European Journal of Preventive Cardiology

Patients with coronary heart disease often suffer from an impaired health-related quality of life (HRQoL). A healthier lifestyle not only extends individuals’ lengths of life but might also improve their HRQoL. The aim of this study was to explore the relation between self-reported lifestyle changes and HRQoL in European coronary patients.

Data on 8745 coronary patients, from 22 countries, participating in the EUROASPIRE III survey (2006–2007) were used. These patients hospitalized for coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, or myocardial ischaemia were interviewed and examined at least 6 months and no later than 3 years after their hospital admission to gather information on their HRQoL, self-reported lifestyle changes, and risk factors.

Significantly better HRQoL scores were found in ex-smokers compared to current smokers. Patients who made an attempt to increase their physical activity level had a better HRQoL compared to those who had not made an attempt. Furthermore dietary changes were associated with HRQoL, with better outcomes in patients who tried to reduce fat and salt intake and increase fish, fruit, and vegetable intake. The intention to change behaviour was not associated with HRQoL.

Better HRQoL scores were found in those coronary patients who adopted a healthier lifestyle. The actual lifestyle changes – smoking cessation, increasing physical activity, and adopting a healthy diet – and not the intention to change are associated with better HRQoL outcomes.

Extracellular matrix-degrading proteinases are upregulated in atherosclerotic lesions and can contribute to subsequent pathological events. In the present nested case–control study, we investigated the association of serum concentrations of matrix metalloproteinases MMP-7, MMP-8, and MMP-13, tissue inhibitor of metalloproteinase-1 (TIMP-1), and neutrophil elastase (NE) with incident cardiovascular disease (CVD) events.

The FINRISK97 cohort included 8090 persons with no history of CVD. During the 10-year follow up, 471 incident CVD cases were ascertained and for them, three individually matched controls (n = 1413) were selected. The CVD events included myocardial infarction, stroke, coronary revascularization, and CVD death.

Compared to the controls, the cases had significantly higher serum mean concentrations of MMP-7, MMP-8, and TIMP-1, as well as MMP-7/TIMP-1 ratio. In multivariate analyses adjusted for CVD risk factors, MMP-7, MMP-8, TIMP-1, and MMP-8/TIMP-1 ratio were associated with the risk for incident CVD: OR 1.16 (95% CI 1.03–1.31), OR 1.13 (95% CI 1.01–1.26), OR 1.16 (95% CI 1.02–1.31), and OR 1.13 (95% CI 1.00–1.27) respectively, per SD-increase of log-transformed unit. The associations, however, attenuated into non-significant after adjusting for C-reactive protein (CRP) concentrations.

MMP-7 and MMP-8, which are upregulated during inflammation, can form a proinflammatory tissue destructive cascade. They can be regarded as risk factors, and thus as potential biomarkers for incident CVD. The balance between these MMPs and their tissue inhibitor may indicate vulnerability to plaque rupture.

Despite the fact that subjects with established coronary heart disease (CHD) are at high risk of further events and deserve meticulous secondary prevention, current audits such as EUROASPIRE show poor control of major risk factors. Ongoing monitoring is required. We present a new risk factor audit system, SURF (Survey of Risk Factor management), that can be conducted much more quickly and easily than existing audit systems and has the potential to allow hospitals of all sizes to participate in a unified international audit system that will complement EUROASPIRE. Initial experience indicates that SURF is truly simple to undertake in an international setting, and this is illustrated with the results of a substantive pilot project conducted in Europe and Asia.

The data collection system was designed to allow rapid and easy data collection as part of routine clinic work. Consecutive patients (aged 18 and over) with established CHD attending outpatient cardiology clinics were included. Information on demographics, previous coronary medical history, smoking history, history of hypertension, dyslipidaemia or diabetes, physical activity, attendance at cardiac rehabilitation, cardiac medications, lipid and glucose levels (and HbA1c in diabetics) if available within the last year, blood pressure, heart rate, body mass index, and waist circumference were collected using a one-page data collection sheet. Years spent in full time education was added as an additional question during the pilot phase.

Three European countries − Ireland (n = 251), Belgium (n = 122), and Croatia (n = 124) − and four Asian countries − Singapore (n = 142), Taiwan (n = 334), India (n = 97), and Korea (n = 45) − were included in the pilot study. The results of initial field testing were confirmed in that it proved possible to collect data within 60−90 seconds per subject. There was poor control of several risk factors including high levels of physical inactivity (41−45%), overweight and obesity (59−78%), and ongoing smoking (15%). There were lower levels of individuals attending cardiac rehabilitation in Asia. More Europeans than Asians reached the low-density lipoprotein cholesterol target of <2.5mmol/l (66 vs. 59%) reflecting differences in medication usage. However, blood pressure control was superior in Asia, with 71% <140/90 compared with 66% of Europeans (NS).

This phase of SURF has confirmed its ease of use which should allow wide participation and the collection of representative risk factor data in subjects with CHD as well as ongoing data collection to monitor secular trends in risk factor control. Notwithstanding that this is a pilot study, the results suggest that risk factor control, particularly for lifestyle-related measures, is poor in both Europe and Asia.

Aromatherapy is widely used around the world for stress relief. Whether exposure to essential oil increases the risk of cardiovascular events is still unknown. The purpose of this study was to investigate the effect of essential oil on heart rate and blood pressure among solus por aqua (spa) workers.

We recruited 100 healthy workers from various spa centres in Taipei, Taiwan. Between July and August of 2010, three repeated measurements – resting heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) – were taken of each spa worker in our study room. Participants were exposed to essential oil vapour generated from an ultrasonic atomizer in the study room for two consecutive hours. The total volatile organic compound (VOC) level in the study room was measured during the study period. We used a linear mixed-effect model to determine the association between the total VOC level and the participants’ HR, SBP, and DBP.

For the times from 15 to 60 min after start of exposure, we found that the VOC level was significantly associated with reduced 15-min mean BP and HR. After exposure for more than 1 hour, from 75 to 120 min after start of exposure, we found that the VOC levels were associated with increased 15-min mean BP and HR.

Exposure to essential oil for 1 hour was found to be an effective method of relaxation, as indicated by decreases in the HR and BP. Prolonged exposure for longer than 1 hour to essential oils may be harmful to cardiovascular health among spa workers.

Coronary heart disease (CHD) mortality has declined substantially in the Czech Republic over the last two decades.

The purpose of this study was to determine what proportion of this CHD mortality decline could be associated with temporal trends in major CHD risk factors and what proportion with advances in medical and surgical treatments.

The validated IMPACT mortality model was used to combine and analyse data on uptake and effectiveness of CHD management and risk factor trends in the Czech Republic in adults aged 25–74 years between 1985 and 2007. The main sources were official statistics, national quality of care registries, published trials and meta-analyses, and the Czech MONICA and Czech post-MONICA studies.

Between 1985 and 2007, age-adjusted CHD mortality rates in the Czech Republic decreased by 66.2% in men and 65.4% in women in the age group 25–74 years, representing 12,080 fewer CHD deaths in 2007. Changes in CHD risk factors explained approximately 52% of the total mortality decrease, and improvements in medical treatments approximately 43%. Increases in body mass index and in diabetes prevalence had a negative impact, increasing CHD mortality by approximately 1% and 5%, respectively.

More than half of the very substantial fall in CHD mortality in the Czech Republic between 1985 and 2007 was attributable to reduction in major cardiovascular risk factors. Improvement in treatments accounted for approximately 43% of the total mortality decrease. These findings emphasize the value of primary prevention and evidence-based medical treatment.

We are unaware of any previous investigation that has compared the relationship of key cardiopulmonary exercise testing (CPX) variables to various measures of pathophysiology between heart failure-reduced ejection fraction (HFrEF) and HF-preserved ejection fraction (HFpEF) cohorts that are well matched with respect to baseline characteristics and their exercise response, which is the purpose of the present study.

Thirty-four patients with HFpEF were randomly matched to 34 subjects with HFrEF according to age and sex as well as peak oxygen consumption (VO₂), ventilatory efficiency (VE/VCO₂ slope), and exercise oscillatory ventilation (EOV). In addition to CPX, patients also underwent echocardiography with tissue Doppler imaging (TDI) and assessment of N-terminal pro-B-type natriuretic peptide (NT-proBNP).

When matched for age, sex, and CPX variables, the HFrEF and HFpEF cohorts had similar echocardiography with TDI and NT-proBNP values, indicating comparable disease severity. In addition, the correlations between key CPX measures (peak VO₂ and VE/VCO₂ slope) and echocardiography with TDI and NT-proBNP measures were similar between HFrEF and HFpEF groups. Of note, the correlation between the VE/VCO₂ slope and pulmonary artery systolic pressure and NT-proBNP was highly significant in both groups (r ≥ 0.65, p < 0.01). Moreover, subjects with EOV in both groups had a significantly higher PASP (∼47 vs. ∼35 mmHg, p < 0.05).

The results of the current study indicate CPX equally represents disease severity in HFrEF and HFpEF patients. This is a novel finding supporting the key role of CPX in the clinical follow-up of HF patients irrespective of LVEF and cardiac phenotype.

Although there is overwhelming evidence that reducing low-density lipoprotein cholesterol (LDL-C) with statins leads to reductions in cardiovascular disease, less is known about the effects in persons with type 2 diabetes mellitus (T2DM) without pre-existing vascular events.

Using the UK-based General Practice Research Database we conducted a retrospective cohort study of 21,998 T2DM patients aged 35–69 with ≥2 prescriptions for lipid-modifying therapy (2000–2009). We categorized LDL-C change (mmol/l) between last available and baseline lipid values as reduction (≥3.0, 2.0–2.9, 1.0–1.9, 0.3–0.9), no-change (±0.2 of baseline), or increase (>0.2). Outcomes were incident composite cardiovascular (n = 621) and cerebrovascular events (n = 274). We estimated hazard ratios (HRs) of study outcomes and 95% confidence intervals (CIs) for LDL-C change compared with the no-change group. Compared to no changes, adjusted HRs of cardiovascular events for a reduction ≥3.0 and a reduction between 2.0–2.9 were 0.41 (95% CI: 0.23–0.71) and 0.51 (95% CI: 0.34–0.76) (p for linear trend <0.001). LDL-C reduction yielded a decreased cerebrovascular event risk compared to no change, even with the smallest reduction (adjusted HR = 0.59, 95% CI: 0.36–0.98).

Decreasing LDL-C is associated with a reduced risk of cardiovascular and cerebrovascular events among T2DM patients without such pre-existing events. The magnitude of the protective effect on cerebrovascular events is less certain, and further studies are warranted.

There are conflicting guidelines regarding the measurement of apolipoproteins (apoB, apoA-1), in addition to standard lipoprotein cholesterol measures, for cardiovascular risk assessment among individuals with obesity or insulin resistance syndromes. This study aims to assess whether apolipoprotein assessments add prognostic information regarding coronary heart disease (CHD) risk beyond standard lipoprotein cholesterol measurements among individuals with obesity, diabetes, and the metabolic syndrome.

We followed 9026 participants in the Atherosclerosis Risk in Communities (ARIC) study without cardiovascular disease at baseline (visit 4, 1996–99). We compared the associations of apoB, apoA-1, and their respective lipoprotein cholesterol measures with incident CHD events among individuals with and without obesity, the metabolic syndrome, or diabetes. Over a median follow up of 10.1 years, there were 903 CHD events. Among participants with obesity, the top quintiles of apoB (HR 2.00, 95% CI 1.40–2.85 compared with the bottom quintile) and the apoB/apoA-1 ratio (HR 2.47, 95% CI 1.53–4.01) did not demonstrate stronger associations with CHD than the top quintiles of non-high-density-lipoprotein cholesterol (non-HDL-C) (HR 2.54, 95% CI 1.65–3.89) and the ratio of non-HDL-C/HDL-C (HR 4.28, 95% CI 2.29–8.03). Analogous findings were seen among patients with diabetes and the metabolic syndrome. In models adjusted for non-HDL-C and HDL-C, apoB (p = 0.94) and apoA-1 (p = 0.55) were not significantly associated with CHD events among those with obesity, in contrast to non-HDL-C and HDL-C (p = 0.02 for both).

Among individuals with obesity and insulin resistance syndromes, apolipoproteins did not provide prognostic information regarding CHD risk beyond that provided by non-HDL-C and HDL-C.

Impaired heart rate recovery (HRR) is a strong predictor of overall mortality and cardio-metabolic risk. This study aimed at investigating (1) the effect of participation in a lifestyle-change programme for weight loss on HRR in overweight and obese children and (2) potential associations between the changes in one minute HRR (HRR₁) and fitness, weight loss and cardio-metabolic risk.

The analysis included 429 individuals (169 boys) aged 13.9 ± 2.3 years who participated in an inpatient weight loss programme for four to six weeks. At baseline and the end of the programme clinical investigations were performed, including blood analyses, blood pressure, anthropometry and maximal cycle ergometer exercise testing with continuous heart rate (HR) monitoring. HRR was calculated as the difference between the highest exercising HR and HR at one, three and five minutes post-exercise.

Average body weight decreased from 90.7 ± 22.5 kg to 81.9 ± 20.0 kg and peak exercise capacity increased from 1.66 ± 0.38 W/kg to 2.05 ± 0.45 W/kg (p < 0.001). Cardio-metabolic risk factors improved (waist circumference, LDL-cholesterol, HOMA insulin ratio, blood pressure; p < 0.05). HDL-cholesterol and triglyceride levels remained unchanged. Compared with baseline, at follow-up the decline in HR was more pronounced (+32%, +18% and +11% for HRR₁, HRR₃ and HRR₅; p < 0.001). Improvements in HRR₁ were weakly correlated with changes in exercise capacity (p < 0.05; r < 0.13), but not with changes in body weight and cardio-metabolic risk factors.

HRR considerably improved after an inpatient weight loss programme in overweight and obese children. This was not associated with improvements in body weight and cardio-metabolic risk; hence HRR would be a valuable addition to cardiovascular risk assessment in this group.

Oxidative stress has a pivotal role in the onset of obesity-related chronic diseases. This study assessed potential gender differences in the associations of adiposity (total vs. central) with oxidative stress markers in healthy young adults.

This cross-sectional study enrolled 272 subjects (97 males, 175 females; 22 ± 3 years, body mass index 22.0 ± 2.8 kg/m²). Body composition, cardiometabolic and lifestyle features, oxidized low-density lipoprotein cholesterol (ox-LDL) concentrations, plasma total antioxidant capacity (TAC), and glutathione peroxidase (GPx) activity in erythrocytes were determined by validated procedures.

Compared to women, men had statistically higher concentrations of ox-LDL (61.7 vs. 53.5 U/l, p = 0.022). In analyses with the whole sample, those individuals included in the highest tertile of central adiposity indicators (waist circumference, WC, or waist-to-hip ratio, WHR) presented higher ox-LDL and lower TAC values (p < 0.01), while no statistical differences were found across tertiles of total body fat. WHR values were more strongly associated with ox-LDL and TAC concentrations, compared to other adiposity indicators, with higher slopes for women. Sex differences in ox-LDL concentrations were abolished (p > 0.05) after individual pairing of men and women for WC (53.8 vs. 61.6 U/l, p = 0.225) or WHR (56.1 vs. 56.3 U/l, p = 0.471). No differences were found in GPx values concerning gender or adiposity indicators.

Plasma ox-LDL and TAC values were more strongly influenced by central adiposity indicators (WHR and WC) in women than in men, suggesting that the change of the gynoid to android pattern phenotype among young women could lead to a steeper unfavourable redox status compared to men.

While cardiorespiratory fitness is strongly related to survival, there are limited data regarding musculoskeletal fitness indicators. Our aim was to evaluate the association between the ability to sit and rise from the floor and all-cause mortality.

Retrospective cohort.

2002 adults aged 51–80 years (68% men) performed a sitting-rising test (SRT) to and from the floor, which was scored from 0 to 5, with one point being subtracted from 5 for each support used (hand/knee). Final SRT score, varying from 0 to 10, was obtained by adding sitting and rising scores and stratified in four categories for analysis: 0–3; 3.5–5.5, 6–7.5, and 8–10.

Median follow up was 6.3 years and there were 159 deaths (7.9%). Lower SRT scores were associated with higher mortality (p < 0.001). A continuous trend for longer survival was reflected by multivariate-adjusted (age, sex, body mass index) hazard ratios of 5.44 (95% CI 3.1–9.5), 3.44 (95% CI 2.0–5.9), and 1.84 (95% CI 1.1–3.0) (p < 0.001) from lower to higher SRT scores. Each unit increase in SRT score conferred a 21% improvement in survival.

Musculoskeletal fitness, as assessed by SRT, was a significant predictor of mortality in 51–80-year-old subjects. Application of a simple and safe assessment tool such as SRT, which is influenced by muscular strength and flexibility, in general health examinations could add relevant information regarding functional capabilities and outcomes in non-hospitalized adults.

The aim of this paper was to identify the extent of socioeconomic inequality in participation at baseline and follow-up visits.

The Inter99 study is a randomized intervention with the aim of investigating the effects of an individualized lifestyle consultation on ischaemic heart disease (IHD). The study comprised 61,301 persons of which 13,016 were assigned to the intervention group. The rest formed the control group. All those in the intervention group were invited to participate in health examinations, risk assessments, and lifestyle consultations. Participants at high risk of IHD were invited to follow-up visits after 1, 3, and 5 years.

Data on five socioeconomic factors were retrieved from nationwide registers. For each socioeconomic factor we estimated the relative risks and relative index of inequality of participation at the baseline visit and among high-risk participants at follow-up visits. In addition, we conducted analyses of trends in socioeconomic inequality in participation across follow-up visits.

Participation rates were 53% at baseline and 61–65% at the three follow-up visits. There was strong socioeconomic inequality in participation at baseline, with increasing probability of participation found with increasing level of socioeconomic position. This was smaller at follow-up visits. Except for education and housing tenure, there was an increase in socioeconomic inequality in participation across follow-up visits.

We found strong socioeconomic inequality in participation at baseline and follow-up visits. Effort should be made to increase participation in individualized lifestyle interventions among persons of low socioeconomic position. Otherwise, the consequence may be increased socioeconomic inequality in IHD.

Heart rate recovery (HRR) is becoming an important prognostic maker in heart failure (HF), but very little is known about the underlying mechanisms responsible for its clinical efficacy. Therefore, we examined echocardiographic and exercise (submaximal and maximal) characteristics to gain a better appreciation of HRR and factors responsible for the development of abnormal HRR in patients with both heart failure reduced ejection fraction (HFrEF) and heart failure preserved ejection fraction (HFpEF).

Cardiopulmonary exercise testing (CPX), a 6-minute walk test (6MWT), and resting 2D echocardiography were randomly performed in 240 HF patients (200 HFrEF, 40 HFpEF) after which HRR was measured. HRR was defined as the difference between heart rate at peak exercise and 1 minute following test termination.

Bivariate correlation analyses found significant relationships among most CPX and 6MWT measurements with the highest correlations between 6MWT HRR and 6MWT peak HR (r = 0.65; p < 0.001) and CPX HRR and CPX HR_reserve (r = 0.63; p < 0.001). The relationship between 6MWT HRR and CPX HRR was very good (r = 0.91; p < 001). Multivariate logistic regression of submaximal and maximal exercise found 6MWT peak HR and exercise oscillatory ventilation (EOV), respectively, were the strongest predictors (p < 0.001) of abnormal HRR. The E/E′ was a significant predictor (p < 0.001) of abnormal HRR, but EOV was the strongest predictor of abnormal HRR (OR = 6.5).

HRR after both CPX and the 6MWT is significantly related to many exercise and echocardiographic measures with the most significant predictors of abnormal HRR being related to indices of cardiorespiratory performance in patients with HFrEF and HFpEF.

Smoking is a major cardiovascular risk factor, and smoking cessation is imperative for patients hospitalized with a cardiovascular event. This study aimed to evaluate a systems-based approach to helping hospitalized smokers quit and to identify implementation barriers.

Prospective intervention study followed by qualitative analysis of staff interviews.

The prospective intervention study assessed the effects of implementing standard operating procedures (SOPs) for the provision of counselling and pharmacotherapy to smokers admitted to cardiology wards on counselling frequency. In addition, a qualitative analysis of staff interviews was undertaken to examine determinants of physician and nurse behaviour; this sought to understand barriers in terms of motivation, capability, and/or opportunity.

A total of 150 smoking patients were included in the study (75 before and 75 after SOP implementation). Before the implementation of SOPs, the proportion of patients reporting to have received cessation counselling from physicians and nurses was 6.7% and 1.3%, respectively. Following SOP implementation, these proportions increased to 38.7% (p < 0.001) and 2.7% (p = 0.56), respectively. Qualitative analysis revealed that lack of motivation, e.g. role incongruence, appeared to be a major barrier.

Introduction of a set of standard operating procedures for smoking cessation advice was effective with physicians but not nurses. Analysis of barriers to implementation highlighted lack of motivation rather than capability or opportunity as a major factor that would need to be addressed.