European Journal of Preventive Cardiology

Background: We assessed the clinical outcomes of symptomatic and asymptomatic coronary heart disease (CHD) with type 2 diabetic patients.

Design: Population-based cohort study.

Methods: The study sample consisted of 380 men and 546 women, aged ≥30 years. Silent CHD was defined using Minnesota coding criteria on baseline electrocardiogram (ECG), in the absence of a history of CHD and symptoms of angina. Participants were categorized into four groups: group 1, participants with no CHD symptoms and with normal ECG; group 2, silent CHD; group 3, participants with symptomatic CHD but with normal ECG; group 4, participants with symptomatic CHD and ECG-determined CHD. Cox regression analysis was used to estimate the hazard ratios (HRs) of cardiovascular disease (CVD) and CHD events for these groups, with group 1 as the reference.

Results: During median follow up of 9.2 years, we ascertained 226 CVD events (202 CHD). In the multivariable-adjusted model, among men, HRs (95% CI) of CVD events were 2.32 (1.29–4.16), 2.56 (1.47–4.46), and 3.97 (2.24–7.02) for groups 2, 3, and 4, respectively; the corresponding figures among women were 1.19 (0.65–2.18), 1.90 (1.24–2.92), and 1.92 (1.02–3.62) respectively. Similar results were achieved for CHD events.

Conclusion: In both sexes, symptomatic CHD was an independent predictor of recurrent CVD/CHD, regardless of ECG results. In diabetic men with asymptomatic CHD, ECG could be of prognostic value for incident CVD/CHD. The present study provides evidence-based support only in men for the ADA recommendation of ‘further cardiac testing for diabetic patients with an abnormal resting ECG’.

Atherosclerotic cardiovascular diseases remain the leading cause of morbidity and mortality in both developed and developing countries. Adequate treatment of vascular risk factors, such as low-density lipoprotein cholesterol and systolic blood pressure are known to reduce the future risk of cardiovascular disease in these patients. However currently, large treatment gaps exist among high-risk individuals, in whom the guidelines recommend concomitant treatment with aspirin, statin, and blood-pressure lowering agents. Combining aspirin, cholesterol, and blood-pressure lowering agents into a single pill called the cardiovascular polypill has been proposed as complementary care in the prevention of cardiovascular diseases in both intermediate- and high-risk patient populations. It is now a decade since the first recommendations to develop and trial cardiovascular polypills. The major scientific debate has been about the appropriate initial target population. This review article focuses on the potential role of fixed-dose combination therapy in different patient populations, outlines the pros and cons of combination therapy, and emphasizes the rationale for trialing their use. Current and planned future cardiovascular polypill trials are summarized and the pre-requisites for implementation of the polypill strategy in both primary and secondary prevention are described. The recent development of combination pills containing off-patent medications holds promise for highly affordable and effective treatment and evidence is emerging on the use of this strategy in high-risk populations.

Background: Functional and morphological arterial wall impairment progresses with ageing. Angiotensin II in the arterial wall is involved in this process. Appropriate early intervention might theoretically slow the progress of age-related changes. Herein, we investigated a new approach to this issue: whether arterial wall changes present in middle-aged males could be reduced by low-dose valsartan intervention.

Methods: Forty apparently healthy, middle-aged males (42.9 ± 0.9 years) were recruited for a double-blind randomized study and received either placebo or valsartan (20 mg daily) for 30 days. Brachial artery flow-mediated dilation (FMD), pulse wave velocity (PWV), and β-stiffness of the common carotid artery were measured using an Aloka alfa-10 Prosound with an integrated eTracking system at inclusion, after 30 days, and after 3 and 8 months.

Results: Intervention resulted in FMD increase (154.2 ± 20.1 %; p < 0.001) and PWV and β-stiffness decrease compared to initial values (−6.9 ± 1.0 % and −13.2 ± 1.4 %; both p < 0.01) whereas values in the untreated group (p < 0.001 for all parameters) remained unchanged throughout the study. The advantageous effects decreased over the months following valsartan discontinuation, but were still significant after 3 months (largely in FMD and less in PWV and β-stiffness), and negligible after 8 months. The beneficial effects were ascribed to valsartan's pleiotropic effects, as no blood pressure changes were recorded.

Conclusions: We showed that age-related arterial wall changes in middle-aged males are reversible and could be reduced by a low-dose, short-term valsartan intervention. The new approach merits detailed investigation in future studies.

Background: European research on ethnic variations in cardiovascular disease has mostly examined mortality endpoints using country of birth as a proxy for ethnicity. We report on chest pain and angina by ethnic group.

Design and methods: Retrospective cohort linking the Census 2001 for Scotland (providing 14 ethnic group categories) and hospital discharge/community and hospital deaths data. Directly age-standardized rates and rate ratios were calculated. Risk ratios were adjusted for age and then highest educational qualification of the individual using Poisson regression. Ratios were multiplied by 100 and 95% confidence intervals (CI) were calculated. The reference was the White Scottish population (100). In the results below, the 95% CI excludes 100.

Results: There was raised chest pain mortality/hospital discharge risk in Indian men (rate ratio 141.2), Other South Asian women (rate ratio 140.9), and Pakistanis (rate ratio 216.2 in men, 243.0 in women). Rate ratios were lowest in other White British (rate ratio 76.1 in men, 73.7 in women) and Chinese (rate ratio 67.6 in men, 76.7 in women). Adjustment for age and education attenuated, but did not abolish, differences in other White British (risk ratio from 73.5 to 83.5) and Pakistani (risk ratio from 209.0 to 198.2) male populations and increased them in most others, e.g. other South Asian men (from risk ratio of 128.9 to 140.1). Pakistani populations had the highest risk of angina (rate ratio 189.3 in men, 159.7 in women). Other White British (rate ratio 81.4 for men, 78.0 for women), Other White (rate ratio 89.6 men, 85.2 women), and Chinese (rate ratio 60.5 men, 67.4 women) had the lowest risk. Adjustment for education did not greatly alter these patterns.

Conclusions: There were important ethnic variations. The results call for replication elsewhere in Europe and targeted prevention programmes and vigilant diagnosis and management by clinicians.

Background: Urban middle-socioeconomic status (SES) subjects have high burden of cardiovascular risk factors in low-income countries. To determine secular trends in risk factors among this population and to correlate risks with educational status we performed epidemiological studies in India.

Methods: Five cross-sectional studies were performed in middle-SES urban locations in Jaipur, India from years 1992 to 2010. Cluster sampling was performed. Subjects (men, women) aged 20–59 years evaluated were 712 (459, 253) in 1992–94, 558 (286, 272) in 1999–2001, 374 (179, 195) in 2002–03, 887 (414, 473) in 2004–05, and 530 (324, 206) in 2009–10. Data were obtained by history, anthropometry, and fasting blood glucose and lipids estimation. Response rates varied from 55 to 75%. Mean values and risk factor prevalence were determined. Secular trends were identified using quadratic and log-linear regression and chi-squared for trend.

Results: Across the studies, there was high prevalence of overweight, hypertension, and lipid abnormalities. Age- and sex-adjusted trends showed significant increases in mean body mass index (BMI), fasting glucose, total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides (quadratic and log-linear regression, p < 0.001). Systolic blood pressure (BP) decreased while insignificant changes were observed for waist–hip ratio and low-density lipoprotein (LDL) cholesterol. Categorical trends showed increase in overweight and decrease in smoking (p < 0.05); insignificant changes were observed in truncal obesity, hypertension, hypercholesterolaemia, and diabetes. Adjustment for educational status attenuated linear trends in BMI and total and LDL cholesterol and accentuated trends in systolic BP, glucose, and HDL cholesterol. There was significant association of an increase in education with decline in smoking and an increase in overweight (two-line regression p < 0.05).

Conclusion: In Indian urban middle-SES subjects there is high prevalence of cardiovascular risk factors. Over a 20-year period BMI and overweight increased, smoking and systolic BP decreased, and truncal obesity, hypercholesterolaemia, and diabetes remained stable. Increasing educational status attenuated trends for systolic BP, glucose and HDL cholesterol, and BMI.

Background: The first (VT1) and second (VT2) ventilatory thresholds are landmarks to tailor exercise rehabilitation in coronary artery disease (CAD) or chronic heart failure (CHF). Methods allowing VT1 and VT2 determination based on heart rate variability (HRV) have been proposed but not yet evaluated in these patients.

Design: To determine the heart rate (HR) associated with VT1 and VT2 by three methods of HRV analyses.

Methods: Fourteen CHF and 24 CAD patients performed an exercise test on a cycle ergometer (10 -W every minute until exhaustion). VT1 and VT2 were determined with the ‘respiratory equivalent’ method. HR at VT1 was determined with the standard deviation (SD) of R⊟R intervals (VT_SD) and of the instantaneous beat-to-beat variability of the Poincaré plot method (VT_Poincaré). HR at VT1 and VT2 was determined through a time-varying HRV analysis method (VT_TV1 and VT_TV2, respectively).

Results: HR at VT_SD was significantly higher than HR at VT1. No significant differences were observed between HR at VT_Poincaré, VT_TV1, and at VT1, nor between HR at VT_TV2 and VT2. HR at VT_SD, VT_Poincaré, and VT1 were significantly correlated, but with a low r² value and a large mean HR difference. With the time-varying method, the mean HR difference was lower than 5% and the correlation coefficients were higher (especially for VT_TV2).

Conclusions: SD and Poincaré plot methods lead to substantial inaccuracy in HR estimates. The time-varying HRV analysis led to strong correlation coefficients and low limits of agreement. Therefore, this method may be a promising, low-cost tool for non-invasive assessment of the ventilatory thresholds in cardiac disease.

Background: This study investigates secular trends in ischaemic heart disease (IHD) and stroke mortality by socioeconomic status (SES) in Australia to determine if absolute and relative differences between low and high SES areas have changed over time.

Methods: IHD and stroke mortality data for adults aged 35–74 years and corresponding population data from Australian censuses for 1979–2006 were stratified into quintiles using an area-based measure of SES and analysed by quinquennia (and 2004–06). IHD and stroke (rates per 100,000) adjusted for age, country of birth, and rurality were compared across SES strata (separately by sex) using Poisson regression.

Results: Mortality declined monotonically over the study period in all SES groups and both sexes. Absolute differences between low and high SES groups narrowed for IHD in females (27 to 23 per 100,000) and stroke in males and females (16 to 13, and 13 to 7 per 100,000, respectively), although absolute differences widened for IHD in males (52 to 63 per 100,000). Relative declines were greater in high compared to low SES groups for IHD (28% average quinquennial decline in high SES; compared with 21% in low SES for males; 30% and 21% for females), and for stroke (25% average quinquennial decline in high SES; 21% in low SES for males; 26% and 23% for females).

Conclusion: Differences in mortality rates between lower and higher SES groups narrowed for both IHD (in females) and stroke (in males and females) from 1979–2006, indicating that the epidemic decline is now at a late stage when low SES groups are benefiting more, in absolute terms, than high SES groups. However males in the lower SES groups are still at an earlier stage of the epidemic decline in IHD mortality.

Background: High levels of lipoprotein(a) [Lp(a)] have been linked to an increased risk of ischaemic cardiovascular events. We examined whether Lp(a) plasma levels are associated with early arteriosclerosis by measuring intima media thickness in an asymptomatic population of Burgos, Spain.

Methods: We determined lipids, lipoprotein(a) by a nephelometry method and the intima-media thickness (IMT) in the far wall of both common carotid arteries by B-mode ultrasound in a group of 172 asymptomatic subjects.

Results: No association was found in the population group between Lp(a) concentrations and left, right, or overall mean IMT by univariate or multivariate regression analysis. The median IMT was not significantly different in individuals with Lp(a) levels >300 mg/l and in individuals with Lp(a) levels <300 mg/l.

Conclusions: These results suggest that increased Lp(a) levels do not confer cardiovascular risk by promoting early atherogenesis, but rather increasing the susceptibility to thrombosis.

Objective: To test whether serum apolipoprotein B (apoB) and low-density lipoprotein (LDL) particle characteristics (oxidation and mean particle size) predict the incidence of metabolic syndrome (MetS).

Methods: The 6-year follow-up study included 1429 adults (baseline mean age 31.5). Lipids, apoB, and apoA1 were measured at baseline in 2001. LDL oxidation was measured with monoclonal antibody-based enzyme-linked immunosorbent assay (oxLDL-prot) and with a method measuring oxidized lipids in LDL (oxLDL-lipids). Mean LDL particle size was calculated from proton nuclear magnetic resonance spectroscopy data.

Results: Increased concentrations of both oxLDL-measures were associated with increased apoB levels but not with LDL particle size. The odds ratios (95% confidence intervals) for MetS incidence during a 6-year follow up by quartiles of apoB were 2.0 (1.0–3.8) for the second quartile, 3.1 (1.7–5.7) for the third quartile, and 4.2 (2.3–7.6) for the fourth quartile. This association remained after adjusting for age, sex, body mass index, homeostasis model assessment for insulin resistance, C-reactive protein, smoking, LDL cholesterol, oxidized LDL measures (p ≤ 0.01) in addition to risk factors comprising the MetS (p = 0.03). OxLDL-prot and oxLDL-lipids levels were not independently associated with incident MetS after adjusting for apoB. Mean LDL particle size was not associated with the incidence of MetS.

Conclusion: ApoB is associated with increased risk of MetS incidence. We found no clear evidence to suggest that increased LDL oxidation or small mean LDL particle size would facilitate the development of MetS.

Aims: We studied trends in first-time myocardial infarction (MI) incidence and case fatality after day 28 and to examine the role of sex, education as an indicator for socioeconomic position, and birth country on these events in Sweden.

Methods and results: Nationwide cohort including 6,752,655 individuals aged 35–89 years living in Sweden between January 1987 and December 2008, of which, 6,464,968 individuals and 366,085 nonfatal first-time MI patients were classified according to their sex, birth country, and education and followed over two decades. Main outcome measures: Incidence and case-fatality rate after day 28 of first-time MI and their trends. A decreasing trend for first-time MI incidence and case fatality after day 28 for both sexes regardless of birth country was observed (p-trend<0.0001). The trend was, however, less pronounced among female and foreign-born. Men had higher incidence than women (incidence rate ratio, IRR 2.09, 95% CI 2.08–2.11). Men born in Southern and Western Asia had 50% (95% CI 40−60%) higher risk than men born in Sweden. Incidence was 50–80% higher in the least educated irrespective of sex and birth country (p-trend<0.0001). This association was stronger for female and foreign-born. We observed a 15% higher case fatality after day 28 among men than women (hazard ratio, HR 1.15, 95% CI 1.13–1.17) and 20−40% lower case fatality after day 28 among patients with no diabetes. Low education was associated with 50% higher case fatality after day 28 regardless of sex and birth country (p-trend <0.0001).

Conclusion: Although incidence of, and fatality after, first-time MI continued to decrease, low socioeconomic position, independent of birth country and sex, remained an important risk indicator for both events.

Aim: Reperfusion therapy in acute myocardial infarction reduces infarct size and increases hospital survival. We investigated whether the benefit of reperfusion therapy for myocardial infarction was sustained long-term and assessed the gain in life expectancy by reperfusion therapy.

Methods and results: We analysed the outcome of 533 patients (mean age 56 years, 82% men), who were randomized to either reperfusion therapy or conventional therapy during 1980−1985. Median follow up was 27 years (25–30 years). At follow up, 59 patients (22%) of the 269 patients allocated to reperfusion treatment and only 39 patients (15%) of the 264 conventionally treated patients were still alive (p = 0.02). The cumulative 10−, 15−, 20−, and 25-year survival rates were 69, 48, 37, and 24% after reperfusion therapy and 59, 38, 27, and 18% in the control group, respectively (p < 0.001). Life expectancy of the reperfusion group was 15.6 years vs. 12.5 years in the conventionally treated group (p < 0.02). Myocardial reinfarction and subsequent coronary interventions were more frequent after reperfusion therapy, particularly during the first year. In multivariable analysis, reperfusion therapy was an important independent predictor of lower mortality at long-term follow up. Other independent predictors of mortality were age, impaired left ventricular function, multivessel disease, infarct size, and inability to perform an exercise test at the time of discharge.

Conclusion: These data confirm that the benefits of early reperfusion therapy for acute myocardial infarction are sustained throughout the lifetime of the patients. More than 3 life years were gained by reperfusion therapy.

Background: Chronic diseases are the leading cause of premature death and disability in the world with overnutrition a primary cause of diet-related ill health. Excess energy intake, saturated fat, sugar, and salt derived from processed foods are a major cause of disease burden. Our objective is to compare the nutritional composition of processed foods between countries, between food companies, and over time.

Design: Surveys of processed foods will be done in each participating country using a standardized methodology. Information on the nutrient composition for each product will be sought either through direct chemical analysis, from the product label, or from the manufacturer. Foods will be categorized into 14 groups and 45 categories for the primary analyses which will compare mean levels of nutrients at baseline and over time. Initial commitments to collaboration have been obtained from 21 countries.

Conclusions: This collaborative approach to the collation and sharing of data will enable objective and transparent tracking of processed food composition around the world. The information collected will support government and food industry efforts to improve the nutrient composition of processed foods around the world.

The beneficial effect of exercise training and exercise-based cardiac rehabilitation on symptom-free exercise capacity, cardiovascular and skeletal muscle function, quality of life, general healthy lifestyle, and reduction of depressive symptoms and psychosocial stress is nowadays well recognized. However, it remains largely obscure, which characteristics of physical activity (PA) and exercise training ⊟ frequency, intensity, time (duration), type (mode), and volume (dose: intensity × duration) of exercise – are the most effective. The present paper, therefore, will deal with these exercise characteristics in the management of individuals with cardiovascular disease, i.e. coronary artery disease and chronic heart failure patients, but also in patients with congenital or valvular heart disease. Based on the current literature, and if sufficient evidence is available, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding frequency, intensity, time and type of PA, and safety aspects during exercise in patients with cardiovascular disease. This paper is the third in a series of three papers, all devoted to the same theme: the importance of the exercise characteristics in the management of cardiovascular health. Part I is directed to the general population and Part II to individuals with cardiovascular risk factors. In general, PA recommendations and exercise training programmes for patients with coronary artery disease or chronic heart failure need to be tailored to the individual’s exercise capacity and risk profile, with the aim to reach and maintain the individually highest fitness level possible and to perform endurance exercise training 30–60 min daily (3–5 days per week) in combination with resistance training 2–3 times a week. Because of the frequently reported dose–response relationship between training effect and exercise intensity, one should seek sufficiently high training intensities, although more scientific evidence on effect sizes and safety is warranted. At present, there is insufficient data to give more specific recommendations on type, dosage, and intensity of exercise in some other cardiovascular diseases, such as congenital heart disease, valve disease, cardiomyopathies, channelopathies, and patients with implanted devices.

Background: The CardioFit internet-based expert system was designed to promote physical activity in patients with coronary heart disease (CHD) who were not participating in cardiac rehabilitation. Design: This randomized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes.

Methods: A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and randomly assigned to either CardioFit (n = 115) or usual care (n = 108). The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking. They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist. Usual care consisted of physical activity guidance from an attending cardiologist. Physical activity was measured by pedometer and self-reported over a 7-day period, 6 and 12 months after randomization.

Results: The CardioFit internet-based physical activity expert system significantly increased objectively measured (p = 0.023) and self-reported physical activity (p = 0.047) compared to usual care. Emotional (p = 0.038) and physical (p = 0.031) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care.

Conclusions: Patients with CHD using an internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care. Use of the CardioFit program could extend the reach of rehabilitation and secondary-prevention services.

Background: There is little information on the prevalence of hypertension and other modifiable cardiovascular risk factors in community-dwelling elderly in the Netherlands and the potential impact of improving antihypertensive treatment on major cardiovascular events.

Design: Cross-sectional analysis of Dutch community-dwelling subjects aged 70–78 years without dementia who were included in the cluster randomized preDIVA trial (Prevention of Dementia by Intensive Vascular care).

Methods: The prevalence of hypertension and other cardiovascular risk factors are described for participants with and without a history of cardiovascular disease (CVD). Projected benefits of blood pressure decrease are calculated using data from a meta-analysis and a large national registry.

Results: Of 3534 subjects, more than one-third (n = 1230, 35.2%) have a history of cardiovascular disease. Overall, 63% of subjects have two or more cardiovascular risk factors amenable to treatment. Systolic blood pressure (SBP) is ≥160 mmHg in 37% of patients with CVD, of which 28% is untreated. In subjects without a history of CVD, 41% have a SBP ≥ 160 mmHg of which 52% is untreated. A 5–15 mmHg decrease in SBP is projected to prevent 12–32% of coronary heart disease and 16–41% of strokes, respectively. This corresponds with 14–38 prevented cases within 2 years in our intervention group (n = 1895).

Conclusions: Hypertension and other cardiovascular risk factors are very common in elderly subjects. Current (primary and secondary) prevention programmes appear insufficient. Improved antihypertensive treatment has the potential to prevent a substantial proportion of strokes and coronary heart disease in this population.

Background: Knowledge of the factors associated with individual differences in patient-reported outcomes is essential to identify high-risk patients and improve secondary prevention. Design: In this meta-analysis, we examined the association between Type D personality and the individual differences in patient-reported physical and mental health status among cardiovascular patients.

Methods: A computerized search of the literature through PUBMED and PsychINFO (from 1995 to May 2011) was performed and prospective studies were selected that analysed the association between Type D personality and health status in cardiovascular patients. Two separate meta-analyses were performed for the association of Type D personality with physical and mental health status, respectively.

Results: Of all identified studies, ten studies met the selection criteria. The meta-analyses showed that Type D was associated with a two-fold increased odds for impaired physical health status (3035 patients, OR 1.94, 95% CI 1.49–2.52) and a 2.5-fold increased odds for impaired mental health status (2213 patients, OR 2.55, 95% CI 1.57–4.16). There was no significant heterogeneity between the studies on physical health status (Q = 12.78; p = 0.17; I²= 29.59), but there was between those on mental health status (Q = 21.91; p = 0.003; I²= 68.04). Subgroup analyses showed that the association between Type D and mental health status decreased yet remained significant when adjusting for baseline health status.

Conclusion: Type D personality was shown to be an independent correlate of impaired patient-reported physical and mental health status in various cardiovascular patient groups. Clinicians should be aware of the association between chronic psychological distress and poor patient-reported outcomes.

Background: Motivational interviewing (MI) is effective in promoting behavioural changes in patients with substance abuse and smoking. However, its effectiveness on health outcomes in cardiac rehabilitation patients is unclear.

Design: A randomized controlled trial.

Method: A total of 146 patients assessed as having poor motivation attended a cardiac rehabilitation programme from February 2008 to June 2010. Patients (n = 73) in the control group received usual care while those in the experimental group (n = 73) received usual care plus four sessions of MI, each lasting 30–45 min. Clinical and psychological outcomes and health-related quality of life were measured at baseline and 3 months after entering the programme. Descriptive statistics, independent t-test, Pearson Chi-squared test, and generalized estimating equations models were used to analyse the data.

Results: There was no significant difference between the two groups on clinical outcomes (all p-values >0.05). Patients in the experimental group had higher increases in health-related quality of life (SF-36) scores in the aspects of general health (4.74, 95% CI 0.04–9.44; p = 0.048) and role limitation due to emotional problems (8.80, 95% CI 1.16–16.43; p = 0.024). However, they reported significantly higher increases in anxiety levels (Hospital Anxiety and Depression Scale) than those in the control group (0.96, 95% CI 0.09–1.83; p = 0.030).

Conclusion: The short-term effectiveness of MI on clinical outcomes and health-related quality of life in poorly motivated cardiac rehabilitation patients is limited. MI, however, was shown to increase anxiety levels of patients during the study period (3 months). More evidence is needed to better understand this phenomenon in the future studies.

Background: Inflammatory markers such as serum C-reactive protein (CRP), serum amyloid A (SAA), and plasma pentraxin 3 (PTX3), which belong to the pentraxin superfamily, increase due to various inflammatory diseases. Some studies demonstrated that serum CRP and SAA are predictors of cardiovascular diseases, and cardiac rehabilitation (CR) induces anti-inflammatory effects. In the present study, we investigated the effects of CR on pentraxins (serum CRP, SAA, and plasma PTX3) in patients with cardiovascular diseases.

Methods: Fifty patients with cardiovascular diseases [61 ± 13 (mean ± SD) years old, male/female 44/6] participated. Each subject performed CR using aerobic bicycle exercise two or three times per week for 3–6 months. We measured resting serum high-sensitivity CRP (hsCRP), SAA, and plasma PTX3 before and 3 and 6 months after CR, and compared them with VO_2peak determined using a standard increment cycle ergometer protocol, B-type natriuretic peptide (BNP), and other biochemical data such as HbA1c.

Results: There was a significant positive correlation between hsCRP and SAA (r = 0.92, p < 0.001), but no relations between these parameters and PTX3. Plasma PTX3 significantly decreased time dependently during CR (at baseline 3.2 ± 2.0 ng/ml, at 3 months 2.3 ± 0.8 ng/ml, at 6 months 2.1 ± 0.7 ng/ml; all p < 0.05). Serum hsCRP tended to decrease, but not statistically significantly. At baseline, plasma PTX3 was negatively correlated with the percentage of the predicted values of VO_2peak and positively correlated with BNP. CR significantly increased the percentage of the predicted values of VO_2peak and decreased BNP.

Conclusions: Plasma PTX3, an inflammatory marker, which was quite different from CRP and SAA, decreased during cardiac rehabilitation with an improvement of exercise capacity in patients with cardiovascular diseases.

Background: Age-related effects on the ability of 6-min walking test (6MWT) and ejection fraction (EF) to predict mortality in coronary artery bypass grafting (CABG) patients undergoing cardiac rehabilitation (CR) is still debated.

Design and methods: In order to verify the role of 6MWT and EF on all-cause mortality in patients undergoing CR following CABG, 882 CABG patients undergoing CR stratified in adults (<65 years) and elderly (≥65 years) were studied.

Results: At the admission, EF was 52.6 ± 9.1% in adults and 51.3 ± 8.9% in elderly (p = 0.234, NS) while 6MWT was 343.8 ± 93.5 m in adults and 258.9 ± 95.7 m in elderly (p < 0.001). After 42.9 ± 14.1 months follow up, mortality was 8.2% in adults and 10.9% in elderly (p = 0.176, NS). Cox regression analysis shows that EF ≥ 50% and 6MWT ≥300 m are protective on mortality in all CABG patients before CR. However, EF ≥50% in adults (HR 0.18, 95% CI 0.06–0.49, p < 0.005) but not in elderly (HR 1.16, 95% CI 0.45–3.42, p = 0.354, NS) and 6MWT ≥300 m in elderly (HR 0.34, 95% CI 0.10–0.79, p = 0.033) but not in adults (HR 0.76, 95% CI 0.31–2.12, p = 0.654, NS) exert a protective role on mortality.

Conclusions: Our results indicate that both EF ≥ 50% and 6MWT ≥ 300 m independently protect against mortality in CABG patients before CR. However, their protective role is age dependent. In fact, EF ≥ 50% is protective in adults but not in elderly while 6MWT ≥ 300 m is protective in elderly but not in adult patients.

Background: Several studies suggested that exercise training might improve myocardial perfusion by inducing coronary vascular adaptations or enhancing collateralization. However, these findings were obtained in patients with chronic coronary artery disease using thallium-201 myocardial perfusion scintigraphy. We evaluated whether a long-term exercise-based cardiac rehabilitation (CR) started early (9 ± 3 days) after ST elevation acute myocardial infarction (STEMI) improves myocardial perfusion and left ventricular (LV) function, evaluated by gated single-photon emission computed tomography (SPECT) imaging.

Design: Randomized controlled study.

Methods: Fifty patients with recent STEMI were randomized into two groups: 24 enrolled in a 6-month exercise-based CR programme (group T) and 26 discharged with generic instructions for maintaining physical activity and correct lifestyle (group C). All patients underwent cardiopulmonary exercise test and gated SPECT within 3 weeks after STEMI and at 6-month follow up.

Results: At follow up, group T showed a significant reduction of stress-induced ischaemia (p < 0.01) and an improvement in resting and post-stress wall motion (both p < 0.005) and resting (p < 0.05) and post-stress wall thickness (p < 0.005) score indexes. At follow up, group T showed an improvement in peak oxygen consumption (p < 0.0001), O₂ pulse (p < 0.05), and in the slope of increase in ventilation over carbon dioxide output (p < 0.001). No changes in myocardial perfusion parameters, LV function, and cardiopulmonary indexes were observed in group C at follow up.

Conclusions: Six months of exercise training early after STEMI reduces stress-induced ischaemia and improves LV wall motion and thickness. Exercise-induced changes in myocardial perfusion and function were associated with the absence of unfavourable LV remodelling and with the improvement of cardiovascular functional capacity.

Aims: The associations of serum levels of homocysteine (tHcy), vitamin B₁₂, and folate with risk of all-cause and coronary heat disease (CHD) mortality is controversial, and the evidence in older adults is limited. The aim of this study was to examine whether serum folate, vitamin B₁₂, and tHcy independently predict risk of CHD-related and all-cause mortality in older adults.

Methods and results: Serum concentrations of folate, vitamin B₁₂, and tHcy were determined from blood samples obtained from 3010 Blue Mountains Eye Study participants (1997–99), aged ≥55 years. CHD and all-cause mortality was confirmed using the Australian National Death Index.

Results: Persons in the highest quartile of serum tHcy had increased risk of CHD mortality compared to those in the lowest quartile (multivariable-adjusted hazard ratio, HR, 2.45, 95% CI 1.30–4.62). A significant continuous association was observed between serum tHcy and CHD mortality (HR per SD ( = 4.8 µmol/l) increase in serum tHcy 1.25, 95% CI 1.08–1.45), after multivariable-adjustment. A significant association between folate deficiency and CHD-mortality was found (multivariable-adjusted HR 1.53, 95% CI 1.01–2.29). Hyperhomocysteinaemia (>15 µmol/l) was a significant predictor of all-cause mortality (multivariable-adjusted HR 1.47, 95% CI 1.18–1.83). A significant interaction was observed between hyperhomocysteinaemia and folate deficiency for all-cause and CHD mortality (p for interaction = 0.03 and p for interaction = 0.05, respectively).

Conclusion: Serum tHcy and folate were independent predictors of CHD and all-cause mortality, while vitamin B₁₂ was not associated. As raised tHcy levels and folate deficiency are associated with poorer lifestyle, changes to a more healthful lifestyle among older adults may minimize the adverse vascular effects of elevated tHcy.

Aims: To compare the value of serial electrocardiographic (ECG) changes by the two most widely used ECG classification systems–the Minnesota Code (MC) and Novacode (Nova) for the prediction of subsequent coronary heart disease (CHD) and total mortality.

Methods and results: We studied 12-lead ECGs from 12,477 participants (average age 54 years at baseline; 58% women; 76% non-Hispanic white) in the Atherosclerosis Risk in Communities (ARIC) Study, who were free of CHD at baseline in 1987, had both good-quality ECGs at baseline and at first study-scheduled follow-up visit, and had ECG QRS duration <120 ms. A total 2119 participants died (17%), including 280 CHD deaths during an average 17-year follow up. Cox regression models assessed outcome associated with significant serial ECG changes by MC and Nova separately. For CHD death the hazard ratio was 6.8 (95% CI 3.5–13.3) for incident Nova myocardial infarction (MI), and 5.7 (95% CI 2.7–11.9) for MC-MI in a multivariable model adjusted for clinical and demographic characteristics, and ECG left ventricular hypertrophy. The increased risk for total mortality doubled for both Nova and MC serial ECG MI. Major evolving ST-T wave abnormalities alone were associated with a ≥132% increased risk for CHD death and a 50% increased risk for total mortality by either Nova or MC.

Conclusion: ECG serial change by both MC and Nova are equally valuable predictors for future fatal cardiac events and total mortality and hence equally useful prognostic indicators in clinical trials and epidemiological studies.

Background: The association between specific sleeping disorders and risk of cardiovascular disease (CVD) is unclear. We assessed the association between sleep loss due to worry and future risk of CVD and death in a representative sample of community dwelling adults.

Methods: A cohort of 11,905 adults (aged 53.4 ± 12.2 years, 42.2% male) without known history of CVD were drawn from the Scottish Health Surveys. Self-reported sleep disturbance was measured using a single item from the General Health Questionnaire. Incident CVD events (comprising CVD death, nonfatal myocardial infarction, coronary surgical procedures, stroke, and heart failure) over 8-year follow up were ascertained by a linkage to national registers; a total of 1448 CVD events and 1249 all-cause deaths were recorded.

Results: 15.6% of the sample reported ‘rather more’ or ‘much more than usual’ sleep loss due to worry over the prior 4 weeks. Sleep loss due to worry (much more than usual) was associated with elevated risk of CVD [age- and sex-adjusted hazard ratio (HR) 1.74, 95% confidence interval (CI) 1.35–2.25] and all-cause mortality (age- and sex-adjusted HR 2.02, 95% CI 1.57–2.61). Adjustment for a range of psychosocial, behavioural, and clinical risk factors partly attenuated the association, and in particular health behaviours (smoking, alcohol, physical inactivity) accounted for approximately 40% of the sleep–CVD relation.

Conclusion: Sleep loss due to worry was associated with a greater risk of CVD and all-cause mortality, but the association can be largely explained by intermediate risk factors such as health behaviours.

Background: The Traveller community are an indigenous minority group in Great Britain and Ireland who experience premature mortality. While minority populations worldwide are known to have high rates of risk factors for cardiovascular disease (CVD), Traveller CVD risk has not previously been defined.

Design: All-Ireland cross-sectional census survey of the Traveller minority population (n = 10,615 families).

Methods: A subsample of adult respondents completed a health survey (n = 2023). CVD was defined as self-report of doctor-diagnosed heart attack, angina, or stroke. CVD risk factors and measures of social position were examined in the Traveller group using age-adjusted prevalence and prevalence ratios (PR). Comparisons were made with a general population sample of low socioeconomic status.

Results: Age-adjusted prevalence of CVD in the Traveller population was 5.6% (95% CI 4.6–6.8), similar to that in the comparator population. Compared to those without CVD, Travellers with CVD had a higher prevalence of self-report of diabetes, hypertension, hypercholesterolaemia, current smoking, and a measure of distrust. Compared with the general population sample, Travellers had a higher prevalence of diabetes (adjusted PR 2.8, 95% CI 2.1–3.8) and lifestyle-related risk factors such as smoking (PR 1.3, 95% CI 1.2–1.4), fried food consumption (PR 2.8, 95% CI 2.4–3.2), and physical inactivity (PR 1.3, 95% CI 1.2–1.4).

Conclusions: This comprehensive census survey confirms CVD as an important health risk in the economically disadvantaged Irish Traveller community. Our findings add to the international knowledge base on minority populations and CVD risk.

This paper presents a summary of the potential practical and economic barriers to implementation of primary prevention of cardiovascular disease guided by total cardiovascular risk estimations in the general population. It also reviews various possible solutions to overcome these barriers. The report is based on discussion among experts in the area at a special CardioVascular Clinical Trialists workshop organized by the European Society of Cardiology Working Group on Cardiovascular Pharmacology and Drug Therapy that took place in September 2009. It includes a review of the evidence in favour of the ‘treat-to-target’ paradigm, as well as potential difficulties with this approach, including the multiple pathological processes present in high-risk patients that may not be adequately addressed by this strategy. The risk-guided therapy approach requires careful definitions of cardiovascular risk and consideration of clinical endpoints as well as the differences between trial and ‘real-world’ populations. Cost-effectiveness presents another issue in scenarios of finite healthcare resources, as does the difficulty of documenting guideline uptake and effectiveness in the primary care setting, where early modification of risk factors may be more beneficial than later attempts to manage established disease. The key to guideline implementation is to improve the quality of risk assessment and demonstrate the association between risk factors, intervention, and reduced event rates. In the future, this may be made possible by means of automated data entry and various other measures. In conclusion, opportunities exist to increase guideline implementation in the primary care setting, with potential benefits for both the general population and healthcare resources.

Background: Cardiovascular disease (CVD) is characterized by slow progressive atherosclerosis and arterial thrombotic events, leading to occlusions. Whether either of these presentations is more likely in patients with a genetic predisposition for CVD is still unknown. We suggest that a genetic predisposition for CVD is related to recurrent events of the same nature.

Methods: We retrospectively investigated 275 patients with premature CVD and divided them in two groups according to their first event: an arterial thrombotic event or stable atherosclerosis. We used a Cox proportional-hazards model to estimate the effect of a positive family history for CVD on recurrent events of the same nature. This was tested in the entire cohort and in patients with coronary artery disease only.

Results: Patients with a first arterial thrombotic event and a positive family history had a threefold increased risk for a recurrent event of the same nature, compared to patients with a negative family history (hazard ratio 3.00, 95% confidence interval 1.32–6.81); p < 0.05). In contrast, a positive family history was not associated with an increased risk for a recurrent stable atherosclerosis (hazard ratio 0.98 (95% confidence interval 0.59–1.63). These findings were similar analysing the patients with coronary artery disease only. Additional adjustments for other risk factors did not change these associations.

Conclusions: Patients with a first premature arterial thrombotic event and a positive family history for CVD have an increased risk for a second event of the same nature. This might be due to unknown hereditary mechanisms leading to recurrent acute events.

Background: Current guidelines recommend that decisions to start preventative therapy for cardiovascular disease (CVD) should be based on absolute risk; however, current risk equations are based on single measurements of risk factors. We aimed to assess whether two measurements of blood pressure and lipids improves the prediction of cardiovascular risk compared to one measurement.

Methods and results: We used sex-specific Cox proportional hazards models to evaluate the risk of first CVD event in 2385 participants of the Framingham Offspring Study attending both the second and third visits. We estimated the effects on risk prediction of using the average of two measurements of blood pressure, total cholesterol, and HDL cholesterol compared to using one measurement of the risk factors. We found that these risk factors were each markedly more predictive of CVD when the average of two measurements was used rather than one measurement and age was less predictive of CVD. There were small improvements in the overall model fit, discrimination, and calibration. Reclassification also showed small improvements across the risk spectrum (net reclassification information, NRI, for women 3.0%, 95% CI −0.9 to 24.8%; NRI for men 4.0%, 95% CI −2.2 to 14.1%) and possibly greater improvements for intermediate-risk individuals (NRI for women 32.3%, 95% CI −21.9 to 46.8%; NRI for men 16.0%, 95% CI −3.3 to 43%).

Conclusions: Averaging two measurements of blood pressure and lipids results in marked increases in the predictiveness of these risk factors and smaller improvements in the overall prediction of cardiovascular risk including reclassification.

Background: Although the overall average 10-year cardiovascular risk for patients with manifest atherosclerosis is considered to be more than 20%, actual risk for individual patients ranges from much lower to much higher. We investigated whether information on metabolic syndrome (MetS) or its individual components improves cardiovascular risk stratification in these patients.

Design and methods: We conducted a prospective cohort study in 3679 patients with clinical manifest atherosclerosis from the Secondary Manifestations of ARTerial disease (SMART) study. Primary outcome was defined as any cardiovascular event (cardiovascular death, ischemic stroke or myocardial infarction). Three pre-specified prediction models were derived, all including information on established MetS components. The association between outcome and predictors was quantified using a Cox proportional hazard analysis. Model performance was assessed using global goodness-of-fit fit (χ²), discrimination (C-index) and ability to improve risk stratification.

Results: A total of 417 cardiovascular events occurred among 3679 patients with 15,102 person-years of follow-up (median follow-up 3.7 years, range 1.6–6.4 years). Compared to a model with age and gender only, all MetS-based models performed slightly better in terms of global model fit (χ²) but not C-index. The Net Reclassification Index associated with the addition of MetS (yes/no), the dichotomous MetS-components or the continuous MetS-components on top of age and gender was 2.1% (p = 0.29), 2.3% (p = 0.31) and 7.5% (p = 0.01), respectively.

Conclusions: Prediction models incorporating age, gender and MetS can discriminate between patients with clinical manifest atherosclerosis at the highest vascular risk and those at lower risk. The addition of MetS components to a model with age and gender correctly reclassifies only a small proportion of patients into higher- and lower-risk categories. The clinical utility of a prediction model with MetS is therefore limited.

Objectives: The aim was to examine and compare the impact of HeartScore and coronary artery calcification (CAC) score on subsequent changes in the use of medication.

Methods: A total of 1156 healthy men and women, aged 50 or 60, had a baseline medical examination and a coronary artery CT-scan as a part of a screening programme. Using the European HeartScore, the total 10-year cardiovascular mortality risk was estimated (≥5% risk was considered as high). Risk factors and CAC scores were reported to both the patients and their general practitioner. Six months after the screening, follow-up questionnaires addressing current medication were mailed to the participants.

Results: A completed questionnaire was returned by 1075 (93%) subjects. At follow up, the overall use of prophylactic medication was significantly increased. Of those with CAC (n = 462) or high HeartScore (n = 233), 21 and 19%, respectively, received lipid-lowering treatment, while 25 and 32%, respectively, received antihypertensive treatment. In multivariate logistic regression analyses, the presence of CAC was associated with an increased use of lipid-lowering treatment (OR 2.2; 95% CI 1.2–4.0), while the presence of a high HeartScore was associated with an increased use of lipid-lowering (OR 2.9; 95% CI 1.6–5.5) and antihypertensive medication (OR 3.4; 95% CI 1.9–6.0).

Conclusion: Knowledge of present cardiovascular risk factors like high HeartScore and/or CAC leads to beneficial changes in medication. However, at follow up only a minority of high-risk subjects did received prophylactic treatment. CAC score was not superior to HeartScore regarding these motivational outcomes.

Background: Ethnic variations in stroke require more European studies, especially as differences are reportedly large.

Methods: We created a retrospective cohort study of 4.65 million people in Scotland linking ethnicity from the census and stroke incidence and mortality from NHS databases. Rate ratios using direct age standardization and risk ratios were calculated, the latter to model the influence of educational qualification in a Poisson regression model.

Results: Age-adjusted rate ratios varied little, compared to the White Scottish group (reference value 100) and the 95% CIs usually included 100, e.g. higher in Pakistani men (120.5, 95% CI 95.2–145.8) and in African men (137.9, 95% CI 91.5–184.4) but not in Pakistani or African women. Stroke rates were low in the Other White British (78.3, 95% CI 75.4−81.2 in men and 84.9, 95% CI 82.0−87.8 in women), Other White (89.8, 95% CI 81.5−98.1 in men and 88.8, 95% CI 80.9−96.7 in women) and Chinese men (70.3, 95% CI 45.7−94.8). Adjusting for highest educational qualification attenuated some and augmented other risk ratios, e.g. in Other White British men, the risk ratio changed from 71.4 to 80.2 (95% CI 74.2−86.6) and in African men from 124.2 to 138.8 (95% CI 107.7−178.8).

Conclusions: Ethnic variations deserve further study, including in White European origin subgroups and the Chinese. Extremely high rates in South Asian and African origin were not corroborated in Scotland. Linkage methods are practical in Europe.