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Hemostatic markers are associated with the risk and prognosis of atrial fibrillation: the ARIC study
Alonso, Alvaro
Tang, Weihong
Agarwal, Sunil K.
Soliman, Elsayed Z.
Chamberlain, Alanna M.
Folsom, Aaron R.
International Journal of Cardiology
Various hemostatic markers are associated with the risk of cardiovascular disease; however, limited information exists on their relationship with the occurrence and prognosis of atrial fibrillation (AF).
To assess whether hemostatic markers are associated with the incidence and prognosis of AF.
We studied 14,858 men and women in the Atherosclerosis Risk in Communities cohort, aged 45–64 and free of AF at baseline (1987–1989). Fibrinogen, von Willebrand factor (vWf), factor VII activity (VIIc), factor VIII activity (VIIIc), protein C, antithrombin III (ATIII), and activated partial thromboplastin time (aPTT) were measured in blood samples at baseline. AF and other cardiovascular outcomes through 2005 were determined following standardized protocols.
During a median follow-up of 16.8 years, 1209 cases of AF were identified. In multivariable Cox models, the hazard ratios (HR) and 95% confidence intervals (CI) of incident AF associated with a 1-standard deviation (SD) increase in each marker were 1.13 (1.07–1.20) for fibrinogen, 1.17 (1.11–1.23) for vWf, 1.17 (1.11–1.24) for factor VIIIc, 0.93 (0.88–1.00) for factor VIIc, 0.98 (0.92–1.04) for protein C, 1.00 (0.94–1.06) for aPTT and 1.00 (0.95–1.06) for ATIII. Greater factor VIIIc, fibrinogen and vWf were consistently associated with a higher risk of cardiovascular outcomes and mortality in those with and without incident AF, while greater protein C was associated with a lower risk of ischemic stroke.
Several hemostatic markers are associated with the incidence of AF independently of other cardiovascular risk factors. Their role in the risk stratification of AF patients should be further studied.
atrial fibrillation; epidemiology; prognosis; fibrinogen; von Willebrand factor
Related Articles
Hemostasis, inflammation and fatal and non-fatal coronary heart disease; long-term follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort
Kucharska-Newton, Anna M.
Couper, David J.
Pankow, James S.
Prineas, Ronald J.
Rea, Thomas D.
Sotoodehnia, Nona
Chakravarti, Aravinda
Folsom, Aaron R.
Siscovick, David S.
Rosamond, Wayne D.
Arteriosclerosis, thrombosis, and vascular biology
This study examines the hypothesis that chronic inflammation is associated with a higher risk of cardiac death compared to the risk of non-fatal myocardial infarction.
Cardiac death and non-fatal MI events were identified in the ARIC cohort during follow-up from 1987 through 2001. Markers of inflammation and hemostasis were determined at baseline using standardized procedures. Cox proportional hazard regression and polytomous logistic regression were used to estimate associations.
We observed a positive gradient in incidence of sudden cardiac death, non-sudden cardiac death and non-fatal MI in association with decreasing levels of albumin and increasing levels of white blood cell count and of markers of hemostasis (fibrinogen, von Willebrand factor, factor VIIIc). Associations for von Willebrand factor (vWF) and factor VIIIc were stronger for fatal relative to non-fatal events (3rd versus 1st tertile hazard ratios: vWF: SCD 2.67 (95% CI 1.80, 3.96), NSCD 2.11 (95% CI 1.40, 3.19), non-fatal MI 1.40 (95% CI 1.17, 1.67); factor VIIIc: SCD 2.58 (95% CI 1.77, 3.78), NSCD 2.01 (95% CI 1.38, 2.93), non-fatal MI 1.48 (95% CI 1.24, 1.78). Gradients of association for fibrinogen and white blood cell count, examined over tertiles of distribution and per one SD increase, were similar for the three endpoints. All associations were independent of smoking status.
Von Willebrand factor and factor VIIIc are associated with an increased risk of cardiac death as compared to the risk of non-fatal MI.
hemostasis; inflammation; von Willebrand factor; sudden cardiac death; non-fatal myocardial infarction
Related Articles
Kidney function and multiple hemostatic markers: cross sectional associations in the multi-ethnic study of atherosclerosis
Dubin, Ruth
Cushman, Mary
Folsom, Aaron R
Fried, Linda F
Palmas, Walter
Peralta, Carmen A
Wassel, Christina
Shlipak, Michael G
BMC Nephrology
Defined as estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2, chronic kidney disease (CKD) is strongly and independently associated with cardiovascular and overall mortality. We hypothesized that reduced kidney function would be characterized by abnormalities of hemostasis.
We tested cross-sectional associations between (eGFR) and multiple hemostatic markers among 6751 participants representing a broad spectrum of kidney function in the Multi-Ethnic Study of Atherosclerosis (MESA). Kidney function was measured using cystatin C (eGFRcys) or creatinine, using CKD Epidemiology Collaboration (eGFRcr). Hemostatic markers included soluble thrombomodulin (sTM), soluble tissue factor (sTF), D-Dimer, von Willebrand factor (vWF), factor VIII, plasmin-antiplasmin complex (PAP), tissue factor pathway inhibitor (TFPI), plasminogen activator inhibitor-1 (PAI-1), and fibrinogen. Associations were tested using multivariable linear regression with adjustment for demographics and comorbidities.
In comparison to persons with eGFRcys >90 ml/min/1.73 m2, subjects with eGFRcys < 60 ml/min/1.73 m2 had adjusted levels of sTM, sTF, D-Dimer, PAP, Factor VIII, TFPI, vWF and fibrinogen that were respectively 86%, 68%, 44%, 22%, 17%, 15%, 12% and 6% higher. Subjects with eGFRcys 60-90 ml/min/1.73 m2 had adjusted levels that were respectively 16%, 14%, 12%, 6%, 6%, 6%, 11% and 4% higher (p < 0.05 for all). Percent differences were not significantly different when groups were categorized by eGFRcr.
Throughout a broad spectrum of kidney function, lower eGFR was associated with higher levels of hemostatic markers. Dysregulation of hemostasis may be a mechanism by which reduced kidney function promotes higher cardiovascular risk.
Related Articles
Are Markers of Inflammation More Strongly Associated with Risk for Fatal Than for Nonfatal Vascular Events?
Sattar, Naveed
Murray, Heather M.
Welsh, Paul
Blauw, Gerard J.
Buckley, Brendan M.
Cobbe, Stuart
de Craen, Anton J. M.
Lowe, Gordon D.
Jukema, J. Wouter
Macfarlane, Peter W.
Murphy, Michael B.
Stott, David J.
Westendorp, Rudi G. J.
Shepherd, James
Ford, Ian
Packard, Chris J.
PLoS Medicine
In a secondary analysis of a randomized trial comparing pravastatin versus placebo for the prevention of coronary and cerebral events in an elderly at-risk population, Naveed Sattar and colleagues find that inflammatory markers may be more strongly associated with risk of fatal vascular events than nonfatal vascular events.
Circulating inflammatory markers may more strongly relate to risk of fatal versus nonfatal cardiovascular disease (CVD) events, but robust prospective evidence is lacking. We tested whether interleukin (IL)-6, C-reactive protein (CRP), and fibrinogen more strongly associate with fatal compared to nonfatal myocardial infarction (MI) and stroke.
Methods and Findings
In the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER), baseline inflammatory markers in up to 5,680 men and women aged 70–82 y were related to risk for endpoints; nonfatal CVD (i.e., nonfatal MI and nonfatal stroke [n = 672]), fatal CVD (n = 190), death from other CV causes (n = 38), and non-CVD mortality (n = 300), over 3.2-y follow-up. Elevations in baseline IL-6 levels were significantly (p = 0.0009; competing risks model analysis) more strongly associated with fatal CVD (hazard ratio [HR] for 1 log unit increase in IL-6 1.75, 95% confidence interval [CI] 1.44–2.12) than with risk of nonfatal CVD (1.17, 95% CI 1.04–1.31), in analyses adjusted for treatment allocation. The findings were consistent in a fully adjusted model. These broad trends were similar for CRP and, to a lesser extent, for fibrinogen. The results were also similar in placebo and statin recipients (i.e., no interaction). The C-statistic for fatal CVD using traditional risk factors was significantly (+0.017; p<0.0001) improved by inclusion of IL-6 but not so for nonfatal CVD events (p = 0.20).
In PROSPER, inflammatory markers, in particular IL-6 and CRP, are more strongly associated with risk of fatal vascular events than nonfatal vascular events. These novel observations may have important implications for better understanding aetiology of CVD mortality, and have potential clinical relevance.
Please see later in the article for Editors' Summary
Editors' Summary
Cardiovascular disease (CVD)—disease that affects the heart and/or the blood vessels—is a common cause of death in developed countries. In the USA, for example, the leading cause of death is coronary heart disease (CHD), a CVD in which narrowing of the heart's blood vessels by "atherosclerotic plaques" (fatty deposits that build up with age) slows the blood supply to the heart and may eventually cause a heart attack (myocardial infarction). Other types of CVD include stroke (in which atherosclerotic plaques interrupt the brain's blood supply) and heart failure (a condition in which the heart cannot pump enough blood to the rest of the body). Smoking, high blood pressure, high blood levels of cholesterol (a type of fat), having diabetes, and being overweight all increase a person's risk of developing CVD. Tools such as the "Framingham risk calculator" take these and other risk factors into account to assess an individual's overall risk of CVD, which can be reduced by taking drugs to reduce blood pressure or cholesterol levels (for example, pravastatin) and by making lifestyle changes.
Why Was This Study Done?
Inflammation (an immune response to injury) in the walls of blood vessels is thought to play a role in the development of atherosclerotic plaques. Consistent with this idea, several epidemiological studies (investigations of the causes and distribution of disease in populations) have shown that people with high circulating levels of markers of inflammation such as interleukin-6 (IL-6), C-reactive protein (CRP), and fibrinogen are more likely to have a stroke or a heart attack (a CVD event) than people with low levels of these markers. Although these studies have generally lumped together fatal and nonfatal CVD events, some evidence suggests that circulating inflammatory markers may be more strongly associated with fatal than with nonfatal CVD events. If this is the case, the mechanisms that lead to fatal and nonfatal CVD events may be subtly different and knowing about these differences could improve both the prevention and treatment of CVD. In this study, the researchers investigate this possibility using data collected in the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER; a trial that examined pravastatin's effect on CVD development among 70–82 year olds with pre-existing CVD or an increased risk of CVD because of smoking, high blood pressure, or diabetes).
What Did the Researchers Do and Find?
The researchers used several statistical models to examine the association between baseline levels of IL-6, CRP, and fibrinogen in the trial participants and nonfatal CVD events (nonfatal heart attacks and nonfatal strokes), fatal CVD events, death from other types of CVD, and deaths from other causes during 3.2 years of follow-up. Increased levels of all three inflammatory markers were more strongly associated with fatal CVD than with nonfatal CVD after adjustment for treatment allocation and for other established CVD risk factors but this pattern was strongest for IL-6. Thus, a unit increase in the log of IL-6 levels increased the risk of fatal CVD by half but increased the risk of nonfatal CVD by significantly less. The researchers also investigated whether including these inflammatory markers in tools designed to predict an individual's CVD risk could improve the tool's ability to distinguish between individuals with a high and low risk. The addition of IL-6 to established risk factors, they report, increased this discriminatory ability for fatal CVD but not for nonfatal CVD.
What Do These Findings Mean?
These findings indicate that, at least for the elderly at-risk patients who were included in PROSPER, inflammatory markers are more strongly associated with the risk of a fatal heart attack or stroke than with nonfatal CVD events. These findings need to be confirmed in younger populations and larger studies also need to be done to discover whether the same association holds when fatal heart attacks and fatal strokes are considered separately. Nevertheless, the present findings suggest that inflammation may specifically help to promote the development of serious, potentially fatal CVD and should stimulate improved research into the use of inflammation markers to predict risk of deaths from CVD.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000099.
The MedlinePlus Encyclopedia has pages on coronary heart disease, stroke, and atherosclerosis (in English and Spanish)
MedlinePlus provides links to many other sources of information on heart diseases, vascular diseases, and stroke (in English and Spanish)
Information for patients and caregivers is provided by the American Heart Association on all aspects of cardiovascular disease, including information on inflammation and heart disease
Information is available from the British Heart Foundation on heart disease and keeping the heart healthy
More information about PROSPER is available on the Web site of the Vascular Biochemistry Department of the University of Glasgow
Related Articles
Inflammation, Hemostasis, and the Risk of Kidney Function Decline in the Atherosclerosis Risk in Communities (ARIC) Study
Bash, Lori D.
Erlinger, Thomas P.
Coresh, Josef
Marsh-Manzi, Jane
Folsom, Aaron R.
Astor, Brad C.
American journal of kidney diseases : the official journal of the National Kidney Foundation
Inflammation and hemostasis may increase the risk of kidney function decline, but data from prospective studies are sparse.
The Atherosclerosis Risk in Communities (ARIC) Study, a prospective observational cohort.
SETTING and PARTICIPANTS
We used data from the 14,854 middle aged adults from 4 different US communities.
Markers of inflammation and hemostasis were examined.
OUTCOMES and MEASUREMENTS
Risk of kidney function decline associated with these markers was studied. Glomerular filtration rate (GFR) was calculated from serum creatinine using the 4-variable MDRD Study equation. Chronic kidney disease (CKD) was defined as 1) a decline in estimated GFR below 60 mL/min/1.73 m2 from above 60 at baseline, or 2) a hospitalization discharge or death coded for CKD. Serum creatinine was measured at baseline and at the 3 and 9-year follow-up visits. Hazard ratios (HR) of CKD associated with increased levels of inflammatory and hemostatic variables were estimated by multivariate Cox proportional hazards regression.
1,787 cases of CKD developed between 1987 and 2004. After adjusting for demographics, smoking, blood pressure, diabetes, lipids, prior myocardial infarction, antihypertensive use, alcohol use, year of marker measurement, and baseline renal function using estimated GFR, the risk of incident CKD rose with increasing quartiles of white blood cell count (HR Q4 vs. Q1=1.30, 95% CI= (1.12–1.50); P trend = 0.001), fibrinogen (1.25, (1.09–1.44); <0.001), von Willebrand Factor (1.46, (1.26–1.68); <0.001), and factor VIIIc (1.39, (1.20–1.60); <0.001). A strong inverse association was found between serum albumin and risk of CKD (0.63, (0.55–0.72); <0.001). No independent association was found with levels of factor VIIc.
Although we lacked a direct measure of kidney function, associations were robust to case definitions.
Markers of inflammation and hemostasis are associated with a greater risk of kidney function decline. Findings suggest that inflammation and hemostasis are antecedent pathways for CKD.
inflammation; hemostasis; kidney; chronic kidney disease; ARIC
Related Articles
Genetic admixture is associated with plasma hemostatic factor levels in self-identified African Americans and Hispanics: The Multi-Ethnic Study of Atherosclerosis (MESA)
Lutsey, PL
Wassel, CL
Cushman, M
Sale, MM
Divers, J
Folsom, AR
Journal of Thrombosis and Haemostasis
Epidemiologic studies report that self-identified African Americans typically have higher hemostatic factor levels than do self-identified Caucasians or Hispanics.
To better understand phenotypic variation in hemostatic factor levels by race/ethnicity we evaluated the relationship between genetic ancestry and hemostatic factor levels among MESA study participants.
Our sample included 712 African American and 701 Hispanic men and women aged 45–84. Individual global ancestry was estimated from 199 genetic markers using STRUCTURE. Linear regression models were used to evaluate the relationship between ancestry and hemostatic factor levels, adjusting for age, sex, education, income, and study site.
Among African Americans, mean±SD ancestry was estimated as 79.9% ± 15.9% African and 20.1% ± 15.9% European. Each SD (16%) greater African ancestry was associated with 2.1% higher fibrinogen levels (p=0.007) and 3.5% higher plasmin-antiplasmin (PAP) levels (p=0.02). Ancestry among African Americans was not related to levels of factor VIII or D-Dimer. Mean±SD estimated ancestry among Hispanics was 48.3% ± 23.8% Native American, 38.8% ± 21.9% European, and 13.0% ±18.9% African. In Hispanics, each SD (19%) greater African ancestry was associated with 2.7% higher fibrinogen levels (p=0.009) and 7.9% higher factor VIII levels (p=0.0002). In Hispanics, there was no relation between African ancestry and D-dimer or PAP levels, or between European ancestry and hemostatic factor levels.
Greater African ancestry among African Americans and Hispanics was associated with higher levels of several hemostatic factors, notably fibrinogen. These results suggest that genetic heterogeneity contributes, albeit modestly, to racial/ethnic differences in hemostatic factor levels.
genetic admixture; African ancestry; fibrinogen; plasmin-antiplasmin; Hispanics; African Americans
Related Articles
Factors Associated with Presence and Extent of Coronary Calcium in Individuals Predicted to be at Low Risk Based on Framingham Risk Score (From The Multi-Ethnic Study of Atherosclerosis)
Okwuosa, Tochi M.
Greenland, Philip
Lakoski, Susan G.
Ning, Hongyan
Kang, Joseph
Blumenthal, Roger S.
Szklo, Moyses
Crouse, John R.
Lima, Joao A. C.
Liu, Kiang
Lloyd-Jones, Donald M.
The American journal of cardiology
Even among asymptomatic people at low risk (<10%) by Framingham Risk Score (FRS), high coronary artery calcium (CAC) scores signify higher predicted risk of coronary heart disease (CHD) events. We sought to determine non-invasive factors (without radiation exposure) significantly associated with CAC in low-risk, asymptomatic persons. In a cross-sectional analysis, we studied 3046 participants from MESA at low 10-year predicted risk (FRS <10%) for CHD events. Multivariable logistic regression was used to assess the association of novel markers with presence of any CAC (CAC >0) and advanced CAC (CAC ≥ 300). CAC >0 and CAC ≥ 300 were present in 30% and 3.5% of participants, respectively. Factor VIIIc, fibrinogen and sICAM were each associated with CAC presence (P ≤ 0.02); and C-reactive protein, D-dimer and carotid intima-media thickness (CIMT) with advanced CAC (P ≤ 0.03). The base model combining traditional risk factors had excellent discrimination for advanced CAC (C-statistic, 0.808). Addition of the 2 best-fit models combining biomarkers plus/minus CIMT improved the c-statistics to 0.822 and 0.820, respectively. All 3 models calibrated well, but were similar in estimating individual risk probabilities for advanced CAC (prevalence = 9.97%, 10.63% and 10.10% in the highest quartiles of predicted probabilities versus 0.26%, 0.26% and 0.26% in the lowest quartiles, respectively). In conclusion, in low risk individuals, traditional risk factors alone predicted advanced CAC with high discrimination and calibration. Biomarker combinations +/− CIMT were also significantly associated with advanced CAC, but improvement in prediction and estimation of clinical risk were modest compared to traditional risk factors alone.
coronary calcium; biomarkers; novel markers; low-risk; risk factors
Related Articles
Haemostatic Parameters in Patients with Behçet's Disease
Alkaabi, Juma K.
Gravell, David
Al-Haddabi, Hamood
Pathare, Anil
Sultan Qaboos University Medical Journal
This study aimed to evaluate the cause of thrombosis in Behçet's disease (BD) patients, since abnormalities in coagulation and fibrinolytic parameters have shown contradictory results.
Haemostatic parameters were retrospectively evaluated in BD patients treated between January 2007 and January 2011 at Sultan Qaboos University Hospital, Oman. The blood samples of 35 Omani BD patients and 30 healthy controls were analysed for factor VIII:C levels, activated protein C resistance (APCR), von Willebrand factor (vWF) antigens (Ag), collagen binding and ristocetin co-factor activity (RiCoF), antithrombin (AT), protein C (chromogenic and clotting), protein S, homocysteine, tissue plasminogen activator, plasminogen activator inhibitor, plasminogen, alpha 2-antiplasmin, lupus anticoagulant and anticardiolipin and beta2-glycoprotein-1 antibodies.
The mean values of factor VIII:C, vWF Ag, AT and protein S were significantly higher in the patient group (P = 0.01, 0.006, 0.04 and 0.01, respectively). There was no deficiency in protein C. Screening for APCR, anticardiolipin antibodies, anti-beta2-glycoprotein-1 antibodies and lupus anticoagulant was negative and there were no differences in homocysteine levels, nor were there differences between patients with and without thrombosis. Six patients had elevated factor VIII:C levels (>150 IU/dL, P <0.02) which normalised on repeat measurements after three months.
The elevation of factors VIII:C, vWF Ag and AT most likely represent an acute phase phenomenon. In this study, thrombophilic factors did not seem to explain thrombotic tendency. Therefore, further mechanistic studies in a larger group of patients are needed to elucidate the basis for thrombosis in BD. We hypothesise that active BD causes vasculitic endothelial perturbation with dysfunction, leading to the observed increased propensity for thrombosis.
Behcet Syndrome; Vasculitis; Blood Vessels; Thrombosis; Hemostasis; Oman
Related Articles
Alcohol Consumption and Risk of Cardiovascular Disease and Mortality in Women: Potential Mediating Mechanisms
Djoussé, Luc
Lee, I-Min
Buring, Julie E
Gaziano, J. Michael
Although an association between moderate alcohol consumption and decreased cardiovascular disease (CVD) and mortality has been reported, limited data are available on potential mediating mechanisms. We examined the association between alcohol and CVD and mortality in 26,399 women and estimated the proportion of reduced risk of CVD/mortality explained by a series of intermediate factors.
Methods and Results:
Alcohol consumption was self-reported at baseline and CVD events and deaths were ascertained via follow-up questionnaires and medical records. Baseline levels of hemoglobin A1c, inflammatory markers, hemostatic factors, and lipids were measured. Blood pressure and hypercholesterolemia; and treatment for lipids were self-reported. During a mean follow up of 12.2 years, 1039 CVD events, 785 deaths (153 CVD deaths) occurred. There was a J-shaped relation between alcohol consumption and incident CVD, total and CVD mortality in a multivariable model. Compared with abstainers, alcohol intake of 5-14.9 g/d was associated with 26%, 35%, and 51% lower risk of CVD, total and CVD mortality, respectively, in a multivariable model. For CVD risk reduction, lipids made the largest contribution to the lower risk of CVD (28.7%), followed by hemoglobin A1c/diabetes (25.3%), inflammatory/hemostatic factors (5%), and blood pressure factors (4.6%). All these mediating factors together explained 86.3%, 18.7%, and 21.8% of the observed lower risk of CVD, total and CVD mortality, respectively.
These data suggest that alcohol effects on lipids and insulin sensitivity may account for a large proportion of the lower risk of CVD/mortality observed with moderate drinking under the assumption that the alcohol-CVD association is causal.
Alcohol drinking; epidemiology; cardiovascular disease
Related Articles
Reduced Glomerular Filtration Rate and Its Association with Clinical Outcome in Older Patients at Risk of Vascular Events: Secondary Analysis
Ford, Ian
Bezlyak, Vladimir
Stott, David J
Sattar, Naveed
Packard, Chris J
Perry, Ivan
Buckley, Brendan M
Jukema, J. Wouter
de Craen, Anton J. M
Westendorp, Rudi G. J
Shepherd, James
PLoS Medicine
Reduced glomerular filtration rate (GFR) is associated with increased cardiovascular risk in young and middle aged individuals. Associations with cardiovascular disease and mortality in older people are less clearly established. We aimed to determine the predictive value of the GFR for mortality and morbidity using data from the 5,804 participants randomized in the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER).
Methods and Findings
Glomerular filtration rate was estimated (eGFR) using the Modification of Diet in Renal Disease equation and was categorized in the ranges ([20–40], [40–50], [50–60]) ≥ 60 ml/min/1.73 m2. Baseline risk factors were analysed by category of eGFR, with and without adjustment for other risk factors. The associations between baseline eGFR and morbidity and mortality outcomes, accrued after an average of 3.2 y, were investigated using Cox proportional hazard models adjusting for traditional risk factors. We tested for evidence of an interaction between the benefit of statin treatment and baseline eGFR status. Age, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, C-reactive protein (CRP), body mass index, fasting glucose, female sex, histories of hypertension and vascular disease were associated with eGFR (p = 0.001 or less) after adjustment for other risk factors. Low eGFR was independently associated with risk of all cause mortality, vascular mortality, and other noncancer mortality and with fatal and nonfatal coronary and heart failure events (hazard ratios adjusted for CRP and other risk factors (95% confidence intervals [CIs]) for eGFR < 40 ml/min/1.73m2 relative to eGFR ≥ 60 ml/min/1.73m2 respectively 2.04 (1.48–2.80), 2.37 (1.53–3.67), 3.52 (1.78–6.96), 1.64 (1.18–2.27), 3.31 (2.03–5.41). There were no nominally statistically significant interactions (p < 0.05) between randomized treatment allocation and eGFR for clinical outcomes, with the exception of the outcome of coronary heart disease death or nonfatal myocardial infarction (p = 0.021), with the interaction suggesting increased benefit of statin treatment in subjects with impaired GFRs.
We have established that, in an elderly population over the age of 70 y, impaired GFR is associated with female sex, with presence of vascular disease, and with levels of other risk factors that would be associated with increased risk of vascular disease. Further, impaired GFR is independently associated with significant levels of increased risk of all cause mortality and fatal vascular events and with composite fatal and nonfatal coronary and heart failure outcomes. Our analyses of the benefits of statin treatment in relation to baseline GFR suggest that there is no reason to exclude elderly patients with impaired renal function from treatment with a statin.
Using data from the PROSPER trial, Ian Ford and colleagues investigate whether reduced glomerular filtration rate is associated with cardiovascular and mortality risk among elderly people.
Editors' Summary
Cardiovascular disease (CVD)—disease that affects the heart and/or the blood vessels—is a common cause of death in developed countries. In the USA, for example, the single leading cause of death is coronary heart disease, a CVD in which narrowing of the heart's blood vessels slows or stops the blood supply to the heart and eventually causes a heart attack. Other types of CVD include stroke (in which narrowing of the blood vessels interrupts the brain's blood supply) and heart failure (a condition in which the heart can no longer pump enough blood to the rest of the body). Many factors increase the risk of developing CVD, including high blood pressure (hypertension), high blood cholesterol, having diabetes, smoking, and being overweight. Tools such as the "Framingham risk calculator" assess an individual's overall CVD risk by taking these and other risk factors into account. CVD risk can be minimized by taking drugs to reduce blood pressure or cholesterol levels (for example, pravastatin) and by making lifestyle changes.
Why Was This Study Done?
Another potential risk factor for CVD is impaired kidney (renal) function. In healthy people, the kidneys filter waste products and excess fluid out of the blood. A reduced "estimated glomerular filtration rate" (eGFR), which indicates impaired renal function, is associated with increased CVD in young and middle-aged people and increased all-cause and cardiovascular death in people who have vascular disease. But is reduced eGFR also associated with CVD and death in older people? If it is, it would be worth encouraging elderly people with reduced eGFR to avoid other CVD risk factors. In this study, the researchers determine the predictive value of eGFR for all-cause and vascular mortality (deaths caused by CVD) and for incident vascular events (a first heart attack, stroke, or heart failure) using data from the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). This clinical trial examined pravastatin's effects on CVD development among 70–82 year olds with pre-existing vascular disease or an increased risk of CVD because of smoking, hypertension, or diabetes.
What Did the Researchers Do and Find?
The trial participants were divided into four groups based on their eGFR at the start of the study. The researchers then investigated the association between baseline CVD risk factors and baseline eGFR and between baseline eGFR and vascular events and deaths that occurred during the 3-year study. Several established CVD risk factors were associated with a reduced eGFR after allowing for other risk factors. In addition, people with a low eGFR (between 20 and 40 units) were twice as likely to die from any cause as people with an eGFR above 60 units (the normal eGFR for a young person is 100 units; eGFR decreases with age) and more than three times as likely to have nonfatal coronary heart disease or heart failure. A low eGFR also increased the risk of vascular mortality, other noncancer deaths, and fatal coronary heart disease and heart failure. Finally, pravastatin treatment reduced coronary heart disease deaths and nonfatal heart attacks most effectively among participants with the greatest degree of eGFR impairment.
What Do These Findings Mean?
These findings suggest that, in elderly people, impaired renal function is associated with levels of established CVD risk factors that increase the risk of vascular disease. They also suggest that impaired kidney function increases the risk of all-cause mortality, fatal vascular events, and fatal and nonfatal coronary heat disease and heart failure. Because the study participants were carefully chosen for inclusion in PROSPER, these findings may not be generalizable to all elderly people with vascular disease or vascular disease risk factors. Nevertheless, increased efforts should probably be made to encourage elderly people with reduced eGFR and other vascular risk factors to make lifestyle changes to reduce their overall CVD risk. Finally, although the effect of statins in elderly patients with renal dysfunction needs to be examined further, these findings suggest that this group of patients should benefit at least as much from statins as elderly patients with healthy kidneys.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000016.
The MedlinePlus Encyclopedia has pages on coronary heart disease, stroke, and heart failure (in English and Spanish)
MedlinePlus provides links to many other sources of information on heart disease, vascular disease, and stroke (in English and Spanish)
The US National Institute of Diabetes and Digestive and Kidney Diseases provides information on how the kidneys work and what can go wrong with them, including a list of links to further information about kidney disease
The American Heart Association provides information on all aspects of cardiovascular disease for patients, caregivers, and professionals (in several languages)
More information about PROSPER is available on the Web site of the Vascular Biochemistry Department of the University of Glasgow
Related Articles
The Association between Lipoprotein-associated Phospholipase A2 and CVD and Total Mortality in Vascular Medicine Patients
Allison, Matthew A.
Denenberg, Julie O.
Nelson, Jeanenne J.
Natarajan, Loki
Criqui, Michael H.
Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
In some community-based studies, Lp-PLA2 has been shown to be independently predictive of future fatal and non-fatal cardiovascular disease (CVD) events. We tested the hypothesis that Lp-PLA2 is independently predictive of mortality in high risk patients from a vascular laboratory.
Between 1990 and 1994, patients seen in the previous 10 years for non-invasive lower extremity arterial testing were invited to return for a vascular examination of the lower extremities. By medical record review, we identified 2,265 eligible patients and of these, 508 returned for interviews, blood collection and arterial examination and represent those who had survived, could be located and were willing to participate. The 508 subjects were followed for an average of 6.7 years until the end of the study period on December 31, 2001. Vital status was ascertained by multiple searches of the social security death index. The primary outcomes for this study were time to any, CVD and coronary heart disease (CHD) mortality.
The mean age was 68.2 years, 88% were male, 87% were non-Hispanic White, 39.1% were diagnosed with PAD only, 9.2% with other CVD only and 28.5% with both PAD and other CVD. Over the entire follow-up period, 299 (59.7%) patients died, 167 from CVD. Eighty-eight of the CVD deaths were due to CHD. With adjustment for CVD risk factors and baseline PAD and other CVD, a 1-SD increment in Lp-PLA2 activity was associated with a 40% higher risk for CHD mortality at 5-years of follow-up (p = 0.04). Additional adjustment for triglycerides, HDL and LDL cholesterol reduced this association to non-significance (HR: 1.12).
In a vascular laboratory patient population, higher levels of LpPLA2 mass and activity were not significantly associated with total, CVD or CHD mortality at 5 years of follow-up and after adjustment for traditional CVD risk factors and the presence of PAD and other CVD at baseline. An apparent elevated risk of CHD death associated with elevated Lp-PLA2 was largely explained by associated elevations in lipids and lipoproteins.
Related Articles
Personalized Prediction of Lifetime Benefits with Statin Therapy for Asymptomatic Individuals: A Modeling Study
Ferket, Bart S.
van Kempen, Bob J. H.
Heeringa, Jan
Spronk, Sandra
Fleischmann, Kirsten E.
Nijhuis, Rogier L. G.
Hofman, Albert
Steyerberg, Ewout W.
Hunink, M. G. Myriam
PLoS Medicine
In a modeling study conducted by Myriam Hunink and colleagues, a population-based cohort from Rotterdam is used to predict the possible lifetime benefits of statin therapy, on a personalized basis.
Physicians need to inform asymptomatic individuals about personalized outcomes of statin therapy for primary prevention of cardiovascular disease (CVD). However, current prediction models focus on short-term outcomes and ignore the competing risk of death due to other causes. We aimed to predict the potential lifetime benefits with statin therapy, taking into account competing risks.
Methods and Findings
A microsimulation model based on 5-y follow-up data from the Rotterdam Study, a population-based cohort of individuals aged 55 y and older living in the Ommoord district of Rotterdam, the Netherlands, was used to estimate lifetime outcomes with and without statin therapy. The model was validated in-sample using 10-y follow-up data. We used baseline variables and model output to construct (1) a web-based calculator for gains in total and CVD-free life expectancy and (2) color charts for comparing these gains to the Systematic Coronary Risk Evaluation (SCORE) charts. In 2,428 participants (mean age 67.7 y, 35.5% men), statin therapy increased total life expectancy by 0.3 y (SD 0.2) and CVD-free life expectancy by 0.7 y (SD 0.4). Age, sex, smoking, blood pressure, hypertension, lipids, diabetes, glucose, body mass index, waist-to-hip ratio, and creatinine were included in the calculator. Gains in total and CVD-free life expectancy increased with blood pressure, unfavorable lipid levels, and body mass index after multivariable adjustment. Gains decreased considerably with advancing age, while SCORE 10-y CVD mortality risk increased with age. Twenty-five percent of participants with a low SCORE risk achieved equal or larger gains in CVD-free life expectancy than the median gain in participants with a high SCORE risk.
We developed tools to predict personalized increases in total and CVD-free life expectancy with statin therapy. The predicted gains we found are small. If the underlying model is validated in an independent cohort, the tools may be useful in discussing with patients their individual outcomes with statin therapy.
Please see later in the article for the Editors' Summary
Editors' Summary
Cardiovascular disease (CVD) affects the heart and/or the blood vessels and is a major cause of illness and death worldwide. In the US, for example, coronary heart disease—a CVD in which narrowing of the heart's blood vessels by fatty deposits slows the blood supply to the heart and may eventually cause a heart attack—is the leading cause of death, and stroke—a CVD in which the brain's blood supply is interrupted—is the fourth leading cause of death. Established risk factors for CVD include smoking, high blood pressure, obesity, and high blood levels of a fat called low-density lipoprotein ("bad cholesterol"). Because many of these risk factors can be modified by lifestyle changes and by drugs, CVD can be prevented. Thus, physicians can assess a healthy individual's risk of developing CVD using a CVD prediction model (equations that take into account the CVD risk factors to which the individual is exposed) and can then recommend lifestyle changes and medications to reduce that individual's CVD risk.
Why Was This Study Done?
Current guidelines recommend that asymptomatic (healthy) individuals whose likely CVD risk is high should be encouraged to take statins—cholesterol-lowering drugs—as a preventative measure. Statins help to prevent CVD in healthy people with a high predicted risk of CVD, but, like all medicines, they have some unwanted side effects, so it is important that physicians can communicate both the benefits and drawbacks of statins to their patients in a way that allows them to make an informed decision about taking these drugs. Telling a patient that statins will reduce his or her short-term risk of CVD is not always helpful—patients really need to know the potential lifetime benefits of statin therapy. That is, they need to know how much longer they might live if they take statins. Here, the researchers use a mathematical model to predict the personalized lifetime benefits (increased total and CVD-free life expectancy) of statin therapy for individuals without a history of CVD.
What Did the Researchers Do and Find?
The researchers used the Rotterdam Ischemic Heart Disease & Stroke Computer Simulation (RISC) model, which simulates the life courses of individuals through six health states, from well through to CVD or non-CVD death, to estimate lifetime outcomes with and without statin therapy in a population of healthy elderly individuals. They then used these outcomes and information on baseline risk factors to develop a web-based calculator suitable for personalized prediction of the lifetime benefits of statins in routine clinical practice. The model estimated that statin therapy increases average life expectancy in the study population by 0.3 years and average CVD-free life expectancy by 0.7 years. The gains in total and CVD-free life expectancy associated with statin therapy increased with blood pressure, unfavorable cholesterol levels, and body mass index (an indicator of body fat) but decreased with age. Notably, the web-based calculator predicted that some individuals with a low ten-year CVD risk might achieve a similar or larger gain in CVD-free life expectancy with statin therapy than some individuals with a high ten-year risk. So, for example, both a 55-year-old non-smoking woman with a ten-year CVD mortality risk of 2% (a two in a hundred chance of dying of CVD within ten years) and a 65-year-old male smoker with a ten-year CVD mortality risk of 15% might both gain one year of CVD-free life expectancy with statin therapy.
What Do These Findings Mean?
These findings suggest that statin therapy can lead on average to small gains in total life expectancy and slightly larger gains in CVD-free life expectancy among healthy individuals, and show that life expectancy benefits can be predicted using an individual's risk factor profile. The accuracy and generalizability of these findings is limited by the assumptions included in the model (in particular, the model did not allow for the known side effects of statin therapy) and by the data fed into it—importantly, the risk prediction model needs to be validated using an independent dataset. If future research confirms the findings of this study, the researchers' web-based calculator could provide complementary information to the currently recommended ten-year CVD mortality risk assessment. Whether communication of personalized outcomes will ultimately result in better clinical outcomes remains to be seen, however, because patients may be less likely to choose statin therapy when provided with more information about its likely benefits.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001361.
The web-based calculator for personalized prediction of lifetime benefits with statin therapy is available (after agreement to software license)
The American Heart Association provides information about many types of cardiovascular disease for patients, carers, and professionals, including information about drug therapy for cholesterol and a heart attack risk calculator
The UK National Health Service Choices website provides information about cardiovascular disease and about statins
Information is available from the British Heart Foundation on heart disease and keeping the heart healthy; information is also available on statins, including personal stories about deciding to take statins
The US National Heart Lung and Blood Institute provides information on a wide range of cardiovascular diseases
The European Society of Cardiology's cardiovascular disease risk assessment model (SCORE) is available
MedlinePlus provides links to many other sources of information on heart diseases, vascular diseases, stroke, and statins (in English and Spanish)
Related Articles
Racial Differences in Risks for First Cardiovascular Events and Non-Cardiovascular Death: the Atherosclerosis Risk in Communities Study (ARIC), the Cardiovascular Health Study (CHS), and the Multi-Ethnic Study of Atherosclerosis (MESA)
Feinstein, Matthew
Ning, Hongyan
Kang, Joseph
Bertoni, Alain
Carnethon, Mercedes
Lloyd-Jones, Donald M.
No studies have compared first CVD events and non-CVD death between races in a competing risks framework, which examines risks for numerous events simultaneously.
Methods and Results
We used competing Cox models to estimate hazards for first CVD events and non-CVD death within and between races in three multi-center, NHLBI-sponsored cohorts. Of 14569 ARIC study participants aged 45–64y with mean follow up of 10.5y, 11.6% had CVD and 5.0% had non-CVD death as first events; among 4237 CHS study participants aged 65–84y and followed for 8.5y, these figures were 43.2% and 15.7%, respectively. Middle-aged blacks were significantly more likely than whites to experience any CVD as a first event; this disparity disappeared by older adulthood and after adjustment for CVD risk factors. The pattern of results was similar for MESA participants. Traditional Cox and competing risks models yielded different results for CHD risk. Black men appeared somewhat more likely than white men to experience CHD using a standard Cox model (HR 1.06; 95% CI 0.90, 1.26) whereas they appeared less likely than white men to have a first CHD event using a competing risks model (HR 0.77; 95% CI 0.60, 1.00).
CVD affects blacks at an earlier age than whites; this may be partially attributable to elevated CVD risk factor levels among blacks. Racial disparities in first CVD incidence disappear by older adulthood. Competing risks analyses may yield somewhat different results than traditional Cox models and provide a complementary approach to examining risks for first CVD events.
cardiovascular diseases; epidemiology; prevention; risk factors; survival
Related Articles
Associations of Pentraxin 3 with Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis
Jenny, Nancy Swords
Blumenthal, Roger S.
Kronmal, Richard A.
Rotter, Jerome I.
Siscovick, David S.
Psaty, Bruce M.
Journal of thrombosis and haemostasis : JTH
Pentraxin 3 (PTX3) is likely a specific marker of vascular inflammation. However, associations of PTX3 with cardiovascular disease (CVD) risk have not been well studied in healthy adults or multi-ethnic populations. We examined associations of PTX3 with CVD risk factors, measures of subclinical CVD, coronary artery calcification (CAC) and CVD events in the Multi-Ethnic Study of Atherosclerosis (MESA).
Approach and Results
2838 participants free of prevalent CVD with measurements of PTX3 were included in the present study. Adjusting for age, sex and ethnicity, PTX3 was positively associated with age, obesity, insulin, systolic blood pressure, C-reactive protein (CRP) and carotid intima media thickness (all p<0.045). A one standard deviation increase in PTX3 (1.62 ng/ml) was associated with the presence of CAC in fully adjusted models including multiple CVD risk factors (relative risk; 95% confidence interval 1.05; 1-01-1.08). In fully adjusted models, a standard deviation higher level of PTX3 was associated with an increased risk of myocardial infarction (hazard ratio; 95% confidence interval 1.51; 1.16-1.97), combined CVD events (1.23; 1.05-1.45) and combined CHD events (1.33; 1.10-1.60) but not stroke, CVD-related mortality or all cause death.
In these apparently healthy adults, PTX3 was associated with CVD risk factors, subclinical CVD, CAC and incident coronary heart disease events independent of CRP and CVD risk factors. These results support the hypothesis that PTX3 reflects different aspects of inflammation than CRP and may provide additional insight into the development and progression of atherosclerosis.
Atherosclerosis; Cardiovascular Diseases; Epidemiology; Inflammation; Pentraxin 3
Related Articles
Mortality in Pharmacologically Treated Older Adults with Diabetes: The Cardiovascular Health Study, 1989–2001
Kronmal, Richard A
Barzilay, Joshua I
Smith, Nicholas L
Psaty, Bruce M
Kuller, Lewis H
Burke, Gregory L
Furberg, Curt
PLoS Medicine
Diabetes mellitus (DM) confers an increased risk of mortality in young and middle-aged individuals and in women. It is uncertain, however, whether excess DM mortality continues beyond age 75 years, is related to type of hypoglycemic therapy, and whether women continue to be disproportionately affected by DM into older age.
Methods and Findings
From the Cardiovascular Health Study, a prospective study of 5,888 adults, we examined 5,372 participants aged 65 y or above without DM (91.2%), 322 with DM treated with oral hypoglycemic agents (OHGAs) (5.5%), and 194 with DM treated with insulin (3.3%). Participants were followed (1989–2001) for total, cardiovascular disease (CVD), coronary heart disease (CHD), and non-CVD/noncancer mortality. Compared with non-DM participants, those treated with OHGAs or insulin had adjusted hazard ratios (HRs) for total mortality of 1.33 (95% confidence interval [CI], 1.10 to 1.62) and 2.04 (95% CI, 1.62 to 2.57); CVD mortality, 1.99 (95% CI, 1.54 to 2.57) and 2.16 (95% CI, 1.54 to 3.03); CHD mortality, 2.47 (95% CI, 1.89 to 3.24) and 2.75 (95% CI, 1.95 to 3.87); and infectious and renal mortality, 1.35 (95% CI, 0.70 to 2.59) and 6.55 (95% CI, 4.18 to 10.26), respectively. The interaction of age (65–74 y versus ≥75 y) with DM was not significant. Women treated with OHGAs had a similar HR for total mortality to men, but a higher HR when treated with insulin.
DM mortality risk remains high among older adults in the current era of medical care. Mortality risk and type of mortality differ between OHGA and insulin treatment. Women treated with insulin therapy have an especially high mortality risk. Given the high absolute CVD mortality in older people, those with DM warrant aggressive CVD risk factor reduction.
The negative impact on mortality of diabetes persists into old age. Elderly people with diabetes might be twice as likely to die from CVD as people without diabetes. More aggressive treatment of CVD risk factors in older patients should be considered.
Editors' Summary
Diabetes is a growing global health problem. By 2030, 300 million people worldwide may have this chronic, incurable disorder, double the current number. People with diabetes have dangerously high amounts of sugar in their blood. Blood-sugar levels are normally controlled by insulin, a hormone made by the pancreas that tells cells to absorb sugar from the blood. This control fails in people with diabetes, either because they make no insulin (type 1 diabetes) or because their cells are insensitive to insulin (type 2 diabetes). Type 1 diabetes is controlled with insulin injections; type 2 diabetes is controlled with diet, exercise, and pills that reduce blood-sugar levels. Long-term complications of diabetes include kidney failure, blindness, and nerve damage. Individuals with diabetes also have an increased risk of developing cardiovascular disease (CVD)—heart problems, strokes, and poor circulation—because of damage to their blood vessels.
Why Was This Study Done?
Epidemiological studies (investigations of disease patterns, causes, and control in populations) have indicated that diabetes increases the risk of death (mortality) from CVD in young and middle-aged people, but it is not known whether this is also true for old people. It is also not known what effect long-term treatment for diabetes has on mortality or whether the risk of death from CVD is decreasing in diabetic people as it is in the general US population. This information would help physicians provide health care and lifestyle advice to people with diabetes. In this study, the researchers have investigated mortality patterns in elderly diabetic people by looking at data collected between 1989 and 2001 by the US Cardiovascular Health Study, an observational study of nearly 6,000 people aged over 65 years (in this type of study participants are observed without imposing any specific changes to their lifestyle, behavior, medical care, or treatments).
What Did the Researchers Do and Find?
Participants were screened at the start of the Cardiovascular Health Study for CVD and diabetes (defined as drug-treated disease), for established CVD risk factors such as high blood pressure and smoking, for recently recognized CVD risk factors (for example, subclinical CVD), and for psychosocial factors associated with diabetes that might influence mortality, such as frailty and depression. At this time, about 5% of the participants were taking oral hypoglycemic agents for diabetes and about 3% were taking insulin. During the 11-year study, 40% of the participants died. After adjusting for CVD risk factors and psychosocial factors, the researchers calculated that people treated with oral hypoglycemic agents were 1.3 times as likely to die from all causes and people treated with insulin were twice as likely to die as people without diabetes. The risk of death from CVD was about twice as high in both groups of diabetic participants as in non-diabetic participants; the risk of death from coronary heart disease was increased about 2.5-fold. These adjusted relative risks are very similar to those found in previous studies. The researchers also report that participants treated with insulin were six times more likely to die from infectious diseases or renal failure than nondiabetic participants, and women treated with insulin had a particularly high mortality risk.
What Do These Findings Mean?
These findings indicate that the negative impact on mortality of diabetes persists into old age and that death from CVD is currently declining in both older diabetic people and nondiabetic people. In addition, they show that diabetic people treated with insulin are at a greater risk of dying relative to people without diabetes and those taking oral hypoglycemic agents. This might reflect the type of diabetes that these people had, but this was not investigated. How long participants had had diabetes was also not considered, nor how many people developed diabetes during the study. These and other limitations might mean that the reported excess mortality due to diabetes is an underestimate. Nevertheless, the estimate that elderly people with diabetes are twice as likely to die from CVD as people without diabetes is important. Many elderly people die anyway because of CVD, so this increased risk represents many more deaths than the similar increased risk in younger diabetic populations. Yet, elderly people often receive less-intensive management of CVD risk factors than younger people. The results of this study suggest that rectifying this situation could prolong the lives of many elderly people with diabetes.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030400.
MedlinePlus encyclopedia has pages on diabetes, heart disease, stroke and poor circulation
The US National Institute of Diabetes and Digestive and Kidney Diseases provides patient information on diabetes
Information for patients on prevention, diagnosis, and management of diabetes is available from the America Diabetes Association
Patient information is available from the American Heart Association on all aspects of heart disease, including its association with diabetes
Wikipedia pages on diabetes and cardiovascular disease (note that Wikipedia is a free online encyclopedia that anyone can edit)
Further information is available about the Cardiovascular Health Study
Related Articles
Erectile Dysfunction Severity as a Risk Marker for Cardiovascular Disease Hospitalisation and All-Cause Mortality: A Prospective Cohort Study
Banks, Emily
Joshy, Grace
Abhayaratna, Walter P.
Kritharides, Leonard
Macdonald, Peter S.
Korda, Rosemary J.
Chalmers, John P.
PLoS Medicine
In a prospective Australian population-based study linking questionnaire data from 2006–2009 with hospitalisation and death data to June 2010 for 95,038 men aged ≥45 years, Banks and colleagues found that more severe erectile dysfunction was associated with higher risk of cardiovascular disease.
Erectile dysfunction is an emerging risk marker for future cardiovascular disease (CVD) events; however, evidence on dose response and specific CVD outcomes is limited. This study investigates the relationship between severity of erectile dysfunction and specific CVD outcomes.
Methods and Findings
We conducted a prospective population-based Australian study (the 45 and Up Study) linking questionnaire data from 2006–2009 with hospitalisation and death data to 30 June and 31 Dec 2010 respectively for 95,038 men aged ≥45 y. Cox proportional hazards models were used to examine the relationship of reported severity of erectile dysfunction to all-cause mortality and first CVD-related hospitalisation since baseline in men with and without previous CVD, adjusting for age, smoking, alcohol consumption, marital status, income, education, physical activity, body mass index, diabetes, and hypertension and/or hypercholesterolaemia treatment. There were 7,855 incident admissions for CVD and 2,304 deaths during follow-up (mean time from recruitment, 2.2 y for CVD admission and 2.8 y for mortality). Risks of CVD and death increased steadily with severity of erectile dysfunction. Among men without previous CVD, those with severe versus no erectile dysfunction had significantly increased risks of ischaemic heart disease (adjusted relative risk [RR] = 1.60, 95% CI 1.31–1.95), heart failure (8.00, 2.64–24.2), peripheral vascular disease (1.92, 1.12–3.29), "other" CVD (1.26, 1.05–1.51), all CVD combined (1.35, 1.19–1.53), and all-cause mortality (1.93, 1.52–2.44). For men with previous CVD, corresponding RRs (95% CI) were 1.70 (1.46–1.98), 4.40 (2.64–7.33), 2.46 (1.63–3.70), 1.40 (1.21–1.63), 1.64 (1.48–1.81), and 2.37 (1.87–3.01), respectively. Among men without previous CVD, RRs of more specific CVDs increased significantly with severe versus no erectile dysfunction, including acute myocardial infarction (1.66, 1.22–2.26), atrioventricular and left bundle branch block (6.62, 1.86–23.56), and (peripheral) atherosclerosis (2.47, 1.18–5.15), with no significant difference in risk for conditions such as primary hypertension (0.61, 0.16–2.35) and intracerebral haemorrhage (0.78, 0.20–2.97).
These findings give support for CVD risk assessment in men with erectile dysfunction who have not already undergone assessment. The utility of erectile dysfunction as a clinical risk prediction tool requires specific testing.
Please see later in the article for the Editors' Summary
Editors' Summary
Erectile dysfunction is the medical term used when a man is unable to achieve or sustain an erection of his penis suitable for sexual intercourse. Although a sensitive topic that can cause much embarrassment and distress, erectile dysfunction is very common, with an estimated 40% of men over the age of 40 years experiencing frequent or occasional difficulties. The most common causes of erectile dysfunction are medications, chronic illnesses such as diabetes, and drinking too much alcohol. Stress and mental health problems can also cause or worsen erectile dysfunction. There is also increasing evidence that erectile dysfunction may actually be a symptom of cardiovascular disease—a leading cause of death worldwide—as erectile dysfunction could indicate a problem with blood vessels or poor blood flow commonly associated with cardiovascular disease.
Why Was This Study Done?
Although previous studies have suggested that erectile dysfunction can serve as a marker for cardiovascular disease in men not previously diagnosed with the condition, few studies to date have investigated whether erectile dysfunction could also indicate worsening disease in men already diagnosed with cardiovascular disease. In addition, previous studies have typically been small and have not graded the severity of erectile dysfunction or investigated the specific types of cardiovascular disease associated with erectile dysfunction. In this large study conducted in Australia, the researchers investigated the relationship of the severity of erectile dysfunction with a range of cardiovascular disease outcomes among men with and without a previous diagnosis of cardiovascular disease.
What Did the Researchers Do and Find?
The researchers used information from the established 45 and Up Study, a large cohort study that includes 123,775 men aged 45 and over, selected at random from the general population of New South Wales, a large region of Australia. A total of 95,038 men were included in this analysis. The male participants completed a postal questionnaire that included a question on erectile functioning, which allowed the researchers to define erectile dysfunction as none, mild, moderate, or severe. Using information captured in the New South Wales Admitted Patient Data Collection—a complete record of all public and private hospital admissions, including the reasons for admission and the clinical diagnosis—and the government death register, the researchers were able to determine health outcomes of all study participants. They then used a statistical model to estimate hospital admissions for cardiovascular disease events for different levels of erectile dysfunction.
The researchers found that the rates of severe erectile dysfunction among study participants were 2.2% for men aged 45–54 years, 6.8% for men aged 55–64 years, 20.2% for men aged 65–74 years, 50.0% for men aged 75–84 years, and 75.4% for men aged 85 years and over. During the study period, the researchers recorded 7,855 hospital admissions related to cardiovascular disease and 2,304 deaths. The researchers found that among men without previous cardiovascular disease, those with severe erectile dysfunction were more likely to develop ischemic heart disease (risk 1.60), heart failure (risk 8.00), peripheral vascular disease (risk 1.92), and other causes of cardiovascular disease (risk 1.26) than men without erectile dysfunction. The risks of heart attacks and heart conduction problems were also increased (1.66 and 6.62, respectively). Furthermore, the combined risk of all cardiovascular disease outcomes was 1.35, and the overall risk of death was also higher (risk 1.93) in these men. The researchers found that these increased risks were similar in men with erectile dysfunction who had previously been diagnosed with cardiovascular disease.
What Do These Findings Mean?
These findings suggest that compared to men without erectile dysfunction, there is an increasing risk of ischemic heart disease, peripheral vascular disease, and death from all causes in those with increasing degrees of severity of erectile dysfunction. The authors emphasize that erectile dysfunction is a risk marker for cardiovascular disease, not a risk factor that causes cardiovascular disease. These findings add to previous studies and highlight the need to consider erectile dysfunction in relation to the risk of different types of cardiovascular disease, including heart failure and heart conduction disorders. However, the study's reliance on the answer to a single self-assessed question on erectile functioning limits the findings. Nevertheless, these findings provide useful information for clinicians: men with erectile dysfunction are at higher risk of cardiovascular disease, and the worse the erectile dysfunction, the higher the risk of cardiovascular disease. Men with erectile dysfunction, even at mild or moderate levels, should be screened and treated for cardiovascular disease accordingly.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001372.
Wikipedia defines erectile dysfunction (note that Wikipedia is a free online encyclopedia that anyone can edit)
MedlinePlus also has some useful patient information on erectile dysfunction
The Mayo Clinic has patient-friendly information on the causes of, and treatments for, erectile dysfunction, and also includes information on the link with cardiovascular disease
The National Heart Foundation of Australia provides information for health professionals, patients, and the general public about how to prevent and manage cardiovascular disease, including assessment and management of cardiovascular disease risk
Related Articles
Age-Related Macular Degeneration and Incident Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis
Fernandez, Antonio B
Wong, Tien Y.
Klein, Ronald
Collins, Dorothea
Burke, Gregory
Cotch, Mary Frances
Klein, Barbara
Sadeghi, Mehran M.
Chen, Jersey
To determine whether age-related macular degeneration (AMD) is a risk indicator for coronary heart disease (CHD) and cardiovascular disease (CVD) events independent of other known risk factors in a multi-ethnic cohort.
Population-based prospective cohort study.
A diverse population sample of 6233 men and women aged 45–84 without known CVD from the Multi-Ethnic Study of Atherosclerosis (MESA).
Participants in the MESA had retinal photographs taken between 2002 and 2003. Photographs were evaluated for AMD. Incident CHD/CVD events were ascertained during clinical follow-up visits for up to 8 years after the retinal images were taken.
Main Outcome Measures
Incident CHD/CVD events.
Of the 6814 persons at risk of CHD, there were 893 participants with early AMD (13.1%) and 27 (0.5%) at baseline. Over a mean follow-up period of 5.4 years, there was no statistically significant difference in incident CHD or CVD between the AMD and non-AMD groups (5.0%vs. 3.9%, p=0.13 for CHD and 6.6 vs. 5.5%, p=0.19 for CVD, respectively). In Cox regression models adjusting for CVD risk factors, there was no significant relationship between presence of any AMD and any CHD/CVD events (HR=0.99, 95% CI 0.74–1.33, p=0.97). No significant association was found between subgroups of early AMD or late AMD and incident CHD/CVD events.
In persons without a history of cardiovascular disease, AMD was not associated with an increased risk of CHD or CVD.
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Traditional risk factors and D-dimer predict incident cardiovascular disease events in chronic HIV infection
FORD, Emily S
GREENWALD, Jamieson H
RICHTERMAN, Aaron G
RUPERT, Adam
DUTCHER, Lauren
BADRALMAA, Yunden
NATARAJAN, Ven
REHM, Catherine
HADIGAN, Colleen
SERETI, Irini
AIDS (London, England)
Cardiovascular disease (CVD) contributes significantly to HIV-related morbidity and mortality. Chronic immune activation and inflammation are thought to augment the progression of atherosclerotic disease. In this retrospective, case-control study of HIV-infected subjects, we investigated the association of traditional cardiac risk factors, HIV-related disease and inflammation with CVD events.
HIV-infected subjects who experienced an incident CVD event while enrolled in National Institutes of Health clinical protocols from 1995-2009 were matched 2:1 to HIV-infected subjects without known CVD. Markers of inflammation and cell activation were measured in serum or plasma using ELISA-based assays and peripheral mononuclear cells by four-color flow cytometry.
Fifty-two patients experienced an incident CVD event. Events were related to smoking, dyslipidemia, hyperglycemia and family history as well as D-dimer, sVCAM-1, TIMP-1, and soluble tissue factor but not hsCRP. No significant differences in antiviral therapy, CD4+ T-cell count or CD38 and HLA-DR expression were identified between cases and controls. In multivariable analysis, smoking, family history, D-dimer, and glucose were independently related to CVD risk.
In this cohort, CVD risk was related to traditional CVD risk factors and markers of thrombosis and endothelial damage but not to hsCRP or markers of T-cell activation such as CD38+/HLA-DR coexpression. D-dimer may help identify HIV-infected patients at elevated CVD risk.
HIV; cardiovascular disease; myocardial infarction; smoking; D-dimer; tissue factor; VCAM-1
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Coagulation factors II, V, IX, X, XI, XII, plasminogen, and α-2 antiplasmin and risk of coronary heart disease
Yamagishi, Kazumasa
Aleksic, Nena
Hannan, Peter J.
Folsom, Aaron R.
Journal of atherosclerosis and thrombosis
Since few studies have examined the associations of plasma levels of coagulation factors II, V, IX, X, XI, XII, plasminogen, or α-2 antiplasmin with coronary heart disease (CHD), we sought to examine the associations of these factors with incident CHD in a prospective case-cohort study.
This case-cohort sample consisted of 368 African-American or white incident CHD cases that occurred between 1990–92 and 1998 in the Atherosclerosis Risk in Communities (ARIC) study, and a cohort random sample of n=412. Hemostatic factors were measured in the case-cohort sample using plasma stored at −70°C since 1990–92.
After adjustment for age, sex and race, coagulation factors IX and XI, and α-2 antiplasmin were associated positively with risk of CHD: The hazard ratio [95% confidence interval] for the highest vs lowest quartiles was 1.52 [1.01–2.27] for factor IX; 2.26 [1.47–3.48] for factor XI; and 1.64 [1.05–2.57] for α-2 antiplasmin. However, these hemostatic factors were correlated with classical risk factors, so that after multivariable adjustment their associations with CHD were attenuated and no longer statistically significant. No associations were observed between CHD and factors II, V, X, XII, or plasminogen.
Positive associations of factors IX and XI, and α-2 antiplasmin with incident CHD were not strong and were accounted for by classical coronary risk factors. (213 words/250 limits)
epidemiology; cardiovascular disease; ischemic disease; fibrinolytic factors; blood clotting
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High apolipoprotein AI concentrations are associated with lower mortality and myocardial infarction five years after coronary artery bypass graft surgery
Skinner, J
Farrer, M
Albers, C
Neil, H
Adams, P
OBJECTIVE—To examine mortality and myocardial infarction five years after coronary artery bypass graft (CABG) surgery and the association with different lipid fractions and haemostatic, glycaemic, and demographic risk factors. SETTING—A regional cardiothoracic centre, Freeman Hospital, and the University Clinical Investigation Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK. DESIGN—353 consecutive patients (297 male, mean age 57.2 years) undergoing first time CABG for stable angina were recruited to a prospective cohort study and studied to five years. MAIN OUTCOME MEASURES—All cause mortality, late cardiac mortality (beyond 30 days) alone and in combination with non-fatal myocardial infarction. Risk factor assessments before operation and 3, 6, 12, 24, and 60 months after surgery. For each laboratory variable a weighted mean for the period of exposure was calculated from the concentration at each time interval and the time between measurements. The distribution was divided into tertiles. RESULTS—41 patients died (16 late cardiac deaths) and eight had a myocardial infarct. An adverse outcome occurred more frequently in the lower tertile of weighted apolipoprotein AI compared with the upper tertile. An adverse outcome was also more common in patients in the upper tertile of weighted total white blood cell count and less consistently so in patients in the upper tertile of the haemostatic covariates, factor VIIc and factor VIIIc. There was no association with other lipid fractions except for total mortality and apolipoprotein B (owing to low levels in five patients with carcinoma). CONCLUSIONS—Low apolipoprotein AI concentrations, but no other markers of an adverse lipid profile, were associated with mortality and myocardial infarction five years after CABG. Apolipoprotein AI is associated with paraoxonase, an enzyme located on high density lipoprotein, which may limit the oxidation of low density lipoprotein. An association between outcome and other covariates such as white cell count provides a credible pointer to inflammation mediating a component of cardiovascular risk. Keywords: coronary artery bypass graft surgery; mortality; myocardial infarction; apolipoprotein AI
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High Diet Quality Is Associated with a Lower Risk of Cardiovascular Disease and All-Cause Mortality in Older Men123
Atkins, Janice L.
Whincup, Peter H.
Morris, Richard W.
Lennon, Lucy T.
Papacosta, Olia
Wannamethee, S. Goya
The Journal of Nutrition
Although diet quality is implicated in cardiovascular disease (CVD) risk, few studies have investigated the relation between diet quality and the risks of CVD and mortality in older adults. This study examined the prospective associations between dietary scores and risk of CVD and all-cause mortality in older British men. A total of 3328 men (aged 60–79 y) from the British Regional Heart Study, free from CVD at baseline, were followed up for 11.3 y for CVD and mortality. Baseline food-frequency questionnaire data were used to generate 2 dietary scores: the Healthy Diet Indicator (HDI), based on WHO dietary guidelines, and the Elderly Dietary Index (EDI), based on a Mediterranean-style dietary intake, with higher scores indicating greater compliance with dietary recommendations. Cox proportional hazards regression analyses assessed associations between quartiles of HDI and EDI and risk of all-cause mortality, CVD mortality, CVD events, and coronary heart disease (CHD) events. During follow-up, 933 deaths, 327 CVD deaths, 582 CVD events, and 307 CHD events occurred. Men in the highest compared with the lowest EDI quartile had significantly lower risks of all-cause mortality (HR: 0.75; 95% CI: 0.60, 0.94; P-trend = 0.03), CVD mortality (HR: 0.63; 95% CI: 0.42, 0.94; P-trend = 0.03), and CHD events (HR: 0.66; 95% CI: 0.45, 0.97; P-trend = 0.05) but not CVD events (HR: 0.79; 95% CI: 0.60, 1.05; P-trend = 0.16) after adjustment for sociodemographic, behavioral, and cardiovascular risk factors. The HDI was not significantly associated with any of the outcomes. The EDI appears to be more useful than the HDI for assessing diet quality in relation to CVD and morality risk in older men. Encouraging older adults to adhere to the guidelines inherent in the EDI criteria may have public health benefits.
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Human factor VIII procoagulant protein. Monoclonal antibodies define precursor-product relationships and functional epitopes.
Fulcher, C A
Roberts, J R
Holland, L Z
Zimmerman, T S
Journal of Clinical Investigation
The human Factor VIII procoagulant protein (VIII:C) purified from commercial Factor VIII concentrate consisted of a polypeptide doublet of 80,000 mol wt, a 92,000-mol wt polypeptide, and additional polypeptides of up to 188,000 mol wt. Thrombin digests contained a doublet of 72,000 mol wt, as well as 54,000- and 44,000-mol wt fragments. Proteolysis studies of purified VIII:C using thrombin and activated protein C have suggested that the 92,000- and 80,000 (or 72,000)-mol wt polypeptides comprise activated VIII:C. We have now used seven monoclonal antibodies raised against purified VIII:C to construct a preliminary epitope map of these VIII:C polypeptides. The specific VIII:C polypeptides with which the monoclonal antibodies reacted were determined by immunoblotting of VIII:C onto nitrocellulose sheets after reduced NaDodSO4-polyacrylamide gel electrophoresis. A minimum of five distinct epitopes were defined by these monoclonal anti-VIII:C antibodies. Identification of polypeptides bearing these epitopes allowed localization of distinct thrombin cleavage sites to the 92,000- and 80,000-mol wt chains, helped define polypeptide chain precursor-product relationships, and suggested that both the 92,000- and 80,000-mol wt polypeptides are necessary for VIII:C function. These data and their interpretation are consistent with the published description of the complete primary structure of VIII:C and its thrombin cleavage products. The 92,000- and 80,000-mol wt chains have been located at the amino- and carboxy-terminal ends of the molecule, respectively.
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Novel Hemostatic Factor Levels and Risk of Ischemic Stroke: The Atherosclerosis Risk in Communities (ARIC) Study
Suri, M. Fareed K.
Yamagishi, Kazumasa
Aleksic, Nena
Hannan, Peter J.
Folsom, Aaron R.
Cerebrovascular Diseases (Basel, Switzerland)
Background and Objective
The role of hemostatic factor levels in cerebral infarction remains uncertain. We studied the association of levels of several under-studied hemostatic factors with ischemic stroke in a population-based cohort.
The Atherosclerosis Risk in Communities (ARIC) study includes 15,792 individuals aged 45–54 years at intake. Hemostatic factors II, V, IX, X, XI, XII, plasminogen and α2-antiplasmin were measured on frozen citrate plasma samples from 1990 to 1992. A case-cohort design was used, including all incident ischemic strokes (n = 89) over a median of 7.5 years and a stratified cohort random sample (n = 412). To determine the association of hemostatic factors with incident ischemic stroke, we computed hazard ratios (HRs) using multivariate proportional hazard regression analyses adjusted for demographic and other cardiovascular risk factors.
The cohort random sample had a mean age (SD) of 56.9 (5.4) years and 42% were men. The age-, sex- and race-adjusted HRs for highest versus lowest quartiles were: factor XI (2.74, 95% CI 1.42–5.29), factor IX (1.92, 95% CI 0.99–3.73), and α2-antiplasmin (2.24, 95% CI 1.16–4.33). Correspondingly, the HRs of ischemic stroke per SD increment of factors XI, IX, and α2-antiplasmin were 1.64, 1.46 and 1.52, respectively (all p < 0.05). After multivariate adjustment including other clinical variables, the standardized HR remained significant for factor XI (1.50, 95% CI 1.10–2.05), but no other factor.
A greater level of factor XI was associated with an increased risk of ischemic stroke. Higher factor XI levels might help identify patients at elevated ischemic stroke risk.
Stroke; Coagulation; Risk factors
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Peroxiredoxin 4, A Novel Circulating Biomarker for Oxidative Stress and the Risk of Incident Cardiovascular Disease and All-Cause Mortality
Abbasi, Ali
Corpeleijn, Eva
Postmus, Douwe
Gansevoort, Ron T.
de Jong, Paul E.
Gans, Rijk O. B.
Struck, Joachim
Schulte, Janin
Hillege, Hans L.
van der Harst, Pim
Peelen, Linda M.
Beulens, Joline W. J.
Stolk, Ronald P.
Navis, Gerjan
Bakker, Stephan J. L.
Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
Oxidative stress has been suggested to play a key role in the development of cardiovascular disease (CVD). The aim of our study was to investigate the associations of serum peroxiredoxin 4 (Prx4), a hydrogen peroxide–degrading peroxidase, with incident CVD and all-cause mortality. We subsequently examined the incremental value of Prx4 for the risk prediction of CVD compared with the Framingham risk score (FRS).
Methods and Results
We performed Cox regression analyses in 8141 participants without history of CVD (aged 28 to 75 years; women 52.6%) from the Prevention of Renal and Vascular End-stage Disease (PREVEND) study in Groningen, The Netherlands. Serum Prx4 was measured by an immunoluminometric assay in baseline samples. Main outcomes were: (1) incident CVD events or CVD mortality and (2) all-cause mortality during a median follow-up of 10.5 years. In total, 708 participants (7.8%) developed CVD events or CVD mortality, and 517 participants (6.3%) died. Baseline serum Prx4 levels were significantly higher in participants with incident CVD events or CVD mortality and in those who died than in participants who remained free of outcomes (both P<0.001). In multivariable models with adjustment for Framingham risk factors, hazard ratios were 1.16 (95% CI 1.06 to 1.27, P<0.001) for incident CVD events or CVD mortality and 1.17 (95% CI 1.06 to 1.29, P=0.003) for all-cause mortality per doubling of Prx4 levels. After the addition of Prx4 to the FRS, the net reclassification improvement was 2.7% (P=0.01) using 10-year risk categories of CVD.
Elevated serum Prx4 levels are associated with a significantly higher risk of incident CVD events or CVD mortality and all-cause mortality after adjustment for clinical risk factors. The addition of Prx4 to the FRS marginally improved risk prediction of future CVD.
cardiovascular disease; epidemiology; mortality; oxidative stress; peroxiredoxin 4
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Liver Transplantation in Hemophilia A
Bontempo, Franklin A.
Lewis, Jessica H.
Gorenc, Toni J.
Spero, Joel A.
Ragni, Margaret V.
Scott, J.P.
Starzl, Thomas E.
Four patients with hemophilia A have undergone liver transplantation in our institution, three successfully. The first was a 21-year-old man with chronic active hepatitis (CAH) in whom the effects of previous abdominal operations prevented the satisfactory technical insertion of the new liver. He died intraoperatively. The second patient was a 15-year-old boy with CAH who began to synthesize factor VIII coagulant activity (F VIII:C) within 18 hours of successful liver transplantation and has continued to do so for almost 2 years (F VIII:C range 0.89 to 3.20 U/mL). The first 2 months of his postoperative course were complicated by infections, but since that time he has done well and has returned to school. The third patient was a 48-year-old man with portal fibrosis and severe ascites. He synthesized F VIII:C (range 0.96 to 1.50 U/mL) within six hours after reestablishment of circulation through the new liver. His postoperative course was complicated by numerous infections, and he died with sepsis and an acquired immunodeficiency-like syndrome 4 months after transplantation. The fourth patient was a 47-year-old mild hemophiliac with CAH who produced adequate factor VIII:C levels following transplantation (range 0.79 to 2.80 U/mL). These patients demonstrate that liver transplantation in hemophiliacs with end-stage liver disease may be lifesaving and results in correction of the F VIII:C deficiency and associated hemorrhagic tendency.
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text:
"World's Largest Hardware Store"
Item #: 352521 Model #: VBV1612.CL
|16 gal
|Peak Horsepower
|Hose Size
|2-1/2" x 10'
|Power Cord Length
|Heavy-Duty Plastic
|Package Quantity
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Channellock 6 Gallon Wet/Dry Vacuum
Item # 300440
Model # VJC607PF 2001
Online Only
Channellock 8 Gallon Wet/Dry Vacuum
Item # 365297
Model # VJC809PF 2001
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Channellock 5 Gallon Wall Mount Wet/Dry Vacuum
Item # 358758
Model # VWM510.CL
I just recently purchased a Channellock VBV1612.CL 16 gallon shop vac. I replaced my aging well used and abused craftsman 16 gallon vac. I liked the bright blue compared to the brick red color of the Craftsman and wanted a change. This one looks to have the identical detachable blower assembly as the Craftsman model 12008. The Channellock model is built in China so I was a little concerned with the quality as I purchased this online without ever seeing one. I was pleasantly surprised as the quality seems quite good. All parts went together easily and fit well. I was interested in the larger wheels and the push handle that the Craftsman did not have and it is much easier to move it around so that is a plus. The push handle feels good and I like being able to tilt the vac to push and pull it around and the larger wheels work well-really good feature. Both units had a supposed 6.5 peak hp motor and a 265 MPH detachable blower. The CL (Channellock) has a 10' hose and the Craftsman has a 7' hose. The hose on the CL has only a single swivel at the canister end and that detracts from using the accessory attachments as they don't swivel as easily as the Craftman that has swivels on both ends of the hose. I've cured this by using one of the old Craftsman hoses as well as the CL hose plugged into the Channellock hose. The CL has about an 18' cord and the Craftman a 20' cord. The one difference I noticed on the new one compared to my older Craftsman was the thickness of the main container. The Craftsman has thicker walled container. The older Craftman has what I would consider large hand friendly hinged handle locking mechanisms for the vac lid. The CL has much smaller and harder to access snap lock devices to latch the vac lid. The new CL's motor is smooth running and came with a silencer to put in the exhaust port that really quiets the air noise considerably-my older vac did not have this. The suction feels comparable with the Craftsman. There are numerous cut outs and molded in mounts for the accessories as well as a canvas type bag to hold things that straps to the handle. For the few tiny little messes that I've used it for it works well. It also came with a fine dust filter instead of a plain pleated filter. Obtaining filters may be the only drawback in that in as exact looking as it is to the Craftsman 12008 the filters do no interchange. I found a Do It Yourself Hardware store that does handle the CL line of vacs that is ordering in one of the standard pleated filters for $15.00 (the filter arrived and is seemingly good quality). That is less than the Craftsman filters so you need to keep a spare. As for price the Craftsman was about $130.00 when I ordered the CL one for $115.00 (with free shipping) and while I was waiting for it the Craftsman went down the $103.00. So far I'm satisfied with my purchase, but only time will tell if it lasts as long as the Craftsman I purchased in 1991. I would buy this again and I would give it 4 1/2 stars.

subset: commoncrawl


text:
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If you do decide to work with a link company of some kind, you really need to understand what you're getting for your money. In the last video, I discussed some of the jargon you'll hear, but often linking companies are also very vague about what they will deliver, sometimes intentionally so. I frequently talk to clients who've worked with linking companies, sometimes for many months, without ever fully understanding what types of links they'll be getting and how many. Many website owners are of course not terribly sophisticated in this area.
They know they need links, but don't understand the kinds of things we've covered in this course so link companies can easily take advantage of them. So in this video, I want to quickly run through a few things you need to ask and understand if you do decide to hire a linking firm. The first question is of course, what type of links are they providing? Links firms are often vague about this. They're just going to get you links; it doesn't seem to matter where. There's often a signal that you're going to get garbage links, because why would they provide high quality links, when you don't even know what you're getting? Are these links in blogs? If so, where? On comments, blogrolls, posts or reviews? Are they social network links? If so, what networks and what types of links? Of course, you'll also need to know if they're getting you follow or no-follow links.
Perhaps some will be no-follows, and that's fine in some circumstances, but at least be aware of what you're getting. How many links are you paying for? It's surprising how many people buy link packages without understanding the number of links that will be created each month, for example. Then will you get reports showing where these links are? If the service doesn't provide reports, you will never know if you're really getting links or not. Are you paying for permanent links? In other words, if you stop paying, will those links disappear? If so, you're basically renting the link.
Again, that can be okay as long as the price is right of course. Are these pages indexed by the search engines, in particular Google? If not, what's the point? And do the pages have any PageRank? That's not to say the pages with no PageRank or low PageRank are of completely no value, but you should at least know what you're getting. You also need to actually see some example links, so you can get an idea of how valuable the links are going to be for you, and if the person you're talking with is being honest.
Are they in posts and high quality blogs for instance? Or in really trashy, unintelligible blogs that look like they were written by someone who can't speak the language, or by a computer program? Are the links in account profiles that contain nothing more than a fake name in the link or are they in genuine well- written content? You need to know what you're getting. Consider also how obvious these links are. How obvious is it that these links are not real, but purely placed for SEO purposes? If it's really obvious to you, there's a good chance that it's also obvious to the search engines, and thus the links will likely have little value.
When talking with these companies, don't be afraid to push for answers you can understand. If the linking company can't or won't explain what they're doing, then you shouldn't be working with them. And if you do work with the firm, check the reports and sample of the links now and then to make sure you're getting what you're paid for. Make sure you're getting follow links, for instance, on pages indexed by Google. If the page is very young, Google may not have gotten around to it yet. In which case you should at least check to see if the site itself is indexed, and perhaps how many pages in the site are indexed.
If only one or two pages from that site were indexed, there's a good chance your link on that new page will never be picked up.
- Understanding Google PageRank results
- Analyzing links
- Building local and directory links
- Working with article syndication services
- Creating link bait
- Distributing links of social networks
- Buying links: the pros and cons


text:
Press Pass: Connor Barwin
Published: Sept. 14, 2016 at 06:33 p.m.
Defensive end Connor Barwin talks after Sunday's win about the defensive performance, getting pressure on Robert Griffin III and his reaction to Carson Wentz's debut.
Published: Sept. 14, 2016 at 06:33 p.m.
Defensive end Connor Barwin talks after Sunday's win about the defensive performance, getting pressure on Robert Griffin III and his reaction to Carson Wentz's debut.
Published: Aug. 23, 2016 at 04:57 p.m.
Connor Barwin discusses veteran leadership, the addition of linebacker Stephen Tulloch, and his preparation heading into the regular season.
Published: Aug. 12, 2016 at 06:18 p.m.
Defensive end Connor Barwin meets with the media after the first preseason game of 2016.
Published: Aug. 7, 2016 at 04:34 p.m.
Defensive end Connor Barwin joins Alex Smith out on the practice field for a one-on-one interview, discussing the major differences in this year's camp and how he fits into the new scheme ...
Published: Aug. 4, 2016 at 12:10 p.m.
Defensive end Connor Barwin discusses the differences between playing on either side of the defensive line and explains how high the energy was during the "live" tackling periods.
Published: April 19, 2016 at 06:55 p.m.
Connor Barwin is making the move from linebacker to defensive end. Hear from the veteran as he talks about getting back to his roots ...
Published: Jan. 4, 2016 at 07:19 p.m.
Connor Barwin talks about Walter Thurmond's interception against the Giants and how he was able to assist on that play ...
Published: Dec. 27, 2015 at 05:28 p.m.
Linebacker Connor Barwin talks to the media and reflects on how the game unfolded versus Washington ...
Published: Dec. 25, 2015 at 07:26 p.m.
Connor Barwin, nominated for Walter Payton Man of the Year, gives you an inside look on how he gives back to the city of Philadelphia.
Published: Nov. 26, 2015 at 05:33 p.m.
Linebacker Connor Barwin shares his thoughts on the game in Detroit and the mistakes that contributed to the outcome of the game ...
Published: Nov. 22, 2015 at 06:22 p.m.
Linebacker Connor Barwin compliments Tampa Bay players Doug Martin and Jameis Winston on their play, and delivers his personal message to Eagles fans ...
Published: Nov. 20, 2015 at 03:23 p.m.
The Eagles got off to a strong start last Sunday, but were unable to finish. DeMarco Murray and Connor Barwin explain how they must learn from that mistake ahead of this week's matchup ...
Published: Nov. 15, 2015 at 07:10 p.m.
Linebacker Connor Barwin emphasizes the defense's quick start, and talks about Bill Davis' defensive scheme ...
Published: Nov. 6, 2015 at 06:35 p.m.
Philadelphia Eagles linebacker Connor Barwin sits down with "Around the NFL" to talk about the team's upcoming game in Dallas and how he helps his community.
Published: Oct. 23, 2015 at 01:49 p.m.
NFL Films presents takes a look at the love that Philadelphia has for Eagles linebacker Connor Barwin due to his efforts to aid his community.
Published: Oct. 23, 2015 at 01:47 p.m.
NFL Films Presents take a look at the impact of Philadelphia Eagles linebacker Connor Barwin on his new home.
Published: Oct. 11, 2015 at 06:26 p.m.
Linebacker Connor Barwin explains how the Eagles were able to come up with four turnovers against Drew Brees and the Saints. Barwin also offered a quick preview of the matchup with the Giants ...
Published: Sept. 30, 2015 at 02:58 p.m.
Hear from Connor Barwin after Wednesday's practice at the NovaCare Complex ...
Published: Sept. 17, 2015 at 04:07 p.m.
Hear from Connor Barwin after Thursday's practice at the NovaCare Complex ...
Published: Sept. 15, 2015 at 12:00 p.m.
Hear from Connor Barwin after Monday's game versus the Atlanta Falcons ...
Published: Aug. 25, 2015 at 07:39 p.m.
Ahead of this weekend's preseason game, linebacker Connor Barwin discussed the performance last season in Green Bay and how much he is looking forward to going up against Aaron Rodgers ...
Published: Aug. 18, 2015 at 10:31 p.m.
What does linebacker Connor Barwin want to take away from Sunday?s preseason game, and what will it be like for him to see former teammate Trent Cole on the other sideline? Hear what he had to say following Thursday's practice ?
Published: July 1, 2015 at 03:00 a.m.
NFL Films presents Philadelphia Eagles linebacker Connor Barwin
Published: June 19, 2015 at 07:53 p.m.
Oakland Raiders linebacker Khalil Mack, Dallas Cowboys cornerback Orlando Scandrick and Philadelphia Eagles linebacker Connor Barwin wish fans a Happy Father's Day.
Published: April 9, 2015 at 08:49 p.m.
NFL Media's Scott Hanson attempts to jump as high as Philadelphia Eagles linebacker Connor Barwin did during a box jump.
© 2016 NFL Enterprises LLC. NFL and the NFL shield design are registered trademarks of the National Football League.The team names, logos and uniform designs are registered trademarks of the teams indicated. All other NFL-related trademarks are trademarks of the National Football League. NFL footage © NFL Productions LLC. PRIVACY POLICY | Terms & Conditions


text:
Environmental Toxicology Companies serving British Columbia
Current filtering criteriaYou can remove a filter by clicking on the x
Category: Health & Safety ×
Subcategory: Environmental Toxicology ×
Employees number: 101-1000 ×
Industry: Manufacturing, Other ×
Serving: Canada ×
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Ocean Optics - a Halma Company
based in Dunedin, FLORIDA (USA)
Ocean Optics is a diversified photonics technology firm and a global leader in optical sensing. With full-service locations in the United States, Europe and Asia, we serve a wide range of markets, including process control, consumer electronics and medical diagnostics.
ADI Systems
based in Fredericton, NEW BRUNSWICK (CANADA)
ADI Systems is a world leader in industrial wastewater treatment and waste-to-energy solutions. Our innovative anaerobic and aerobic technologies reliably treat wastewater to help plants comply with environmental regulations and reduce/eliminate wastewater surcharges. We can assist with water reuse opportunities, and capture and treat biogas produced by anaerobic ...
UL - The Wercs
based in Latham, NEW YORK (USA)
UL - The Wercs, is a software development company located in NY that provides SDS software tools and services to help organizations author, manage, and distribute Safety Data Sheets, Labels, and various documents required under OSHA, EU Directives, and other regulatory bodies worldwide. In addition to keeping compliant with regulations, The WERCS and its chemical ...
3E Company
based in Carlsbad, CALIFORNIA (USA)
3E Company's comprehensive suite of data products and information services enable improved compliance with global Environmental Health & Safety (EH&S) requirements related to the safe manufacturing, distribution, transportation, usage and disposal of chemicals and hazardous products. This full chemical lifecycle approach enables in-house EH&S staff to reduce cost, risk ...


text:
A fourth defendant charged in the abortion-horror case - known as "Dr. Steve" at Kermit Gosnell's former clinic - is expected to plead guilty during a court hearing Thursday.
Steven Massof, 49, a medical-school graduate who never obtained a medical license or any certification, faces a status hearing before Common Pleas Judge Benjamin Lerner, the same judge who accepted guilty pleas last month from three of the case's 10 defendants.
Massof, of Pittsburgh, was employed from 2003 to 2008 in the West Philadelphia clinic and is charged with numerous crimes, including the murders of two viable babies born alive at the clinic.