Childhood Poverty Grows into Adult Heart Disease

Childhood Poverty Grows into Adult Heart Disease - CME Teaching Brief® - MedPage Today: ", Nov. 27 -- A poor childhood more than doubles the risk of early heart disease among white male physicians who achieve a high socioeconomic status, found researchers here. Action Points

Explain to patients who ask that this study suggests that relative poverty in childhood has a persistent effect and increases the risk of heart disease as adults among white male physicians who achieve high socioeconomic status.


Point out that this increased risk is not mediated by established coronary heart disease risk factors.
The finding, based on a long-running prospective study of the precursors of heart disease, underlines the persistent effect of relative poverty on children's future health, according to Michelle Kittleson, M.D., Ph.D., of Johns Hopkins.
Interestingly, the effect appears to moderate over time, as other risk factors for coronary heart disease begin to predominate with increasing age, Dr. Kittleson (now at the UCLA) and colleagues reported in the Nov. 27 issue of Archives of Internal Medicine.
Dr. Kittleson and colleagues analyzed data from the John Hopkins Precursors Study, which enrolled graduates of the university's medical school between 1948 and 1964. Median follow-up has reached 40 years.
The cohort was valuable to examine the effects of childhood socioeconomic status, Dr. Kittleson and colleagues said, because it eliminated a key adult confounding effect. All of the participants went on to enjoy the income and professional status of physicians.
For this analysis, the researchers excluded female graduates, those of non-European background, those who did not provide information about parental occupation, and those who were unavailable for follow-up, leaving 1,131 volunteers."

The polypill: at what price would it become cost effective? -- Franco et al. 60 (3): 213 -- Journal of Epidemiology and Community Health

The polypill: at what price would it become cost effective? -- Franco et al. 60 (3): 213 -- Journal of Epidemiology and Community Health: "Introduction: A promising concept in cardiovascular disease prevention (the polypill) was introduced in 2003. Although the polypill may seem as an effective intervention, data on its costs and cost effectiveness remain unknown. The aim of this study was to determine the maximum price of the polypill for it to be a cost effective alternative in the primary prevention of cardiovascular disease.
Methods: Data on the hypothetical effects of the polypill were taken from the literature. Using data from the Framingham heart study and the Framingham offspring study, life tables were built to model the assumed benefits of the polypill. Using a third party payer perspective and a 10 years time horizon, the authors calculated what should be the maximum drug cost of the polypill for it to be cost effective (using a 20 000/year of life saved threshold) in the primary prevention of cardiovascular disease among populations at different levels of absolute risk of coronary heart disease and age.
Results: To be cost effective among populations at levels of 10 year coronary heart disease risk over 20% (high risk), the annual cost of medication for the polypill therapy should be no more than 302 or 410 for men at age 50 and 60 years respectively. For cost effective prevention in populations at levels of coronary heart disease risk between 10% and 20% the costs should be two to three times lower.
Conclusion: Although the polypill could theoretically be a highly effective intervention, the costs of the medication could be its caveat for implementation in the primary prevention of cardiovascular disease. "

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational obs

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE) -- Fox et al. 333 (7578): 1091 -- BMJ: "Objective To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome. Design Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation. Setting Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand. Population 43 810 patients (21 688 in derivation set; 22 122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005. Main outcome measures Death and myocardial infarction. Results 1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries). Conclusions This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome. "

Time course of depression and outcome of myocardial infarction.

De: Marcelo Gustavo Colominas [mailto:mgcolominas@hotmail.com]
Enviada em: quinta-feira, 23 de novembro de 2006 00:50
Arch Intern Med. 2006 Oct 9;166(18):2035-43.
Time course of depression and outcome of myocardial infarction.
Parashar S, Rumsfeld JS, Spertus JA, Reid KJ, Wenger NK, Krumholz HM, Amin A, Weintraub WS, Lichtman J, Dawood N, Vaccarino V.
Divisions of General Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA. smallik@emory.edu
BACKGROUND: Depression predicts worse outcomes after myocardial infarction (MI), but whether its time course in the month following MI has prognostic importance is unknown. Our objective was to evaluate the prognostic importance of transient, new, or persistent depression on outcomes at 6 months after MI. METHODS: In a prospective registry of acute MI (Prospective Registry Evaluating outcomes after Myocardial Infarction: Events and Recovery [PREMIER]), depressive symptoms were measured in 1873 patients with the Patient Health Questionnaire (PHQ) during hospitalization and 1 month after discharge and were classified as transient (only at baseline), new (only at 1 month), or persistent (at both times). Outcomes at 6 months included (1) all-cause rehospitalization or mortality and (2) health status (angina, physical limitation, and quality of life using the Seattle Angina Questionnaire). RESULTS: Compared with nondepressed patients, all categories of depression were associated with higher rehospitalization or mortality rates, more frequent angina, more physical limitations, and worse quality of life. The adjusted hazard ratios for rehospitalization or mortality were 1.34, 1.71, and 1.42 for transient, new, and persistent depression, respectively (all P<.05). Corresponding odds ratios were 1.62, 2.73, and
2.64 (all P<.01) for angina and 1.69, 2.25, and 3.27 (all P<.05) for physical limitation. Depressive symptoms showed a stronger association with health status compared with traditional measures of disease severity.
CONCLUSION: Depressive symptoms after MI, irrespective of whether they persist, subside, or newly develop in the first month after hospitalization, are associated with worse outcomes after MI.
Publication Types:
Multicenter Study
PMID: 17030839 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17030839&dopt=Abstract
_________________
Marcelo G. Colominas
EyP-FAC
SCChaco

Researchers isolate a master heart cell

Researchers isolate a master heart cell - The Boston Globe: "A team of Harvard scientists announced yesterday that it has discovered a single kind of cell that builds the three main types of heart tissue, an advance that boosts the prospects of using cells to treat heart disease, the nation's top killer.
The team identified the heart cell in mice, and proved that it develops into the muscle cells that power the heart, the cells that make up blood vessels, and the smooth muscle cells that allow the vessels to expand and contract.
If the human equivalent of the new cells is found, it could be given to patients to rebuild heart tissue that cannot be repaired today. The work could also give biologists new tools to look for heart drugs.
There has been a rush of work in recent years to develop therapies that inject cells capable of repairing patients' damaged heart muscle. But the field has been hampered because biologists have not known what type of cell to use. Researchers around the world have launched clinical trials, but the trials have used blood cells, not heart cells, and the results have been modest, at best.
The research identifies, for the first time, a kind of master heart cell, similar to a stem cell, with a proven ability to build a wide range of heart tissues. The scientists cautioned that important obstacles remain before cell therapies based on the research can be tested in humans."

Extending the Horizon in Chronic Heart Failure. Effects of Multidisciplinary, Home-Based Intervention Relative to Usual Care -- Inglis et al., 10.1161

Background--The long-term impact of chronic heart failure management programs over the typical life span of affected individuals is unknown.
Methods and Results--The effects of a nurse-led, multidisciplinary, home-based intervention (HBI) in a typically elderly cohort of patients with chronic heart failure initially randomized to either HBI (n=149) or usual postdischarge care (UC) (n=148) after a short-term hospitalization were studied for up to 10 years of follow-up (minimum 7.5 years of follow-up). Study end points were all-cause mortality, event-free survival (event was defined as death or unplanned hospitalization), recurrent hospital stay, and cost per life-year gained. Median survival in the HBI cohort was almost twice that of UC (40 versus 22 months; P<0.001), with fewer deaths overall (HBI, 77% versus 89%; adjusted relative risk, 0.74; 95% CI, 0.53 to 0.80; P<0.001). HBI was associated with prolonged event-free survival (median, 7 versus 4 months; P<0.01). HBI patients had more unplanned readmissions (560 versus 550) but took 7 years to overtake UC; the rates of readmission (2.04±3.23 versus 3.66±7.62 admissions; P<0.05) and related hospital stay (14.8±23.0 versus 28.4±53.4 days per patient per year; P<0.05) were significantly lower in the HBI group. HBI was associated with 120 more life-years per 100 patients treated compared with UC (405 versus 285 years) at a cost of $1729 per additional life-year gained when we accounted for healthcare costs including the HBI.
Conclusions--In altering the natural history of chronic heart failure relative to UC (via prolonged survival and reduced frequency of recurrent hospitalization), HBI is a remarkably cost- and time-effective strategy over the longer term.

Risk Factors Socioeconomic status

Impact of Traditional and Novel Risk Factors on the Relationship Between Socioeconomic Status and Incident Cardiovascular Events -- Albert et al., 10.1161/CIRCULATIONAHA.106.660043 -- Circulation: "Background--Persons of lower socioeconomic status have greater cardiovascular risk than those of higher socioeconomic status. However, the mechanism through which socioeconomic status affects cardiovascular disease (CVD) is uncertain. Virtually no data are available that examine the prospective association between novel inflammatory and hemostatic CVD risk indicators, socioeconomic status, and incident CVD events. Methods and Results--We assessed the relationship between 2 indicators of socioeconomic status (education and income), traditional and novel CVD risk factors (high sensitivity C-reactive protein, soluble intercellular adhesion molecule-1, fibrinogen, and homocysteine), and incident CVD events among 22 688 apparently healthy female health professionals participating in the Women’s Health Study. These women were followed up for 10 years for the development of myocardial infarction, ischemic stroke, coronary revascularization, and cardiovascular death. More educated women were less likely to be smokers; had a lower prevalence of hypertension, diabetes, and obesity; and were more likely to participate in vigorous physical activity than less educated women. At baseline, median total cholesterol, low-density lipoprotein, triglyceride, C-reactive protein, intercellular adhesion molecule-1, fibrinogen, and homocysteine levels for women in 5 categories of education (<2 trend="0.006),">Conclusions--In this prospective analysis, we observed a decrease in incident CVD events with increasing levels of education and income. In contrast to the relationship between income and CVD events, the relationship of CVD events with education was explained only partially by traditional and novel risk factors for CVD."

Alzheimer's heart link explained

BBC NEWS Health Alzheimer's heart link explained: "Both conditions lead to a reduction of oxygen flow to the brain.
A University of British Columbia team, studying mice, found this stimulates increased development of the protein clumps thought to cause Alzheimer's.
The lack of oxygen increases activity in a gene controlling production of the key protein, found the Proceedings of the National Academy of Sciences study. "

cocoa's medicinal potential

The Standard - Mars talks up cocoa's medicinal potential - World Section: "Mars is holding ''serious discussions with large pharmaceutical companies'' about the development of a line of cocoa-based prescription drugs that could help treat diabetes, some forms of dementia and other ailments. "

Novel Drug Effective for Hyponatremia in Heart Failure Patients

AHA: Novel Drug Effective for Hyponatremia in Heart Failure Patients - CME Teaching Brief® - MedPage Today: "CHICAGO, Nov. 15 -- Tolvaptan, an investigational selective oral vasopressin V2-receptor antagonist, restored serum sodium concentrations in heart failure and cirrhosis patients with hyponatremia, researchers reported here.

Compared with placebo patients in randomized, double blind studies of patients with euvolemic or hypervolemic hyponatremia, serum sodium concentrations increased in the tolvaptan arm by day four and the rise was durable at 30 days (P<0.001), said Mihai Gheorghiade, M.D., of Northwestern University. "

High Uric Acid Levels Signal Hypertension in Blacks

High Uric Acid Levels Signal Hypertension in Blacks - CME Teaching Brief® - MedPage Today:
Primary source: HypertensionSource reference: Mellen PB et al. "Serum Uric Acid Predicts Incident Hypertension in a Biethnic Cohort: The Atherosclerosis Risk in Communities Study." Hypertension. 2006;48:1-6. DOI: 10.1161/01.HYP.0000249768.26560.66
"WINSTON-SALEM, N.C., Nov. 6 -- High serum levels of uric acid are strongly associated with risk for hypertension, particularly among blacks, according to researchers here."

How Important Is Diabetes as a Risk Factor for Cardiovascular and Other Diseases in Older Adults?

PLoS Medicine: How Important Is Diabetes as a Risk Factor for Cardiovascular and Other Diseases in Older Adults?: "I is well established that diabetes mellitus is associated with adverse health outcomes. Data from general population cohorts indicate a 2- to 3-fold increase in cardiovascular risks and about a 50 percent increase in the risks of non-cardiovascular mortality associated with this condition [1–3]. These associations appear largely consistent across populations in different regions of the world [3].
There is some evidence that diabetes may be a more important determinant of cardiovascular risk for women than men [4]. However, the relative effects of diabetes on vascular and other diseases among older, compared with younger, individuals is less certain. Heterogeneity by age in the association between diabetes and cardiovascular disease has been reported, with a consistently weaker association observed among older individuals [3,5]. Given this possible age-dependency in the epidemiological associations, and the frequent observation that cardiovascular risk factors are often managed less aggressively in older people than in younger people [6], a better understanding of the relationship between diabetes and disease-specific causes of death among older people is important./.../"

Atividade Física e Saúde CV

Enviado por: Timóteo Leandro de Araújo [timoteo@celafiscs.org.br]

Gostaria de perguntar sobre alguma informação ou tema sobre o impacto da Prática da Atividade na reunião do SBC?
Encaminho a agenda dos programas que estamos colaborando com a TV Cultura em SP nessa sexta-feira será discutido a AF x Infarto.
Um grande abraço.
dia 03/11 – pgm 15 – AF X prevenção do infarto do miocárdio ( Claudia Forjaz / Dr. Nabil Ghaorayeb / Dr. José Aguilar Cortez)
dia 10/11 – pgm 16 – caminhada + promoção saúde ( Timóteo Araújo / Erinaldo Andrade)
dia 17/11 – pgm 17 – atividade física no setor privado (Dr. Márcio Marega)
dia 24/11 – pgm 18 – atividade física e hipertensão (Dr. Celso Amadeo)
dia 01/12 – pgm 19 – atividade física no setor públici de saúde (Dra. Marizete Medeiros)
dia 08/12 – pgm 20 – atividade física nas Ongs (Dr. Mário Albanese)

Prof. Timóteo Araújo

61. Congresso Brasileiro de Cardiologia

Estivemos em Recife participando do 61 Congresso da SBC.
Entre tantas oportunidades de contato e troca de conhecimento e experiências que podem ser visitados no endereço da SBC e no Congresso Virtual, gostaria de registrar com satisfação a premiação de membros da lista AMICOR: Geniberto Paiva Campos, Carisi Polanckzyc, Nadine Clasusell juntamente com o esposo da Dra. Carisi, Dr. Rohde.
Também gostaria de assinalar que entre os candidatos à presidência da SBC constam ilustres AMICOR: Abrahão Afiune Neto, Flávio Danni Fuchs, Jorge Ilha Guimarães e Paulo César B. Jardim.

Juntamente com vários outros membros de nossa lista tive a satisfação de participar de três atividades:

• Abrindo com uma palestra a primeira sessão de temas livres sobre Epidemiologia, abordando "Ultrapassando o Setor Saúde"
• Coordenando e traçando retrato do tabagismo no BR no simpósio sobre "Tabagismo: Doença Negligenciada" com Analice Gigliotti, Jacqueline Issa e José Miguel Chatkin
• Participando de Sessão Especial sobre Tabagismo Passivo, juntamente com Aristóteles Comte de Alencar Fo. Jacqueline Scholz Issa e Silvia Maria Cury Ismael.

ICMJE - Uniform Requirements for Manuscripts Submitted to Biomedical Journals

ICMJE - Uniform Requirements for Manuscripts Submitted to Biomedical Journals:
(Recebido de Fábio Vilas-Boas, Editor dos Arquivos Brasileiros de Cardiologia)
"A small group of editors of general medical journals met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the National Library of Medicine, were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE gradually has broadened its concerns to include ethical principles related to publication in biomedical journals./.../"

How Important Is Diabetes as a Risk Factor for Cardiovascular and Other Diseases in Older Adults?

PLoS Medicine: How Important Is Diabetes as a Risk Factor for Cardiovascular and Other Diseases in Older Adults?: "Clinical Implications
So what are the implications of the results of this study for clinical practice? Primarily, these data confirm that older adults with diabetes are at very high absolute risk of death from cardiovascular causes (four to five percent per year). Thus, strategies aimed at reducing these risks should be aggressively pursued among such individuals, wherever possible.
Fortunately, a range of preventive treatments of proven efficacy are at our disposal, including blood pressure lowering [9] and the use of statins [10]. Intensive glucose lowering in type 2 diabetes has been shown to reduce microvascular (retinal and renal) events. However, the balance of risks and benefits of lowering haemoglobin A1c levels below seven percent (as recommended by many current guidelines), particularly with respect to macrovascular events such as myocardial infarction and stroke, remains uncertain. At least two large-scale randomised clinical trials evaluating this question are ongoing, one of which has no upper age restriction [11] while the other includes participants aged up to 80 years at randomisation [12]. Importantly, to reach such targets for intensive glucose lowering, insulin therapy will be frequently required. Should the trials demonstrate that the benefits of intensive glucose lowering outweigh the risks, these data, rather than observational data suggesting possible harm associated with the use of insulin, should take precedence in guiding clinical practice."

Investigational Drug Converts Afib to Sinus Rhythm

Teaching Brief® - MedPage Today: "NEW ORLEANS Oct. 16 -- For converting atrial fibrillation to sinus rhythm in patients on rate-control or rhythm-control background therapy, an investigational injectable was effective rapidly for most patients, investigators reported here.
In a pooled analysis of two phase 3 clinical trials, vernakalant (RSD1235) converted atrial fibrillation to a sinus rhythm in a median 10 minutes, and nearly all patients who converted had a persistent sinus rhythm over 24 hours, reported Ian Stiell, M.D., from the University of Ottawa, in Ontario, and colleagues.
Vernakalant is a frequency-dependent Na+ and early-activating K+ channel blocker that 'selectively prolongs the atrial refractory period without significantly altering ventricular refractoriness,' the authors said in a poster presentation at the American College of Emergency Physicians meeting.
The randomized, double-blind, placebo controlled ACT (Atrial Arrhythmia Conversion Trials) I and III studies were designed to study the efficacy and safety of vernakalant in patients using concomitant rate- or rhythm-control medications. /.../"

Additional cardiovascular risk factors associated with excess weigth in children and adolescents: the Belo Horizonte heart study

Arquivos Brasileiros de Cardiologia - Additional cardiovascular risk factors associated with excess weigth in children and adolescents: the Belo Horizonte heart study:
"Robespierre Q. C. Ribeiro; Paulo A. Lotufo; Joel A. Lamounier; Reynaldo G. Oliveira; José Francisco Soares; Denise Aparecida Botter
Universidade de São Paulo e Universidade Federal de Minas Gerais - São Paulo, SP - Minas Gerais, MG
Correspondência

RESUMO
OBJETIVO: Examinar a associação de sobrepeso e obesidade com perfis de atividade física, pressão arterial (PA) e lípides séricos. MÉTODOS: Inquérito epidemiológico com 1.450 estudantes – seis a dezoito anos, em Belo Horizonte-MG. Dados: peso, altura, PA, espessura de pregas cutâneas, circunferência das cinturas, atividade física, colesterol total (CT), LDL-c, HDL-c, e hábitos alimentares. RESULTADOS:Prevalências de sobrepeso e obesidade foram 8,4% e 3,1%. Em relação aos estudantes situados no quartil inferior (Q1) da distribuição da prega subescapular, os estudantes do quartil superior (Q4) apresentaram um risco (odds ratio) 3,7 vezes maior de ter um CT aumentado. Os estudantes com sobrepeso e obesos tiveram 3,6 vezes mais risco de apresentar PA sistólica aumentada, e 2,7 vezes para PA diastólica aumentada, em relação aos estudantes com peso normal. Os estudantes menos ativos, no Q1 da distribuição de MET, apresentaram 3,8 vezes mais riscos de terem CT aumentado comparados com os mais ativos (Q4). CONCLUSÃO: Estudantes com sobrepeso ou obesos ou nos quartis superiores para outras variáveis de adiposidade, assim como os estudantes com baixos níveis de atividade física ou sedentários apresentaram níveis mais elevados de PA e perfil lipídico de risco aumentado para o desenvolvimento de aterosclerose"

Walnuts may be heart-healthy nuts

Teaching Brief® - MedPage Today: "
MedPage Today Action Points
Explain to interested patients that walnuts contain alpha-linoleic acid (a plant-based omega-3 fatty acid) and other "cardioprotective constituents" such as L-arginine and antioxidants.
Caution patients that the study looked at the effect of walnuts or olive oil added to a fatty meal in individuals on an otherwise healthy Mediterranean diet, rather than the effect on individuals who repeatedly ate high fat content meals, and did not deal with weight gain.

Review
BARCELONA, Spain, Oct. 10 -- Walnuts may be heart-healthy nuts, suggest Spanish researchers.
While both raw walnuts and olive oil decreased the sudden onset of arterial inflammation and oxidation after an unhealthy meal, the walnuts were better at keeping arteries flexible, they found.
But patients should not take this as an excuse to regularly eat fat-filled meals, followed by a handful of walnuts, said Emilio Ros, M.D., Ph.D., of the Lipid Clinic at Hospital Clínico here, and colleagues, in the Oct. 17 Journal of the American College of Cardiology.
The study, they pointed out, was small, and it looked at the effect of a single meal on individuals whose regular fare was a healthy Mediterranean diet.
Yet study participants had better arterial elasticity after a walnut-containing meal than an olive oil-containing meal. For those with moderately high cholesterol, postprandial flow-mediated dilation of the brachial artery was:
Improved by 24% when they ate walnuts with their high-fat meal (4.1% dilation before meal to 5.1% after), but
Impaired by 36% when they ate olive oil with the meal instead (3.6% dilation before meal to 2.3% after).
For individuals with normal cholesterol levels, the postprandial flow-mediated dilation was:
Unchanged in participants with normal cholesterol levels when they ate walnuts with the meal (4.2% dilation before meal to 4.2% after),
But impaired by 17% after they ate the olive oil-containing meal (4.7% dilation before meal to 3.9% after). /.../"

Psoriasis Increases Risk for Myocardial Infarction

Psoriasis Increases Risk for Myocardial Infarction - CME Teaching Brief® - MedPage Today: "PHILADELPHIA, Oct. 10 -- Psoriasis appears to be an independent risk factor for myocardial infarction, especially for younger patients with severe disease, researchers reported.
Action Points:
Encourage psoriasis patients to aggressively control their modifiable cardiovascular risk factors.
Younger patients, 30 to 40 years old, with severe psoriasis had almost twice the risk of an MI compared with similar patients without psoriasis. By contrast, 60-year-old patients with severe disease had only a 36% increased MI risk, reported Joel Gelfand, M.D., of the University of Pennsylvania here, and colleagues in the Oct. 11 issue of the Journal of the American Medical Association.
These findings came from a prospective, population-based cohort study in the United Kingdom comparing 556,995 controls and 127,139 patients with mild psoriasis and 3,837 with severe disease, in which the researchers controlled for major cardiovascular risk factors. The data have been used widely in epidemiological studies. "