Kerri Wachter

NEW YORK — Stent grafts for patients with type B aortic dissections may be no better than best medical management alone in terms of mortality, according to preliminary data presented at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

“At 1 year, a slightly higher but not statistically different rate of all-cause mortality was observed in the stent graft arm,” said Dr. Christoph A. Nienaber, head of cardiology and vascular medicine at the University of Rostock (Germany).

In the Investigation of Stent Grafts in Patients with Type B Aortic Dissection (INSTEAD) trial, Dr. Nienaber and his colleagues evaluated 1-year all-cause mortality for patients with uncomplicated type B aortic dissections when treated by stent graft as an adjunct to best medical therapy or by best medical treatment alone.

The study was conducted at seven centers across Europe and involved 136 patients. Patients were included if they had a type B dissection between 2 and 52 weeks of duration, the diameter of the target vessel was no larger than 6 cm, and aortic kinking was less than 75 degrees. Patients were excluded if they had thrombocytopenia or were receiving anticoagulation therapy, had renal failure and/or a serum creatinine level greater than 2.4 mg/dL, complete thrombosis of the false lumen, ongoing infection, or cancer with a life expectancy less than 1 year.

In all, 70 patients were randomized to receive thoracic stents (Talent stent graft by Medtronic Inc.) and tailored antihypertensive therapy, while 66 patients were treated with tailored antihypertensive therapy alone.

Patients were clinically evaluated and imaged at 3, 12, and 24 months. Mortality at 1 year was 10% for the stent group and 3% for the medical management group. Of note, seven patients originally in the medical therapy group crossed over to the stent group and two patients originally in the stent group crossed over to the medical therapy group.

“Early complications within 30 days seemed to be more prevalent in the active treatment group … whereas the later complications, beyond the first month to the end of the first year, were more prevalent and more frequent in the medical group,” said Dr. Nienaber.

Standard treatment for Stanford classification type B aortic dissections has been medical management (antihypertensives). However, 1-year survival for patients treated medically is thought to be about 20%, based on various trials and registries.

Dr. Nienaber disclosed that he has no conflicts of interest.

NEW YORK — Stent grafts for patients with type B aortic dissections may be no better than best medical management alone in terms of mortality, according to preliminary data presented at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

“At 1 year, a slightly higher but not statistically different rate of all-cause mortality was observed in the stent graft arm,” said Dr. Christoph A. Nienaber, head of cardiology and vascular medicine at the University of Rostock (Germany).

In the Investigation of Stent Grafts in Patients with Type B Aortic Dissection (INSTEAD) trial, Dr. Nienaber and his colleagues evaluated 1-year all-cause mortality for patients with uncomplicated type B aortic dissections when treated by stent graft as an adjunct to best medical therapy or by best medical treatment alone.

The study was conducted at seven centers across Europe and involved 136 patients. Patients were included if they had a type B dissection between 2 and 52 weeks of duration, the diameter of the target vessel was no larger than 6 cm, and aortic kinking was less than 75 degrees. Patients were excluded if they had thrombocytopenia or were receiving anticoagulation therapy, had renal failure and/or a serum creatinine level greater than 2.4 mg/dL, complete thrombosis of the false lumen, ongoing infection, or cancer with a life expectancy less than 1 year.

In all, 70 patients were randomized to receive thoracic stents (Talent stent graft by Medtronic Inc.) and tailored antihypertensive therapy, while 66 patients were treated with tailored antihypertensive therapy alone.

Patients were clinically evaluated and imaged at 3, 12, and 24 months. Mortality at 1 year was 10% for the stent group and 3% for the medical management group. Of note, seven patients originally in the medical therapy group crossed over to the stent group and two patients originally in the stent group crossed over to the medical therapy group.

“Early complications within 30 days seemed to be more prevalent in the active treatment group … whereas the later complications, beyond the first month to the end of the first year, were more prevalent and more frequent in the medical group,” said Dr. Nienaber.

Standard treatment for Stanford classification type B aortic dissections has been medical management (antihypertensives). However, 1-year survival for patients treated medically is thought to be about 20%, based on various trials and registries.

Dr. Nienaber disclosed that he has no conflicts of interest.

NEW YORK — Stent grafts for patients with type B aortic dissections may be no better than best medical management alone in terms of mortality, according to preliminary data presented at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

“At 1 year, a slightly higher but not statistically different rate of all-cause mortality was observed in the stent graft arm,” said Dr. Christoph A. Nienaber, head of cardiology and vascular medicine at the University of Rostock (Germany).

In the Investigation of Stent Grafts in Patients with Type B Aortic Dissection (INSTEAD) trial, Dr. Nienaber and his colleagues evaluated 1-year all-cause mortality for patients with uncomplicated type B aortic dissections when treated by stent graft as an adjunct to best medical therapy or by best medical treatment alone.

The study was conducted at seven centers across Europe and involved 136 patients. Patients were included if they had a type B dissection between 2 and 52 weeks of duration, the diameter of the target vessel was no larger than 6 cm, and aortic kinking was less than 75 degrees. Patients were excluded if they had thrombocytopenia or were receiving anticoagulation therapy, had renal failure and/or a serum creatinine level greater than 2.4 mg/dL, complete thrombosis of the false lumen, ongoing infection, or cancer with a life expectancy less than 1 year.

In all, 70 patients were randomized to receive thoracic stents (Talent stent graft by Medtronic Inc.) and tailored antihypertensive therapy, while 66 patients were treated with tailored antihypertensive therapy alone.

Patients were clinically evaluated and imaged at 3, 12, and 24 months. Mortality at 1 year was 10% for the stent group and 3% for the medical management group. Of note, seven patients originally in the medical therapy group crossed over to the stent group and two patients originally in the stent group crossed over to the medical therapy group.

“Early complications within 30 days seemed to be more prevalent in the active treatment group … whereas the later complications, beyond the first month to the end of the first year, were more prevalent and more frequent in the medical group,” said Dr. Nienaber.

Standard treatment for Stanford classification type B aortic dissections has been medical management (antihypertensives). However, 1-year survival for patients treated medically is thought to be about 20%, based on various trials and registries.

Dr. Nienaber disclosed that he has no conflicts of interest.

NEW YORK — While stent grafting of thoracic aortic aneurysm has become more routine, the procedure still has a number of limitations, Martin Malina, Ph.D., said at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

Currently-available thoracic endografts are limited by issues of access, hostile neck, deployment, and durability. Dr. Malina, a consultant vascular surgeon at Malmö (Sweden) University Hospital, offered thoughts on these limitations and tips for overcoming them.

▸ Access. “We do have many quite simple tricks to get around this problem,” of access said Dr. Malina.

He recommends using an ultra-stiff guidewire. And don't push the graft in. “The more you push, the more the wire buckles,” he said. To avoid this, use a brachial wire to pull the graft by placing a clamp at the lower end of the wire. “This way, the more you pull, the more the wire will get straightened out.”

Iliac stenosis poses an access problem. One alternative is to make an incision in the groin and to advance the sheath outside of and parallel to the external iliac artery, inserting the graft at a more favorable angle.

▸ The neck. “Very often there is no neck,” said Dr. Malina. One option in these cases is to push the stent graft further around the arch, covering the left subclavian artery. Contraindications to this technique include right vertebral stenosis, aberrant right subclavian artery lusoria, and left internal mammary artery coronary bypass.

“In these cases, you still can cover the left subclavian, if you do it first,” said Dr. Malina. This can be followed by transposition of the subclavian or carotid-subclavian bypass.

▸ Deployment. “It is actually very hard to assess where the stent graft will be deployed,” said Dr. Malina. Whether the carotid artery will be covered is of particular concern, even after the stent has been deployed. Some projections used to view the stent may give the appearance that the carotid artery is not covered, when in fact it is or vice versa. “You have to find the ideal projection … to really prove that you have not covered the vessel,” he said.

▸ Durability. When the stent is deployed at the vertex of an elongated aortic arch, “the blood will hit the upper surface of the stent-graft and you will end up having a flapping motion,” which contributes to material fatigue and possibly stent collapse, leading to occlusion or migration and high risk of death. said Dr. Malina. “Also this flapping motion may erode the arch and cause immediate rupture and hemorrhage.”

Motion also should be avoided when telescoping the various components, or the stent-graft can disintegrate. Also, without sufficient overlap, the stent can migrate upward. “So wherever you place the stent-graft, you must make sure that you have enough overlap and secure the position of the stent-graft without any motion,” said Dr. Malina, who disclosed that he had no conflicts of interest.

NEW YORK — While stent grafting of thoracic aortic aneurysm has become more routine, the procedure still has a number of limitations, Martin Malina, Ph.D., said at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

Currently-available thoracic endografts are limited by issues of access, hostile neck, deployment, and durability. Dr. Malina, a consultant vascular surgeon at Malmö (Sweden) University Hospital, offered thoughts on these limitations and tips for overcoming them.

▸ Access. “We do have many quite simple tricks to get around this problem,” of access said Dr. Malina.

He recommends using an ultra-stiff guidewire. And don't push the graft in. “The more you push, the more the wire buckles,” he said. To avoid this, use a brachial wire to pull the graft by placing a clamp at the lower end of the wire. “This way, the more you pull, the more the wire will get straightened out.”

Iliac stenosis poses an access problem. One alternative is to make an incision in the groin and to advance the sheath outside of and parallel to the external iliac artery, inserting the graft at a more favorable angle.

▸ The neck. “Very often there is no neck,” said Dr. Malina. One option in these cases is to push the stent graft further around the arch, covering the left subclavian artery. Contraindications to this technique include right vertebral stenosis, aberrant right subclavian artery lusoria, and left internal mammary artery coronary bypass.

“In these cases, you still can cover the left subclavian, if you do it first,” said Dr. Malina. This can be followed by transposition of the subclavian or carotid-subclavian bypass.

▸ Deployment. “It is actually very hard to assess where the stent graft will be deployed,” said Dr. Malina. Whether the carotid artery will be covered is of particular concern, even after the stent has been deployed. Some projections used to view the stent may give the appearance that the carotid artery is not covered, when in fact it is or vice versa. “You have to find the ideal projection … to really prove that you have not covered the vessel,” he said.

▸ Durability. When the stent is deployed at the vertex of an elongated aortic arch, “the blood will hit the upper surface of the stent-graft and you will end up having a flapping motion,” which contributes to material fatigue and possibly stent collapse, leading to occlusion or migration and high risk of death. said Dr. Malina. “Also this flapping motion may erode the arch and cause immediate rupture and hemorrhage.”

Motion also should be avoided when telescoping the various components, or the stent-graft can disintegrate. Also, without sufficient overlap, the stent can migrate upward. “So wherever you place the stent-graft, you must make sure that you have enough overlap and secure the position of the stent-graft without any motion,” said Dr. Malina, who disclosed that he had no conflicts of interest.

NEW YORK — While stent grafting of thoracic aortic aneurysm has become more routine, the procedure still has a number of limitations, Martin Malina, Ph.D., said at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

Currently-available thoracic endografts are limited by issues of access, hostile neck, deployment, and durability. Dr. Malina, a consultant vascular surgeon at Malmö (Sweden) University Hospital, offered thoughts on these limitations and tips for overcoming them.

▸ Access. “We do have many quite simple tricks to get around this problem,” of access said Dr. Malina.

He recommends using an ultra-stiff guidewire. And don't push the graft in. “The more you push, the more the wire buckles,” he said. To avoid this, use a brachial wire to pull the graft by placing a clamp at the lower end of the wire. “This way, the more you pull, the more the wire will get straightened out.”

Iliac stenosis poses an access problem. One alternative is to make an incision in the groin and to advance the sheath outside of and parallel to the external iliac artery, inserting the graft at a more favorable angle.

▸ The neck. “Very often there is no neck,” said Dr. Malina. One option in these cases is to push the stent graft further around the arch, covering the left subclavian artery. Contraindications to this technique include right vertebral stenosis, aberrant right subclavian artery lusoria, and left internal mammary artery coronary bypass.

“In these cases, you still can cover the left subclavian, if you do it first,” said Dr. Malina. This can be followed by transposition of the subclavian or carotid-subclavian bypass.

▸ Deployment. “It is actually very hard to assess where the stent graft will be deployed,” said Dr. Malina. Whether the carotid artery will be covered is of particular concern, even after the stent has been deployed. Some projections used to view the stent may give the appearance that the carotid artery is not covered, when in fact it is or vice versa. “You have to find the ideal projection … to really prove that you have not covered the vessel,” he said.

▸ Durability. When the stent is deployed at the vertex of an elongated aortic arch, “the blood will hit the upper surface of the stent-graft and you will end up having a flapping motion,” which contributes to material fatigue and possibly stent collapse, leading to occlusion or migration and high risk of death. said Dr. Malina. “Also this flapping motion may erode the arch and cause immediate rupture and hemorrhage.”

Motion also should be avoided when telescoping the various components, or the stent-graft can disintegrate. Also, without sufficient overlap, the stent can migrate upward. “So wherever you place the stent-graft, you must make sure that you have enough overlap and secure the position of the stent-graft without any motion,” said Dr. Malina, who disclosed that he had no conflicts of interest.

NEW YORK — Conservative management of arterial insufficiency and limb ulceration results in complete wound closure in slightly more than half of patients and limb amputation in less than a quarter, Dr. Blair A. Keagy said at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

“Many lower grade Wagner lesions can be successfully given conservative management, while lower extremity revascularization may be overused,” said Dr. Keagy, chief of the division of vascular surgery at University of North Carolina Hospitals in Chapel Hill.

There are several methods of percutaneous revascularization, but not all patients are good candidates for such procedures. Very little is known about the natural history of arterial insufficiency and limb ulceration.

Dr. Keagy and his colleagues conducted a retrospective review of patients with arterial insufficiency (defined as ankle-brachial index less than 0.7 or a toe pressure less than 50 mm Hg) and full-thickness limb ulcers of at least 6 weeks in duration. Wounds had to measure at least 1 cm in any dimension at the initial visit. Patients determined to be poor candidates for revascularization because of severe medical comorbidity, nonambulatory status, inadequate outflow vessels, or patient/family refusal were treated using a wound management protocol only.

A total of 169 limbs in 142 patients were treated with wound management alone. More than half of these patients (70%) had diabetes. Most wounds (76%) were classified as Wagner grade 1. The average wound size was 8 cm

Wounds were graded using the six-grade Wagner scale. Grade 0 wounds are defined as preulcerative, healed ulcers, or bony deformities. Grade 1 wounds are defined as superficial ulcers with no subcutaneous tissue exposure; grade 2 wounds involve penetration through the subcutaneous tissue (and may expose bone, tendon, ligament, or joint); grade 3 wounds involve osteitis, abscess, or osteomyelitis; grade 4 wounds involve gangrene of the forefoot; grade 5 wounds involve gangrene of the entire foot.

Patients were excluded if they had grade 4 wounds with extensive tissue loss, grade 5 wounds, necrotizing foot infections, or other major infections.

Patients came in for weekly outpatient visits for the first 4 weeks, followed by visits every 1–3 weeks thereafter. The wound management protocol focused on debridement, pressure relief, infection control, and creating and maintaining moist wound healing environments. Wounds were documented using digital photography and wound planimetry.

The primary end point was the incidence of major limb amputation at 1 year. The secondary end point was the incidence of wound closure at 1 year. Wound closure was defined as complete epithelial coverage with no drainage at two consecutive visits. At 1 year follow-up, 147 limbs were evaluated. Of these, 23% of patients required amputation and 52% had complete closure.

ABI was independently associated with amputation at 1 year, based on multivariate analysis. Of patients with an ABI less than 0.5, 34% had amputations at 1 year, compared with 15% of those with ABI greater than 0.5.

In addition, an initial wound grade of 1 or 2 resulted in amputation less frequently (19%) than wound grades of 3 or 4 (27%), though there were few patients with wound grades 3 or 4. The only significant predictor of amputation was the initial wound size.

Advanced healing techniques were used at the physicians' discretion and included platelet-derived growth factor (12% of limbs), negative pressure therapy (4% of limbs), and bioengineered living dermis (9% of limbs). Overall, 19% of patients received one or more of these treatments.

Dr. Keagy disclosed that he has no conflicts of interest.

NEW YORK — Conservative management of arterial insufficiency and limb ulceration results in complete wound closure in slightly more than half of patients and limb amputation in less than a quarter, Dr. Blair A. Keagy said at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

“Many lower grade Wagner lesions can be successfully given conservative management, while lower extremity revascularization may be overused,” said Dr. Keagy, chief of the division of vascular surgery at University of North Carolina Hospitals in Chapel Hill.

There are several methods of percutaneous revascularization, but not all patients are good candidates for such procedures. Very little is known about the natural history of arterial insufficiency and limb ulceration.

Dr. Keagy and his colleagues conducted a retrospective review of patients with arterial insufficiency (defined as ankle-brachial index less than 0.7 or a toe pressure less than 50 mm Hg) and full-thickness limb ulcers of at least 6 weeks in duration. Wounds had to measure at least 1 cm in any dimension at the initial visit. Patients determined to be poor candidates for revascularization because of severe medical comorbidity, nonambulatory status, inadequate outflow vessels, or patient/family refusal were treated using a wound management protocol only.

A total of 169 limbs in 142 patients were treated with wound management alone. More than half of these patients (70%) had diabetes. Most wounds (76%) were classified as Wagner grade 1. The average wound size was 8 cm

Wounds were graded using the six-grade Wagner scale. Grade 0 wounds are defined as preulcerative, healed ulcers, or bony deformities. Grade 1 wounds are defined as superficial ulcers with no subcutaneous tissue exposure; grade 2 wounds involve penetration through the subcutaneous tissue (and may expose bone, tendon, ligament, or joint); grade 3 wounds involve osteitis, abscess, or osteomyelitis; grade 4 wounds involve gangrene of the forefoot; grade 5 wounds involve gangrene of the entire foot.

Patients were excluded if they had grade 4 wounds with extensive tissue loss, grade 5 wounds, necrotizing foot infections, or other major infections.

Patients came in for weekly outpatient visits for the first 4 weeks, followed by visits every 1–3 weeks thereafter. The wound management protocol focused on debridement, pressure relief, infection control, and creating and maintaining moist wound healing environments. Wounds were documented using digital photography and wound planimetry.

The primary end point was the incidence of major limb amputation at 1 year. The secondary end point was the incidence of wound closure at 1 year. Wound closure was defined as complete epithelial coverage with no drainage at two consecutive visits. At 1 year follow-up, 147 limbs were evaluated. Of these, 23% of patients required amputation and 52% had complete closure.

ABI was independently associated with amputation at 1 year, based on multivariate analysis. Of patients with an ABI less than 0.5, 34% had amputations at 1 year, compared with 15% of those with ABI greater than 0.5.

In addition, an initial wound grade of 1 or 2 resulted in amputation less frequently (19%) than wound grades of 3 or 4 (27%), though there were few patients with wound grades 3 or 4. The only significant predictor of amputation was the initial wound size.

Advanced healing techniques were used at the physicians' discretion and included platelet-derived growth factor (12% of limbs), negative pressure therapy (4% of limbs), and bioengineered living dermis (9% of limbs). Overall, 19% of patients received one or more of these treatments.

Dr. Keagy disclosed that he has no conflicts of interest.

NEW YORK — Conservative management of arterial insufficiency and limb ulceration results in complete wound closure in slightly more than half of patients and limb amputation in less than a quarter, Dr. Blair A. Keagy said at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

“Many lower grade Wagner lesions can be successfully given conservative management, while lower extremity revascularization may be overused,” said Dr. Keagy, chief of the division of vascular surgery at University of North Carolina Hospitals in Chapel Hill.

There are several methods of percutaneous revascularization, but not all patients are good candidates for such procedures. Very little is known about the natural history of arterial insufficiency and limb ulceration.

Dr. Keagy and his colleagues conducted a retrospective review of patients with arterial insufficiency (defined as ankle-brachial index less than 0.7 or a toe pressure less than 50 mm Hg) and full-thickness limb ulcers of at least 6 weeks in duration. Wounds had to measure at least 1 cm in any dimension at the initial visit. Patients determined to be poor candidates for revascularization because of severe medical comorbidity, nonambulatory status, inadequate outflow vessels, or patient/family refusal were treated using a wound management protocol only.

A total of 169 limbs in 142 patients were treated with wound management alone. More than half of these patients (70%) had diabetes. Most wounds (76%) were classified as Wagner grade 1. The average wound size was 8 cm

Wounds were graded using the six-grade Wagner scale. Grade 0 wounds are defined as preulcerative, healed ulcers, or bony deformities. Grade 1 wounds are defined as superficial ulcers with no subcutaneous tissue exposure; grade 2 wounds involve penetration through the subcutaneous tissue (and may expose bone, tendon, ligament, or joint); grade 3 wounds involve osteitis, abscess, or osteomyelitis; grade 4 wounds involve gangrene of the forefoot; grade 5 wounds involve gangrene of the entire foot.

Patients were excluded if they had grade 4 wounds with extensive tissue loss, grade 5 wounds, necrotizing foot infections, or other major infections.

Patients came in for weekly outpatient visits for the first 4 weeks, followed by visits every 1–3 weeks thereafter. The wound management protocol focused on debridement, pressure relief, infection control, and creating and maintaining moist wound healing environments. Wounds were documented using digital photography and wound planimetry.

The primary end point was the incidence of major limb amputation at 1 year. The secondary end point was the incidence of wound closure at 1 year. Wound closure was defined as complete epithelial coverage with no drainage at two consecutive visits. At 1 year follow-up, 147 limbs were evaluated. Of these, 23% of patients required amputation and 52% had complete closure.

ABI was independently associated with amputation at 1 year, based on multivariate analysis. Of patients with an ABI less than 0.5, 34% had amputations at 1 year, compared with 15% of those with ABI greater than 0.5.

In addition, an initial wound grade of 1 or 2 resulted in amputation less frequently (19%) than wound grades of 3 or 4 (27%), though there were few patients with wound grades 3 or 4. The only significant predictor of amputation was the initial wound size.

Advanced healing techniques were used at the physicians' discretion and included platelet-derived growth factor (12% of limbs), negative pressure therapy (4% of limbs), and bioengineered living dermis (9% of limbs). Overall, 19% of patients received one or more of these treatments.

Dr. Keagy disclosed that he has no conflicts of interest.

Coronary artery calcium scoring by CT can be a useful tool in the evaluation of asymptomatic patients with an intermediate risk of coronary heart disease but not those with low or high risk, according to expert consensus.

On Jan. 23, the American College of Cardiology Foundation and the American Heart Association jointly released an expert consensus document that updates information and opinion on coronary artery calcium (CAC) scoring by CT, particularly with regard to global cardiovascular risk assessment and evaluation of patients with chest pain (J. Am. Coll. Cardiol. 2007;49:378–402). The last consensus document on the use of electron-beam CT for the diagnosis and prognosis of coronary artery disease (CAD) was published in 2000.

On the basis of data available since that time, the committee concluded that CAC measurement using CT scanning is a reasonable tool for evaluating asymptomatic patients with a 10-year risk of estimated CHD events between 10% and 20%.

“The test does what it does very well—it detects calcium. It's a marker of atherosclerosis and ergo a marker of higher risk,” said Dr. Robert O. Bonow, a member of the writing committee and chief of the division of cardiology at Northwestern Memorial Hospital in Chicago in an interview. With the intermediate group, CAC measurement could help cardiologists decide how aggressive to be with treatment.

However, the authors advised against the use of CAC measurement in patients with low CHD risk (below 10% 10-year risk of estimated CHD events). They noted that CAC measurements in this patient group would be similar to using the technique for population screening, which the committee also counseled against.

Likewise, the authors advised against the use of CAC measurements in asymptomatic patients with high CHD risk (greater than 20% 10-year risk of estimated CHD events or established coronary disease, or other high-risk diagnoses). Patients in this category “should be treated aggressively consistent with secondary prevention goals based upon the current National Cholesterol Education Program III guidelines and thus should not require additional testing, including CAC scoring, to establish this risk evaluation,” they wrote.

“If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk,” said Dr. Bonow. “If you're very high risk, it's high risk no matter what.”

While the recommendations give the thumbs up to the use of CAC to evaluate patients with intermediate risk, the authors noted that there have been no head-to-head comparisons of CAC with other assessment tools. Some, such as ankle/brachial index or carotid ultrasound, may be less expensive.

There have also been no randomized trials that demonstrate that CAC measurement improves outcomes. “This created a lot of discussion in the committee,” said Dr. Bonow. “The problem is that it's not clear that the trial will ever be done. Meanwhile, we have data that [CAC] might be a useful test in certain subsets of patients,” said Dr. Bonow.

The committee also noted that the strongest CAC data are for white men. Until additional data in other groups are available, the authors recommended caution in extrapolating CAC data derived from these studies in women and ethnic minorities.

The committee also reviewed the use of CAC measurement in patients with diabetes. It has been noted in several cross-sectional studies that patients with diabetes have a higher prevalence and degree of coronary calcium than nondiabetic patients.

The authors noted that there is some evidence to suggest “that coronary calcium might be useful to further stratify short-term risk in diabetic patients.” However, they cautioned that additional studies from nonreferral populations with longer follow-up are needed.

'If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk.' DR. BONOW

Coronary artery calcium scoring by CT can be a useful tool in the evaluation of asymptomatic patients with an intermediate risk of coronary heart disease but not those with low or high risk, according to expert consensus.

On Jan. 23, the American College of Cardiology Foundation and the American Heart Association jointly released an expert consensus document that updates information and opinion on coronary artery calcium (CAC) scoring by CT, particularly with regard to global cardiovascular risk assessment and evaluation of patients with chest pain (J. Am. Coll. Cardiol. 2007;49:378–402). The last consensus document on the use of electron-beam CT for the diagnosis and prognosis of coronary artery disease (CAD) was published in 2000.

On the basis of data available since that time, the committee concluded that CAC measurement using CT scanning is a reasonable tool for evaluating asymptomatic patients with a 10-year risk of estimated CHD events between 10% and 20%.

“The test does what it does very well—it detects calcium. It's a marker of atherosclerosis and ergo a marker of higher risk,” said Dr. Robert O. Bonow, a member of the writing committee and chief of the division of cardiology at Northwestern Memorial Hospital in Chicago in an interview. With the intermediate group, CAC measurement could help cardiologists decide how aggressive to be with treatment.

However, the authors advised against the use of CAC measurement in patients with low CHD risk (below 10% 10-year risk of estimated CHD events). They noted that CAC measurements in this patient group would be similar to using the technique for population screening, which the committee also counseled against.

Likewise, the authors advised against the use of CAC measurements in asymptomatic patients with high CHD risk (greater than 20% 10-year risk of estimated CHD events or established coronary disease, or other high-risk diagnoses). Patients in this category “should be treated aggressively consistent with secondary prevention goals based upon the current National Cholesterol Education Program III guidelines and thus should not require additional testing, including CAC scoring, to establish this risk evaluation,” they wrote.

“If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk,” said Dr. Bonow. “If you're very high risk, it's high risk no matter what.”

While the recommendations give the thumbs up to the use of CAC to evaluate patients with intermediate risk, the authors noted that there have been no head-to-head comparisons of CAC with other assessment tools. Some, such as ankle/brachial index or carotid ultrasound, may be less expensive.

There have also been no randomized trials that demonstrate that CAC measurement improves outcomes. “This created a lot of discussion in the committee,” said Dr. Bonow. “The problem is that it's not clear that the trial will ever be done. Meanwhile, we have data that [CAC] might be a useful test in certain subsets of patients,” said Dr. Bonow.

The committee also noted that the strongest CAC data are for white men. Until additional data in other groups are available, the authors recommended caution in extrapolating CAC data derived from these studies in women and ethnic minorities.

The committee also reviewed the use of CAC measurement in patients with diabetes. It has been noted in several cross-sectional studies that patients with diabetes have a higher prevalence and degree of coronary calcium than nondiabetic patients.

The authors noted that there is some evidence to suggest “that coronary calcium might be useful to further stratify short-term risk in diabetic patients.” However, they cautioned that additional studies from nonreferral populations with longer follow-up are needed.

'If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk.' DR. BONOW

Coronary artery calcium scoring by CT can be a useful tool in the evaluation of asymptomatic patients with an intermediate risk of coronary heart disease but not those with low or high risk, according to expert consensus.

On Jan. 23, the American College of Cardiology Foundation and the American Heart Association jointly released an expert consensus document that updates information and opinion on coronary artery calcium (CAC) scoring by CT, particularly with regard to global cardiovascular risk assessment and evaluation of patients with chest pain (J. Am. Coll. Cardiol. 2007;49:378–402). The last consensus document on the use of electron-beam CT for the diagnosis and prognosis of coronary artery disease (CAD) was published in 2000.

On the basis of data available since that time, the committee concluded that CAC measurement using CT scanning is a reasonable tool for evaluating asymptomatic patients with a 10-year risk of estimated CHD events between 10% and 20%.

“The test does what it does very well—it detects calcium. It's a marker of atherosclerosis and ergo a marker of higher risk,” said Dr. Robert O. Bonow, a member of the writing committee and chief of the division of cardiology at Northwestern Memorial Hospital in Chicago in an interview. With the intermediate group, CAC measurement could help cardiologists decide how aggressive to be with treatment.

However, the authors advised against the use of CAC measurement in patients with low CHD risk (below 10% 10-year risk of estimated CHD events). They noted that CAC measurements in this patient group would be similar to using the technique for population screening, which the committee also counseled against.

Likewise, the authors advised against the use of CAC measurements in asymptomatic patients with high CHD risk (greater than 20% 10-year risk of estimated CHD events or established coronary disease, or other high-risk diagnoses). Patients in this category “should be treated aggressively consistent with secondary prevention goals based upon the current National Cholesterol Education Program III guidelines and thus should not require additional testing, including CAC scoring, to establish this risk evaluation,” they wrote.

“If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk,” said Dr. Bonow. “If you're very high risk, it's high risk no matter what.”

While the recommendations give the thumbs up to the use of CAC to evaluate patients with intermediate risk, the authors noted that there have been no head-to-head comparisons of CAC with other assessment tools. Some, such as ankle/brachial index or carotid ultrasound, may be less expensive.

There have also been no randomized trials that demonstrate that CAC measurement improves outcomes. “This created a lot of discussion in the committee,” said Dr. Bonow. “The problem is that it's not clear that the trial will ever be done. Meanwhile, we have data that [CAC] might be a useful test in certain subsets of patients,” said Dr. Bonow.

The committee also noted that the strongest CAC data are for white men. Until additional data in other groups are available, the authors recommended caution in extrapolating CAC data derived from these studies in women and ethnic minorities.

The committee also reviewed the use of CAC measurement in patients with diabetes. It has been noted in several cross-sectional studies that patients with diabetes have a higher prevalence and degree of coronary calcium than nondiabetic patients.

The authors noted that there is some evidence to suggest “that coronary calcium might be useful to further stratify short-term risk in diabetic patients.” However, they cautioned that additional studies from nonreferral populations with longer follow-up are needed.

'If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk.' DR. BONOW

Coronary artery calcium scoring by CT can be considered as a useful tool in the evaluation of asymptomatic patients with an intermediate risk of coronary heart disease but not those with low or high risk, according to expert consensus.

On Jan. 23, the American College of Cardiology Foundation and the American Heart Association jointly released an expert consensus document that updates information and opinion on coronary artery calcium (CAC) scoring by CT, particularly with regard to global cardiovascular risk assessment and evaluation of patients with chest pain (J. Am. Coll. Cardiol. 2007;49:378–402). The last consensus document on the use of electron-beam CT for the diagnosis and prognosis of coronary artery disease (CAD) was published in 2000.

On the basis of data available since that time, the committee concluded that CAC measurement using CT scanning is a reasonable tool for evaluating asymptomatic patients with a 10-year risk of estimated coronary heart disease (CHD) events between 10% and 20%.

“The test does what it does very well—it detects calcium. It's a marker of atherosclerosis and ergo a marker of higher risk,” said Dr. Robert O. Bonow, a member of the writing committee and chief of the division of cardiology at Northwestern Memorial Hospital in Chicago, in an interview.

With the intermediate group, CAC measurement could help cardiologists decide how aggressive to be with treatment.

However, the investigators advised against the use of CAC measurement in patients with low CHD risk (below 10% 10-year risk of estimated CHD events). They noted that CAC measurements in this patient group would be similar to using the technique for population screening, which the committee also counseled against.

Similarly, the authors advised against the use of CAC measurements in asymptomatic patients who have a high risk of CHD (greater than 20% 10-year risk of estimated CHD events or established coronary disease, or other high-risk diagnoses). Patients who fall under this category “should be treated aggressively consistent with secondary prevention goals based upon the current National Cholesterol Education Program III guidelines and thus should not require additional testing, including CAC scoring, to establish this risk evaluation,” the researchers wrote.

“If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk,” Dr. Bonow said. “If you're very high risk, it's high risk no matter what.”

While the recommendations give the thumbs up to the use of CAC to evaluate patients with intermediate risk, the authors noted that there have been no head-to-head comparisons of CAC with other assessment tools. Some, such as ankle-brachial index or carotid ultrasound, may be less expensive.

There have also been no randomized trials that demonstrate that CAC measurement improves outcomes. “This created a lot of discussion in the committee,” Dr. Bonow said.

“The problem is that it's not clear that the trial will ever be done. Meanwhile, we have data that [CAC] might be a useful test in certain subsets of patients,” he continued.

The committee also noted that the strongest CAC data are for white men. Until additional data in other groups are available, the authors recommended caution in extrapolating CAC data derived from these studies in women and ethnic minorities.

The committee also reviewed the use of CAC measurement in patients with diabetes. It has been documented in several cross-sectional studies that patients with diabetes have a higher prevalence and degree of coronary calcium than nondiabetic patients.

The authors noted that there is some evidence to suggest “that coronary calcium might be useful to further stratify short-term risk in diabetic patients.” However, they cautioned that additional studies from nonreferral populations with longer follow-up are needed.

Coronary artery calcium is 'a marker of atherosclerosis and ergo a marker of higher risk.' DR. BONOW

Coronary artery calcium scoring by CT can be considered as a useful tool in the evaluation of asymptomatic patients with an intermediate risk of coronary heart disease but not those with low or high risk, according to expert consensus.

On Jan. 23, the American College of Cardiology Foundation and the American Heart Association jointly released an expert consensus document that updates information and opinion on coronary artery calcium (CAC) scoring by CT, particularly with regard to global cardiovascular risk assessment and evaluation of patients with chest pain (J. Am. Coll. Cardiol. 2007;49:378–402). The last consensus document on the use of electron-beam CT for the diagnosis and prognosis of coronary artery disease (CAD) was published in 2000.

On the basis of data available since that time, the committee concluded that CAC measurement using CT scanning is a reasonable tool for evaluating asymptomatic patients with a 10-year risk of estimated coronary heart disease (CHD) events between 10% and 20%.

“The test does what it does very well—it detects calcium. It's a marker of atherosclerosis and ergo a marker of higher risk,” said Dr. Robert O. Bonow, a member of the writing committee and chief of the division of cardiology at Northwestern Memorial Hospital in Chicago, in an interview.

With the intermediate group, CAC measurement could help cardiologists decide how aggressive to be with treatment.

However, the investigators advised against the use of CAC measurement in patients with low CHD risk (below 10% 10-year risk of estimated CHD events). They noted that CAC measurements in this patient group would be similar to using the technique for population screening, which the committee also counseled against.

Similarly, the authors advised against the use of CAC measurements in asymptomatic patients who have a high risk of CHD (greater than 20% 10-year risk of estimated CHD events or established coronary disease, or other high-risk diagnoses). Patients who fall under this category “should be treated aggressively consistent with secondary prevention goals based upon the current National Cholesterol Education Program III guidelines and thus should not require additional testing, including CAC scoring, to establish this risk evaluation,” the researchers wrote.

“If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk,” Dr. Bonow said. “If you're very high risk, it's high risk no matter what.”

While the recommendations give the thumbs up to the use of CAC to evaluate patients with intermediate risk, the authors noted that there have been no head-to-head comparisons of CAC with other assessment tools. Some, such as ankle-brachial index or carotid ultrasound, may be less expensive.

There have also been no randomized trials that demonstrate that CAC measurement improves outcomes. “This created a lot of discussion in the committee,” Dr. Bonow said.

“The problem is that it's not clear that the trial will ever be done. Meanwhile, we have data that [CAC] might be a useful test in certain subsets of patients,” he continued.

The committee also noted that the strongest CAC data are for white men. Until additional data in other groups are available, the authors recommended caution in extrapolating CAC data derived from these studies in women and ethnic minorities.

The committee also reviewed the use of CAC measurement in patients with diabetes. It has been documented in several cross-sectional studies that patients with diabetes have a higher prevalence and degree of coronary calcium than nondiabetic patients.

The authors noted that there is some evidence to suggest “that coronary calcium might be useful to further stratify short-term risk in diabetic patients.” However, they cautioned that additional studies from nonreferral populations with longer follow-up are needed.

Coronary artery calcium is 'a marker of atherosclerosis and ergo a marker of higher risk.' DR. BONOW

Coronary artery calcium scoring by CT can be considered as a useful tool in the evaluation of asymptomatic patients with an intermediate risk of coronary heart disease but not those with low or high risk, according to expert consensus.

On Jan. 23, the American College of Cardiology Foundation and the American Heart Association jointly released an expert consensus document that updates information and opinion on coronary artery calcium (CAC) scoring by CT, particularly with regard to global cardiovascular risk assessment and evaluation of patients with chest pain (J. Am. Coll. Cardiol. 2007;49:378–402). The last consensus document on the use of electron-beam CT for the diagnosis and prognosis of coronary artery disease (CAD) was published in 2000.

On the basis of data available since that time, the committee concluded that CAC measurement using CT scanning is a reasonable tool for evaluating asymptomatic patients with a 10-year risk of estimated coronary heart disease (CHD) events between 10% and 20%.

“The test does what it does very well—it detects calcium. It's a marker of atherosclerosis and ergo a marker of higher risk,” said Dr. Robert O. Bonow, a member of the writing committee and chief of the division of cardiology at Northwestern Memorial Hospital in Chicago, in an interview.

With the intermediate group, CAC measurement could help cardiologists decide how aggressive to be with treatment.

However, the investigators advised against the use of CAC measurement in patients with low CHD risk (below 10% 10-year risk of estimated CHD events). They noted that CAC measurements in this patient group would be similar to using the technique for population screening, which the committee also counseled against.

Similarly, the authors advised against the use of CAC measurements in asymptomatic patients who have a high risk of CHD (greater than 20% 10-year risk of estimated CHD events or established coronary disease, or other high-risk diagnoses). Patients who fall under this category “should be treated aggressively consistent with secondary prevention goals based upon the current National Cholesterol Education Program III guidelines and thus should not require additional testing, including CAC scoring, to establish this risk evaluation,” the researchers wrote.

“If you have someone at low risk and a positive calcium scan doubles your risk from 1% to 2%, it's still low risk,” Dr. Bonow said. “If you're very high risk, it's high risk no matter what.”

While the recommendations give the thumbs up to the use of CAC to evaluate patients with intermediate risk, the authors noted that there have been no head-to-head comparisons of CAC with other assessment tools. Some, such as ankle-brachial index or carotid ultrasound, may be less expensive.

There have also been no randomized trials that demonstrate that CAC measurement improves outcomes. “This created a lot of discussion in the committee,” Dr. Bonow said.

“The problem is that it's not clear that the trial will ever be done. Meanwhile, we have data that [CAC] might be a useful test in certain subsets of patients,” he continued.

The committee also noted that the strongest CAC data are for white men. Until additional data in other groups are available, the authors recommended caution in extrapolating CAC data derived from these studies in women and ethnic minorities.

The committee also reviewed the use of CAC measurement in patients with diabetes. It has been documented in several cross-sectional studies that patients with diabetes have a higher prevalence and degree of coronary calcium than nondiabetic patients.

The authors noted that there is some evidence to suggest “that coronary calcium might be useful to further stratify short-term risk in diabetic patients.” However, they cautioned that additional studies from nonreferral populations with longer follow-up are needed.

Coronary artery calcium is 'a marker of atherosclerosis and ergo a marker of higher risk.' DR. BONOW

PHILADELPHIA — Teriparatide appears to increase bone mineral density regardless of prior antiresorptive therapy response, said Dr. Barbara Obermayer-Pietsch at the annual meeting of the American Society for Bone and Mineral Research.

Dr. Obermayer-Pietsch of Universitätsklinik für Innere Medizin in Graz, Austria, and her colleagues looked at bone mineral density (BMD) changes at the lumbar spine, femoral neck, and total hip in 503 women who received teriparatide (Forteo) for 2 years.

The women were grouped by exposure and response to previous antiresorptive therapy (no prior therapy, adequate response to prior therapy, and inadequate response to prior therapy).

Inadequate response was defined as at least one new clinical fragility fracture after 12 months of therapy, a T score less than or equal to -3 after 24 months of therapy, or a BMD decrease of at least 3.5% after more than 24 months of therapy.

In all, 84 women were antiresorptive-treatment naive, 109 were adequate responders, and 310 were inadequate responders.

In terms of previous treatment, 86% of bisphosphonate users in the adequate-response group and 93% of bisphosphonate users in the inadequate-response group used alendronate, risedronate, or etidronate.

The remaining patients used selective estrogen-receptor modulators, hormone therapy, or vitamin supplements.

“We found an immediate and continuous increase of BMD at the lumbar spine in all groups. However, this was more pronounced in the treatment-naive group,” said Dr. Obermayer-Pietsch.

The antiresorptive-therapy inadequate responders initially had a transient decrease in lumbar spine, total hip, and femoral neck BMD but caught up with the other two groups at the end of 2 years (see box, below right).

The women were enrolled as part of the European Forteo Study trial, which compared three different teriparatide treatment regimens in postmenopausal women with established osteoporosis.

All enrolled women (868) were treated with teriparatide (20 mcg/day), calcium (500 mg/day), and vitamin D (400–800 IU/day) supplements for 1 year.

At the end of the first year, the women were randomized at a ratio of 3:1:1 to 1 year of treatment with 20 mcg/day teriparatide, treatment with 60 mg/day raloxifene (Evista), or treatment with calcium and vitamin D supplements alone.

A fourth cohort of women who were determined to have had an inadequate response to prior antiresorptive therapy received 20 mcg/day teriparatide for 2 years.

This study was funded in part by Eli Lilly & Co., the manufacturer of teriparatide. Dr. Obermayer-Pietsch disclosed that she has received grants from Eli Lilly & Co.

ELSEVIER GLOBAL MEDICAL NEWS

PHILADELPHIA — Teriparatide appears to increase bone mineral density regardless of prior antiresorptive therapy response, said Dr. Barbara Obermayer-Pietsch at the annual meeting of the American Society for Bone and Mineral Research.

Dr. Obermayer-Pietsch of Universitätsklinik für Innere Medizin in Graz, Austria, and her colleagues looked at bone mineral density (BMD) changes at the lumbar spine, femoral neck, and total hip in 503 women who received teriparatide (Forteo) for 2 years.

The women were grouped by exposure and response to previous antiresorptive therapy (no prior therapy, adequate response to prior therapy, and inadequate response to prior therapy).

Inadequate response was defined as at least one new clinical fragility fracture after 12 months of therapy, a T score less than or equal to -3 after 24 months of therapy, or a BMD decrease of at least 3.5% after more than 24 months of therapy.

In all, 84 women were antiresorptive-treatment naive, 109 were adequate responders, and 310 were inadequate responders.

In terms of previous treatment, 86% of bisphosphonate users in the adequate-response group and 93% of bisphosphonate users in the inadequate-response group used alendronate, risedronate, or etidronate.

The remaining patients used selective estrogen-receptor modulators, hormone therapy, or vitamin supplements.

“We found an immediate and continuous increase of BMD at the lumbar spine in all groups. However, this was more pronounced in the treatment-naive group,” said Dr. Obermayer-Pietsch.

The antiresorptive-therapy inadequate responders initially had a transient decrease in lumbar spine, total hip, and femoral neck BMD but caught up with the other two groups at the end of 2 years (see box, below right).

The women were enrolled as part of the European Forteo Study trial, which compared three different teriparatide treatment regimens in postmenopausal women with established osteoporosis.

All enrolled women (868) were treated with teriparatide (20 mcg/day), calcium (500 mg/day), and vitamin D (400–800 IU/day) supplements for 1 year.

At the end of the first year, the women were randomized at a ratio of 3:1:1 to 1 year of treatment with 20 mcg/day teriparatide, treatment with 60 mg/day raloxifene (Evista), or treatment with calcium and vitamin D supplements alone.

A fourth cohort of women who were determined to have had an inadequate response to prior antiresorptive therapy received 20 mcg/day teriparatide for 2 years.

This study was funded in part by Eli Lilly & Co., the manufacturer of teriparatide. Dr. Obermayer-Pietsch disclosed that she has received grants from Eli Lilly & Co.

ELSEVIER GLOBAL MEDICAL NEWS

PHILADELPHIA — Teriparatide appears to increase bone mineral density regardless of prior antiresorptive therapy response, said Dr. Barbara Obermayer-Pietsch at the annual meeting of the American Society for Bone and Mineral Research.

Dr. Obermayer-Pietsch of Universitätsklinik für Innere Medizin in Graz, Austria, and her colleagues looked at bone mineral density (BMD) changes at the lumbar spine, femoral neck, and total hip in 503 women who received teriparatide (Forteo) for 2 years.

The women were grouped by exposure and response to previous antiresorptive therapy (no prior therapy, adequate response to prior therapy, and inadequate response to prior therapy).

Inadequate response was defined as at least one new clinical fragility fracture after 12 months of therapy, a T score less than or equal to -3 after 24 months of therapy, or a BMD decrease of at least 3.5% after more than 24 months of therapy.

In all, 84 women were antiresorptive-treatment naive, 109 were adequate responders, and 310 were inadequate responders.

In terms of previous treatment, 86% of bisphosphonate users in the adequate-response group and 93% of bisphosphonate users in the inadequate-response group used alendronate, risedronate, or etidronate.

The remaining patients used selective estrogen-receptor modulators, hormone therapy, or vitamin supplements.

“We found an immediate and continuous increase of BMD at the lumbar spine in all groups. However, this was more pronounced in the treatment-naive group,” said Dr. Obermayer-Pietsch.

The antiresorptive-therapy inadequate responders initially had a transient decrease in lumbar spine, total hip, and femoral neck BMD but caught up with the other two groups at the end of 2 years (see box, below right).

The women were enrolled as part of the European Forteo Study trial, which compared three different teriparatide treatment regimens in postmenopausal women with established osteoporosis.

All enrolled women (868) were treated with teriparatide (20 mcg/day), calcium (500 mg/day), and vitamin D (400–800 IU/day) supplements for 1 year.

At the end of the first year, the women were randomized at a ratio of 3:1:1 to 1 year of treatment with 20 mcg/day teriparatide, treatment with 60 mg/day raloxifene (Evista), or treatment with calcium and vitamin D supplements alone.

A fourth cohort of women who were determined to have had an inadequate response to prior antiresorptive therapy received 20 mcg/day teriparatide for 2 years.

This study was funded in part by Eli Lilly & Co., the manufacturer of teriparatide. Dr. Obermayer-Pietsch disclosed that she has received grants from Eli Lilly & Co.

ELSEVIER GLOBAL MEDICAL NEWS

The patient's twin brother and one sister had been diagnosed with rheumatoid arthritis (RA). On the basis of these findings and the physical evaluation, the primary care physician had diagnosed the man with RA and initiated treatment with nonsteroidal anti-inflammatory agents and prednisone. However, the symptoms did not lessen with treatment.

Physical examination demonstrated dorsal soft-tissue thickening of the bilateral index- and long-finger proximal interphalangeal (PIP) joints, said Dr. Graciela S. Alarcón, the Jane Knight Lowe Chair of Medicine in Rheumatology, in the division of clinical immunology and rheumatology at the University of Alabama, Birmingham. In addition, the patient had severe flexion contractures in the palmar fascia or flexor tendons of both hands—a finding consistent with Dupuytren's contractures. This would explain the man's inability to extend his fingers. Another test for rheumatoid factor was negative and his erythrocyte sedimentation rate was 19 mm/hr.

The presumptive diagnosis included Dupuytren's contracture, a benign, slowly progressive fibroproliferative disease of the palmar fascia that has no clear etiology or pathogenesis, and knuckle pads. The term “knuckle pad” is most often used to describe benign cutaneous lesions of the extensor surfaces of the fingers. However, the lesions most commonly affect the PIP joints rather than the entire extensor surface. These discrete round skin nodules are usually soft and free moving.

Many physicians are unfamiliar with this diagnostic condition; ultrasound examination confirmed the absence of synovitis and the presence of periarticular soft-tissue fullness in this case and several others reported by Dr. Alarcón and her colleagues (Skeletal Radiol. 2006;35:823–7). This may be important to reassure patients and physicians that they are not dealing with RA.

Knuckle pads are commonly associated with palmar and plantar fibromatosis, occurring in up to 20% of patients with Dupuytren's contracture. Less well-defined or softer knuckle pads may be confused with more common causes of soft-tissue swelling, such as inflammatory arthritis. The presence of knuckle pads may lessen the accuracy of the physical exam when assessing the presence of underlying synovitis.

The radiograph shows periarticular soft-tissue fullness, which can sometimes be seen in RA, leaving the diagnosis unclear, said Dr. Robert Lopez, a radiologist at the University of Alabama, Birmingham, who specializes in musculoskeletal imaging.

Ultrasound is demonstrably better than standard clinical joint assessment for synovitis and is more sensitive than radiography in identifying erosive disease in inflammatory arthritis. Another advantage of ultrasound is that it allows physicians to quickly see in the office what the likely causes are, said Dr. Lopez.

In their small series of patients, Dr. Alarcón and Dr. Lopez noted a difference in the sonographic appearance of knuckle pads in patients with and without Dupuytren's in a small series. These two patients showed diffuse areas of lower echo signal and skin thickening overlying the dorsum of the affected PIP joints with a linear hypoechoic band paralleling the epidermis layer. Focal subcutaneous areas of lower echo signal are more suggestive of rheumatoid nodules and neurofibromas.

No sonographic evidence of synovitis was identified in this patient, but there were clear subcutaneous areas of lower echo signal. With arthritis, the joint capsule would appear distended and the cortical surface would be irregular, while the soft tissue would appear normal.

This image shows that “the joint is fine. This person does not have an inflammatory arthritis. What he has is this condition that infiltrates the skin,” said Dr. Lopez.

The patient was reassured that he did not have rheumatoid arthritis, to his relief. He was advised to continue using anti-inflammatories on an as-needed basis but was strongly encouraged not to take them routinely. He was not referred for surgery, because the pads were not causing significant functional impairment and if removed, they are likely to return.

Periarticular soft-tissue fullness is visible on x-ray. Photos couresty Dr. Robert Lopez

Longitudinal ultrasound of the fourth PIP shows diffuse areas of low echo signal.

The patient's twin brother and one sister had been diagnosed with rheumatoid arthritis (RA). On the basis of these findings and the physical evaluation, the primary care physician had diagnosed the man with RA and initiated treatment with nonsteroidal anti-inflammatory agents and prednisone. However, the symptoms did not lessen with treatment.

Physical examination demonstrated dorsal soft-tissue thickening of the bilateral index- and long-finger proximal interphalangeal (PIP) joints, said Dr. Graciela S. Alarcón, the Jane Knight Lowe Chair of Medicine in Rheumatology, in the division of clinical immunology and rheumatology at the University of Alabama, Birmingham. In addition, the patient had severe flexion contractures in the palmar fascia or flexor tendons of both hands—a finding consistent with Dupuytren's contractures. This would explain the man's inability to extend his fingers. Another test for rheumatoid factor was negative and his erythrocyte sedimentation rate was 19 mm/hr.

The presumptive diagnosis included Dupuytren's contracture, a benign, slowly progressive fibroproliferative disease of the palmar fascia that has no clear etiology or pathogenesis, and knuckle pads. The term “knuckle pad” is most often used to describe benign cutaneous lesions of the extensor surfaces of the fingers. However, the lesions most commonly affect the PIP joints rather than the entire extensor surface. These discrete round skin nodules are usually soft and free moving.

Many physicians are unfamiliar with this diagnostic condition; ultrasound examination confirmed the absence of synovitis and the presence of periarticular soft-tissue fullness in this case and several others reported by Dr. Alarcón and her colleagues (Skeletal Radiol. 2006;35:823–7). This may be important to reassure patients and physicians that they are not dealing with RA.

Knuckle pads are commonly associated with palmar and plantar fibromatosis, occurring in up to 20% of patients with Dupuytren's contracture. Less well-defined or softer knuckle pads may be confused with more common causes of soft-tissue swelling, such as inflammatory arthritis. The presence of knuckle pads may lessen the accuracy of the physical exam when assessing the presence of underlying synovitis.

The radiograph shows periarticular soft-tissue fullness, which can sometimes be seen in RA, leaving the diagnosis unclear, said Dr. Robert Lopez, a radiologist at the University of Alabama, Birmingham, who specializes in musculoskeletal imaging.

Ultrasound is demonstrably better than standard clinical joint assessment for synovitis and is more sensitive than radiography in identifying erosive disease in inflammatory arthritis. Another advantage of ultrasound is that it allows physicians to quickly see in the office what the likely causes are, said Dr. Lopez.

In their small series of patients, Dr. Alarcón and Dr. Lopez noted a difference in the sonographic appearance of knuckle pads in patients with and without Dupuytren's in a small series. These two patients showed diffuse areas of lower echo signal and skin thickening overlying the dorsum of the affected PIP joints with a linear hypoechoic band paralleling the epidermis layer. Focal subcutaneous areas of lower echo signal are more suggestive of rheumatoid nodules and neurofibromas.

No sonographic evidence of synovitis was identified in this patient, but there were clear subcutaneous areas of lower echo signal. With arthritis, the joint capsule would appear distended and the cortical surface would be irregular, while the soft tissue would appear normal.

This image shows that “the joint is fine. This person does not have an inflammatory arthritis. What he has is this condition that infiltrates the skin,” said Dr. Lopez.

The patient was reassured that he did not have rheumatoid arthritis, to his relief. He was advised to continue using anti-inflammatories on an as-needed basis but was strongly encouraged not to take them routinely. He was not referred for surgery, because the pads were not causing significant functional impairment and if removed, they are likely to return.

Periarticular soft-tissue fullness is visible on x-ray. Photos couresty Dr. Robert Lopez

Longitudinal ultrasound of the fourth PIP shows diffuse areas of low echo signal.

The patient's twin brother and one sister had been diagnosed with rheumatoid arthritis (RA). On the basis of these findings and the physical evaluation, the primary care physician had diagnosed the man with RA and initiated treatment with nonsteroidal anti-inflammatory agents and prednisone. However, the symptoms did not lessen with treatment.

Physical examination demonstrated dorsal soft-tissue thickening of the bilateral index- and long-finger proximal interphalangeal (PIP) joints, said Dr. Graciela S. Alarcón, the Jane Knight Lowe Chair of Medicine in Rheumatology, in the division of clinical immunology and rheumatology at the University of Alabama, Birmingham. In addition, the patient had severe flexion contractures in the palmar fascia or flexor tendons of both hands—a finding consistent with Dupuytren's contractures. This would explain the man's inability to extend his fingers. Another test for rheumatoid factor was negative and his erythrocyte sedimentation rate was 19 mm/hr.

The presumptive diagnosis included Dupuytren's contracture, a benign, slowly progressive fibroproliferative disease of the palmar fascia that has no clear etiology or pathogenesis, and knuckle pads. The term “knuckle pad” is most often used to describe benign cutaneous lesions of the extensor surfaces of the fingers. However, the lesions most commonly affect the PIP joints rather than the entire extensor surface. These discrete round skin nodules are usually soft and free moving.

Many physicians are unfamiliar with this diagnostic condition; ultrasound examination confirmed the absence of synovitis and the presence of periarticular soft-tissue fullness in this case and several others reported by Dr. Alarcón and her colleagues (Skeletal Radiol. 2006;35:823–7). This may be important to reassure patients and physicians that they are not dealing with RA.

Knuckle pads are commonly associated with palmar and plantar fibromatosis, occurring in up to 20% of patients with Dupuytren's contracture. Less well-defined or softer knuckle pads may be confused with more common causes of soft-tissue swelling, such as inflammatory arthritis. The presence of knuckle pads may lessen the accuracy of the physical exam when assessing the presence of underlying synovitis.

The radiograph shows periarticular soft-tissue fullness, which can sometimes be seen in RA, leaving the diagnosis unclear, said Dr. Robert Lopez, a radiologist at the University of Alabama, Birmingham, who specializes in musculoskeletal imaging.

Ultrasound is demonstrably better than standard clinical joint assessment for synovitis and is more sensitive than radiography in identifying erosive disease in inflammatory arthritis. Another advantage of ultrasound is that it allows physicians to quickly see in the office what the likely causes are, said Dr. Lopez.

In their small series of patients, Dr. Alarcón and Dr. Lopez noted a difference in the sonographic appearance of knuckle pads in patients with and without Dupuytren's in a small series. These two patients showed diffuse areas of lower echo signal and skin thickening overlying the dorsum of the affected PIP joints with a linear hypoechoic band paralleling the epidermis layer. Focal subcutaneous areas of lower echo signal are more suggestive of rheumatoid nodules and neurofibromas.

No sonographic evidence of synovitis was identified in this patient, but there were clear subcutaneous areas of lower echo signal. With arthritis, the joint capsule would appear distended and the cortical surface would be irregular, while the soft tissue would appear normal.

This image shows that “the joint is fine. This person does not have an inflammatory arthritis. What he has is this condition that infiltrates the skin,” said Dr. Lopez.

The patient was reassured that he did not have rheumatoid arthritis, to his relief. He was advised to continue using anti-inflammatories on an as-needed basis but was strongly encouraged not to take them routinely. He was not referred for surgery, because the pads were not causing significant functional impairment and if removed, they are likely to return.

Periarticular soft-tissue fullness is visible on x-ray. Photos couresty Dr. Robert Lopez

Longitudinal ultrasound of the fourth PIP shows diffuse areas of low echo signal.

NEW YORK — While procedural complication rates for carotid artery stenting for restenosis after previous ipsilateral carotid endarterectomy are very low, the rate of in-stent restenosis is high and appears to be an ongoing process, according to data presented at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

Technical success of carotid artery stenting for restenosis was 100% in one study involving 57 procedures in 55 patients. However, survival without in-stent restenosis fell from 93% at 1 year to 76% at 4 years, said Dr. Gerrit de Borst, of the University Medical Center, Utrecht, the Netherlands.

“Our data demonstrate that restenosis is an ongoing process,” said Dr. de Borst.

The researchers followed 55 patients (63% men, mean age 70 years) who underwent 57 carotid artery stent procedures for restenosis after prior ipsilateral carotid endarterectomy between 1998 and 2004. Thirty-four Wallstents, 17 Cordis stents, and 6 other stents were used. Patients underwent serial duplex scanning and clinical evaluation at 3 and 12 months, and yearly thereafter.

The mean interval between the two procedures was 83 months. Only nine patients had symptomatic high-grade restenosis. The procedure was performed using local anesthesia and femoral access.

No deaths or strokes occurred during the procedure. However, two patients had transient ischemic attacks during the procedure. Both patients recovered prior to discharge. One patient had a groin hematoma that was treated conservatively.

Mean follow-up was 36 months. In that time, there were three deaths (because of cardiac reasons). One patient had a transient ischemic attack at 30 months, and one had a minor stroke at 60 months.

Eleven patients had restenosis defined as at least 50% during the follow-up period. Of these, three were detected at 3 months, three at 12 months, two at 24 months, one at 36 months, one at 48 months, and one at 60 months. This indicates that “restenosis is not a process that only occurs early after stent placement,” said Dr. de Borst.

Six patients had to have an additional procedure for restenosis. Three had carotid endarterectomy with stent removal. The other three had percutaneous transluminal angioplasty. Reintervention-free survival was 96% at 1 year, 94% at 2 years, 90% at 3 years, and 84% at 4 years.

Dr. de Borst disclosed that he has no conflicts of interest.

NEW YORK — While procedural complication rates for carotid artery stenting for restenosis after previous ipsilateral carotid endarterectomy are very low, the rate of in-stent restenosis is high and appears to be an ongoing process, according to data presented at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

Technical success of carotid artery stenting for restenosis was 100% in one study involving 57 procedures in 55 patients. However, survival without in-stent restenosis fell from 93% at 1 year to 76% at 4 years, said Dr. Gerrit de Borst, of the University Medical Center, Utrecht, the Netherlands.

“Our data demonstrate that restenosis is an ongoing process,” said Dr. de Borst.

The researchers followed 55 patients (63% men, mean age 70 years) who underwent 57 carotid artery stent procedures for restenosis after prior ipsilateral carotid endarterectomy between 1998 and 2004. Thirty-four Wallstents, 17 Cordis stents, and 6 other stents were used. Patients underwent serial duplex scanning and clinical evaluation at 3 and 12 months, and yearly thereafter.

The mean interval between the two procedures was 83 months. Only nine patients had symptomatic high-grade restenosis. The procedure was performed using local anesthesia and femoral access.

No deaths or strokes occurred during the procedure. However, two patients had transient ischemic attacks during the procedure. Both patients recovered prior to discharge. One patient had a groin hematoma that was treated conservatively.

Mean follow-up was 36 months. In that time, there were three deaths (because of cardiac reasons). One patient had a transient ischemic attack at 30 months, and one had a minor stroke at 60 months.

Eleven patients had restenosis defined as at least 50% during the follow-up period. Of these, three were detected at 3 months, three at 12 months, two at 24 months, one at 36 months, one at 48 months, and one at 60 months. This indicates that “restenosis is not a process that only occurs early after stent placement,” said Dr. de Borst.

Six patients had to have an additional procedure for restenosis. Three had carotid endarterectomy with stent removal. The other three had percutaneous transluminal angioplasty. Reintervention-free survival was 96% at 1 year, 94% at 2 years, 90% at 3 years, and 84% at 4 years.

Dr. de Borst disclosed that he has no conflicts of interest.

NEW YORK — While procedural complication rates for carotid artery stenting for restenosis after previous ipsilateral carotid endarterectomy are very low, the rate of in-stent restenosis is high and appears to be an ongoing process, according to data presented at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

Technical success of carotid artery stenting for restenosis was 100% in one study involving 57 procedures in 55 patients. However, survival without in-stent restenosis fell from 93% at 1 year to 76% at 4 years, said Dr. Gerrit de Borst, of the University Medical Center, Utrecht, the Netherlands.

“Our data demonstrate that restenosis is an ongoing process,” said Dr. de Borst.

The researchers followed 55 patients (63% men, mean age 70 years) who underwent 57 carotid artery stent procedures for restenosis after prior ipsilateral carotid endarterectomy between 1998 and 2004. Thirty-four Wallstents, 17 Cordis stents, and 6 other stents were used. Patients underwent serial duplex scanning and clinical evaluation at 3 and 12 months, and yearly thereafter.

The mean interval between the two procedures was 83 months. Only nine patients had symptomatic high-grade restenosis. The procedure was performed using local anesthesia and femoral access.

No deaths or strokes occurred during the procedure. However, two patients had transient ischemic attacks during the procedure. Both patients recovered prior to discharge. One patient had a groin hematoma that was treated conservatively.

Mean follow-up was 36 months. In that time, there were three deaths (because of cardiac reasons). One patient had a transient ischemic attack at 30 months, and one had a minor stroke at 60 months.

Eleven patients had restenosis defined as at least 50% during the follow-up period. Of these, three were detected at 3 months, three at 12 months, two at 24 months, one at 36 months, one at 48 months, and one at 60 months. This indicates that “restenosis is not a process that only occurs early after stent placement,” said Dr. de Borst.

Six patients had to have an additional procedure for restenosis. Three had carotid endarterectomy with stent removal. The other three had percutaneous transluminal angioplasty. Reintervention-free survival was 96% at 1 year, 94% at 2 years, 90% at 3 years, and 84% at 4 years.

Dr. de Borst disclosed that he has no conflicts of interest.

WILLIAMSBURG, VA. — A segmental plaquelike facial hemangioma should be a tip-off to evaluate an infant for PHACES syndrome (posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and other cardiac defects, eye abnormalities, sternal defects), Dr. Sharon A. Glick said at a meeting sponsored by Skin Disease Education Foundation.

To date, there have been about 200 case reports of PHACES syndrome, with a “strikingly female preponderance,” said Dr. Glick, director of pediatric dermatology at the State University of New York Downstate Medical Center in New York. The female to male ratio is 9:1.

Most patients (70%) have only one extracutaneous manifestation. “You do not need to have all the findings, you just need one extracutaneous. Of course, the common feature is a segmental plaquelike facial hemangioma,” she said.

In a recently published prospective study, 25 out of 1,096 children seen with infantile hemangioma met the criteria for PHACES syndrome in 1 year—a 2.3% incidence. Of the 127 infants with segmental type facial infantile hemangioma, 25 had PHACES sydrome—a 20% incidence (Am. J. Med. Genet. 2006;140A:975–86).

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

WILLIAMSBURG, VA. — A segmental plaquelike facial hemangioma should be a tip-off to evaluate an infant for PHACES syndrome (posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and other cardiac defects, eye abnormalities, sternal defects), Dr. Sharon A. Glick said at a meeting sponsored by Skin Disease Education Foundation.

To date, there have been about 200 case reports of PHACES syndrome, with a “strikingly female preponderance,” said Dr. Glick, director of pediatric dermatology at the State University of New York Downstate Medical Center in New York. The female to male ratio is 9:1.

Most patients (70%) have only one extracutaneous manifestation. “You do not need to have all the findings, you just need one extracutaneous. Of course, the common feature is a segmental plaquelike facial hemangioma,” she said.

In a recently published prospective study, 25 out of 1,096 children seen with infantile hemangioma met the criteria for PHACES syndrome in 1 year—a 2.3% incidence. Of the 127 infants with segmental type facial infantile hemangioma, 25 had PHACES sydrome—a 20% incidence (Am. J. Med. Genet. 2006;140A:975–86).

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

WILLIAMSBURG, VA. — A segmental plaquelike facial hemangioma should be a tip-off to evaluate an infant for PHACES syndrome (posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and other cardiac defects, eye abnormalities, sternal defects), Dr. Sharon A. Glick said at a meeting sponsored by Skin Disease Education Foundation.

To date, there have been about 200 case reports of PHACES syndrome, with a “strikingly female preponderance,” said Dr. Glick, director of pediatric dermatology at the State University of New York Downstate Medical Center in New York. The female to male ratio is 9:1.

Most patients (70%) have only one extracutaneous manifestation. “You do not need to have all the findings, you just need one extracutaneous. Of course, the common feature is a segmental plaquelike facial hemangioma,” she said.

In a recently published prospective study, 25 out of 1,096 children seen with infantile hemangioma met the criteria for PHACES syndrome in 1 year—a 2.3% incidence. Of the 127 infants with segmental type facial infantile hemangioma, 25 had PHACES sydrome—a 20% incidence (Am. J. Med. Genet. 2006;140A:975–86).

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

PHILADELPHIA — White men and black women are at an increased risk for cardiovascular disease for each standard deviation decrease in volumetric bone mineral density, according to data presented at the annual meeting of the American Society for Bone and Mineral Research.

White men have an almost 40% increased risk for each standard deviation decrease in volumetric spine bone mineral density (BMD), while black women appear to have up to a 44% increased risk for each standard deviation decrease in areal BMD, presenting a complicated picture of how bone mass and cardiovascular disease interact with gender and race, said Ghada N. Farhat, Ph.D., an epidemiology research associate at the University of Pittsburgh.

Previous studies have linked low bone mass with increased cardiovascular mortality and morbidity and clinical measures of atherosclerosis. However, many of these studies primarily have involved white women. Less is known about the associations between bone mass and cardiovascular disease (CVD) in men and other races, Dr. Farhat said.

Dr. Farhat and her colleagues performed a longitudinal analysis looking at CVD incidence and bone mass using data from the Health, Aging and Body Composition (Health ABC) study. The Health ABC study was designed to assess the association between changes in body composition and functional decline.

This analysis involved 2,310 adults aged 68–80 years who were included if CVD-free at baseline. The cohort was composed of slightly more men (55%) and white patients (58%). Study participants had to be free of disability in activities of daily living and free of functional limitations (defined as any difficulty walking a quarter of a mile or walking up 10 steps without resting) at baseline.

Incidence of CVD was defined as the onset of one or more of the following conditions between study entry and mean follow-up of 5.4 years: coronary heart disease, cerebrovascular disease, peripheral artery disease, and coronary artery disease.

Baseline areal BMD data (obtained by dual-energy x-ray absorptiometry) was available for the total hip, femoral neck, and trochanter in all patients. Baseline volumetric BMD data (obtained by quantitative CT) was available for the trabecular, integral, and cortical spine in a subset of 1,095 patients.

Regression analysis was used to assess associations of BMD measures (per standard deviation decrease) with CVD. The researchers controlled for body mass index, physical activity level, lipids, blood pressure, and other covariates in their analysis models.

During follow-up, 23% of the men and 14% of the women developed CVD. White men had the highest incidence, followed by black men, black women, and white women.

Significant interactions were observed between race and spine volumetric BMD in men. “In black men, no associations were observed between volumetric BMD measures and CVD,” Dr. Farhat said. However, in white men, significant associations were observed between spine volumetric BMD measures and CVD. White men had an increased risk of 39% and 38% for each decrease of one standard deviation for integral and cortical spine BMD, respectively.

Significant interactions were also observed between race and all of the areal BMD hip measures among women. “In black women, we observed that all of the areal BMD measures of the hip showed significant associations with CVD,” Dr. Farhat said. In black women, the risk of CVD was increased by 36%, 44%, and 34% for each decrease of one standard deviation in areal BMD of the total hip, femoral neck, and trochanter, respectively.

Neither IL-6 nor TNF-α nor oxidized LDL cholesterol levels could explain the association of BMD with the incidence of CVD, she said.

Dr. Farhat reported that she had no conflicts of interest.

PHILADELPHIA — White men and black women are at an increased risk for cardiovascular disease for each standard deviation decrease in volumetric bone mineral density, according to data presented at the annual meeting of the American Society for Bone and Mineral Research.

White men have an almost 40% increased risk for each standard deviation decrease in volumetric spine bone mineral density (BMD), while black women appear to have up to a 44% increased risk for each standard deviation decrease in areal BMD, presenting a complicated picture of how bone mass and cardiovascular disease interact with gender and race, said Ghada N. Farhat, Ph.D., an epidemiology research associate at the University of Pittsburgh.

Previous studies have linked low bone mass with increased cardiovascular mortality and morbidity and clinical measures of atherosclerosis. However, many of these studies primarily have involved white women. Less is known about the associations between bone mass and cardiovascular disease (CVD) in men and other races, Dr. Farhat said.

Dr. Farhat and her colleagues performed a longitudinal analysis looking at CVD incidence and bone mass using data from the Health, Aging and Body Composition (Health ABC) study. The Health ABC study was designed to assess the association between changes in body composition and functional decline.

This analysis involved 2,310 adults aged 68–80 years who were included if CVD-free at baseline. The cohort was composed of slightly more men (55%) and white patients (58%). Study participants had to be free of disability in activities of daily living and free of functional limitations (defined as any difficulty walking a quarter of a mile or walking up 10 steps without resting) at baseline.

Incidence of CVD was defined as the onset of one or more of the following conditions between study entry and mean follow-up of 5.4 years: coronary heart disease, cerebrovascular disease, peripheral artery disease, and coronary artery disease.

Baseline areal BMD data (obtained by dual-energy x-ray absorptiometry) was available for the total hip, femoral neck, and trochanter in all patients. Baseline volumetric BMD data (obtained by quantitative CT) was available for the trabecular, integral, and cortical spine in a subset of 1,095 patients.

Regression analysis was used to assess associations of BMD measures (per standard deviation decrease) with CVD. The researchers controlled for body mass index, physical activity level, lipids, blood pressure, and other covariates in their analysis models.

During follow-up, 23% of the men and 14% of the women developed CVD. White men had the highest incidence, followed by black men, black women, and white women.

Significant interactions were observed between race and spine volumetric BMD in men. “In black men, no associations were observed between volumetric BMD measures and CVD,” Dr. Farhat said. However, in white men, significant associations were observed between spine volumetric BMD measures and CVD. White men had an increased risk of 39% and 38% for each decrease of one standard deviation for integral and cortical spine BMD, respectively.

Significant interactions were also observed between race and all of the areal BMD hip measures among women. “In black women, we observed that all of the areal BMD measures of the hip showed significant associations with CVD,” Dr. Farhat said. In black women, the risk of CVD was increased by 36%, 44%, and 34% for each decrease of one standard deviation in areal BMD of the total hip, femoral neck, and trochanter, respectively.

Neither IL-6 nor TNF-α nor oxidized LDL cholesterol levels could explain the association of BMD with the incidence of CVD, she said.

Dr. Farhat reported that she had no conflicts of interest.

PHILADELPHIA — White men and black women are at an increased risk for cardiovascular disease for each standard deviation decrease in volumetric bone mineral density, according to data presented at the annual meeting of the American Society for Bone and Mineral Research.

White men have an almost 40% increased risk for each standard deviation decrease in volumetric spine bone mineral density (BMD), while black women appear to have up to a 44% increased risk for each standard deviation decrease in areal BMD, presenting a complicated picture of how bone mass and cardiovascular disease interact with gender and race, said Ghada N. Farhat, Ph.D., an epidemiology research associate at the University of Pittsburgh.

Previous studies have linked low bone mass with increased cardiovascular mortality and morbidity and clinical measures of atherosclerosis. However, many of these studies primarily have involved white women. Less is known about the associations between bone mass and cardiovascular disease (CVD) in men and other races, Dr. Farhat said.

Dr. Farhat and her colleagues performed a longitudinal analysis looking at CVD incidence and bone mass using data from the Health, Aging and Body Composition (Health ABC) study. The Health ABC study was designed to assess the association between changes in body composition and functional decline.

This analysis involved 2,310 adults aged 68–80 years who were included if CVD-free at baseline. The cohort was composed of slightly more men (55%) and white patients (58%). Study participants had to be free of disability in activities of daily living and free of functional limitations (defined as any difficulty walking a quarter of a mile or walking up 10 steps without resting) at baseline.

Incidence of CVD was defined as the onset of one or more of the following conditions between study entry and mean follow-up of 5.4 years: coronary heart disease, cerebrovascular disease, peripheral artery disease, and coronary artery disease.

Baseline areal BMD data (obtained by dual-energy x-ray absorptiometry) was available for the total hip, femoral neck, and trochanter in all patients. Baseline volumetric BMD data (obtained by quantitative CT) was available for the trabecular, integral, and cortical spine in a subset of 1,095 patients.

Regression analysis was used to assess associations of BMD measures (per standard deviation decrease) with CVD. The researchers controlled for body mass index, physical activity level, lipids, blood pressure, and other covariates in their analysis models.

During follow-up, 23% of the men and 14% of the women developed CVD. White men had the highest incidence, followed by black men, black women, and white women.

Significant interactions were observed between race and spine volumetric BMD in men. “In black men, no associations were observed between volumetric BMD measures and CVD,” Dr. Farhat said. However, in white men, significant associations were observed between spine volumetric BMD measures and CVD. White men had an increased risk of 39% and 38% for each decrease of one standard deviation for integral and cortical spine BMD, respectively.

Significant interactions were also observed between race and all of the areal BMD hip measures among women. “In black women, we observed that all of the areal BMD measures of the hip showed significant associations with CVD,” Dr. Farhat said. In black women, the risk of CVD was increased by 36%, 44%, and 34% for each decrease of one standard deviation in areal BMD of the total hip, femoral neck, and trochanter, respectively.

Neither IL-6 nor TNF-α nor oxidized LDL cholesterol levels could explain the association of BMD with the incidence of CVD, she said.

Dr. Farhat reported that she had no conflicts of interest.