Adherence to the Mediterranean diet and 20-year incidence of hypertension: the ATTICA prospective epidemiological study (2002-2022)

BACKGROUND/OBJECTIVES

Dietary habits are a significant predictor of hypertension (HTN). We aimed to evaluate the long-term association between adherence to the Mediterranean diet and HTN incidence.

SUBJECTS/METHODS

This was a prospective study among 1415 non-hypertensive adults (44% men, age: 41 ± 13 years) followed up for 20 years. Anthropometric, lifestyle, and clinical parameters were evaluated at baseline. Adherence to the Mediterranean diet was evaluated both at baseline and 10 years through the MedDietScore (range: 0-55, higher values indicate greater adherence).

RESULTS

At the 20-year follow-up, 314 new HTN cases were recorded. HTN incidence was 35.5%, 22.5%, and 8.7% in the lowest, middle, and upper tertile of baseline MedDietScore, respectively (p < 0.001). For each 1-point increase in baseline MedDietScore, the 20-year HTN risk decreased by 7% [relative risk (RR): 0.925, 95% confidence interval (CI): 0.906, 0.943], and this effect remained significant after adjustment for age, sex, and baseline lifestyle and clinical confounders, i.e., body mass index, physical activity, smoking, systolic and diastolic blood pressure, family history of HTN, and presence of hypercholesterolemia and diabetes mellitus (RR: 0.973, 95%CI: 0.949, 0.997). In a similar multiadjusted model, compared to subjects who were consistently away from the Mediterranean diet (in the lowest MedDietScore tertile both at baseline and 10 years), only those who were consistently close (in the middle and upper MedDietScore tertiles both at baseline and 10 years) exhibited a 47% lower 20-year HTN risk.

CONCLUSION

A high adherence to the Mediterranean diet, particularly when longitudinally sustained, is associated with lower incidence of HTN.

Long-Term Adherence to the Mediterranean Diet Reduces 20-Year Diabetes Incidence: The ATTICA Cohort Study (2002-2022)

This study aimed to evaluate the association between adherence to the Mediterranean diet and the 20-year incidence of type II diabetes mellitus (T2DM) among adults from the ATTICA study. This study involved a prospective cohort of 3042 men and women recruited at baseline from the Attica region in Greece. Sociodemographic, anthropometric, lifestyle, and clinical characteristics were evaluated at baseline and follow-up examinations; adherence to the Mediterranean diet was assessed through the MedDietScore (range 0-55); four Mediterranean diet trajectories were identified (i.e., increasing, decreasing, and sustained high and sustained low adherence levels). For the present analysis, data from 2000 individuals with complete information were used (age 43 ± 13 years; 49% men). Over the 20-year period, 26.3% (95%CI 24.4%, 28.3%) of participants developed T2DM; men exhibited a 1.5-times higher incidence compared to women (p < 0.001). Individuals consistently close to the Mediterranean diet throughout the studied period had an improved glycemic and lipidemic profile (at baseline and at 10-y follow-up) (all p-values < 0.001) and showed a 21% reduction in their 20-year risk of developing T2DM compared to those who were consistently away (RR = 0.79, 95%CI 0.47, 0.86). A long-term adherence to the Mediterranean diet is protective against the onset of T2DM and, therefore, could be incorporated in public health actions for the prevention of the disease.

Non-invasive tools for liver steatosis and steatohepatitis predict incidence of diabetes, cardiovascular disease and mortality 20 years later: The ATTICA cohort study (2002-2022)

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) or, as recently renamed, metabolic dysfunction-associated steatotic liver disease (MASLD), has common metabolic pathways with diabetes and cardiovascular disease (CVD). Non-invasive tools (NITs) for liver steatosis and steatohepatitis (MASH) were studied as potential predictors of diabetes, cardiovascular disease (CVD) and mortality over a 20-year period.

METHODS

In 2001-02, 3042 individuals from the Attica region of Greece were recruited randomly, and were stratified by subgroups of sex, age and region to reflect the general urban population in Athens, Greece. Validated NITs for hepatic steatosis (Hepatic Steatosis Index (HIS), Fatty Liver Index (FLI), Lipid Accumulation Product (LAP), NAFLD liver fat score (NAFLD-LFS)) and steatohepatitis (Index of non-alcoholic steatohepatitis (ION), aminotransferase-creatinine-clearance non-alcoholic steatohepatitis (acNASH)) were calculated. Incidence of diabetes, CVD and mortality were recorded 5, 10 and 20 years later.

RESULTS

Within a 20-year observation period, the diabetes and CVD incidence was 26.3% and 36.1%, respectively. All hepatic steatosis and steatohepatitis NITs were independently associated with diabetes incidence. ION and acNASH presented independent association with CVD incidence [(Hazard Ratio (HR)per 1 standard deviation (SD) = 1.33, 95% Confidence Interval (95% CI) (1.07, 1.99)) and (HRper 1 SD = 1.77, 95% CI (1.05, 2.59)), respectively]. NAFLD-LFS which is a steatosis NIT indicating features of steatohepatitis, was linked with increased CVD mortality (HRper 1 SD = 1.35, 95% CI (1.00, 2.30)) and all-cause mortality (HRper 1 SD = 1.43, 95% CI (1.08, 2.01)). Overall, steatohepatitis NITs (i.e., ION and acNASH) presented stronger associations with the outcomes of interest compared with steatosis NITs. Clinically important trends were observed in relation to diabetes and CVD incidence progressively over time, i.e. 5, 10 and 20 years after baseline.

CONCLUSIONS

Easily applicable and low-cost NITs representing steatohepatitis may be early predictors of diabetes and CVD onset. More importantly, these NITs increased the attributable risk conveyed by conventional CVD risk factors by 10%. Thus, their potential inclusion in clinical practice and guidelines should be studied further.

Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023

Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.

Cognitive vulnerability, anxiety, and physical well-being in relation to 10-year cardiovascular disease risk: The ATTICA epidemiological study

This study aimed to evaluate the association between irrational beliefs and the 10-year cardiovascular disease (CVD) incidence among apparently healthy adults. The ATTICA study is a population-based, prospective cohort (2002-2012) consisting of 853 participants without evidence of CVD (453 men and 400 women) who underwent psychological evaluations. Participants completed the Irrational Beliefs Inventory (IBI, range 0-88), a self-reported measure consistent with the Ellis model of psychological disturbance. We conducted a factor analysis to develop irrational beliefs factors to evaluate the association between subcategories of irrational beliefs and CVD incidence. Demographic characteristics, detailed medical history, other psychological factors, and dietary and other lifestyle habits were also evaluated. The incidence of CVD was defined according to the International Coding Diseases (ICD)-10 criteria. The identified dominant irrational beliefs factor, "cognitive vulnerability to anxiety," consisted of demandingness, perfectionism, emotional irresponsibility, anxious overconcern, dependence on others, and overconcern for the welfare of others, was strongly associated with an increased 10-year CVD risk. Nested multi-adjusted regression analysis revealed that anxiety, as well as negative physical well-being, mediated this relationship, and subset of irrational beliefs predicted CVD risk directly and indirectly through anxiety and negative physical well-being. These findings further map the path through which irrational beliefs can contribute to CVDs and provide insights in favor of preventive healthcare.

Food Compass Score predicts incident cardiovascular disease: The ATTICA cohort study (2002-2022)

BACKGROUND

The Food Compass Score (FCS) is a novel nutrient profiling system, which evaluates food and diet quality. The present study aimed to prospectively assess the relationship of FCS with short-term (10 years) and long-term (20 years) cardiovascular disease (CVD) incidence and to explore whether this relationship is modified by long-term adherence to a Mediterranean type diet (MTD).

METHODS

Volunteers of the ATTICA cohort study, with complete data for the calculation of FCS and incident CVD were included (n = 759). Development of CVD was determined at 10 and 20 years after baseline. Dietary intake was assessed through a validated food frequency questionnaire. The FCS was calculated for each participant based on the published algorithm. Long-term adherence to a MTD was evaluated through MedDietScore.

RESULTS

FCS was inversely associated with CVD incidence (hazard ratio [HR] for 20-year follow-up = 0.97, 95% confidence interval [CI] = 0.95-0.99; HR for 10-year follow-up = 0.98, 95% CI = 0.96-1.01) in the total sample, as well as in those with a high baseline adherence to a MTD (HR for 20-year follow-up = 0.96, 95% CI = 0.93-0.99; HR for 10-year follow-up = 0.98, 95% CI = 0.95-1.02). FCS was also inversely associated with CVD risk in those who went away from the MTD (HR = 0.97, 95% CI = 0.96-0.99).

CONCLUSIONS

FCS, a novel tool for assessing overall diet quality, was also found to be useful in identifying potential CVD candidates in a long-term period, even in populations with good background dietary habits, such as those following a MTD.

Mediterranean diet trajectories and 20-year incidence of cardiovascular disease: The ATTICA cohort study (2002-2022)

BACKGROUND AND AIMS

Only few studies have assessed longitudinal dietary trends in relation to cardiovascular disease (CVD) risk. We aimed to evaluate the association between adherence to the Mediterranean diet, both baseline and longitudinal, and 20-year CVD incidence.

METHODS AND RESULTS

This was a prospective study among 1988 Greek adults (50% men, age: 45 ± 14years). Adherence to the Mediterranean diet was evaluated at baseline and 10 years through the MedDietScore, based on which longitudinal Mediterranean diet trajectories were identified. CVD incidence was recorded at 20 years. Each one-unit increase in baseline MedDietScore was associated with an 8% reduction in 20-year CVD incidence. Compared to subjects in the lowest tertile of baseline MedDietScore, those in the highest exhibited a 44% lower 20-year CVD risk (relative risk: 0.56, 95% confidence interval: 0.32, 0.97) adjusted for age, sex, baseline body mass index, smoking, physical activity, presence of hypercholesterolemia, hypertension and diabetes mellitus, and family history of CVD; further adjustment for high-sensitivity C-reactive protein, uric acid and estimated glomerular filtration rate attenuated this association. Results were similar in models adjusted for longitudinal changes in body weight, physical activity and smoking, and 10-year medical status. Mediterranean diet trajectory analysis revealed that 24.7%, 8.6%, 45.8% and 20.9% of participants longitudinally sustained a low adherence, moved closer, moved away or sustained a high adherence, respectively; among those, the corresponding CVD incidence was 63.3%, 65.5%, 28.1% and 9.4% (p-value<0.001).

CONCLUSION

The Mediterranean diet offers long-term protection against CVD, part of which is mediated by inflammation, uricemia and renal function.

Evaluation of the usability of the digital platform navigator KardioUp for the journey of patients with chronic heart failure

INTRODUCTION

Digital health interventions constitute a promising supplementary approach for further improvement of the quality and experience of cardiovascular care in patients with heart failure (HF). However, concerns about privacy, security, and quality may arise additionally to lack of personal motivation and accessibility to digital resources. Therefore, the proposed system aims to implement innovative technological trends in HF monitoring by recording clinical, biological, and biometric parameters.

METHODS

The availability and feasibility of the digital platform KardioUp was evaluated in a group of 25 patients with HF (mean age: 60 years) and 15 medical doctors (mean age 40 years) in two University Cardiology Clinics of the country. Connectivity of platform with the application and Android devices, use of alerts in clinical measurements, educational material provided, and total satisfaction by both patients and physicians were also evaluated. Patients with health barriers to understand the use of digital platforms or low eHealth ≤8 (digital unawareness) were excluded.

RESULTS

All patients answered that the upload of measurements of blood pressure, blood glucose, and weight into the application were feasible. Patients mean eHealth score was 32,7. Additionally, the graphics of the application were friendly and educational material was also easily approached. Patients felt that this application can enable real patient-empowerment and self-management support.

CONCLUSIONS

KardioUp was evaluated as a non-pharmacological intervention that could promote autonomous living of patients. Thus, possible alterations in daily activities and other parameters will be continuously evaluated providing metrics' monitoring on patients' performance, adherence to their treatment plan, avoidance of rehospitalizations, and overall health metrics.

Increased body weight and central adiposity markers are positively associated with the 20-year incidence of cardiovascular disease: The ATTICA epidemiological study (2002-2022)

Increased adiposity predisposes to cardiovascular disease (CVD). We hypothesized that the presence of obesity would be positively associated with CVD risk, and that the co-presence of central obesity would modify/enhance this association. This was a prospective study (2002-2022) among 1845 Greek adults (mean age, 44.8 ± 13.5 years; men, 49.8%). At baseline, the presence of overweight/obesity was assessed via body mass index (BMI), whereas central obesity was defined as waist circumference ≥102/88 cm, waist-to-hip-ratio ≥0.95/0.80, or waist-to-height-ratio ≥0.50 in men/women. BMI was reevaluated at 10 years and longitudinal BMI trajectories (2002-2012) were identified. CVD incidence was recorded at 20 years (ratio of new cases to the number of participants assessed). Compared with participants with normal weight at baseline, those with obesity exhibited a 27% higher 20-year CVD risk after adjustment for age, sex, lifestyle habits, and medical status (hazard ratio, 1.271; 95% confidence interval, 1.012-1.597). In similar multiadjusted models, compared with participants who were always non-overweight/obese, those who were always overweight/obese exhibited a 40% higher 20-year CVD risk (hazard ratio, 1.403; 95% confidence interval, 1.018-1.936). Additional control for high-sensitivity C-reactive protein attenuated the associations. In the combined baseline body weight classification analysis, CVD incidence was the lowest in participants with normal weight without central obesity, moderate in those with overweight/obesity without central obesity, and highest in those with normal weight and central obesity and overweight/obesity and central obesity (P < .001). Obesity leads to increased CVD risk, partly mediated by inflammation. The combination of BMI with simple measures of abdominal adiposity is superior for CVD risk screening.

Mediterranean Diet and Cardiovascular Disease: The Moderating Role of Adequate Sleep-Results from the ATTICA Cohort Study (2002-2022)

The relationship between diet, sleep duration and cardiovascular disease (CVD) has not been well understood. The aim of the present study was to test the potential modifying role of sleep duration in the association between adherence to the Mediterranean-type diet (MD) and CVD risk. The study consisted of n = 313 initially free-of-CVD adults, from the ATTICA cohort study (2002-2022), with available information on sleep habits. Sleep habits were categorized as inadequate and adequate sleep duration (< or ≥7 h/day, respectively). In multi-adjusted analysis, MD adherence was inversely associated with CVD risk [Hazard Ratio-HR per 1/55 in MedDietScore: 0.80, 95% Confidence Interval-CI: 0.65, 0.98]. A significant interaction between sleep duration and MedDietScore was observed (p < 0.001). In subgroup analysis, the protective association between MD adherence and CVD risk was found only in participants who slept adequately, i.e., >7 h/day [HR:0.80, 95%CI: 0.65, 0.98]. Those who had a high adherence to the MD along with adequate sleep habits, had a 70% reduced 20-year CVD risk [HR:0.30, 95%CI: 0.11, 0.80], compared to those who had a low MD adherence and inadequate sleep habits. Sleep duration should be a part of an individual's lifestyle, together with dietary and other habits, to effectively evaluate CVD risk for future events.

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Associations between meat type consumption pattern and incident cardiovascular disease: The ATTICA epidemiological cohort study (2002-2022)

BACKGROUND

Meat consumption has shown from detrimental to beneficial effects against cardiovascular disease (CVD) incidence, mainly depending on the type of meat studied (i.e., red/white, processed/unprocessed) and quantity consumed.

OBJECTIVE

To examine the associations between meat type consumption patterns and incident CVD among apparently healthy adults.

DESIGN

ATTICA study was conducted in the greater metropolitan Athens area, Greece, during 2001-2002 studying adults free-of-CVD at baseline. Twenty-year follow-up was performed in n = 1988 participants (n = 718 incident cases). Meat consumption during the follow-up period was categorized as: never/rare meat consumption (i.e., <1 time/week), mostly red meat (i.e., compared to other types of meat or processed meat), mostly white meat, and mostly processed meat products (e.g., bacon, sausage).

RESULTS

Approximately 38% of the participants reported rare or no consumption of any type of meat, 31% consumed mostly red meat, 19% mostly white meat and the remainder 12% mostly processed meat. In multivariate analysis, compared to never/rarely consuming any type of meat, consuming mostly processed meat [HR: 2.89, 95%CI: 1.05, 7.89], but not red meat [HR: 1.22, 95%CI: 0.81, 1.82], was positively associated with incident CVD during 20 years of follow-up, while consuming mostly white meat was inversely associated with incident CVD [HR: 0.35, 95%CI: 0.17, 0.71].

CONCLUSIONS

The findings of this study suggest that the type of meat, irrespective of the frequency of consumption, plays a role in the risk of developing CVD. In clinical practice, emphasis should be placed on avoiding processed meat and replacing it with white unprocessed meat.

Prediction of lifetime risk for cardiovascular disease, by risk factors level: the ATTICA epidemiological cohort study (2002-2022)

PURPOSE

We aimed to predict lifetime risk for cardiovascular disease (CVD).

METHODS

The sample consisted of 1988 participants with complete CVD data during the 20-year follow-up (50% men, 45 ± 14 years) of the ATTICA study. Lifetime risk for CVD was predicted at specific index ages (40, 50, and 60 years), based on the life-table method, with death free-of-CVD treated as a competing event.

RESULTS

718 participants experienced a fatal or nonfatal CVD event, corresponding to a crude CVD incidence of 36.1% (men: 40.2%, women: 32.1%, P-value < .001). Overall, women and men had similar lifetime CVD risk (P-value = .245); at index age of 40, the lifetime risk for CVD was 68% for men and 63% for women, with a progressive decline to 56% and 50% at the index age of 50, and to 55% for both men and women, at the index age of 60 years, respectively.

CONCLUSIONS

These results on lifetime risk for CVD can guide the allocation of resources to improve public health and preventive services, especially in ages below 50 years, in both men and women.

Prediction of 10-Year Cardiovascular Disease Risk, by Diabetes status and Lipoprotein-a levels; the HellenicSCORE II

BACKGROUND

The aim of this study was to develop an updated model to predict10-year cardiovascular disease (CVD) risk for Greek adults, i.e., the HellenicSCORE II+, based on smoking, systolic blood pressure (SBP), total and High-Density-Lipoprotein-(HDL) cholesterol levels, and stratified by age group, sex, history of diabetes, and Lipoprotein (Lp)-a levels.

METHODS

Individual CVD risk scores were calculated through logit-function models, using the beta-coefficients derived from SCORE2. The Attica Study data were used for the calibration (3,042 participants, aged 45(14) years; 49.1% men). Discrimination ability of the HellenicSCORE II+ was assessed using C-index (range 0-1), adjusted for competing risks.

RESULTS

The mean HellenicSCORE II+ score was 6.3% (95% Confidence Interval (CI) 5.9% to 6.6%) for men and 3.7% (95% CI 3.5% to 4.0%) for women (p<0.001), and were higher compared to the relevant SCORE2; 23.5% of men were classified as low risk, 40.2% as moderate and 36.3% as high risk, whereas the corresponding percentages for women were 56.2%, 18.6% and 25.2%. C-statistic index was 0.88 for women and 0.79 for men, when the HellenicSCORE II+ was applied to the ATTICA Study data, suggesting very good accuracy. Stratified analysis by Lp(a) levels led to a 4% improvement in correct classification among participants with high Lp(a).

CONCLUSION

HellenicSCORE II+ values were higher than SCORE2, confirming that the Greek population is at moderate-to-high CVD risk. Stratification by Lp(a) levels may assist to better identify individuals at high CVD risk.

Diet Quality and Consumption of Healthy and Unhealthy Foods Measured via the Global Diet Quality Score in Relation to Cardiometabolic Outcomes in Apparently Healthy Adults from the Mediterranean Region: The ATTICA Epidemiological Cohort Study (2002-2022)

The Global Diet Quality Score (GDQS) is a novel food-based score that assesses both nutrient adequacy and chronic disease risk, by evaluating healthy (GDQS+) and unhealthy foods (GDQS-). The aim of this study was to evaluate the association among GDQS, GDQS+, and GDQS- against the 20-year risk of cardiometabolic outcomes in a Mediterranean population. The sample was n = 2169 initially free of cardiovascular disease (CVD) participants of the ATTICA study (2002-2022) that participated in the 20-year follow-up. The incidence of CVD, hypertension, hypercholesterolemia, and type 2 diabetes mellitus (T2DM) was defined according to WHO-ICD-10 criteria. The GDQS was computed based on previously published instructions. In multivariate analyses, a higher diet quality, per 1/49 of the GDQS, was associated with an 8% [95% Confidence Interval-CI: 6-9%] and 2% [95% CI: 1-3%] lower CVD and T2DM risk, respectively. A higher consumption of healthy foods, per 1/32 of GDQS+, was associated with a 9% [95% CI: 7-11%] and 2% [95% CI: 1-3%] lower CVD and T2DM risk, respectively. Contrarily, a lower consumption of unhealthy foods (GDQS-) was not associated with cardiometabolic events in the adjusted models (all p value< 0.05). In clinical practice or future public health actions to ameliorate dietary habits and prevent CVD and T2DM, more attention should be focused on healthy foods that should be included in our diets.

Comparative performance of equations to estimate low-density lipoprotein cholesterol levels and cardiovascular disease incidence: The ATTICA study (2002-2022)

Accurate estimation of low-density lipoprotein cholesterol (LDL-C) is important for monitoring cardiovascular disease (CVD) risk and guiding lipid-lowering therapy. This study aimed to evaluate the magnitude of discordance of LDL-C levels calculated by different equations and its effect on CVD incidence. The study sample consisted of 2354 CVD-free individuals (49% males, mean age 45 ± 14 years); 1600 were re-evaluated at 10 years and 1570 at 20 years. LDL-C was estimated using the Friedewald, Martin/Hopkins, and Sampson equations. Participants were categorized as discordant if estimated LDL-C was below the CVD-risk specific cut-off for one equation and equal/above for its comparator. The Friedewald and Martin/Hopkins equations presented a similar performance in estimating LDL-C; however, both yielded lower values compared to the Sampson. In all pairwise comparisons, differences were more pronounced at lower LDL-C levels, while the Friedewald equation significantly underestimated LDL-C in hypertriglyceridemic participants. Discordance was evident in 11% of the study population, and more specifically 6%, 22%, and 20% for Friedewald versus Martin/Hopkins, Friedewald versus Sampson and Martin/Hopkins versus Sampson equations, respectively. Among discordant participants, median (1st, 3rd quartile) difference in LDL-C was -4.35 (-10.1, 1.95), -10.6 (-12.3, -9.53) and -11.3 (-11.9, -10.6) mg/dL for Friedewald versus Martin/Hopkins, Friedewald versus Sampson and Martin/Hopkins versus Sampson equations, respectively. The 10- and 20-year CVD survival model that included LDL-C values of the Martin-Hopkins equation outperformed the predictive ability of those based on the Friedewald or Sampson equations. Significant differences in estimated LDL-C exist among equations, which may result in LDL-C underestimation and undertreatment.

Association Between Family History of Diabetes, Irrational Beliefs, and Health Anxiety with 10-Year Risk of Type 2 Diabetes Mellitus: the ATTICA Epidemiological Study (2002-2012)

BACKGROUND

This study aimed to examine the relationship between family history of diabetes, irrational beliefs, and health anxiety in the development of type 2 diabetes mellitus (T2DM).

METHOD

ATTICA is a prospective, cohort study (2002-2012). The working sample included 845 participants (18-89 years), free of diabetes at baseline. Α detailed biochemical, clinical, and lifestyle evaluation was performed, while participants' irrational beliefs and health anxiety were assessed through the Irrational Beliefs Inventory and the Whiteley index scale, respectively. We evaluated the association between the participants' family history of diabetes mellitus with the 10-year risk of diabetes mellitus, both in the total study's sample and separately according to their levels of health anxiety and irrational beliefs.

RESULTS

The crude 10-year risk of T2DM was 12.9% (95%CI: 10.4, 15.4), with 191 cases of T2DM. Family history of diabetes was associated with 2.5 times higher odds (2.53, 95%CI 1.71, 3.75) of T2DM compared to those without family history. Among participants with family history of diabetes, the highest likelihood of developing T2DM, regarding their tested psychological features (i.e., low/high irrational beliefs in the entire group, low/high health anxiety in the entire group, and low/high irrational beliefs, low/high healthy anxiety), had people with high irrational beliefs, low health anxiety (OR 3.70, 95%CI 1.83, 7.48).

CONCLUSIONS

The findings underline the important moderating role of irrational beliefs and health anxiety in the prevention of T2DM, among participants at increased risk of T2DM.

Lifestyle Trajectories Are Associated with Incidence of Cardiovascular Disease: Highlights from the ATTICA Epidemiological Cohort Study (2002-2022)

The study aimed to assess the trajectories of lifestyle characteristics and their association with 20-year cardiovascular disease (CVD) incidence. In 2002, 3042 Greek adults (aged: 45 (12) years) free of CVD were enrolled. In 2022, the 20-year follow-up was performed on 2169 participants; of those, 1988 had complete data for CVD. The 20-year CVD incidence was 3600 cases/10,000 individuals; the man-to-woman ratio was 1.25, with the peak difference in the 35-45 age group (i.e., 2.1); however, a reversal of the trend was observed in the age-groups 55-65 and 65-75, with a resumption of an almost equal incidence in those >75 years. In multi-adjusted analysis, age, sex, abnormal waist circumference, hypercholesterolemia, hypertension, and diabetes were positively associated with 20-year CVD risk, explaining 56% of the excess CVD risk, whereas an additional 30% was attributed to lifestyle trajectories; being physically active throughout life-course and being close to the Mediterranean diet were protective, while continuous smoking was detrimental against CVD risk. Mediterranean diet adherence protected against CVD development even if not sustained, while quitting smoking or engaging in physical activities during the 20-year observation did not offer any significant protection. A life-course personalized approach that is cost-effective and long-term sustained is needed to prevent CVD burden.

Exploring the Role of Irrational Beliefs, Lifestyle Behaviors, and Educational Status in 10-Year Cardiovascular Disease Risk: the ATTICA Epidemiological Study

BACKGROUND

Irrational beliefs, maladaptive emotions, and unhealthy lifestyle behaviors can adversely affect health status. However, limited research has examined the association between irrational beliefs and cardiovascular disease (CVD). The aim of this study was to evaluate the association between irrational beliefs and the 10-year CVD incidence among apparently healthy adults, considering the potential moderating or mediating role of particular social and lifestyle factors.

METHODS

The ATTICA study is a population-based, prospective cohort (2002-2012), in which 853 participants without a history of CVD [453 men (aged 45 ± 13 years) and 400 women (aged 44 ± 18 years)] underwent psychological evaluations. Among other tools, participants completed the irrational beliefs inventory (IBI, range 0-88), a self-reported measure consistent with the Ellis model of psychological disturbance. Demographic characteristics, detailed medical history, dietary, and other lifestyle habits were also evaluated. Incidence of CVD (i.e., coronary heart disease, acute coronary syndromes, stroke, or other CVD) was defined according to the International Coding Diseases (ICD)-10 criteria.

RESULTS

Mean IBI score was 53 ± 2 in men and 53 ± 3 in women (p = 0.88). IBI score was positively associated with 10-year CVD risk (hazard ratio 1.07, 95%CI 1.04, 1.13), in both men and women, and more prominently among those with less healthy dietary habits and lower education status; specifically, higher educational status leads to lower IBI score, and in conjunction they lead to lower 10-year CVD risk (HR for interaction 0.98, 95%CI 0.97, 0.99).

CONCLUSIONS

The findings of this study underline the need to build new, holistic approaches in order to better understand the inter-relationships between irrational beliefs, lifestyle behaviors, social determinants, and CVD risk in individuals.

High fish intake rich in n-3 polyunsaturated fatty acids reduces cardiovascular disease incidence in healthy adults: The ATTICA cohort study (2002-2022)

Background: The long-term effects of high fish intake rich in n-3 fatty acids for deterring cardiovascular disease (CVD) and related adverse outcomes in healthy individuals have not been yet elucidated.

Purpose: To evaluate the association between total seafood, as well as small fish, intake on 10- and 20-year CVD incidence and mortality in healthy adults.

Methods: A prospective cohort study (n = 2,020) was conducted in healthy community dwelling adults in Athens, Greece, selected following age- and sex-based random multistage sampling (mean ± SD age at baseline: 45.2 ± 14.0 years). Seafood (high (&gt;2 servings/week) vs. low (≤2 servings/week) intake), including small fish rich in n-3 fatty acids (high (&gt;1 serving/week) vs. low (≤1 serving/week) intake), consumption was evaluated by semi-quantitative food frequency questionnaire at baseline. The occurrence of non-fatal and/or fatal CVD events (ICD-10) was assessed during 10- and 20-year follow-up periods.

Results: Only 32.7% and 9.6% of participants had high seafood and small fish intakes, respectively. Participants with high seafood intake had 27% decreased 10-year CVD risk (adj. HR:0.73; 95% CI:0.55-0.98) and 74% lower attributable mortality (adj. HR:0.26; 95% CI:0.11-0.58). Participants with high seafood intake also sustained a 24% lower 20-year risk of CVD mortality (adj. HR: 0.76; 95% CI: 0.55-0.98). Moreover, participants with high small fish intake had a lower 10-year CVD risk and 76% decreased risk of 10-year CVD mortality (adj. HR:0.24; 95% CI:0.06-0.99), even among normotensive individuals (adj. HR:0.31; 95% CI:0.13-0.73). When analogous analyses focused on 20-year CVD incidence and mortality, similar but not significant associations were observed (all p-values &gt;0.10).

Conclusion: High intake of seafood, and particularly small fish rich in n-3 fatty acids, was associated with a lower risk of 10-year fatal and non-fatal CVD. Thus, public health interventions aimed at enhancing small fish consumption may most effectively deter long-term CVD outcomes, particularly among low risk normotensive individuals.

Cardiometabolic Care: Assessing Patients with Diabetes Mellitus with No Overt Cardiovascular Disease in the Light of Heart Failure Development Risk

The mechanisms leading to the development of heart failure (HF) in diabetes mellitus (DM) patients are multifactorial. Assessing the risk of HF development in patients with DM is valuable not only for the identification of a high-risk subgroup, but also equally important for defining low-risk subpopulations. Nowadays, DM and HF have been recognized as sharing similar metabolic pathways. Moreover, the clinical manifestation of HF can be independent of LVEF classification. Consequently, approaching HF should be through structural, hemodynamic and functional evaluation. Thus, both imaging parameters and biomarkers are important tools for the recognition of diabetic patients at risk of HF manifestation and HF phenotypes, and arrhythmogenic risk, and eventually for prognosis, aiming to improve patients' outcomes utilizing drugs and non-pharmaceutical cardioprotective tools such as diet modification.

Irrational beliefs, depression and anxiety, in relation to 10-year cardiovascular disease risk: the ATTICA Epidemiological Study

BACKGROUND AND OBJECTIVES

Various bio-psychosocial mechanisms underlying the link between anxiety, depression and cardiovascular disease risk, remain unknown. We investigated the role of irrational beliefs in conjunction with anxiety and depression in the 10-year cardiovascular disease (CVD) incidence, and the effect of biochemical and socio-behavioral factors.

DESIGN

853[453 men (45 ± 13 years) and 400 women (44 ± 18 years)] from the ATTICA study (2002-2012) and without evidence of CVD were assessed.

METHODS

The Irrational Beliefs Inventory (IBI), the Zung Self-Rating-Depression-Scale (ZDRS) and the State-Trait-Anxiety-Inventory (STAI) were used for the assessments. Incidence of CVD was defined according to the International Coding Diseases (ICD)-10 criteria.

RESULTS

Participants with high irrational beliefs and anxiety symptoms had a 138% greater risk of developing CVD during the 10-year follow-up (2.38; 95%CI 1.75, 3.23) as compared to those without anxiety. Among others, C-reactive protein, interleukin-6 and total antioxidant capacity were mediators in the tested association. Interaction of irrational beliefs and depression was not associated with the 10-year CVD in all models.

CONCLUSIONS

Inflammation and oxidative stress, partially explained the associations between irrational beliefs and anxiety in predicting CVD risk. These findings advance psychological research in the area of primary prevention of mental health and cardiovascular diseases.

The association of specific types of vegetables consumption with 10-year type II diabetes risk: Findings from the ATTICA cohort study

BACKGROUND

The present study aimed to investigate the association between vegetable consumption, in total as well as per type/category, and 10-year type-2 diabetes mellitus (T2DM) incidence.

METHODS

The ATTICA study was conducted during 2001-2012 in 3042 apparently healthy adults living in Athens area, Greece. A detailed biochemical, clinical, and lifestyle evaluation was performed; vegetable consumption (total, per type) was evaluated through a validated semi-quantitative food frequency questionnaire. After excluding those with no complete information of diabetes status or those lost at the 10-year follow-up, data from 1485 participants were used for the current analysis.

RESULTS

After adjusting for several participants' characteristics, including overall dietary habits, it was observed that participants consuming at least 4 servings/day of vegetables had a 0.42-times lower risk of developing T2DM (hazard ratio [HR] = 0.42; 95% confidence interval [CI] = 0.29-0.61); the benefits of consumption were greater in women (HR = 0.29; 95% CI = 0.16-0.53) compared to men (HR = 0.56; 95% CI = 0.34-0.92). Only 33% of the sample consumed vegetables 4 servings/day. The most significant associations were observed for allium vegetables in women and for red/orange/yellow vegetables, as well as for legumes in men.

CONCLUSIONS

The intake of at least 4 servings/day of vegetables was associated with a considerably reduced risk of T2DM, independently of other dietary habits; underlying the need for further elaboration of current dietary recommendations at the population level.

Long-term prognostic value of LDL-C, HDL-C, lp(a) and TG levels on cardiovascular disease incidence, by body weight status, dietary habits and lipid-lowering treatment: the ATTICA epidemiological cohort study (2002-2012)

BACKGROUND

The link between blood lipids and cardiovascular disease (CVD) is complex. Our aim was to assess the differential effect of blood lipids on CVD risk according to age, sex, body weight, diet quality, use of lipid-lowering drugs and presence of hypercholesterolemia.

METHODS

In this secondary analysis of the ATTICA prospective cohort study, serum blood lipids, i.e., total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and liproprotein(a) [Lp(a)], and sociodemographic, anthropometric, lifestyle and clinical parameters were evaluated at baseline (2001/2002) in 2020 CVD-free men and women. CVD incidence was recorded at the 10-year follow-up (2011/2012).

RESULTS

All blood lipids assessed were univariately related to CVD risk; however, associations remained significant only for HDL-C and TG in multivariate models adjusted for age, sex, body mass index, smoking, Mediterranean Diet Score, physical activity, presence of hypercholesterolemia, hypertension and diabetes mellitus, use of lipid-lowering drugs, and family history of CVD [RR per 1 mg/dL (95% CI): 0.983 (0.967, 1.000) and 1.002 (1.001, 1.003), respectively]. In stratified analyses, TC and LDL-C predicted CVD risk in younger subjects, normal-weight subjects, and those not on lipid-lowering drugs, while HDL-C and TG were significant predictors in older subjects, those with low adherence to the Mediterranean diet, and hypercholesterolemic subjects; a significant effect on CVD risk was also observed for TG in males, overweight participants and lipid-lowering medication users and for Lp(a) in older subjects and females (all p ≤ 0.050).

CONCLUSIONS

The impact of blood lipids on CVD risk differs according to several biological, lifestyle and clinical parameters.

Egg Consumption, Cardiovascular Disease and Cardiometabolic Risk Factors: The Interaction with Saturated Fatty Acids. Results from the ATTICA Cohort Study (2002-2012)

Purpose: To examine the association of egg intake with 10-year risk of cardiovascular disease (CVD) and other cardiometabolic risk factors in a sample of individuals of Mediterranean origin. Methods: In 2001−2002, n = 1514 men and n = 1528 women (>18 years old) from the greater Athens area, Greece, were enrolled. Information on any egg intake, eaten as a whole, partly or in recipes was assessed via a validated semi-quantitative food frequency questionnaire. Follow-up for CVD evaluation (2011−2012) was achieved in n = 2020 participants (n = 317 CVD cases). Results: Ranking from lowest (<1 serving/week) to intermediate (1−4 servings/week) and high (4−7 servings/week) egg consumption tertiles, lower CVD incidence was observed (18%, 9% and 8%, respectively, p-for-trend = 0.004). Unadjusted analysis revealed that 1−3 eggs/week and 4−7 eggs/week were associated with a 60% and 75%, respectively, lower risk of developing CVD compared with the reference group (<1 egg/week). When adjusting for sociodemographic, lifestyle and clinical factors, significance was retained only for 1−3 eggs/week (hazard ratio (HR) = 0.53, 95% confidence interval (95% CI) = 0.28, 1.00). When total saturated fatty acid (SFA) intake was taken into account, this inverse association was non-significant. Multi-adjusted analysis revealed that in participants of low SFA intake, 1 serving/day increase in egg intake resulted in 45% lower risk of developing CVD. In the case of higher SFA consumption, only 1−3 eggs/week seemed to protect against CVD (HR = 0.25, 95% CI = 0.07, 0.86). In the case of intermediate cardiometabolic disorders, no significant trend was observed. Conclusions: Overall dietary habits principally in terms of SFA intake may be detrimental to define the role of eggs in cardiac health.

Peak oxygen consumption is associated with the inotropic reserve in patients with heart failure with reduced ejection fraction undergoing cardiopulmonary testing

Background

The role of cardiopulmonary exercise testing (CPET) in the prognostic evaluation of heart failure with reduced ejection fraction (HFrEF) is powerful and well-established. Nevertheless, the value of CPET in predicting left ventricular inotropic reserve in HFrEF remains unknown.

Purpose

The investigation of possible associations between CPET variables and left ventricular contractile reserve in patients with HFrEF.

Methods

Consecutive patients aged ≥18 years old with a diagnosis of heart failure and a left ventricular ejection fraction ≤40%, as assessed by echocardiography, were prospectively enrolled. Demographic and clinical data were recorded. All subject underwent CPET with either a Bruce or a modified Bruce protocol. Peak oxygen consumption (VO2), carbondioxide production (VCO2), minute ventilation to carbon dioxide production (VE/VCO2) slope, minute ventilation (VE), and VO2/heart rate (HR) values were calculated, while hemodynamic parameters during the test were also measured.

Results

In total, 191 patients with HFrEF were included in the analysis. The mean age was 58.8±11.8 years and 30 (15.7%) patients were women. Ischemic heart disease was the etiology of HFrEF in 101 (52.9%) patients, whereas 90 (47.1%) patients had a history of dilated cardiomyopathy. The mean exercise time was 7.6±.3 minutes. Mean peak VO2 and VE/VCO2 slope values were calculated at 19.1±6.1 ml kg–1 min–1 and 43.7±10.1, respectively. According to peak VO2 values, 70 patients (37.2%) were in Weber class A, 57 (29.8%) in class B, 48 (25.1%) in class C and 15 (7.9%) in class D. In univariate analysis, the change between rest and peak systolic blood pressure (ΔSBP), which is considered to reflect the left ventricular inotropic reserve, was positively correlated to the peak VO2 (p&lt;0.001), the total pulmonary ventilation (VE) (p&lt;0.001) and the peak heart rate during exercise (p=0.02). In multivariable analysis, peak VO2 was independently, linearly associated with the ΔSBP during CPET (Figure 1) (β=0.661, p=0.022). In Roc analysis, it was found that a cut-off value for peak VO2 of 16 ml kg–1 min–1 exhibits 64% sensitivity and 60% specificity in predicting a ΔSBP&gt;40mmHg during exercise (area under the curve: 0.657, p&lt;0.001 – Figure 2).

Conclusion

The peak oxygen consumption during cardiopulmonary testing represents an acceptable predictor of inotropic reserve in patients with HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Low muscle mass is linked with presence of non-alcoholic fatty liver disease irrespective to central obesity: highlights from a prospective epidemiological study in Greece

Background/Introduction

The association between sarcopenia and nonalcoholic fatty liver (NAFL) is highlighted in recent epidemiological studies, although results remain inconsistent.

Purpose

This study aimed to examine the association of low skeletal muscle mass with NAFL as well as the potential mediating effect of waist circumference on the examined association.

Methods

At baseline, 3,042 participants from the Attica region of Greece were recruited. NAFL was assessed through hepatic steatosis index (HSI). Skeletal muscle mass index (SMI) was indirectly calculated using a standard validated procedure.

Results

Ranking from 1st to 3rd SMI tertiles NAFL rate was 45%, 33% and 22%, respectively (p&lt;0.001). Multi-adjusted logistic regression analysis revealed that participants assigned in the 2nd (Odds Ratio (OR): 0.50, 95% Confidence Interval (95% CI): 0.41–0.61)) and 3rd SMI tertile had 50% and 76% (OR: 0.24, 95% CI: 0.19–0.29) lower likelihood to have NAFL compared with their 1st tertile counterparts. This association remained robust after multiple adjustments; however, significance was marginally lost, when waist circumference was added to the model. Subsequently, a multi-adjusted dose-response analysis between SMI and NAFL was performed in the total sample, as well as in the subcategories of normal and abnormal waist circumference. In the total sample, a significant inverse association between SMI and NAFL was observed [OR (per 2 points increase in SMI) = 0.94 (95% CI: 0.92–0.95); p=0.001]. When categorized by waist circumference, participants with moderate/high SMI and normal waist circumference had the lowest NAFL rates (24.3%). Those with low SMI and normal waist circumference and those with moderate/high SMI and abnormal waist circumference had similar rates of NAFL (47.4% and 50.3%, respectively; p=0.25). Participants with both low SMI and abnormal waist circumference presented the highest NAFL rate (60.5%), which was significantly higher compared with the rest subgroups (p&lt;0.001). These findings were confirmed in multi-adjusted analysis to assess NAFL odds per case: participants with adnormal waist, [OR (per 2 points increase in SMI) = 0.97 (95% CI: 0.94–1.00)] vs. participants with normal waist [OR (per 2 points increase in SMI) = 0.89 (95% CI: 0.84–0.95)].

Conclusions

Increasing SMI was associated with lower rates of NAFL independently to abdominal obesity, whereas the two interact as key determinants of NAFL.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Hellenic Society of Cardiology

Optimization of biventricular cardiac resynchronization improves cardiac power and atrial kinetics in patients with systolic heart failure with often hospitalizations for decompensation

 

Cardiac resynchronization therapy (CRT) reduces symptoms and improves left ventricular function in patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. In this work the biochemical, clinical and echocardiographic outcome of optimizing CRT (optCRT) function by the optimal VTI value of left ventricular outflow track.

Methods

80 NYHA III patients (68±10 years; 75% men; 53% ischemic cardiomyopathy-ICM), under optimal tolerated medical therapy, with standard BVP indication, having been implanted with a CRT system. Echocardiographic measurements, including aortoventricular coupling (VAC) calculation, 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months on optCRT. Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451.

Results

End-systolic volume of left ventricle was reduced (p=0.001) in both ischemic and non-ICM; while max left atrial volume was reduced only in non-ICM patients (72.1±32 to 65.8±30, p=0.04). Global longitudinal strain was improved in non ICM patients (p=0.015). Systolic strain of right ventricle was improved in non-ICM (9.4±2.2 to 10.7±2.3 vs. 8.7±3 to 8.9±3.2, p=0.03 for non-ICM); while left atrial function and the ratio E to E TDI of mitral annulus were not improved in either group. Non-ICM patients improved VAC (baseline: 1,36±0,3; CRT: 1.11±0.2; p=0.01) and CP (baseline 660±160 to 782±260, p=0.001); while no significant improvement was detected to ICM patients. 6-min-walk test was improved up to 30% (p=0.05). NtproBNP levels were decreased only in non-ICM patients (1759±1060.9 to 1015±650 vs. 2063,8±1800 to 1950.7±2342, p=0.001). MLHFQ improved in non-ICM patients (p=0.015); while non-significant improvement was detected in ICM patients.

Conclusion

Optimization of cardiac resynchronization therapy based on stroke volume maximization benefits quality of life and exercise tolerance, mainly in non-ICM. GLPS and aorto-ventricular coupling was improved in non-ischemic patients, reflecting the better adaptation of CRT in this population. Thus, CRT optimization by echocardiographic evaluation may be useful in improve clinical status and quality of life in CRT non-responder patients.

Funding Acknowledgement

Type of funding sources: None.

Psychological factors in relation to the 10-year incidence of metabolic syndrome: The ATTICA epidemiological study (2002-2012)

BACKGROUND AND AIMS

Various bio-psychological mechanisms underlying the association between mental health problems and metabolic syndrome remain unknown. We investigated the role of irrational beliefs in conjunction with anxiety, depression and hostility in the 10-year metabolic syndrome (MetS) incidence, and the effect of biochemical and socio-behavioral factors on the aforementioned associations.

METHODS AND RESULTS

ATTICA is a prospective, cohort study (2002-2012). The sample included 591 participants [51.3% men (aged 41.5 ± 10 years) and 48.7% women (aged 37.5 ± 11.5 years)], free of MetS at baseline. Detailed biochemical, clinical, and lifestyle evaluations were performed, while participants' irrational beliefs, anxiety, depression and hostility were assessed using the Irrational Beliefs Inventory, the Spielberger State-Trait Anxiety Inventory, the Zung Self-Rating Depression Scale and the Hostility and Direction of Hostility Questionnaire, respectively. Multiple logistic regression was applied to estimate the odds ratio (OR) of developing MetS and to control for confounders, as well as stratified logistic regression to detect moderator effects. High irrational beliefs were associated with 1.5-times higher odds of developing MetS than low irrational beliefs. Especially, participants with high irrational beliefs and high anxiety were 96% more likely to develop MetS, compared with those with low irrational beliefs and low or high anxiety (OR = 1.96; 95% CI = 1.01, 3.80).

CONCLUSION

The findings of the study underline the important role of irrational beliefs and anxiety in the development of MetS and the need to build new holistic approaches focused on the primary prevention of both mental health and MetS.

Longitudinal Trends, Determinants, and Cardiometabolic Impact of Adherence to the Mediterranean Diet among Greek Adults

Despite the well-established health benefits of the Mediterranean diet, there are signs that Mediterranean populations are deviating from this traditional pattern. We aimed to evaluate longitudinal changes in adherence to the Mediterranean diet, its determinants and health effects in a representative sample of the adult Greek population. This was a secondary analysis of the ATTICA epidemiological cohort study conducted in 2001/2002 and 2011/2012. The study sample consisted of 3042 men and women free of cardiovascular diseases living in Attica, Greece; of them, 2583 were followed-up for 10 years. Participants were evaluated in terms of sociodemographic, lifestyle and clinical parameters at baseline, and incidence of cardiometabolic diseases was recorded at follow-up. Dietary habits were assessed both at baseline and 10 years through a validated food frequency questionnaire and adherence to the Mediterranean diet was evaluated through the MedDietScore, based on which four trajectories were identified, i.e., low−low, low−high, high−low and high−high. During the study period, 45.6% of participants moved away from the Mediterranean diet (high−low), 9.0% moved closer (low−high), while 18.7% sustained a high adherence (high−high). Participants in the high−high trajectory were younger, mostly women, more physically active, had a higher socioeconomic status, and a more favorable body composition and cardiometabolic profile at baseline, and exhibited lower 10-year incidence rates of hyperlipidemia, hypertension, diabetes mellitus and cardiovascular disease compared to other trajectories (all p-values < 0.050). Adherence to the Mediterranean diet is declining among Greek adults. Staying close to the Mediterranean diet is associated with significant health benefits and should be a major target of public health strategies.

Fluid and Salt Balance and the Role of Nutrition in Heart Failure

The main challenges in heart failure (HF) treatment are to manage patients with refractory acute decompensated HF and to stabilize the clinical status of a patient with chronic heart failure. Beyond the use of medications targeted in the inhibition of the neurohormonal system, the balance of salt and fluid plays an important role in the maintenance of clinical compensation in respect of renal function. In the case of heart failure, a debate of opinion exists on salt restriction. Restricted dietary sodium might lead to worse outcomes in heart failure patients due to the activation of the neurohormonal system and malnutrition. On the contrary, positive sodium balance is the primary driver of water retention and, ultimately, volume overload in acute HF. Some recent studies reported associations of decreased salt consumption with higher readmission rates and increased mortality. Thus, the usefulness of salt restriction in heart failure management remains debated. The use of individualized nutritional support, compared with standard hospital food, was effective in reducing these risks, particularly in the group of patients at high nutritional risk.

The presence of NAFLD influences the transition of metabolically healthy to metabolically unhealthy obesity and the ten-year cardiovascular disease risk: A population-based cohort study

BACKGROUND/OBJECTIVES

We evaluated the role of the presence of non-alcoholic fatty liver disease (NAFLD) at baseline in the transition from metabolically healthy to metabolically unhealthy obesity (MHO to MUO) ten years later.

METHODS

A prospective cohort study (ATTICA study, Greece) was performed between 2002 and 2012 studying a sample from the greater metropolitan Athens area. In total, 1514 (49·8%) men and 1528 (50.2%) women (aged >18 years old) free-of-CVD were included. Healthy metabolic status was defined as absence of all NCEP ATP III (2005) metabolic syndrome components. NAFLD was defined according to validated liver steatosis indices. Follow-up CVD assessment (2011-2012) was achieved in n = 2020 participants (n = 317 cases).

RESULTS

NAFLD prevalence among MHO participants ranged from 29% to 39% according to the specific NAFLD score used. MHO participants who developed metabolically unhealthy status had about two times higher odds to have NAFLD at baseline compared with their metabolically healthy normal weight counterparts whereas stable MHO was not associated significantly with NAFLD. Moreover, MHO status accompanied by NAFLD was associated with increased CVD risk (Hazard Ratio = 2.90 95% Confidence Interval (1.35, 5.40)) in comparison to their non-NAFLD MHO counterparts. Further analysis revealed that in the obese, NAFLD indices and not simply visceral adiposity increased significantly the ability of metabolic status (using standard definition) to predict long-term CVD incidence.

CONCLUSIONS

Considering NAFLD, even when assessed using validated indices only, in the clinical assessment of apparently healthy obese individuals predicts who is to develop MUO and contributes independently and more accurately to defining future cardiometabolic risk.

Hypertensive urgencies during the first wave of the COVID-19 pandemic in a tertiary hospital setting: a U-shaped alarming curve

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic provoked unprecedented disturbance in hypertension care, while alarming concerns arose about its long-term consequences. We investigated the trends of emergency visits and admissions regarding uncontrolled hypertension in order to assess the impact of COVID-19 spread on population behavior towards hypertension urgencies during its first wave.

MATERIAL AND METHODS

Data from daily unscheduled visits and admission counts in the Cardiology sector were collected from the Emergency Department database of a tertiary General Hospital in Athens, Greece for the period January 15^th to July 15^th 2020. These data were compared with those from the previous year. Cases of patients who presented with hypertensive urgency or who were admitted due to uncontrolled hypertension were separately analyzed.

RESULTS

A total of 7,373 patient records were analyzed. Hypertension urgency cases demonstrated a U-shaped distribution in 2020, showing a declining trend during the rapid virus spread, an image that was reversed after the transmission rate's decline. COVID-19 incidence in Greece was inversely associated with uncontrolled hypertension admissions during its declining phase (r = -0.64, p = 0.009), whereas total attendance exhibited a similar correlation during the first and the following months of the pandemic (r = 0.677, p = 0.031, r = -0.789, p = 0.001). Uncontrolled hypertension rate on admission was positively related to the national incidence of COVID-19 cases during the first months of 2020 (r = 0.82, p = 0.045).

CONCLUSIONS

Hypertensive urgency-related visits followed a U-shape distribution during the pandemic's first wave with the attendance nadir coinciding with the virus spread peak. This is a complex phenomenon, closely related to increased levels of public stress, disruptions in health care services and to a lesser extent to the imposed restrictions in transportation. The initial relative increase in uncontrolled hypertension-related admissions rate, combined with the later increase of hypertensive urgencies may be indicative of blood pressure deregulation among the studied population, which is multifactorial and potentially detrimental.

Ultra-processed foods and ten-year cardiovascular disease incidence in a Mediterranean population: results from a population-based cohort study

Background/Introduction

Although cardiovascular disease (CVD) guidelines emphasize consuming minimally processed foods, such as fruits, vegetables, whole grain products, nuts and seeds, less attention has been given to the importance of minimizing ultra-processed foods, probably due to the paucity of studies that exist.

Purpose

The aim of the present work was to investigate the association between the consumption of ultra-processed foods and ten-year first fatal/non fatal CVD event in a sample from Greece.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 men and n=1,528 women (&gt;18 years old) free of CVD. Baseline dietary assessment was based on a validated semi-quantitative food frequency questionnaire. Ultra-processed foods were defined according to a standardized procedure and included among others sweets and desserts, beverages, salty snacks, breakfast cereals and fast foods. Follow-up assessment of first fatal/non fatal CVD event (2011–2012) was achieved in n=2,020 participants (n=317 cases). Cox proportional hazards models were constructed to determine the multiadjusted association between ultra-processed food intake (energy-adjusted servings per week) and incident fatal/non fatal CVD.

Results

On average, participants consumed about 15 servings of ultra-processed foods per week. Ranking from 1st to 3rd ultra-processed food consumption tertile (low to high level of intake) CVD incidence was 8.1%, 12.2%, 16.6% (p=0.006). Each additional weekly serving of ultra-processed food was associated with 10% higher CVD risk within the decade (Hazard Ratio (HR)=1.10, 95% Confidence Interval (95% CI) (1.02, 1.21), p=0.04). This association was reexamined according to participants' level of adherence to a cardiac friendly dietary pattern i.e. Mediterranean diet (defined through MedDietScore, range 1–55). In particular, the aggravating effect of ultra-processed foods was retained and only slightly attenuated even in the subset of participants with moderate to high level of adherence to Mediterranean diet (defined as MedDietScore&gt;27) (HRper 1 serving/week=1.08, 95% CI (0.98, 1.19), p=0.09). On the other side, it became even stronger in case of low level of adherence to this pattern (HRper 1 serving/week=1.19, 95% CI (1.12, 1.25), p=0.02).

Conclusions

Current findings support that even in a population with Mediterranean origins and easy access to healthy least processed choices, systematic consumption of ultra-processed foods on a weekly basis was associated with increased risk of hard CVD events. Tailor-made public health initiatives and nutrition policies are demanded to promote healthy and sustainable dietary patterns with less-processed foods of high nutritional value.

Funding Acknowledgement

Type of funding sources: None.

The quality of plant-based dietary patterns affects the ten-year cardiovascular disease risk of participants with non-alcoholic fatty liver disease: highlights from a population-based cohort study

Background/Introduction

Some plant-based diets like the Mediterranean diet have been suggested to have a beneficial impact on liver disease. However, the quality of plant-based diets – in general – varies.

Purpose

The association between plant-based diet indices and non-alcoholic fatty liver disease (NAFLD) as well as their interaction on ten-year cardiovascular disease incidence was examined.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 males and n=1,528 females (aged &gt;18 years old) free of CVD. Healthy metabolic status was defines as absence of all NCEP ATP III (2005) metabolic syndrome components (excluding waist circumference). Follow-up CVD assessment (2011–2012) was achieved in n=2,020 participants (n=317 cases). Overall, healthful and unhealthful plant-based dietary indices (PDI, hPDI and uPDI) were created through a standard procedure; hPDI was principally characterized by increased consumption of fruits/vegetables, whole grains, nuts, legumes, oils, tea/coffee while uPDI was related with increased intake of juices, sweetened beverages, refined grains, potatoes and sweets. NAFLD was defined according to validated liver steatosis indices.

Results

In total, n=707 (35%) participants presented NAFLD at baseline. Ranking from 1st to 3rd PDI tertile, NAFLD prevalence was 40.3%, 35.6% and 30.9%, respectively (p=0.04). Multiadjusted analysis revealed significant inverse associations between PDI and NAFLD prevalence [Odds Ratio (OR) (3rd vs. 1st tertile)=0.60 95% Confidence Interval (95% CI) (0.35, 0.92)] as well as hPDI [OR (3rd vs. 1st tertile) = 0.75 95% CI (0.64, 0.89)]. On the other side, increased uPDI had a positive association with NAFLD prevalence [OR (3rd vs. 1st hPDI tertile) = 1.22 95% CI (1.05, 1.34)]. NAFLD predicted CVD in multi-adjusted model [Hazard Ratio (HR) = 1.35, 95% CI (1.08, 2.10)]. Subgroup analyses according to participants' adherence to overall, healthy and unhealthy plant-based patterns revealed that this observation remained significant in the following cases: participants in the 1st PDI tertile, [HR=1.40, 95% CI (1.15, 2.09)] and participants in the 1st hPDI tertile [HR=1.47, 95% CI (1.22, 2.12)].

Conclusions

Lower adherence to plant-based diet was associated with substantially higher long-term CVD risk for a NAFLD individual. Most importantly, the healthy or unhealthy food choices within this pattern seemed to determine liver steatosis progression and in turn cardiometabolic health.

Funding Acknowledgement

Type of funding sources: None.

Peritoneal dialysis as a therapeutic solution in elderly patients with cardiorenal syndrome and heart failure: a case-series report

Background

The aim of this work was to evaluate the impact of peritoneal dialysis (PD) on venous congestion, right ventricle function, systolic arterial pulmonary pressure and clinical functional status in elderly patients with cardiorenal syndrome (CRS) and chronic heart failure (HF).

Methods

A case series of 21 (17 males, 70±11 years) consecutive pts with diuretic-resistance heart failure and right ventricular dysfunction (median renal failure duration (RF) 60 months, range 13–287 months, mean ejection fraction 36±11%) having been engaged in PD (median of 12.5 months, range 2–28); 77% of the pts were under Automated Peritoneal Dialysis (APD), whereas the rest were under Continuous Ambulatory PD (CAPD). Patients' Pulmonary Artery Systolic Pressure (PASP), Central Venus Pressure (CVP) – through compression sonography – and body weight were evaluated in 6 intermediate clinical visits.

Results

During the follow-up period, the mortality rate was 8 deaths out of 21 pts (38%) (or 3 deaths/100 person-months).A significant reduction by 29.9% in PASP levels (p=0.013)and by 42% in CVP levels (p&lt;0.001), and in right ventricular function was observed; whereas pts weight increased by 3.7% (p=0.001). NYHA class improved in 12 pts; whereas, in the rest pts remained constant (p=0.046). In 8 pts complications were reported (mainly presence of staphylococcus. aureus).

Conclusion

PD seems to confer a substantial benefit in clinical status, in line with improvement in venous congestion and right ventricle systolic pressure among elderly HF patients with CRS.

Funding Acknowledgement

Type of funding sources: None.

A-posteriori protein-rich dietary patterns and their association with ten-year transition to metabolically unhealthy status: highlights from a population-based cohort study

Background/Introduction

The role of dietary protein on cardiometabolic health remains complex influenced by concomitant changes in overall diet composition. The quality of protein sources is currently suggested as more detrimental than the level of consumption itself.

Purpose

The association between different protein-rich dietary patterns and 10-year transition to metabolically unhealthy status in a sample from Greece was evaluated.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 men and n=1,528 women (&gt;18 years old) free of CVD. Healthy metabolic status was defined as absence of all NCEP ATP III (2005) metabolic syndrome components. Baseline dietary assessment was based on a validated semi-quantitative food frequency questionnaire. Dietary protein was calculated through standardized food database. Follow-up cardiometabolic assessment (2011–2012) was achieved in n=2,020 participants. Protein-rich dietary patterns were derived through factor analysis in the subsample of participants with high daily protein intake (&gt;15% of total energy intake corresponding to the median consumption level). Patterns were named according to food scores that correlated most with the factor (scores&gt;0.5).

Results

Overall, six of ten participants lost their metabolically healthy status within a decade. Multiadjusted analysis revealed an inverse yet non-significant association between total energy-standardized protein intake and transition to metabolically unhealthy status [Odds ratio (OR) (high vs. low protein intake)=0.59, 95% Confidence Interval (95% CI) (0.32, 1.10), p=0.09]. Factor analysis extracted three protein-rich dietary patterns, explained 55% of the total variation in intake. Factor A was characterized by increased consumption of processed meet, unprocessed red meat and eggs, factor B was characterized by increased consumption of nuts and seeds, legumes, whole grain products and fish while factor C was characterized by increased consumption of dairy products, poultry and vegetables. Multiadjusted logistic regression analysis revealed that factor B had the strongest protective effect against 10-year transition to metabolically unhealthy status [ORper 1 point increase in factor B score=0.74, 95% CI (0.60, 0.85), p=0.01] followed by a marginally protective effect of factor C [ORper 1 point increase in factor C score=0.89, 95% CI (0.73, 1.05), p=0.07]. Participants with higher adherence to factor A had an increased likelihood to lose their metabolically healthy status [ORper 1 point increase in factor A score=1.15, 95% CI (1.02, 1.30), p=0.04].

Conclusions

The present work confirms that within an increased level of dietary protein intake, different cardiometabolic outcomes were observed according to the quality of protein food sources consumed.

Funding Acknowledgement

Type of funding sources: None.

Multipoint left ventricular pacing effects on hemodynamic parameters and functional status: HUMVEE single-arm clinical trial

Objectives

The aim of this study was to assess the capacity of optimized multipoint pacing (MPP) over optimized cardiac resynchronization therapy (CRT), in terms of clinical, functional, and echocardiographic parameters among dyssynchronous heart failure patients.

Methods

Eighty patients (Caucasian, 77.5% male, 68.4±10.1 years, 53.8% ischemic cardiomyopathy) sequentially received optimized CRT and optimized MPP over 6 and 12-month periods, in a single-arm clinical trial. Clinical, laboratory and echocardiographic assessment was conducted at baseline and following completion of each step.

Results

Significant additive effects of optimized MPP over optimized CRT were noted regarding 6-minute walking distance (baseline/optCRT/optMPP: 293±120m vs 367±94m vs 405±129m, p&lt;0.001), NYHA class (2.36 vs 2.19 vs 1.45, p&lt;0.001), VTIlvot (14.25±3.2cm vs 16.2±4cm vs 17.5±3.4cm, p&lt;0.001), stroke volume (48±13.5ml vs 55±15ml vs 59±15ml, p&lt;0.001), LVEF (29%±7.1% vs 33%±7.3% vs 37%±7.7%, p&lt;0.001), maximal left atrial volume (77.2±34.2ml vs 74.2±39.5ml vs 67.7±32ml, p=0.02), pulmonary artery systolic pressure (35.9mmHg vs 33.5mmHg vs 31mmHg, p&lt;0.001), and right ventricular strain (−8.3%±6.9% vs −8.8%±6.6% vs −11.8%±6.1%, p=0.022). Regarding VAC SW and CP as percentages of maximal, there was significant difference detected compared to baseline for both CRT and MPP. Additive effects persisted only if suitable MPP dipoles were present. Exploratory analysis revealed that ischemic cardiomyopathy continued to exhibit significant differences favoring MPP, whereas nonischemic cardiomyopathy had similar findings regarding total left atrial strain and quality of life.

Conclusions

Optimized MPP showed significant improvements on hemodynamic parameters and ventricular function, in heart failure patients over optimized CRT. The beneficial effect was more prominent in men and in those with rather reduced LVEF, consistent with findings suggesting a beneficial trend in VAC and CP with the more homogenous depolarization offered by optimized MPP

Funding Acknowledgement

Type of funding sources: None.

Liver steatosis, metabolically healthy obesity and ten-year cardiovascular disease risk: results from a population based cohort study

Background/Introduction

Inclusion of non-alcoholic fatty liver disease (NAFLD) as a component of metabolic syndrome (MetS) and/or a criterion for defining metabolically healthy vs. unhealthy obese (MHO vs MUO) status remains to be decided.

Purpose

The present work evaluated the role of NAFLD at baseline in the transition of MHO to MUO status, and its role in predicting cardiovascular disease (CVD) incidence ten years later.

Methods

A prospective longitudinal study was performed between 2001 and 2012 studying 1,514 (49·8%) men and 1,528 (50.2%) women (&gt;18 years old) free of CVD at baseline and residing in the greater Athens area, Greece. Follow-up assessment of first fatal/non fatal CVD event (2011–2012) was achieved in n=2,020 participants (n=317 cases). Healthy metabolic status was defined as absence of all NCEP ATP III (2005) metabolic syndrome components. NAFLD was defined according to validated liver steatosis indices.

Results

Among obese participants, MHO prevalence was 9.8% (n=277). Only half of the MHO subjects retained their metabolically healthy status one decade later. NAFLD was an important predictor of this transition; MHO participants with NAFLD at baseline had about two times higher odds to develop unhealthy metabolic status compared with their non-NAFLD counterparts. Subsequently, MHO status accompanied by NAFLD was associated with increased CVD risk (Hazard Ratio=2.90 95%Confidence Interval (1.35, 5.40)) in contrast to their non-NAFLD MHO counterparts. C-statistics revealed that NAFLD significantly increased the discriminative ability of the standardly defined metabolic status (p for C-index change=0.002), yet in the total sample its contribution to the model seemed to be similar with the common metric of central obesity i.e. waist circumference (CNAFLD=0.711 vs. Cwc=0.710). When the analysis was restricted to the obese subset, it was revealed that the discriminative ability of the model adjusted for NAFLD was significantly higher compared with the one adjusted for waist circumference (CNAFLD=0.719 vs. Cwc=0.702).

Conclusions

Taking under consideration NAFLD – via validated indices – in the clinical assessment of an apparently healthy obese individual contributes to better defining future risk of conversion to metabolically unhealthy obesity and future cardiometabolic risk.

Funding Acknowledgement

Type of funding sources: None.

Hypertensive crisis and pulmonary edema following rituximab-induced anaphylaxis

Rituximab is a monoclonal antibody against the protein CD20. Various lymphomas as well as non-malignant immune disorders are treated with this antibody. Hypersensitivity reactions associated with the use of rituximab include urticaria, hypotension, chest tightness, vomiting, oxygen desaturation and bronchospasm. A very uncommon case of hypertensive crisis and pulmonary edema following rituximab-induced hypersensitivity reaction in an 80-year-old man receiving rituximab for non-Hodgkin lymphoma is reported. Anaphylaxis manifesting as coronary vasospasm following drug treatment, including rituximab, could be proved a serious condition in patients who need specific treatment. In these patients desensitization protocols seem to be mandatory.

The association between serum uric acid levels and 10-year cardiovascular disease incidence: results from the ATTICA prospective study

Limited data suggests possible gender-specific association between serum uric acid (SUA) and cardiovascular disease (CVD) incidence. The aim of the present analysis was to evaluate the association between SUA levels and 10-year CVD incidence (2002-2012) in the ATTICA study participants. Overall, 1687 apparently healthy volunteers, with SUA measurements, residing in the greater metropolitan Athens area (Greece), were included. Multivariable Cox-regression models were used to estimate the hazard ratios for SUA in relation to 10-year CVD incidence. Receiver operating curve analysis was conducted to detect optimal SUA cut-off values. Participants in the 2nd and 3rd SUA tertile had 29 and 73% higher 10-year CVD incidence compared with those in the 1st tertile (p < 0.001). In gender-specific analysis, only in women SUA was independently associated with CVD incidence; women in the 3rd SUA tertile had 79% greater 10-year CVD event risk compared to their 1st tertile counterparts. Obese in the 3rd SUA tertile had 2-times higher CVD incidence compared to those in the 1st tertile. Similar findings were observed in metabolically healthy (vs. unhealthy) and metabolically healthy obese. SUA thresholds best predicting 10-year CVD incidence was 5.05 and 4.15 mg/dL (0.30 and 0.25 mmol/L) in men and women, respectively. In conclusion, increased SUA levels were independently related to 10-year CVD event rate in women, obese and metabolically healthy individuals. SUA could predict 10-year CVD incidence even at low levels. Further studies are warranted to identify SUA cut-off values that may improve the detection of individuals at higher CVD risk in clinical practice.

Primary prevention of acute coronary events through the adoption of a Mediterranean-style diet

We evaluated the role of a Mediterranean-style diet in preventing acute coronary syndromes [ACS]. Data from CARDIO2000, a multi-centre retrospective case-control study investigating the association between ACS and demographic, nutritional, lifestyle and medical risk factors were used. We studied 661 patients hospitalized for a first ACS event and 661 matched controls without clinical suspicion of cardiovascular disease. The Mediterranean diet significantly reduced [by 16%] the risk of developing ACS. The association remained significant in the presence of hypertension, hypercholesterolaemia, sedentary lifestyle, diabetes mellitus or a combination of two of these cardiovascular risk factors. Our findings illustrate the importance of the Mediterranean diet in the primary prevention of acute coronary events

Women leaders in Cardiology. Contemporary profile of the WHO European region

Aims

Women’s participation is steadily growing in medical schools, but they are still not sufficiently represented in cardiology, particularly in cardiology leadership positions. We present the contemporary distribution of women leaders in cardiology departments in the World Health Organization European region.

Methods and results

Between August and December 2020, we applied purposive sampling to collect data and analyse gender distribution of heads of cardiology department in university/third level hospitals in 23 countries: Austria, Azerbaijan, Belgium, Bosnia-Herzegovina, Croatia, France, Germany, Greece, Italy, North Macedonia, Morocco, Poland, Portugal, Russia, Serbia, Slovakia, Slovenia, Spain, Switzerland, Tunisia, Turkey, Ukraine, and the UK. Age, cardiology subspecialty, and number of scientific publications were recorded for a subgroup of cardiology leaders for whom data were available. A total of 849 cardiology departments were analysed. Women leaders were only 30% (254/849) and were younger than their men counterpart (♀ 52.2 ± 7.7 years old vs. ♂ 58.1 ± 7.6 years old, P = 0.00001). Most women leaders were non-interventional experts (♀ 82% vs. ♂ 46%, P &lt; 0.00001) and had significantly fewer scientific publications than men {♀ 16 [interquartile range (IQR) 2–41] publications vs. ♂ 44 (IQR 9–175) publications, P &lt; 0.00001}.

Conclusion

Across the World Health Organization European region, there is a significant gender disparity in cardiology leadership positions. Fostering a diverse and inclusive workplace is a priority to achieve the full potential and leverage the full talents of both women and men.