European Journal of Preventive Cardiology

Background This study was conducted to explain the variance in quality of life (QoL) and activity capacity of patients with congestive heart failure from pathophysiological changes as estimated by laboratory data.

Methods Peak oxygen consumption (peak VO₂) and ventilation (VE)/carbon dioxide output (VCO2) slope derived from cardiopulmonary exercise testing, plasma N-terminal prohormone of B-type natriuretic peptide (NT-proBNP), and echocardiographic markers [left atrium (LA), left ventricular ejection fraction (LVEF)] were measured in 62 patients with congestive heart failure, who also completed the Minnesota Living with Heart Failure Questionnaire and the Specific Activity Questionnaire. All regression models were adjusted for age and sex.

Results On linear regression analysis, peak VO₂ with P value less than 0.001, VE/VCO₂ slope with P value less than 0.01, LVEF with P value less than 0.001, LA with P = 0.001, and logNT-proBNP with P value less than 0.01 were found to be associated with QoL. On stepwise multiple linear regression, peak VO₂ and LVEF continued to be predictive, accounting for 40% of the variability in Minnesota Living with Heart Failure Questionnaire score. On linear regression analysis, peak VO₂ with P value less than 0.001, VE/VCO₂ slope with P value less than 0.001, LVEF with P value less than 0.05, LA with P value less than 0.001, and logNT-proBNP with P value less than 0.001 were found to be associated with activity capacity. On stepwise multiple linear regression, peak VO₂ and LA continued to be predictive, accounting for 53% of the variability in Specific Activity Questionnaire score.

Conclusion Peak VO₂ is independently associated both with QoL and activity capacity. In addition to peak VO₂, LVEF is independently associated with QoL, and LA with activity capacity.

Background Self-reported physical activity (PA) is well associated with cardiorespiratory fitness and exercise capacity. The short International Physical Activity Questionnaire (IPAQ-short) is a frequently used instrument for cross-national assessments of PA in adults. The purpose of this study was to validate IPAQ-short against exercise capacity in Greek young adults.

Design and methods One hundred and thirteen men and 105 women, aged 20-29 years, were randomly selected from a larger population of young health-science students. A Greek version of IPAQ-short (IPAQ-Gr) was administered to all participants before their exercise capacity evaluation with a maximal Bruce treadmill test. Multiple regression and correlation analyses were used to examine the associations between all IPAQ-Gr outcomes with exercise capacity based on maximal treadmill time.

Results Spearman's correlations for total and vigorous PA against maximal treadmill time were significant in all groups examined, ranging from 0.35 to 0.43. Moderate and walking PA correlations were poor and nonsignificant, ranging from near-zero values to 0.19. In multiple linear regression analysis, only sex, smoking, and vigorous PA from all personal and log-transformed IPAQ-Gr data were significantly associated with maximal treadmill time. Partial correlation analysis for the overall population, adjusted for sex and smoking, showed that total PA (r = 0.37) and vigorous PA (r = 0.47) were significantly associated with exercise capacity.

Conclusion IPAQ-Gr was tested against exercise capacity and showed acceptable validity properties in Greek young adults. Total and vigorous weekly PA expenditure were well associated with exercise capacity, presenting significant validity correlations against maximal treadmill time.

Background Exercise training is an important part of cardiac rehabilitation to reduce morbidity and mortality. Low-intensity exercise training can start as soon as the myocardial infarction (MI) patient is stable. Our objective was to evaluate the effect of an early start of exercise training in MI patients.

Design A randomized controlled trial.

Methods Thirty-nine MI patients were randomized to either an early start of exercise training group (EG) or to a delayed start control group (CG). The EG participated in an outpatient low-intensity EG (phase 2a) two times a week for 4 weeks before entering ordinary exercise training of moderate-to-high intensity (phase 2b). CG entered phase 2b directly after 4 weeks of delay. Primary outcome measure was peak oxygen consumption (VO_2peak), measured at baseline, after 4 weeks and after 16 weeks. Secondary outcome measure was health-related quality of life.

Results VO_2peak did not change from baseline to 4 weeks, either in EG [30.6 ± 6.7 ml/kg/min vs. 30.7 ± 6.2 ml/kg/min, not significant (NS)] or CG (29.8 ± 6.1 ml/kg/min vs. 30.7 ± 6.2 ml/kg/min, NS). After 16 weeks VO_2peak increased in both groups to 33.1 ± 7.1 ml/kg/min in EG (P [ 0.005) and 33.0 ml/kg/min ± 8.6 in CG (P [ 0.005), group differences NSH. Health-related quality of life increased in every domain but physical functioning for both groups (group differences NS).

Conclusion An early start of exercise training did not increase VO_2peak compared to 4 weeks of delay. For low-risk patients with high motivation for exercise training, home-based walking is an option as a moderate start of cardiac rehabilitation the first weeks after MI.

Background Heart failure is a common and costly condition, particularly in the elderly. A range of models of interventions have shown the capacity to decrease hospitalizations and improve health-related outcomes. Potentially, cardiac rehabilitation models can also improve outcomes.

Aim To assess the impact of a nurse-coordinated multidisciplinary, cardiac rehabilitation program to decrease hospitalizations, increase functional capacity, and meet the needs of patients with heart failure.

Method In a randomized control trial, a total of 105 patients were recruited to the study. Patients in the intervention group received an individualized, multidisciplinary 12-week cardiac rehabilitation program, including an individualized exercise component tailored to functional ability and social circumstances. The control group received an information session provided by the cardiac rehabilitation coordinator and then follow-up care by either their cardiologist or general practitioner. This trial was stopped prematurely after the release of state-based guidelines and funding for heart failure programs.

Results During the study period, patients in the intervention group were less likely to have been admitted to hospital for any cause (44 vs. 69%, P = 0.01) or after a major acute coronary event (24 vs. 55%, P = 0.001). Participants in the intervention group were more likely to be alive at 12 months, (93 vs. 79%; P = 0.03) (odds ratio =3.85; 95% confidence interval = 1.0314.42; P = 0.0042). Quality of life scores improved at 3 months compared with baseline (intervention t = 4.37, P [ 0.0001; control t= 3.52, P [0.01). Improvement was also seen in 6-min walk times at 3 months compared with baseline in the intervention group (t = 3.40; P = 0.01).

Conclusion This study shows that a multidisciplinary heart failure cardiac rehabilitation program, including an individualized exercise component, coordinated by a specialist heart failure nurse can substantially reduce both all-cause and cardiovascular readmission rates, improve functional status at 3 months and exercise tolerance.

Background The aim of this study was to build risk charts for the assessment of cardiovascular mortality of the CUORE project, an Italian longitudinal study, and to compare them with the systematic coronary risk evaluation (SCORE) project charts for low risk European countries.

Design Random population samples enrolled in the 1980s and 1990s in Italy were included in the analysis: 7520 men and 13 127 women aged 35-69 years without previous cardiovascular events and with a mean follow-up period of 10 years for cardiovascular disease. ICD-9 codes of death certificates similar to those of the SCORE project were considered when they appear as first cause of death.

Methods Sex-stratified Cox proportional hazard model including age, systolic blood pressure, ratio between total and HDL cholesterol, and smoking habit as risk factors was used to assess cardiovascular mortality.

Results Analysis showed that all risk factors included in the model were statistically significant. The corresponding area under the receiver operating characteristic curve was 0.825 (95% confidence interval: 0.803-0.846) for men and 0.850 (0.823-0.877) for women. The CUORE project charts yielded similar results to the corresponding charts of the SCORE project: Lin's coefficient was 0.929 for men and 0.935 for women.

Conclusion The comparison between CUORE and SCORE mortality risk charts shows that SCORE charts reflect quite well the Italian cardiovascular mortality and, correspondingly, Italian cohorts of the CUORE project are quite representative of European countries at low risk for cardiovascular mortality.

Background Cardiac rehabilitation (CR) programmes support patients to achieve professionally recommended cardiovascular prevention targets and thus good clinical status and improved quality of life and prognosis. Information on CR service delivery in Europe is sketchy.

Design Postal survey of national CR-related organizations in European countries.

Methods The European Cardiac Rehabilitation Inventory Survey assessed topics including national guidelines, legislation and funding mechanisms, phases of CR provided and characteristic of included patients.

Results Responses were available for 28 of 39 (72%) countries; 61% had national CR associations; 57% national professional guidelines. Most countries (86%) had phase I (acute inhospital) CR, but with differing service availability. Only 29% reported provision to more than 80% patients. Phase II was also available, but 15 countries reported provision levels below 30%. Almost half (46%) had national legislation regarding phase II CR; three-quarters had government funding. Phase III was less supported: although available in most countries, 11 could not provide estimates of numbers participating. Thirteen reported that all costs were met by patients.

Conclusion Fewer than half of eligible cardiovascular patients benefit from CR in most European countries. Deficits include absent or inadequate legislation, funding, professional guidelines and information systems in many countries. Priorities for improvement include promoting national laws and guidelines specific for CR and increasing both CR programme participation rates and CR infrastructure. The European Association of Cardiovascular Prevention and Rehabilitation can have an important coordinating role in sharing expertise among national CR-related agencies. Ultimately, such cooperation can accelerate CR delivery to the benefit of cardiac patients across Europe.

Background Acute myocardial infarction is known as an acute metabolic stress, but clinicians currently have limited guidance regarding the evaluation and management of hyperglycemia after revascularization.

Methods and results We assessed the prognostic role of three different ranges of in-hospital peak glycemia ([ 140, 140180, and > 180 mg/dl) in 252 acute ST-segment elevation myocardial infarction patients without earlier known diabetes submitted to percutaneous coronary intervention consecutively admitted to our intensive cardiac care unit (ICCU). Patients with highest peak glycemia showed the highest intra-ICCU mortality (7/44, 15.9%), which was significantly higher with respect to the other two subgroups (P = 0.001 and 0.034, respectively). At backward stepwise logistic regression analysis, peak glycemia (odds ratio: 3.14; 95% confidence interval: 1.019.74, P =0.047) was an independent predictor of intra-ICCU mortality.

Conclusion In acute ST-segment elevation myocardial infarction patients without earlier known diabetes submitted to mechanical revascularization, the poorer in-hospital glucose control was associated with higher mortality; peak glycemia greater than 180 mg/dl was associated with the highest mortality, whereas patients with peak glycemia comprised between 140 and 180 mg/dl exhibited intermediate mortality rates. According to our data during hospitalization intensivists should achieve glucose control values less than 140 mg/dl, as peak glycemia resulted in the independent predictor of intra-ICCU mortality.

Aims Atherosclerosis causes coronary artery disease (CAD), cerebrovascular disease (CVD) or peripheral arterial obstructive disease (PAOD). The risk of new vascular events and mortality is high. Direct comparisons of vascular event rates are scarce.

Methods and results Vascular risk factors and outcome events of 3563 patients from a university hospital presenting with nondisabling CAD, CVD or PAOD were compared with regression analyses, adjusted for age and sex (median follow-up, 3.9 years). The primary outcome was the composite of myocardial infarction, stroke and vascular death. The risk among the three groups of outcomes was compared using the Cox regression analysis. At baseline, CAD patients were the most obese; PAOD patients smoked the most and suffered more often from hypertension and hyperlipidaemia. The average rate of vascular events was 2.5% per year; the hazard ratio (HR) of CVD/CAD was 1.7 [95% confidence interval (CI): 1.3-2.2] and PAOD/CAD was 1.8 (95% CI: 1.5-2.0). PAOD patients had a higher risk for coronary events than CAD (HR: 1.6; 95% CI: 1.2-2.1). Patients with CVD or PAOD had a higher risk for major bleeding than CAD patients (HR: 2.1; 95% CI: 1.4-3.2).

Conclusion Patients with a recent CVD or PAOD have almost twice the risk for future vascular events than those with CAD.

Aims In this study we investigated the effects of the physical work environment on two physiological measures of the stress response.

Methods and results Circadian variations in vagally mediated heart rate variability (HRV) and the morning rise in cortisol were evaluated in 60 participants working in a government building either in a traditional (individual offices and old cubicles; n= 40) or a modern workspace (individualized cubicles with improved views and lighting; n= 20). Results revealed significant linear (B = 1.03; confidence interval: 1.05 to 1.01, P [ 0.05) and quadratic (B = 1.001; confidence interval: 1.00041.002, P [ 0.05) trends by office type interactions for indices of vagally mediated HRV. Individuals in the old office space had flatter slopes and thus less circadian variation including less HRV at night, and a larger rise in cortisol upon awakening compared with those in the new office space.

Conclusion These results indicate that physical features of the work environment may affect two aspects of the physiological stress response: circadian variations in HRV and the morning rise in cortisol. These findings have important social, economic, and public health implications for work environment risk factors on health.

Background Farmers from Crete as first studied within the framework of the Seven Countries Study, were historically known for holding the title of the ‘gold standard’ of health status globally and had a very low prevalence of both cardiovascular disease (CVD) and cancer. Taking the above into account we evaluated the changes in CVD risk factors among farmers in Crete, Greece and compared our findings with data from the 1960s.

Design Cross-sectional.

Methods Five hundred and two farmers (18–79 years old) from the Valley of Messara in Crete were randomly selected and examined in 2005. Complete clinical, biochemical, dietetic, anthropometrical and lifestyle CVD risk factors were assessed, matched and compared with published data from the 1960s.

Results In comparison with 45 years ago, present day male farmers from Crete were found to have a 30% higher BMI (29.8 vs. 22.9 kg/m², P [0.001) and a 16% higher total cholesterol level (239.6 vs. 206.9 mg/dl, P[ 0.001) and also a not so favourable daily dietary intake (increase in meat and saturated fat and decrease in fruit, P [0.001, respectively), while a significant reduction in systolic blood pressure and energy intake was noticed. In regards to changes in subcutaneous adipose tissue fatty acid composition, a decrease in monounsaturated (P [ 0.001) and an increase in saturated fatty acids (P[ 0.001) was also found elucidating the temporal change in dietary habits.

Conclusion The population's lack of adherence to the Mediterranean diet, have led to the fact that currently farmers from Crete are likely to be at a higher risk for developing CVD in comparison with earlier generations.

Aims Several studies have reported increasing obesity rates in the general population. Using data from the EUROASPIRE III survey, we investigated as to what extent the obesity epidemic affects the high priority group of coronary heart disease patients.

Methods and results Data from 8924 patients, who had experienced a recent coronary acute event, from 22 countries in Europe participating in the EUROASPIRE III study were gathered in 2006–2007. Eight centres had also participated in the earlier two EUROASPIRE surveys carried out in 1994–1995 and 1999–2000. In these eight centres, obesity prevalence in coronary patients had increased from 25 to 38% during the past decade. The most recent survey shows that obesity is more prevalent in women (45 vs. 32% in men) and is a major health problem across all the 22 countries. Only 18% of all the patients were found to reach a body mass index below 25 kg/m² whereas 53% were diagnosed with central obesity. Since their hospital discharge, only half of the obese patients reported to have followed the dietary recommendations and 48% reported engagement in more physical activity. Only 13% of the patients who were overweight at the time of the coronary event reached the target of ≥5% weight loss whereas 21% of them presented with a weight gain of 5% or more.

Conclusion The prevalence of obesity is still increasing and reaching epidemic proportions in the high priority group of coronary patients all over Europe. Patients’ awareness and current management of obesity seems inadequate. More intensive programs focusing on diet and especially physical activity are urgently required.

Background Statin therapy has been found to substantially and significantly reduce coronary events in carriers of the KIF6 719Arg variant (rs20455) but not in noncarriers. We investigated whether, among the elderly, statin therapy also significantly reduced coronary events in carriers but not in noncarriers.

Design and methods Among 5752 patients of the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) study, we assessed the effect of pravastatin, compared with placebo, on coronary events according to 719Arg carrier status using proportional hazards models.

Results Since benefit from statin therapy in elderly patients has been primarily shown among those with prior vascular disease, we performed analyses in PROSPER patients with prior disease and found that pravastatin therapy significantly reduced events in 719Arg carriers [hazards ratio (HR): 0.66, 95% confidence interval (CI): 0.52–0.86] but not in noncarriers (HR: 0.94, 95% CI: 0.69–1.28), P= 0.09 for interaction between treatment and carrier status. Among those without prior disease, no significant benefit was observed in either carriers or noncarriers. Among those with prior vascular disease in the placebo arm, Trp719Arg heterozygotes were at significantly greater risk, compared with noncarriers (HR: 1.36, 95% CI: 1.03–1.81, P = 0.03); the HR of 719Arg carriers, compared with noncarriers, was 1.28 (95% CI: 0.98–1.69, P =0.07).

Conclusion Elderly carriers of the KIF6 719Arg variant with prior vascular disease received significant benefit from pravastatin therapy; no benefit was observed in noncarriers with prior disease or in those without prior disease (carriers or noncarriers).

Background Abnormal non-ST segment treadmill parameters are associated with an increased mortality risk. Such measures include fitness, resting heart rate (HR), chronotropic incompetence, and HR recovery. However, whether there is an additive association among these parameters and the risk of mortality is unknown.

Design Prospective observational registry study.

Methods We assessed the risk of cardiovascular and all-cause mortality in 25 642 individuals as an additive function of the number of these parameters. Abnormal responses were defined as follows: abnormal resting HR as a HR ≥ 80 bpm, abnormal fitness as an adjusted fitness level in the lowest 20%, chronotropic incompetence as an inability to achieve at least 80% of the predicted HR reserve, and abnormal HR recovery as an HR decline less than 12bpm 1 min after exercise. Results During 7.2 years of follow-up, 392 participants died, with 94 from cardiovascular causes. Each parameter was significantly associated with all-cause and cardiovascular mortality (P [ 0.01) after adjustment for cardiovascular risk factors. There was a significant trend between both all-cause or cardiovascular mortality and the number of abnormal parameters (P [0.05).

Conclusion There is a continuum of risk as the number of abnormal parameters increases, suggesting that it may be important to determine their presence and number during exercise testing.

Aims Cardiopulmonary exercise testing (CPET) is a widely applied clinical procedure. There is uncertainty to what extent nutritional status, β blockers and smoking should be taken into account in the interpretation of exercise parameters to describe abnormality. This study planned to consider the impact of these factors on CPET values and develop reference equations on the basis of a large-scale population-based survey.

Methods and results An incremental cycle exercise protocol was applied to 1708 volunteers. Individuals with structural heart disease, echocardiographic or lung function pathologies were excluded. Age, height, weight, smoking, and β blockers were analysed for their influencing power in each sex. Reference values of CPET parameters were determined by regression analyses. The final study sample consisted of 1203 volunteers (626 female), aged 25–85 years. Exercise capacity, gas exchange, and ventilatory efficiency for carbon dioxide removal were significantly dependent on sex, age, height, weight, and cigarette smoking. In the dosages used, β blockers did not significantly interfere with gas exchange.

Conclusion Sex, height, weight, and age significantly influence gas exchange. This study provides a comprehensive set of reference values in a large number of volunteers within a population-based survey, with reference values corrected for influencing factors.

Aim To assess the changes in the utilization of antihypertensive, and lipid-lowering drugs among all adult Finnish coronary heart disease (CHD) patients between 2000 and 2006, and to evaluate the treatment and control of hypertension and dyslipidemia in a population-based sample of CHD patients.

Methods From the databases of the Social Insurance Institution of Finland, 192 440 CHD patients aged 30 years or more in 2000 and 206 394 in 2006, respectively, were identified. Changes in the utilization of antihypertensive and lipid-lowering drugs were determined. In addition, from the Health 2000 Survey representing the whole Finnish population aged 30 years or more, 527 CHD patients were identified, to assess their characteristics and control of hypertension and dyslipidemia.

Results Between the fall of 2000 and spring of 2001, 75% of the CHD patients were classified as hypertensives and 85% of these used antihypertensive medication. From 2000 to 2006, the utilization of lipid-lowering, and antihypertensive drugs increased from 33 to 52% and from 74 to 78%, respectively. Moreover, combination antihypertensive medication increased from 37 to 48%. Amidst the patients using antihypertensive drugs, the use of renin-angiotensin system blockers increased from 27 to 46% because of more than a three-fold increase in the use of angiotensin receptor blockers.

Conclusion Utilization of antihypertensive agents (especially angiotensin receptor blockers) and lipid-lowering drugs has increased remarkably by the end of 2006. However, the treatments are still far from optimal.

Background Although overweight and obesity are associated with cardiovascular disease (CVD), it is unclear which clinical measure of overweight and obesity is the strongest predictor of CVD, and it is unclear whether the various measures of overweight and obesity are indeed independent predictors of CVD.

Methods This study was a prospective population-based study of 2493 Danish men and women, age 41–72 years, without major CVD at baseline. At baseline, body mass index, waist circumference, hip circumference, waist-to-hip ratio (WHR), and traditional and new risk factors were recorded.

Results Over a median follow-up of 12.6 years, the incidence of a combined CV event (CV death, nonfatal ischemic heart disease, and nonfatal stroke) amounted to 328 cases. Of the various measures of overweight and obesity, in Cox-proportional hazard models, adjusted for age, only WHR was significantly associated with incident CVD with a hazard ratio (95% confidence interval) in women of 2.22 (1.31–3.77; P = 0.0032) in the highest compared with the lowest quartile, and a hazard ratio in men of 1.73 (1.12–2.66; P = 0.014) in the highest compared with the lowest quartile. However, when adjustments were made for the presence of diabetes, dyslipidemia, hypertension, hyperinsulinemia, and inflammation, WHR was no longer significantly (P > 0.41) associated with incident CVD.

Conclusion In this study, of the various measures of overweight and obesity, WHR was the only significant predictor of incident CVD, and the relationship between WHR and risk of CVD was mediated by well-known risk factors of CVD.