 2.1 to 14.5 +/- 2.0 [mu]mol/L in the first 6 months of weight loss (mean, 15 lb; P < .0001). In contrast, homocysteine levels in group B remained constant (10.1 +/- 2 to 10.3 +/- 2.3 [mu]mol/L) during the same period despite similar weight loss (mean, 17 lb; P < .0001, group B vs group A). At 6 months, group A was started on group B's high-dose regimen, and at 9 months, group A's levels fell to 11.2 +/- 2.5 [mu]mol/L (P < .001 vs 6-month group A). The authors concluded that during weight loss induced by dietary changes, homocysteine levels dramatically increase unless patients are given high-dose folic acid and vitamin B supplementation. Unless treated, elevated homocysteine levels induced by "healthy" weight loss may have negative cardiovascular health consequences.
Folic Acid, B Vitamins Not Supported
Christine Albert, MD, presented results as part of the randomized, double-blind, placebo-controlled Women's Antioxidant and Folic Acid Cardiovascular Study. Results of a randomized trial of folic acid and B vitamins in secondary prevention of cardiovascular events in women did not support their use as preventive agents against cardiovascular disease in women with established vascular disease or those at high risk. The combination did lower homocysteine levels by approximately 18% but did not reduce the risk of total cardiovascular events among 5,442 women at high risk.
Lipoprotein(a), Hormone Replacement Therapy, and Risk of Future Cardiovascular Disease in Women
Although multiple studies indicate that hormone replacement therapy (HRT) decreases plasma levels of lipoprotein (a) (Lp(a)), whether this effect alters the relationship of Lp(a) with cardiovascular risk is unknown. Danik and colleagues measured Lp(a) at baseline among 27,791 initially healthy women, of whom 12,075 were on HRT and 15,661 were not. The risk of firstever major cardiovascular events during a 10-year period (nonfatal myocardial infarction, nonfatal cerebrovascular event, coronary revascularization, or cardiovascular deaths) was assessed. As anticipated, Lp(a) values were lower among women taking HRT (median, 9.4 vs 11.6 mg/dL; P < .0001). The authors concluded that the relationship of high Lp(a) levels and incident cardiovascular events was modified by HRT in women.
Children With Heart Disease Risk Factors Should Get Preventive Treatment
Children with risk factors such as high blood pressure, obesity, diabetes, and high cholesterol levels already show signs of fatty buildup in their arteries that could lead to heart disease in adulthood. Piran and colleagues reviewed 26 studies from the United States, Netherlands, Australia, Finland, Norway, and Italy that used noninvasive methods to measure the thickness of the artery walls and blood flow in arteries of children without risk factors, as well as in children with risk factors for cardiovascular disease. The 26 studies included 3,630 children aged 5 to 18 years and compared healthy children to children with cardiovascular risk factors such as high blood pressure, high cholesterol levels, diabetes, and obesity. Early atherosclerosis was identified as follows: (1) children with risk factors for heart disease and stroke had an average of 8.7% more carotid artery intima-media thickening via ultrasound and (2) an average of 37% decreased blood flow via brachial or femoral artery flow-mediated dilation than children without risk factors. The results indicate structural abnormalities and artery wall dysfunction, both signs of the early stages of atherosclerosis among children with risk factors. This research suggests that primary prevention programs should be initiated in childhood along with a family-oriented approach to cardiovascular prevention to address risk factors.
Convenience, Education Improves Elderly's Medication Adherence, Blood Pressure, and Cholesterol Levels
Organizing and prepackaging medication, combined with pharmacist-directed education, substantially increased the number of elderly patients complying with complicated medicine schedules, according to the results of the Federal study of Adherence to Medications in the Elderly (FAME) trial. Elderly patients who were taking 4 or more daily medications for multiple chronic conditions received hand-packaged blister packs of their medications. For example, a patient taking medicine 3 times a day would receive a morning pack containing a 1-month supply of medications counted out, grouped, labeled, and packaged into each daily morning dose of all appropriate pills, as well as similar packs for noon and evening. Patients received all of their pills at once and could tell at a glance if they had taken their medications- particularly helpful to patients with memory problems. Pharmacists also helped patients learn the names of their medicines, reasons for taking them, doses of the pills, possible side effects, best time to take their pills, and interaction information when needed. After 6 months, adherence rates increased from 61% to 97%, and significant improvements in systolic blood pressure and low-density lipoprotein cholesterol were seen. "The FAME results call for greater emphasis within healthcare delivery systems and policy organizations on development and promotion of clinical programs to enhance medication adherence, particularly among the at-risk elderly" said Dr Allen Taylor, senior author of the clinical trial.
Women and Heart Disease-Highlights From American Heart Association Scientific Sessions, Chicago 2006
Currently accepted risk factors may not apply to women, according to Ann Bolger, MD, professor of clinical medicine at the University of California/San Francisco and chair of the American Heart Association Council on Clinical Cardiology. Traditional risk assessment profiles were developed during a time when women were underrepresented in clinical trials and gender differences were not as readily reported in research findings. Dr Bolger encourages more research that carefully analyzes gender differences as they relate to heart disease risk assessment.
Testosterone deficiency in women may be one such risk factor that needs to be studied more carefully. Postmenopausal women with low testosterone levels had twice the risk of myocardial infarction (MI), revascularization surgery, and mortality when compared to women with higher levels, said Gail A. Laughlin, PhD, assistant adjunct professor of family and preventive medicine at the University of California, San Diego/ La Jolla. The 20-year study of 678 woman aged 50 to 90 years also found low testosterone levels more common in women who were younger and nonsmokers and those who had undergone hysterectomy or bilateral oophorectomy.
High levels of anxiety worsen outcomes for women post-MI. "Women's higher anxiety levels were closely associated with both the rate of complications and the difference in complications between genders," said Debra K. Moser, DNSc, professor of nursing at the University of Kentucky, Lexington. She said that 30% of women experienced post-MI anxiety versus 22% of men and that women with anxiety had a 30% higher hazard ratio for complications. "The good news is that anti-anxiety medication reduced complications in both men and women," she said.
It is well known that women have greater complications when undergoing traditional coronary artery bypass surgery with the use of cardiopulmonary bypass pumps. Using "off-pump" surgery seems to neutralize the disparity in complications and deaths between women and men associated with coronary artery bypass surgery, according to John D. Puskas, MD, chief of cardiac surgery at Emory Crawford Long Hospital and associate chief of cardiothoracic surgery at Emory University, Atlanta. The retrospective study reviewed risk factors and clinical outcomes after major cardiac events in 11,413 bypass procedures. "Disproportionately fewer women experienced major cardiac events with off-pump surgery and fewer deaths or strokes-so much that the gender disparity with men was neutralized," Dr Puskas reported.
Women with cardiovascular disease receive less-aggressive secondary prevention therapy than men, including less lipid-lowering therapy (62.6% vs 67.1%) and anti-platelet therapy (76.6% vs 85%). The study of disparities in secondary prevention, led by Leslie Cho, MD, director of the Women's Cardiovascular Center and the medical director of preventive cardiology and rehabilitation at the Cleveland Clinic Foundation, followed 2,462 men and women for 7 years. Dr Cho said that the data held true, even though the women's median age was higher than men's, they were hypertensive, and they had statistically higher baseline levels of C-reactive protein and total and LDL-cholesterol levels. Dr Cho also noted that both men and women received less therapy than the guidelines recommend.
Adams Honored With Excellence in Cardiovascular Practice Award
Cynthia Adams, NP, was awarded the Excellence in Cardiovascular Nursing Clinical Practice Award at the recent American Heart Association Council of Cardiovascular Nursing Annual Dinner and Business Meeting on Tuesday, November 14, in Chicago, Ill. This award is sponsored by the Preventive Cardiovascular Nurses Association (PCNA) to promote excellence in practice.
Cindy has an impressive career in cardiovascular nursing, with specific emphasis on disease management of the heart failure population and, more recently, on preventive cardiology. She developed the Healthy Hearts Clinic, a 4-hospital system in urban Indianapolis. In this nurse practitioner-directed clinic, she provided care to more than 200 heart failure patients annually. From there, she assumed the manager role in preventive cardiology for a large physician practice. Currently, she is the director of cardiovascular services for a 4-hospital Community Health Network.
Adams is a researcher, has presented nationwide, and has authored both research and clinical articles. Besides work in her practice, leadership, and consultation, she is a tireless volunteer for many specialty organizations, serving on task forces for American Heart Association, American College of Cardiology, Heart Failure Society of America, and Sigma Theta Tau, among others. And what makes this award most exciting is that she is also an active PCNA member. Congratulations, Cindy!
Several other PCNA members were honored at the Council Meeting. Congratulations to the following: Debra Moser, DNSc, FAHA (Katharine Lembright Award); Lola Coke, DNSc (Martha N. Hill New Investigator Award); Sandra Dunbar, RN, DSN, FAAN, FAHA (Best Abstract Award); and Gayle Whitman, PhD, RN, FAAN, FAHA (Distinguished Achievement Award).
Section Description
The Journal of Cardiovascular Nursing is the official journal of the Preventive Cardiovascular Nurses Association. PCNA is the leading nursing organization dedicated to preventing cardiovascular disease through assessing risk, facilitating lifestyle changes, and guiding individuals to achieve treatment goals.