Obesity a Risk Even in Young Men
Even in men aged 15 to 34 years, obesity is associated with accelerated atherosclerosis, according to researchers involved in the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study in a report in this week’s issue of Circulation (Circulation. 2002;105:2712–2718). Given the current epidemic, this underscores the importance of controlling obesity at all ages to reduce the international burden of coronary heart disease among adults, said the authors, led by Henry C. McGill, Jr, MD, of the Southwest Foundation for Biomedical Research.
In the PDAY study, researchers studied collected arteries, blood, and other tissue from approximately 3000 persons aged 15 to 34 years who died of external causes. They found that a high body mass index (BMI) in young men was associated with both fatty streaks and raised lesions in the right coronary artery, along with high American Heart Association lesion grades and stenosis in the left anterior descending artery. High BMI was not associated with coronary atherosclerosis in young women.
In an accompanying survey editorial, F. Scott Grundy, MD, of the Center for Human Nutrition and Departments of Internal Medicine and Clinical Nutrition at The University of Texas Southwestern Medical Center at Dallas, noted: “Public health efforts to prevent obesity in the general public should be a high national priority. From a clinical viewpoint, attention should focus on those individuals who are susceptible to the development of risk factors and the metabolic syndrome. These individuals will need direct clinical intervention. In some cases, weight reduction and increased physical activity may be sufficient to eliminate their risk factors. In other cases, drug therapies may be required to control risk factors” (Circulation. 2002;105:2696–2698).
Brachytherapy 5 Years Later in an Era of Coated Stents
Five years after 55 patients were enrolled in a study of brachytherapy to treat restenotic coronary arteries, the 26 individuals who received treatment with catheter-based Indium-192 appear to have a lower rate of events such as death, myocardial infarction, or target lesion revascularization than those who received placebo (Circulation. 2002;105:2737–2740).
The researchers, led by Mark Grise, MD, of Scripps Clinic in La Jolla, Calif, concluded that although there appeared to be some mitigation of efficacy over time, “The early clinical benefits following intracoronary gamma radiation with 192Ir appear durable at 5-year clinical follow-up.”
In an accompanying editorial, David O. Williams, MD, of the Division of Cardiology at Brown University School of Medicine in Providence, RI, noted that the technique is particularly difficult to perform, often requiring significant prolongation of the procedure and the presence of several personnel. In addition, he wrote, “The emergence of stents that elute drugs capable of inhibiting neointimal hyperplasia and clinical restenosis poses an enormous threat to intracoronary brachytherapy. Advances in stent design and refinement of deployment techniques have substantially reduced rates of stent restenosis. Further reductions of angiographic restenosis rates to <5% have been reported with stents that elute the antiproliferative agent sirolimus. . .Should further evaluations of drug-eluting stents confirm the very favorable initial results, the need for any other technology to treat in-stent restenosis will be minimal” (Circulation. 2002;105:2699–2700).
He noted that some technological methods used for interventional cardiology are frequently bypassed for others, even though the original method may have had positive outcomes. “The terminal event is not a shortcoming of the technology, but rather the emergence of yet a newer predator. Certainly, the course of directional atherectomy represented such a lifespan. It is quite likely that we are now witnessing a similar lifespan for intracoronary brachytherapy.”
Clopidogrel Versus Aspirin: The Cost Versus the Effect
Aspirin and clopidogrel, both accepted as effective in secondary prevention for patients with coronary heart disease, have very different cost-benefit ratios, according to a host of national and international researchers, led by Jean-Michel Gaspoz, MD, of the Clinique de Medecine II and the Division of Cardiology Hopitaux Universitaires of Geneva, Switzerland, in an article in the June 6, 2002, issue of the New England Journal of Medicine (N Engl J Med. 2002;346:1800–1806).
The researchers extrapolated that extending aspirin therapy from current levels to all eligible patients for 25 years would have an estimated cost-effectiveness ratio of ≈$11 000 per quality-adjusted year of life gained. For the 5% of the population who cannot take aspirin, the use of clopidogrel would cost ≈$31 000 per quality-adjusted year of life gained. However, if clopidogrel alone was used for all patients or in combination with aspirin, the cost jumps to $130 000 per quality-adjusted year of life gained.
They concluded that the increased prescribing of aspirin is attractive because it is cost-effective and that the more costly drug clopidogrel is presently unattractive unless restricted to patients who cannot take aspirin.