RESUMEN
The insulin resistance syndrome, consisting of resistance to insulin and several metabolic abnormalities, is associated with an increased risk of symptomatic coronary artery disease. Asymptomatic persons with increased coronary calcification have increased coronary plaque and an increased likelihood of future cardiovascular events. Electron-beam computed tomography-derived coronary artery calcium scores, metabolic and anthropometric parameters, and fasting and stimulated concentrations of glucose and insulin were measured in 1160 asymptomatic men and women. Coronary artery calcium scores were positively correlated with glucose, insulin, and homeostasis model assessment (HOMA) insulin resistance. Calcium scores were positively correlated with intra-abdominal adiposity, age, total cholesterol/high density lipoprotein (HDL) ratio, low density lipoprotein, triglycerides, blood pressure, and HOMA beta cell function and inversely correlated with HDL and peripheral fat. These correlations, except for 2-hour glucose, remained significant for all subjects with fasting serum glucose <126 mg/dL or all subjects with fasting serum glucose 110 mg/dL. In a multivariate analysis, age, sex, family history of premature coronary artery disease, intra-abdominal adiposity, low density lipoprotein, and smoking independently predicted calcium scores. Blood pressure, HDL, triglycerides, glucose, insulin, and HOMA insulin resistance or beta cell function were not independently correlated with coronary artery calcium scores. Asymptomatic individuals with insulin resistance have elevated coronary calcium scores. The association between insulin resistance and coronary calcification persists with impaired glucose tolerance and normal fasting serum glucose. Central/visceral adiposity may be a determinant of insulin resistance and atherosclerosis even in asymptomatic nondiabetic persons.
Asunto(s)
Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Tejido Adiposo/metabolismo , Comorbilidad , Diabetes Mellitus/epidemiología , Femenino , Humanos , Resistencia a la Insulina , Masculino , Persona de Mediana Edad , Análisis Multivariante , Ciudad de Nueva York/epidemiología , Obesidad , Prevalencia , Factores de Riesgo , Grosor de los Pliegues Cutáneos , Tomografía Computarizada por Rayos XRESUMEN
Early detection of asymptomatic subjects who are at risk for future cardiovascular events may allow for earlier medical treatment in order to prevent disease progression and future events. Electron-beam computed tomography accurately identifies people with increased coronary calcification, which is correlated with increased coronary plaque mass, increased likelihood of obstructive coronary disease, and increased likelihood of future cardiovascular events. The St. Francis Heart Study is a single-center combination study of men and women 50-70 years old that includes a natural history study of the relation between calcium scores and cardiovascular events (n = 5582), the association of calcium scores with traditional and nontraditional coronary disease risk factors (n = 1160), and a randomized clinical trial designed to assess the benefit of combination treatment with atorvastatin, vitamin C, and vitamin E, as compared to placebos, in subjects with elevated age- and gender-adjusted coronary calcification (n = 1007). Mean follow-up duration will be 4 years. The study is proceeding on schedule with anticipated completion by August 2002. It should provide important information regarding the benefits of treating asymptomatic men and women who have elevated coronary artery calcium, using cholesterol reduction and antioxidant therapy. The article describes the design of the St. Francis Heart Study.
Asunto(s)
Selección de Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Proyectos de Investigación , Anciano , Antioxidantes/administración & dosificación , Antioxidantes/uso terapéutico , Atorvastatina , Calcinosis/tratamiento farmacológico , Enfermedad Coronaria/tratamiento farmacológico , Quimioterapia Combinada , Femenino , Ácidos Heptanoicos/administración & dosificación , Ácidos Heptanoicos/uso terapéutico , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Masculino , Persona de Mediana Edad , Pirroles/administración & dosificación , Pirroles/uso terapéuticoRESUMEN
OBJECTIVES: We sought to determine the prognostic accuracy of electron beam computed tomographic (EBCT) scanning of the coronary arteries at three to four years. BACKGROUND: Coronary artery calcium scores determined by EBCT correlate with the severity of coronary artery disease. However, previous reports of the prognostic accuracy of EBCT scanning for coronary events in asymptomatic individuals are conflicting. METHODS: Asymptomatic men and women undergoing coronary EBCT completed initial and follow-up evaluations, which included past medical history, the Rose angina questionnaire and interim cardiovascular events. Reported coronary events (death, nonfatal myocardial infarction [MI] and revascularization procedures) were confirmed without knowledge of the scan results. RESULTS: Information was obtained in 1,172 (99.6%) of 1,177 eligible subjects (baseline age 53 +/- 11 years, 71% men). During an average follow-up of 3.6 years, 39 subjects sustained coronary events: three coronary deaths, 15 nonfatal MIs and 21 coronary artery revascularization procedures. The mean coronary artery calcium score was 764 +/- 935 among subjects with events as compared with 135 +/- 432 among those without events (p < 0.0001). For the prediction of all coronary events and of nonfatal MIs and deaths, the areas under the receiver-operator characteristics curve were 0.84 and 0.86, respectively, and a coronary calcium score > or =160 was associated with odds ratios of 15.8 and 22.2, respectively. The odds ratios for all events remained high (14.3 to 20.2) after adjustment for self-reported cardiovascular risk factors. CONCLUSIONS: In asymptomatic adults, EBCT of the coronary arteries predicts coronary death and nonfatal MI and the need for revascularization procedures.
Asunto(s)
Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto , Anciano , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/etiología , Angina de Pecho/mortalidad , Causas de Muerte , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/etiología , Infarto del Miocardio/mortalidad , Pronóstico , Curva ROC , Reproducibilidad de los Resultados , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
The objective of this study was to assess the risk of multiple recurrences after an initial seizure recurrence in childhood. In a prospective study, 407 children were followed for a mean of 9.6 years from the time of their first unprovoked seizure. Data regarding each seizure recurrence were obtained and analyzed using statistical methods for survival analysis. The cumulative risk of a second seizure was 29%, 37%, 43%, and 46% at 1, 2, 5, and 10 years, respectively. Of the 182 children who experienced a second seizure, 131 (72%) experienced a third seizure, 105 (58%) have had 4 or more seizures, and 52 (29%) have experienced 10 or more seizures. The cumulative risk of a third seizure was 57%, 63%, and 71% at 1, 2, and 5 years, respectively, after the second seizure. After a third seizure, the cumulative risk of another seizure was 69%, 72%, and 81% at 1, 2, and 5 years, respectively. After a second seizure, factors associated with an increased risk of additional recurrences included a remote symptomatic etiology (rate ratio = 1.7) and the occurrence of a second seizure within 6 months of the first seizure (rate ratio = 1.7). After a second seizure, the risk of subsequent seizures was greater than 50% even in the lowest risk group. With the exception of etiology, factors associated with an increased risk of multiple recurrences after the initial seizure were different than those associated with multiple recurrences after a second seizure. Factors associated with multiple recurrent seizures may be different than those associated with an initial recurrence. As most patients who experience a second seizure experience further seizures, these data suggest that two seizures are a sufficient epidemiological criterion for the definition of epilepsy.
Asunto(s)
Epilepsia/fisiopatología , Convulsiones/fisiopatología , Adolescente , Adulto , Niño , Preescolar , Estudios de Cohortes , Humanos , Lactante , Pronóstico , Estudios Prospectivos , Recurrencia , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: The amount of coronary artery calcification, measured using electron beam computed tomography, is correlated with the volume of coronary artery atherosclerotic plaque, the severity of stenosis by angiography, and with the likelihood of future cardiovascular events. The deposition of calcium in atherosclerotic plaques may also be influenced by determinants of calcium metabolism, thus contributing to the variance of the relation between coronary artery calcification and extent of atherosclerosis. Our objective was to determine whether this variance could be explained by differences in the parameters of calcium metabolism. DESIGN AND METHODS: We measured serum concentrations of calcium, 1,25(OH)2 vitamin D and parathyroid hormone (PTH) in 50 subjects undergoing angiography for clinical indications, and evaluated the correlations between these concentrations and calcium deposition in the coronary arteries, and the ratio of calcium deposition to extent of atherosclerosis using coronary angiography. RESULTS AND CONCLUSIONS: Serum concentrations of calcium 1,25(OH)2 vitamin D and PTH were not correlated with coronary calcification or the ratio of coronary calcification to the extent of coronary stenosis. We conclude that, in subjects undergoing coronary angiography, the variance of the relationship between coronary atherosclerosis and coronary calcium is not a result of differences in serum concentrations of calcium, 1,25(OH)2 vitamin D or PTH.
Asunto(s)
Calcitriol/sangre , Calcio/sangre , Enfermedad de la Arteria Coronaria/sangre , Hormona Paratiroidea/sangre , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: To determine whether electron beam computed tomography (CT) adds to conventional risk factor assessment in the prediction of angiographic coronary artery disease. BACKGROUND: Electron beam CT scanning can be used to predict the severity of coronary atherosclerosis, but whether it does so independently of conventional risk factors is unclear. METHODS: Electron beam CT scans were performed and conventional risk factors were measured in 290 men and women undergoing coronary arteriography for clinical indications. The association of the electron beam CT-derived coronary artery calcium score and conventional risk factors with the presence and severity of angiographically defined coronary atherosclerosis was analyzed by logistic regression and receiver-operator characteristics analysis. RESULTS: Age, the ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol and the coronary calcium score were significantly and independently associated with the presence of any coronary disease and obstructive coronary disease. In association with any coronary disease, odds ratios for age, the ratio of total cholesterol to HDL cholesterol and calcium score, highest quartile vs. lowest quartile, were 6.01 (95% confidence interval 2.87 to 12.56), 3.14 (1.56 to 6.31) and 94.08 (21.06 to 420.12), respectively. For obstructive coronary disease, highest quartile vs. lowest quartile, the respective odds ratios for age, the ratio of total cholesterol to HDL and calcium score were 3.86 (1.86 to 8.00), 4.11 (1.98 to 8.52) and 34.12 (12.67 to 91.86). Male gender was also significantly associated with any coronary disease (odds ratio 2.19, p=0.04) and obstructive coronary disease (odds ratio 2.07, p=0.04). Cigarette smoking was significantly associated with any coronary disease (odds ratio=2.74, p=0.004), and diabetes was significantly associated with obstructive disease (odds ratio 3.16, p=0.01). After adjustment for the coronary calcium score and other risk factors, it was determined that triglycerides, family history and hypertension were not significantly associated with any disease state. A coronary calcium score >80 (Agatston method) was associated with an increased likelihood of any coronary disease regardless of the number of risk factors, and a coronary calcium score > or = 170 was associated with an increased likelihood of obstructive coronary disease regardless of the number of risk factors (p < 0.001). CONCLUSIONS: Electron beam CT scanning offers improved discrimination over conventional risk factors in the identification of persons with any angiographic coronary disease or angiographic obstructive coronary disease.
Asunto(s)
Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto , Anciano , Calcinosis/diagnóstico por imagen , Colesterol/sangre , HDL-Colesterol/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Factores de Riesgo , Sensibilidad y EspecificidadRESUMEN
PURPOSE: Status epilepticus (SE) is an uncommon but potentially life-threatening seizure. It is most common in children. Little is known about the differences within the pediatric age group in terms of the type of patient seen with SE. METHODS: We analyzed the records of 394 children aged 1 month to 16 years who were part of two large studies of pediatric SE conducted in Bronx, New York, and Richmond, Virginia. The 394 children had a mean age of 4.4 years and included 349 (89%) with an initial episode of SE. RESULTS: Status epilepticus was most common in younger children with >40% of cases occurring in those younger than 2 years. The distribution of causes was highly age dependent. More than 80% of children younger than 2 years had SE of febrile or acute symptomatic origin, whereas cryptogenic and remote symptomatic causes were most common in older children (p < 0.001). One hundred fifty-eight (40%) of the cases were known to be previously neurologically abnormal, including 35 (21%) of 169 younger than age 2 years and 123 (55%) of 225 older than 2 years (p < 0.001). One hundred seventy-seven (45%) children had a history of seizures including 142 (41%) of the 349 children with a first episode of SE. A history of seizures was present in 34 (20%) of those younger than 2 years and 143 (64%) of those older than 2 years (p < 0.001). The effect of age remained significant even when the analysis was limited to those with SE of cryptogenic or remote symptomatic origin. CONCLUSIONS: There is a strong effect of age on the frequency and etiology of SE, as well as on the type of child who has SE. In young children, SE occurs primarily in children who are neurologically normal and with no history of unprovoked seizures. In older children, SE occurs primarily in those who are known to have prior unprovoked seizures and who are often also neurologically abnormal.
Asunto(s)
Estado Epiléptico/epidemiología , Adolescente , Distribución por Edad , Factores de Edad , Preescolar , Estudios de Cohortes , Comorbilidad , Estudios de Seguimiento , Humanos , Lactante , Enfermedades del Sistema Nervioso/diagnóstico , Enfermedades del Sistema Nervioso/epidemiología , Examen Neurológico , Ciudad de Nueva York/epidemiología , Estudios Prospectivos , Recurrencia , Estudios Retrospectivos , Estado Epiléptico/clasificación , Estado Epiléptico/diagnóstico , Virginia/epidemiologíaRESUMEN
The authors describe a new test for clinical sensibility, initiated in response to the need of the senior author for a rapid, reliable method to evaluate sensibility. Using this test, the patient develops a ratio between normal light moving touch and diminished moving touch. Subsequent determinations can detect serial changes. The ratios obtained can be compared with a standard scale of sensibility with a high degree of validity and reliability. The interexaminer and intraexaminer results obtained are reliable and repeatable. Statistical evaluations substantiating the validity of the test are presented. Simplicity and depend-ability recommend this test for use in a busy clinical setting.
Asunto(s)
Examen Neurológico , Tacto , Humanos , Variaciones Dependientes del Observador , SensaciónRESUMEN
OBJECTIVE: To assess the long-term recurrence risks after a first unprovoked seizure in childhood. METHODS: In a prospective study, 407 children who presented with a first unprovoked seizure were then followed for a mean of 6.3 years from the time of first seizure. RESULTS: One hundred seventy-one children (42%) experienced subsequent seizures. The cumulative risk of seizure recurrence was 29%, 37%, 42%, and 44% at 1, 2, 5, and 8 years, respectively. The median time to recurrence was 5.7 months, with 53% of recurrences occurring within 6 months, 69% within 1 year, and 88% within 2 years. Only 5 recurrences (3%) occurred after 5 years. On multivariable analysis, risk factors for seizure recurrence included a remote symptomatic etiology, an abnormal electroencephalogram (EEG), a seizure occurring while asleep, a history of prior febrile seizures, and Todd's paresis. In cryptogenic cases, the risk factors were an abnormal EEG and an initial seizure during sleep. In remote symptomatic cases, risk factors were a history of prior febrile seizures and age of onset younger than 3 years. Risk factors for late recurrences (after 2 years) were etiology, an abnormal EEG, and prior febrile seizures in the overall group and an abnormal EEG in the cryptogenic group. These are similar to the risk factors for early recurrence. CONCLUSIONS: The majority of children with a first unprovoked seizure will not have recurrences. Children with cryptogenic first seizures and a normal EEG whose initial seizure occurs while awake have a particularly favorable prognosis, with a 5-year recurrence risk of only 21%. Late recurrences do occur but are uncommon.