Vascular screening: Value, but at what cost?
A single-center community-based screening program for vascular disease uncovered severe and moderate disease in the study population (2.2% and 6.9%, respectively), say researchers from Anne Arundel Medical Center in Annapolis, Maryland. But the authors acknowledge that such general screening efforts run counter to recommendations of the US Preventive Services Task Force and broad-based population screening is unaffordable.
The program, called Dare to C.A.R.E. (Carotid artery stenosis, Abdominal aortic aneurysms, Renal artery stenosis, and Extremity artery stenosis), is a 2-day process intended to raise awareness of vascular issues by providing an educational lecture, blood pressure and cholesterol testing, and screening carotid and abdominal aortic ultrasounds, and ankle-brachial index determination. Anyone aged ≥ 60 years or ≥ 50 years with risk factors (ie, smoking history, diabetes, hypertension, hyperlipidemia, or a cardiac history) is eligible for this program. Dare to C.A.R.E., which began in June 2000, screens 4000 to 5000 persons per year.
Initially, volunteers ran the program, which was offered quarterly. Two years later, Dare to C.A.R.E. hired part-time staff and offered services 2 to 4 days per week, depending on the availability of ultrasound technologists. First-year start-up costs, which included purchase of ultrasound machines and other equipment, were $130,000. In subsequent years, costs have dropped to just above $100,000, which includes 1 full-time equivalent (FTE) vascular technician, 1 FTE administrator, a small office, and phone lines. This has been offset by $40,000 in unsolicited donations from patients as well as support from medical device and pharmaceutical companies.
"The program has been 'reproduced' at other centers, but none are running [this] kind of continuous program," says lead author Jon A. Hupp, MD.
Journal of Vascular Surgery
Other authors on the study include John D. Martin, MD, and Louise O. Hansen, CRNP. The full study is in the (2007;46:182-189).
Two studies challenge approach to fasting lipid measurements
Two studies examining the connection between triglyceride measurements and future cardiac events cast doubt on the tradition of conducting these measurements in a fasting state. The research appears in the July 18 issue of .
Prior to direct measurement of low-density lipoprotein cholesterol (LDL-C) levels, fasting measurement was the only way to obtain these values. In addition, the variability of nonfasting triglyceride levels is greater.
In the first study, researchers from Denmark prospectively followed 7587 women and 6394 men from the general population of Copenhagen for a mean follow-up time of 24 years. Baseline nonfasting triglyceride levels of study participants were taken. Using hospital admissions, diagnoses, and death records from Danish registries, researchers tracked this population for occurrences of myocardial infarction (MI), ischemic heart disease (IHD), and death. Because these registries are so detailed, no patients were lost to follow-up.
Baseline triglyceride measurements were stratified into 6 increasing levels. In both men and women, the cumulative incidence of MI, IHD, and death rose with increasing levels of nonfasting triglycerides. During the study, 1793 participants experienced MI, 3479 developed heart disease, and 7818 died.
The authors posit that elevated nonfasting triglycerides indicate remnant lipoproteins, which carry large amounts of cholesterol and can enter the arterial intima, causing atherosclerosis.
The second study, from a different group, examined a related question. More than 26,500 participants from the Women's Health Study were followed for a median of 11.4 years to determine the association of fasting or nonfasting triglyceride levels and risk of cardiovascular events, including nonfatal MI and ischemic stroke, coronary revascularization, or cardiovascular death.
During follow-up, there were 276 nonfatal MIs, 265 ischemic strokes, 628 coronary revascularizations, and 163 cardiovascular deaths. After controlling for age, blood pressure, smoking, and use of hormone therapy in fasting and nonfasting groups, both fasting and nonfasting triglyceride levels predicted cardiovascular events. Secondary analyses showed that triglyceride levels measured 2 to 4 hours postprandially had the strongest association with cardiovascular events.
The idea of using nonfasting triglyceride measurements has been brewing for a while, according to Peter H. Jones, MD, an associate professor at Baylor College of Medicine and a member of the editorial and consultant board. (Dr Jones was not involved in either study.) "Twenty-five years ago, my mentors were writing articles saying that nonfasting lipids predicted heart disease." Dr Jones pointed out that although there are no good cut points to guide clinical action when measuring triglycerides, clinicians should not dismiss the cholesterol levels of nonfasting tests.
The first study can be found in 2007;298(3):299-308, while the second is in the same issue on pages 308-316.
New Product News
Genetic Testing for hypertrophic cardiomyopathy may ease diagnosis
Genetic testing for hypertrophic cardiomyopathy (HCM), an often difficult-to-diagnose condition that is the leading cause of sudden cardiac death in children and young adults, is becoming more accessible thanks to the release of another genetic test.
In July, Correlagen Diagnostics, Inc announced the release of an HCM genetic sequencing test that can evaluate all (8), some, or individual genes responsible for this hereditary condition. The company says this option is affordable for patients and is working to get Medicare to reimburse it under its guidelines for genetic testing.
"HCM can be a difficult disease to diagnose, particularly in young patients participating in competitive sports," said Martin Maron, codirector of the Hypertrophic Cardiomyopathy Center, Tufts-New England Medical Center. "Since symptoms can vary greatly and often are similar to those of other noncardiac diseases, patients with HCM may not realize they have the disease. And because HCM is a genetically transmitted heart disease, it is important to identify whether other family members are affected."
Although genetic tests may simplify the diagnosis, treating this condition remains problematic. Symptoms can be treated and the disease process slowed, but lifestyle modification is the cornerstone to reduce the risk of cardiac death.
More information is available at