European guidelines on cardiovascular disease prevention in clinical practice Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of eight societies and by invited experts)

Secondary prevention care and effect: Total and low-density lipoprotein cholesterol levels and lipid-lowering drug use in women and men after incident myocardial infarction – The Tromsø Study 1994–2016

Background: Secondary prevention guidelines after myocardial infarction (MI) are gender neutral, but underutilisation of treatment in women has been reported. Design: We investigated the change in total and low-density lipoprotein (LDL) cholesterol levels and lipid-lowering drug (LLD) use after first-ever MI in a population-based study. Methods: We followed 10,005 participants (54% women) attending the Tromsø Study 1994–1995 and 8483 participants (55% women) attending the Tromsø Study 2007–2008 for first-ever MI up to their participation in 2007–2008 and 2015–2016, respectively. We used linear and logistic regression models to investigate sex differences in change in lipid levels. Results: A total of 395 (MI cohort I) and 132 participants (MI cohort II) had a first-ever MI during 1994–2008 and 2007–2013, respectively. Mean change in total cholesterol was −2.34 mmol/L (SD 1.15) in MI cohort I, and in LDL cholesterol was −1.63 mmol/L (SD 1.12) in MI cohort II. Men had a larger decrease in lipid levels compared to women: the linear regression coefficient for change was −0.33 (95% confidence interval [CI] −0.51 to −0.14) for total cholesterol and −0.21 (95% CI −0.37 to −0.04) for LDL cholesterol, adjusted for baseline lipid value, age and cohort. Men had 73% higher odds (95% CI 1.15−2.61) of treatment target achievement compared to women, adjusted for baseline lipid value, age and cohort. LLD use was reported in 85% of women and 92% of men in MI cohort I, and 80% in women and 89% in men in MI cohort II. Conclusions: Compared to men, women had significantly less decrease in lipid levels after MI, and a smaller proportion of women achieved the treatment target.

High prevalence of poor fitness among Danish adults, especially among those with high cardiovascular mortality risk

Background

: Poor cardiorespiratory fitness (CRF) is an independent predictor of cardiovascular and all-cause mortality. Yet, our knowledge about the prevalence of poor CRF is limited. We investigated the prevalence of poor CRF among middle-aged Danish adults from a community-based health promotion program, including identification of a subgroup with high cardiovascular mortality risk. This cross-sectional study included 2,253 middle-aged adults, who completed a preventive health check including CRF testing. CRF (ml O 2 /min/kg) was assessed using the Astrand-Ryhming cycle ergometer test. High 10-year cardiovascular mortality risk as defined in the Danish 2016 guidelines was assessed using questionnaires, health examinations, and prescription data from the Danish National Prescription Registry. The prevalence of poor CRF was 51.7% (95% confidence interval [CI] 48.7-54.7) among men and 31.3% (95% CI 28.7-34.1) among women. A total of 216 (19.4%) men and 220 (19.3%) women were identified with a high 10-year cardiovascular mortality risk. Among these, 65.0% of men (95% CI 58.2-71.3) and 44.1% of women (95% CI 37.4-50.9) had poor CRF. Half of men and one third of women participating in a community-based health promotion program were identified with poor CRF. Among high-risk individuals, two thirds of men and almost every second woman had a poor CRF. Our results emphasise the need for effective public health strategies and interventions to increase CRF in the general population and among high-risk individuals in particular in order to improve public health and reduce mortality.

The Use of Computerized Decision Support Systems in Preventive Cardiology—Principal Results from the National Precard® Survey in Denmark

Background

The PRECARD® program has been used for electronic cardiovascular disease (CVD) risk assessment and management in Denmark since 1999. The use of and attitudes toward the program are reported.

Design and Methods

Using an Internet and postal survey to all Danish general practitioners, a total of 592 Danish general practitioners participated in the Internet part of the survey (response rate 19%) and 291 in the postal survey (response rate 73%).

Results

in all, 21.5% of the GPs use PRECARD®, whereas 10% are ex-users. The program is used on average once a week and 64% of the users report that PRECARD® prolongs the consultation somewhat or a lot Both users and ex-users perceive the program to have a favourable effect on the patients, and as an improvement to the dialogue between GP and patient Reasons for no longer using the program are varied, such as technical problems and lack of routine with the program.

Conclusions

Our results indicate that an electronic risk management tool like PRECARD®, is perceived as a quality improvement in preventive cardiology in primary care. However the use of the program is not optimal and it may prolong the consultation. Eur J Cardiovasc Prev Rehabil 12:52-55 © 2005 The European Society of Cardiology

Parental Age of Onset of Cardiovascular Disease as a Predictor for Offspring Age of Onset of Cardiovascular Disease

OBJECTIVE

The risk for cardiovascular disease (CVD) is higher for individuals with a first-degree relative who developed premature CVD (with a threshold at age 55 years for a male or 65 years for a female). However, little is known about the effect that each unit increase or decrease of maternal or paternal age of onset of CVD has on offspring age of onset of CVD. We hypothesized that there is an association between maternal and paternal age of onset of CVD and offspring age of onset of CVD.

METHODS

We used the Framingham Heart Study database and performed conditional imputation for CVD-censored parental age (i.e. parents that didn't experience onset of CVD) and Cox proportional regression analysis, with offspring's age of onset of CVD as the dependent variable and parental age of onset of CVD as the primary predictor. Modifiable risk factors in offspring, such as cigarette smoking, body mass index (BMI), diabetes mellitus, systolic blood pressure (SBP), high-density lipoprotein (HDL) level, and low-density lipoprotein (LDL) level, were controlled for. Separate analyses were performed for the association between maternal age of onset of CVD and offspring age of onset of CVD and the association between paternal age of onset of CVD and offspring age of onset of CVD.

RESULTS

Parental age of onset of CVD was predictive of offspring age of onset of CVD for maternal age of onset of CVD (P < .0001; N = 1401) and for paternal age of onset of CVD (P = 0.0134; N = 1221). A negative estimate of the coefficient of interest signifies that late onset of cardiovascular events in parents is protective of onset of CVD in offspring. Cigarette smoking and HDL level were important associated confounders.

CONCLUSIONS

Offspring age of onset of cardiovascular disease is significantly associated with both maternal and paternal age of onset CVD. The incorporation of the parameters, maternal or paternal age of onset of CVD, into risk estimate calculators may improve accuracy of identification of high-risk patients in clinical settings.

Relative hypocortisolism is associated with obesity and the metabolic syndrome in recurrent affective disorders

BACKGROUND

Cardiovascular disease (CVD) is one of the main causes of excess deaths in affective disorders. Affective disorders are associated with increased frequencies of CVD risk-factors such as obesity, dyslipidemia, and metabolic syndrome. Stress-induced chronic cortisol excess has been suggested to promote obesity and metabolic syndrome. Chronic stress with frequent or persisting hypothalamic-pituitary-adrenal-axis (HPA-axis) hyperactivity may, over time, lead to a state of low HPA-axis activity, also denoted hypocortisolism. A low-dose weight-adjusted dexamethasone-suppression-test (DST) is considered to be a sensitive measure of hypocortisolism.

METHODS

245 patients with recurrent depression or bipolar disorder and 258 controls participated in a low-dose DST and were also examined with regard to metabolic status.

RESULTS

Patients with hypocortisolism (low post-DST cortisol) compared with patients without hypocortisolism (normal or high post-DST cortisol) exhibited increased odds ratios (OR) for obesity (OR=4.0), overweight (OR=4.0), large waist (OR=2.7), high LDL (OR=4.2), low HDL (OR=2.4), high LDL/HDL ratio (OR=3.3), high TC/HDL ratio (OR=3.4) and metabolic syndrome (OR=2.0). A similar pattern but less pronounced was also found in the control sample.

LIMITATIONS

The cross sectional study design and absence of analyses addressing lifestyle factors.

CONCLUSIONS

Our findings suggest that a substantial portion of the metabolic disorders and cardiovascular risk factors seen in recurrent affective disorders are found among individuals exhibiting hypocortisolism. This might indicate that long-term stress is a central contributor to metabolic abnormalities and CVD mortality in recurrent affective disorders.

An evaluation of the performance of SCORE Sweden 2015 in estimating cardiovascular risk

Background

Risk prediction models for cardiovascular death are important for providing advice on lifestyle and in decision-making regarding primary preventive drug treatment. The latest Swedish version of the Systematic COronary Risk Evaluation (SCORE 2015) has yet not been tested in the population.

Objective

The objective of this study was to estimate the prevalence of high and very high risk of fatal cardiovascular disease (CVD) of the current population according to 2015 SCORE Sweden and to evaluate the predictive accuracy of the 2003 Swedish version of SCORE (2003 SCORE Sweden) and 2015 SCORE Sweden in a population with declining CVD mortality.

Methods

We estimated the high and very high risk group for cardiovascular death for individuals 40–65 years of age in the 2014 Northern Sweden MONICA population survey excluding subjects with known diabetes or previous CVD ( n = 813). Using the 1999 MONICA survey ( n = 3347) followed up for 10 years for CVD mortality, we assessed the calibration of both 2003 and 2015 SCORE Sweden.

Results

In 2014 2.6% of the population was considered at high or very high risk for fatal CVD, 95% were men and 76% were in the age group 60–65 years. Including subjects with a single markedly elevated risk factor, known diabetes or CVD, 12% of the population was at high or very high risk. During 10 years of follow-up of the 1999 cohort, 34 CVD deaths (24 men and 10 women) occurred. The 2003 SCORE overestimated the risk of death from CVD (ratio predicted/observed 2.3, P < 0.001) whereas the 2015 SCORE slightly overestimated the number of deaths (predicted/observed 1.3, P = 0.12). The 2015 SCORE predicted more accurately than the 2003 SCORE the number of deaths in the different risk and age categories.

Conclusion

The 2015 SCORE Sweden more adequately than 2003 SCORE Sweden predicts the number of deaths. In 2014, the proportion of high-risk individuals is small in northern Sweden. The main use of 2015 SCORE Sweden would therefore be as an educational tool between the physician and people without diabetes or CVD in a consultation regarding cardiovascular risk.

Lifestyle and risk factor management in people at high risk of cardiovascular disease. A report from the European Society of Cardiology European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV cross-sectional survey in 14 European regions

Background European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV in primary care was a cross-sectional survey carried out by the European Society of Cardiology, EURObservational Research Programme in 2014-2015 in 71 centres from 14 European countries. The main objective was to determine whether the 2012 Joint European Societies' guidelines on cardiovascular disease (CVD) prevention in people at high CVD risk have been followed in clinical practice. Methods Patients without a history of atherosclerotic disease started on either blood pressure and/or lipid and/or glucose-lowering treatments were identified and interviewed at least six months after the start of medication. Results Medical notes of 6700 patients were reviewed, and 4579 patients (58.7% women; mean age 58.8 (standard deviation (SD) 11.3) years) interviewed (interview rate 68.3%). Overall, 16.6% were smokers, 39.9% were overweight (body mass index (BMI)≥25 and <30 kg/m²), 43.5% obese (BMI ≥30 kg/m²) and 63.9% centrally obese (waist circumference of ≥88 cm for women, ≥102 cm for men). The medical risk factor control was very poor, with less than half (42.8%) of the patients on blood pressure lowering medication reaching the target of <140/90 mm Hg (<140/80 mm Hg in people with self-reported diabetes). Among treated dyslipidaemic patients only 32.7% attained the low-density lipoprotein (LDL)-cholesterol target of <2.5 mmol/l. Among people treated for type 2 diabetes mellitus, 58.5% achieved the glycated haemoglobin (HbA1c) target of <7.0%. Conclusion The EUROASPIRE IV survey shows that large proportions of patients at high CVD risk have unhealthy lifestyle habits and uncontrolled blood pressure, lipids and diabetes. The present data make it clear that more efforts must be taken to improve cardiovascular prevention in people at high CVD risk.

Association of Empirically Derived Dietary Patterns with Cardiovascular Risk Factors: A Comparison of PCA and RRR Methods

Introduction

Principal component analysis is used to determine dietary behaviors of a population whereas reduced rank regression is used to construct disease-related dietary patterns. This study aimed to compare both types of DP and theirs associations with cardiovascular risk factors (CVRF).

Materiel and Methods

Data were derived from the cross sectional NESCAV (Nutrition, Environment and Cardiovascular Health) study, aiming to describe the cardiovascular health of the Greater region’s population (Grand duchy of Luxembourg, Wallonia (Belgium), Lorraine (France)). 2298 individuals were included for this study and dietary intake was assessed using a 134-item food frequency questionnaire.

Results

We found that CVRF-related patterns also reflect eating behaviours of the population. Comparing concordant food groups between both dietary pattern methods, a diet high in fruits, oleaginous and dried fruits, vegetables, olive oil, fats rich in omega 6 and tea and low in fried foods, lean and fatty meat, processed meat, ready meal, soft drink and beer was associated with lower prevalence of CVRF. In the opposite, a pattern characterized by high intakes of fried foods, meat, offal, beer, wine and aperitifs and spirits, and low intakes of cereals, sugar and sweets and soft drinks was associated with higher prevalence of CVRF.

Conclusion

In sum, we found that a “Prudent” and “Animal protein and alcohol” patterns were both associated with CVRF and behaviourally meaningful. Moreover, the relationships of those dietary patterns with lifestyle characteristics support the theory that food choices are part of a larger pattern of healthy lifestyle.

A Qualitative Study of the Information Needs of Acute Myocardial Infarction Patients, and Their Preferences for Follow-up Contact After Discharge

Background: Several studies have claimed that patients have unmet information needs after discharge following acute myocardial infarction (AMI). Our overall goal is to develop a post-discharge nursing intervention program to provide patients with appropriate information and support in contexts where existing follow-up services are poorly developed.

Aims: To explore the information needs of inpatients with AMI and their preferences for follow-up contact after discharge from hospital.

Methods: Fourteen AMI patients aged 42–69 years participated in one of three focus groups, held between 3 and 5 months after their discharge.

Results and conclusions: The findings are grouped into three themes corresponding to the major topics in the interview guide: the hospital stay, coming home, and patients' follow-up preferences. The data support the findings of previous studies that there is a systemic failure to meet patients’ in-hospital and post-discharge information needs. Most importantly, our participants’ follow-up preferences favoured open telephone lines and telephone follow-up. The results of this study provide some of the knowledge that is necessary to improve patient information and support following AMI.

Single and mixed dyslipidaemia in Canadian primary care settings: findings from the Canadian primary care sentinel surveillance network database

OBJECTIVES

Dyslipidaemia is a major risk factor to cardiovascular disease (CVD)--the leading cause of death worldwide. Limited data are available about the prevalence of various dyslipidaemia in Canada. The objective of this study is to describe the prevalence of various single and mixed dyslipidaemia within the Canadian population in a primary care setting.

SETTING

A cross-sectional study, using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), was undertaken.

PARTICIPANTS

Non-pregnant adults older than 20 years were included.

OUTCOME MEASURES

Canadian guidelines were used to define dyslipidaemia. Descriptive statistics and multivariate regression analyses were conducted to compare the prevalence of single/mixed dyslipidaemia.

RESULTS

134,074 individuals with a mean age of 59.2 (55.8% women) were identified. 34.8% of this population had no lipid abnormality, whereas 35.8%, 17.3% and 3.2% had abnormalities in one, two and three lipid components, respectively. Approximately 86% of these patients did not receive any lipid-lowering medication. Among the medication users (14%), approximately 12% were on statin monotherapy. Statin users (n=16,036) had a lower rate of low-density lipoprotein dyslipidaemia compared to non-medication users (3% vs 17%), whereas the prevalence of high-density lipoprotein (HDL) (20% vs 12%) and triglycerides (TG) (12% vs 7%) dyslipidaemia were higher in statin users. Statin users had a greater prevalence of HDL, TG and combined HDL-TG dyslipidaemia compared to non-medication users (OR 1.44, 95% CI 1.36 to 153), (OR 1.18, 95% CI 1.10 to 1.27) and (OR 1.30, 95% CI 1.22 to 1.38), respectively, (all p values<0.0001).

CONCLUSIONS

One of every five patients in primary care settings in Canada is suffering from mixed dyslipidaemia. The overall prevalence of dyslipidaemia remains the same between treated and untreated groups, although the type of abnormal lipid component is considerably different. Among the CVD risk factors, obesity has the greatest effect on the prevalence of all types of dyslipidaemia.

Metabolic syndrome related to cardiovascular events in a 10-year prospective study

BACKGROUND

Metabolic syndrome (MetS) becomes a serious society health problem. The main risk factors of MetS are related to the increased risk of cardiovascular diseases, appearance of stroke, type 2 diabetes mellitus and the growing risk of mortality. MetS stimulates the appearance of early atherosclerosis, its progress and accelerates the frequency of cardiovascular complications related to atherosclerosis and diabetes mellitus.

OBJECTIVE

To evaluate the risk of cardiovascular events (myocardial infarction, stroke) among the individuals with MetS in a 10 year prospective study; to identify MetS components that determine risk and character of cardiovascular events.

METHODS

The study design was prospective. It was started in 2003 to assess the risk factors, clinical components, diagnostic criteria of MetS. At the second stage in 2013 the individuals were repeatedly invited to evaluate cardiovascular pathology that was confirmed by cardiologist and neurologist. The 45 years old and older citizens of Lithuanian district participated in the study. 1115 individuals (562 men and 553 women) were randomly selected in 2003. 538 respondents: 278 (51.70 %) men and 260 (48.30 %) women participated in the repeated study in 2013.

RESULTS

During the study myocardial infarction (MI) was confirmed to 7.43 % individuals taken part in the study, stroke-to 4.28 % individuals. The odds' ratio (OR) of MI between individuals with MetS and without MetS was 1.80 (95 % CI 1.67-1.97), p < 0.05. The OR of stroke for individuals with MetS and without MetS was 2.05 (95 % CI 1.21-2.54), p < 0.05. The OR of MI between men with abdominal obesity and identified MetS was 3.12 (95 % CI 2.77-3.53), p < 0.05. The OR of stroke between men with low level of high density lipoprotein cholesterol and identified MetS was 4.98 (95 % CI 4.40-5.65), p < 0.05. The OR of stroke between men with hypertriglyceridemia and identified MetS was 8.43 (95 % CI 7.45-9.54), p < 0.05.

CONCLUSIONS

Individuals with identified MetS have 1.80 and 2.05 times higher statistically significant probability, respectively, for MI and stroke events, than individuals without MetS. Separate components or MetS increase risk of cardiovascular events in men: abdominal obesity increases risk of MI, and low level of high density lipoprotein cholesterol and hypertriglyceridemia increase risk of stroke.

Does marital status contribute to the explanation of the hypercholesterolemia paradox in relation to long term mortality in myocardial infarction? Findings from the MONICA/KORA Myocardial Infarction Registry

OBJECTIVE

A recent study found long-term mortality after first acute myocardial infarction (AMI) to be particularly reduced among married individuals with hypercholesterolemia. This study explores, whether statin treatments during the last week prior to AMI offer an explanation to this phenomenon.

METHODS

Data were retrieved 2000-2008 from the population-based KORA myocardial infarction registry, located in Bavaria, Germany. The sample included 3162 individuals, alive 28days after first AMI, who received statins both in hospital and at discharge. Associations with long-term mortality were examined via multivariable Cox regression. Among patients with hypercholesterolemia, individuals with and without prior statin treatment were each tested against the reference group "neither (hypercholesterolemia nor statin)" and tested for interaction with "marital status".

RESULTS

Among patients with and without prior statins, hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.46-0.93 and HR 0.72, 95% CI 0.55-0.94, were observed, respectively. Mortality reductions diminished after introduction of the following interaction terms with marital status: HR 0.49, p 0.042 for patients with and HR 0.77, p 0.370, for patients without prior statins.

CONCLUSIONS

Prior statin treatments appear to be an underlying factor for long-term mortality reduction in married AMI-survivors with hypercholesterolemia. Confirmation of our results in further studies is warranted.

[A pilot study in a community pharmacy to determine the efficiency and the effectiveness of statin prescriptions]

BACKGROUND

The efficacy of statins to reduce LDL-cholesterol serum levels is high, but effectiveness is limited and costs are elevated.

OBJECTIVE

The efficiency and effectiveness of prescriptions were analyzed in a pilot study in a community pharmacy.

DESIGN

A cross-sectional study.

LOCATION

Community pharmacy. Prescriptions from two Murcian Health Service Centers in Lorca, Murcia (Spain).

PARTICIPANTS

A total of 141 patients and 32 general practitioners were included. The efficiency was analyzed in 141 and effectiveness in 110 patients.

MAIN MEASUREMENTS

Socio-demographic characteristics and clinical history of patients and information about statin type and dosage were collected. Each patient was analyzed to determine the effectiveness of treatment according to cardiovascular risk and previous LDL-cholesterol level, and efficiency comparing the statin prescribed against other statins with equal pharmacological power.

RESULTS

The most prescribed statin was atorvastatin (57.4%). Almost two-thirds (63.9%) of prescriptions were inefficient, and 17.3% were ineffective. In a bivariate analysis, patients with previous cardiovascular events (8/38; 21% vs 41/103; 39.8%. P=.040) and smokers (42/114; 36.8% vs 4/23; 17.4%, P=.047) were more likely to receive an inefficient prescription than patients with no cardiovascular events and non-smokers. In a multivariate analysis, smokers were more likely to receive an inefficient prescription than non-smokers (OR ajusted 3.76; 95% CI;1.03-0.77, P=.012).

CONCLUSIONS

Most of the participants reached therapeutic objectives for LDL-Cholesterol levels, but more than half of the prescriptions were considered inefficient.

Low-density lipoprotein cholesterol was inversely associated with 3-year all-cause mortality among Chinese oldest old: data from the Chinese Longitudinal Healthy Longevity Survey

OBJECTIVE

Low-density lipoprotein cholesterol (LDL-C) is a risk factor for survival in middle-aged individuals, but conflicting evidence exists on the relationship between LDL-C and all-cause mortality among the elderly. The goal of this study was to assess the relationship between LDL-C and all-cause mortality among Chinese oldest old (aged 80 and older) in a prospective cohort study.

METHODS

LDL-C concentration was measured at baseline and all-cause mortality was calculated over a 3-year period. Multiple statistical models were used to adjust for demographic and biological covariates.

RESULTS

During three years of follow-up, 447 of 935 participants died, and the overall all-cause mortality was 49.8%. Each 1 mmol/L increase of LDL-C concentration corresponded to a 19% decrease in 3-year all-cause mortality (hazard ratio [HR] 0.81, 95% confidence interval [CI] 0.71-0.92). The crude HR for abnormally higher LDL-C concentration (≥3.37 mmol/L) was 0.65 (0.41-1.03); and the adjusted HR was statistically significant around 0.60 (0.37-0.95) when adjusted for different sets of confounding factors. Results of sensitivity analysis also showed a significant association between higher LDL-C and lower mortality risk.

CONCLUSIONS

Among the Chinese oldest old, higher LDL-C level was associated with lower risk of all-cause mortality. Our findings suggested the necessity of re-evaluating the optimal level of LDL-C among the oldest old.

Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS)

PURPOSE

This review evaluates the current and future role of cardiopulmonary exercise testing (CPET) in the context of Enhanced Recovery After Surgery (ERAS) programs.

PRINCIPAL FINDINGS

There is substantial literature confirming the relationship between physical fitness and perioperative outcome in general. The few small studies in patients undergoing surgery within an ERAS program describe less fit individuals having a greater incidence of morbidity and mortality. There is evidence of increasing adoption of perioperative CPET, particularly in the UK. Although CPET-derived variables have been used to guide clinical decisions about choice of surgical procedure and level of perioperative care as well as to screen for uncommon comorbidities, the ability of CPET-derived variables to guide therapy and thereby improve outcome remains uncertain. Recent studies have reported a reduction in CPET-defined physical fitness following neoadjuvant therapies (chemo- and radio-therapy) prior to surgery. Preliminary data suggest that this effect may be associated with an adverse effect on clinical outcomes in less fit patients. Early reports suggest that CPET-derived variables can be used to guide the prescription of exercise training interventions and thereby improve physical fitness in patients prior to surgery (i.e., prehabilitation). The impact of such interventions on clinical outcomes remains uncertain.

CONCLUSIONS

Perioperative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of prehabilitation. These indications are potentially of importance to patients having surgery within an ERAS program, but there are currently few publications specific to CPET in the context of ERAS programs.

Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS)

PURPOSE

This review evaluates the current and future role of cardiopulmonary exercise testing (CPET) in the context of Enhanced Recovery After Surgery (ERAS) programs.

PRINCIPAL FINDINGS

There is substantial literature confirming the relationship between physical fitness and perioperative outcome in general. The few small studies in patients undergoing surgery within an ERAS program describe less fit individuals having a greater incidence of morbidity and mortality. There is evidence of increasing adoption of perioperative CPET, particularly in the UK. Although CPET-derived variables have been used to guide clinical decisions about choice of surgical procedure and level of perioperative care as well as to screen for uncommon comorbidities, the ability of CPET-derived variables to guide therapy and thereby improve outcome remains uncertain. Recent studies have reported a reduction in CPET-defined physical fitness following neoadjuvant therapies (chemo- and radio-therapy) prior to surgery. Preliminary data suggest that this effect may be associated with an adverse effect on clinical outcomes in less fit patients. Early reports suggest that CPET-derived variables can be used to guide the prescription of exercise training interventions and thereby improve physical fitness in patients prior to surgery (i.e., prehabilitation). The impact of such interventions on clinical outcomes remains uncertain.

CONCLUSIONS

Perioperative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of prehabilitation. These indications are potentially of importance to patients having surgery within an ERAS program, but there are currently few publications specific to CPET in the context of ERAS programs.

New risk markers for cardiovascular prevention

The importance of total cardiovascular (CV) risk estimation before management decisions are taken is well established. Models have been developed that allow physicians to stratify the asymptomatic population in subgroups at low, moderate, high, and very high total CV risk. Most models are based on classical CV risk factors: age, gender, smoking, blood pressure, and lipid levels. The impact of additional risk factors is discussed here, looking separately at the predictive increments of novel biomarkers and of indicators of subclinical atherosclerotic disease. The contribution of biomarkers to the total CV risk estimation is generally modest, and their usage should be limited to subjects at intermediate total CV risk. Detection of subclinical vascular damage may improve total CV risk estimation in asymptomatic subjects who are close to a threshold that could affect management decisions and in whom the chances of re-classification in a different risk category are great. There is, however, an urgent need for trials in which the value of using total CV risk estimation models is tested.

The incidence of cardiovascular events after hospitalization due to CAP and their association with different inflammatory markers

Background

Late prognosis of Community-Acquired Pneumonia (CAP) patients is related to cardiovascular events. Persistence of inflammation-related markers, defined by high circulatory levels of interleukin 6 and 10 (IL-6/IL-10), is associated with a higher post-event mortality rate for CAP patients. However, association between these markers and other components of the immune response, and the risk of cardiovascular events, has not been adequately explored. The main objectives of this study are: 1) to quantify the incidence of cardiovascular disease, in the year post-dating their hospital admittance due to CAP and, 2) to describe the distribution patterns of a wide spectrum of inflammatory markers upon admittance to and release from hospital, and to determine their relationship with the incidence of cardiovascular disease.

Methods/design

A cohort prospective study. All patients diagnosed and hospitalized with CAP will be candidates for inclusion. The study will take place in the Universitary Hospital La Princesa, Spain, during two years. Two samples of blood will be taken from each patient: the first upon admittance and the second one prior to release, in order to analyse various immune agents. The main determinants are: pro-adrenomedullin, copeptin, IL-1, IL-6, TNF-α, IL-17, IFN-γ, IL-10 and TGF-β, E-Selectin, ICAM-1, VCAM-1 and subpopulations of peripheral T lymphocytes (T regulator, Th1 and Th17), together with other clinical and analytical variables. Follow up will start at admittance and finish a year after discharge, registering incidence of death and cardiovascular events. The main objective is to establish the predictive power of different inflammatory markers in the prognosis of CAP, in the short and long term, and their relationship with cardiovascular disease.

Discussion

The level of some inflammatory markers (IL-6/IL-10) has been proposed as a means to differentiate the degree of severity of CAP, but their association with cardiovascular risk is not well established. In this study we aim to define new inflammatory markers associated with cardiovascular disease that could be helpful for the prognosis of CAP patients, by describing the distribution of a wide spectrum of inflammatory mediators and analyzing their association with the incidence of cardiovascular disease and mortality one year after release from hospital.

Contribution of depression and anxiety to impaired quality of life in survivors of myocardial infarction

OBJECTIVE

To quantify the adverse influence of depression and anxiety assessed at the time of myocardial infarction, on the quality of life 5 years after the infarction.

METHODS

The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI) were completed in a group of 196 patients admitted in the hospital following non-fatal myocardial infarction, and the SF-12 quality of life questionnaire was administered during the 5- year follow-up.

RESULTS

Regression analysis showed a strong association between baseline depression and QoL in both the physical and mental domains; the higher the depression scores, the poorer the QoL. However, anxiety present at the time of myocardial infarction did not predict later QoL.

CONCLUSIONS

Depression but not anxiety following MI predicts longer-term quality of life in myocardial infarction survivors.

Revising the fasting glucose threshold for detection of cardiovascular risk factors: analysing two representative population-based studies of more than 50,000 Iranians in 3 years: The National Survey of Risk Factors for Non-Communicable Diseases of Iran

OBJECTIVES

To study the prevalence of cardiovascular risk factors across different glycaemia strata and to assess the optimal cut-off value of fasting plasma glucose (FPG) to identify the constellation of cardiovascular risk factors.

METHODS

Data of the National Survey of Risk Factors for Non-Communicable Diseases of Iran (SURFNCD 2005-2007) were analysed. Prevalence rates of obesity, central obesity, hypertension and hypercholesterolemia of individuals with Impaired Fasting Glucose (IFG) were compared with those of individuals with normal fasting glycaemia and newly diagnosed diabetes. Optimal FPG cut-point to diagnose subjects with cardiovascular risk factors was assessed.

RESULTS

Prevalence of each and combinations of cardiovascular risk factors were higher among subjects with IFG compared to those with normal fasting glycaemia. The areas under the curve (AUC) for detecting cardiovascular risk were highest at FPG values of 90 mg/dL. FPG of 90 mg/dL was the optimal cut-off and, in comparison to 100 mg/dL, corresponds to correct detection of 26-29% of obese, 22-27% of centrally obese, 26-29% of hypertensive and 25-30% of hypercholesterolemic individuals.

CONCLUSIONS

IFG and even lower levels of FPG are associated with high prevalence of cardiovascular risk factors in Iranian adults. This study suggests the FPG cut-off to be revised at 90 mg/dL to identify people with increased cardiovascular risk.

Prevalence and determinants of electrocardiographic abnormalities in African Americans with type 2 diabetes

Background: Electrocardiographic (ECG) abnormalities are independently associated with poor outcomes in the general population. Their prevalence and determinants were assessed in the understudied African American population with type 2 diabetes.

Methods: Standard 12-lead ECGs were digitally recorded in 635 unrelated African American-Diabetes Heart Study (AA-DHS) participants, automatically processed at a central lab, read, and coded using standard Minnesota ECG Classification. Age- and sex-specific prevalence rates of ECG abnormalities were calculated and logistic regression models were fitted to examine cross-sectional associations between participant characteristics and ECG abnormalities.

Results: Participants were 56% women with a mean age of 56 years; 60% had at least one minor or major ECG abnormality [23% ⩾1 major (or major plus minor), and 37% ⩾1 minor (with no major)]. Men had a higher prevalence of ⩾1 minor or major ECG abnormality (66.1% men vs. 55.6% women, p = 0.0089). In univariate analysis, age, past history of cardiovascular disease, diabetes duration, systolic blood pressure, sex and statin use were associated with the presence of any (major or minor) ECG abnormalities. In a multivariate model including variables, female sex (OR [95% CI] 0.79 [0.67, 0.93]), statin use (0.79 [0.67, 0.93]) and diabetes duration (1.03 [1.0, 1.05]) remained statistically significant.

Conclusions: Nearly three out of five African Americans with diabetes had at least one ECG abnormality. Female sex and statin use were significantly associated with lower odds of any ECG abnormality and diabetes duration was significantly associated with higher odds of any ECG abnormality in the multivariable model.

Impact of health counselling on cardiovascular disease risk in middle aged men: influence of socioeconomic status

BACKGROUND

The inverse association between socioeconomic status and cardiovascular disease is well documented. We examined whether the impact of health counselling on cardiovascular risk factors in middle-aged men differed according to socioeconomic status.

METHODS

We used data from a community based study assessing the risk for cardiovascular disease among middle-aged men in Helsinki, Finland. Traditional cardiovascular disease risk factors were measured and cardiovascular disease risk was assessed by a modified risk tool used in the North Karelia project (CVD Risk Score). Those men with increased risk for cardiovascular disease at their baseline visit in 2006 received lifestyle counselling. After two years these high-risk men were invited to a follow-up visit. The same measurements and risk assessments were repeated.

RESULTS

Based on the CVD Risk Score there were significant differences between the groups at baseline (p = 0.001) and at follow-up (p<0.001) with the highest scores in the lowest educational group. There were no significant differences in traditional cardiovascular risk factors according to educational attainment between groups either at baseline or at follow-up. Baseline lifestyle characteristics differed between the groups regarding use of soft fat (p = 0.019). All groups responded positively to lifestyle counselling.

CONCLUSIONS

The present study showed that lifestyle counselling is feasible in high-risk middle-aged men and lifestyle intervention works in all educational groups. Interestingly the traditional risk factors did not show improvement, but the risk score improved. From a practical point of view our findings stress the importance of using risk score calculators in health counselling instead of looking at individual cardiovascular disease risk factors.

Target-attainment rates of low-density lipoprotein cholesterol using lipid-lowering drugs one year after acute myocardial infarction in sweden

The objective of this prospective cohort study was to describe real-life use of lipid-lowering drugs and low-density lipoprotein cholesterol (LDL-C) target-attainment rates 1 year after acute myocardial infarction (AMI). LDL-C was recorded at hospital admission for AMI and at follow-up at 2 and 12 months after AMI in 17,236 patients in the Swedish heart registry, SWEDEHEART, from 2004 through 2009. Lipid-lowering treatments were identified using the Swedish Prescribed Drug Register. More than 90% of patients received statins after AMI. Simvastatin ≤40 mg was used by 80% of patients at discharge and at 2 months and 68% at 1 year after AMI. Intensive statin therapy (LDL-C-lowering capacity >40%) was prescribed for 8.4%, 11.9%, and 12.2% at these time points, and combinations of statin/ezetimibe for 1.1%, 2.8%, and 5.0%, respectively. The LDL-C target of <2.5 mmol/L (97 mg/dl) was achieved in 74.5% of patients at 2 months and 72.3% at 12 months after AMI. Treatment was intensified for only 21.3% of patients with LDL-C above target at 2 months. In multivariate analysis, higher LDL-C levels at admission and at 2 months correlated to increased risk for under treatment at 12 months after AMI. In conclusion, statin treatment after AMI in Sweden has become standard, but titration to reach recommended LDL-C levels is still suboptimal. Strategies to further improve implementation of guidelines are needed.

Prevalence dependent calibration of a predictive model for nasal carriage of methicillin-resistant Staphylococcus aureus

BACKGROUND

Published models predicting nasal colonization with Methicillin-resistant Staphylococcus aureus among hospital admissions predominantly focus on separation of carriers from non-carriers and are frequently evaluated using measures of discrimination. In contrast, accurate estimation of carriage probability, which may inform decisions regarding treatment and infection control, is rarely assessed. Furthermore, no published models adjust for MRSA prevalence.

METHODS

Using logistic regression, a scoring system (values from 0 to 200) predicting nasal carriage of MRSA was created using a derivation cohort of 3091 individuals admitted to a European tertiary referral center between July 2007 and March 2008. The expected positive predictive value of a rapid diagnostic test (GeneOhm, Becton & Dickinson Co.) was modeled using non-linear regression according to score. Models were validated on a second cohort from the same hospital consisting of 2043 patients admitted between August 2008 and January 2012. Our suggested correction score for prevalence was proportional to the log-transformed odds ratio between cohorts. Calibration before and after correction, i.e. accurate classification into arbitrary strata, was assessed with the Hosmer-Lemeshow-Test.

RESULTS

Treating culture as reference, the rapid diagnostic test had positive predictive values of 64.8% and 54.0% in derivation and internal validation corhorts with prevalences of 2.3% and 1.7%, respectively. In addition to low prevalence, low positive predictive values were due to high proportion (> 66%) of mecA-negative Staphylococcus aureus among false positive results. Age, nursing home residence, admission through the medical emergency department, and ICD-10-GM admission diagnoses starting with "A" or "J" were associated with MRSA carriage and were thus included in the scoring system, which showed good calibration in predicting probability of carriage and the rapid diagnostic test's expected positive predictive value. Calibration for both probability of carriage and expected positive predictive value in the internal validation cohort was improved by applying the correction score.

CONCLUSIONS

Given a set of patient parameters, the presented models accurately predict a) probability of nasal carriage of MRSA and b) a rapid diagnostic test's expected positive predictive value. While the former can inform decisions regarding empiric antibiotic treatment and infection control, the latter can influence choice of screening method.

The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology

The environment in which the field of cardiology finds itself has been rapidly changing. This supplement, an expansion of a report created for the Board of Trustees, is intended to provide a timely snapshot of the socio-economic, political, and scientific aspects of this environment as it applies to practice both in the United States and internationally. This publication should assist healthcare professionals looking for the most recent statistics on cardiovascular disease and the risk factors that contribute to it, drug and device trends affecting the industry, and how the practice of cardiology is changing in the United States.

Treatment strategies for chronic stable angina

INTRODUCTION

Stable angina pectoris - generally the expression of an imbalance between myocardial oxygen demand and supply - is often the first manifestation of ischemic heart disease. The effective management of this highly prevalent condition is largely dependent on the identification of the prevailing pathogenic mechanism, the implementation of lifestyle changes and the appropriate use of pharmacological agents and revascularization techniques. There is abundant literature on management of chronic stable angina, but publications are generally devoted to focused areas. There is a need for a comprehensive review that addresses both the different types of angina and their pathogenic mechanisms, as well as rational approaches to patient management.

AREAS COVERED

This paper reviews the pathogenesis and pathophysiological mechanisms of myocardial ischemia, along with its consequences and current treatment options. Relevant papers in the English literature were identified via PubMed, using the following keywords relating to chronic stable angina: ischemic heart disease, coronary artery disease and antianginal therapy.

EXPERT OPINION

The treatment of chronic stable angina has improved in recent years as a result of a better understanding of its pathogenic mechanisms, the implementation of lifestyle changes and aggressive management of risk factors, as well as pharmacological advances and better revascularization techniques. Understanding the pathogenesis of the disease is important to identify effective treatment strategies. A careful clinical history, the implementation of appropriate diagnostic tests and a rational use of antianginal drugs and revascularization protocols often ensure the successful control of the patient's symptoms.

Coronary artery calcification by computed tomography in epidemiologic research and cardiovascular disease prevention

Both American and European guidelines recommend coronary artery calcification (CAC) as a tool for screening asymptomatic individuals at intermediate risk for coronary heart disease (CHD). These recommendations are based on epidemiologic studies mostly in the United States. We review (1) the use of CAC in primary prevention of CHD in the United States, (2) epidemiologic studies of CAC in asymptomatic adults outside of the United States, and (3) international epidemiologic studies of CAC. This review will not consider clinical studies of CAC among patients or symptomatic individuals. US studies have shown that CAC is a strong independent predictor of CHD in both sexes among middle-aged and old age groups, various ethnic groups, and individuals with and without diabetes and that CAC plays an important role in reclassifying individuals from intermediate to high risk. Studies in Europe support these conclusions. The Electron-Beam Tomography, Risk Factor Assessment Among Japanese and US Men in the Post-World-War-II birth cohort (ERA JUMP) Study is the first international study to compare subclinical atherosclerosis, including CAC among Japanese, Japanese Americans, Koreans, and whites. It showed that as compared with whites, Japanese had lower levels of atherosclerosis, whereas Japanese Americans had similar or higher levels. CAC is being increasingly used as a screening tool for asymptomatic individuals in Europe and the United States. CAC is a powerful research tool, because it enables us to describe differences in atherosclerotic burden across populations. Such research could identify factors responsible for differences among populations, which may improve CHD prevention.

Randomized controlled trial on the long-term efficacy of a multifaceted, interdisciplinary lifestyle intervention in reducing cardiovascular risk and improving lifestyle in patients at risk of cardiovascular disease

The objective of the study was to evaluate the efficacy of an interdisciplinary intervention known as Educoeur in reducing cardiovascular risk and improving health behaviors in people without evidence of cardiovascular disease and to compare the Educoeur program to interventions in a specialized clinic and in usual care family practice. In a parallel, randomized, controlled trial of 185 adults with at least two modifiable cardiovascular risk factors, patients were randomly assigned to either Educoeur, specialized clinic or usual care. Cardiovascular risk, biological and lifestyle measures were assessed at baseline and at 2 years. In Educoeur, measurements were also taken before and after the lifestyle group treatment program. In 12 weeks, patients in Educoeur significantly lowered their cardiovascular risk, weight, body mass index, waist circumference, systolic blood pressure, kilocalories intake and improved their VO2 Max and mental health. Changes remained significant at 2 years. Between group comparisons at 2 years demonstrated that Educoeur was significantly better in reducing cardiovascular risk than interventions in usual care. Together, these results highlight the importance of providing interdisciplinary programs that optimize cardiovascular risk reduction and promote active lifestyles in patients at risk of cardiovascular disease.

An international randomised placebo-controlled trial of a four-component combination pill ("polypill") in people with raised cardiovascular risk

BACKGROUND

There has been widespread interest in the potential of combination cardiovascular medications containing aspirin and agents to lower blood pressure and cholesterol ('polypills') to reduce cardiovascular disease. However, no reliable placebo-controlled data are available on both efficacy and tolerability.

METHODS

We conducted a randomised, double-blind placebo-controlled trial of a polypill (containing aspirin 75 mg, lisinopril 10 mg, hydrochlorothiazide 12.5 mg and simvastatin 20 mg) in 378 individuals without an indication for any component of the polypill, but who had an estimated 5-year cardiovascular disease risk over 7.5%. The primary outcomes were systolic blood pressure (SBP), LDL-cholesterol and tolerability (proportion discontinued randomised therapy) at 12 weeks follow-up.

FINDINGS

At baseline, mean BP was 134/81 mmHg and mean LDL-cholesterol was 3.7 mmol/L. Over 12 weeks, polypill treatment reduced SBP by 9.9 (95% CI: 7.7 to 12.1) mmHg and LDL-cholesterol by 0.8 (95% CI 0.6 to 0.9) mmol/L. The discontinuation rates in the polypill group compared to placebo were 23% vs 18% (RR 1.33, 95% CI 0.89 to 2.00, p = 0.2). There was an excess of side effects known to the component medicines (58% vs 42%, p = 0.001), which was mostly apparent within a few weeks, and usually did not warrant cessation of trial treatment.

CONCLUSIONS

This polypill achieved sizeable reductions in SBP and LDL-cholesterol but caused side effects in about 1 in 6 people. The halving in predicted cardiovascular risk is moderately lower than previous estimates and the side effect rate is moderately higher. Nonetheless, substantial net benefits would be expected among patients at high risk.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12607000099426.