European Journal of Preventive Cardiology

Both exercise training and diet are recommended to prevent and control hypertension and overweight/obesity.

The purpose of this study was to determine the effectiveness of different 16-week aerobic exercise programmes with hypocaloric diet on blood pressure, body composition, cardiorespiratory fitness and pharmacological treatment.

Overweight/obese, sedentary participants (n = 175, aged 54.0 ± 8.2 years) with hypertension were randomly assigned into an attention control group (physical activity recommendations) or one of three supervised exercise groups (2 days/week: high-volume with 45 minutes of moderate-intensity continuous training (MICT), high-volume and high-intensity interval training (HIIT), alternating high and moderate intensities, and low-volume HIIT (20 minutes)). All variables were assessed pre- and post-intervention. All participants received the same hypocaloric diet.

Following the intervention, there was a significant reduction in blood pressure and body mass in all groups with no between-group differences for blood pressure. However, body mass was significantly less reduced in the attention control group compared with all exercise groups (attention control –6.6%, high-volume MICT –8.3%, high-volume HIIT –9.7%, low-volume HIIT –6.9%). HIIT groups had significantly higher cardiorespiratory fitness than high-volume MICT, but there were no significant between-HIIT differences (attention control 16.4%, high-volume MICT 23.6%, high-volume HIIT 36.7%, low-volume HIIT 30.5%). Medication was removed in 7.6% and reduced in 37.7% of the participants.

The combination of hypocaloric diet with supervised aerobic exercise 2 days/week offers an optimal non-pharmacological tool in the management of blood pressure, cardiorespiratory fitness and body composition in overweight/obese and sedentary individuals with hypertension. High-volume HIIT seems to be better for reducing body mass compared with low-volume HIIT. The exercise-induced improvement in cardiorespiratory fitness is intensity dependent with low-volume HIIT as a time-efficient method in this population.

ClinicalTrials.gov Registration: NCT02283047.

There are limited contemporary data regarding the association between improvement in cardiovascular fitness in heart failure patients who participate in a cardiac rehabilitation programme and the risk of subsequent hospitalisations.

The study population comprised 421 patients with heart failure who participated in our cardiac rehabilitation programme between the years 2009 and 2016. All were evaluated by a standard exercise stress test before initiation, and underwent a second exercise stress test on completion of 3 ± 1 months of training. Participants were dichotomised by fitness level at baseline, according to the percentage of predicted age and sex norms achieved. Each group was further divided according to its degree of functional improvement, between the baseline and the follow-up exercise stress test. Major improvement was defined as improvement above the median value in each group. The combined primary endpoint was cardiac hospitalisation or all-cause mortality.

A total of 211 (50%) patients had low baseline fitness (<73% (median)) for age and sex-predicted metabolic equivalents of task value. Compared to patients with higher fitness, those with a low baseline fitness were more commonly smokers, had diabetes and were obese (P < 0.05 for all). Multivariable Cox proportional hazard regression analysis showed that, independent of baseline capacity, an improvement of 5% of predicted fitness was associated with a corresponding 10% reduced risk of cardiac hospitalisation or all-cause mortality (P < 0.001).

In heart failure patients participating in a cardiac rehabilitation programme, improved cardiovascular fitness is associated with reduced mortality or cardiac hospitalisation risk during long-term follow-up, independent of baseline fitness.

We assessed the clinical characteristics and prognosis of chronic heart failure patients with improved ejection fraction (HFIEF) compared with persistently reduced ejection fraction (HFpREF) after evidence-based therapy.

We performed a meta-analysis including 24 eligible observational studies comparing 2663 HFIEF (≥5% left ventricular ejection fraction (LVEF) improvement) versus 8355 HFpREF patients who received recommended drug therapy, cardiac resynchronization therapy and/or intracardiac defibrillator. LVEF was assessed at baseline and reassessed after 19 ± 19 months. The primary endpoints were all-cause mortality and appropriate shocks. The mean duration of follow-up was 39 ± 12 months. Among HFIEF patients, LVEF improved 16.3 percentage points (95% confidence interval 15.9–16.6, p < 0.0001). Compared with HFpREF patients, HFIEF patients had a comparable mean age (60.9 years vs. 62.4 years, p = 0.11), were more often women (33% vs. 25%), had a higher prevalence of non-ischaemic heart failure (58% vs. 53%), less diabetes (27% vs. 28%), higher systolic blood pressure (127.5 ± 9 vs. 122 ± 12 mmHg) and lower left ventricle end-diastolic diameter (64.1 ± 3.7 vs. 67.4 ± 4.9 mmHg), all p-values < 0.05. Absolute risk of all-cause mortality was lower in HFIEF (5.8%) compared with HFpREF (17.5%) with a risk ratio of 0.34 (95% confidence interval 0.28-0.41), p < 0.001. Risk of appropriate shocks was significantly lower in HFIEF versus HFpREF (risk ratio 0.58 (95% confidence interval 0.46–0.74), p < 0.001).

In heart failure patients, we identified several baseline characteristics in favour of an improved LVEF, in response to evidence based therapy. Patients with improved LVEF had significantly lower risks of mortality and appropriate shocks compared with patients with persistently reduced LVEF.

Chronic ischaemic cardiovascular disease (CICD) remains a leading cause of morbidity and mortality worldwide. The CICD Pilot Registry enrolled 2420 patients across 10 European Society of Cardiology countries prospectively to describe characteristics, management strategies and clinical outcomes in this setting. We report here the six-month outcomes.

From the overall population, 2203 patients were analysed at six months. Fifty-eight patients (2.6%) died after inclusion; 522 patients (23.7%) experienced all-cause hospitalisation or death. The rate of prescription of angiotensin-converting enzyme inhibitors, beta-blockers and aspirin was mildly decreased at six months (all P < 0.02). Patients who experienced all-cause hospitalisation or death were older, more often had a history of non-ST-segment elevation myocardial infarction, of chronic kidney disease, peripheral revascularisation and/or chronic obstructive pulmonary disease than those without events. Independent predictors of all-cause mortality/hospitalisation were age (hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.07–1.27) per 10 years, and a history of previous peripheral revascularisation (HR 1.45, 95% CI 1.03–2.03), chronic kidney disease (HR 1.31, 95% CI 1.0–1.68) or chronic obstructive pulmonary disease (HR 1.42, 95% CI 1.06–1.91, all P < 0.05). We observed a higher rate of events in eastern, western and northern countries compared to southern countries and in cohort 1.

In this contemporary European registry of CICD patients, the rate of severe clinical outcomes at six months was high and was influenced by age, heart rate and comorbidities. The medical management of this condition remains suboptimal, emphasising the need for larger registries with long-term follow-up. Ad-hoc programmes aimed at implementing guidelines adherence and follow-up procedures are necessary, in order to improve quality of care and patient outcomes.

Obesity is an increasing public health problem and a risk factor for cardiovascular diseases. The aim of the study was to determine the main features and aetiologies in a large cohort of sudden cardiac deaths that occurred in obese subjects.

Between 1994 and 2014, 3684 consecutive cases of unexpected sudden cardiac death were referred to our cardiac pathology centre. This study was confined to young individuals (age ≤ 35 years) for whom information about body mass index was available and consisted of 1033 cases.

Two-hundred and twelve individuals (20%) were obese. In obese sudden cardiac death victims the main post-mortem findings were: normal heart (sudden arrhythmic death syndrome) (n = 108; 50%), unexplained left ventricular hypertrophy (n = 25; 12%) and critical coronary artery disease (n = 25; 12%). Less common were hypertrophic cardiomyopathy (n = 4; 2%) and arrhythmogenic right ventricular cardiomyopathy (n = 4;2%). When compared with non-obese sudden cardiac death victims, sudden arrhythmic death syndrome was less common (50% vs. 60%, P < 0.01), whereas left ventricular hypertrophy and critical coronary artery disease were more frequent (12% vs. 2%, P < 0.001 and 12% vs. 3%, P < 0.001, respectively). The prevalence of critical and non-critical coronary artery disease was significantly higher in obese individuals (23% vs. 10% in non-obese individuals, P < 0.001).

Various conditions underlie sudden cardiac death in obesity, with a prevalence of sudden arrhythmic death syndrome, left ventricular hypertrophy and coronary artery disease. The degree of left ventricular hypertrophy measured by heart weight is excessive even after correction for body size. Almost one in four young obese sudden death patients show some degree of coronary artery disease, underscoring the need for primary prevention in this particular subgroup.

Cardiac surgery is an aggressive procedure, inducing a great level of stress and disturbance to the homeostasis of the organism and underlying several postoperative complications. Surgical prehabilitation comprises pre-operative physical conditioning designed to improve the physiological and functional capacities of the individual, prepare the organism for surgical stress and reduce the risk of postoperative morbidity.

This systematic review and meta-analysis is aimed at evaluating the ability of prehabilitation to prevent post-surgical complications in cardiac patients.

We selected studies conducted among patients who were waiting for non-urgent cardiac surgical procedures, where a comparison between prehabilitation and standard treatment was made. A total of 3650 possible studies were researched, of which eight were selected for inclusion.

A reduction in the number of complications in the groups submitted to prehabilitation (odds ratio = 0.41; 95% confidence interval (CI): 0.28–0.62; p < 0.001; I²= 0%) was observed, as well as a significant increase in maximal inspiratory pressure (standard mean difference (SMD) = 0.66; 95% CI: 0.35–0.96; p < 0.001; I²= 58%), a non-significant decrease in the length of stay (SMD = –0.56; 95% CI: −1.13, 0.01; p = 0.05; I²= 93%), a non-significant increase in the distance walked by the intervention group in the six-minute walk test (SMD = 0.89; 95% CI −0.06, 1.84; p = 0.07) and a lack of effect on mechanical ventilation time (SMD = −0.03; 95% CI: −0.22, 0.16; p = 0.75; I²= 0%).

Prehabilitation reduces the number of post-surgical complications and increases maximal inspiratory pressure; a reduction in the length of stay and an improvement of functional capacities are also probable.

The purpose of this study was to determine how American College of Cardiology/American Heart Association (ACC/AHA) 2013 and European Society of Cardiology 2016 guidelines for the primary prevention of atherosclerotic cardiovascular disease (CVD) compare in reflecting the totality of accrued randomised clinical trial evidence for statin treatment at population level.

From 1997–2008, 7279 participants aged 45–75 years, free of atherosclerotic cardiovascular disease, from the population-based Rotterdam Study were included. For each participant, we compared eligibility for each one of 11 randomised clinical trials on statin use in primary prevention of CVD, with recommendations on lipid-lowering therapy from the ACC/AHA and European Society of Cardiology (ESC) guidelines. Atherosclerotic cardiovascular disease incidence and cardiovascular disease mortality rates were calculated.

The proportion of participants eligible for each trial ranged from 0.4% for ALLHAT-LLT to 30.8% for MEGA. The likelihood of being recommended for lipid-lowering treatment was lowest for those eligible for low-to-intermediate risk RCTs (HOPE-3, MEGA, and JUPITER), and highest for high-risk individuals with diabetes (MRC/BHF HPS, CARDS, and ASPEN) or elderly PROSPER. Eligibility for an increasing number of randomised clinical trials correlated with a greater likelihood of being recommended lipid-lowering treatment by either guideline (p < 0.001 for both guidelines).

Compared to RCTs done in high risk populations, randomised clinical trials targeting low-to-intermediate risk populations are less well-reflected in the ACC/AHA, and even less so in the ESC guideline recommendations. Importantly, the low-to-intermediate risk population targeted by HOPE-3, the most recent randomised clinical trial in this field, is not well-captured by the current European prevention guidelines and should be specifically considered in future iterations of the guidelines.

Prevalence of undetected heart failure in older individuals is high in the community, with patients being at increased risk of morbidity and mortality due to the chronic and progressive nature of this complex syndrome. An essential, yet currently unavailable, strategy to pre-select candidates eligible for echocardiography to confirm or exclude heart failure would identify patients earlier, enable targeted interventions and prevent disease progression. The aim of this study was therefore to develop and validate such a model that can be implemented clinically.

Individual patient data from four primary care screening studies were analysed. From 1941 participants >60 years old, 462 were diagnosed with heart failure, according to criteria of the European Society of Cardiology heart failure guidelines. Prediction models were developed in each cohort followed by cross-validation, omitting each of the four cohorts in turn. The model consisted of five independent predictors; age, history of ischaemic heart disease, exercise-related shortness of breath, body mass index and a laterally displaced/broadened apex beat, with no significant interaction with sex. The c-statistic ranged from 0.70 (95% confidence interval (CI) 0.64–0.76) to 0.82 (95% CI 0.78–0.87) at cross-validation and the calibration was reasonable with Observed/Expected ratios ranging from 0.86 to 1.15. The clinical model improved with the addition of N-terminal pro B-type natriuretic peptide with the c-statistic increasing from 0.76 (95% CI 0.70–0.81) to 0.89 (95% CI 0.86–0.92) at cross-validation.

Easily obtainable patient characteristics can select older men and women from the community who are candidates for echocardiography to confirm or refute heart failure.