European Journal of Preventive Cardiology

Estimates of incidence are crucial to the planning of public health measures, but most studies of incidence of, for example, acute myocardial infarction (MI) are troubled by methodological problems such as; (i) selection biases of the patients being included for study, (ii) lack of identification and control of the cohort under observation, (iii) inconsistencies in the use of diagnostic criteria, and (iv) missing data. We aimed to measure directly the incidence of the entire spectrum of the acute coronary syndrome (ACS), consisting of unstable angina pectoris, MI and sudden cardiac death (SCD), by use of the new criteria for MI as proposed in 2000. Design Cohort study.

From a cohort of 138 290 residents of the municipality of Aarhus, Denmark, aged 30-69 years, with a demographic structure known at the individual population member level, we prospectively identified all consecutive ACS patients from 1 April 2000 to 31 March 2002. The population was identified from Danish Population Registers.

A total of 189 victims of SCD and 457 ACS patients who survived until admission to hospital were present. Consequently, crude incidence rate of ACS was 234 per 100000 person-years. Unstable angina pectoris constituted for 16.9%, MI for 53.8% and SCD for 29.3% of ACS patients.

Crude incidence rates of ACS were 137 and 331 per 100 000 person years for women and men, respectively. The incidence rate of ACS, as measured directly, was insignificantly 6% higher than expected from Danish administrative databases. Eur J Cardiovasc Prev Rehabil 14:608-614 © 2007 The European Society of Cardiology

The aim of this study was to validate the Total Activity Measure, a brief questionnaire, to measure physical activity in an older adult population with heart disease.

Two versions of the Total Activity Measure were administered twice, 7 days apart. The Total Activity Measure 1 asked respondents for the frequency and average duration of bouts of physical activity at three different intensity levels per week, whereas the Total Activity Measure 2 asked respondents for the total time spent in activity at each activity level per week. Questionnaire accuracy was studied in 62 men and 15 women aged 47-84 years, by repeatability and comparison of both administrations of the Total Activity Measure 1 and Total Activity Measure 2 with 7-day RT3 accelerometer data.

Seventy-three adults (58 men, 15 women) were used for all statistical analyses. Intraclass correlation coefficients for the Total Activity Measure 1 and Total Activity Measure 2 total activity scores (metabolic equivalent per minute) were r = 0.73 (95% confidence intervals, 0.56-0.83) and r = 0.82 (95% confidence intervals, 0.71-0.88), respectively. Correlations between the Total Activity Measure 1 and RT3 accelerometer for total activity score (metabolic equivalent per minute) were significant, r = 0.26 at time 1 and r = 0.27 at time 2 for moderate intensity activities. Correlations between the Total Activity Measure 2 and RT3 accelerometer for total activity score (metabolic equivalent per minute) were also significant, r = 0.38 at time 1 and r = 0.36 at time 2, r = 0.31 at time 2 for strenuous intensity activities and r = 0.29 at time 1 and r = 0.25 at time 2 for moderate intensity activities. Participants overestimated the amount of physical activity on both questionnaires as compared with the RT3 accelerometer.

The Total Activity Measure 2 was reasonably accurate in assessing total and moderate intensity activity over a 7-day period and demonstrated good test-retest reliability. The Total Activity Measure 1 was less accurate. The Total Activity Measure 2 is a suitable measure of total or moderate intensity physical activity for surveys and audits in an adult cardiac population. Eur J Cardiovasc Prev Rehabil 14:615-623 © 2007 The European Society of Cardiology

To examine anthropometric measures and birthweight as predictors of blood pressure (BP) in a cohort of children.

Cross-sectional and longitudinal study comprising baseline anthropometric and BP measurements conducted in 1994 (n = 1230), with follow-up in 1997 (n = 628).

Seventy-five inner-Sydney primary schools.

School children aged 8-9 years at baseline and 11-12 years at follow-up.

Systolic and diastolic BP (SBP and DBP).

Current weight, body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHR), weight gain since birth and birth weight. Potential confounders: age, sex and socioeconomic status (on the basis of the area of residence).

Current weight was significantly associated with both SBP and DBP in boys and girls at baseline and follow-up. BMI and WC were similar predictors of SBP and DBP in each survey, but longitudinal BMI change has a stronger association with SBP (r = 0.43, P <0.001) and DBP (r = 0.26, P < 0.001) than changes in WC (r = 0.18, P < 0.001 for SBP and r = 0.16, P < 0.001 for DBP) and WHR in boys with the similar results for girls. The unadjusted associations between SBP and DBP and birthweight were nonsignificant. After adjustments for age, height and socioeconomic status, however, the association becomes negative and significant in boys (β = −1.47, P = 0.04 for SBP and β = −1.33, P = 0.03 for DBP).

Longitudinal change in BMI is a better predictor of BP than change in WC or the WHR, although cross-sectional measurements of BMI and WC are very similar predictors of BP. In preventing subsequent adverse effects on BP, attending to body weight during childhood is important. Eur J Cardiovasc Prev Rehabil 14:624-629 © 2007 The European Society of Cardiology

The glutathione (GSH) antioxidant system has been shown to play an important role in the maintenance of good health and disease prevention. Various approaches have been used to enhance GSH availability including diet, nutritional supplementation, and drug administration, with minor to moderate success. Exercise training has evolved as a new approach. The purpose of this study was to investigate the effects of aerobic exercise training (AET), circuit weight training (CWT), and combined training (AET + CWT) on general adaptations, and resistance to acutely induced oxidative stress, as assessed by changes in the GSH antioxidant system.

Eighty healthy sedentary volunteers participated in the study who were randomly assigned to four groups: control (no exercise); AET, CWT, and AET + CWT. Exercise training programs were designed to simulate outpatient cardiac rehabilitation (40 min × 3 days × 6 weeks). Venous blood sampling was taken at rest and post maximal graded exercise test (GXT). A new improved spectrophotometric venous assay analysis technique was used. A mixed model repeated measures analysis of variance design was used with t-tests for preplanned comparisons evaluated at Bonferroni-adjusted α levels.

Effectiveness of the exercise training programs was demonstrated by significant between-group (exercise group versus control) comparisons. AET, CWT, and AET + CWT showed significant pretraining-posttraining increases in resting GSH and glutathione-glutathione disulfide ratio (GSH:GSSG), and significant decreases in GSSG levels (P <0.005). AET + CWT showed the most pronounced effect compared with AET or CWT alone (P <0.025).

This study represents the first longitudinal investigation involving the effects of multiple modes of exercise training on the GSH antioxidant system with evidence, suggesting the GHS:GSSG ratio as the most sensitive change marker. The significant findings of this study have potential clinical implications to individuals involved in cardiac and pulmonary rehabilitation. Eur J Cardiovasc Prev Rehabil 14:630-637 © 2007 The European Society of Cardiology

Associations of three markers of thrombotic tendency, von Willebrand factor, tissue plasminogen activator antigen and fibrin D-dimer, with coronary heart disease have been reported in meta-analyses. It is not known, however, whether findings are generalizable to older women.

Prospective cohort of 3582 women aged 60-79 years randomly selected from 23 towns without evidence of cardiovascular disease at entry into the British Women's Heart and Health Study.

Women were followed for 4.7 years for incident coronary heart disease. Cox proportional hazard models were used to compare the hazard ratio of coronary heart disease per doubling for each thrombotic factor.

In models adjusting for age and town only there was no association between von Willebrand factor or D-dimer and incidence of coronary heart disease, but there was a positive association of tissue plasminogen activator: coronary heart disease hazard ratio per doubling was 1.37 (95% confidence interval: 1.08-1.75). Adjustment for potential confounders (socio-economic position, smoking, lung function, physical activity, alcohol consumption, body mass index, waist-to-hip ratio) attenuated association to 1.20 (0.92-1.58). Further adjustment for risk factors that may be part of the same pathophysiological process linking tissue plasminogen activator to coronary heart disease (high density lipoprotein cholesterol, triglycerides, blood pressure, fasting glucose, insulin, C-reactive protein, fibrinogen) attenuated the hazard ratio to 1.05 (0.79-1.40).

In older women, tissue plasminogen activator was associated with incident coronary heart disease, but does not appear to be an independent risk factor for coronary heart disease as the association was attenuated by adjustment for confounding and other metabolic and vascular risk factors. Eur J Cardiovasc Prev Rehabil 14:638-645 © 2007 The European Society of Cardiology

Smoking is a major cause of cardiovascular disease and mortality. Smoking-related deaths in Greece account for 23%, whereas 41% of young Greeks are smokers, the highest percentage in Europe. The purpose of this study was to examine the effects of chronic smoking on the rate-pressure product and exercise tolerance in young, healthy male smokers.

Forty-two smokers and 51 nonsmokers were selected from a population of 543 students based on their age, sex, body mass index, physical fitness, smoking habit and health status. All participants were tested with the standard Bruce treadmill protocol. The rate-pressure product was obtained at rest and during exercise at a given submaximal workload. The evaluation of exercise tolerance was based on peak workload achieved and maximal exercise test duration.

The smokers had a higher rate-pressure product at rest (P < 0.001) due to their higher resting heart rate (P < 0.001). Resting values of blood pressure did not differ significantly between the two groups. During exercise, smokers had a greater rate-pressure product (P < 0.001), mainly due to their significantly higher systolic blood pressure (P = 0.008). The smokers had a higher submaximal heart rate (P = 0.005), but the differences in heart rate between groups were reduced for smokers during exercise when compared to rest. The smokers' exercise tolerance was impaired and their maximal exercise test duration time was significantly shorter (P < 0.001).

Chronic smoking was found to affect young male smokers' cardiovascular fitness, impairing the economy and decreasing the capacity of their circulatory system. Eur J Cardiovasc Prev Rehabil 14:646-652 © 2007 The European Society of Cardiology

High prevalence of cardiovascular risk factors has been observed in Spain along with low incidence of acute myocardial infarction. Our objective was to determine the trends of cardiovascular risk factor prevalence between 1995 and 2005 in the 35-74-year-old population of Gerona, Spain.

Comparison of cross-sectional studies were conducted in random population samples in 1995, 2000, and 2005 at Gerona, Spain.

An electrocardiogram was obtained, along with standardized measurements of body mass index, lipid profile, systolic and diastolic blood pressure, glycaemia, energy expenditure in physical activity, smoking, use of lipid-lowering and antihypertensive medications, and cardiovascular risk. Prevalence of diabetes, hypertension, and obesity was calculated and standardized for age.

A total of 7571 individuals (52.0% women) were included (response rate 72%). Low-density lipoprotein cholesterol > 3.4 mmol/l (130 mg/dl) (49.7%) and hypertension (39.1%) were the most prevalent cardiovascular risk factors. In 1995, 2000 and 2005, low-density lipoprotein cholesterol decreased in both men and women: 4.05-3.913.55 mmol/l (156-151-137 mg/dl) and 3.84-3.81-3.40 mmol/l (148-147-131 mg/dl), respectively. Increases were observed in lipid-lowering drug use (5.7-6.3-9.6% in men and 4.0-5.8-8.0% in women), controlled hypertension (14.8-35.4-37.7% in men and 21.3-36.9-45.0% in women); (all P-trends < 0.01), and obesity (greatest for men: 17.5-26.0-22.7%, P-trends = 0.020). Prevalence of myocardial infarction or possibly abnormal Q waves in electrocardiogram also increased significantly (3.9-4.7-6.4%, P-trends = 0.018).

The cardiovascular risk factor prevalence change in Gerona was marked in this decade by a shift of total cholesterol and low-density lipoprotein cholesterol distributions to the left, independent of the increase in lipid-lowering drug use, and better hypertension control with increased use of antihypertensive drugs. Eur J Cardiovasc Prev Rehabil 14:653-659 © 2007 The European Society of Cardiology

Sedentary behaviour, especially TV viewing, has been identified as a possible risk factor for cardiovascular disease, whereas physical activity seems to protect against major cardiovascular risk factors: obesity, dyslipidemia and hypertension. The aim of this study was to explore the association between both time spent on TV viewing and vigorous intensity physical activity in relation to body mass index, waist circumference, waist/hip ratio, serum lipids and blood pressure.

A total of 1693 men and women, 33-64 years of age, from the 3-year follow-up of a population-based intervention study, The Inter 99 study, were included in this cross-sectional design. Information on TV viewing, physical activity and other lifestyle habits was obtained by self-report questionnaire. Associations between TV viewing/physical activity and biological cardiovascular risk factors were explored by multiple linear regression analyses.

Data from 835 (51%) men and 805 (49%) women were included. Mean age was 50.8 years (33.0-64.6). Men had a higher overall physical activity score than women (P < 0.0001). TV viewing was significantly, positively associated with waist/hip ratio (P = 0.005), body mass index (P = 0.03), triglycerides (P = 0.005), low density lipoprotein cholesterol (P = 0.03), total cholesterol (P = 0.01), systolic (P = 0.05) and diastolic blood pressure (P = 0.03), but not with waist circumference and high density lipoprotein cholesterol (HDL). Engaging in vigorous intensity physical activity was associated with higher HDL (P = 0.0006) and lower waist circumference (P < 0.0001).

TV viewing and physical activity should be regarded as separate types of behaviour that relate to different cardiovascular disease risk factors. Eur J Cardiovasc Prev Rehabil 14:660-665 © 2007 The European Society of Cardiology

Both diabetes mellitus (DM) and hyperglycaemia are known to predict outcome after acute coronary syndrome (ACS). Recent work has suggested women with DM have greater baseline cardiovascular risk and poorer outcome after ACS. The interaction between sex and abnormal glucose homoeostasis in patients without diabetes is unexplored; we aimed to assess this relationship.

Retrospective analysis of data from a prospective cohort study of 1575 patients with a confirmed ACS and no previous diagnosis of DM in 11 UK hospitals. Multivariable analysis was performed to assess the value of clinical variables, including hyperglycaemia and sex, in predicting 2 year all-cause mortality. Sex and hyperglycaemia interacted in predicting mortality. In men, mortality risk increased more steeply with incremental levels of glycaemia than in women (glucose ≥ 11.1 mmol/l, hazard ratio, 2.19; 95% confidence interval, 1.2-4.0). In both sex groups increasing glycaemia predicted mortality at levels currently not recommended for acute therapeutic intervention (7.8-11.0 mmol/l).

In patients not known to have diabetes, hyperglycaemia is a concentration-dependent predictor of long-term mortality after ACS; this predictive value is stronger in men than women. Eur J Cardiovasc Prev Rehabil 14:666-671 © 2007 The European Society of Cardiology

To assess the impact of a sexual therapy module on male patients participating in phase 2 cardiac rehabilitation after a cardiac event.

We randomly assigned 92 consecutive male patients (age ≤ 70 years, mean age 58 years), on their admission to phase 2 cardiac rehabilitation after myocardial infarction/acute coronary syndromes and/or coronary artery bypass graft, into a ‘sexual therapy group’ (n = 47) and a ‘control group’ (n = 45). Two cotherapists met with the patient and spouse for 5 h in three sessions, in addition to cardiac rehabilitation. Sexual therapy included patient education, cognitive restructuring, emotional support, guided imagery, and medication (Viagra). Controls participated in cardiac rehabilitation without sexual therapy. Self-report questionnaires were used three times: before, 1, and 4 months after sexual therapy. Baseline characteristics of both groups were similar. More sexual therapy patients resumed sexual activity within 1 month (87% vs. 50% in control). Sexual therapy patients improved more than controls in quality of sexual function in terms of libido, confidence to attain erection, satisfaction with sexual relationship, frequency of erection, and enjoyment of sex. Sexual therapy patients were highly satisfied with cardiac rehabilitation and sexual therapy.

Sexual therapy is significantly effective in improving the frequency and quality of sexual activity in a patient's postcardiac event beyond the usual cardiac rehabilitation. Sexual therapy should be an integral part of cardiac rehabilitation. Eur J Cardiovasc Prev Rehabil 14:672-678 © 2007 The European Society of Cardiology

The effects of inspiratory muscle training on plasma cytokines, C-reactive protein and the soluble apoptosis mediators Fas and Fas ligand in chronic heart failure are unknown.

Thirty-eight patients with chronic heart failure, age 57 ± 2 years, New York Heart Association classification II-III, were assigned to either a high intensity training group (n = 15, age 53±2 years) exercised at 60% of sustained maximal inspiratory pressure, or a low intensity training group (n = 23, age 59 ± 2 years), exercised at 15% of sustained maximal inspiratory pressure, three times per week for 10 weeks. Patients in the high intensity training group and low intensity training group were matched for age, sex and New York Heart Association functional class. Plasma levels of tumor necrosis factor (TNF)-α, soluble TNF receptor I, interleukin-6, C-reactive protein, soluble apoptosis mediators Fas and Fas ligand were measured at baseline and at post-inspiratory muscle training. Pulmonary function was assessed by spirometry, exercise capacity by a cardiopulmonary exercise test and the 6 min walk test, whereas dyspnea by the Borg scale after the 6 min walk test.

High intensity training group improved inspiratory muscle strength (105.1 ± 4.9 vs. 79.8 ± 4.7 cmH₂O, P < 0.001), sustained maximal inspiratory pressure (504.5 ± 39.7 vs. 312.5 ± 26.5cmH₂O/s/10³, P<0.001), forced vital capacity (98.9 ± 3.9 vs. 96 ± 3.3%, P<0.05), peak Vo₂ (19.4 ± 1.2 vs. 17.3 ± 0.9 ml/kg per min, P<0.01), 6 min walk test distance (404.3 ± 11.9 vs. 378.2 ± 10.4 m, P<0.01) and dyspnea (8.0 ± 0.4 vs. 9.2 ± 0.4, P<0.01). Circulating TNF-α, soluble TNF receptor I, interleukin-6, C-reactive protein, soluble apoptosis mediators Fas and Fas ligand were not significantly altered. Low intensity training group increased only the inspiratory muscle strength (90.3 ± 5.9 vs. 80.2 ± 5cmH₂O, P<0.01). Comparison between groups was significant for soluble TNF receptor I change (high intensity training group, 5.8 ± 0.49 vs. 6.1 ± 0.42; low intensity training group, 8.4 ± 0.6 vs. 7.8 ± 0.6, P<0.01).

A high intensity inspiratory muscle training program resulted in improvement in functional status of chronic heart failure patients compared with low intensity inspiratory muscle training. Improvement in exercise capacity was not associated with an anti-inflammatory effect, although a beneficial influence on soluble TNF receptor I was recorded. Possible reasons include inadequate level of muscle mass exercise and the low pretraining New York Heart Association class. Eur J Cardiovasc Prev Rehabil 14:679-685 © 2007 The European Society of Cardiology

Patients with idiopathic dilated cardiomyopathy (DCMid) account for about one-third of patients with heart failure. Recent studies found a myocardial viral genomic persistence in up to 67% of DCMid patients, indicating a possible inflammatory etiology (DCMi). Considering the importance of DCMi, we aimed to study the present knowledge on risk factors in DCMi.

Review of published literature on risk factors for DCMi/DCMid from 1989 through 2005 in Medline database and the Cochrane library (search terms ‘epidemiology’, ‘risk factors’, ‘inflammatory dilated cardiomyopathy’ and ‘idiopathic dilated cardiomyopathy’).

An extended array of risk factors in DCMid has been investigated in 11 studies. No studies addressing specifically DCMi, however, were found. Consistent associations with DCMid were reported only for diabetes mellitus, black race, male sex and estimated low income. Inconsistent results were observed for the presence of asthma, hypertension and smoking. Few studies addressed potential risk factors such as low education level, infectious diseases and environmental factors.

Considering the high number of potential DCMi patients among patients with DCMid, results on risk factors for DCMid are likely relevant to at least a number of patients with DCMi. Future studies of risk factors in DCMi should include specific case classification and the application of standardized instruments for risk-factor assessment. The four-center SFB/TR 19 study aims to establish a prospective cohort of DCMi patients validated by endomyocardial biopsy. Eur J Cardiovasc Prev Rehabil 14:686-693 © 2007 The European Society of Cardiology

Previous studies have shown dose-dependent and time-dependent effects of cigarette smoking and smoking cessation on C-reactive protein (CRP) concentrations in men, but results were inconsistent for women. The aim of this study was to evaluate the dose-dependent and time-dependent association of smoking and smoking cessation with CRP concentrations in men and women using a novel comprehensive smoking index (CSI).

Cross-sectional study of representative US survey data (National Health and Nutrition Examination Survey 1999-2002).

The CSI simultaneously accounts for intensity, duration and time since cessation of smoking. We analyzed data of 3505 men and 3896 women using sex-specific multiple linear regression models adjusting for other determinants of CRP concentrations, including age, race/ethnicity, body mass index, alcohol intake, diabetes, physical activity, oral hormone use among women, and history of coronary heart disease, stroke, chronic obstructive pulmonary disease and arthritis.

A positive association of similar strength was found between smoking and CRP concentrations in both men and women who did not use exogenous oral hormones. Among women who used exogenous oral hormones, no association with smoking was found. In older men and women it took several years after smoking cessation for CRP concentrations to return to that of individuals who never smoked.

Smoking is associated with dose-dependent and time-dependent increases in CRP concentrations in both men and women. Furthermore, the effect of exogenous oral hormones on CRP concentrations in women is affected by smoking in a dose-dependent fashion. Eur J Cardiovasc Prev Rehabil 14:694-700 © 2007 The European Society of Cardiology

The hypothesis that diets rich in total and saturated fat and poor in unsaturated fats increase the risk for cardiovascular disease is still vividly debated. The aim of this study was to examine whether total fat, saturated fat, or unsaturated fat intakes are independent risk factors for cardiovascular events in a large population-based cohort.

28098 middle-aged individuals (61% women) participated in the Malmö Diet and Cancer Study between 1991 and 1996. In this analysis, individuals with an earlier history of cardiovascular disease were excluded. With adjustments made for confounding by age and various anthropometric, social, dietary, and life-style factors, hazard ratios (HR) were estimated for individuals categorized by quartiles of fat intake [HR (95% confidence interval, CI), Cox's regression model].

No trend towards higher cardiovascular event risk for women or men with higher total or saturated fat intakes, was observed. Total fat: HR (95% CI) for fourth quartile was 0.98 (0.77-1.25) for women, 1.02 (0.84-1.23) for men; saturated fat: 0.98 (0.71-1.33) for women and 1.05 (0.83-1.34) for men. Inverse associations between unsaturated fat intake and cardiovascular event risk were not observed.

In relation to risks of cardiovascular events, our results do not suggest any benefit from a limited total or saturated fat intake, nor from relatively high intake of unsaturated fat. Eur J Cardiovasc Prev Rehabil 14:701-706 © 2007 The European Society of Cardiology

The effects of opium consumption on coronary artery disease are still unknown.

A cross-sectional study was conducted on 2405 patients admitted to the Angiographic Ward at Tehran Heart Center from 7 May 2005 to 13 August 2005.

After adjusting for conventional cardiovascular risk factors, opium consumption was a significant risk factor for coronary artery disease (P=0.01 and odds ratio = 1.8). Moreover, the amount of opium consumption was associated significantly with the severity of coronary atherosclerosis, as measured by clinical vessel score (r=0.2, P=0.002).

To our knowledge, this is the first time that the adverse effects of opium consumption on coronary arteries was defined. Eur J Cardiovasc Prev Rehabil 14:715-717 © 2007 The European Society of Cardiology