European Journal of Preventive Cardiology

While secondary prevention improves prognosis after acute myocardial infarction (AMI), previous studies have suggested suboptimal guideline adherence, lack of improvement over time and gender differences. This study contributes contemporary data from a large national cohort.

We identified 51,620 patients <75 years examined at two and/or twelve months post AMI in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART). Risk factor control and readmissions at one year were compared between the 2005 and 2012 cohorts, and between genders.

Lipid control (LDL-cholesterol <2.5 mmol/L) improved from 67.9% to 71.1% (p = 0.016) over time, achieved by 67.9% vs 63.3%, p < 0.001 of men vs women. Blood pressure control (<140 mmHg systolic) increased over time (59.1% vs 69.5%, p < 0.001 in 2005 and 2012 cohorts) and was better in men (66.4% vs 61.9%, p < 0.001). Smoking cessation rate was 55.6% without differences between genders or over time. Cardiac readmissions occurred in 18.2% of women and 15.5% of men, decreasing from 2005 to 2012 (20.8% vs 14.9%). Adjusted odds ratio was 1.22 (95% CI 1.14–1.32) for women vs men and 0.94 (95% CI 0.92–0.96) for the 2012 vs the 2005 cohort.

Although this study compares favourably to previous studies of risk factor control post AMI, improvement over time was mainly seen regarding blood pressure, revealing substantial remaining preventive potential. The reasons for gender differences seen in risk factor control and readmissions require further analysis.

A reduction in number and function of endothelial progenitor cells (EPCs) occurs in both physiologic aging and chronic heart failure (CHF). We assessed whether disease and aging have additive effects on EPCs or whether beneficial effects of exercise training are diminished in old age.

We randomized 60 patients with stable CHF and 60 referent controls to a training or a control group. To detect possible aging effects we included subjects below 55 (young) and above 65 years (older). Subjects in the training group exercised four times daily at 60% to 70% of VO₂max for four weeks under supervision. At baseline and after the intervention the number and function of EPCs were assessed.

As compared with young referent controls, older referent controls showed at baseline a reduced EPC number (young: 190 ± 37 CD34/KDR positive cells/ml blood; older: 131 ± 26 CD34/KDR positive cells/ml blood; p < 0.05) and function (young: 230 ± 41 migrated cells/1000 plated cells; older: 185 ± 28 cells/1000 plated cells; p < 0.05). In young and older CHF patients EPC-number (young: 85 ± 21 CD34/KDR positive cells/ml blood; older: 78 ± 20 CD34/KDR positive cells/ml blood) and EPC-function (young: 113 ± 26 cells/1000 plated cells; older: 120 ± 27 cells/1000 plated cells) were impaired. As a result of exercise training, EPC function improved by 24% in older referent controls (p < 0.05), while it remained unchanged in young training referent controls and controls respectively. In young and older patients with CHF four weeks of exercise training resulted in a significant improvement in EPC numbers and EPC function (young: number +66% function +43%; p < 0.05; older: number +69% function +36%; p < 0.05). These results were accompanied by a significant increase in flow mediated dilatation in the training groups of young/older CHF patients and in older referent controls.

Four weeks of exercise training are effective in improving EPC number and EPC function in CHF patients. These training effects were not impaired among older patients, emphasizing the potentials of rehabilitation interventions in a patient group where CHF has a high prevalence.

We aimed to investigate associations between combinations of body mass index (BMI)-categories, levels of physical activity and long-term risk of cardiovascular disease.

At age 50 years, cardiovascular risk factors were assessed in 2196 participating men of the ULSAM-study. This investigation was repeated at age 60, 70, 77 and 82 years. Being physically active (PA) was defined as three hours of recreational or hard physical training per week. The men were categorized according to BMI/PA-status, as PA/normal weight (n = 593 at baseline), non-PA/normal weight (BMI < 25 kg/m², n = 580), PA/overweight (n = 418), non-PA/overweight (BMI 25–30 kg/m², n = 462), PA/obese (n = 62), non-PA/obese (BMI >30 kg/m², n = 81). We used updated data on BMI and physical activity obtained at all examinations. During follow-up (median 30 years) 850 individuals suffered a cardiovascular disease (myocardial infarction, stroke or heart failure). Using updated data on BMI/PA categories, an increased risk for cardiovascular disease was seen with increasing BMI, but a high physical activity was associated with a lower risk of cardiovascular disease within each BMI category: non-PA/normal weight (hazard ratio (HR) 1.31, 95% confidence interval (CI) 1.04–1.66), PA/overweight (HR 1.52, 95% CI 1.20–1.94), non-PA/overweight (HR 1.65, 95% CI 1.31–2.07) PA/obese (HR 2.05, 95% CI 1.44–2.92) and non-PA/obese (HR 2.39, 95% CI 1.74–3.29), using PA/normal weight men as referent.

Although physical activity was beneficial at all levels of BMI regarding the risk of future cardiovascular disease, there was still a substantial increased risk associated with being overweight or obese during 30 years of follow-up.

Arterial hypertension is a main determinant of arterial remodelling and atherosclerosis. Coronary artery calcium score and carotid intima-media thickness are recognized indices of vascular remodelling. Established biohumoral markers for the diagnosis of atherosclerosis are still lacking in asymptomatic subjects with hypertension.

We aimed to test the association of plasma N-terminal pro B-type natriuretic peptide concentrations with either coronary artery calcium score or carotid intima-media thickness in asymptomatic hypertensive subjects.

We conducted a case–control study on 436 hypertensi.ve and 436 age/sex-matched normotensive subjects from the population of the Montignoso HEart and Lung Project, a community-based study of asymptomatic general population ≥45 years. Subjects underwent N-terminal pro B-type natriuretic peptide measurement, echocardiography and evaluation of coronary artery calcium score and carotid intima-media thickness.

Hypertensive subjects had higher median coronary artery calcium score (60 (interquartile range, 30–112) vs. 15 (interquartile range 3–70) Agatson units, p = 0.007), carotid intima-media thickness (8.6 (interquartile range 7.5–9.1) vs. 7.9 (7.1–8.4) µm, p < 0.001) and indexed left ventricular mass (101 (interquartile range 82–126) vs. 87 (63–91) mg/m2, p = 0.03) than controls, with no differences in left ventricular ejection fraction, diameters, E/E′, left atrial area. N-terminal pro B-type natriuretic peptide concentrations were higher in hypertensive subjects with either coronary artery calcium score (p = 0.008) or carotid intima-media thickness >75th (p < 0.006) percentile and highest in combined coronary artery calcium score/carotid intima-media thickness >75th percentile (p = 0.021). In multivariable analysis, N-terminal pro B-type natriuretic peptide independently predicted either coronary artery calcium score or carotid intima-media thickness >75th percentile, but only in hypertensive subjects (odds ratio = 1.87, 95% confidence interval 1.30–2.74, p = 0.001 and odds ratio = 1.99, 95% confidence interval 1.43–2.76, p = 0.001).

In asymptomatic subjects with hypertension, N-terminal pro B-type natriuretic peptide is a marker of hypertension-mediated preclinical vascular disease.

It is unknown whether the symptoms of first and recurrent acute myocardial infarction (AMI) are similar in the same person. This study examined the frequency of symptom mismatch, which factors are associated with a symptom mismatch and how symptom mismatch is related to 28-day case fatality.

Observational study.

The sample consisted of 1282 persons with a first and recurrent AMI, recruited from a population-based AMI registry, 1985–2011. Occurrence of 11 symptoms was recorded in first and recurrent AMI using standardized patient interview. Logistic regression modelling adjusted for demographic and clinical variables was applied.

Mismatch was highest for dyspnoea (40.6%) and lowest for chest symptoms (10.4%). Compared with women, men were less likely to have a mismatch of pain between the shoulder blades (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.43–0.79), pain in the throat/jaw (OR 0.67, 95% CI 0.50–0.91), nausea (OR 0.62, 95% CI 0.47–0.82), vomiting (OR 0.50, 95% CI 0.36–0.71), or fear of death (OR 0.71, 95% CI 0.53–0.94), or to have three or more mismatching symptoms (OR 0.60, 95% CI 0.45–0.79). Persons with diabetes were more likely to have a mismatch in chest symptoms, whereas persons with hyperlipidaemia or persons who received any revascularization therapy at first infarction were significantly less likely to have a mismatch of chest symptoms. Twenty-eight-day case fatality significantly increased with the number of mismatching symptoms (OR 1.14, 95% CI 1.02–1.28).

Patients with AMI may benefit from information about the possibility that a recurrent infarction may be associated with different symptoms.

The pace and pathways of early growth have major influences on later health. Coronary heart disease (CHD) is a major killer and kills more women than men, but usually manifests about 10 years later in women. Therefore there are fewer studies of early growth and CHD amongst women than men.

The Helsinki Birth Cohort Study includes 9817 women born during 1924–1944. We used national registers to identify hospital admissions and deaths from CHD during 1971–2010. We used a Cox model to obtain hazard ratios (HRs) for CHD.

Altogether 967 women (9.9%) developed CHD. Socioeconomic factors were strongly and inversely associated with CHD. Neither maternal age nor body mass index (BMI) was associated with CHD in the daughters. There were inverse associations of birth weight (p = 0.07) and length (p = 0.02) with CHD in adult life. We divided the mothers according to parity. Daughters of primiparous women had lower birth weight and shorter birth length than the offspring of multiparous women (both p-values < 0.001). Birth weight (p = 0.008), birth length (p = 0.05) and birth BMI (p = 0.02) were all inversely associated with CHD. Among first-born women, a 1 kg increase in birth weight was associated with a 25% lower risk for CHD (HR 0.75, 95% confidence interval (CI) 0.60–0.93). The findings changed little after adjustment for socioeconomic factors. Among later-born women none of the birth characteristics was associated with CHD.

Small birth size is associated with CHD among women. First-born women with high birth weight appear to be at lower risk for CHD compared with later born women.

Higher parity has been associated with increased maternal risk of cardiovascular disease, but the mechanism is not well delineated. Whether the number of live births is associated with coronary and aortic subclinical atherosclerosis has not been fully evaluated.

Women from the Dallas Heart Study, a multiethnic population-based cohort of subjects aged 30–65 years, were included if they had data on self-reported live births and coronary artery calcium (CAC) measured by computed tomography or aortic wall thickness (AWT) by MRI. Coronary artery calcium was positive if >10 Agatston units, and aortic wall thickness if greater than the 75^th percentile reference point for age and gender. Among the 1644 women included in the study, the mean age was 45 years and 55% were Black. Sequential multivariable models were done adjusting for age, race, traditional cardiovascular risk factors, body mass index, income, education, hormone replacement therapy, oral contraceptives, and physical activity. Using women with 2–3 live births as the reference, those with four or more live births had an increased prevalence of elevated coronary artery calcium (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.28–3.65) and aortic wall thickness (OR 1.6, 95% CI 1.04–2.41). Women with 0–1 live births also had increased coronary artery calcium (OR 1.9, 95% CI 1.16–3.03) and aortic wall thickness (OR 1.5, 95% CI 1.05–2.09) after multivariable adjustment.

The number of live births is associated with subclinical coronary and aortic atherosclerosis, with an apparent U-shaped relationship. Further studies are needed to confirm this association and explore the biological underpinnings of these findings.

Adherence to the Mediterranean diet is associated with lower mortality in a general population but limited evidence exists on the effect of a Mediterranean diet on mortality in subjects with diabetes. We aim to examine the association between the Mediterranean diet and mortality in diabetic individuals.

Prospective cohort study on 1995 type 2 diabetic subjects recruited within the MOLI-SANI study.

Methods: Food intake was recorded by the European Project Investigation into Cancer and Nutrition food frequency questionnaire. Adherence to the Mediterranean diet was appraised by the Greek Mediterranean diet score. Hazard ratios were calculated using multivariable Cox-proportional hazard models.

During follow-up (median 4.0 years), 109 all-cause including 51 cardiovascular deaths occurred. A 2-unit increase in Mediterranean diet score was associated with 37% (19%–51%) lower overall mortality. Data remained unchanged when restricted to those being on a hypoglycaemic diet or on antidiabetic drug treatment. A similar reduction was observed when cardiovascular mortality only was considered (hazard ratio = 0.66; 0.46–0.95). A Mediterranean diet-like pattern, originated from principal factor analysis, indicated a reduced risk of overall death (hazard ratio = 0.81; 0.62–1.07). The effect of Mediterranean diet score was mainly contributed by moderate alcohol drinking (14.7% in the reduction of the effect), high intake of cereals (12.2%), vegetables (5.8%) and reduced consumption of dairy and meat products (13.4% and 3.4% respectively).

The traditional Mediterranean diet was associated with reduced risk of both total and cardiovascular mortality in diabetic subjects, independently of the severity of the disease. Major contributions were offered by moderate alcohol intake, high consumption of cereals, fruits and nuts and reduced intake of dairy and meat products.

Although South Asians experience cardiovascular disease (CVD) and risk factors at an early age, the distribution of CVD risks across the socioeconomic spectrum remains unclear.

We analysed the 2011 Centre for Cardiometabolic Risk Reduction in South Asia survey data including 16,288 non-pregnant adults (≥20 years) that are representative of Chennai and Delhi, India, and Karachi, Pakistan. Socioeconomic status (SES) was defined by highest education (primary schooling, high/secondary schooling, college graduate or greater); wealth tertiles (low, middle, high household assets) and occupation (not working outside home, semi/unskilled, skilled, white-collar work). We estimated age and sex-standardized prevalence of behavioural (daily fruit/vegetables; tobacco use), weight (body mass index; waist-to-height ratio) and metabolic risk factors (diabetes, hypertension, hypercholesterolaemia; hypo-HDL; and hypertriglyceridaemia) by each SES category.

Across cities, 61.2% and 16.1% completed secondary and college educations, respectively; 52.8% reported not working, 22.9% were unskilled; 21.3% were skilled and 3.1% were white-collar workers. For behavioural risk factors, low fruit/vegetable intake, smoked and smokeless tobacco use were more prevalent in lowest education, wealthy and occupation (for men only) groups compared to higher SES counterparts, while weight-related risks (body mass index 25.0–29.9 and ≥30 kg/m²; waist-to-height ratio ≥0.5) were more common in higher educated and wealthy groups, and technical/professional men. For metabolic risks, a higher prevalence of diabetes, hypertension and dyslipidaemias was observed in more educated and affluent groups, with unclear patterns across occupation groups.

SES-CVD patterns are heterogeneous, suggesting customized interventions for different SES groups may be warranted. Different behavioural, weight, and metabolic risk factor prevalence patterns across SES indicators may signal on-going epidemiological transition in South Asia.

We have shown that a case-based training programme for general practitioners, aimed to implement evidence-based care of patients at very high risk of coronary death, was associated with decreased mortality. In the present study we assessed long-term cost-effectiveness of this programme.

Registry-based long-term cost-effectiveness analysis on a clinical trial.

Costs of the programme, health care, drugs and added years of life were included. Costs were adjusted to 2012 level and discounted by 3%. Life-years gained were estimated as the difference between the survival curves of the trial. The effectiveness measure, quality adjusted life-years (QALYs), was constructed by multiplying each life-year with a quality of life weight corresponding to the health status of that year. QALYs were also discounted by 3%. Incremental cost-effectiveness ratio (ICER) was estimated as the incremental cost per QALY gained.

The number of undiscounted life-years gained was 365 days in the intervention group as compared to control (p = 0.02). The number of discounted QALYs gained was 0.66. The net increase in total costs was estimated as 17,862 € when costs of added years of life were included and 4621 € exclusive of these costs. This implied an ICER of 27,063 € per gained QALY. This ICER is well below commonly used threshold values of the societal willingness to pay for a QALY.

The results show that a case-based training programme of general practitioners is a cost-effective way to save years of life in patients with very high risk of coronary death.

There is convincing evidence of an association between the QT interval on electrocardiograms and general mortality. However, results are inconclusive regarding the extent to which this association depends on ventricular mass and size.

Data were obtained from the prospective, population-based CARLA study, with a mean follow-up of 8.8 years, after exclusion of subjects with atrial fibrillation (919 men, 797 women aged 45–83 years remained eligible). Echocardiographic parameters were left ventricular mass index, left ventricular diastolic dimension index, diastolic interventricular septum thickness, diastolic left ventricular posterior wall and the relative left ventricular wall thickness. Heart rate-corrected QT interval (QTc) was measured with standard 12-lead electrocardiograms using the MEANS algorithm. The association between QTc and survival was modelled using Cox-regression models (crude- and covariate-adjusted). Values were standardized by dividing the QTc by the standard deviation. The association between QTc and survival was assessed in terms of tertiles of echocardiographic parameters.

In covariate-adjusted models, QTc was associated with general mortality (hazard ratio (HR): 1.19; 95% confidence interval (CI): 1.03, 1.38). Compared with higher tertiles, subjects in the lowest tertile of left ventricular mass index (HR=1.73, 95% CI: 1.26, 2.36) showed the strongest association with general mortality, which was also true for the lowest tertile of diastolic left ventricular posterior wall thickness (HR=1.49, 95% CI: 1.10, 2.02).

In the general population, the association between QTc and general mortality is strongest in subjects with low left ventricular mass index and diastolic thickness of the left ventricular posterior wall, thus the prognostic value of QTc needs to be interpreted with regard to these echocardiographic parameters.

The development and rapid dissemination of two-dimensional echocardiography led to important further advances in our understanding of athletes’ heart that has been the subject of several echocardiographic studies involving many thousands of athletes. The description of ventricular chamber enlargement, myocardial hypertrophy and atrial dilatation has led to a more comprehensive understanding of cardiac adaptation to exercise conditioning. Most recently, advanced echocardiographic techniques have begun to clarify significant functional adaptations of the myocardium that accompany previously reported morphological features of athletes’ heart. In particular, speckle-tracking echocardiography (STE) has recently provided further insights into the characterisation of myocardial properties.

STE is a relatively new, largely angle-independent, non-invasive imaging technique that allows for an objective and quantitative evaluation of global and regional myocardial function. STE has enhanced our understanding of athletes’ heart through a comprehensive characterisation of biventricular and biatrial function, providing novel insights into the investigation of physiological adaptation of the heart to exercise conditioning. These peculiarities can provide further useful data to distinguish between athletes’ heart and cardiomyopathies. Furthermore, STE represents a promising tool to address new concerns on right ventricular function and to increase understanding of the complexity of the non-systemic circulation, especially in the athletic population.

This review article analyses new data on cardiac function in athletes by novel echocardiographic techniques with a particular attention to the application of STE to characterise biventricular and biatrial function in athletes.