Journal: Eur J Prev Cardiol

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Abstract

Follow-up of patients after revascularisation for peripheral arterial diseases: a consensus document from the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery.

Venermo M, Sprynger M, Desormais I, Björck M, ... Aboyans V,

Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient\'s general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.



Eur J Prev Cardiol: 31 Oct 2019:2047487319846999; epub ahead of print
Venermo M, Sprynger M, Desormais I, Björck M, ... Aboyans V,
Eur J Prev Cardiol: 31 Oct 2019:2047487319846999; epub ahead of print | PMID: 31672063
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Abstract

Sex-related differences in exercise performance and outcome of patients with hypertrophic cardiomyopathy.

Ghiselli L, Marchi A, Fumagalli C, Maurizi N, ... Mori F, Olivotto I
Aims
Exercise performance is known to predict outcome in hypertrophic cardiomyopathy (HCM), but whether sex-related differences exist is unresolved. We explored whether functional impairment, assessed by exercise echocardiography, has comparable predictive accuracy in females and males with HCM.
Methods
We retrospectively evaluated 292 HCM patients (46 ± 16 years, 72% males), consecutively referred for exercise echocardiography; 242 were followed for 5.9 ± 4.2 years.
Results
Peak exercise capacity was 6.5 ± 1.6 metabolic equivalents (METs). Sixty patients (21%) showed impaired exercise capacity (≤5 METs). Exercise performance was reduced in females, compared with males (5.6 ± 1.6 vs 6.9 ± 1.5 METs,  < 0.001; peak METs ≤ 5 in 40% vs 13%,  < 0.001), largely driven by a worse performance in women >50 years of age. At multivariable analysis, female sex was independently associated with impaired exercise capacity (odds ratio: 4.67; 95% confidence interval (CI): 1.83-11.90;  = 0.001). During follow-up, 24 patients (10%) met the primary endpoint (a combination of cardiac death, heart failure requiring hospitalization, sustained ventricular tachycardia, appropriate implantable cardioverter defibrillator discharge, resuscitated sudden cardiac death and cardioembolic stroke). Event-free survival was reduced in females ( = 0.035 vs males). Peak METs were inversely related to outcome in males (hazard ratio (HR) per unit increase: 0.57; 95% CI: 0.39-0.84;  = 0.004) but not in females (HR: 1.22; 95% CI: 0.66-2.24;  = 0.53).
Conclusions
Female patients with HCM showed significant age-related impairment in functional capacity compared with males, particularly evident in post-menopausal age groups. While women were at greater risk of HCM-related complications and death, impaired exercise capacity predicted adverse outcome only in men. These findings suggest the need for sex-specific management strategies in HCM.



Eur J Prev Cardiol: 06 Nov 2019:2047487319886961; epub ahead of print
Ghiselli L, Marchi A, Fumagalli C, Maurizi N, ... Mori F, Olivotto I
Eur J Prev Cardiol: 06 Nov 2019:2047487319886961; epub ahead of print | PMID: 31698967
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Abstract

Modifiable lifestyle risk factors and C-reactive protein in patients with coronary artery disease: Implications for an anti-inflammatory treatment target population.

Blaum C, Brunner FJ, Kröger F, Braetz J, ... Seiffert M, Waldeyer C
Background
Modifiable lifestyle risk factors (modRF) of coronary artery disease (CAD) are associated with increased inflammation represented by elevated C-reactive protein (CRP) levels. Lifestyle changes may influence the inflammatory burden in patients with CAD, relevantly modifying the target population for emerging anti-inflammatory compounds.
Aims
The aims of this study were to analyse the association of modRF and CRP levels in CAD patients, and to define a potential target population for anti-inflammatory treatment with and without the optimisation of modRF.
Methods
We included all patients with angiographically documented CAD from the observational cohort study INTERCATH. Patients with recent myocardial infarction, malignancy, infectious disease, and pre-existing immunosuppressive medication including a history of solid organ transplantation were excluded. Overweight (body mass index (BMI) ≥ 25 kg/m), smoking, lack of physical activity (PA; <1.5 h/week), and poor diet (≤12 points of an established Mediterranean diet score (MDS), range 0-28 points) were considered as modRF. CRP was measured by a high-sensitivity assay (hsCRP) at baseline. We performed multivariable linear regressions with log-transformed hsCRP as the dependent variable. Based on these associations, we calculated potential hsCRP levels for each patient, assuming optimisation of the individual modRF.
Results
Of 1014 patients, 737 (73%) were male, the mean age was 69 years, and 483 (48%) had an hsCRP ≥ 2 mg/l. ModRF were significantly overrepresented in patients with hsCRP ≥ 2 mg/l compared to patients with an hsCRP < 2 mg/l (BMI ≥ 25 kg/m: 76% vs 61%; PA < 1.5 h/week: 69% vs 57%; MDS ≤ 12: 46% vs 37%; smoking: 61% vs 54%;  < 0.05 for all). hsCRP increased with the incremental number of modRF present (median hsCRP values for  = 0, 1, 2, 3, and 4 modRF: 1.1, 1.0, 1.6, 2.4, 2.8 mg/l,  < 0.001). Multivariable linear regression adjusting for age, sex, intake of lipid-lowering medication, and diabetes mellitus revealed independent associations between log-transformed hsCRP and all modRF (BMI ≥ 25 kg/m: exp(ß) = 1.55,  < 0.001; PA < 1.5 h/week: exp(ß) = 1.33,  < 0.001; MDS ≤ 12: exp(ß) = 1.18,  = 0.018; smoking: exp(ß) = 1.18,  = 0.019). Individual recalculation of hsCRP levels assuming optimisation of modRF identified 183 out of 483 (38%) patients with hsCRP ≥ 2 mg/l who could achieve an hsCRP < 2 mg/l via lifestyle changes.
Conclusion
modRF are strongly and independently associated with CRP levels in patients with CAD. A relevant portion of CAD patients with high inflammatory burden could achieve an hsCRP < 2 mg/l by lifestyle changes alone. This should be considered both in view of the cost and side-effects of pharmacological anti-inflammatory treatment and for the design of future clinical trials in this field.



Eur J Prev Cardiol: 09 Nov 2019:2047487319885458; epub ahead of print
Blaum C, Brunner FJ, Kröger F, Braetz J, ... Seiffert M, Waldeyer C
Eur J Prev Cardiol: 09 Nov 2019:2047487319885458; epub ahead of print | PMID: 31707846
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Abstract

High-intensity interval training has a greater effect on reverse cholesterol transport elements compared with moderate-intensity continuous training in obese male rats.

Rahmati-Ahmadabad S, Azarbayjani MA, Farzanegi P, Moradi L
Objectives
The present study compares the effect of high-intensity interval training (HIIT; 18 min) and moderate-intensity continuous training (MIT; 1 h) on reverse cholesterol transport (RCT) elements in obese subjects.
Methods
Thirty adult male rats were induced high-fat diet (HFD) for 12 weeks. After four weeks, the rats were randomly divided into three groups while simultaneously continuing the HFD for the remaining eight weeks. Group specificities were HFD-control, HFD-MIT and HFD-HIIT. The rats were sacrificed 48 h after the last training session and the samples were collected. Analysis of variance and Pearson\'s correlation test were used for the statistical analyses (significance level: 0.05).
Results
The results showed that both HIIT and MIT improved heart ABCA1, ABCG1, ABCG4, ABCG5, ABCG8, LXR-α and PPARγ gene expression as well as plasma Apo A1, LCAT, lipids and lipoproteins (0.05). Moreover, higher cardiac ABCA1, ABCG1, ABCG4, ABCG5, ABCG8 and PPARγ expression and plasma high-density lipoprotein cholesterol ( ≤ 0.05) concentrations were found in the HFD-HIIT group compared with the HFD-MIT group.
Conclusion
HIIT may have more cardioprotective effects than MIT against atherosclerosis, along with saving time, as supported by the changes observed in the main factors involved in the RCT process.



Eur J Prev Cardiol: 11 Nov 2019:2047487319887828; epub ahead of print
Rahmati-Ahmadabad S, Azarbayjani MA, Farzanegi P, Moradi L
Eur J Prev Cardiol: 11 Nov 2019:2047487319887828; epub ahead of print | PMID: 31718266
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Abstract

Acute impact of an endurance race on cardiac function and biomarkers of myocardial injury in triathletes with and without myocardial fibrosis.

Tahir E, Scherz B, Starekova J, Muellerleile K, ... Patten M, Lund GK
Aims
The aim of this study was to investigate the occurrence of myocardial injury and cardiac dysfunction after an endurance race by biomarkers and cardiac magnetic resonance in triathletes with and without myocardial fibrosis.
Methods and results
Thirty asymptomatic male triathletes (45 ± 10 years) with over 10 training hours per week and 55 ± 8 ml/kg per minute maximal oxygen uptake during exercise testing were studied before (baseline) and 2.4 ± 1.1 hours post-race. Baseline cardiac magnetic resonance included cine, T1/T2, late gadolinium enhancement (LGE) and extracellular volume imaging. Post-race non-contrast cardiac magnetic resonance included cine and T1/T2 mapping. Non-ischaemic myocardial fibrosis was present in 10 triathletes (LGE+) whereas 20 had no fibrosis (LGE-). At baseline, LGE + triathletes had higher peak exercise systolic blood pressure with 222 ± 21 mmHg compared to LGE- triathletes (192 ± 30 mmHg,  < 0.01). Post-race troponin T and creatine kinase MB were similarly increased in both groups, but there was no change in T2 and T1 from baseline to post-race with 54 ± 3 ms versus 53 ± 3 ms ( = 0.797) and 989 ± 21 ms versus 989 ± 28 ms ( = 0.926), respectively. However, post-race left atrial ejection fraction was significantly lower in LGE + triathletes compared to LGE- triathletes (53 ± 6% vs. 59 ± 6%,  < 0.05). Furthermore, baseline atrial peak filling rates were lower in LGE -  triathletes (121 ± 30 ml/s/m) compared to LGE + triathletes (161 ± 34 ml/s/m,  < 0.01). Post-race atrial peak filling rates increased in LGE- triathletes to 163 ± 46 ml/s/m,  < 0.001), but not in LGE + triathletes (169 ± 50ml/s/m,  = 0.747).
Conclusion
Despite post-race troponin T release, we did not find detectable myocardial oedema by cardiac magnetic resonance. However, the unfavourable blood pressure response during exercise testing seemed to be associated with post-race cardiac dysfunction, which could explain the occurrence of myocardial fibrosis in triathletes.



Eur J Prev Cardiol: 30 Dec 2019; 27:94-104
Tahir E, Scherz B, Starekova J, Muellerleile K, ... Patten M, Lund GK
Eur J Prev Cardiol: 30 Dec 2019; 27:94-104 | PMID: 31242053
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Abstract

Sleep - the yet underappreciated player in cardiovascular diseases: A clinical review from the German Cardiac Society Working Group on Sleep Disordered Breathing.

Spiesshoefer J, Linz D, Skobel E, Arzt M, ... Oldenburg O, On Behalf Of The German Cardiac Society Working Group On Sleep Disordered Breathing Ag-Deutsche Gesellschaft Für Kardiologie Herz Und Kreislaufforschung E V O

Patients with a wide variety of cardiovascular diseases, including arterial and pulmonary hypertension, arrhythmia, coronary artery disease and heart failure, are more likely to report impaired sleep with reduced sleep duration and quality, and also, sometimes, sleep interruptions because of paroxysmal nocturnal dyspnoea or arrhythmias. Overall, objective short sleep and bad sleep quality (non-restorative sleep) and subjective long sleep duration are clearly associated with major cardiovascular diseases and fatal cardiovascular outcomes. Sleep apnoea, either obstructive or central in origin, represents the most prevalent, but only one, of many sleep-related disorders in cardiovascular patients. However, observations suggest a bidirectional relationship between sleep and cardiovascular diseases that may go beyond what can be explained based on concomitant sleep-related disorders as confounding factors. This makes sleep itself a modifiable treatment target. Therefore, this article reviews the available literature on the association of sleep with cardiovascular diseases, and discusses potential pathophysiological mechanisms. In addition, important limitations of the current assessment, quantification and interpretation of sleep in patients with cardiovascular disease, along with a discussion of suitable study designs to address future research questions and clinical implications are highlighted. There are only a few randomised controlled interventional outcome trials in this field, and some of the largest studies have failed to demonstrate improved survival with treatment (with worse outcomes in some cases). In contrast, some recent pilot studies have shown a benefit of treatment in selected patients with underlying cardiovascular diseases.



Eur J Prev Cardiol: 28 Oct 2019:2047487319879526; epub ahead of print
Spiesshoefer J, Linz D, Skobel E, Arzt M, ... Oldenburg O, On Behalf Of The German Cardiac Society Working Group On Sleep Disordered Breathing Ag-Deutsche Gesellschaft Für Kardiologie Herz Und Kreislaufforschung E V O
Eur J Prev Cardiol: 28 Oct 2019:2047487319879526; epub ahead of print | PMID: 31658829
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Abstract

Circulating biomarkers for long-term cardiovascular risk stratification in apparently healthy individuals from the MONICA 10 cohort.

Frary CE, Blicher MK, Olesen TB, Stidsen JV, ... Olsen MH, Pareek M
Aims
The aim of this study was to examine whether high-sensitivity C-reactive protein (hs-CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP), and soluble urokinase plasminogen activator receptor (suPAR) carried incremental prognostic value in predicting cardiovascular morbidity and mortality beyond traditional risk factors in apparently healthy individuals.
Methods and results
This was a prospective population-based cohort study comprising 1951 subjects included in the 10-year follow-up of the MONItoring of trends and determinants in CArdiovascular disease (MONICA) study, between 1993 and 1994. The principal endpoint was death from cardiovascular causes. Secondary endpoints were death from any cause, coronary artery disease, heart failure, and cerebrovascular disease. Predictive capabilities of each of the three biomarkers were tested using Cox proportional-hazards regression, Harrell\'s concordance index (C-index), and net reclassification improvement (NRI). Study participants were aged 41, 51, 61, or 71 years, and equally distributed between the two sexes. During a median follow-up of 18.5 years (interquartile range: 18.1-19.0), 177 (9.1%) subjects died from a cardiovascular cause. Hs-CRP (adjusted standardized hazard ratio (HR): 1.37, 95% confidence interval (CI): 1.17-1.60), NT-proBNP (HR: 1.90, 95% CI: 1.58-2.29), and suPAR (HR: 1.35, 95% CI: 1.17-1.57) were all significantly associated with cardiovascular deaths after adjustment for age, sex, smoking status, systolic blood pressure, and total cholesterol ( < 0.001 for all). Furthermore, all three biomarkers were significantly associated with significant NRI. However, only NT-proBNP significantly raised the C-index in predicting death from cardiovascular causes when added to the risk factors (C-index 0.860 versus 0.847;  = 0.02).
Conclusions
Hs-CRP, suPAR, and particularly NT-proBNP predicted cardiovascular death and may enhance prognostication beyond traditional risk factors in apparently healthy individuals.



Eur J Prev Cardiol: 11 Nov 2019:2047487319885457; epub ahead of print
Frary CE, Blicher MK, Olesen TB, Stidsen JV, ... Olsen MH, Pareek M
Eur J Prev Cardiol: 11 Nov 2019:2047487319885457; epub ahead of print | PMID: 31718257
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Abstract

Revisiting the obesity paradox in heart failure: Per cent body fat as predictor of biomarkers and outcome.

Aimo A, Januzzi JL, Vergaro G, Clerico A, ... Passino C, Emdin M
Aims
Obesity defined by body mass index (BMI) is characterized by better prognosis and lower plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure. We assessed whether another anthropometric measure, per cent body fat (PBF), reveals different associations with outcome and heart failure biomarkers (NT-proBNP, high-sensitivity troponin T (hs-TnT), soluble suppression of tumorigenesis-2 (sST2)).
Methods
In an individual patient dataset, BMI was calculated as weight (kg)/height (m), and PBF through the Jackson-Pollock and Gallagher equations.
Results
Out of 6468 patients (median 68 years, 78% men, 76% ischaemic heart failure, 90% reduced ejection fraction), 24% died over 2.2 years (1.5-2.9), 17% from cardiovascular death. Median PBF was 26.9% (22.4-33.0%) with the Jackson-Pollock equation, and 28.0% (23.8-33.5%) with the Gallagher equation, with an extremely strong correlation ( = 0.996,  < 0.001). Patients in the first PBF tertile had the worst prognosis, while patients in the second and third tertile had similar survival. The risks of all-cause and cardiovascular death decreased by up to 36% and 27%, respectively, per each doubling of PBF. Furthermore, prognosis was better in the second or third PBF tertiles than in the first tertile regardless of model variables. Both BMI and PBF were inverse predictors of NT-proBNP, but not hs-TnT. In obese patients (BMI ≥ 30 kg/m, third PBF tertile), hs-TnT and sST2, but not NT-proBNP, independently predicted outcome.
Conclusion
In parallel with increasing BMI or PBF there is an improvement in patient prognosis and a decrease in NT-proBNP, but not hs-TnT or sST2. hs-TnT or sST2 are stronger predictors of outcome than NT-proBNP among obese patients.



Eur J Prev Cardiol: 30 Oct 2019; 26:1751-1759
Aimo A, Januzzi JL, Vergaro G, Clerico A, ... Passino C, Emdin M
Eur J Prev Cardiol: 30 Oct 2019; 26:1751-1759 | PMID: 31154828
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Abstract

Health behaviours reported by adults with congenital heart disease across 15 countries.

Holbein CE, Peugh J, Veldtman GR, Apers S, ... Moons P,
Background
Health behaviours are essential to maintain optimal health and reduce the risk of cardiovascular complications in adults with congenital heart disease. This study aimed to describe health behaviours in adults with congenital heart disease in 15 countries and to identify patient characteristics associated with optimal health behaviours in the international sample.
Design
This was a cross-sectional observational study.
Methods
Adults with congenital heart disease ( = 4028, median age = 32 years, interquartile range 25-42 years) completed self-report measures as part of the Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study (APPROACH-IS). Participants reported on seven health behaviours using the Health Behaviors Scale-Congenital Heart Disease. Demographic and medical characteristics were assessed via medical chart review and self-report. Multivariate path analyses with inverse sampling weights were used to investigate study aims.
Results
Health behaviour rates for the full sample were 10% binge drinking, 12% cigarette smoking, 6% recreational drug use, 72% annual dental visit, 69% twice daily tooth brushing, 27% daily dental flossing and 43% sport participation. Pairwise comparisons indicated that rates differed between countries. Rates of substance use behaviours were higher in younger, male participants. Optimal dental health behaviours were more common among older, female participants with higher educational attainment while sports participation was more frequent among participants who were younger, male, married, employed/students, with higher educational attainment, less complex anatomical defects and better functional status.
Conclusions
Health behaviour rates vary by country. Predictors of health behaviours may reflect larger geographic trends. Our findings have implications for the development and implementation of programmes for the assessment and promotion of optimal health behaviours in adults with congenital heart disease.



Eur J Prev Cardiol: 16 Sep 2019:2047487319876231; epub ahead of print
Holbein CE, Peugh J, Veldtman GR, Apers S, ... Moons P,
Eur J Prev Cardiol: 16 Sep 2019:2047487319876231; epub ahead of print | PMID: 31529991
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Abstract

Cardiac structure and function in response to a multi-stage marathon over 4486 km.

Klenk C, Brunner H, Nickel T, Sagmeister F, ... Schütz U, Schmidt-Trucksäss A
Aims
To investigate whether participation in the Trans Europe Foot Race 2009 (TEFR), an ultramarathon race held over 64 consecutive days and 4486 km, led to changes in cardiac structure and function.
Methods
Cardiac magnetic resonance imaging was performed in 20 of 67 participating runners (two women; mean ± SD age 47.8 ± 10.4 years) at three time points (baseline scan at 294 ± 135 km (B), scan two at 1735 ± 86 km (T1) and scan three at 3370 ± 90 km (T2)) during the TEFR. Imaging included an assessment of left ventricular structure (mass) and function (strain). In parallel, cardiac troponin I, NT-pro-BNP, myostatin and GDF11 were determined in venous blood samples. A subsample of ten runners returned for a follow-up scan eight months after the race.
Results
Left ventricular mass increased significantly (B, 158.5 ± 23.8 g; T1, 165.1 ± 23.2 g; T2, 167 ± 24.6 g;  < 0.001) over the course of the race, although no significant change was seen in the remaining structural and functional parameters. Serum concentrations of cardiac troponin I and NT-proBNP significantly increased 1.5 - and 3.5-fold, respectively, during the first measurement interval, with no further increase thereafter (cardiac troponin I, 6.8 ± 3.1 (B), 16.9 ± 10.4 (T1) and 17.1 ± 9.7 (T2); NT-proBNP, 30.3 ± 22.8 (B), 135.9 ± 177.5 (T1) and 111.2 ± 87.3 (T2)), whereas the growth markers myostatin and GDF11 did not change. No association was observed with functional parameters, including the ejection fraction and the volume of both ventricles. The follow-up scans showed a reduction to baseline values (left ventricular mass 157 ± 19.3 g).
Conclusions
High exercise-induced cardiac volume load for >2 months in ultra-endurance runners results in a physiological structural adaptation with no sign of adverse cardiovascular remodelling.



Eur J Prev Cardiol: 25 Oct 2019:2047487319885035; epub ahead of print
Klenk C, Brunner H, Nickel T, Sagmeister F, ... Schütz U, Schmidt-Trucksäss A
Eur J Prev Cardiol: 25 Oct 2019:2047487319885035; epub ahead of print | PMID: 31657224
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Abstract

Effects of apixaban compared with warfarin as gain in event-free time - a novel assessment of the results of the ARISTOTLE trial.

Berglund E, Wallentin L, Oldgren J, Renlund H, ... McMurray JJ, Lytsy P
Background
A novel approach to determine the effect of a treatment is to calculate the delay of event, which estimates the gain of event-free time. The aim of this study was to estimate gains in event-free time for stroke or systemic embolism, death, bleeding events, and the composite of these events, in patients with atrial fibrillation randomized to either warfarin or apixaban in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial (ARISTOTLE).
Design
The ARISTOTLE study was a randomized double-blind trial comparing apixaban with warfarin.
Methods
Laplace regression was used to estimate the delay in time to the outcomes between the apixaban and the warfarin group in 6, 12, 18 and 22 months of follow-up.
Results
The gain in event-free time for apixaban versus warfarin was 181 (95% confidence interval 76 to 287) days for stroke or systemic embolism and 55 (-4 to 114) days for death after 22 months of follow-up. The corresponding gains in event-free times for major and intracranial bleeding were 206 (130 to 281) and 392 (249 to 535) days, respectively. The overall gain for the composite of all these events was a gain of 116 (60 to 171) days.
Conclusions
In patients with atrial fibrillation, 22 months of treatment with apixaban, as compared with warfarin, provided gains of approximately 6 months in event-free time for stroke or systemic embolism, 7 months for major bleeding and 13 months for intracranial bleeding.



Eur J Prev Cardiol: 06 Nov 2019:2047487319886959; epub ahead of print
Berglund E, Wallentin L, Oldgren J, Renlund H, ... McMurray JJ, Lytsy P
Eur J Prev Cardiol: 06 Nov 2019:2047487319886959; epub ahead of print | PMID: 31698965
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Abstract

Phenomapping of subgroups in hypertensive patients using unsupervised data-driven cluster analysis: An exploratory study of the SPRINT trial.

Yang DY, Nie ZQ, Liao LZ, Zhang SZ, ... Zhuang XD, Liao XX
Background
Hypertensive patients are highly heterogeneous in cardiovascular prognosis and treatment responses. A better classification system with phenomapping of clinical features would be of greater value to identify patients at higher risk of developing cardiovascular outcomes and direct individual decision-making for antihypertensive treatment.
Methods
An unsupervised, data-driven cluster analysis was performed for all baseline variables related to cardiovascular outcomes and treatment responses in subjects from the Systolic Blood Pressure Intervention Trial (SPRINT), in order to identify distinct subgroups with maximal within-group similarities and between-group differences. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for cardiovascular outcomes and compare the effect of intensive antihypertensive treatment in different clusters.
Results
Four replicable clusters of patients were identified: cluster 1 (index hypertensives); cluster 2 (chronic kidney disease hypertensives); cluster 3 (obese hypertensives) and cluster 4 (extra risky hypertensives). In terms of prognosis, individuals in cluster 4 had the highest risk of developing primary outcomes. In terms of treatment responses, intensive antihypertensive treatment was shown to be beneficial only in cluster 4 (HR 0.73, 95% CI 0.55-0.98) and cluster 1 (HR 0.54, 95% CI 0.37-0.79) and was associated with an increased risk of severe adverse effects in cluster 2 (HR 1.18, 95% CI 1.05-1.32).
Conclusion
Using a data-driven approach, SPRINT subjects can be stratified into four phenotypically distinct subgroups with different profiles on cardiovascular prognoses and responses to intensive antihypertensive treatment. Of note, these results should be taken as hypothesis generating that warrant further validation in future prospective studies.



Eur J Prev Cardiol: 30 Oct 2019; 26:1693-1706
Yang DY, Nie ZQ, Liao LZ, Zhang SZ, ... Zhuang XD, Liao XX
Eur J Prev Cardiol: 30 Oct 2019; 26:1693-1706 | PMID: 31213079
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Abstract

Cardiovascular health literacy and patient-physician communication intervention in women from disadvantaged communities.

Greenberg KL, Leiter E, Donchin M, Agbaria N, Karjawally M, Zwas DR
Background
For many women in low socioeconomic status communities, limited health literacy is an obstacle to following medical guidance and engaging in health-promoting behaviours. Low health literacy skills are also associated with an increased risk of cardiovascular disease.
Design
A health literacy intervention was designed through focus groups with women in low socioeconomic status communities. The primary health literacy issue identified was communication challenges at doctors\' visits. A unique intervention tailored to the participants\' preferences was designed consisting of three workshops conducted in community women\'s groups in low socioeconomic status Jerusalem communities. The intervention aimed to increase patient-physician communication skills through doctor visit preparation and better visit management, improve perceived efficacy in patient-physician interaction and expand cardiovascular disease knowledge.
Methods
Questionnaires were completed before and 3 months after the intervention, assessing knowledge of cardiovascular disease risk factors and symptoms, self-report of behaviours in preparations for a doctor\'s visit, and perceived efficacy in patient-physician interaction.
Results
A total of 407 women from low socioeconomic status communities completed questionnaires. Post-intervention, the percentage of women that reported preparing for doctors\' visits increased significantly. Women with initially low levels of perceived efficacy in patient-physician interaction showed a significant increase in perceived efficacy, while initially higher perceived efficacy in patient-physician interaction participants showed a decrease. Participants also demonstrated an increase in knowledge of several risk factors for cardiovascular disease and heart attack symptoms.
Conclusions
A community-based cardiovascular health literacy intervention improved cardiovascular knowledge and reported doctor visit preparation in low socioeconomic status women as well as increased perceived efficacy in patient-physician interaction among participants with low baseline perceived efficacy in patient-physician interaction. This may lead to improved health care utilisation, preventing chronic illness. Registered at ClinicalTrials.gov, https://www.clinicaltrials.gov , registration number: NCT03203018.



Eur J Prev Cardiol: 30 Oct 2019; 26:1762-1770
Greenberg KL, Leiter E, Donchin M, Agbaria N, Karjawally M, Zwas DR
Eur J Prev Cardiol: 30 Oct 2019; 26:1762-1770 | PMID: 31189377
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Abstract

Body mass index in women aged 18 to 45 and subsequent risk of heart failure.

Björck L, Lundberg C, Schaufelberger M, Lissner L, Adiels M, Rosengren A
Background
The incidence of heart failure (HF) is decreasing in older ages, but increasing rates have been observed among younger persons in Sweden. Therefore, we investigated the relationship between risk of hospitalization for HF and body mass index (BMI).
Methods
This was a prospective registry-based cohort study. We included 1,374,031 women aged 18-45 years (mean age 27.9 years) who gave birth during 1982-2014, and were registered in the Medical Birth Register. Information on hospitalization because of HF was collected through linkage to the National Inpatient Register.
Results
Compared to women with a BMI of 20-<22.5 kg/m, women with a BMI of 22.5-<25.0 had a hazard ratio (HR) of 1.24 (95% confidence interval (CI), 1.10-1.39) for HF after adjustment for age, year, parity, baseline disorders, smoking, and education. The HR (95% CI) increased to 1.56 (1.36-1.78), 2.39 (2.05-2.78), 2.82 (2.43-3.28), and 4.51 (3.63-5.61) in women with a BMI of 25-<27.5, 27.5-<30, 30-<35, and ≥35 kg/m, respectively. The multiple-adjusted HRs (95% CI) associated with risk of HF per one-unit increase in BMI in women with a BMI ≥ 22.5 kg/m ranged from 1.01 (0.97-1.06) for HF related to valvular disease to 1.14 (1.12-1.15) for coronary heart disease, diabetes, or hypertension.
Conclusion
Increasing body weight was strongly associated with the risk of early HF in women. Compared with lean women, the risk for HF started to increase at high-normal BMI levels, and was nearly five-fold in women with a BMI ≥ 35 kg/m.



Eur J Prev Cardiol: 04 Nov 2019:2047487319882510; epub ahead of print
Björck L, Lundberg C, Schaufelberger M, Lissner L, Adiels M, Rosengren A
Eur J Prev Cardiol: 04 Nov 2019:2047487319882510; epub ahead of print | PMID: 31684761
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Abstract

Socioeconomic position and one-year mortality risk among patients with heart failure: A nationwide register-based cohort study.

Andersen J, Gerds TA, Gislason G, Schou M, ... Madelaire C, Strandberg-Larsen K
Aims
We sought to determine whether socioeconomic position affects the survival of patients with heart failure treated in a national healthcare system.
Methods
We linked national Danish registers, identified 145,690 patients with new-onset heart failure between 2000 and 2015, and obtained information on education and income levels. We analysed differences in survival by income quartile and educational level using multiple Cox regression, stratified by sex. We standardised one-year mortality risks according to income level by age, year of diagnosis, cohabitation status, educational level, comorbidities and medical treatment of all patients. We standardised one-year mortality risk according to educational level by age and year of diagnosis.
Results
One-year mortality was inversely related to income. In women the standardised average one-year mortality risk was 28.0% in the lowest income quartile and 24.3% in the highest income quartile, a risk difference of -3.8% (95% confidence interval (CI) -4.9% to -2.6%). In men the standardised one-year mortality risk was 26.1% in the lowest income quartile and 20.2% in the highest income quartile, a risk difference of -5.8% (95% CI -6.8% to -4.9%). Similar gradients in standardised mortality were present between the highest and lowest educational levels: -6.6% (95% CI -9.6% to -3.5%) among women and -5.0% (95% CI -6.3% to -3.7%) among men.
Conclusions
Income and educational level affect the survival of patients with heart failure, even in a national health system. Research is needed to investigate how socioeconomic differences affect survival.



Eur J Prev Cardiol: 30 Dec 2019; 27:79-88
Andersen J, Gerds TA, Gislason G, Schou M, ... Madelaire C, Strandberg-Larsen K
Eur J Prev Cardiol: 30 Dec 2019; 27:79-88 | PMID: 31349771
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Abstract

Integrating natriuretic peptides and diastolic dysfunction to predict adverse events in high-risk asymptomatic subjects.

Gori M, Lam CS, D\'Elia E, Iorio AM, ... Gavazzi A, Senni M
Background
Natriuretic peptides and diastolic dysfunction have prognostic value in asymptomatic subjects at risk for heart failure. Their integration might further refine the risk stratification process in this setting. Aim of this paper was to explore the possibility to predict heart failure and death combining diastolic dysfunction and natriuretic peptides in an asymptomatic population at risk for heart failure.
Methods
Among 4047 subjects aged ≥55/≤80 years followed by 10 general practitioners in Italy, the DAVID-Berg study prospectively enrolled 623 asymptomatic outpatients at increased risk for heart failure. Baseline evaluation included electrocardiogram, echocardiogram, and natriuretic peptides collection. Based on diastolic dysfunction and natriuretic peptides, subjects were classified in four groups: control group (no diastolic dysfunction/normal natriuretic peptides, 57%), no diastolic dysfunction/high natriuretic peptides (9%), diastolic dysfunction/normal natriuretic peptides (24%), and diastolic dysfunction/high natriuretic peptides (11%). We applied Cox multivariable and Classification and Regression Tree analyses.
Results
The mean age of the population was 69 ± 7 years, 44% were women, mean left ventricular ejection fraction was 61%, and 35% had diastolic dysfunction. During a median follow-up of 5.7 years, 95 heart failure/death events occurred. Overall, diastolic dysfunction and natriuretic peptides were predictive of adverse events (respectively, hazard ratio 1.91, confidence interval 1.19-3.05,  = 0.007, and hazard ratio 2.25, confidence interval 1.35-3.74,  = 0.002) with Cox analysis. However, considering the four study subgroups, only the group with diastolic dysfunction/high natriuretic peptides had a significantly worse prognosis compared to the control group (hazard ratio 4.48, confidence interval 2.31-8.70,  < 0.001). At Classification and Regression Tree analysis, diastolic dysfunction/high natriuretic peptides was the strongest prognostic factor (risk range 24-58%).
Conclusions
The DAVID-Berg data suggest that we look for the quite common combination of diastolic dysfunction/high natriuretic peptides to correctly identify asymptomatic subjects at greater risk for incident heart failure/death, thus more suitable for preventive interventions.



Eur J Prev Cardiol: 02 Feb 2020:2047487319899618; epub ahead of print
Gori M, Lam CS, D'Elia E, Iorio AM, ... Gavazzi A, Senni M
Eur J Prev Cardiol: 02 Feb 2020:2047487319899618; epub ahead of print | PMID: 32013597
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Abstract

Hypertensive disorders of pregnancy and cardiometabolic outcomes in childhood: A systematic review.

Jansen MA, Pluymen LP, Dalmeijer GW, Groenhof TKJ, ... Smit HA, van Rossem L
Background
Hypertensive disorders of pregnancy (HDPs) are among the leading causes of maternal and perinatal morbidity and mortality worldwide and have been suggested to increase long-term cardiovascular disease risk in the offspring.
Objective
The objective of this study was to investigate whether HDPs are associated with cardiometabolic markers in childhood.
Search strategy
PubMed, The Cochrane Library and reference lists of included studies up to January 2019.
Selection criteria
Studies comparing cardiometabolic markers in 2-18-year-old children of mothers with HDP in utero, to children of mothers without HDP.
Data collection and analysis
Sixteen studies reported in 25 publications were included in this systematic review, of which three were considered as having high risk of bias. Thus 13 studies were included in the evidence synthesis: respectively two and eight reported pregnancy induced hypertension and preeclampsia, and three studies reported on both HDPs.
Main results
Most studies ( = 4/5) found a higher blood pressure in children exposed to pregnancy induced hypertension. Most studies ( = 7/10) found no statistically significantly higher blood pressure in children exposed to preeclampsia. No association was found between exposure to HDP and levels of cholesterol, triglycerides or glucose ( = 5/5). No studies investigated an association with (carotid) intima-media thickness, glycated haemoglobin or diabetes mellitus type 2.
Conclusions
Most studies showed that exposure to pregnancy induced hypertension is associated with a higher offspring blood pressure. There is no convincing evidence for an association between exposure to preeclampsia and blood pressure in childhood. Based on current evidence, exposure to HDP is not associated with blood levels of cholesterol, triglycerides and glucose in childhood.



Eur J Prev Cardiol: 30 Oct 2019; 26:1718-1747
Jansen MA, Pluymen LP, Dalmeijer GW, Groenhof TKJ, ... Smit HA, van Rossem L
Eur J Prev Cardiol: 30 Oct 2019; 26:1718-1747 | PMID: 31132891
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Abstract

Assessment of peripheral endothelial function predicts future risk of solid-tumor cancer.

Toya T, Sara JD, Corban MT, Taher R, ... Lerman LO, Lerman A
Aims
Cardiovascular health metrics predict the risk not only of cardiovascular diseases but also of several types of cancers. Microvascular endothelial dysfunction can predict future cardiovascular adverse events, but the predictive value of microvascular endothelial dysfunction for future risk of solid-tumor cancer has not been characterized.
Methods
A total of 488 patients who underwent microvascular endothelial function assessment using reactive hyperemia peripheral arterial tonometry were included in this study. Microvascular endothelial dysfunction was defined as a reactive hyperemia peripheral arterial tonometry index ≤2.0.
Results
Of 221 patients with a baseline reactive hyperemia peripheral arterial tonometry index ≤2.0, 21 patients (9.5%) were diagnosed with incident solid-tumor cancer during follow-up, whereas of 267 patients with a baseline reactive hyperemia peripheral arterial tonometry index >2.0, 10 patients (3.7%) were diagnosed with incident solid-tumor cancer during follow-up ( = 0.009). Patients with a reactive hyperemia peripheral arterial tonometry index ≤2.0 had lower solid-tumor cancer-free survival compared to patients with a reactive hyperemia peripheral arterial tonometry index >2.0 (log-rank  = 0.017) (median follow-up 6.0 (3.0-9.1) years). Cox proportional hazard analyses showed that a reactive hyperemia peripheral arterial tonometry index ≤2.0 predicted the incidence of solid-tumor cancer, with a hazard ratio of 2.52 (95% confidence interval 1.17-5.45;  = 0.019) after adjusting for age, sex, and coronary artery disease, 2.83 (95% confidence interval 1.30-6.17;  = 0.009) after adjusting for diabetes mellitus, hypertension, smoking status, and body mass index >30 kg/m, 2.79 (95% confidence interval 1.21-6.41;  = 0.016) after adjusting for fasting plasma glucose, systolic blood pressure, smoking status (current or former), and body mass index, and 2.43 (95% confidence interval 1.10-5.34;  = 0.028) after adjusting for Framingham risk score.
Conclusion
Microvascular endothelial dysfunction, as defined by a reactive hyperemia peripheral arterial tonometry index ≤2.0, was associated with a greater than two-fold increased risk of solid-tumor cancer. Microvascular endothelial dysfunction may be a useful marker to predict the future risk of solid-tumor cancer, in addition to its known ability to predict cardiovascular disease. Further research is necessary to develop adequate cancer screening strategies for patients with microvascular endothelial dysfunction.



Eur J Prev Cardiol: 30 Oct 2019:2047487319884246; epub ahead of print
Toya T, Sara JD, Corban MT, Taher R, ... Lerman LO, Lerman A
Eur J Prev Cardiol: 30 Oct 2019:2047487319884246; epub ahead of print | PMID: 31668110
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Abstract

Heart failure and its complications in patients with diabetes: Mounting evidence for a growing burden.

Ferrini M, Johansson I, Aboyans V

Heart failure (HF) is one of the major challenges in the management of diabetes patients. Among subjects with diabetes, up to 20% could have HF. Conversely, diabetes prevalence in HF patients varies greatly from more than 10% up to 50%. When it is present, the risk of mortality and rehospitalization increases substantially. In addition, current evidence points to an increased risk of atrial fibrillation and sudden cardiac death in patients with diabetes. The inter-relation between diabetes cardiomyopathy, left ventricular hypertrophy, coronary artery disease and renal dysfunction indicates complex and intricate pathways. Despite the great value of clinical assessment and echocardiography, there is insufficient data to suggest systematic screening for HF in asymptomatic patients with diabetes. There is little evidence to indicate that improved glycaemic control improves HF outcome in this population. In the case of established HF, the general guidelines apply in diabetes patients. However, recent advances concerning glucose-lowering treatment in patients with cardiovascular disease suggest that the choice of glucose-lowering agent is of crucial interest and should be based on the patient\'s phenotype. New drug classes, such as SGLT2 inhibitors, seem to be of particular benefit in these patients. In the future, new personalized strategies should aim at not only good control of the glycaemic level but also the reduction and possibly the prevention of HF onset.



Eur J Prev Cardiol: 29 Nov 2019; 26:106-113
Ferrini M, Johansson I, Aboyans V
Eur J Prev Cardiol: 29 Nov 2019; 26:106-113 | PMID: 31766920
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Abstract

Exercise intolerance and fatigue in chronic heart failure: is there a role for group III/IV afferent feedback?

Angius L, Crisafulli A

Exercise intolerance and early fatiguability are hallmark symptoms of chronic heart failure. While the malfunction of the heart is certainly the leading cause of chronic heart failure, the patho-physiological mechanisms of exercise intolerance in these patients are more complex, multifactorial and only partially understood. Some evidence points towards a potential role of an exaggerated afferent feedback from group III/IV muscle afferents in the genesis of these symptoms. Overactivity of feedback from these muscle afferents may cause exercise intolerance with a double action: by inducing cardiovascular dysregulation, by reducing motor output and by facilitating the development of central and peripheral fatigue during exercise. Importantly, physical inactivity appears to affect the progression of the syndrome negatively, while physical training can partially counteract this condition. In the present review, the role played by group III/IV afferent feedback in cardiovascular regulation during exercise and exercise-induced muscle fatigue of healthy people and their potential role in inducing exercise intolerance in chronic heart failure patients will be summarised.



Eur J Prev Cardiol: 10 Feb 2020:2047487320906919; epub ahead of print
Angius L, Crisafulli A
Eur J Prev Cardiol: 10 Feb 2020:2047487320906919; epub ahead of print | PMID: 32046526
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Abstract

Influence of visceral adiposity accumulation on adverse left and right ventricular mechanics in the community.

Sawada N, Nakanishi K, Daimon M, Yoshida Y, ... Homma S, Komuro I
Aims
Obesity carries significant risk for unfavorable ventricular remodeling and subsequent heart failure (HF) development, although the association between abdominal fat distribution and subclinical ventricular dysfunction is unclear. This study aimed to compare the subcutaneous and visceral abdominal adiposity with the risk of decreased ventricular strain.
Methods
We included 340 participants without overt cardiac disease who underwent laboratory testing, abdominal computed tomographic examination, and speckle-tracking echocardiography. Abdominal adiposity was quantitatively assessed as visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus. Speckle-tracking echocardiography was performed to assess left ventricular global longitudinal strain (LVGLS) and right ventricular free-wall longitudinal strain (RVLS).
Results
Mean age was 56 ± 9 years, and 244 of the participants (72%) were male. The mean LVGLS and RVLS were -19.1 ± 3.0% and -25.0 ± 4.1%, respectively. Both VFA and SFA correlated with LVGLS ( = 0.46 and  = 0.15, both  < 0.01) and RVLS ( = 0.38 and  = 0.12, both  < 0.05), demonstrating a stronger correlation between VFA and ventricular strain. Multivariable analysis showed that VFA was significantly associated with LVGLS and RVLS, independent of traditional cardiovascular risk factors as well as pertinent laboratory and echocardiographic parameters (both  < 0.05), whereas SFA was not. Serum adiponectin level was correlated with LVGLS ( = -0.34,  < 0.001) and RVLS ( = -0.25,  < 0.001), although it lost statistical significance following multivariable adjustment.
Conclusion
In a sample of the general population, VFA, but not SFA, accumulation was significantly associated with decreased LV and RV strain, an association that may be involved in the increased risk of HF in obese individuals.



Eur J Prev Cardiol: 02 Dec 2019:2047487319891286; epub ahead of print
Sawada N, Nakanishi K, Daimon M, Yoshida Y, ... Homma S, Komuro I
Eur J Prev Cardiol: 02 Dec 2019:2047487319891286; epub ahead of print | PMID: 31795766
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Abstract

Exercise training intensity determination in cardiovascular rehabilitation: Should the guidelines be reconsidered?

Hansen D, Bonné K, Alders T, Hermans A, ... Frederix I, Dendale P
Aims
In the rehabilitation of cardiovascular disease patients a correct determination of the endurance-type exercise intensity is important to generate health benefits and preserve medical safety. It remains to be assessed whether the guideline-based exercise intensity domains are internally consistent and agree with physiological responses to exercise in cardiovascular disease patients.
Methods
A total of 272 cardiovascular disease patients without pacemaker executed a maximal cardiopulmonary exercise test on bike (peak respiratory gas exchange ratio >1.09), to assess peak heart rate (HR), oxygen uptake (VO) and cycling power output (W). The first and second ventilatory threshold (VT1 and VT2, respectively) was determined and extrapolated to %VO, %HR, %heart rate reserve (%HRR) and %W for comparison with guideline-based exercise intensity domains.
Results
VT1 was noted at 62 ± 10% VO, 75 ± 10% HR, 42 ± 14% HRR and 47 ± 11% W, corresponding to the high intensity exercise domain (for %VO and %HR) or low intensity exercise domain (for %W and %HRR). VT2 was noted at 84 ± 9% VO, 88 ± 8% HR, 74 ± 15% HRR and 76 ± 11% W, corresponding to the high intensity exercise domain (for %HRR and %W) or very hard exercise domain (for %HR and %VO). At best (when using %W) in only 63% and 72% of all patients VT1 and VT2, respectively, corresponded to the same guideline-based exercise intensity domain, but this dropped to about 48% and 52% at worst (when using %HRR and %HR, respectively). In particular, the patient\'s VO related to differently elicited guideline-based exercise intensity domains ( < 0.05).
Conclusion
The guideline-based exercise intensity domains for cardiovascular disease patients seem inconsistent, thus reiterating the need for adjustment.



Eur J Prev Cardiol: 29 Nov 2019; 26:1921-1928
Hansen D, Bonné K, Alders T, Hermans A, ... Frederix I, Dendale P
Eur J Prev Cardiol: 29 Nov 2019; 26:1921-1928 | PMID: 31219704
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Abstract

Cardiac rehabilitation after acute myocardial infarction in Sweden - evaluation of programme characteristics and adherence to European guidelines: The Perfect Cardiac Rehabilitation (Perfect-CR) study.

Ögmundsdottir Michelsen H, Sjölin I, Schlyter M, Hagström E, ... Zaman MJ, Leosdottir M
Background
While patient performance after participating in cardiac rehabilitation programmes after acute myocardial infarction is regularly reported through registry and survey data, information on cardiac rehabilitation programme characteristics is less well described.
Aim
The aim of this study was to evaluate Swedish cardiac rehabilitation programme characteristics and adherence to European Guidelines on Cardiovascular Disease Prevention.
Method
Cardiac rehabilitation programme characteristics at all 78 cardiac rehabilitation centres in Sweden in 2016 were surveyed using a web-based questionnaire (100% response rate). The questions were based on core components of cardiac rehabilitation as recommended by European Guidelines.
Results
There was a wide variation in programme duration (2-14 months). All programmes reported offering an individual post-discharge visit with a nurse, and 90% ( = 70) did so within three weeks from discharge. Most programmes offered centre-based exercise training ( = 76, 97%) and group educational sessions ( = 61, 78%). All programmes reported to the national audit, SWEDEHEART, and 60% ( = 47) reported that performance was regularly assessed using audit data, to improve quality of care. Ninety-six per cent ( = 75) had a core team consisting of a cardiologist, a physiotherapist and a nurse and 76% ( = 59) reported having a medical director. Having other allied healthcare professionals included in the cardiac rehabilitation team varied. Forty per cent ( = 31) reported having regular team meetings where nurses, physiotherapists and cardiologist could discuss patient cases.
Conclusion
The overall quality of cardiac rehabilitation programmes provided in Sweden is high. Still, there are several areas of potential improvement. Monitoring programme characteristics as well as patient outcomes might improve programme quality and patient outcomes both at a local and a national level.



Eur J Prev Cardiol: 30 Dec 2019; 27:18-27
Ögmundsdottir Michelsen H, Sjölin I, Schlyter M, Hagström E, ... Zaman MJ, Leosdottir M
Eur J Prev Cardiol: 30 Dec 2019; 27:18-27 | PMID: 31349776
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Abstract

Walking pace improves all-cause and cardiovascular mortality risk prediction: A UK Biobank prognostic study.

Argyridou S, Zaccardi F, Davies MJ, Khunti K, Yates T
Aims
The purpose of this study was to quantify and rank the prognostic relevance of dietary, physical activity and physical function factors in predicting all-cause and cardiovascular mortality in comparison with the established risk factors included in the European Society of Cardiology Systematic COronary Risk Evaluation (SCORE).
Methods
We examined the predictive discrimination of lifestyle measures using C-index and R in sex-stratified analyses adjusted for: model 1, age; model 2, SCORE variables (age, smoking status, systolic blood pressure, total and high-density lipoprotein cholesterol).
Results
The sample comprised 298,829 adults (median age, 57 years; 53.5% women) from the UK Biobank free from cancer and cardiovascular disease at baseline. Over a median follow-up of 6.9 years, there were 2174 and 3522 all-cause and 286 and 796 cardiovascular deaths in women and men, respectively. When added to model 1, self-reported walking pace improved C-index in women and men by 0.013 (99% CI: 0.007-0.020) and 0.022 (0.017-0.028) respectively for all-cause mortality; and by 0.023 (0.005-0.042) and 0.034 (0.020-0.048) respectively for cardiovascular mortality. When added to model 2, corresponding values for women and men were: 0.008 (0.003-0.012) and 0.013 (0.009-0.017) for all-cause mortality; and 0.012 (-0.001-0.025) and 0.024 (0.013-0.035) for cardiovascular mortality. Other lifestyle factors did not consistently improve discrimination across models and outcomes. The pattern of results for R mirrored those for C-index.
Conclusion
A simple self-reported measure of walking pace was the only lifestyle variable found to improve risk prediction for all-cause and cardiovascular mortality when added to established risk factors.



Eur J Prev Cardiol: 06 Nov 2019:2047487319887281; epub ahead of print
Argyridou S, Zaccardi F, Davies MJ, Khunti K, Yates T
Eur J Prev Cardiol: 06 Nov 2019:2047487319887281; epub ahead of print | PMID: 31698963
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Abstract

Cost-effectiveness of exercise therapy in patients with coronary heart disease, chronic heart failure and associated risk factors: A systematic review of economic evaluations of randomized clinical trials.

Oldridge N, Taylor RS
Aims
Prescribed exercise is effective in adults with coronary heart disease (CHD), chronic heart failure (CHF), intermittent claudication, body mass index (BMI) ≥25 kg/m, hypertension or type 2 diabetes mellitus (T2DM), but the evidence for its cost-effectiveness is limited, shows large variations and is partly contradictory. Using World Health Organization and American Heart Association/American College of Cardiology value for money thresholds, we report the cost-effectiveness of exercise therapy, exercise training and exercise-based cardiac rehabilitation.
Methods
Electronic databases were searched for incremental cost-effectiveness and incremental cost-utility ratios and/or the probability of cost-effectiveness of exercise prescribed as therapy in economic evaluations conducted alongside randomized controlled trials (RCTs) published between 1 July 2008 and 28 October 2018.
Results
Of 19 incremental cost-utility ratios reported in 15 RCTs in patients with CHD, CHF, intermittent claudication or BMI ≥25 kg/m, 63% met both value for money thresholds as \'highly cost-effective\' or \'high value\', with 26% \'not cost-effective\' or of \'low value\'. The probability of intervention cost-effectiveness ranged from 23 to 100%, probably due to the different populations, interventions and comparators reported in the individual RCTs. Confirmation with the Consolidated Health Economic Evaluation Reporting checklist varied widely across the included studies.
Conclusions
The findings of this review support the cost-effectiveness of exercise therapy in patients with CHD, CHF, BMI ≥25 kg/m or intermittent claudication, but, with concerns about reporting standards, need further confirmation. No eligible economic evaluation based on RCTs was identified in patients with hypertension or T2DM.



Eur J Prev Cardiol: 25 Oct 2019:2047487319881839; epub ahead of print
Oldridge N, Taylor RS
Eur J Prev Cardiol: 25 Oct 2019:2047487319881839; epub ahead of print | PMID: 31657233
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Abstract

Diabetes as a cardiovascular risk factor: An overview of global trends of macro and micro vascular complications.

Dal Canto E, Ceriello A, Rydén L, Ferrini M, ... Standl E, Beulens JW

The global prevalence of diabetes is predicted to increase dramatically in the coming decades as the population grows and ages, in parallel with the rising burden of overweight and obesity, in both developed and developing countries. Cardiovascular disease represents the principal cause of death and morbidity among people with diabetes, especially in those with type 2 diabetes mellitus. Adults with diabetes have 2-4 times increased cardiovascular risk compared with adults without diabetes, and the risk rises with worsening glycaemic control. Diabetes has been associated with 75% increase in mortality rate in adults, and cardiovascular disease accounts for a large part of the excess mortality. Diabetes-related macrovascular and microvascular complications, including coronary heart disease, cerebrovascular disease, heart failure, peripheral vascular disease, chronic renal disease, diabetic retinopathy and cardiovascular autonomic neuropathy are responsible for the impaired quality of life, disability and premature death associated with diabetes. Given the substantial clinical impact of diabetes as a cardiovascular risk factor, there has been a growing focus on diabetes-related complications. While some population-based studies suggest that the epidemiology of such complications is changing and that rates of all-cause and cardiovascular mortality among individuals with diabetes are decreasing in high-income countries, the economic and social burden of diabetes is expected to rise due to changing demographics and lifestyle especially in middle- and low-income countries. In this review we outline data from population-based studies on recent and long-term trends in diabetes-related complications.



Eur J Prev Cardiol: 12 Nov 2019:2047487319878371; epub ahead of print
Dal Canto E, Ceriello A, Rydén L, Ferrini M, ... Standl E, Beulens JW
Eur J Prev Cardiol: 12 Nov 2019:2047487319878371; epub ahead of print | PMID: 31722562
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Abstract

Progression of conventional cardiovascular risk factors and vascular disease risk in individuals: insights from the PROG-IMT consortium.

Bahls M, Lorenz MW, Dörr M, Gao L, ... Thompson SG,
Aims
Averaged measurements, but not the progression based on multiple assessments of carotid intima-media thickness, (cIMT) are predictive of cardiovascular disease (CVD) events in individuals. Whether this is true for conventional risk factors is unclear.
Methods and results
An individual participant meta-analysis was used to associate the annualised progression of systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol with future cardiovascular disease risk in 13 prospective cohort studies of the PROG-IMT collaboration ( = 34,072). Follow-up data included information on a combined cardiovascular disease endpoint of myocardial infarction, stroke, or vascular death. In secondary analyses, annualised progression was replaced with average. Log hazard ratios per standard deviation difference were pooled across studies by a random effects meta-analysis. In primary analysis, the annualised progression of total cholesterol was marginally related to a higher cardiovascular disease risk (hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.00 to 1.07). The annualised progression of systolic blood pressure, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol was not associated with future cardiovascular disease risk. In secondary analysis, average systolic blood pressure (HR 1.20 95% CI 1.11 to 1.29) and low-density lipoprotein cholesterol (HR 1.09, 95% CI 1.02 to 1.16) were related to a greater, while high-density lipoprotein cholesterol (HR 0.92, 95% CI 0.88 to 0.97) was related to a lower risk of future cardiovascular disease events.
Conclusion
Averaged measurements of systolic blood pressure, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol displayed significant linear relationships with the risk of future cardiovascular disease events. However, there was no clear association between the annualised progression of these conventional risk factors in individuals with the risk of future clinical endpoints.



Eur J Prev Cardiol: 15 Oct 2019:2047487319877078; epub ahead of print
Bahls M, Lorenz MW, Dörr M, Gao L, ... Thompson SG,
Eur J Prev Cardiol: 15 Oct 2019:2047487319877078; epub ahead of print | PMID: 31619084
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Abstract

Comparison of non-exercise cardiorespiratory fitness prediction equations in apparently healthy adults.

Peterman JE, Whaley MH, Harber MP, Fleenor BS, ... Arena R, Kaminsky LA
Aims
A recent scientific statement suggests clinicians should routinely assess cardiorespiratory fitness using at least non-exercise prediction equations. However, no study has comprehensively compared the many non-exercise cardiorespiratory fitness prediction equations to directly-measured cardiorespiratory fitness using data from a single cohort. Our purpose was to compare the accuracy of non-exercise prediction equations to directly-measured cardiorespiratory fitness and evaluate their ability to classify an individual\'s cardiorespiratory fitness.
Methods
The sample included 2529 tests from apparently healthy adults (42% female, aged 45.4 ± 13.1 years (mean±standard deviation). Estimated cardiorespiratory fitness from 28 distinct non-exercise prediction equations was compared with directly-measured cardiorespiratory fitness, determined from a cardiopulmonary exercise test. Analysis included the Benjamini-Hochberg procedure to compare estimated cardiorespiratory fitness with directly-measured cardiorespiratory fitness, Pearson product moment correlations, standard error of estimate values, and the percentage of participants correctly placed into three fitness categories.
Results
All of the estimated cardiorespiratory fitness values from the equations were correlated to directly measured cardiorespiratory fitness ( < 0.001) although thevalues ranged from 0.25-0.70 and the estimated cardiorespiratory fitness values from 27 out of 28 equations were statistically different compared with directly-measured cardiorespiratory fitness. The range of standard error of estimate values was 4.1-6.2 ml·kg·min. On average, only 52% of participants were correctly classified into the three fitness categories when using estimated cardiorespiratory fitness.
Conclusion
Differences exist between non-exercise prediction equations, which influences the accuracy of estimated cardiorespiratory fitness. The present analysis can assist researchers and clinicians with choosing a non-exercise prediction equation appropriate for epidemiological or population research. However, the error and misclassification associated with estimated cardiorespiratory fitness suggests future research is needed on the clinical utility of estimated cardiorespiratory fitness.



Eur J Prev Cardiol: 21 Oct 2019:2047487319881242; epub ahead of print
Peterman JE, Whaley MH, Harber MP, Fleenor BS, ... Arena R, Kaminsky LA
Eur J Prev Cardiol: 21 Oct 2019:2047487319881242; epub ahead of print | PMID: 31640418
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Impact:
Abstract

Targets for blood glucose: What have the trials told us.

Valensi P, Prévost G, Schnell O, Standl E, Ceriello A

The challenges of diabetes treatment are to prevent or delay microangiopathic complications and macrovascular disease. Early, effective and sustained glycaemic control is advocated by all diabetes guidelines to mitigate the risks of prolonged hyperglycaemia. The post-hoc analyses of the large randomised glucose intervention trials and the long-term results of these trials have shown clearly that intensive glycaemic control may have more favourable cardiovascular effects when initiated earlier in the course of diabetes, particularly among in patients without cardiovascular disease. Based on the intervention trials a haemoglobin A1c level of less than 7.0% (<53 mmol/mol) is a generally accepted target to reduce microvascular disease and should be initiated early in the course of the diabetes. However, haemoglobin A1c targets should be individualised. Achieving a good glycaemic control without detrimental effect and preferably with benefit to the cardiovascular system and to renal function is an important challenge. When targeting a tight glycaemic control, avoidance of hypoglycaemia is crucial particularly in patients with coronary artery disease and in patients with heart failure. The cardiovascular outcomes trials performed to test the cardiovascular safety of the new glucose-lowering therapies offer compelling evidence in favour of the role of these drugs for cardiovascular prevention. Thus, both the glycaemic target and the choice of therapies should now be defined on an individual basis.



Eur J Prev Cardiol: 29 Nov 2019; 26:64-72
Valensi P, Prévost G, Schnell O, Standl E, Ceriello A
Eur J Prev Cardiol: 29 Nov 2019; 26:64-72 | PMID: 31766916
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Abstract

Glucose-lowering therapies in patients with type 2 diabetes and cardiovascular diseases.

Prattichizzo F, La Sala L, Rydén L, Marx N, ... Valensi P, Ceriello A

Type 2 diabetes mellitus is a major risk factor for developing cardiovascular disease, and many patients with diabetes have prevalent cardiovascular complications. Recent cardiovascular outcome clinical trials suggest that certain new glucose-lowering drugs are accompanied by additional cardioprotective properties. Indeed, selected glucagon-like peptide-1 receptor agonists have a proved cardiovascular benefit in terms of a reduced incidence of ischaemic events, while sodium/glucose co-transporter-2 inhibitors have also shown significant protection, with a striking effect on heart failure and renal endpoints. These findings have been integrated in recent guidelines which now recommend prescribing (when initial metformin monotherapy fails) a glucagon-like peptide-1 receptor agonist or a sodium/glucose co-transporter-2 inhibitor with clinical trial-confirmed benefit in patients with diabetes and atherosclerotic cardiovascular disease, and a sodium/glucose co-transporter-2 inhibitor in such patients with heart failure or chronic kidney disease at initial stages. Furthermore, the new 2019 European Society of Cardiology guidelines in collaboration with the European Association for the Study of Diabetes recommend a glucagon-like peptide-1 receptor agonist or a sodium/glucose co-transporter-2 inhibitor in treatment-naive patients with type 2 diabetes mellitus with pre-existing cardiovascular disease or at high cardiovascular risk. Future research will disentangle the mechanisms underpinning these beneficial effects and will also establish to what extent these results are generalisable to the whole diabetes population. In the meantime, available evidence should prompt a wide diffusion of these two classes of drugs among patients with diabetes and cardiovascular disease. Here, we briefly summarise recent findings emerging from cardiovascular outcome clinical trials, discuss their impact on treatment algorithms and propose new possible approaches to improve our knowledge further regarding the cardiovascular effect of glucose-lowering medications.



Eur J Prev Cardiol: 29 Nov 2019; 26:73-80
Prattichizzo F, La Sala L, Rydén L, Marx N, ... Valensi P, Ceriello A
Eur J Prev Cardiol: 29 Nov 2019; 26:73-80 | PMID: 31766918
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Abstract

Antihypertensive drugs and the risks of cancer: More fakes than facts.

Battistoni A, Tocci G, Presta V, Volpe M

In the last century, the diffusion of medical news to the public has been profoundly changed by the progressive spread of more pervasive, but at the same time often unreliable, means of communication. The misinterpretation of scientific evidence or fallacious presentation through social media could play as a great drawback to the success in the management of many diseases. This may become particularly alarming when concerning chronic diseases widely affecting the population. Arterial hypertension is still today one of the major causes of mortality and morbidity in most countries, and its management generally requires chronic therapy lasting for decades. Therefore, a recent debate about the potential oncogenic effect of antihypertensive drugs has been made widely available to patients mostly through social media. Since this is a topic of great impact for millions of patients and of main relevance for the scientific community, it must not be contaminated by the spread of fake or twisted news. The objective of this article is to briefly discuss the almost complete lack of hard evidence about the potential oncogenic effect of the major classes of antihypertensive drugs as opposed to the exaggerated mediatic communication and impact of scattered and unconfirmed observations. We believe that it is of key importance to provide authoritative support for patients and clinicians from scientific societies and guidelines to balance an unopposed widespread penetration of twisted or even fake news.



Eur J Prev Cardiol: 23 Oct 2019:2047487319884823; epub ahead of print
Battistoni A, Tocci G, Presta V, Volpe M
Eur J Prev Cardiol: 23 Oct 2019:2047487319884823; epub ahead of print | PMID: 31648551
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Abstract

Heritability of a resting heart rate in a 20-year follow-up family cohort with GWAS data: Insights from the STANISLAS cohort.

Xhaard C, Dandine-Roulland C, Villemereuil P, Floch EL, ... Rossignol P, Girerd N
Background
The association between resting heart rate (HR) and cardiovascular outcomes, especially heart failure, is now well established. However, whether HR is mainly an integrated marker of risk associated with other features, or rather a genetic origin risk marker, is still a matter for debate. Previous studies reported a heritability ranging from 14% to 65%.
Design
We assessed HR heritability in the STANISLAS family-study, based on the data of four visits performed over a 20-year period, and adjusted for most known confounding effects.
Methods
These analyses were conducted using a linear mixed model, adjusted on age, sex, tea or coffee consumption, beta-blocker use, physical activity, tobacco use, and alcohol consumption to estimate the variance captured by additive genetic effects, via average information restricted maximum likelihood analysis, with both self-reported pedigree and genetic relatedness matrix (GRM) calculated from genome-wide association study data.
Results
Based on the data of all visits, the HR heritability (h) estimate was 23.2% with GRM and 24.5% with pedigree. However, we found a large heterogeneity of HR heritability estimations when restricting the analysis to each of the four visits (h from 19% to 39% using pedigree, and from 14% to 32% using GRM). Moreover, only a little part of variance was explained by the common household effect (<5%), and half of the variance remained unexplained.
Conclusion
Using a comprehensive analysis based on a family cohort, including the data of multiple visits and GRM, we found that HR variability is about 25% from genetic origin, 25% from repeated measures and 50% remains unexplained.



Eur J Prev Cardiol: 01 Dec 2019:2047487319890763; epub ahead of print
Xhaard C, Dandine-Roulland C, Villemereuil P, Floch EL, ... Rossignol P, Girerd N
Eur J Prev Cardiol: 01 Dec 2019:2047487319890763; epub ahead of print | PMID: 31791143
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Abstract

Improvement in VO predicts readmissions for cardiovascular disease and mortality in patients undergoing cardiac rehabilitation.

Mikkelsen N, Cadarso-Suárez C, Lado-Baleato O, Díaz-Louzao C, ... Rasmusen H, Prescott E
Background
Improvement in exercise capacity is a main goal of cardiac rehabilitation but the effects are often lost at long-term follow-up and thus also the benefits on prognosis. We assessed whether improvement in VO during a cardiac rehabilitation programme predicts long-term prognosis.
Methods and results
We performed a retrospective analysis of 1561 cardiac patients completing cardiac rehabilitation in 2011-2017 in Copenhagen. Mean age was 63.6 (11) years, 74% were male and 84% had coronary artery disease, 6% chronic heart failure and 10% heart valve replacement. The association between baseline VO and improvement after cardiac rehabilitation and being readmitted for cardiovascular disease and/or all-cause mortality was assessed with three different analyses: Cox regression for the combined outcome, for all-cause mortality and a multi-state model. During a median follow-up of 2.3 years, 167 readmissions for cardiovascular disease and 77 deaths occurred. In adjusted Cox regression there was a non-linear decreasing risk of the combined outcome with higher baseline VO and with improvement of VO after cardiac rehabilitation. A similar linear association was seen for all-cause mortality. Applying the multi-state model, baseline VO and change in VO were associated with risk of a cardiovascular disease readmission and with all-cause mortality but not with mortality in those having an intermediate readmission for cardiovascular disease.
Conclusion
VO as well as change in VO were highly predictive of future risk of readmissions for cardiovascular disease and all-cause mortality. The predictive value did not extend beyond the next admission for a cardiovascular event.



Eur J Prev Cardiol: 18 Nov 2019:2047487319887835; epub ahead of print
Mikkelsen N, Cadarso-Suárez C, Lado-Baleato O, Díaz-Louzao C, ... Rasmusen H, Prescott E
Eur J Prev Cardiol: 18 Nov 2019:2047487319887835; epub ahead of print | PMID: 31744334
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Abstract

High prevalence of physical inactivity after heart valve surgery and its association with long-term mortality: A nationwide cohort study.

Kim SH, Cha S, Kang S, Han K, Paik NJ, Kim WS
Aims
Physical activity (PA) and systematic efforts, such as cardiac rehabilitation, are recommended by several national guidelines for those who have received heart valve surgery. However, only a few studies have demonstrated real-world situations, such as changes in the PA level after heart valve surgery, and their effects on long-term outcomes. We designed this study to investigate the changes in PA after heart valve surgery and their associations with mortality using nationwide representative data.
Methods
This study was performed using the Korean National Health Insurance Service database. We included patients who received heart valve surgery from 2009 to 2015 and underwent regular health checkups before and after surgery. Subjects were grouped according to their PA level before and after the surgery. Information on all-cause mortality was obtained until 31 December 2016, with a maximum follow-up period of 5 years.
Results
Of the 6587 subjects, 3258 (49.5%) were physically inactive after surgery. Among patients who were physically active ( = 3070), 1196 (39.0%) became inactive after surgery. The postoperative \'inactive\' group showed higher mortality than the \'active\' group (hazard ratio (HR): 1.41, 95% confidence interval (CI): 1.08-1.83). The \'inactive/inactive\' group showed the highest risk of mortality (HR: 1.69, 95% CI: 1.19-2.40) compared with the \'active/active\' group.
Conclusions
Insufficient PA level after heart valve surgery is associated with higher risk of mortality. However, maintaining sufficient PA after heart valve surgery may be challenging for many patients. Therefore, systematic efforts, such as cardiac rehabilitation, should be considered in those who received heart valve surgery.



Eur J Prev Cardiol: 12 Feb 2020:2047487320903877; epub ahead of print
Kim SH, Cha S, Kang S, Han K, Paik NJ, Kim WS
Eur J Prev Cardiol: 12 Feb 2020:2047487320903877; epub ahead of print | PMID: 32053015
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Abstract

The link between diabetes and atherosclerosis.

La Sala L, Prattichizzo F, Ceriello A

Atherosclerosis is one of the main complications of diabetes involving multiple causative factors. Dysfunction of the vascular endothelium is a hallmark of most conditions that are associated with both diabetes and atherosclerosis. Although the pathological link between diabetes and atherosclerosis is well-established, better comprehension of the underlying mechanisms is of utmost importance to identify novel potential molecular targets. It is difficult to separate the effects of hyperglycaemia from those of other atherogenic factors: recent evidence shows that they share many common mechanisms, such as endothelial activation and inflammation, mitochondrial oxidative stress, changes in extracellular matrix components and disruption of cellular defence systems. The plausible hypothesis of the \'common soil\' between diabetes and atherosclerosis seems to be born from a unique \'ancestor\': the nuclear factor κB, a transcription factor able to guide multiple molecular processes. It seems that this master regulator triggers either some hyperglycaemia-induced effects on the endothelial function, or the expression of certain microRNAs (in particular miR-126, -21 and miR-146a-5p) involved in favouring atherosclerosis. Here, we review the latest evidence and proposed mechanisms, aiming to understand the link between diabetes and atherosclerosis.



Eur J Prev Cardiol: 12 Nov 2019:2047487319878373; epub ahead of print
La Sala L, Prattichizzo F, Ceriello A
Eur J Prev Cardiol: 12 Nov 2019:2047487319878373; epub ahead of print | PMID: 31722564
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Abstract

Exploring the determinants of the cardiac changes after ultra-long duration exercise: The echocardiographic Spartathlon study.

Christou GA, Pagourelias ED, Anifanti MA, Sotiriou PG, ... Kouidi EJ, Deligiannis AP
Aim
The investigation of the pathophysiological determinants of cardiac changes following ultra-long duration exercise.
Methods
Twenty-seven runners who finished a 246 km running race were examined both before and after the finish of the race. Examinations included echocardiography and measurement of body weight and blood biochemical parameters.
Results
Exercise increased left ventricular end-diastolic interventricular septum thickness (LVIVSd) ( < 0.001) and posterior wall thickness (LVPWTd) ( = 0.001) and right ventricular end-diastolic area ( = 0.005), while reduced tricuspid annular plane systolic excursion (TAPSE) ( = 0.004). A minor decrease in the peak absolute values of both left ventricular (from -20.9 ± 2.3% to -18.8 ± 2.0%,  = 0.009) and right ventricular (from -22.9 ± 3.6% to -21.2 ± 3.0%,  = 0.040) global longitudinal strains occurred. There was decrease in body weight ( < 0.001) and increase in both circulating high-sensitivity troponin I ( = 0.028) and amino-terminal pro-B type natriuretic peptide (NT-proBNP) ( = 0.018). The change in the sum of LVIVSd and LVPWTd correlated negatively with percentage change of body weight ( = -0.416,  = 0.049). The only independent determinant of post-exercise NT-proBNP was pulmonary artery systolic pressure ( = 0.797,  = 0.002). Post-exercise NT-proBNP correlated positively with percentage changes of basal (RVbas) ( = 0.582,  = 0.037) and mid-cavity (RVmid) ( = 0.618,  = 0.043) right ventricular diameters and negatively with percentage change of TAPSE ( = -0.720,  = 0.008). Similar correlations with RVbas, RVmid and TAPSE were found for pulmonary artery systolic pressure. Post-exercise high-sensitivity troponin I correlated negatively with percentage change of body weight ( = -0.601,  = 0.039), but was not associated with any cardiac parameter.
Conclusion
The main cardiac effects of ultra-long duration exercise were the decrease in left ventricular end-diastolic dimensions and increase in left ventricular wall thickness, as well as minimal dilatation and alteration in systolic function of right ventricle, possibly due to the altered exercise-related right ventricular afterload.



Eur J Prev Cardiol: 02 Feb 2020:2047487319898782; epub ahead of print
Christou GA, Pagourelias ED, Anifanti MA, Sotiriou PG, ... Kouidi EJ, Deligiannis AP
Eur J Prev Cardiol: 02 Feb 2020:2047487319898782; epub ahead of print | PMID: 32013601
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Abstract

Mortality risk comparing walking pace to handgrip strength and a healthy lifestyle: A UK Biobank study.

Zaccardi F, Franks PW, Dudbridge F, Davies MJ, Khunti K, Yates T
Aims
Brisk walking and a greater muscle strength have been associated with a longer life; whether these associations are influenced by other lifestyle behaviours, however, is less well known.
Methods
Information on usual walking pace (self-defined as slow, steady/average, or brisk), dynamometer-assessed handgrip strength, lifestyle behaviours (physical activity, TV viewing, diet, alcohol intake, sleep and smoking) and body mass index was collected at baseline in 450,888 UK Biobank study participants. We estimated 10-year standardised survival for individual and combined lifestyle behaviours and body mass index across levels of walking pace and handgrip strength.
Results
Over a median follow-up of 7.0 years, 3808 (1.6%) deaths in women and 6783 (3.2%) in men occurred. Brisk walkers had a survival advantage over slow walkers, irrespective of the degree of engagement in other lifestyle behaviours, except for smoking. Estimated 10-year survival was higher in brisk walkers who otherwise engaged in an unhealthy lifestyle compared to slow walkers who engaged in an otherwise healthy lifestyle: 97.1% (95% confidence interval: 96.9-97.3) vs 95.0% (94.6-95.4) in women; 94.8% (94.7-95.0) vs 93.7% (93.3-94.2) in men. Body mass index modified the association between walking pace and survival in men, with the largest survival benefits of brisk walking observed in underweight participants. Compared to walking pace, for handgrip strength there was more overlap in 10-year survival across lifestyle behaviours.
Conclusion
Except for smoking, brisk walkers with an otherwise unhealthy lifestyle have a lower mortality risk than slow walkers with an otherwise healthy lifestyle.



Eur J Prev Cardiol: 11 Nov 2019:2047487319885041; epub ahead of print
Zaccardi F, Franks PW, Dudbridge F, Davies MJ, Khunti K, Yates T
Eur J Prev Cardiol: 11 Nov 2019:2047487319885041; epub ahead of print | PMID: 31711304
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Abstract

Prevalence and patterns of cognitive impairment in acute coronary syndrome patients: A systematic review.

Zhao E, Lowres N, Woolaston A, Naismith SL, Gallagher R
Background
Minimising risk factors through secondary prevention behaviour is challenging for patients following an acute coronary syndrome. Cognitive impairment can potentially make these changes more difficult. However, cognitive impairment prevalence in acute coronary syndrome patients is poorly understood.
Design
This study was based on a systematic review.
Methods
A systematic review was conducted of PubMed, Medline, PsycINFO and Cochrane databases up to March 2019, to identify studies reporting the prevalence of cognitive impairment in acute coronary syndrome patients. Predefined inclusion criteria were specified, including use of a validated cognitive impairment screening tool. Studies were excluded if patients had diagnosed dementia or coronary artery bypass graft surgery. Strengthening The Reporting of Observational Studies in Epidemiology and Cochrane Risk of Bias tools were used to assess quality.
Results
From 747 potential studies, nine were included. The total sample size was 6457 (range 53-2174), mean age range was 51.3-77.4 years, and range of proportions of males was 57-100%. Reported cognitive impairment prevalence rates varied substantially (9-85%) with no clear pattern over time. From the two studies which examined domains, verbal fluency, memory and language were affected the most. Meta-analysis could not be undertaken due to diverse screening tools ( = 9), cut-off scores and screening timepoints.
Conclusions
Cognitive impairment in acute coronary syndrome patients is currently poorly described, and likely affects a substantial number of acute coronary syndrome patients who remain undetected and have the potential to develop to dementia in the future. As domains are most affected, this could impact understanding and retention of health education. Research is needed to accurately determine the prevalence of cognitive impairment in acute coronary syndrome patients and create suitable standardised measures and thresholds.



Eur J Prev Cardiol: 23 Oct 2019:2047487319878945; epub ahead of print
Zhao E, Lowres N, Woolaston A, Naismith SL, Gallagher R
Eur J Prev Cardiol: 23 Oct 2019:2047487319878945; epub ahead of print | PMID: 31645116
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Abstract

The Timed Up and Go test and the ageing heart: Findings from a national health screening of 1,084,875 community-dwelling older adults.

Chun S, Shin DW, Han K, Jung JH, ... Lee SP, Lee SC
Aim
This study aimed to evaluate the relationship between Timed Up and Go test performance and the incidence of older adult heart diseases and mortality.
Methods
This was a retrospective cohort study of 1,084,875 older adults who participated in a national health screening program between 2009-2014 (all aged 66 years old). Participants free of myocardial infarction, congestive heart failure, and atrial fibrillation at baseline were included and were divided into Group 1 (<10 s), Group 2 (10-20 s) and Group 3 (≥20 s) using the Timed Up and Go test scores. The endpoints were incident myocardial infarction, congestive heart failure, atrial fibrillation, and all-cause mortality.
Results
During mean follow-up of 3.6 years (maximum 8.0 years), 8885 myocardial infarctions, 10,617 congestive heart failures, 15,322 atrial fibrillations, and 22,189 deaths occurred. Compared with participants in Group 1, Group 2 and Group 3 participants had higher incidences of myocardial infarction (Group 3: adjusted hazard ratio = 1.40, 95% confidence interval = 1.11-1.77), congestive heart failure (Group 3: adjusted hazard ratio = 1.59, 95% confidence interval = 1.31-1.94) and total mortality (Group 3: adjusted hazard ratio=1.93, 95% confidence interval = 1.69-2.20). The additional risks remained after adjusting for multiple conventional risk factors. For atrial fibrillation, a linear trend of increased risk was observed with slower Timed Up and Go test speed, but was statistically marginal (Group 3: adjusted hazard ratio=1.17, 95% confidence interval=0.96-1.44).
Conclusion
Slower Timed Up and Go test speed is associated with increased risk of developing myocardial infarction, congestive heart failure, and mortality in older adults.



Eur J Prev Cardiol: 19 Oct 2019:2047487319882118; epub ahead of print
Chun S, Shin DW, Han K, Jung JH, ... Lee SP, Lee SC
Eur J Prev Cardiol: 19 Oct 2019:2047487319882118; epub ahead of print | PMID: 31630561
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Abstract

Associations of anger, vital exhaustion, anti-depressant use, and poor social ties with incident atrial fibrillation: The Atherosclerosis Risk in Communities Study.

Garg PK, Claxton JS, Soliman EZ, Chen LY, ... Mosley T, Alonso A
Background
We examined the relationships of anger, vital exhaustion, anti-depressant use, and poor social ties with incident atrial fibrillation in a biracial cohort of middle and older-aged adults.
Methods
This analysis included 11,445 Atherosclerosis Risk in Communities Study participants who were free of atrial fibrillation at baseline in 1990-1992. Vital exhaustion was assessed at baseline and defined as a score in the highest quartile on the 21-item Vital Exhaustion Questionnaire. Baseline anti-depressant use was self-reported. The Spielberger Trait Anger Scale to assess anger and both the Interpersonal Support Evaluation List and the Lubben Social Network Scale to assess social ties were also administered at baseline. The primary outcome was incident atrial fibrillation throughout 2016, identified by electrocardiogram, hospital discharge coding of atrial fibrillation, and death certificates.
Results
A total of 2220 incident atrial fibrillation cases were detected over a median follow-up of 23.4 years. After adjusting for age, race-center, sex, education, and height, participants in the 4th Vital Exhaustion Questionnaire quartile (referent = 1st Vital Exhaustion Questionnaire quartile) and those reporting anti-depressant use were at increased risk for atrial fibrillation (hazard ratio = 1.45, 95% confidence interval 1.29-1.64 for Vital Exhaustion Questionnaire; hazard ratio = 1.37, 95% confidence interval 1.11-1.69 for anti-depressant use). The increased atrial fibrillation risk observed for 4th Vital Exhaustion Questionnaire quartile participants remained significant after additional adjustment for relevant comorbidities (hazard ratio = 1.20; confidence interval 1.06-1.35). No significant associations were observed for anger or poor social ties with development of atrial fibrillation.
Conclusions
Vital exhaustion is associated with an increased risk of incident atrial fibrillation.



Eur J Prev Cardiol: 12 Jan 2020:2047487319897163; epub ahead of print
Garg PK, Claxton JS, Soliman EZ, Chen LY, ... Mosley T, Alonso A
Eur J Prev Cardiol: 12 Jan 2020:2047487319897163; epub ahead of print | PMID: 31930923
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Abstract

Parental alcohol consumption and the risk of congenital heart diseases in offspring: An updated systematic review and meta-analysis.

Zhang S, Wang L, Yang T, Chen L, ... Zheng Z, Qin J
Objective
The aim of this study was to provide updated evidence to assess the association between parental alcohol consumption and the risk of total congenital heart diseases (CHDs) and specific CHD phenotypes in offspring, and explore the possible dose-response pattern.
Methods
PubMed, Embase and Chinese databases were searched with an end-date parameter of July 24, 2019 to identify studies meeting pre-stated inclusion criteria. A random-effects model was used to calculate the overall combined risk estimates. A meta-analysis of the dose-response relationship was performed. Subgroup analysis, sensitivity analysis, and Galbraith plot were conducted to explore potential heterogeneity moderators.
Results
A total of 55 studies involving 41,747 CHD cases and 297,587 controls were identified. Overall, both maternal (odds ratio (OR) = 1.16; 95% confidence interval (CI): 1.05-1.27) and paternal (OR = 1.44; 95% CI: 1.19-1.74) alcohol exposures were significantly associated with risk of total CHDs in offspring. Additionally, a nonlinear dose-response relationship between parental alcohol exposure and risk of total CHDs was observed. With an increase in parental alcohol consumption, the risk of total CHDs in offspring also gradually increases. For specific CHD phenotypes, a statistically significant association was found between maternal alcohol consumption and risk of tetralogy of fallot (OR = 1.20; 95% CI: 1.08-1.33). Relevant heterogeneity moderators have been identified by subgroup analysis, and sensitivity analysis yielded consistent results.
Conclusions
Although the role of potential bias and evidence of heterogeneity should be carefully evaluated, our review indicates that parental alcohol exposures are significantly associated with the risk of CHDs in offspring, which highlights the necessity of improving health awareness to prevent alcohol exposure during preconception and conception periods.



Eur J Prev Cardiol: 01 Oct 2019:2047487319874530; epub ahead of print
Zhang S, Wang L, Yang T, Chen L, ... Zheng Z, Qin J
Eur J Prev Cardiol: 01 Oct 2019:2047487319874530; epub ahead of print | PMID: 31578093
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Abstract

Management of patients with type 2 diabetes in cardiovascular rehabilitation.

Hansen D, Kraenkel N, Kemps H, Wilhelm M, ... Cornelissen V, Völler H

The clinical benefits of rehabilitation in cardiovascular disease are well established. Among cardiovascular disease patients, however, patients with type 2 diabetes mellitus require a distinct approach. Specific challenges to clinicians and healthcare professionals in patients with type 2 diabetes include the prevalence of peripheral and autonomic neuropathy, retinopathy, nephropathy, but also the intake of glucose-lowering medication. In addition, the psychosocial wellbeing, driving ability and/or occupational status can be affected by type 2 diabetes. As a result, the target parameters of cardiovascular rehabilitation and the characteristics of the cardiovascular rehabilitation programme in patients with type 2 diabetes often require significant reconsideration and a multidisciplinary approach. This review explains how to deal with diabetes-associated comorbidities in the intake screening of patients with type 2 diabetes entering a cardiovascular rehabilitation programme. Furthermore, we discuss diabetes-specific target parameters and characteristics of cardiovascular rehabilitation programmes for patients with type 2 diabetes in a multidisciplinary context, including the implementation of guideline-directed medical therapy.



Eur J Prev Cardiol: 12 Nov 2019:2047487319882820; epub ahead of print
Hansen D, Kraenkel N, Kemps H, Wilhelm M, ... Cornelissen V, Völler H
Eur J Prev Cardiol: 12 Nov 2019:2047487319882820; epub ahead of print | PMID: 31722560
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Abstract

Efficacy of pre-participation cardiac evaluation recommendations among athletes participating in World Athletics Championships.

Dahlström Ö, Adami PE, Fagher K, Jacobsson J, ... Bermon S, Timpka T
Background
Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes\' age category, gender, event group and medical insurance type.
Design
Cross-sectional web-based survey.
Methods
A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination.
Results
A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation.
Conclusions
The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.



Eur J Prev Cardiol: 23 Oct 2019:2047487319884385; epub ahead of print
Dahlström Ö, Adami PE, Fagher K, Jacobsson J, ... Bermon S, Timpka T
Eur J Prev Cardiol: 23 Oct 2019:2047487319884385; epub ahead of print | PMID: 31648553
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Abstract

Exercise-based cardiac rehabilitation for patients with catheter ablation for persistent atrial fibrillation: A randomized controlled clinical trial.

Kato M, Ogano M, Mori Y, Kochi K, ... Takagi H, Tanabe J
Aims
The efficacy and safety of cardiac rehabilitation for patients with persistent atrial fibrillation who restored sinus rhythm after catheter ablation remains unclear. The aim of the present study was to evaluate the effects of cardiac rehabilitation on exercise capacity, inflammatory status, cardiac function, and safety in patients with persistent atrial fibrillation who had catheter ablation.
Methods
In this randomized controlled study, 61 patients treated with catheter ablation for persistent atrial fibrillation (male, 80%; mean age, 66 ± 9 years) were analyzed. Thirty patients underwent cardiac rehabilitation (rehabilitation group), whereas the remaining 31 patients received usual care (usual care group). The rehabilitation group underwent endurance and resistance training with moderate intensity, at least three times per week for six months. Six-minute walk distance, muscle strength, serum high-sensitivity C-reactive protein, plasma pentraxin 3, left ventricular ejection fraction and atrial fibrillation recurrence were assessed at baseline and at six-month follow-up.
Results
In the rehabilitation group, significant increases in the six-minute walk distance, handgrip strength, leg strength and left ventricular ejection fraction and significant decreases in high-sensitivity C-reactive protein and plasma pentraxin 3 concentrations were observed at six-month follow-up compared with baseline (all  < 0.05). No significant changes were observed in the usual care group. During the six-month follow-up period, the number of patients with atrial fibrillation recurrence was six (21.4%) in the rehabilitation group and eight (25.8%) in the usual care group (risk ratio, 0.83; 95% confidence interval, 0.33 to 2.10).
Conclusions
Cardiac rehabilitation improved exercise capacity without increasing the risk for atrial fibrillation recurrence. It may also be effective in managing systemic inflammatory status and systolic left ventricular function in patients with persistent atrial fibrillation treated with catheter ablation.



Eur J Prev Cardiol: 29 Nov 2019; 26:1931-1940
Kato M, Ogano M, Mori Y, Kochi K, ... Takagi H, Tanabe J
Eur J Prev Cardiol: 29 Nov 2019; 26:1931-1940 | PMID: 31272205
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Impact:
Abstract

Burden of premature atrial beats in middle-aged endurance athletes with and without lone atrial fibrillation versus sedentary controls.

Cipriani A, Vio R, Mastella G, Ciarmatori N, ... Corrado D, Zorzi A
Background
The burden of premature atrial beats (PABs) at 24-h electrocardiographic (ECG) monitoring correlates with the risk of atrial fibrillation. It is unknown whether prolonged and intense exercise increases the burden of PABs, thus contributing to the higher prevalence of atrial fibrillation observed in middle-aged athletes.
Methods
We compared the burden of PABs at 24-h ECG monitoring off therapy in 134 healthy middle-aged (30-60-year-old) competitive athletes who had practised 9 (7-11) h of endurance sports for 8 (4-15) consecutive years, 134 age- and gender-matched healthy sedentary individuals, and 66 middle-aged patients (20 athletes and 46 non-athletes) with \'lone\' paroxysmal atrial fibrillation.
Results
More than 50 PABs/24 h or ≥1 run of ≥3 PABs were recorded in 23/134 (17%) healthy athletes and in 29/134 (22%) sedentary controls ( = 0.61). Healthy athletes with frequent or repetitive PABs were older (median 50 years . 43 years,  < 0.01) and had practised sport for a longer time (median 10 years . 6 years,  = 0.03). At multivariable analysis only age (odds ratio 1.11, 95% confidence interval 1.04-1.20,  < 0.01) remained an independent predictor of a higher burden of PABs. Also among patients with \'lone\' paroxysmal atrial fibrillation, there was no difference in the prevalence of >50 PABs/24 h or ≥1 run of ≥3 PABs between athletes (40%) and controls (48%,  = 0.74)
Conclusions
Middle-aged endurance athletes, with or without paroxysmal atrial fibrillation, did not show a higher burden of PABs at 24-h ECG monitoring than sedentary controls. Age, but not intensity and duration of sports activity, predicted a higher burden of PABs among healthy athletes.



Eur J Prev Cardiol: 10 Oct 2019:2047487319880042; epub ahead of print
Cipriani A, Vio R, Mastella G, Ciarmatori N, ... Corrado D, Zorzi A
Eur J Prev Cardiol: 10 Oct 2019:2047487319880042; epub ahead of print | PMID: 31604380
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Impact:
Abstract

Remnant cholesterol, coronary atheroma progression and clinical events in statin-treated patients with coronary artery disease.

Elshazly MB, Mani P, Nissen S, Brennan DM, ... Nicholls SJ, Puri R
Aim
Remnant cholesterol has been proposed to promote atherosclerotic cardiovascular disease independent of low-density lipoprotein cholesterol, yet the underlying mechanisms are not well understood. We aimed to study the association of remnant cholesterol with coronary atheroma progression and clinical events.
Methods
We analyzed data from 5754 patients with coronary artery disease undergoing serial intravascular ultrasonography who were enrolled in 10 trials examining various medical therapies. Remnant cholesterol was calculated as (non-high-density lipoprotein cholesterol - low-density lipoprotein cholesterol (estimated using the Hopkins-Martin equation)). Changes in percentage atheroma volume and 2-year major adverse cardiovascular events were compared across various levels of remnant cholesterol, and multivariable models were used to assess the independent relationship of remnant cholesterol with changes in percentage atheroma volume.
Results
The mean age was 58.1 ± 9.2 years, 28% were women and 96% received a statin. Percentage atheroma volume progression (changes in percentage atheroma volume > 0) occurred in a linear fashion at on-treatment remnant cholesterol levels of 25 mg/dL or greater. The highest on-treatment remnant cholesterol quartile demonstrated greater percentage atheroma volume progression (+0.53 ± 0.26 vs. -0.15 ± 0.25%,  < 0.001) and 2-year major adverse cardiovascular events (23% vs. 14%, log-rank  < 0.001) compared with the lowest. In multivariable analyses, changes in percentage atheroma volume significantly correlated with on-treatment remnant cholesterol ( < 0.001] independent of low-density lipoprotein cholesterol, apolipoprotein B, C-reactive protein, high-density lipoprotein cholesterol levels and clinical risk factors. Changes in percentage atheroma volume also significantly correlated with changes in remnant cholesterol following multivariable adjustment.
Conclusions
In statin-treated patients with atherosclerotic cardiovascular disease, remnant cholesterol was associated with coronary atheroma progression regardless of conventional lipid parameters, C-reactive protein or clinical risk factors. Higher remnant cholesterol levels also correlated with higher major adverse cardiovascular events. These data support further investigations into remnant cholesterol-lowering interventions in statin-treated patients harboring residual atherosclerotic cardiovascular disease risk.



Eur J Prev Cardiol: 18 Nov 2019:2047487319887578; epub ahead of print
Elshazly MB, Mani P, Nissen S, Brennan DM, ... Nicholls SJ, Puri R
Eur J Prev Cardiol: 18 Nov 2019:2047487319887578; epub ahead of print | PMID: 31744333
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Impact:
Abstract

Screening young athletes for diseases at risk of sudden cardiac death: role of stress testing for ventricular arrhythmias.

Zorzi A, Vessella T, De Lazzari M, Cipriani A, ... Corrado D, Sarto P
Aims
The athletic preparticipation evaluation (PPE) protocol proposed by he European Society of Cardiology includes history, physical examination and resting electrocardiogram (ECG). The aim of this study was to assess the results of adding constant-load ECG stress testing (EST) to the protocol for the evaluation of ventricular arrhythmias (VA) inducibility.
Methods
We evaluated a consecutive cohort of young athletes with history, physical examination, resting ECG and EST. Athletes with VA induced by EST underwent 24-hour 12-lead Holter monitoring and echocardiography. Cardiac magnetic resonance (CMR) was reserved for those with frequent, repetitive or exercise-worsened VA, and for athletes with echocardiographic abnormalities.
Results
Of 10,985 athletes (median age 15 years, 66% males), 451 (4.1%) had an abnormal history, physical examination or resting ECG and 31 (0.28%) were diagnosed with a cardiac disease and were at risk of sudden cardiac death. Among the remaining 10,534 athletes, VA at EST occurred in 524 (5.0%) and a previously missed at-risk condition was identified in 23 (0.22%); the most common ( = 10) was an echocardiographically silent non-ischaemic left-ventricular fibrosis evidenced by CMR. The addition of EST increased the diagnostic yield of PPE by 75% (from 0.28% to 0.49%) and decreased the positive predictive value by 20% (from 6.9% to 5.5%). During a 32 ± 21 months follow-up, no cardiac arrests occurred among either eligible athletes or non-eligible athletes with cardiovascular disease.
Conclusions
The addition of exercise testing for the evaluation of VA inducibility to history, physical examination and ECG resulted in an increase of the diagnostic yield of PPE at the expense of an increase in false-positive findings.



Eur J Prev Cardiol: 01 Dec 2019:2047487319890973; epub ahead of print
Zorzi A, Vessella T, De Lazzari M, Cipriani A, ... Corrado D, Sarto P
Eur J Prev Cardiol: 01 Dec 2019:2047487319890973; epub ahead of print | PMID: 31791144
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Abstract

Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk.

Lindahl B, Norberg M, Johansson H, Lindvall K, ... Vanoli D, Schulz PJ
Aims
Health literacy, the degree to which individuals understand and act upon health information, may have a pivotal role in the prevention of cardiovascular disease (CVD), with low health literacy potentially explaining poorer adherence to prevention guidelines. We investigated the associations between health literacy, ultrasound-detected carotid atherosclerosis and cardiovascular risk factors.
Methods
Baseline data (cross-sectional analysis) from a randomized controlled trial, integrated within the Västerbotten Intervention Program, Northern Sweden, was used. We included 3459 individuals, aged 40 or 50 years with ≥1 conventional risk factor or aged 60 years old. The participants underwent clinical examination, blood sampling, carotid ultrasound assessment of intima-media wall thickness (CIMT) and plaque formation, and answered a questionnaire on health literacy - the Brief Health Literacy Screen. The European Systematic Coronary Risk Evaluation and Framingham Risk Score were calculated.
Results
About 20% of the participants had low health literacy. Low health literacy was independently associated with the presence of ultrasound-detected carotid artery plaques after adjustment for age and education, odds ratio (95% confidence interval) 1.54 (1.28-1.85), demonstrating a similar level of risk as for smoking. Health literacy was associated with CIMT in men. Low health literacy was associated with higher CVD risk scores. Sensitivity analyses with low health literacy set to 9% or 30% of the study sample, respectively, yielded essentially the same results.
Conclusions
Low health literacy was independently associated with carotid artery plaques and a high level of CVD risk scores. Presenting health information in a fashion that is understood by all patients may improve preventive efforts.



Eur J Prev Cardiol: 14 Oct 2019:2047487319882821; epub ahead of print
Lindahl B, Norberg M, Johansson H, Lindvall K, ... Vanoli D, Schulz PJ
Eur J Prev Cardiol: 14 Oct 2019:2047487319882821; epub ahead of print | PMID: 31615294
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Impact:
Abstract

Heart failure is a common complication after acute myocardial infarction in patients with diabetes: A nationwide study in the SWEDEHEART registry.

Ritsinger V, Nyström T, Saleh N, Lagerqvist B, Norhammar A
Background
Several glucose lowering drugs with preventive effects on heart failure and death have entered the market, however, still used in low proportions after acute myocardial infarction. We explored the complication rates of heart failure and death after acute myocardial infarction in patients with and without diabetes.
Methods
All patients ( = 73,959) with acute myocardial infarction admitted for coronary angiography included in the SWEDEHEART registry during the years 2012-2017 were followed for heart failure (until 31 December 2017) and mortality (until 30 June 2018); mean follow-up time 1223 (SD ± 623) days.
Results
Mean age was 69 years (SD ± 12), 69% were male and 24% had diabetes. Heart failure occurred more often in diabetes (22% . 12% if no diabetes), especially if previous MI (33% vs. 23%). Patients with diabetes had increased risk of HF regardless of previous myocardial infarction (MI); with previous MI adjusted hazard ratio 2.09 (95% confidence interval 1.96-2.20) and without MI 1.52 (1.44-1.61) respectively when non-diabetes patients with first MI served as reference. In patients with no previous heart failure or MI and discharged with left ventricular ejection fraction ≥50% the risk of heart failure was particularly high in those with diabetes (1.56; 1.39-1.76) when compared with those without. Similar findings were seen for death and combined event (heart failure and death).
Conclusions
Heart failure is a common complication after acute myocardial infarction in diabetes, increasing the risk by 50-60% regardless of previous heart failure or MI. This risk is present even with normal reported left ventricular ejection fraction, indicating the existence of a large diabetes population at heart failure risk after acute myocardial infarction.



Eur J Prev Cardiol: 03 Feb 2020:2047487319901063; epub ahead of print
Ritsinger V, Nyström T, Saleh N, Lagerqvist B, Norhammar A
Eur J Prev Cardiol: 03 Feb 2020:2047487319901063; epub ahead of print | PMID: 32019365
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Abstract

The developing athlete\'s heart: a cohort study in young athletes transitioning through adolescence.

Bjerring AW, Landgraff HE, Stokke TM, Murbræch K, ... Edvardsen T, Sarvari SI
Background
Athlete\'s heart is a term used to describe physiological changes in the hearts of athletes, but its early development has not been described in longitudinal studies. This study aims to improve our understanding of the effects of endurance training on the developing heart.
Methods
Cardiac morphology and function in 48 cross-country skiers were assessed at age 12 years (12.1 ± 0.2 years) and then again at age 15 years (15.3 ± 0.3 years). Echocardiography was performed in all subjects including two-dimensional speckle-tracking strain echocardiography and three-dimensional echocardiography. All participants underwent cardiopulmonary exercise testing at both ages 12 and 15 years to assess maximal oxygen uptake and exercise capacity.
Results
Thirty-one (65%) were still active endurance athletes at age 15 years and 17 (35%) were not. The active endurance athletes had greater indexed maximal oxygen uptake (62 ± 8 vs. 57 ± 6 mL/kg/min,  < 0.05) at follow-up. There were no differences in cardiac morphology at baseline. At follow-up the active endurance athletes had greater three-dimensional indexed left ventricular end-diastolic (84 ± 11 mL/m vs. 79 ± 10 mL/m,  < 0.05) and end-systolic volumes (36 ± 6 mL/m vs. 32 ± 3 mL/m,  < 0.05). Relative wall thickness fell in the active endurance athletes, but not in those who had quit (-0.05 ΔmL/m vs. 0.00 mL/m,  = 0.01). Four active endurance athletes had relative wall thickness above the upper reference values at baseline; all had normalised at follow-up.
Conclusion
After an initial concentric remodelling in the pre-adolescent athletes, those who continued their endurance training developed eccentric changes with chamber dilatation and little change in wall thickness. Those who ceased endurance training maintained a comparable wall thickness, but did not develop chamber dilatation.



Eur J Prev Cardiol: 29 Nov 2019; 26:2001-2008
Bjerring AW, Landgraff HE, Stokke TM, Murbræch K, ... Edvardsen T, Sarvari SI
Eur J Prev Cardiol: 29 Nov 2019; 26:2001-2008 | PMID: 31284749
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Abstract

Risk prediction of maternal cardiovascular disease one year after hypertensive pregnancy complications or gestational diabetes mellitus.

Moe K, Sugulle M, Dechend R, Staff AC
Background
Previous preeclampsia, gestational hypertension and gestational diabetes mellitus show a firm epidemiological association to maternal cardiovascular disease risk. Cardiovascular disease risk assessment is recommended in women after these pregnancy complications, but not offered in most countries. We therefore wanted to evaluate the applicability of currently recommended cardiovascular disease risk scores for women one-year postpartum of such pregnancy complications.
Design and methods
We tested applicability of three scoring systems, the Atherosclerotic Cardiovascular Disease (ASCVD) score, the Joint British Societies for the Prevention of Cardiovascular Disease (JBS3) score and Framingham 30 year Risk Score-Cardiovascular Disease (FRS-CVD) in 235 women one-year postpartum (controls: 94, gestational hypertension: 35, preeclampsia: 81, gestational diabetes mellitus: 25). Statistical analysis was performed with Mann-Whitneytest for continuous and Fisher\'s mid-correctedand Pearson\'sfor dichotomous variables. A value of  < 0.050 was considered significant.
Results
Most women (87.7%) were below 40 years of age, rendering 10-year risk estimations recommended by American and European societies inapplicable. FRS-CVD could be assessed in all women. Significantly fewer could be assessed by the ASCVD (81.5%) and JBS3 (91.6%). All scoring systems showed small, but significant increases in risk scores for one or more of the pregnancy complication groups, but none at the risk magnitude for cardiovascular disease shown in epidemiological studies.
Conclusion
We demonstrate that ASCVD, JBS3 and FRS-CVD are inadequate in assessing cardiovascular disease risk one-year postpartum. We suggest that pregnancy complications need to be considered separately when evaluating maternal cardiovascular disease risk and need for postpartum follow-up.



Eur J Prev Cardiol: 09 Oct 2019:2047487319879791; epub ahead of print
Moe K, Sugulle M, Dechend R, Staff AC
Eur J Prev Cardiol: 09 Oct 2019:2047487319879791; epub ahead of print | PMID: 31600083
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Abstract

Impact of preventive screening and lifestyle interventions in women with a history of preeclampsia: A micro-simulation study.

Lagerweij GR, Brouwers L, De Wit GA, Moons K, ... van Rijn BB, Koffijberg H
Background
Preeclampsia is a female-specific risk factor for the development of future cardiovascular disease. Whether early preventive cardiovascular disease risk screenings combined with risk-based lifestyle interventions in women with previous preeclampsia are beneficial and cost-effective is unknown.
Methods
A micro-simulation model was developed to assess the life-long impact of preventive cardiovascular screening strategies initiated after women experienced preeclampsia during pregnancy. Screening was started at the age of 30 or 40 years and repeated every five years. Data (initial and follow-up) from women with a history of preeclampsia was used to calculate 10-year cardiovascular disease risk estimates according to Framingham Risk Score. An absolute risk threshold of 2% was evaluated for treatment selection, i.e. lifestyle interventions (e.g. increasing physical activity). Screening benefits were assessed in terms of costs and quality-adjusted-life-years, and incremental cost-effectiveness ratios compared with no screening.
Results
Expected health outcomes for no screening are 27.35 quality-adjusted-life-years and increase to 27.43 quality-adjusted-life-years (screening at 30 years with 2% threshold). The expected costs for no screening are €9426 and around €13,881 for screening at 30 years (for a 2% threshold). Preventive screening at 40 years with a 2% threshold has the most favourable incremental cost-effectiveness ratio, i.e. €34,996/quality-adjusted-life-year, compared with other screening scenarios and no screening.
Conclusions
Early cardiovascular disease risk screening followed by risk-based lifestyle interventions may lead to small long-term health benefits in women with a history of preeclampsia. However, the cost-effectiveness of a lifelong cardiovascular prevention programme starting early after preeclampsia with risk-based lifestyle advice alone is relatively unfavourable. A combination of risk-based lifestyle advice plus medical therapy may be more beneficial.



Eur J Prev Cardiol: 12 Feb 2020:2047487319898021; epub ahead of print
Lagerweij GR, Brouwers L, De Wit GA, Moons K, ... van Rijn BB, Koffijberg H
Eur J Prev Cardiol: 12 Feb 2020:2047487319898021; epub ahead of print | PMID: 32054298
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Impact:
Abstract

Risk factors and clinical outcomes in chronic coronary and peripheral artery disease: An analysis of the randomized, double-blind COMPASS trial.

Vanassche T, Verhamme P, Anand SS, Shestakovska O, ... Eikelboom JW, Bosch J
Aims
Secondary prevention in patients with coronary artery disease and peripheral artery disease involves antithrombotic therapy and optimal control of cardiovascular risk factors. In the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) study, adding low-dose rivaroxaban on top of aspirin lowered cardiovascular events, but there is limited data about risk factor control in secondary prevention. We studied the association between risk factor status and outcomes, and the impact of risk factor status on the treatment effect of rivaroxaban, in a large contemporary population of patients with coronary artery disease or peripheral artery disease.
Methods and results
We reported ischemic events (cardiovascular death, stroke, or myocardial infarction) in participants from the randomized, double-blind COMPASS study by individual risk factor (blood pressure, smoking status, cholesterol level, presence of diabetes, body mass index, and level of physical activity), and by number of risk factors. We compared rates and hazard ratios of patients treated with rivaroxaban plus aspirin vs aspirin alone within each risk factor category and tested for interaction between risk factor status and antithrombotic regimen. Complete baseline risk factor status was available in 27,117 (99%) patients. Status and number of risk factors were both associated with increased risk of ischemic events. Rates of ischemic events (hazard ratio 2.2; 95% confidence interval 1.8-2.6) and cardiovascular death (hazard ratio 2.0; 1.5-2.7) were more than twofold higher in patients with 4-6 compared with 0-1 risk factors ( < 0.0001 for both). Rivaroxaban reduced event rates independently of the number of risk factors ( interaction 0.93), with the largest absolute benefit in patients with the highest number of risk factors.
Conclusion
More favorable risk factor status and low-dose rivaroxaban were independently associated with lower risk of cardiovascular events.



Eur J Prev Cardiol: 14 Oct 2019:2047487319882154; epub ahead of print
Vanassche T, Verhamme P, Anand SS, Shestakovska O, ... Eikelboom JW, Bosch J
Eur J Prev Cardiol: 14 Oct 2019:2047487319882154; epub ahead of print | PMID: 31615291
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Abstract

Anakinra for corticosteroid-dependent and colchicine-resistant pericarditis: The IRAP (International Registry of Anakinra for Pericarditis) study.

Imazio M, Andreis A, De Ferrari GM, Cremer PC, ... Brucato A, Adler Y
Aims
Novel therapies are needed for recurrent pericarditis, particularly when corticosteroid dependent and colchicine resistant. Based on limited data, interleukin-1 blockade with anakinra may be beneficial. The aim of this multicentre registry was to evaluate the broader effectiveness and safety of anakinra in a \'real world\' population.
Methods and results
This registry enrolled consecutive patients with recurrent pericarditis who were corticosteroid dependent and colchicine resistant and treated with anakinra. The primary outcome was the pericarditis recurrence rate after treatment. Secondary outcomes included emergency department visits, hospitalisations, corticosteroid use and adverse events. Among 224 patients (46 ± 14 years old, 63% women, 75% idiopathic), the median duration of disease was 17 months (interquartile range 9-33). Most patients had elevated C-reactive protein (91%) and pericardial effusion (88%). After a median treatment of 6 months (3-12), pericarditis recurrences were reduced six-fold (2.33-0.39 per patient per year), emergency department admissions were reduced 11-fold (1.08-0.10 per patient per year), hospitalisations were reduced seven-fold (0.99-0.13 per patient per year). Corticosteroid use was decreased by anakinra (respectively from 80% to 27%;  < 0.001). No serious adverse events occurred; adverse events consisted mostly of transient skin reactions (38%) at the injection site. Adverse events led to discontinuation in 3%. A full-dose treatment duration of over 3 months followed by a tapering period of over 3 months were the therapeutic schemes associated with a lower risk of recurrence.
Conclusion
In patients with recurrent pericarditis, anakinra appears efficacious and safe in reducing recurrences, emergency department admissions and hospitalisations.



Eur J Prev Cardiol: 14 Oct 2019:2047487319879534; epub ahead of print
Imazio M, Andreis A, De Ferrari GM, Cremer PC, ... Brucato A, Adler Y
Eur J Prev Cardiol: 14 Oct 2019:2047487319879534; epub ahead of print | PMID: 31610707
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Abstract

Physical activity may drive healthy microvascular ageing via downregulation of p66.

Streese L, Khan AW, Deiseroth A, Hussain S, ... Hanssen H, Cosentino F
Background
Narrower retinal arterioles and wider venules are linked to adverse cardiovascular outcomes. The mitochondrial adaptor p66 is a major source of ageing-induced generation of reactive oxygen species. Promoter DNA methylation inhibits p66 gene transcription. This cross-sectional study was designed to investigate the link between physical activity, retinal vessel diameters and p66 expression in active and sedentary ageing subjects.
Design/methods
Altogether 158 subjects were included in the study (mean age 59.4 ± 7.0 years). Thirty-eight subjects were healthy active, 36 were healthy sedentary and 84 were sedentary with ≥2 cardiovascular risk factors. Retinal arteriolar and venular diameters were measured by means of a retinal vessel analyser. As a marker of oxidative stress, plasma 3-nitrotyrosine was determined by enzyme-linked immunosorbent assay. Gene expression of p66 and DNA methylation were assessed in mononuclear cells by real-time quantitative polymerase chain reaction and methylated-DNA capture (MethylMiner Enrichment kit) coupled with quantitative polymerase chain reaction, respectively.
Results
Wider retinal arterioles (179 ± 14 vs 172 ± 11 and 171 ± 14 µm;  < 0.05 and narrower venules (204 ± 17 vs 209 ± 11 and 218 ± 16 µm;  < 0.001) were observed in healthy active subjects compared with healthy sedentary subjects and sedentary subjects with ≥2 cardiovascular risk factors, respectively. Furthermore, healthy active subjects had blunted p66 expression and lower 3-nitrotyrosine plasma levels compared with healthy sedentary and sedentary subjects with ≥2 cardiovascular risk factors. Accordingly, hypomethylation of p66 promoter observed in healthy sedentary and sedentary subjects with ≥2 cardiovascular risk factors was not found in healthy active subjects.
Conclusion
Long-term physical activity-induced DNA methylation of p66 may represent a putative mechanistic link whereby active lifestyle promotes healthy microvascular ageing.



Eur J Prev Cardiol: 14 Oct 2019:2047487319880367; epub ahead of print
Streese L, Khan AW, Deiseroth A, Hussain S, ... Hanssen H, Cosentino F
Eur J Prev Cardiol: 14 Oct 2019:2047487319880367; epub ahead of print | PMID: 31610708
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Abstract

Comparative efficacy of exercise and anti-hypertensive pharmacological interventions in reducing blood pressure in people with hypertension: A network meta-analysis.

Noone C, Leahy J, Morrissey EC, Newell J, ... Murphy AW, Molloy GJ
Aims
This analysis aims to estimate the comparative efficacy of anti-hypertensive medications and exercise interventions on systolic and diastolic blood pressure reduction in people with hypertension.
Methods
A systematic review was conducted focusing on randomised controlled trials (RCTs) of exercise interventions and first-line anti-hypertensives where blood pressure reduction was the primary outcome in those with hypertension. Network meta-analyses were conducted to generate estimates of comparative efficacy.
Results
We identified 93 RCTs ( = 32,404, mean age in RCTs: 39-70 years) which compared placebo or usual care with first-line antihypertensives including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers and thiazide-like diuretics and exercise interventions including aerobic training and dynamic resistance training. Of these, there were 81 (87%) trials related to medications ( = 31,347, 97%) and 12 (13%) trials related to exercise ( = 1057, 3%). The point estimates suggested that antihypertensive medications were more effective than exercise but there was insufficient evidence to suggest that first-line medications significantly reduced blood pressure to a greater extent than did the exercise interventions. Of the first-line treatments, angiotensin receptor blockers and calcium channel blockers had the highest treatment ranking, while exercise had the second lowest treatment ranking, followed by control conditions.
Conclusion
The current evidence base with a bias towards medication research may partly explain the circumspection around the efficacy of exercise in guidelines and practice. Clinicians may justifiably consider exercise for low risk hypertension patients who confirm a preference for such an approach.



Eur J Prev Cardiol: 14 Oct 2019:2047487319879786; epub ahead of print
Noone C, Leahy J, Morrissey EC, Newell J, ... Murphy AW, Molloy GJ
Eur J Prev Cardiol: 14 Oct 2019:2047487319879786; epub ahead of print | PMID: 31615283
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Abstract

Pre-pregnancy parental BMI and offspring blood pressure in infancy.

Jansen MAC, Dalmeijer GW, Saldi SR, Grobbee DE, ... Uiterwaal CS, Idris NS
Aims
A growing body of evidence suggests that a higher maternal pre-pregnancy body mass index results in higher offspring\'s blood pressure, but there is inconsistency about the impact of father\'s body mass index. Furthermore, evidence is limited with regard to low and middle income countries. We aimed to determine the association between parental pre-pregnancy body mass index and offspring\'s blood pressure during the first year of life.
Methods
In 587 infants of the BReastfeeding Attitude and Volume Optimization (BRAVO) trial systolic and diastolic blood pressure were measured twice at the right leg in a supine position, using an automatic oscillometric device at day 7, month 1, 2, 4, 6, 9 and 12. Parental pre-pregnancy body mass index was based on self-reported weight and height. Linear mixed models were performed to investigate the associations between parental pre-pregnancy body mass index and offspring blood pressure patterns.
Results
Each unit increase in maternal body mass index was associated with 0.24 mmHg (95% confidence interval 0.05; 0.44) and 0.13 mmHg (0.01; 0.25) higher offspring\'s mean systolic and diastolic blood pressure, respectively, during the first year of life. A higher offspring blood pressure with increased maternal pre-pregnancy body mass index was seen at birth and remained higher during the first year of life. The association with systolic blood pressure remained similar after including birth size and offspring\'s weight and height over time. The association with diastolic blood pressure attenuated slightly to a non-significant result after including these variables. Paternal body mass index was not associated with offspring\'s blood pressure.
Conclusion
Higher maternal pre-pregnancy body mass index, but not paternal pre-pregnancy body mass index, is associated with higher offspring blood pressure already from birth onwards.



Eur J Prev Cardiol: 29 Sep 2019; 26:1581-1590
Jansen MAC, Dalmeijer GW, Saldi SR, Grobbee DE, ... Uiterwaal CS, Idris NS
Eur J Prev Cardiol: 29 Sep 2019; 26:1581-1590 | PMID: 31238715
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Abstract

Keys to early diagnosis of cardiac amyloidosis: red flags from clinical, laboratory and imaging findings.

Vergaro G, Aimo A, Barison A, Genovesi D, ... Passino C, Emdin M

Cardiac involvement in systemic amyloidosis, due either to immunoglobulin light-chain or transthyretin amyloidosis, influences clinical presentation and is a strong predictor of unfavourable outcome. Until recently considered as a rare, incurable disease, cardiac amyloidosis, is still mis/underdiagnosed, although treatments effective in improving patient survival are now available for both subtypes, including chemotherapy regimens for immunoglobulin light-chain amyloidosis and tetramer stabiliser for transthyretin amyloidosis. Achieving a timely diagnosis allows initiating life-saving therapies and requires the early recognition of clinical, laboratory and imaging signs of cardiac involvement, some of them may be apparent well before the disease becomes clinically manifest. Given the systemic nature of amyloidosis, a close interaction among experts in multiple specialties is also required, including cardiologists, nephrologists, haematologists, neurologists, radiologists, nuclear medicine specialists and internists. As an increased awareness about disease presentation is required to ameliorate diagnostic performance, we aim to provide the clinician with a guide to the screening and early diagnosis of cardiac amyloidosis, and to review the clinical, biohumoral and instrumental \'red flags\' that should raise the suspicion of cardiac amyloidosis.



Eur J Prev Cardiol: 03 Oct 2019:2047487319877708; epub ahead of print
Vergaro G, Aimo A, Barison A, Genovesi D, ... Passino C, Emdin M
Eur J Prev Cardiol: 03 Oct 2019:2047487319877708; epub ahead of print | PMID: 31581822
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Abstract

Leisure time and occupational physical activity, resting heart rate and mortality in the Arctic region of Norway: The Finnmark Study.

Hermansen R, Jacobsen BK, Løchen ML, Morseth B
Aims
This study examined the association of leisure time physical activity, occupational physical activity, and resting heart rate with all-cause and cardiovascular disease mortality in Sami and non-Sami populations.
Study design
This was a longitudinal, observational population-based study.
Methods
The Finnmark 3 study cohort was examined in 1987-1988 and followed for all-cause and cardiovascular disease mortality for 26 years. The cohort included 17,697 men and women with a mean age of 47.2 years at baseline. Leisure time physical activity and occupational physical activity were assessed with a validated questionnaire at baseline, whereas cause of death was obtained from the Norwegian Cause of Death Registry.
Results
A total of 1983 women and 3147 men died during follow-up. Leisure time physical activity was linearly and inversely associated with all-cause mortality, but not coronary heart disease mortality. Compared to inactive subjects, all-cause mortality was significantly reduced by 16% in the active leisure time physical activity group (hazard ratio 0.84; 95% confidence interval 0.76-0.92). Both for all-cause and cardiovascular disease mortality, we observed a U-shaped relationship with occupational physical activity, as participants in the walking and lifting group had significantly lower mortality than both the mostly sedentary and the heavy manual labour group ( < 0.05). An increase in resting heart rate by one beat per minute was associated with a 1.1% increase in all-cause mortality (hazard ratio 1.011; 95% confidence interval 1.009-1.013). The associations were similar in Sami and non-Sami subjects.
Conclusion
In this population-based study, leisure time physical activity was inversely associated with all-cause mortality, whereas resting heart rate was positively associated with all-cause and cardiovascular disease mortality. There was a U-shaped association between occupational physical activity and cardiovascular disease and all-cause mortality.



Eur J Prev Cardiol: 29 Sep 2019; 26:1636-1644
Hermansen R, Jacobsen BK, Løchen ML, Morseth B
Eur J Prev Cardiol: 29 Sep 2019; 26:1636-1644 | PMID: 31109185
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Impact:
Abstract

Plasma proprotein convertase subtilisin/kexin type 9 concentration and recurrent cardiovascular events in patients with familial hypercholesterolemia.

Cao YX, Liu HH, Jin JL, Sun D, ... Santos RD, Li JJ
Aims
Familial hypercholesterolemia patients are characterized by early onset of coronary artery calcification and atherosclerosis, and high incidence of cardiovascular events. Plasma proprotein convertase subtilisin/kexin type 9 was reported to be a predictor for cardiovascular risk in the general population. However, its prognostic value for predicting recurrent cardiovascular events in familial hypercholesterolemia patients remains undetermined.
Methods
A total of 249 patients with molecularly and/or clinically (Dutch Lipid Clinic Network score > 6) defined familial hypercholesterolemia who had experienced a first cardiovascular event were consecutively included and plasma proprotein convertase subtilisin/kexin type 9 concentrations were measured by enzyme-linked immunosorbent assay. Coronary artery calcification was measured using Agatston method and coronary severity was assessed by Gensini score, respectively. All patients received standard lipid-lowering therapy and were followed-up for recurrent cardiovascular events. Univariate and multivariate regression and Cox analyses was used to calculate hazard ratios with 95% confidence interval.
Results
Circulating proprotein convertase subtilisin/kexin type 9 concentrations were positively associated with coronary artery calcification scores and Gensini score by both univariate and multivariate analyses. During a mean follow-up of 43 ± 19 months, 29 (11.51%) recurrent cardiovascular events occurred. Kaplan-Meier analysis showed that patients with the highest proprotein convertase subtilisin/kexin type 9 levels had the lowest event-free survival time. Multivariable Cox regression analysis revealed that proprotein convertase subtilisin/kexin type 9 was independently associated with recurrent cardiovascular events (hazard ratio: 1.45, 95% confidence interval: 1.11-1.88). The combination of proprotein convertase subtilisin/kexin type 9 to Cox prediction model led to an enhanced predictive value for recurrent cardiovascular events.
Conclusions
Increased level of proprotein convertase subtilisin/kexin type 9 was a significant risk factor of atherosclerosis and independently predicted future recurrent cardiovascular events in familial hypercholesterolemia patients receiving standard lipid-lowering treatment.



Eur J Prev Cardiol: 10 Oct 2019:2047487319880985; epub ahead of print
Cao YX, Liu HH, Jin JL, Sun D, ... Santos RD, Li JJ
Eur J Prev Cardiol: 10 Oct 2019:2047487319880985; epub ahead of print | PMID: 31604401
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Impact:
Abstract

The benefits of exercise in cancer patients and the criteria for exercise prescription in cardio-oncology.

D\'Ascenzi F, Anselmi F, Fiorentini C, Mannucci R, Bonifazi M, Mondillo S

Cancer and cardiovascular diseases are the leading causes of death in high-income countries. Cardiovascular complications can be found in cancer patients, being the result of so-called \'cardio-toxicity\'. Therefore, it becomes essential to thoroughly investigate the origin of cardiac damage and the strategy to prevent it or to reverse the negative remodelling associated with cardiotoxicity. In this review the beneficial effects of physical exercise in cancer patients were analysed, particularly to prevent cardio-toxicity before its clinical manifestation. According to the relevance of exercise, we suggest strategies for exercise prescription with a tailored approach in these patients. In conclusion, physical exercise seems to be a promising and effective treatment for cancer patients during and after therapy and seems to counteract the negative effects induced by drugs on the cardiovascular system. Exercise prescription should be tailored according to patient\'s individual characteristics, to the drugs administered, to the personal history, and to his/her response to exercise, taking into account that different types of training can be prescribed according also to the patient\'s choice. A cardiological evaluation including exercise testing is essential for an appropriate prescription of exercise in these patients.



Eur J Prev Cardiol: 05 Oct 2019:2047487319874900; epub ahead of print
D'Ascenzi F, Anselmi F, Fiorentini C, Mannucci R, Bonifazi M, Mondillo S
Eur J Prev Cardiol: 05 Oct 2019:2047487319874900; epub ahead of print | PMID: 31587570
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Impact:
Abstract

Systematic review of cardiac rehabilitation guidelines: Quality and scope.

Mehra VM, Gaalema DE, Pakosh M, Grace SL

Cardiac rehabilitation is a comprehensive model of secondary prevention proven to reduce mortality and morbidity. The World Health Organization is developing a Package of Rehabilitation Interventions for implementation by ministries of health as part of universal healthcare across the continuum. Through a systematic review, we sought to identify the best-quality cardiac rehabilitation guidelines, and extract their recommendations for implementation by member states. A systematic search was undertaken of academic databases and guideline repositories, among other sources, through to April 2019, for English-language cardiac rehabilitation guidelines from the last 10 years, free from conflicts, and with strength of recommendations. Two authors independently considered all citations. Potentially eligible guidelines were rated for quality using the Appraisal of Guidelines for Research and Evaluation tool, and for other characteristics such as being multi-professional, comprehensive and international in perspective; the latter criteria were used to inform selection of 3-5 guidelines meeting inclusion criteria. Equity considerations were also extracted. Altogether, 2076 unique citations were identified. Thirteen passed title and abstract screening, with six guidelines potentially eligible for inclusion in the Package of Rehabilitation Interventions and rated for quality; for two guidelines the Appraisal of Guidelines for Research and Evaluation tool ratings did not meet World Health Organization minimums. Of the four eligible guidelines, three were selected: the International Council of Cardiovascular Prevention and Rehabilitation (2016), National Institute for Health and Care Excellence (#172; 2013) and Scottish Intercollegiate Guideline Network (#150; 2017). Extracted recommendations were comprehensive, but psychosocial recommendations were contradictory and diet recommendations were inconsistent. A development group of the World Health Organization will review and refine the recommendations which will then undergo peer review, before open source dissemination for implementation.



Eur J Prev Cardiol: 03 Oct 2019:2047487319878958; epub ahead of print
Mehra VM, Gaalema DE, Pakosh M, Grace SL
Eur J Prev Cardiol: 03 Oct 2019:2047487319878958; epub ahead of print | PMID: 31581808
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Impact:
Abstract

Socioeconomic position and intergenerational associations of ideal health behaviors.

Komulainen K, Mittleman MA, Jokela M, Laitinen TT, ... Keltikangas-Järvinen L, Pulkki-Råback L
Background
Promoting ideal cardiovascular health behaviors is an objective of the American Heart Association 2020 goals. We hypothesized that ideal health behaviors of parents are associated with health behaviors of their adult offspring, and that higher socioeconomic position in either generation enhances intergenerational associations of ideal health behaviors.
Design
Prospective cohort study.
Methods
We included 1856 Young Finns Study participants who had repeated measurements of socioeconomic position (education, income, occupation), smoking status, body mass index, physical activity and diet from 2001, 2007 and 2011, and data on parental socioeconomic position and health behaviors from 1980. We calculated the total number of ideal behaviors in both generations using American Heart Association definitions. Intergenerational associations were examined using ordinal and linear multilevel regression with random intercepts, in which each participant contributed one, two or three measurements of adult health behaviors (2001, 2007, 2011). All analyses were adjusted for offspring sex, birth year, age, parental education and single parenthood.
Results
Overall, parental ideal health behaviors were associated with ideal behaviors among offspring (odds ratio (OR) 1.28, 95% confidence interval 1.17, 1.39). Furthermore, ORs for these intergenerational associations were greater among offspring whose parents or who themselves had higher educational attainment (OR 1.56 for high vs. OR 1.19 for low parental education;  = 0.01 for interaction, OR 1.32 for high vs. OR 1.04 for low offspring education;  = 0.02 for interaction). Similar trends were seen with parental income and offspring occupation. Results from linear regression analyses were similar.
Conclusions
These prospective data suggest higher socioeconomic position in parents or in their adult offspring strengthens the intergenerational continuum of ideal cardiovascular health behaviors.



Eur J Prev Cardiol: 29 Sep 2019; 26:1605-1612
Komulainen K, Mittleman MA, Jokela M, Laitinen TT, ... Keltikangas-Järvinen L, Pulkki-Råback L
Eur J Prev Cardiol: 29 Sep 2019; 26:1605-1612 | PMID: 31088119
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Impact:
Abstract

The impact of systolic and diastolic blood pressure variability on mortality is age dependent: Data from the Dublin Outcome Study.

Bilo G, Dolan E, O\'Brien E, Facchetti R, ... Mancia G, Parati G
Background
Twenty-four-hour blood pressure variability (BPV) is independently related to cardiovascular outcomes, but limited and conflicting evidence is available on the relative prognostic importance of systolic and diastolic BPV. The aim of this study was to verify the hypothesis that the association of systolic and diastolic blood pressure variability over 24 h with cardiovascular mortality in untreated subjects is affected by age.
Design and methods
The study included 9154 untreated individuals assessed for hypertension between 1982 and 2002 in the frame of the Dublin Outcome Study, in which 24 h ambulatory blood pressure monitoring was obtained (age 54.1 ± 14.3 years, 47% males). The association of short-term systolic and diastolic blood pressure variability with cardiovascular and all-cause mortality in the entire sample and separately in younger and older age subgroups was assessed over a median follow-up period of 6.3 years.
Results
Diastolic BPV was directly and independently related to cardiovascular mortality (adjusted hazard ratio (adjHR) for daytime standard deviation 1.16 (95% confidence interval 1.08-1.26)) with no significant differences among age groups. Conversely, systolic BPV was independently associated with cardiovascular mortality only in younger (<50 years) subjects (adjHR for daytime standard deviation 1.72 (95% confidence interval 1.33-2.23)), superseding the predictive value of diastolic BPV in this group.
Conclusions
Diastolic short-term BPV independently predicts cardiovascular mortality in hypertensive subjects at all ages, while systolic BPV seems a particularly strong predictor in young adults. If confirmed, these findings might improve the understanding of the prognostic value of BPV, with new perspectives for its possible clinical application.



Eur J Prev Cardiol: 10 Sep 2019:2047487319872572; epub ahead of print
Bilo G, Dolan E, O'Brien E, Facchetti R, ... Mancia G, Parati G
Eur J Prev Cardiol: 10 Sep 2019:2047487319872572; epub ahead of print | PMID: 31510817
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Impact:
Abstract

Myocarditis in athletes: A clinical perspective.

Halle M, Binzenhöfer L, Mahrholdt H, Johannes Schindler M, Esefeld K, Tschöpe C

Myocarditis is an important cause of arrhythmias and sudden cardiac death (SCD) in both physically active individuals and athletes. Elite athletes seem to have an increased risk for viral infection and subsequent myocarditis due to increased exposure to pathogens (worldwide traveling/international competition) or impaired immune system (continuing training during infections/resuming training early thereafter, strenuous exercise training or competition, and exercising in extreme weather conditions). Initial clinical presentation is variable, but athletes characteristically express non-specific symptoms of fatigue, muscle soreness, increased heart rate at rest, as well as during exercise and reduced overall exercise capacity. Beyond resting electrocardiogram (ECG), cardiac biomarkers, echocardiography, and 24-hour Holter ECG, diagnostic work-up should include cardiac magnetic resonance imaging (CMR) assessing inflammation, oedema, and fibrosis by late gadolinium enhancement (LGE), respectively, as these measures are crucial for prognosis and sports eligibility. For patients with insufficient cardiac recovery, endomyocardial biopsy is recommended to clarify differential diagnoses and initiate specific treatment options. In uncomplicated cases with normal left ventricular function during acute phase and absent LGE, eligibility for sports can be attested to three months after clinical recovery. In those with persistent pathological findings, even after six months, the risk for SCD remains increased and resuming exercise beyond recreational activities can only be recommended individually based on course of disease, left ventricular function, arrhythmias, pattern of LGE in CMR, as well as intensity and volume of exercise performed during training and competition. For all athletes, follow-up examination should be performed yearly.



Eur J Prev Cardiol: 02 Mar 2020:2047487320909670; epub ahead of print
Halle M, Binzenhöfer L, Mahrholdt H, Johannes Schindler M, Esefeld K, Tschöpe C
Eur J Prev Cardiol: 02 Mar 2020:2047487320909670; epub ahead of print | PMID: 32126831
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Impact:
Abstract

Workload-indexed blood pressure response is superior to peak systolic blood pressure in predicting all-cause mortality.

Hedman K, Cauwenberghs N, Christle JW, Kuznetsova T, Haddad F, Myers J
Aims
The association between peak systolic blood pressure (SBP) during exercise testing and outcome remains controversial, possibly due to the confounding effect of external workload (metabolic equivalents of task (METs)) on peak SBP as well as on survival. Indexing the increase in SBP to the increase in workload (SBP/MET-slope) could provide a more clinically relevant measure of the SBP response to exercise. We aimed to characterize the SBP/MET-slope in a large cohort referred for clinical exercise testing and to determine its relation to all-cause mortality.
Methods and results
Survival status for male Veterans who underwent a maximal treadmill exercise test between the years 1987 and 2007 were retrieved in 2018. We defined a subgroup of non-smoking 10-year survivors with fewer risk factors as a lower-risk reference group. Survival analyses for all-cause mortality were performed using Kaplan-Meier curves and Cox proportional hazard ratios (HRs (95% confidence interval)) adjusted for baseline age, test year, cardiovascular risk factors, medications and comorbidities. A total of 7542 subjects were followed over 18.4 (interquartile range 16.3) years. In lower-risk subjects ( = 709), the median (95th percentile) of the SBP/MET-slope was 4.9 (10.0) mmHg/MET. Lower peak SBP (<210 mmHg) and higher SBP/MET-slope (>10 mmHg/MET) were both associated with 20% higher mortality (adjusted HRs 1.20 (1.08-1.32) and 1.20 (1.10-1.31), respectively). In subjects with high fitness, a SBP/MET-slope > 6.2 mmHg/MET was associated with a 27% higher risk of mortality (adjusted HR 1.27 (1.12-1.45)).
Conclusion
In contrast to peak SBP, having a higher SBP/MET-slope was associated with increased risk of mortality. This simple, novel metric can be considered in clinical exercise testing reports.



Eur J Prev Cardiol: 29 Sep 2019:2047487319877268; epub ahead of print
Hedman K, Cauwenberghs N, Christle JW, Kuznetsova T, Haddad F, Myers J
Eur J Prev Cardiol: 29 Sep 2019:2047487319877268; epub ahead of print | PMID: 31564136
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Impact:
Abstract

The prevalence and impact of depression and anxiety in cardiac rehabilitation: A longitudinal cohort study.

Rao A, Zecchin R, Newton PJ, Phillips JL, ... Denniss AR, Hickman LD
Background
Co-morbid depression and anxiety symptoms are frequently under-recognised and under-treated in heart disease and this negatively impacts self-management.
Aims
The purpose of this study was to determine the prevalence, correlates and predictors of depression and anxiety in cardiac rehabilitation programmes, the impact of cardiac rehabilitation on moderate depression, anxiety and stress symptoms, and the relationship between moderate depression, anxiety and stress symptoms and cardiac rehabilitation adherence.
Methods
This was a retrospective cohort study of 5908 patients entering cardiac rehabilitation programmes from 2006-2017, across two Sydney metropolitan teaching hospitals. Variables included demographics, diagnoses, cardiovascular risk factors, medication use, participation rates, health status (Medical Outcomes Study Short Form-36) and psychological health (Depression Anxiety Stress Scales) subscale scores.
Results
Moderate depression, anxiety or stress symptoms were prevalent in 18%, 28% and 13% of adults entering cardiac rehabilitation programmes, respectively. Adults with moderate depression (24% vs 13%), anxiety (32% vs 23%) or stress (18% vs 10%) symptoms were significantly less likely to adhere to cardiac rehabilitation compared with those with normal-mild symptoms ( < 0.001). Anxiety (odds ratio 4.395, 95% confidence interval 3.363-5.744,  < 0.001) and stress (odds ratio 4.527, 95% confidence interval 3.315-6.181,  < 0.001) were the strongest predictors of depression. Depression (odds ratio 3.167, 95% confidence interval 2.411-4.161) and stress (odds ratio 5.577, 95% confidence interval 4.006-7.765,  < 0.001) increased the risk of anxiety on entry by more than three times, above socio-demographic factors, cardiovascular risk factors, diagnoses and quality of life.
Conclusion
Monitoring depression and anxiety symptoms on entry and during cardiac rehabilitation can assist to improve adherence and may identify the need for additional psychological health support. Exploring the relevance and use of adjunct psychological support strategies within cardiac rehabilitation programmes is warranted.



Eur J Prev Cardiol: 08 Oct 2019:2047487319871716; epub ahead of print
Rao A, Zecchin R, Newton PJ, Phillips JL, ... Denniss AR, Hickman LD
Eur J Prev Cardiol: 08 Oct 2019:2047487319871716; epub ahead of print | PMID: 31597473
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Impact:
Abstract

Cognitive behavioural therapy significantly reduces anxiety in patients with implanted cardioverter defibrillator compared with usual care: Findings from the Screen-ICD randomised controlled trial.

Berg SK, Rasmussen TB, Herning M, Svendsen JH, Christensen AV, Thygesen LC
Aim
The aim of this study was to investigate the effect of a cognitive behavioural therapy intervention provided by trained cardiac nurses plus usual care compared with usual care alone in patients with an implanted cardioverter defibrillator who, prior to randomization, had presented with symptoms of anxiety measured by the Hospital Anxiety and Depression Scale.
Background
Around 20-25% of all patients with an implanted cardioverter defibrillator experience anxiety. Among these patients anxiety is associated with mortality, presumably explained by risk behaviour and activation of the autonomic nervous system. We hypothesised that cognitive behavioural therapy provided by cardiac nurses in an out-patient setting would be an effective treatment of anxiety.
Methods
This was an investigator-initiated randomised clinical superiority trial with blinded outcome assessment, with 1:1 randomisation to cognitive behavioural therapy plus usual care or to usual care. The primary outcome was Hospital Anxiety and Depression Scale-Anxiety mean score at 16 weeks. Secondary outcomes included Hospital Anxiety and Depression Scale-Depression, Becks Anxiety Inventory, HeartQoL and Hamilton Anxiety Scale. Primary outcome analysis was based on the intention-to-treat principle.
Results
A total of 88 participants were included, 66% men, mean age 64.3 years and 61% had primary indication implantable cardioverter defibrillator. A significant difference after 16 weeks was found between groups: intervention group (Hospital Anxiety and Depression Scale-A mean (standard deviation) 4.95 points (3.30) versus usual care group 8.98 points (4.03) ( < 0.0001)). Cohen\'s d was -0.86, indicating a strong clinical effect. The effect was supported by secondary outcomes.
Conclusion
Cognitive behavioural therapy provided by cardiac nurses to patients with a positive screening for anxiety had a statistically and clinically significant effect on anxiety compared with patients not receiving cognitive behavioural therapy.



Eur J Prev Cardiol: 01 Oct 2019:2047487319874147; epub ahead of print
Berg SK, Rasmussen TB, Herning M, Svendsen JH, Christensen AV, Thygesen LC
Eur J Prev Cardiol: 01 Oct 2019:2047487319874147; epub ahead of print | PMID: 31575299
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Impact:
Abstract

Sacubitril-valsartan versus enalapril for acute decompensated heart failure: a cost-effectiveness analysis.

Perera K, Ademi Z, Liew D, Zomer E
Background
The Comparison of Sacubitril-Valsartan versus Enalapril on Effect on NT-proBNP in Patients Stabilised from an Acute Heart Failure Episode (PIONEER-HF) trial demonstrated significant reductions in N-terminal pro-B-type natriuretic peptide. Our study explored the cost-effectiveness of the use of sacubitril-valsartan versus enalapril in acute decompensated heart failure from the Australian healthcare perspective.
Methods
A Markov model was designed using data from the PIONEER-HF trial to model the clinical progress and costs of patients over a lifetime time horizon. The model consisted of three health states: \'alive and event-free\', \'alive after non-fatal hospitalisation for acute decompensated heart failure\' or \'dead\'. Costs and utilities were estimated from published sources. The cost of sacubitril-valsartan (per the Australian pharmaceutical benefits schedule) was AU$7.08/day. Outcomes of interest were the incremental cost-effectiveness ratios in terms of cost per quality-adjusted life year gained and cost per year of life saved. Cost and benefits were discounted at 5.0% per annum.
Results
Compared to enalapril, sacubitril-valsartan was estimated to cost an additional AU$7464 (discounted) per person, but lead to 0.127 years of life saved (discounted) and 0.096 quality-adjusted life years gained (discounted) over a lifetime analysis. These equated to incremental cost-effectiveness ratios of AU$58,629/year of life saved (US$41,795, EU€58,629, GBP£32,001) and AU$77,889/quality-adjusted life year gained (US$55,526, EU€49,202, GBP£42,504). We have assumed a threshold of AU$50,000/quality-adjusted life year gained to suggest cost-effectiveness.
Conclusions
At its current acquisition price, sacubitril-valsartan in comparison to enalapril is not likely to be cost-effective in the management of acute decompensated heart failure in Australia. A price reduction of more than 25% would confer cost-effectiveness.



Eur J Prev Cardiol: 03 Oct 2019:2047487319878953; epub ahead of print
Perera K, Ademi Z, Liew D, Zomer E
Eur J Prev Cardiol: 03 Oct 2019:2047487319878953; epub ahead of print | PMID: 31581810
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Impact:
Abstract

Completion and adherence rates to exercise interventions in intermittent claudication: Traditional exercise versus alternative exercise - a systematic review.

Lin E, Nguyen CH, Thomas SG
Background
Intermittent claudication, defined as fatigue or pain in the legs while walking, is a common symptom in peripheral arterial disease. Although exercise effectively improves function and manages symptoms, adherence rates are not ideal. The high levels of pain experienced in traditional exercise programmes may explain the suboptimal adherence. Alternative modalities of exercise can elicit similar benefits to traditional walking exercise. The purpose of this systematic review was to compare completion and adherence rates of exercise programmes in traditional exercise interventions versus alternative exercise interventions among patients with intermittent claudication.
Design
Systematic review.
Methods
The electronic databases of Medline, SPORTDiscus and CINAHL were searched from the earliest records to March 2018. Search terms were based on \'peripheral artery disease\' and \'exercise\'. Studies were included if they involved structured exercise and explicitly reported the number of participants that commenced and completed the programme.
Results
The search identified 6814 records based on inclusion criteria. Eighty-four full-text records were reviewed in further detail. Out of the 84 studies, there was a total of 122 separate exercise groups, with 64 groups of \'traditional walking exercise\' and 58 groups of \'alternative exercise\'. Completion and adherence rates for traditional exercise were 80.8% and 77.6%, respectively. Completion and adherence rates for alternative exercise were 86.6% and 85.5%, respectively.
Conclusions
The use of alternative modalities of exercise, which have been proved to be as effective as traditional exercise, may offer a solution to the poor participation and adherence rates to exercise in this population.



Eur J Prev Cardiol: 29 Sep 2019; 26:1625-1633
Lin E, Nguyen CH, Thomas SG
Eur J Prev Cardiol: 29 Sep 2019; 26:1625-1633 | PMID: 31216860
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Impact:
Abstract

Identification of novel diagnostic and prognostic biomarkers for abdominal aortic aneurysm.

Memon AA, Zarrouk M, Ågren-Witteschus S, Sundquist J, Gottsäter A, Sundquist K
Aims
Abdominal aortic aneurysm is a life-threatening condition due to the risk of aneurysm growth and rupture. There are no approved diagnostic or prognostic biomarkers for abdominal aortic aneurysm. We aimed to identify diagnostic and prognostic biomarkers for abdominal aortic aneurysm and to investigate their relationship with abdominal aortic aneurysm diameter and growth.
Methods
In this case-control study, patients were included from an abdominal aortic aneurysm screening study on men aged ≥65 years. Of 24,589 examined men, 415 had abdominal aortic aneurysm, out of whom 134 consented to participate in the present study. One hundred and thirty-six screened men with aortic diameter <30 mm, matched for comorbidities and time of sampling were included as non-abdominal aortic aneurysm patients. Ninety-one cardiovascular specific proteins in plasma samples were measured by the Proseek Multiplex CVD III panel.
Results
After Bonferroni correction, plasma levels of 21 proteins associated with proteolysis, oxidative-stress, lipid metabolism, and inflammation were significantly increased, whereas levels of paraoxonase 3, associated with high-density lipoprotein metabolism, were decreased in abdominal aortic aneurysm patients. Combination of growth/differentiation factor 15 and cystatin B had the best ability to discriminate abdominal aortic aneurysm from non-abdominal aortic aneurysm (area under the curve, 0.76; sensitivity, 80% and specificity, 52%). Myeloperoxidase showed the best prognostic value (area under the curve, 0.71; sensitivity, 80% and specificity, 59%) and higher baseline levels of myeloperoxidase were significantly associated with faster abdominal aortic aneurysm growth compared with lower levels, independent of baseline diameter.
Conclusions
We have identified multiple proteins associated with abdominal aortic aneurysm diameter and growth with a potential to become novel diagnostic and prognostic biomarkers for abdominal aortic aneurysm.



Eur J Prev Cardiol: 28 Aug 2019:2047487319873062; epub ahead of print
Memon AA, Zarrouk M, Ågren-Witteschus S, Sundquist J, Gottsäter A, Sundquist K
Eur J Prev Cardiol: 28 Aug 2019:2047487319873062; epub ahead of print | PMID: 31466471
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Impact:
Abstract

Towards a personalised approach in exercise-based cardiovascular rehabilitation: How can translational research help? A \'call to action\' from the Section on Secondary Prevention and Cardiac Rehabilitation of the European Association of Preventive Cardiology.

Gevaert AB, Adams V, Bahls M, Bowen TS, ... Van Craenenbroeck EM, Kränkel N

The benefit of regular physical activity and exercise training for the prevention of cardiovascular and metabolic diseases is undisputed. Many molecular mechanisms mediating exercise effects have been deciphered. Personalised exercise prescription can help patients in achieving their individual greatest benefit from an exercise-based cardiovascular rehabilitation programme. Yet, we still struggle to provide truly personalised exercise prescriptions to our patients. In this position paper, we address novel basic and translational research concepts that can help us understand the principles underlying the inter-individual differences in the response to exercise, and identify early on who would most likely benefit from which exercise intervention. This includes hereditary, non-hereditary and sex-specific concepts. Recent insights have helped us to take on a more holistic view, integrating exercise-mediated molecular mechanisms with those influenced by metabolism and immunity. Unfortunately, while the outline is recognisable, many details are still lacking to turn the understanding of a concept into a roadmap ready to be used in clinical routine. This position paper therefore also investigates perspectives on how the advent of \'big data\' and the use of animal models could help unravel inter-individual responses to exercise parameters and thus influence hypothesis-building for translational research in exercise-based cardiovascular rehabilitation.



Eur J Prev Cardiol: 03 Oct 2019:2047487319877716; epub ahead of print
Gevaert AB, Adams V, Bahls M, Bowen TS, ... Van Craenenbroeck EM, Kränkel N
Eur J Prev Cardiol: 03 Oct 2019:2047487319877716; epub ahead of print | PMID: 31581819
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Impact:
Abstract

Relationship between physical activity and long-term outcomes in patients with stable coronary artery disease.

Biscaglia S, Campo G, Sorbets E, Ford I, ... Steg PG,
Aims
The aims of this study were to ascertain the relationship between level of physical activity and outcomes and to discriminate the determinants of physical activity performance or avoidance.
Methods
CLARIFY is an international prospective registry of 32,370 consecutive outpatients with stable coronary artery disease who were followed for up to five years. Patients were grouped according to the level and frequency of physical activity: i) sedentary ( = 5223; 16.1%); ii) only light physical activity most weeks (light;  = 16,634; 51.4%); iii) vigorous physical activity once or twice per week (vigorous ≤ 2×;  = 5427; 16.8%); iv) vigorous physical activity three or more times per week (vigorous >2×;  = 5086; 15.7%). The primary outcome was the composite of cardiovascular death, myocardial infarction and stroke.
Results
Patients performing vigorous physical activity ≤2 × had the lowest risk of the primary outcome (hazard ratio, 0.82; 95% confidence interval, 0.71-0.93;  = 0.0031) taking the light group as reference. Engaging in more frequent exercise did not result in further outcome benefit. All-cause death, cardiovascular death, and stroke occurred less frequently in patients performing vigorous physical activity ≤2×. However, the rate of myocardial infarction was comparable between the four physical activity groups. Female sex, peripheral artery disease, diabetes, previous myocardial infarction or stroke, pulmonary disease and body mass index all emerged as independent predictors of lower physical activity.
Conclusion
Vigorous physical activity once or twice per week was associated with superior cardiac outcomes compared with patients performing no or a low level of physical activity in outpatients with stable coronary artery disease.



Eur J Prev Cardiol: 25 Sep 2019:2047487319871217; epub ahead of print
Biscaglia S, Campo G, Sorbets E, Ford I, ... Steg PG,
Eur J Prev Cardiol: 25 Sep 2019:2047487319871217; epub ahead of print | PMID: 31558054
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Impact:
Abstract

Attending Heart School and long-term outcome after myocardial infarction: A decennial SWEDEHEART registry study.

Wallert J, Olsson EM, Pingel R, Norlund F, ... Burell G, Held C
Background
The Heart School is a standard component of cardiac rehabilitation after myocardial infarction in Sweden. The group-based educational intervention aims to improve modifiable risks, in turn reducing subsequent morbidity and mortality. However, an evaluation with respect to mortality is lacking.
Aims
Using linked population registries, we estimated the association of attending Heart School with both all-cause and cardiovascular mortality, two and five years after admission for first-time myocardial infarction.
Methods
Patients with first-time myocardial infarction (<75 years) were identified as consecutively registered in the nationwide heart registry, SWEDEHEART (2006-2015), with >99% complete follow-up in the Causes of Death registry for outcome events. Of 192,059 myocardial infarction admissions, 47,907 unique patients with first-time myocardial infarction surviving to the first cardiac rehabilitation visit constituted the study population. The exposure was attending Heart School at the first cardiac rehabilitation visit 6-10 weeks post-myocardial infarction. Data on socioeconomic status was acquired from Statistics Sweden. After multiple imputation, propensity score matching was performed. The association of exposure with mortality was estimated with Cox regression and survival curves.
Results
After matching, attending Heart School was associated (hazard ratio (95% confidence interval)) with a markedly lower risk of both all-cause (two-year hazard ratio = 0.53 (0.44-0.64); five-year hazard ratio = 0.62 (0.55-0.69)) and cardiovascular (0.50 (0.38-0.65); 0.57 (0.47-0.69)) mortality. The results were robust in several sensitivity analyses.
Conclusions
Attending Heart School during cardiac rehabilitation is associated with almost halved all-cause and cardiovascular mortality after first-time myocardial infarction. The result warrants further investigation through adequately powered randomised trials.



Eur J Prev Cardiol: 12 Sep 2019:2047487319871714; epub ahead of print
Wallert J, Olsson EM, Pingel R, Norlund F, ... Burell G, Held C
Eur J Prev Cardiol: 12 Sep 2019:2047487319871714; epub ahead of print | PMID: 31514507
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Impact:
Abstract

The efficacy of acupuncture for stable angina pectoris: A systematic review and meta-analysis.

Yang M, Sun M, Du T, Long H, ... Liang F, Lao L
Objective
The aim of this study was to assess the efficacy and safety of acupuncture in the treatment of patients with stable angina pectoris.
Methods
A literature search was performed in nine databases, including PubMed and the Cochrane Library, from their inception to 30 August 2018. Randomized controlled trials that compared acupuncture therapy with sham acupuncture or no treatment were included. Two reviewers under the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines assessed the eligibility of each record and extracted essential information independently. The data were merged using a fixed-effect model.
Results
Pooled analysis of 17 eligible trials with 1516 participants showed that acupuncture was associated with reduced angina attack frequency (-4.91; 95% confidence interval, -6.01- -3.82;  < 0.00001) and improved depression (-1.23; 95% confidence interval, -1.47- -1.00;  < 0.00001) and anxiety level (-0.96; 95% confidence interval, -1.16- -0.75;  < 0.00001) relative to sham treatment or standard care alone. No increased risk of adverse events was observed during treatment (relative risk, 0.70; 95% confidence interval, 0.33-1.48;  = 0.35). No significant improvement was shown in nitroglycerin use or angina intensity. The included studies were associated with unclear to high risk of selection or performance bias, and the quality of evidence was low to moderate.
Conclusions
Acupuncture may safely and effectively improve physical restrictions, emotional distress, and attack frequency in patients with stable angina pectoris. However, angina intensity and medication use were not reduced. Studies with adequate blinding and a valid sham control group are still warranted due to the current low quality of evidence.



Eur J Prev Cardiol: 16 Sep 2019:2047487319876761; epub ahead of print
Yang M, Sun M, Du T, Long H, ... Liang F, Lao L
Eur J Prev Cardiol: 16 Sep 2019:2047487319876761; epub ahead of print | PMID: 31529993
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Impact:
Abstract

The association of resistance training with mortality: A systematic review and meta-analysis.

Saeidifard F, Medina-Inojosa JR, West CP, Olson TP, ... Vinciguerra M, Lopez-Jimenez F
Background
The benefits of aerobic exercise are well-studied; there is no consensus on the association between resistance training and major adverse cardiovascular outcomes. This systematic review and meta-analysis aimed to address this issue.
Design and methods
We searched for randomized trials and cohort studies that evaluated the association between resistance training and mortality and cardiovascular events. Two investigators screened the identified abstracts and full-texts independently and in duplicate. Cochrane tools were used to assess the risk of bias. We calculated hazard ratios and 95% confidence intervals using random effect models.
Results
From the 1430 studies identified, 11 (one randomized trial and 10 cohort studies) met the inclusion criteria, totaling 370,256 participants with mean follow-up of 8.85 years. The meta-analysis showed that, compared with no exercise, resistance training was associated with 21% (hazard ratio (95% confidence interval (CI)), 0.79 (0.69-0.91)) and 40% (hazard ratio (95% CI), 0.60 (0.49-0.72)) lower all-cause mortality alone and when combined with aerobic exercise, respectively. Furthermore, resistance training had a borderline association with lower cardiovascular mortality (hazard ratio (95% CI), 0.83 (0.67-1.03)). In addition, resistance training showed no significant association with cancer mortality. Risk of bias was low to intermediate in the included studies. One cohort study looked at the effect of resistance training on coronary heart disease events in men and found a 23% risk reduction (risk ratio, 0.77, CI: 0.61-0.98).
Conclusion
Resistance training is associated with lower mortality and appears to have an additive effect when combined with aerobic exercise. There are insufficient data to determine the potential beneficial effect of resistance training on non-fatal events or the effect of substituting aerobic exercise with resistance training.



Eur J Prev Cardiol: 29 Sep 2019; 26:1647-1665
Saeidifard F, Medina-Inojosa JR, West CP, Olson TP, ... Vinciguerra M, Lopez-Jimenez F
Eur J Prev Cardiol: 29 Sep 2019; 26:1647-1665 | PMID: 31104484
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Impact:
Abstract

Do rebreathing manoeuvres for non-invasive measurement of cardiac output during maximum exercise test alter the main cardiopulmonary parameters?

Vignati C, Morosin M, Fusini L, Pezzuto B, ... Sinagra G, Agostoni P
Background
Inert gas rebreathing has been recently described as an emergent reliable non-invasive method for cardiac output determination during exercise, allowing a relevant improvement of cardiopulmonary exercise test clinical relevance. For cardiac output measurements by inert gas rebreathing, specific respiratory manoeuvres are needed which might affect pivotal cardiopulmonary exercise test parameters, such as exercise tolerance, oxygen uptake and ventilation vs carbon dioxide output (VE/VCO) relationship slope.
Method
We retrospectively analysed cardiopulmonary exercise testing of 181 heart failure patients who underwent both cardiopulmonary exercise testing and cardiopulmonary exercise test+cardiac output within two months (average 16 ± 15 days). All patients were in stable clinical conditions (New York Heart Association I-III) and on optimal medical therapy.
Results
The majority of patients were in New York Heart Association Class I and II (78.8%), with a mean left ventricular ejection fraction of 31 ± 10%. No difference was found between the two tests in oxygen uptake at peak exercise (1101 (interquartile range 870-1418) ml/min at cardiopulmonary exercise test vs 1103 (844-1389) at cardiopulmonary exercise test-cardiac output) and at anaerobic threshold. However, anaerobic threshold and peak heart rate, peak workload (75 (58-101) watts and 64 (42-90),  < 0.01) and carbon dioxide output were significantly higher at cardiopulmonary exercise testing than at cardiopulmonary exercise test+cardiac output, whereas VE/VCO slope was higher at cardiopulmonary exercise test+cardiac output (30 (27-35) vs 33 (28-37),  < 0.01).
Conclusion
The similar anaerobic threshold and peak oxygen uptake in the two tests with a lower peak workload and higher VE/VCO slope at cardiopulmonary exercise test+cardiac output suggest a higher respiratory work and consequent demand for respiratory muscle blood flow secondary to the ventilatory manoeuvres. Accordingly, VE/VCO slope and peak workload must be evaluated with caution during cardiopulmonary exercise test+cardiac output.



Eur J Prev Cardiol: 29 Sep 2019; 26:1616-1622
Vignati C, Morosin M, Fusini L, Pezzuto B, ... Sinagra G, Agostoni P
Eur J Prev Cardiol: 29 Sep 2019; 26:1616-1622 | PMID: 31023097
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Impact:
Abstract

Cardiovascular risk stratification in primary care patients with arterial hypertension: Results from the Swiss Hypertension Cohort Study (HccH).

Handschin A, Brighenti-Zogg S, Mundwiler J, Giezendanner S, ... Zeller A, Dieterle T
Aims
Few data are available on cardiovascular risk stratification in primary care patients treated for arterial hypertension. This study aimed at evaluating the cardiovascular risk profile of hypertensive patients included into the Swiss Hypertension Cohort Study according to the 2013 European Society of Hypertension/European Society of Cardiology Guidelines.
Methods
The Swiss Hypertension Cohort Study is a prospective, observational study conducted by the Centre for Primary Health Care of the University of Basel from 2006 to 2013. Patients with a diagnosis of arterial hypertension (office blood pressure measurement ≥140/90 mmHg) were enrolled. Office blood pressure measurement, cardiovascular risk factors, subclinical organ damage, diabetes mellitus, and established cardiovascular and renal disease were recorded at baseline and at an annual interval during routine consultations by general practitioners in Switzerland.
Results
In total, 1003 patients were eligible for analysis (55.6% male, mean age: 64.0 ± 13.2 years). At baseline, 78.5% of patients presented with either more than three additional cardiovascular risk factors, diabetes mellitus or subclinical organ damage, while 44.4% of patients had a high or very high overall cardiovascular risk. Cardiovascular risk factors and information about diabetes mellitus, established cardiovascular disease and renal disease were recorded mostly completely, whereas substantial gaps were revealed regarding the assessment of subclinical organ damage.
Conclusion
The present findings demonstrate that the majority of primary care patients with arterial hypertension bear a substantial number of additional cardiovascular risk factors, subclinical and/or established organ damage. This emphasizes the need for continuous cardiovascular risk stratification and adequate treatment of arterial hypertension in Switzerland.



Eur J Prev Cardiol: 30 Oct 2019; 26:1843-1851
Handschin A, Brighenti-Zogg S, Mundwiler J, Giezendanner S, ... Zeller A, Dieterle T
Eur J Prev Cardiol: 30 Oct 2019; 26:1843-1851 | PMID: 31189378
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Impact:
Abstract

Does prior antithrombotic therapy influence recurrence and bleeding risk in stroke patients with atrial fibrillation or atrial flutter?

Gamble DT, Buono R, Mamas MA, Leslie S, ... Potter JF, Myint PK
Background
Whilst antithrombotic therapy is recommended in people with atrial fibrillation, little is known about the survival benefits of antithrombotic treatment in those with both high ischaemic and bleeding risk scores. We aim to describe the distribution of these risk scores in those with a prior diagnosis of atrial fibrillation who have suffered stroke and to determine the net clinical benefit of antithrombotic treatment.
Methods
We used regional stroke register data in the UK. Patients with a prior diagnosis of atrial fibrillation and ischaemic or haemorrhagic stroke patients were selected and their ischaemic stroke risk score (CHADS-VAS) and bleeding risk score (HEMORRHAGES) scores retrospectively calculated. Logistic regression and Cox proportional hazards models were constructed to determine the association between antithrombotic therapy prior to stroke and in-hospital and long-term mortality.
Results
A total of 1928 stroke patients (mean age 81.3 years (standard deviation 8.5), 56.8% women) with prior atrial fibrillation were included. Of these, 1761 (91.3%) suffered ischaemic stroke. The most common phenotype (64%) was of those with both high CHADS-VAS (≥2) and high HEMORRHAGES score (≥4). In our fully adjusted model, patients on antithrombotic treatment with both high ischaemic and bleeding risk had a significant reduction in odds of 31% for in-hospital mortality (odds ratio 0.69 (95% confidence interval 0.48-1.00:  = 0.049)) and 17% relative risk reduction for long-term mortality (hazard ratio 0.83 (95% confidence interval 0.71-0.97:  = 0.02)).
Conclusions
Our study suggests that antithrombotic treatment has a prognostic benefit following incident stroke in those with both high ischaemic risk and high bleeding risk. This should be considered when choosing treatment options in this group of patients.



Eur J Prev Cardiol: 02 Sep 2019:2047487319871709; epub ahead of print
Gamble DT, Buono R, Mamas MA, Leslie S, ... Potter JF, Myint PK
Eur J Prev Cardiol: 02 Sep 2019:2047487319871709; epub ahead of print | PMID: 31480875
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Impact:
Abstract

The effect of exercise training on blood pressure in African and Asian populations: A systematic review and meta-analysis of randomized controlled trials.

Bersaoui M, Baldew SM, Cornelis N, Toelsie J, Cornelissen VA
Background
Exercise is key in the primary prevention and management of hypertension. Yet, current exercise recommendations are predominantly based on meta-analyses involving populations of European descent. Since blood pressure (BP) responses to pharmaceutical interventions are known to differ among ethnic groups, we aimed to investigate the BP responses to exercise training in non-European descendants.
Purpose
The aim of this study was to systematically summarize the available literature on the efficacy of exercise on BP in healthy adults (age ≥18 years) of African or Asian origin.
Methods
We searched the MEDLINE database for randomized controlled trials that evaluated the effect of exercise training on BP in healthy African and Asian adults with optimal BP, elevated BP or hypertension and published in a peer-reviewed journal up to May 2019. Random effect models were fitted to estimate the effect sizes.
Results
We identified 22 trials involving individuals of Asian origin ( = 931; mean age: 44 years; 41% male) and four trials involving individuals of African origin ( = 510; mean age: 56.7 years; 80% male). Aerobic exercise training significantly ( < 0.001) reduced systolic and diastolic BP in each ethnic group. Resistance training did not affect the BP of Asian participants with optimal BP. The effect of resistance training in Asians with elevated BP or hypertension and Africans could not be determined due to lack of data. Sub-analyses suggested somewhat larger reductions in systolic BP following aerobic training in hypertensive Africans compared with hypertensive Asians.
Conclusions
We found favorable effects of aerobic exercise training on BP in the African and the Asian populations. However, the overall low number of studies and especially the lack of data on resistance training and combined training in African and Asian populations warrant more research to improve the quality of evidence.



Eur J Prev Cardiol: 25 Aug 2019:2047487319871233; epub ahead of print
Bersaoui M, Baldew SM, Cornelis N, Toelsie J, Cornelissen VA
Eur J Prev Cardiol: 25 Aug 2019:2047487319871233; epub ahead of print | PMID: 31450966
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Impact:
Abstract

Cardiac reinnervation affects cardiorespiratory adaptations to exercise training in individuals with heart transplantation.

Ciolac EG, Castro RE, Marçal IR, Bacal F, Bocchi EA, Guimarães GV
Purpose
The purpose of this study was to investigate the hemodynamic and cardiorespiratory adaptations to exercise in individuals with heart transplantation with evidence of cardiac reinnervation (cardiac reinnervation group) versus without evidence of cardiac reinnervation (no cardiac reinnervation group).
Methods
Sedentary individuals with heart transplantation (age = 45.5 ± 2.2 years; time elapsed since surgery = 6.7 ± 0.7 years) were divided into the cardiac reinnervation ( = 16) and no cardiac reinnervation ( = 17) groups according to their heart rate response to cardiopulmonary exercise testing. The 24-hour ambulatory blood pressure, carotid-femoral pulse wave velocity, and cardiorespiratory fitness were assessed before and after 12 weeks of a thrice-weekly exercise program (five minutes of warm-up, 30 min of endurance exercise, one set of 10-15 reps in five resistance exercises, and five minutes of cool-down).
Results
The cardiac reinnervation group had reduced ( < 0.01) 24-hour systolic/diastolic blood pressure (7/9 mm Hg), daytime systolic/diastolic blood pressure (9/10 mm Hg) and nighttime diastolic blood pressure (6 mm Hg) after training. The no cardiac reinnervation group reduced ( < 0.05) only 24-hour (5 mm Hg), daytime (5 mm Hg) and nighttime (6 mm Hg) diastolic blood pressure after training. Hourly analysis showed that the cardiac reinnervation group reduced systolic/diastolic blood pressure for 10/21 h, while the no cardiac reinnervation group reduced systolic/diastolic blood pressure for only 3/11 h. The cardiac reinnervation group also improved both maximal oxygen consumption (10.8%) and exercise tolerance (13.4%) after training, but the no cardiac reinnervation group improved only exercise tolerance (9.9%). Pulse wave velocity did not change in both groups.
Conclusion
There were greater improvements in ambulatory blood pressure and maximal oxygen consumption in the cardiac reinnervation than the no cardiac reinnervation group. These results suggest that cardiac reinnervation associates with hemodynamic and cardiorespiratory adaptations to exercise training in individuals with heart transplantation.



Eur J Prev Cardiol: 10 Oct 2019:2047487319880650; epub ahead of print
Ciolac EG, Castro RE, Marçal IR, Bacal F, Bocchi EA, Guimarães GV
Eur J Prev Cardiol: 10 Oct 2019:2047487319880650; epub ahead of print | PMID: 31604403
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Impact:
Abstract

High prevalence of cardiac dysfunction or overt heart failure in 71-year-old men: A 21-year follow-up of \"The Study of men born in 1943\".

Chen X, Thunström E, Hansson PO, Rosengren A, ... Caidahl K, Fu M
Background
Knowledge about long-term risk factors and the prevalence of heart failure stages in general population is limited. We aimed to study the prevalence of cardiac dysfunction and heart failure in 71-year-old men and potential risk factors in the past two decades.
Design
This research was based on a randomized selected population study with longitudinal follow-up.
Methods
A random sample of men born in 1943 in Gothenburg, Sweden were examined in 1993 (at 50 years of age) and re-examined 21 years later in 2014 (at 71 years of age). Cardiac dysfunction or heart failure was classified into four stages (A-D) according to American Heart Association/American College of Cardiology guidelines on heart failure.
Results
Of the 798 men examined in 1993 (overall cohort), 535 (67%) were re-examined in 2014 (echo cohort). In the echo cohort 122 (23%) men had normal cardiac function, 135 (25%) were at stage A, 207 (39%) men were at stage B, 66 (12%) men were at stage C, and five (1%) men were at stage D. Multivariable logistic regression demonstrated that elevated body mass index at 50 years old was the only independent risk factor for developing heart failure/cardiac dysfunction during the subsequent 21 years. For each unit (1 kg/m) of increased body mass index, the odds ratio for stages C/D heart failure vs no heart failure/stage A increased by 1.20 (95% confidence interval, 1.11-1.31,  < 0.001), after adjustment for smoking, sedentary life style, systolic blood pressure, diabetes, and hyperlipidemia.
Conclusion
In a random sample of men at 71 years of age, half presented with either cardiac dysfunction or clinical heart failure. High body mass index was associated with an increased risk for developing cardiac dysfunction or heart failure over a 21-year period.



Eur J Prev Cardiol: 24 Aug 2019:2047487319871644; epub ahead of print
Chen X, Thunström E, Hansson PO, Rosengren A, ... Caidahl K, Fu M
Eur J Prev Cardiol: 24 Aug 2019:2047487319871644; epub ahead of print | PMID: 31446787
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Impact:
Abstract

Persistent emotional distress after a first-time myocardial infarction and its association to late cardiovascular and non-cardiovascular mortality.

Lissåker CT, Norlund F, Wallert J, Held C, Olsson EM
Background
Patients with symptoms of depression and/or anxiety - emotional distress - after a myocardial infarction (MI) have been shown to have worse prognosis and increased healthcare costs. However, whether specific subgroups of patients with emotional distress are more vulnerable is less well established. The purpose of this study was to identify the association between different patterns of emotional distress over time with late cardiovascular and non-cardiovascular mortality among first-MI patients aged <75 years in Sweden.
Methods
We utilized data on 57,602 consecutive patients with a first-time MI from the national SWEDEHEART registers. Emotional distress was assessed using the anxiety/depression dimension of the European Quality of Life Five Dimensions questionnaire two and 12 months after the MI, combined into persistent (emotional distress at both time-points), remittent (emotional distress at the first follow-up only), new (emotional distress at the second-follow up only) or no distress. Data on cardiovascular and non-cardiovascular mortality were obtained until the study end-time. We used multiple imputation to create complete datasets and adjusted Cox proportional hazards models to estimate hazard ratios.
Results
Patients with persistent emotional distress were more likely to die from cardiovascular (hazard ratio: 1.46, 95% confidence interval: 1.16, 1.84) and non-cardiovascular causes (hazard ratio: 1.54, 95% confidence interval: 1.30, 1.82) than those with no distress. Those with remittent emotional distress were not statistically significantly more likely to die from any cause than those without emotional distress.
Discussion
Among patients who survive 12 months, persistent, but not remittent, emotional distress was associated with increased cardiovascular and non-cardiovascular mortality. This indicates a need to identify subgroups of individuals with emotional distress who may benefit from further assessment and specific treatment.



Eur J Prev Cardiol: 30 Aug 2019; 26:1510-1518
Lissåker CT, Norlund F, Wallert J, Held C, Olsson EM
Eur J Prev Cardiol: 30 Aug 2019; 26:1510-1518 | PMID: 31159570
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Impact:
Abstract

Poor adherence to guideline recommendations among patients with atrial fibrillation and acute myocardial infarction.

Jortveit J, Pripp AH, Langørgen J, Halvorsen S
Background
The prevalence of atrial fibrillation in patients with acute myocardial infarction is largely unknown. The aims of the present study were to assess the prevalence of atrial fibrillation in a nationwide cohort of patients with acute myocardial infarction, to assess the prescription of anticoagulation therapy, and to study the long-term outcomes.
Design
A nationwide registry-based cohort study.
Methods
All patients registered in the Norwegian Myocardial Infarction Registry between 2013 and 2016 were included and followed up through 2017. Stroke rates during follow-up were obtained through linkage with the Norwegian Patient Registry.
Results
In total, 47,204 patients were registered in the Norwegian Myocardial Infarction Registry. Atrial fibrillation on admission was recorded in 5393 (11%) patients, and 2190 (5%) additional patients developed atrial fibrillation during their hospital stay. Only 45% of patients with atrial fibrillation on admission and CHADS-VASc score ≥ 2 were treated with anticoagulation therapy prior to myocardial infarction, and 56% of patients with atrial fibrillation and CHADS-VASc score ≥ 2 were prescribed anticoagulation therapy at discharge. Patients with myocardial infarction and atrial fibrillation had an increased risk of stroke or death during 822 (426, 1278) days of follow-up compared with patients without atrial fibrillation (multivariate adjusted hazard ratio 1.4, 95% confidence interval 1.3-1.4).
Conclusions
Almost half of patients with atrial fibrillation and myocardial infarction were not prescribed the guideline recommended treatment with anticoagulation therapy at discharge, and their long-term risk of stroke and death was increased compared with patients without atrial fibrillation. Increased efforts to improve the treatment of patients with myocardial infarction and atrial fibrillation are needed.



Eur J Prev Cardiol: 30 Aug 2019; 26:1373-1382
Jortveit J, Pripp AH, Langørgen J, Halvorsen S
Eur J Prev Cardiol: 30 Aug 2019; 26:1373-1382 | PMID: 30966816
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Impact:
Abstract

Age differences in contemporary treatment of patients with chronic heart failure and reduced ejection fraction.

Veenis JF, Brunner-La Rocca HP, Linssen GC, Geerlings PR, ... Brugts JJ,
Background
Elderly patients are underrepresented in clinical trials but comprise the majority of heart failure patients. Data on age-specific use of heart failure therapy are limited. The European Society of Cardiology heart failure guidelines provide no age-specific treatment recommendations. We investigated practice-based heart failure management in a large registry at heart failure outpatient clinics.
Design and methods
We studied 8351 heart failure with reduced ejection fraction patients at 34 Dutch outpatient clinics between 2013 and 2016. The mean age was 72.3 ± 11.8 years and we divided age into three categories: less than 60 years (13.9%); 60-74 years (36.0%); and 75 years and over (50.2%).
Results
Elderly heart failure with reduced ejection fraction patients (≥75 years) received significantly fewer beta-blockers (77.8% vs. 84.2%), renin-angiotensin system inhibitors (75.2% vs. 89.7%), mineralocorticoid receptor antagonists (50.6% vs. 59.6%) and ivabradine (2.9% vs. 9.3%), but significantly more diuretics (88.1% vs. 72.6%) compared to patients aged less than 60 years ( < 0.01). Moreover, the prescribed target dosages were significantly lower in elderly patients. Also, implantable cardioverter defibrillator (18.9% vs. 44.1%) and cardiac resynchronisation therapy device (14.6% vs. 16.7%) implantation rates were significantly lower in elderly patients. A similar trend in drug prescription was observed in patients with heart failure with mid-range ejection fraction as in heart failure with reduced ejection fraction.
Conclusion
With increasing age, heart failure with reduced ejection fraction patients less often received guideline-recommended medication prescriptions and also in a lower dosage. In addition, a lower percentage of implantable cardioverter defibrillator and cardiac resynchronisation therapy device implantation in elderly patients was observed.



Eur J Prev Cardiol: 30 Aug 2019; 26:1399-1407
Veenis JF, Brunner-La Rocca HP, Linssen GC, Geerlings PR, ... Brugts JJ,
Eur J Prev Cardiol: 30 Aug 2019; 26:1399-1407 | PMID: 30866680
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Impact:
Abstract

Threshold body mass index and sex-specific waist circumference for increased risk of heart failure with preserved ejection fraction.

Campbell DJ, Gong FF, Jelinek MV, Castro JM, ... Reid CM, Prior DL
Background
Body mass index Deceased. (BMI) is a risk factor for heart failure with preserved ejection fraction (HFpEF).
Design
We investigated the threshold BMI and sex-specific waist circumference associated with increased HFpEF incidence in the SCReening Evaluation of the Evolution of New Heart Failure (SCREEN-HF) study, a cohort study of a community-based population at increased cardiovascular disease risk.
Methods
Inclusion criteria were age ≥60 years with one or more of self-reported hypertension, diabetes, heart disease, abnormal heart rhythm, cerebrovascular disease or renal impairment. Exclusion criteria were known heart failure, ejection fraction <50% or more than mild valve abnormality. Among 3847 SCREEN-HF participants, 73 were diagnosed with HFpEF at a median of 4.5 (interquartile range: 2.9-5.5) years after enrolment.
Results
HFpEF incidence rates were higher for BMI ≥27.5 kg/m than for BMI < 25 kg/m, and for waist circumference >100 cm (men) or > 90 cm (women) than for waist circumference ≤94 cm (men) or ≤ 83 cm (women) in Poisson regression analysis. Semiparametric proportional hazards analyses confirmed these BMI and waist circumference thresholds, and exceeding these thresholds was associated with an attributable risk of HFpEF of 44-49%.
Conclusions
Both central obesity and overweight were associated with increased HFpEF incidence. Although a randomised trial of weight control would be necessary to establish a causal relationship between obesity/overweight and HFpEF incidence, these data suggest that maintenance of BMI and waist circumference below these thresholds in a community similar to that of the SCREEN-HF cohort may reduce the HFpEF incidence rate by as much as 50%.



Eur J Prev Cardiol: 29 Sep 2019; 26:1594-1602
Campbell DJ, Gong FF, Jelinek MV, Castro JM, ... Reid CM, Prior DL
Eur J Prev Cardiol: 29 Sep 2019; 26:1594-1602 | PMID: 31104485
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Impact:
Abstract

LDL-cholesterol lowering with evolocumab, and outcomes according to age and sex in patients in the FOURIER Trial.

Sever P, Gouni-Berthold I, Keech A, Giugliano R, ... Sabatine MS, O\'Donoghue ML
Aims
Some trials have reported diminished efficacy for statins in the elderly, and in women compared with men. We examined the efficacy and safety of evolocumab by patient age and sex in the FOURIER trial, the first major cardiovascular outcome trial of a PCSK9 inhibitor.
Methods and results
FOURIER was a randomised, double blind trial, comparing evolocumab with placebo in 27,564 patients with atherosclerotic cardiovascular disease receiving statin therapy (median follow-up 2.2 years). The primary endpoint was cardiovascular death, myocardial infarction, stroke, hospitalisation for unstable angina or coronary revascularisation. Cox proportional hazards models were used to assess the efficacy of evolocumab versus placebo stratified by quartiles of patient age and by sex. There were small variations in the cardiovascular event rate across the age range (for the primary endpoint, Kaplan-Meier at 3 years 15.6%, >69 years, vs. 15.1%, ≤56 years,  = 0.45); however, the relative efficacy of evolocumab was consistent regardless of patient age (for the primary endpoint (Q1 hazard ratio, 95% confidence interval) 0.83, 0.72-0.96, Q2 0.88, 0.76-1.01, Q3 0.82, 0.71-0.95, Q4 0.86, 0.74-1.00;  = 0.91), and the key secondary endpoint (cardiovascular death, myocardial infarction, stroke) (Q1 0.74 (0.61-0.89), Q2 0.83 (0.69-1.00), Q3 0.78 (0.65-0.94), Q4 0.82 (0.69-0.98));  = 0.81). Women had a lower primary endpoint rate than men (Kaplan-Meier at 3 years 12.5 vs. 15.3%, respectively,  < 0.001). Relative risk reductions in the primary endpoint and key secondary endpoint were similar in women (0.81 (0.69-0.95) and 0.74 (0.61-0.90), respectively) compared with men (0.86 (0.80-0.94) and 0.81 (0.73-0.90), respectively),  = 0.48 and 0.44, respectively. Adverse events were more common in women and with increasing age but, with the exception of injection site reactions, there were no important significant differences reported by those assigned evolocumab versus placebo.
Conclusions
The efficacy and safety of evolocumab are similar throughout a broad range of ages and in both men and women.



Eur J Prev Cardiol: 03 Feb 2020:2047487320902750; epub ahead of print
Sever P, Gouni-Berthold I, Keech A, Giugliano R, ... Sabatine MS, O'Donoghue ML
Eur J Prev Cardiol: 03 Feb 2020:2047487320902750; epub ahead of print | PMID: 32019364
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Impact:
Abstract

Cardiovascular care of patients with stroke and high risk of stroke: The need for interdisciplinary action: A consensus report from the European Society of Cardiology Cardiovascular Round Table.

Doehner W, Mazighi M, Hofmann BM, Lautsch D, ... Touyz RM, Widimsky P

Comprehensive stroke care is an interdisciplinary challenge. Close collaboration of cardiologists and stroke physicians is critical to ensure optimum utilisation of short- and long-term care and preventive measures in patients with stroke. Risk factor management is an important strategy that requires cardiologic involvement for primary and secondary stroke prevention. Treatment of stroke generally is led by stroke physicians, yet cardiologists need to be integrated care providers in stroke units to address all cardiovascular aspects of acute stroke care, including arrhythmia management, blood pressure control, elevated levels of cardiac troponins, valvular disease/endocarditis, and the general management of cardiovascular comorbidities. Despite substantial progress in stroke research and clinical care has been achieved, relevant gaps in clinical evidence remain and cause uncertainties in best practice for treatment and prevention of stroke. The Cardiovascular Round Table of the European Society of Cardiology together with the European Society of Cardiology Council on Stroke in cooperation with the European Stroke Organisation and partners from related scientific societies, regulatory authorities and industry conveyed a two-day workshop to discuss current and emerging concepts and apparent gaps in stroke care, including risk factor management, acute diagnostics, treatments and complications, and operational/logistic issues for health care systems and integrated networks. Joint initiatives of cardiologists and stroke physicians are needed in research and clinical care to target unresolved interdisciplinary problems and to promote the best possible outcomes for patients with stroke.



Eur J Prev Cardiol: 29 Sep 2019:2047487319873460; epub ahead of print
Doehner W, Mazighi M, Hofmann BM, Lautsch D, ... Touyz RM, Widimsky P
Eur J Prev Cardiol: 29 Sep 2019:2047487319873460; epub ahead of print | PMID: 31569966
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Impact:
Abstract

Brief recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Borjesson M, Dellborg M, Niebauer J, LaGerche A, ... van Buuren F, Pelliccia A

This paper presents a brief summary of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology (EAPC) on sports-participation in patients with coronary artery disease, coronary artery anomalies or spontaneous dissection of the coronary arteries, all entities being associated with myocardial ischaemia. Given the wealth of evidence supporting the benefits of exercise for primary and secondary prevention of coronary artery disease, individuals should be restricted from competitive sport only when a substantial risk of adverse event or disease progression is present. These recommendations aim to encourage regular physical activity including participation in sports and, with reasonable precaution, ensure a high level of safety for all individuals with coronary artery disease. The present document is based on available current evidence, but in most instances because of lack of evidence, also on clinical experience and expert opinion.



Eur J Prev Cardiol: 11 Sep 2019:2047487319876186; epub ahead of print
Borjesson M, Dellborg M, Niebauer J, LaGerche A, ... van Buuren F, Pelliccia A
Eur J Prev Cardiol: 11 Sep 2019:2047487319876186; epub ahead of print | PMID: 31514519
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Abstract

Brief recommendations for participation in competitive sports of athletes with arterial hypertension: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Niebauer J, Börjesson M, Carre F, Caselli S, ... Sharma S, Pelliccia A

Owing to its undisputed multitude of beneficial effects, European Society of Cardiology guidelines advocate regular physical activity as a class IA recommendation for the prevention and treatment of cardiovascular disease. Nonetheless, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. Guidance to physicians will be given in this summary of our recently published recommendations for participation in competitive sports of athletes with arterial hypertension.



Eur J Prev Cardiol: 30 Aug 2019; 26:1549-1555
Niebauer J, Börjesson M, Carre F, Caselli S, ... Sharma S, Pelliccia A
Eur J Prev Cardiol: 30 Aug 2019; 26:1549-1555 | PMID: 31122039
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This program is still in alpha version.