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(Circulation. 1999;100:1366-1368.)
© 1999 American Heart Association, Inc.

Editorial

Lack of Association of Infectious Agents With Risk of Future Myocardial Infarction and Stroke

Definitive Evidence Disproving the Infection/Coronary Artery Disease Hypothesis?

Stephen E. Epstein, MD; Jianhui Zhu, MD, PhD

From the Cardiovascular Research Institute, Washington Hospital Center, Washington, DC.

Correspondence to Stephen E. Epstein, MD, Cardiovascular Research Foundation, Suite 4B-1, 110 Irving St, Washington Hospital Center, Washington, DC 20010. E-mail sxe2@mhg.edu

Key Words: Editorials • atherosclerosis • infectious agents • coronary disease

	Introduction

 
Over the past decade, increasing evidence has accumulated implicating a role for infectious agents in the genesis of atherosclerosis. Although far short of definitive, the increasing number of articles suggesting a causal role has led to the perception the case is proven, even stimulating some physicians and the media to wonder whether antibiotics should now be given to patients with coronary artery disease (CAD). However, it must be appreciated that publication bias has the tendency to lead to far more "positive" studies being published (the positive results often deriving from poor study designs) than negative studies (often deriving from excellent study designs). One of the best examples of this publication bias in the area of infection and CAD is seen in the ROXIS (ROXithromycin Ischemic Syndromes) trial, which was preliminarily published in the Lancet as a "positive pilot randomized trial" and has recently been published in final form in the European Heart Journal as a negative study.^{1 2} Given this publication bias and the as-yet-unproven nature of the infection/CAD hypothesis, it would seem important to emphasize those studies containing results that appear to be at variance with the concept that infection can contribute to CAD.

Two such studies, important because they involve a large cohort and because they are prospective in design, have been published recently in Circulation.^{3 4} However, just as there is the danger of prematurely accepting the infection/CAD hypothesis as proven, there is also the danger of using the results of such apparently conclusive negative studies to peremptorily . . . [Full Text of this Article]

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