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Is polycystic ovary syndrome a risk factor for atherosclerosis?
SCIENCE AND MEDICINE
Laser therapy takes the pain out of angina day, brought on by slight exertion, despite intensive medication”, explains Horvath. 20–25 small channels were made in the heart muscle at various points, mainly in the left ventricle walls. Postoperatively, 66% of patients showed a significant improvement in angina symptoms to either class I or class II; 17% of patients were completely free of symptoms. James Jones (University of Missouri School of Medicine, Columbia, USA) comments that “surgical TMR is continuing to gain acceptance in the United States, with virtually all well-designed studies reporting substantial relief of angina.” Jones welcomes the reported persistence of angina relief for up to 8 or 9 years Exercise can be fatal in the unfit following TMR, but People who exercise infrequently run a greater risk of warns that “we must dying from an exercise-related heart attack than those await accumulation of who exercise regularly. Barry Franklin (William larger samples as the Beaumont Hospital, Royal Oak, Michigan, USA) studied years pass”. statistics from a large chain of health centres in the In another presentaUSA. In 1 year, 71 fatal heart attacks or strokes tion, Gregg Stone occurred in a total of 182·3 million workouts; most of (Lenox Hill Hospital, the deaths occurred in older men who exercised less New York, USA) than once a week. Kathryn Senior described a modified, non-surgical form of
study presented at the American Heart Association meeting (New Orleans, USA; Nov 12–15, 2000) has revealed that transmyocardial revascularisation (TMR) provides long-term relief from the symptoms of angina. “Patients who improve after TMR stabilise after about a year, and their symptoms do not worsen again for as long as 8 or 9 years”, says Keith Horvath (Northwestern University Medical School, Chicago, USA), the lead investigator of the study. The group of 80 patients, who were aged 63 years on average, all had end-stage cardiovascular disease. 70% had class IV angina, the rest had class III. “These patients were having several angina attacks every
A
TMR, percutaneous TMR (PTMR). Jones points out that PTMR techniques have not yet been approved for clinical application in the USA, and that the results of PTMR clinical trials have been less convincing than with TMR. “This is an outpatient procedure that requires only sedation and results from 142 patients in a trial of PTMR against standard drug therapy are encouraging”, stresses Stone. There are several theories to explain how TMR works. “When we examined the heart muscle of treated patients using MRI scanning, it was clear that TMR does not cause micro-infarcts”, says Horvath. He is more convinced by the proposal that the laser–tissue interaction stimulates angiogenesis in the heart muscle, which increases blood flow and lessens angina symptoms. Horvath predicts that TMR may find maximum use in patients having bypass surgery. “TMR done in combination with bypass surgery may provide greater benefits than either treatment alone and studies are in progress to substantiate this”, he reports. Kathryn Senior
Is polycystic ovary syndrome a risk factor for atherosclerosis?
W
omen with polycystic ovary syndrome (PCOS) are at increased risk of developing earlyonset atherosclerosis, a new study shows. But lifestyle changes may not be enough to reduce the risk, because there seems to be an additional, independent factor, related to hormonal dysregulation. Evelyn Talbott (University of Pittsburg, PA, USA) and colleagues used carotid ultrasonography to measure intima–media wall thickness (IMT) and areas of focal plaque in 267 women aged 30 years and older. They found that 21·6% of the 125 women with PCOS had atherosclerotic plaques, compared with 15·5% of age-matched controls—a non-significant difference. However, IMT was significantly higher in women with PCOS who were aged 45 years and over than in agematched controls. The difference remained significant after adjustment for body mass index. Furthermore, a high plaque index (a large plaque occupying more than 50% of the vessel diameter or multiple plaques with at least one plaque
1742
30–50% of vessel diameter) was significantly more common in women with PCOS than controls (7·2% vs 0·7%). Among women aged 45 years and over, the difference was even greater (14·9% vs 0%; Arterioscler Thromb Vasc Biol 2000; 20: 2414–21). “A combination of cardiovascular risk factors—obesity, adverse lipid profile, and high blood pressure—is common in patients with PCOS, but even thin patients in the study were at increased risk of premature atherosclerosis”, explains Talbott. “The first line of management should be appropriate lifestyle changes, such as weight control, avoidance of fatty foods, and physical activity”, she adds. “But elevated insulin levels are also a big part of the problem in PCOS, and this is underscored by the fact that even thin women with PCOS are at increased cardiovascular risk.” Talbott suggests that the use of an insulin-lowering drug in younger women with PCOS should be investigated as a long-term means of reducing the risk of cardiovascular
disease in later life. “PCOS affects about 7% of all women, so patients with the syndrome may represent the largest female group at high risk of developing early-onset coronary heart disease”, says Talbott. “Most women with PCOS consult their doctor initially because of menstrual irregularities or infertility, and it is important that physicians recognise that these symptoms may be part of a broader, chronic disorder. Patients even as young as 14–18 should have a full diagnostic workup, including insulin, cholesterol, and blood pressure measurements.” Hugh Tunstall-Pedoe (University of Dundee, UK) adds: “The syndrome gives a head start in the atheroma stakes. Follow-up should show whether differences continue well beyond the menopause or disappear. PCOS may provide clues to the unexplained sex difference in coronary risk and the so-called syndrome X or metabolic cardiovascular syndrome.” Dorothy Bonn
THE LANCET • Vol 356 • 18 November, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
Laser therapy takes the pain out of angina day, brought on by slight exertion, despite intensive medication”, explains Horvath. 20–25 small channels were made in the heart muscle at various points, mainly in the left ventricle walls. Postoperatively, 66% of patients showed a significant improvement in angina symptoms to either class I or class II; 17% of patients were completely free of symptoms. James Jones (University of Missouri School of Medicine, Columbia, USA) comments that “surgical TMR is continuing to gain acceptance in the United States, with virtually all well-designed studies reporting substantial relief of angina.” Jones welcomes the reported persistence of angina relief for up to 8 or 9 years Exercise can be fatal in the unfit following TMR, but People who exercise infrequently run a greater risk of warns that “we must dying from an exercise-related heart attack than those await accumulation of who exercise regularly. Barry Franklin (William larger samples as the Beaumont Hospital, Royal Oak, Michigan, USA) studied years pass”. statistics from a large chain of health centres in the In another presentaUSA. In 1 year, 71 fatal heart attacks or strokes tion, Gregg Stone occurred in a total of 182·3 million workouts; most of (Lenox Hill Hospital, the deaths occurred in older men who exercised less New York, USA) than once a week. Kathryn Senior described a modified, non-surgical form of
study presented at the American Heart Association meeting (New Orleans, USA; Nov 12–15, 2000) has revealed that transmyocardial revascularisation (TMR) provides long-term relief from the symptoms of angina. “Patients who improve after TMR stabilise after about a year, and their symptoms do not worsen again for as long as 8 or 9 years”, says Keith Horvath (Northwestern University Medical School, Chicago, USA), the lead investigator of the study. The group of 80 patients, who were aged 63 years on average, all had end-stage cardiovascular disease. 70% had class IV angina, the rest had class III. “These patients were having several angina attacks every
A
TMR, percutaneous TMR (PTMR). Jones points out that PTMR techniques have not yet been approved for clinical application in the USA, and that the results of PTMR clinical trials have been less convincing than with TMR. “This is an outpatient procedure that requires only sedation and results from 142 patients in a trial of PTMR against standard drug therapy are encouraging”, stresses Stone. There are several theories to explain how TMR works. “When we examined the heart muscle of treated patients using MRI scanning, it was clear that TMR does not cause micro-infarcts”, says Horvath. He is more convinced by the proposal that the laser–tissue interaction stimulates angiogenesis in the heart muscle, which increases blood flow and lessens angina symptoms. Horvath predicts that TMR may find maximum use in patients having bypass surgery. “TMR done in combination with bypass surgery may provide greater benefits than either treatment alone and studies are in progress to substantiate this”, he reports. Kathryn Senior
Is polycystic ovary syndrome a risk factor for atherosclerosis?
W
omen with polycystic ovary syndrome (PCOS) are at increased risk of developing earlyonset atherosclerosis, a new study shows. But lifestyle changes may not be enough to reduce the risk, because there seems to be an additional, independent factor, related to hormonal dysregulation. Evelyn Talbott (University of Pittsburg, PA, USA) and colleagues used carotid ultrasonography to measure intima–media wall thickness (IMT) and areas of focal plaque in 267 women aged 30 years and older. They found that 21·6% of the 125 women with PCOS had atherosclerotic plaques, compared with 15·5% of age-matched controls—a non-significant difference. However, IMT was significantly higher in women with PCOS who were aged 45 years and over than in agematched controls. The difference remained significant after adjustment for body mass index. Furthermore, a high plaque index (a large plaque occupying more than 50% of the vessel diameter or multiple plaques with at least one plaque
1742
30–50% of vessel diameter) was significantly more common in women with PCOS than controls (7·2% vs 0·7%). Among women aged 45 years and over, the difference was even greater (14·9% vs 0%; Arterioscler Thromb Vasc Biol 2000; 20: 2414–21). “A combination of cardiovascular risk factors—obesity, adverse lipid profile, and high blood pressure—is common in patients with PCOS, but even thin patients in the study were at increased risk of premature atherosclerosis”, explains Talbott. “The first line of management should be appropriate lifestyle changes, such as weight control, avoidance of fatty foods, and physical activity”, she adds. “But elevated insulin levels are also a big part of the problem in PCOS, and this is underscored by the fact that even thin women with PCOS are at increased cardiovascular risk.” Talbott suggests that the use of an insulin-lowering drug in younger women with PCOS should be investigated as a long-term means of reducing the risk of cardiovascular
disease in later life. “PCOS affects about 7% of all women, so patients with the syndrome may represent the largest female group at high risk of developing early-onset coronary heart disease”, says Talbott. “Most women with PCOS consult their doctor initially because of menstrual irregularities or infertility, and it is important that physicians recognise that these symptoms may be part of a broader, chronic disorder. Patients even as young as 14–18 should have a full diagnostic workup, including insulin, cholesterol, and blood pressure measurements.” Hugh Tunstall-Pedoe (University of Dundee, UK) adds: “The syndrome gives a head start in the atheroma stakes. Follow-up should show whether differences continue well beyond the menopause or disappear. PCOS may provide clues to the unexplained sex difference in coronary risk and the so-called syndrome X or metabolic cardiovascular syndrome.” Dorothy Bonn
THE LANCET • Vol 356 • 18 November, 2000
For personal use only. Not to be reproduced without permission of The Lancet.