Journal: Eur J Prev Cardiol

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Abstract

The effect of high-intensity interval training on exercise capacity in post-myocardial infarction patients: a systematic review and meta-analysis.

Qin Y, Kumar Bundhun P, Yuan ZL, Chen MH
Aims
Exercise-based cardiac rehabilitation has been recommended a treatment for patients with cardiovascular disease. Nevertheless, it remains controversial which exercise characteristics are most beneficial for post-myocardial infarction (MI) patients. We performed a systematic review and meta-analysis to investigate the effects of high-intensity interval training (HIIT) in these patients.
Methods and results
We searched PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical Database (VIP), and Wanfang Dataset (from the earliest date available to February 2021) for randomized controlled trials and cohort studies that evaluated the effects of HIIT on post-MI patients. Studies were selected according to inclusion and exclusion criteria. Data synthesis was performed with R software version 4.0.1. Eight studies met the study criteria, including 387 patients. Compared to the control group [moderate-intensity continuous training (MICT) and/or routine physical activity], HIIT significantly improved peak oxygen uptake (peak VO2) [mean difference = 3.83 mL/kg/min, 95% confidence interval (CI) (3.25, 4.41), P < 0.01]. No significant difference in systolic and diastolic blood pressures, peak and resting heart rate, left ventricular ejection fraction, left ventricular end-diastolic volume, and the quality of life was found between HIIT group and control group. The duration of follow-up ranged from 6 to 12 weeks. The incidence of adverse events was similar between groups [risk difference = 0.01, 95% CI (-0.02, 0.04), P = 0.53].
Conclusion
Compared with MICT and routine physical activity, HIIT could significantly improve exercise capacity in post-MI patients, and appears to be safe.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 18 Jul 2021; epub ahead of print
Qin Y, Kumar Bundhun P, Yuan ZL, Chen MH
Eur J Prev Cardiol: 18 Jul 2021; epub ahead of print | PMID: 34279621
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Impact:
Abstract

Incremental prognostic value of non-alcoholic fatty liver disease over coronary computed tomography angiography findings in patients with suspected coronary artery disease.

Ichikawa K, Miyoshi T, Osawa K, Miki T, ... Morita H, Ito H
Aims
This study aimed to investigate additional risk stratification benefits of hepatic steatosis (HS) concurrently assessed during coronary computed tomography angiography (CTA) in a large patient cohort with suspected stable coronary artery disease (CAD).
Methods and results
In this prospective study, 1148 Japanese outpatients without a history of CAD who underwent coronary CTA for suspected stable CAD (mean age 64 ± 14 years) were included. HS, defined on CT as a hepatic-to-spleen attenuation ratio of <1.0, was examined just before the evaluation of adverse CTA findings, defined as obstructive and/or high-risk plaque. The major adverse cardiac events (MACE) were the composite of cardiac death, acute coronary syndrome, and late revascularization. The incremental predictive value of HS was evaluated using the global χ2 test and C-statistic. HS was identified in 247 (22%) patients. During a median follow-up of 3.9 years, MACE was observed in 40 (3.5%) patients. HS was significantly associated with MACE in a model that included adverse CTA findings (hazard ratio 4.01, 95% confidence interval 2.12-7.59, P < 0.001). By adding HS to the Framingham risk score and adverse CTA findings, the global χ2 score and C-statistic significantly increased from 29.0 to 49.5 (P < 0.001) and 0.74 to 0.81 (P = 0.026), respectively. In subgroup analyses in patients with diabetes mellitus and metabolic syndrome, HS had significant additive predictive value for MACE over the Framingham risk score and adverse CTA findings.
Conclusion
In patients with suspected stable CAD, concurrent evaluation of HS during coronary CTA enables more accurate detection of patients at higher risk of MACE.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 18 Jul 2021; epub ahead of print
Ichikawa K, Miyoshi T, Osawa K, Miki T, ... Morita H, Ito H
Eur J Prev Cardiol: 18 Jul 2021; epub ahead of print | PMID: 34279027
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Abstract

Poor adherence to lifestyle recommendations in patients with coronary heart disease: results from the EUROASPIRE surveys.

De Bacquer D, Astin F, Kotseva K, Pogosova N, ... Jennings C, EUROASPIRE IV and V surveys of the European Observational Research Programme of the European Society of Cardiology
Aims 
Despite the high use of cardioprotective medications, the risk factor control in patients with coronary heart disease (CHD) is still inadequate. Guidelines identify healthy lifestyles as equally important in secondary prevention as pharmacotherapy. Here, we describe reasons for poor lifestyle adherence from the patient\'s perspective.
Methods and results 
In the EUROASPIRE IV and V surveys, 16 259 CHD patients were examined and interviewed during a study visit ≥6 months after hospital discharge. Data gathering was fully standardized. The Brief Illness Perception questionnaire was completed by a subsample of 2379 patients. Half of those who were smoking prior to hospital admission, were still smoking; 37% of current smokers had not attempted to quit and 51% was not considering to do so. The prevalence of obesity was 38%. Half of obese patients tried to lose weight in the past month and 61% considered weight loss in the following month. In relation to physical activity, 40% was on target with half of patients trying to do more everyday activities. Less than half had the intention to engage in planned exercise. Only 29% of all patients was at goal for all three lifestyle factors. The number of adverse lifestyles was strongly related to the way patients perceive their illness as threatening. Lifestyle modifications were more successful in those having participated in a cardiac rehabilitation and prevention programme. Patients indicated lack of self-confidence as the main barrier to change their unhealthy behaviour.
Conclusion 
Modern secondary prevention programmes should target behavioural change in all patients with adverse lifestyles.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 18 Jul 2021; epub ahead of print
De Bacquer D, Astin F, Kotseva K, Pogosova N, ... Jennings C, EUROASPIRE IV and V surveys of the European Observational Research Programme of the European Society of Cardiology
Eur J Prev Cardiol: 18 Jul 2021; epub ahead of print | PMID: 34293121
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Impact:
Abstract

Frailty in cardiology: definition, assessment and clinical implications for general cardiology. A consensus document of the Council for Cardiology Practice (CCP), Acute Cardiovascular Care Association (ACCA), Association of Cardiovascular Nursing and Allied Professions (ACNAP), European Association of Preventive Cardiology (EAPC), European Heart Rhythm Association (EHRA), Council on Valvular Heart Diseases (VHD), Council on Hypertension (CHT), Council of Cardio-Oncology (CCO), Working Group (WG) Aorta and Peripheral Vascular Diseases, WG e-Cardiology, WG Thrombosis, of the European Society of Cardiology, European Primary Care Cardiology Society (EPCCS).

Richter D, Guasti L, Walker D, Lambrinou E, ... Aboyans V, Asteggiano R
Abstract
Frailty is a health condition leading to many adverse clinical outcomes. The relationship between frailty and advanced age, multimorbidity and disability has a significant impact on healthcare systems. Frailty increases cardiovascular (CV) morbidity and mortality both in patients with or without known CV disease. Though the recognition of this additional risk factor has become increasingly clinically relevant in CV diseases, uncertainty remains about operative definitions, screening, assessment, and management of frailty. Since the burdens of frailty components and domains may vary in the various CV diseases and clinical settings, the relevance of specific frailty-related aspects may be different. Understanding these issues may allow general cardiologists a clearer focus on frailty in CV diseases and thereby make more tailored clinical decisions and therapeutic choices in outpatients. Guidance on identification and management of frailty are sparse and an international consensus document on frailty in general cardiology is lacking. Moreover, new options linked with eHealth are going to better define and manage frailty. This consensus document on definition, assessment, clinical implications, and management of frailty provides an input to integrate strategies pre- and post-acute CV events with a comprehensive view including out of hospital, office-based diagnostic and therapeutic choices, and based on a multidisciplinary team approach (general cardiologists, nurses, and general practitioners).

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 15 Jul 2021; epub ahead of print
Richter D, Guasti L, Walker D, Lambrinou E, ... Aboyans V, Asteggiano R
Eur J Prev Cardiol: 15 Jul 2021; epub ahead of print | PMID: 34270717
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Abstract

Gain in net survival from hypertension control over the last half-century.

Lantelme P, Moulayat C, Courand PY, Mouly-Bertin C, ... Riche B, Rabilloud M
Aims
This study determined whether the improvements in hypertension management over the last five decades have influenced subjects\' prognosis.
Methods and results 
The study considered 5693 eligible subjects seen January 1969 to February 1991 (follow-up until December 2003) or January 1995 to October 2014 (follow-up until July 2016) in an all-grade hypertension reference centre. Missing data or incomplete follow-ups led to exclude 1036 subjects (18%). The outcome was all-cause death. An adjusted modelling of the excess mortality rate assessed subjects\' net survival over five inclusion periods to allow for the increase in life expectancy of the general population during the same periods. The analysis of 4657 records (mean age: 47 years; 43.2% women) showed that the proportion of subjects with grade 3 hypertension decreased significantly from 43.3% (1142) to only 6.3% (22) over the five periods and that the net survival improved in men and women regardless of the hypertension grade; i.e. the gain in net survival at 15 years was estimated at 12.3% (95% confidence interval: 8.1-22.3). The 15-year restricted mean survival was estimated at 13 years over the first period and 14.8 years over the last period, which is nearly a 2-year gain in life expectancy at 15 years.
Conclusion 
Since the 70s and the advent of modern management, the excess mortality of hypertensive subjects (vs. the general population) was markedly reduced. Within a context of trivialization of blood pressure measurement and reluctance to long-term treatments, physicians should consider this advantage and use it to promote blood pressure control.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 15 Jul 2021; epub ahead of print
Lantelme P, Moulayat C, Courand PY, Mouly-Bertin C, ... Riche B, Rabilloud M
Eur J Prev Cardiol: 15 Jul 2021; epub ahead of print | PMID: 34269383
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Impact:
Abstract

Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function.

Mazzolai L, Ageno W, Alatri A, Bauersachs R, ... Righini M, Aboyans V
This consensus document is proposed to clinicians to provide the whole spectrum of deep vein thrombosis management as an update to the 2017 consensus document. New data guiding clinicians in indicating extended anticoagulation, management of patients with cancer, and prevention and management of post-thrombotic syndrome are presented. More data on benefit and safety of non-vitamin K antagonists oral anticoagulants are highlighted, along with the arrival of new antidotes for severe bleeding management.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 12 Jul 2021; epub ahead of print
Mazzolai L, Ageno W, Alatri A, Bauersachs R, ... Righini M, Aboyans V
Eur J Prev Cardiol: 12 Jul 2021; epub ahead of print | PMID: 34254133
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Abstract

Effectiveness of home-based cardiac telerehabilitation as an alternative to Phase 2 cardiac rehabilitation of coronary heart disease: a systematic review and meta-analysis.

Ramachandran HJ, Jiang Y, Tam WWS, Yeo TJ, Wang W
Aims
The onset of the COVID-19 pandemic saw the suspension of centre-based cardiac rehabilitation (CBCR) and has underscored the need for home-based cardiac telerehabilitation (HBCTR) as a feasible alternative rehabilitation delivery model. Yet, the effectiveness of HBCTR as an alternative to Phase 2 CBCR is unknown. We aimed to conduct a meta-analysis to quantitatively appraise the effectiveness of HBCTR.
Methods and results
PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and PsycINFO were searched from inception to January 2021. We included randomized controlled trials (RCTs) comparing HBCTR to Phase 2 CBCR or usual care in patients with coronary heart disease (CHD). Out of 1588 studies, 14 RCTs involving 2869 CHD patients were included in this review. When compared with usual care, participation in HBCTR showed significant improvement in functional capacity {6-min walking test distance [mean difference (MD) 25.58 m, 95% confidence interval (CI) 14.74-36.42]}; daily step count (MD 1.05 K, 95% CI 0.36-1.75) and exercise habits [odds ratio (OR) 2.28, 95% CI 1.30-4.00)]; depression scores (standardized MD -0.16, 95% CI -0.32 to 0.01) and quality of life [Short-Form mental component summary (MD 2.63, 95% CI 0.06-5.20) and physical component summary (MD 1.99, 95% CI 0.83-3.16)]. Effects on medication adherence were synthesized narratively. HBCTR and CBCR were comparably effective.
Conclusion
In patients with CHD, HBCTR was associated with an increase in functional capacity, physical activity (PA) behaviour, and depression when compared with UC. When HBCTR was compared to CBCR, an equivalent effect on functional capacity, PA behaviour, QoL, medication adherence, smoking behaviour, physiological risk factors, depression, and cardiac-related hospitalization was observed.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 12 Jul 2021; epub ahead of print
Ramachandran HJ, Jiang Y, Tam WWS, Yeo TJ, Wang W
Eur J Prev Cardiol: 12 Jul 2021; epub ahead of print | PMID: 34254118
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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.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur J Prev Cardiol: 09 Jul 2021; 28:704-712
Zaccardi F, Franks PW, Dudbridge F, Davies MJ, Khunti K, Yates T
Eur J Prev Cardiol: 09 Jul 2021; 28:704-712 | PMID: 34247229
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Impact:
Abstract

Compositional analysis of the association between mortality and 24-hour movement behaviour from NHANES.

McGregor DE, Palarea-Albaladejo J, Dall PM, Del Pozo Cruz B, Chastin SFM
Aims
Previous prospective studies of the association between mortality and physical activity have generally not fully accounted for the interplay between movement behaviours. A compositional data modelling approach accounts for relative scale and co-dependency in time-use data across physical activity behaviours of the 24-hour day.
Methods
A prospective analysis of the National Health and Nutrition Examination Survey 2005-2006 on N = 1468 adults (d = 135 deaths) in ages 50-79 years was undertaken using compositional Cox regression analysis. Daily time spent in sedentary behaviour, light intensity (LIPA) and moderate-to-vigorous physical activity (MVPA) was determined from waist-mounted accelerometer data (Actigraph 7164) and supplemented with self-reported sleep data to determine the daily time-use composition.
Results
The composition of time spent in sedentary behaviour, LIPA, MVPA and sleep was associated with mortality rate after allowing for age and sex effects (p < 0.001), and remained significant when other lifestyle factors were added (p < 0.001). This was driven primarily by the preponderance of MVPA; however, significant changes are attributable to LIPA relative to sedentary behaviour and sleep, and sedentary behaviour relative to sleep. The final ratio ceased to be statistically significant after incorporating lifestyle factors. The preponderance of MVPA ceased to be statistically significant after incorporating health at outset and physical limitations on movement.
Conclusions
An association is inferred between survival rate and the physical activity composition of the day. The MVPA time share is important, but time spent in LIPA relative to sedentary behaviour and sleep is also a significant factor. Increased preponderance of MVPA may have detrimental associations at higher levels of MVPA.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: [email protected]

Eur J Prev Cardiol: 09 Jul 2021; 28:791-798
McGregor DE, Palarea-Albaladejo J, Dall PM, Del Pozo Cruz B, Chastin SFM
Eur J Prev Cardiol: 09 Jul 2021; 28:791-798 | PMID: 34247228
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Impact:
Abstract

Age matters: differences in exercise-induced cardiovascular remodelling in young and middle aged healthy sedentary individuals.

Torlasco C, D\'Silva A, Bhuva AN, Faini A, ... Sharma S, Moon JC
Aims
Remodelling of the cardiovascular system (including heart and vasculature) is a dynamic process influenced by multiple physiological and pathological factors. We sought to understand whether remodelling in response to a stimulus, exercise training, altered with healthy ageing.
Methods
A total of 237 untrained healthy male and female subjects volunteering for their first time marathon were recruited. At baseline and after 6 months of unsupervised training, race completers underwent tests including 1.5T cardiac magnetic resonance, brachial and non-invasive central blood pressure assessment. For analysis, runners were divided by age into under or over 35 years (U35, O35).
Results
Injury and completion rates were similar among the groups; 138 runners (U35: n = 71, women 49%; O35: n = 67, women 51%) completed the race. On average, U35 were faster by 37 minutes (12%). Training induced a small increase in left ventricular mass in both groups (3 g/m2, P < 0.001), but U35 also increased ventricular cavity sizes (left ventricular end-diastolic volume (EDV)i +3%; left ventricular end-systolic volume (ESV)i +8%; right ventricular end-diastolic volume (EDV)i +4%; right ventricular end-systolic volume (ESV)i +5%; P < 0.01 for all). Systemic aortic compliance fell in the whole sample by 7% (P = 0.020) and, especially in O35, also systemic vascular resistance (-4% in the whole sample, P = 0.04) and blood pressure (systolic/diastolic, whole sample: brachial -4/-3 mmHg, central -4/-2 mmHg, all P < 0.001; O35: brachial -6/-3 mmHg, central -6/-4 mmHg, all P < 0.001).
Conclusion
Medium-term, unsupervised physical training in healthy sedentary individuals induces measurable remodelling of both heart and vasculature. This amount is age dependent, with predominant cardiac remodelling when younger and predominantly vascular remodelling when older.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 09 Jul 2021; 28:738-746
Torlasco C, D'Silva A, Bhuva AN, Faini A, ... Sharma S, Moon JC
Eur J Prev Cardiol: 09 Jul 2021; 28:738-746 | PMID: 34247225
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Impact:
Abstract

Long Term Prognostic Impact of Sex-specific Longitudinal Changes in Blood Pressure. The EPIC-Norfolk Prospective Population Cohort Study.

Pana TA, Luben RN, Mamas MA, Potter JF, ... Khaw KT, Myint PK
Aims
We aimed to determine the sex differences in longitudinal systolic and diastolic blood pressure (SBP and DBP) trajectories in mid-life and delineate the associations between these and mortality (all-cause, cardiovascular, and non-cardiovascular) and incident cardiovascular disease (CVD) in old age.
Methods and results
Participants were selected from the European Prospective Investigation into Cancer, Norfolk (EPIC-Norfolk) cohort study. Sex-specific trajectories were determined using group-based trajectory models using three clinic BP measurements acquired between 1993 and 2012 (mean exposure ∼12.9 years). Multivariable Cox regressions determined the associations between trajectories and incident outcomes over the follow-up (median follow-up 9.4 years). A total of 2897 men (M) and 3819 women (F) were included. At baseline, women were younger (F-55.5, M-57.1), had a worse cardiometabolic profile and were less likely to receive primary CVD prevention including antihypertensive treatment (F-36.0%, M-42.0%). Over the exposure period, women had lower SBP trajectories while men exhibited more pronounced SBP decreases over this period. Over the follow-up period, women had lower mortality (F-11.9%, M-20.5%) and CVD incidence (F-19.8%, M-29.6%). Compared to optimal SBP (≤120 mmHg) and DBP (≤70 mmHg) trajectories, hypertensive trajectories were associated with increased mortality and incident CVD in both men and women during follow-up at univariable level. These associations were nevertheless not maintained upon extensive confounder adjustment including antihypertensive therapies.
Conclusion
We report sex disparities in CVD prevention which may relate to worse cardiometabolic profiles and less pronounced longitudinal SBP decreases in women. Effective anti-hypertensivetherapy may offset the adverse outcomes associated with prolonged exposure to high blood pressure.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 04 Jul 2021; epub ahead of print
Pana TA, Luben RN, Mamas MA, Potter JF, ... Khaw KT, Myint PK
Eur J Prev Cardiol: 04 Jul 2021; epub ahead of print | PMID: 34223881
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Abstract

Prophylactic anticoagulation in sinus rhythm for stroke prevention in cardiovascular disease: contemporary meta-analysis of large randomized trials.

Lander K, Thakeria P, Nayyar S
Aims
Anticoagulation with non-vitamin K oral anticoagulants (NOACs) to prevent stroke is a mainstay of atrial fibrillation (AF) management. However, multiple cardiovascular diseases (CVDs) are associated with elevated ischaemic stroke risk even in sinus rhythm. In this meta-analysis, we assess efficacy and safety of prophylactic NOAC agents for stroke prevention in patients without AF.
Methods and results
A search was conducted for randomized controlled trials (RCTs) that evaluated an NOAC and control drug (placebo or antiplatelet) in non-AF patients with mixed CVD. The primary efficacy and safety outcomes were ischaemic stroke and major bleeding, respectively. Results were stratified based on primary- and mini-NOAC doses. Thirteen RCTs were identified with a total of 89 383 patients with CVD in sinus rhythm (53 778 on NOAC, 35 605 on control drug; mean age 65.5 ± 2.7 years). Over a mean follow-up of 18.3 months, 1429 (1.6%) ischaemic strokes occurred. Use of NOAC was associated with 26% reduction in stroke [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.62-0.87; 1.1 vs. 1.8 events per 100 person-years], with numbers needed to treat of 153 patients to prevent one stroke. Major bleeding was increased with NOAC (OR 1.74, 95% CI 1.44-2.09; 2.1 vs. 1.0 events per 100 person-years). The weighted net clinical benefit (wNCB, composite of ischaemic stroke and bleeding) did not suggest a favourable effect with any NOAC dose (wNCB for primary-dose: -0.35; mini-dose: -0.06).
Conclusion
Current evidence does not support use of NOACs for stroke prevention in non-AF CVD population as risk of major bleeding still exceeds ischaemic stroke benefit.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 04 Jul 2021; epub ahead of print
Lander K, Thakeria P, Nayyar S
Eur J Prev Cardiol: 04 Jul 2021; epub ahead of print | PMID: 34223629
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Impact:
Abstract

Prevalence and extent of coronary artery calcification in the middle-aged and elderly population.

Gerke O, Lindholt JS, Abdo BH, Lambrechtsen J, ... Mickley H, Diederichsen ACP
Aims
Coronary artery calcification (CAC) measured on cardiac computed tomography (CT) is an important risk marker for cardiovascular disease (CVD) and has been included in the prevention guidelines. The aim of this study was to describe CAC score reference values in the middle-aged and elderly population and to develop a freely available CAC calculator.
Methods and results
All participants from two population-based cardiac CT screening cohorts (DanRisk and DANCAVAS) were included. The CAC score was measured as a part of a screening session. Positive CAC scores were log-transformed and non-parametrically regressed on age for each gender, and percentile curves were transposed according to proportions of zero CAC scores. Men had higher CAC scores than women, and the prevalence and extend of CAC increased steadily with age. An online CAC calculator was developed, http://flscripts.dk/cacscore. After entering sex, age, and CAC score, the CAC score percentile and the coronary age are depicted including a figure with the specific CAC score and 25%, 50%, 75%, and 90% percentiles. The specific CAC score can be compared to the entire background population or only those without prior CVD.
Conclusion
This study provides modern population-based reference values of CAC scores in men and woman and a freely accessible online CAC calculator. Physicians and patients are very familiar with blood pressure and lipids, but unfamiliar with CAC scores. Using the calculator makes it easy to see if a CAC value is low, moderate, or high, when a physician in the future communicate and discusses a CAC score with a patient.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 27 Jun 2021; epub ahead of print
Gerke O, Lindholt JS, Abdo BH, Lambrechtsen J, ... Mickley H, Diederichsen ACP
Eur J Prev Cardiol: 27 Jun 2021; epub ahead of print | PMID: 34179988
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Impact:
Abstract

Cardiovascular events in patients with chronic myeloid leukaemia treated with tyrosine kinase inhibitors in Taiwan: a nationwide population-based study.

Yang YC, Huang RY, Tsai HJ, Li PC, Yang YH, Hsieh KP
Aims
New-generation breakpoint cluster region-Abelson tyrosine kinase inhibitors (TKIs) have a higher incidence of cardiovascular events than imatinib in patients with chronic myeloid leukaemia (CML). However, this knowledge is insufficiently proven. Hence, this study aimed to explore the association between cardiovascular events and TKIs in patients with CML.
Methods and results
This retrospective population-based cohort study enrolled first-time users of imatinib, dasatinib, and nilotinib between 1 January 2007 and 31 December 2016. Arterial thromboembolic events (ATEs) were the primary outcome, while other cardiovascular-related events were the secondary outcomes. The event rates were estimated using Kaplan-Meier estimates, and the hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression. Additionally, the competing risk was adjusted using the Fine and Gray competing risk model. We included 1207 patients. Nilotinib had a significantly higher ATE risk (subdistribution HR = 4.92, 95% CI = 1.68-14.36) than imatinib. Conversely, no difference was found for other cardiovascular-related events. Risks of ATE and other cardiovascular-related events were similar between dasatinib and imatinib and between nilotinib and dasatinib. The risk of ATE hospitalization consistently increased throughout the main analyses and sensitivity analyses.
Conclusion
Nilotinib-treated patients had a significantly higher risk of developing ATE than imatinib-treated patients. However, the risks of ATE and other cardiovascular-related events were not significantly different between dasatinib and imatinib.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 27 Jun 2021; epub ahead of print
Yang YC, Huang RY, Tsai HJ, Li PC, Yang YH, Hsieh KP
Eur J Prev Cardiol: 27 Jun 2021; epub ahead of print | PMID: 34179961
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Impact:
Abstract

Is the SMART risk prediction model ready for real-world implementation? A validation study in a routine care setting of approximately 380 000 individuals.

McKay AJ, Gunn LH, Ference BA, Dorresteijn JAN, ... Visseren FLJ, Ray KK
Aims
Reliably quantifying event rates in secondary prevention could aid clinical decision-making, including quantifying potential risk reductions of novel, and sometimes expensive, add-on therapies. We aimed to assess whether the SMART risk prediction model performs well in a real-world setting.
Methods and results
We conducted a historical open cohort study using UK primary care data from the Clinical Practice Research Datalink (2000-2017) diagnosed with coronary, cerebrovascular, peripheral, and/or aortic atherosclerotic cardiovascular disease (ASCVD). Analyses were undertaken separately for cohorts with established (≥6 months) vs. newly diagnosed ASCVD. The outcome was first post-cohort entry occurrence of myocardial infarction, stroke, or cardiovascular death. Among the cohort with established ASCVD [n = 244 578, 62.1% male, median age 67.3 years, interquartile range (IQR) 59.2-74.0], the calibration and discrimination achieved by the SMART model was not dissimilar to performance at internal validation [Harrell\'s c-statistic = 0.639, 95% confidence interval (CI) 0.636-0.642, compared with 0.675, 0.642-0.708]. Decision curve analysis indicated that the model outperformed treat all and treat none strategies in the clinically relevant 20-60% predicted risk range. Consistent findings were observed in sensitivity analyses, including complete case analysis (n = 182 482; c = 0.624, 95% CI 0.620-0.627). Among the cohort with newly diagnosed ASCVD (n = 136 445; 61.0% male; median age 66.0 years, IQR 57.7-73.2), model performance was weaker with more exaggerated risk under-prediction and a c-statistic of 0.559, 95% CI 0.556-0.562.
Conclusions
The performance of the SMART model in this validation cohort demonstrates its potential utility in routine healthcare settings in guiding both population and individual-level decision-making for secondary prevention patients.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 22 Jun 2021; epub ahead of print
McKay AJ, Gunn LH, Ference BA, Dorresteijn JAN, ... Visseren FLJ, Ray KK
Eur J Prev Cardiol: 22 Jun 2021; epub ahead of print | PMID: 34160035
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Abstract

Evidence of a double anaerobic threshold in healthy subjects.

Rovai S, Magini A, Cittar M, Masè M, ... Sinagra G, Agostoni P
Aims
The anaerobic threshold (AT) is an important cardiopulmonary exercise test (CPET) parameter both in healthy and in patients. It is normally determined with three approaches: V-slope method, ventilatory equivalent method, and end-tidal method. The finding of different AT values with these methods is only anecdotic. We defined the presence of a double threshold (DT) when a ΔVO2 > 15 mL/min was observed between the V-slope method (met AT) and the other two methods (vent AT). The aim was to identify whether there is a DT in healthy subjects.
Methods and results
We retrospectively analysed 476 healthy subjects who performed CPET in our laboratory between 2009 and 2018. We identified 51 subjects with a DT (11% of cases). Cardiopulmonary exercise test data at rest and during the exercise were not different in subjects with DT compared to those without. Met AT always preceded vent AT. Compared to subjects without DT, those with DT showed at met AT lower carbon dioxide output (VCO2), end-tidal carbon dioxide tension (PetCO2) and respiratory exchange ratio (RER), and higher ventilatory equivalent for carbon dioxide (VE/VCO2). Compared to met AT, vent AT showed a higher oxygen uptake (VO2), VCO2, ventilation, respiratory rate, RER, work rate, and PetCO2 but a lower VE/VCO2 and end-tidal oxygen tension. Finally, subjects with DT showed a higher VO2 increase during the isocapnic buffering period.
Conclusion
Double threshold was present in healthy subjects. The presence of DT does not influence peak exercise performance, but it is associated with a delayed before acidosis-induced hyperventilation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 22 Jun 2021; epub ahead of print
Rovai S, Magini A, Cittar M, Masè M, ... Sinagra G, Agostoni P
Eur J Prev Cardiol: 22 Jun 2021; epub ahead of print | PMID: 34160034
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Abstract

Comparison of cardiovascular outcomes and cardiometabolic risk factors between patients with type 2 diabetes treated with sodium-glucose cotransporter-2 inhibitors and dipeptidyl peptidase-4 inhibitors: a meta-analysis.

Wang S, Wu T, Zuo Z, Jin P, Luo X, Deng M
Aims 
Prevention of cardiovascular outcomes is a goal of the management of patients with type 2 diabetes mellitus patients as important as lowering blood glucose levels. Among the various glucose-lowering agents, the effects of sodium-glucose cotransporter-2 inhibitors (SGLT-2Is) and dipeptidyl peptidase-4 inhibitors (DPP-4Is) on cardiovascular outcomes have become the focus of recent researches.
Methods and results 
A systematic search was performed through several online database. All studies that compared the effects of SGLT-2Is and DPP-4Is on cardiovascular outcomes and cardiometabolic risk factors were reviewed. A total of 30 studies were included. Compared with DPP-4Is, SGLT-2Is treatment reduced the risk of stroke [risk ratio (RR) = 0.80; 95% confidence interval (CI), 0.76-0.84], myocardial infarction (RR = 0.85; 95% CI, 0.81-0.89), heart failure (RR = 0.58; 95% CI, 0.54-0.62), cardiovascular mortality (RR = 0.55; 95% CI, 0.51-0.60), and all-cause mortality (RR = 0.60; 95% CI, 0.57-0.63). In addition, SGLT-2Is presented favourable effects on hemoglobinA1c, fasting plasma glucose, systolic blood pressure, and diastolic blood pressure. The differences in blood lipids were also compared.
Conclusion
Sodium-glucose cotransporter-2 inhibitors are superior to DPP-4Is in terms of cardiovascular outcomes. Sodium-glucose cotransporter-2 inhibitors bring more benefits with respect to the cardiometabolic risk factors.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 16 Jun 2021; epub ahead of print
Wang S, Wu T, Zuo Z, Jin P, Luo X, Deng M
Eur J Prev Cardiol: 16 Jun 2021; epub ahead of print | PMID: 34136913
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Abstract

Participation in exercise-based cardiac rehabilitation is related to reduced total mortality in both men and women: results from the SWEDEHEART registry.

Ekblom Ö, Cider Å, Hambraeus K, Bäck M, ... Lönn A, Börjesson M
Aims
Participation in exercise-based cardiac rehabilitation (exCR) increases aerobic capacity and improves outcomes in patients following myocardial infarction (MI) and is therefore universally recommended. While meta-analyses consistently report that participation in exCR reduces cardiovascular mortality, there are conflicting results regarding effects on total mortality. Presently, many eligible patients do not receive exCR in clinical practice. We aimed to investigate the relation between participation in exCR post-MI and total mortality in men and women in a nationwide real-world cohort from the SWEDEHEART registry.
Design
Longitudinal, observational cohort study.
Methods and results
In total, 20 895 patients from the SWEDEHEART registry were included. Mortality data were obtained from the Swedish National Population Registry. During a mean of 4.55 (±2.33) years of follow-up, 1000 patients died. Using Cox regression for proportional odds and taking a wide range of potential confounders into consideration, participation in exCR was related to significantly lower total mortality [hazard ratio (HR) 0.72, 95% confidence interval 0.62-0.83]. Excluding patients with shorter follow-up than 2 years did not alter the results. Exercise-based CR participation was related to lowered total mortality in most of the investigated subgroups. The risk reduction was more pronounced in women than in men (HR 0.54 vs. 0.81, respectively).
Conclusion
Participation in exCR was associated with reduced total mortality, and more pronounced in women, compared with men. Our results further support the recommendations to participate in exCR, and hence we argue that exCR should be a mandatory part of comprehensive CR programmes, offered to all patients post-MI.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 06 Jun 2021; epub ahead of print
Ekblom Ö, Cider Å, Hambraeus K, Bäck M, ... Lönn A, Börjesson M
Eur J Prev Cardiol: 06 Jun 2021; epub ahead of print | PMID: 34097031
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Abstract

Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: why and how: a position statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology.

Hansen D, Abreu A, Ambrosetti M, Cornelissen V, ... Völler H, Piepoli M
A proper determination of the exercise intensity is important for the rehabilitation of patients with cardiovascular disease (CVD) since it affects the effectiveness and medical safety of exercise training. In 2013, the European Association of Preventive Cardiology (EAPC), together with the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation, published a position statement on aerobic exercise intensity assessment and prescription in cardiovascular rehabilitation (CR). Since this publication, many subsequent papers were published concerning the determination of the exercise intensity in CR, in which some controversies were revealed and some of the commonly applied concepts were further refined. Moreover, how to determine the exercise intensity during resistance training was not covered in this position paper. In light of these new findings, an update on how to determine the exercise intensity for patients with CVD is mandatory, both for aerobic and resistance exercises. In this EAPC position paper, it will be explained in detail which objective and subjective methods for CR exercise intensity determination exist for aerobic and resistance training, together with their (dis)advantages and practical applications.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 01 Jun 2021; epub ahead of print
Hansen D, Abreu A, Ambrosetti M, Cornelissen V, ... Völler H, Piepoli M
Eur J Prev Cardiol: 01 Jun 2021; epub ahead of print | PMID: 34077542
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Abstract

Primary cardiovascular risk prediction by LDL-cholesterol in Caucasian middle-aged and older adults: a joint analysis of three cohorts.

Hilvo M, Dhar I, Lääperi M, Lysne V, ... Schöttker B, Laaksonen R
Aims
Low-density lipoprotein cholesterol (LDL-C) is an established causal driver of atherosclerotic cardiovascular disease (ASCVD), but its performance and age-dependency as a biomarker for incident events and mortality arising from ASCVD is less clear. The aim was to determine the value of LDL-C as a susceptibility/risk biomarker for incident coronary heart disease (CHD), ASCVD, and stroke events and deaths, for the age groups <50 and ≥50 years.
Methods and results
The performance of LDL-C was evaluated in three cohorts, FINRISK 2002 (n = 7709), HUSK (n = 5431), and ESTHER (n = 4559), by Cox proportional hazards models, C-statistics, and net reclassification index calculations. Additionally, the hazard ratios (HRs) for the three cohorts were pooled by meta-analysis. The most consistent association was observed for CHD [95% confidence interval (CI) for HRs per standard deviation ranging from 0.99 to 1.37], whereas the results were more modest for ASCVD (0.96-1.18) due to lack of association with stroke (0.77-1.24). The association and discriminatory value of LDL-C with all endpoints in FINRISK 2002 and HUSK were attenuated in subjects 50 years and older [HRs (95% CI) obtained from meta-analysis 1.11 (1.04-1.18) for CHD, 1.15 (1.02-1.29) for CHD death, 1.02 (0.98-1.06) for ASCVD, 1.12 (1.02-1.23) for ASCVD death, and 0.97 (0.89-1.05) for stroke].
Conclusion
In middle-aged and older adults, associations between LDL-C and all the studied cardiovascular endpoints were relatively weak, while LDL-C showed stronger association with rare events of pre-mature CHD or ASCVD death among middle-aged adults. The predictive performance of LDL-C also depends on the studied cardiovascular endpoint.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 31 May 2021; epub ahead of print
Hilvo M, Dhar I, Lääperi M, Lysne V, ... Schöttker B, Laaksonen R
Eur J Prev Cardiol: 31 May 2021; epub ahead of print | PMID: 34060615
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Abstract

Genetically predicted circulating vitamin C in relation to cardiovascular disease.

Yuan S, Zheng JS, Mason AM, Burgess S, Larsson SC
Aim
We conducted a two-sample Mendelian randomization (MR) study to assess the associations of genetically predicted circulating vitamin C levels with cardiovascular diseases (CVDs).
Methods and results
Ten lead single-nucleotide polymorphisms associated with plasma vitamin C levels at the genome-wide significance level were used as instrumental variables. Summary-level data for 15 CVDs were obtained from corresponding genetic consortia, the UK Biobank study, and the FinnGen consortium. The inverse-variance-weighted method was the primary analysis method, supplemented by the weighted median and MR-Egger methods. Estimates for each CVD from different sources were combined. Genetically predicted vitamin C levels were not associated with any CVD after accounting for multiple testing. However, there were suggestive associations of higher genetically predicted vitamin C levels (per 1 standard deviation increase) with lower risk of cardioembolic stroke [odds ratio, 0.79; 95% confidence interval (CI), 0.64, 0.99; P = 0.038] and higher risk of atrial fibrillation (odds ratio, 1.09; 95% CI, 1.00, 1.18; P = 0.049) in the inverse-variance-weighted method and with lower risk of peripheral artery disease (odds ratio, 0.76, 95% CI, 0.62, 0.93; P = 0.009) in the weighted median method.
Conclusion
We found limited evidence with MR techniques for an overall protective role of vitamin C in the primary prevention of CVD. The associations of vitamin C levels with cardioembolic stroke, atrial fibrillation, and peripheral artery disease need further study.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 30 May 2021; epub ahead of print
Yuan S, Zheng JS, Mason AM, Burgess S, Larsson SC
Eur J Prev Cardiol: 30 May 2021; epub ahead of print | PMID: 34057996
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Abstract

Trends in blood pressure, blood lipids, and smoking from 259 753 patients with hypertension in a Swedish primary care register: results from QregPV.

Bager JE, Mourtzinis G, Andersson T, Nåtman J, ... Manhem K, Hjerpe P
Aims
To describe 8-year trends in blood pressure (BP) control, blood lipid control, and smoking habits in patients with hypertension from QregPV, a primary care register in the Region of Västra Götaland, Sweden.
Methods and results
QregPV features clinical data on BP, low-density lipoprotein cholesterol (LDL-C), and smoking habits in 392 277 patients with hypertension or coronary heart disease or diabetes mellitus or any combination of the three diagnoses. Data from routine clinical practice have been automatically reported on a monthly basis to QregPV from all primary care centres in Västra Götaland (population 1.67 million) since 2010. Additional data on diagnoses, dispensed drugs and socioeconomic factors were acquired through linkage to regional and national registers. We identified 259 753 patients with hypertension, but without coronary heart disease and diabetes mellitus, in QregPV. From 2010 to 2017, the proportion of patients with BP <140/90 mmHg increased from 38.9% to 49.1%, while the proportion of patients with LDL-C <2.6 mmol/L increased from 19.7% to 21.1% and smoking decreased from 15.7% to 12.3%. However, in 2017, only 10.0% of all patients with hypertension had attained target levels of BP <140/90 mmHg, LDL-C < 2.6 mmol/L while being also non-smokers. The remaining 90.0% were still exposed to at least one uncontrolled, modifiable risk factor for cardiovascular disease.
Conclusions
These regionwide data from eight consecutive years in 259 753 patients with hypertension demonstrate a large potential for risk factor improvement. An increased use of statins and antihypertensive drugs should, in addition to lifestyle modifications, decrease the risk of cardiovascular disease in these patients.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 30 May 2021; epub ahead of print
Bager JE, Mourtzinis G, Andersson T, Nåtman J, ... Manhem K, Hjerpe P
Eur J Prev Cardiol: 30 May 2021; epub ahead of print | PMID: 34056646
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Abstract

Association of premature atherosclerotic cardiovascular disease with higher risk of cancer: a behavioral risk factor surveillance system study.

Jain V, Rifai MA, Brinzevich D, Taj M, ... Mahtta D, Virani SS
Aim 
The aim of this study was to investigate a possible association between atherosclerotic cardiovascular disease (ASCVD) and risk of cancer in young adults.
Methods 
We utilized data from the Behavioral Risk Factor Surveillance System, a nationally representative US telephone-based survey to identify participants in the age group of 18-55 years who reported a history of ASCVD. These patients were defined as having premature ASCVD. Weighted multivariable logistic regression models were used to study the association between premature ASCVD and cancer including various cancer subtypes.
Results 
Between 2016 and 2019, we identified 28 522 (3.3%) participants with a history of premature ASCVD. Compared with patients without premature ASCVD, individuals with premature ASCVD were more likely to be Black adults, have lower income, lower levels of education, reside in states without Medicaid expansion, have hypertension, diabetes mellitus, chronic kidney disease, obesity, and had delays in seeking medical care. Individuals with premature ASCVD were more likely to have been diagnosed with any form of cancer (13.7% vs 3.9%), and this association remained consistent in multivariable models (odds ratio, 95% confidence interval: 2.08 [1.72-2.50], P < 0.01); this association was significant for head and neck (21.08[4.86-91.43], P < 0.01), genitourinary (18.64 [3.69-94.24], P < 0.01), and breast cancer (3.96 [1.51-10.35], P < 0.01). Furthermore, this association was consistent when results were stratified based on gender and race, and in sensitivity analysis using propensity score matching.
Conclusion 
Premature ASCVD is associated with a higher risk of cancer. These data have important implications for the design of strategies to prevent ASCVD and cancer in young adults.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 30 May 2021; epub ahead of print
Jain V, Rifai MA, Brinzevich D, Taj M, ... Mahtta D, Virani SS
Eur J Prev Cardiol: 30 May 2021; epub ahead of print | PMID: 34059910
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Abstract

Global, regional, and national quality of care of ischaemic heart disease from 1990 to 2017: a systematic analysis for the Global Burden of Disease Study 2017.

Aminorroaya A, Yoosefi M, Rezaei N, Shabani M, ... Larijani B, Farzadfar F
Aims
By 2030, we seek to reduce premature deaths from non-communicable diseases, including ischaemic heart disease (IHD), by one-third to reach the sustainable development goal (SDG) target 3.4. We aimed to investigate the quality of care of IHD across countries, genders, age groups, and time using the Global Burden of Diseases Study (GBD) 2017 estimates.
Methods and results
We did a principal component analysis on IHD mortality to incidence ratio, disability-adjusted life-years (DALYs) to prevalence ratio, and years of life lost to years lived with disability ratio using the results of the GBD 2017. The first principal component was scaled from 0 to 100 and designated as the quality of care index (QCI). We evaluated gender inequity by the gender disparity ratio (GDR), defined as female to male QCI. From 1990 to 2017, the QCI and GDR increased from 71.2 to 76.4 and from 1.04 to 1.08, respectively, worldwide. In the study period, countries of Western Europe, Scandinavia, and Australasia had the highest QCIs and a GDR of 1 to 1.2; however, African and South Asian countries had the lowest QCIs and a GDR of 0.8 to 1. Moreover, the young population experienced more significant improvements in the QCI compared to the elderly in 2017.
Conclusion
From 1990 to 2017, the QCI of IHD has improved; nonetheless, there are remarkable disparities between countries, genders, and age groups that should be addressed. These findings may guide policymakers in monitoring and modifying our path to achieve SDGs.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 25 May 2021; epub ahead of print
Aminorroaya A, Yoosefi M, Rezaei N, Shabani M, ... Larijani B, Farzadfar F
Eur J Prev Cardiol: 25 May 2021; epub ahead of print | PMID: 34041535
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Abstract

Socioeconomic position and first-time major cardiovascular event in patients with type 2 diabetes: a Danish nationwide cohort study.

Falkentoft AC, Zareini B, Andersen J, Wichmand C, ... Bruun NE, Ruwald AC
Aims 
The association between socioeconomic position and cardiovascular disease has not been well studied in patients with type 2 diabetes. We aimed to examine the association between socioeconomic position and first-time major adverse cardiovascular events (MACE) in patients with type 2 diabetes.
Methods and results 
Through the Danish nationwide registers, we identified all residents with newly diagnosed type 2 diabetes between 2012 and 2017. Based on sex-stratified multivariable cause-specific Cox regression models, we calculated the standardized absolute 5-year risk of the composite outcome of first-time myocardial infarction, stroke, or cardiovascular mortality (MACE) according to income quartiles. A total of 57 106 patients with type 2 diabetes were included. During 155 989 person years, first-time MACE occurred in 2139 patients. Among both men and women, income was inversely associated with the standardized absolute 5-year risk of MACE. In men, the 5-year risk of MACE increased from 5.7% [95% confidence interval (CI) 4.9-6.5] in the highest income quartile to 9.3% (CI 8.3-10.2) in the lowest income group, with a risk difference of 3.5% (CI 2.4-4.7). In women, the risk of MACE increased from 4.2% (CI 3.4-5.0) to 6.1% (CI 5.2-7.0) according to income level, with a risk difference of 1.9% (CI 0.8-2.9).
Conclusion 
Despite free access to medical care in Denmark, low-socioeconomic position was associated with a higher 5-year risk of first-time MACE in patients with incident type 2 diabetes. Our results suggest prevention strategies could be developed specifically for patients with low-socioeconomic position.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 24 May 2021; epub ahead of print
Falkentoft AC, Zareini B, Andersen J, Wichmand C, ... Bruun NE, Ruwald AC
Eur J Prev Cardiol: 24 May 2021; epub ahead of print | PMID: 34037228
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Abstract

Utility of risk prediction models to detect atrial fibrillation in screened participants.

Poorthuis MHF, Jones NR, Sherliker P, Clack R, ... Halliday A, Bulbulia R
Aims
Atrial fibrillation (AF) is associated with higher risk of stroke. While the prevalence of AF is low in the general population, risk prediction models might identify individuals for selective screening of AF. We aimed to systematically identify and compare the utility of established models to predict prevalent AF.
Methods and results
Systematic search of PubMed and EMBASE for risk prediction models for AF. We adapted established risk prediction models and assessed their predictive performance using data from 2.5M individuals who attended vascular screening clinics in the USA and the UK and in the subset of 1.2M individuals with CHA2DS2-VASc ≥2. We assessed discrimination using area under the receiver operating characteristic (AUROC) curves and agreement between observed and predicted cases using calibration plots. After screening 6959 studies, 14 risk prediction models were identified. In our cohort, 10 464 (0.41%) participants had AF. For discrimination, six prediction model had AUROC curves of 0.70 or above in all individuals and those with CHA2DS2-VASc ≥2. In these models, calibration plots showed very good concordance between predicted and observed risks of AF. The two models with the highest observed prevalence in the highest decile of predicted risk, CHARGE-AF and MHS, showed an observed prevalence of AF of 1.6% with a number needed to screen of 63. Selective screening of the 10% highest risk identified 39% of cases with AF.
Conclusion
Prediction models can reliably identify individuals at high risk of AF. The best performing models showed an almost fourfold higher prevalence of AF by selective screening of individuals in the highest decile of risk compared with systematic screening of all cases.
Registration
This systematic review was registered (PROSPERO CRD42019123847).

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 21 May 2021; 28:586-595
Poorthuis MHF, Jones NR, Sherliker P, Clack R, ... Halliday A, Bulbulia R
Eur J Prev Cardiol: 21 May 2021; 28:586-595 | PMID: 33624100
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Abstract

Anticoagulation in patients with atrial fibrillation and active cancer: an international survey on patient management.

Boriani G, Lee G, Parrini I, Lopez-Fernandez T, ... Asteggiano R, Council of Cardio-Oncology of the European Society of Cardiology
Background
In patients with active cancer and atrial fibrillation (AF) anticoagulation, thrombotic and bleeding risk still entail uncertainty.
Aim
We explored the results of an international survey examining the knowledge and behaviours of a large group of physicians.
Methods and results
A web-based survey was completed by 960 physicians (82.4% cardiologists, 75.5% from Europe). Among the currently available anticoagulants for stroke prevention in patients with active cancer, direct oral anticoagulants (DOACs) were preferred by 62.6%, with lower values for low molecular weight heparin (LMWH) (24.1%) and for warfarin (only 7.3%). About 46% of respondents considered that DOACs should be used in all types of cancers except in non-operable gastrointestinal cancers. The lack of controlled studies on bleeding risk (33.5% of respondents) and the risk of drug interactions (31.5%) were perceived as problematic issues associated with use of anticoagulants in cancer. The decision on anticoagulation involved a cardiologist in 27.8% of cases, a cardiologist and an oncologist in 41.1%, and a team approach in 21.6%. The patient also was involved in decision-making, according to ∼60% of the respondents. For risk stratification, use of CHA2DS2-VASc and HAS-BLED scores was considered appropriate, although not specifically validated in cancer patients, by 66.7% and 56.4%, respectively.
Conclusion
This survey highlights that management of anticoagulation in patients with AF and active cancer is challenging, with substantial heterogeneity in therapeutic choices. Direct oral anticoagulants seems having an emerging role but still the use of LMWH remains substantial, despite the absence of long-term data on thromboprophylaxis in AF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 21 May 2021; 28:611-621
Boriani G, Lee G, Parrini I, Lopez-Fernandez T, ... Asteggiano R, Council of Cardio-Oncology of the European Society of Cardiology
Eur J Prev Cardiol: 21 May 2021; 28:611-621 | PMID: 33624005
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Abstract

Life-threatening and major cardiac events during long-distance races: updates from the prospective RACE PARIS registry with a systematic review and meta-analysis.

Gerardin B, Guedeney P, Bellemain-Appaix A, Levasseur T, ... Collet JP, Groupe de Réflexions sur la Cardiologie Interventionnelle
Aims
Limited data exist regarding the incidence and aetiology of life-threatening events such as major cardiac events or exertional heat stroke during long-distance races. We aimed to provide an updated incidence, etiology and prognosis of life-threatening events during long-distance races.
Methods
The prospective RACE PARIS registry recorded all life-threatening events/fatal events occurring during 46 marathons, half-marathons and other long-distance races in the Paris area between 2006 and 2016, comprising 1,073,722 runners. Event characteristics were determined by review of medical records and interviews with survivors.
Results
The incidence of life-threatening events, exertional heat stroke and major cardiac events was 3.35 per 100,000, 1.02 per 100,000 and 2.33 per 100,000, respectively, including 18 sudden cardiac arrests (1.67 per 100,000). The main aetiology of sudden cardiac arrest was myocardial ischaemia (11/18), due to acute coronary thrombosis (6/11), stable atherosclerotic coronary artery disease (2/11), coronary dissection (1/11), anomalous connection (1/11) or myocardial bridging (1/11). A third of participants with ischaemia-related major cardiac events presented with pre-race clinical symptoms. Major cardiac events were more frequent in the case of a high pollution index (6.78 per 100,000 vs. 2.07 per 100,000, odds ratio 3.27, 95% confidence interval 1.12-9.54). Case fatality was low (0.19 per 100,000). Similarly, we report in a meta-analysis of eight long-distance race registries comprising 16,223,866 runners a low incidence of long-distance race-related sudden cardiac arrest (0.82 per 100,000) and fatality (0.39 per 100,000). Death following sudden cardiac arrest was strongly associated with initial asystole or pulseless rhythm.
Conclusion
Long-distance race-related life-threatening events remain rare although serious events. Better information for runners on the risk of pre-race clinical symptoms, outside air pollution and temperature may reduce their incidence.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 21 May 2021; 28:679-686
Gerardin B, Guedeney P, Bellemain-Appaix A, Levasseur T, ... Collet JP, Groupe de Réflexions sur la Cardiologie Interventionnelle
Eur J Prev Cardiol: 21 May 2021; 28:679-686 | PMID: 34021577
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Impact:
Abstract

Detecting undiagnosed atrial fibrillation in UK primary care: Validation of a machine learning prediction algorithm in a retrospective cohort study.

Sekelj S, Sandler B, Johnston E, Pollock KG, ... Ng FS, Farooqui U
Aims
To evaluate the ability of a machine learning algorithm to identify patients at high risk of atrial fibrillation in primary care.
Methods
A retrospective cohort study was undertaken using the DISCOVER registry to validate an algorithm developed using a Clinical Practice Research Datalink (CPRD) dataset. The validation dataset included primary care patients in London, England aged ≥30 years from 1 January 2006 to 31 December 2013, without a diagnosis of atrial fibrillation in the prior 5 years. Algorithm performance metrics were sensitivity, specificity, positive predictive value, negative predictive value (NPV) and number needed to screen (NNS). Subgroup analysis of patients aged ≥65 years was also performed.
Results
Of 2,542,732 patients in DISCOVER, the algorithm identified 604,135 patients suitable for risk assessment. Of these, 3.0% (17,880 patients) had a diagnosis of atrial fibrillation recorded before study end. The area under the curve of the receiver operating characteristic was 0.87, compared with 0.83 in algorithm development. The NNS was nine patients, matching the CPRD cohort. In patients aged ≥30 years, the algorithm correctly identified 99.1% of patients who did not have atrial fibrillation (NPV) and 75.0% of true atrial fibrillation cases (sensitivity). Among patients aged ≥65 years (n = 117,965), the NPV was 96.7% with 91.8% sensitivity.
Conclusions
This atrial fibrillation risk prediction algorithm, based on machine learning methods, identified patients at highest risk of atrial fibrillation. It performed comparably in a large, real-world population-based cohort and the developmental registry cohort. If implemented in primary care, the algorithm could be an effective tool for narrowing the population who would benefit from atrial fibrillation screening in the United Kingdom.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 21 May 2021; 28:598-605
Sekelj S, Sandler B, Johnston E, Pollock KG, ... Ng FS, Farooqui U
Eur J Prev Cardiol: 21 May 2021; 28:598-605 | PMID: 34021576
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Impact:
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.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 21 May 2021; 28:633-640
Garg PK, Claxton JS, Soliman EZ, Chen LY, ... Mosley T, Alonso A
Eur J Prev Cardiol: 21 May 2021; 28:633-640 | PMID: 34021575
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Impact:
Abstract

Non-genetic risk factors for atrial fibrillation are equally important in both young and old age: A nationwide population-based study.

Kim YG, Han KD, Choi JI, Choi YY, ... Park YG, Kim YH
Aims
There are several non-genetic risk factors for new-onset atrial fibrillation, including age, sex, obesity, hypertension, diabetes, and alcohol consumption. However, whether these non-genetic risk factors have equal significance among different age groups is not known. We performed a nationwide population-based analysis to compare the clinical significance of non-genetic risk factors for new-onset atrial fibrillation in various age groups.
Methods and results
A total of 9,797,409 people without a prior diagnosis of atrial fibrillation who underwent a national health check-up in 2009 were included. During 80,130,090 person-years of follow-up, a total of 196,136 people were diagnosed with new-onset atrial fibrillation. The impact of non-genetic risk factors on new-onset atrial fibrillation was examined in different age groups. Obesity, male sex, heavy alcohol consumption, smoking, hypertension, diabetes and chronic kidney disease were associated with an increased risk of new-onset atrial fibrillation. With minor variations, these risk factors were consistently associated with the risk of new-onset atrial fibrillation among various age groups. Using these risk factors, we created a scoring system to predict future risk of new-onset atrial fibrillation in different age groups. In receiver operating characteristic curve analysis, the predictive value of these risk factors ranged between 0.556 and 0.603, and no significant trends were observed.
Conclusions
Non-genetic risk factors for new-onset atrial fibrillation may have a similar impact on different age groups. Except for sex, these non-genetic risk factors can be modifiable. Therefore, efforts to control non-genetic risk factors might have relevance for both the young and old.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 21 May 2021; 28:666-676
Kim YG, Han KD, Choi JI, Choi YY, ... Park YG, Kim YH
Eur J Prev Cardiol: 21 May 2021; 28:666-676 | PMID: 34021574
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Impact:
Abstract

Caffeinated coffee consumption and risk of atrial fibrillation in two Spanish cohorts.

Bazal P, Gea A, Navarro AM, Salas-Salvadó J, ... Martínez-González MA, Ruiz-Canela M
Aims
The association between caffeinated coffee consumption and atrial fibrillation remains unclear. Recent studies suggest an inverse association only between a moderate caffeinated coffee consumption and atrial fibrillation, but others have reported no association. The aim of our study was to prospectively assess the association between caffeinated coffee consumption and atrial fibrillation in two Spanish cohorts, one of adults from a general population and another of elderly participants at high cardiovascular risk.
Methods and results
We included 18,983 and 6479 participants from the \'Seguimiento Universidad de Navarra\' (SUN) and \'Prevención con Dieta Mediterránea\' (PREDIMED) cohorts, respectively. Participants were classified according to their caffeinated coffee consumption in three groups: ≤3 cups/month, 1-7 cups/week, and >1 cup/day. We identified 97 atrial fibrillation cases after a median follow-up of 10.3 years (interquartile range 6.5-13.5), in the SUN cohort and 250 cases after 4.4 years median follow-up (interquartile range 2.8-5.8) in the PREDIMED study. No significant associations were observed in the SUN cohort although a J-shaped association was suggested. A significant inverse association between the intermediate category of caffeinated coffee consumption (1-7 cups/week) and atrial fibrillation was observed in PREDIMED participants with a multivariable-adjusted hazard ratio = 0.53 (95% confidence interval 0.36-0.79) when compared with participants who did not consume caffeinated coffee or did it only occasionally. No association was found for higher levels of caffeinated coffee consumption (>1 cup per day), hazard ratio = 0.79 (95% confidence interval 0.49-1.28). In the meta-analysis of both PREDIMED and SUN studies, the hazard ratio for intermediate consumption of caffeinated coffee was 0.60 (95% confidence interval 0.44-0.82) without evidence of heterogeneity. Similar findings were found for the association between caffeine intake and atrial fibrillation risk.
Conclusion
Intermediate levels of caffeinated coffee consumption (1-7 cups/week) were associated with a reduction in atrial fibrillation risk in two prospective Mediterranean cohorts.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 21 May 2021; 28:648-657
Bazal P, Gea A, Navarro AM, Salas-Salvadó J, ... Martínez-González MA, Ruiz-Canela M
Eur J Prev Cardiol: 21 May 2021; 28:648-657 | PMID: 34021573
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Impact:
Abstract

Stage 1 hypertension, sex, and acute coronary syndromes during midlife: the Hordaland Health Study.

Kringeland E, Tell GS, Midtbø H, Igland J, Haugsgjerd TR, Gerdts E
Aims
Hypertension has been suggested as a stronger risk factor for acute coronary syndromes (ACS) in women than men. Whether this also applies to stage 1 hypertension [blood pressure (BP) 130-139/80-89 mmHg] is not known.
Methods and results
We tested associations of stage 1 hypertension with ACS in 12 329 participants in the Hordaland Health Study (mean baseline age 41 years, 52% women). Participants were grouped by baseline BP category: Normotension (BP < 130/80 mmHg), stage 1 and stage 2 hypertension (BP ≥140/90 mmHg). ACS was defined as hospitalization or death due to myocardial infarction or unstable angina pectoris during 16 years of follow-up. At baseline, a lower proportion of women than men had stage 1 and 2 hypertension, respectively (25 vs. 35% and 14 vs. 31%, P < 0.001). During follow-up, 1.4% of women and 5.7% of men experienced incident ACS (P < 0.001). Adjusted for diabetes, smoking, body mass index, cholesterol, and physical activity, stage 1 hypertension was associated with higher risk of ACS in women [hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.32-3.60], while the association was non-significant in men (HR 1.30, 95% CI 0.98-1.71). After additional adjustment for systolic and diastolic BP, respectively, stage 1 diastolic hypertension was associated with ACS in women (HR 2.79 [95% CI 1.62-4.82]), but not in men (HR 1.24 [95% CI 0.95-1.62]), while stage 1 systolic hypertension was not associated with ACS in either sex.
Conclusion
Among subjects in their early 40s, stage 1 hypertension was a stronger risk factor for ACS during midlife in women than in men.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur J Prev Cardiol: 15 May 2021; epub ahead of print
Kringeland E, Tell GS, Midtbø H, Igland J, Haugsgjerd TR, Gerdts E
Eur J Prev Cardiol: 15 May 2021; epub ahead of print | PMID: 33993298
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Impact:
Abstract

Offering, participation and adherence to cardiac rehabilitation programmes in the elderly: a European comparison based on the EU-CaRE multicentre observational study.

González-Salvado V, Peña-Gil C, Lado-Baleato Ó, Cadarso-Suárez C, ... Prins L, González Juanatey JR
Aims 
Cardiac rehabilitation (CR) is strongly recommended but participation of elderly patients has not been well characterized. This study aims to analyse current rates and determinants of CR referral, participation, adherence, and compliance in a contemporary European cohort of elderly patients.
Methods and results 
The EU-CaRE observational study included data from consecutive patients aged ≥ 65 with acute coronary syndrome, revascularization, stable coronary artery disease, or heart valve replacement, recruited in eight European centres. Rates and factors determining offering, participation, and adherence to CR programmes and compliance with training sessions were studied across centres, under consideration of extensive-outpatient vs. intensive-inpatient programmes. Three thousand, four hundred, and seventy-one patients were included in the offering and participation analysis. Cardiac rehabilitation was offered to 80.8% of eligible patients, formal contraindications being the main reason for not offering CR. Mean participation was 68.0%, with perceived lack of usefulness and transport issues being principal barriers. Mean adherence to CR programmes of participants in the EU-CaRE study (n = 1663) was 90.3%, with hospitalization/physical impairment as principal causes of dropout. Mean compliance with training sessions was 86.1%. Older age was related to lower offering and participation, and comorbidity was associated with lower offering, participation, adherence, and compliance. Intensive-inpatient programmes displayed higher adherence (97.1% vs. 85.9%, P < 0.001) and compliance (full compliance: 66.0% vs. 38.8%, P < 0.001) than extensive-outpatient programmes.
Conclusion 
In this European cohort of elderly patients, older age and comorbidity tackled patients\' referral and uptake of CR programmes. Intensive-inpatient CR programmes showed higher completion than extensive-outpatient CR programmes, suggesting this formula could suit some elderly patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 13 May 2021; 28:558-568
González-Salvado V, Peña-Gil C, Lado-Baleato Ó, Cadarso-Suárez C, ... Prins L, González Juanatey JR
Eur J Prev Cardiol: 13 May 2021; 28:558-568 | PMID: 33558875
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Impact:
Abstract

A computerized decision support system did not improve personalization of exercise-based cardiac rehabilitation according to latest recommendations.

Vromen T, Peek NB, Abu-Hanna A, Kornaat M, Kemps HM
Aims
Recent studies showed that exercise-based cardiac rehabilitation (ECR) programmes are often not personalized to individual patient characteristics according to latest recommendations. This study investigates whether a computerized decision support (CDS) system based on latest recommendations and guidelines can improve personalization of ECR prescriptions. Pseudo-randomized intervention study.
Methods and results
Among participating Dutch cardiac rehabilitation centres, ECR programme characteristics of consecutive patients were recorded during 1 year. CDS was used during a randomly assigned 4-month period within this year. Primary outcome was concordance to latest recommendations in three phases (before, during, and after CDS) for 12 ECR programme characteristics. Secondary outcome was variation in training characteristics. We recruited ten Dutch CR centres and enrolled 2258 patients to the study. Overall concordance of ECR prescriptions was 59.9% in Phase 1, 62.1% in Phase 2 (P = 0.82), and 59.9% in Phase 3 (P = 0.56). Concordance varied from 0.0% to 99.9% for the 12 ECR characteristics. There was significant between-centre variation for most training characteristics in Phases 1 and 2. In Phase 3, there was only a significant variation for aerobic and resistance training intensity (P = 0.01), aerobic training volume (P < 0.01), and the number of strengthening exercises but no longer for the other characteristics. Aerobic training volume was often below recommended (28.2%) and declined during the study.
Conclusion
CDS did not substantially improve concordance with ECR prescriptions. As aerobic training volume was often lower than recommended and reduced during the study, a lack of institutional resources might be an important barrier in personalizing ECR prescriptions.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 13 May 2021; 28:572-580
Vromen T, Peek NB, Abu-Hanna A, Kornaat M, Kemps HM
Eur J Prev Cardiol: 13 May 2021; 28:572-580 | PMID: 33624044
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Impact:
Abstract

Greater burden of risk factors and less effect of cardiac rehabilitation in elderly with low educational attainment: The Eu-CaRE study.

Kjesbu IE, Mikkelsen N, Sibilitz KL, Wilhelm M, ... de Kluiver EP, Prescott E
Aims
Socioeconomic status is a strong predictor of cardiovascular health. The aim of this study was to describe the immediate and long-term effects of cardiac rehabilitation (CR) across socioeconomic strata in elderly cardiac patients in Europe.
Methods and results
The observational EU-CaRE study is a prospective study with eight CR sites in seven European countries. Patients ≥65 years with coronary heart disease or heart valve surgery participating in CR were consecutively included. Data were obtained at baseline, end of CR and at one-year follow up. Educational level as a marker for socioeconomic status was divided into basic, intermediate and high. The primary endpoint was exercise capacity (peak oxygen consumption (VO2peak)). Secondary endpoints were cardiovascular risk factors, medical treatment and scores for depression, anxiety and quality of life (QoL). A total of 1626 patients were included; 28% had basic, 48% intermediate and 24% high education. A total of 1515 and 1448 patients were available for follow-up analyses at end of CR and one-year, respectively. Patients with basic education were older and more often female. At baseline we found a socioeconomic gradient in VO2peak, lifestyle-related cardiovascular risk factors, anxiety, depression and QoL. The socioeconomic gap in VO2peak increased following CR (p for interaction <0.001). The socioeconomic gap in secondary outcomes was unaffected by CR. The use of evidence-based medication was good in all socioeconomic groups.
Conclusions
We found a strong socioeconomic gradient in VO2peak and cardiovascular risk factors that was unaffected or worsened after CR. To address inequity in cardiovascular health, the individual adaption of CR according to socioeconomic needs should be considered.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 13 May 2021; 28:513-519
Kjesbu IE, Mikkelsen N, Sibilitz KL, Wilhelm M, ... de Kluiver EP, Prescott E
Eur J Prev Cardiol: 13 May 2021; 28:513-519 | PMID: 33989388
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Impact:
Abstract

Achieved low-density lipoprotein cholesterol level and stroke risk: A meta-analysis of 23 randomised trials.

Shin J, Chung JW, Jang HS, Lee J, ... Kim GM, Seo WK
Aims
Lowering the low-density lipoprotein cholesterol level reduces the risk of stroke, but it has not been clear whether the stroke risk would continuously decrease by lowering low-density lipoprotein cholesterol to a very low level. The purpose of this study was to evaluate the association between achieved low-density lipoprotein cholesterol levels and stroke risk.
Methods and results
A systematic search of MEDLINE, EMBASE and Cochrane Library databases was conducted to identify randomised controlled trials that tested cholesterol-lowering pharmacological therapies and reported both achieved low-density lipoprotein cholesterol levels and stroke outcomes. A meta-regression analysis was conducted to assess the linear association between the achieved low-density lipoprotein cholesterol levels and stroke risk. In addition, we evaluated pooled estimates of low-density lipoprotein cholesterol-lowering effect stratified by achieved low-density lipoprotein cholesterol levels of active arms. A total of 222,149 participants in 23 trials (52 arms of 26 studies) were included. The meta-regression analysis showed that each 1 mmol/L decrease in the achieved low-density lipoprotein cholesterol level (down to 0.78 mmol/L) was associated with a significant reduction of 23.5% (slope 0.235, 95% confidence interval 0.007-0.464, P = 0.044) in stroke risk. Irrespective of achieved low-density lipoprotein cholesterol levels in the active arms, the effects of lowering the low-density lipoprotein cholesterol level on stroke risk were significant and consistent (test for subgroup difference, P = 0.23, I2 = 31%). However, there was no significant increase in haemorrhagic stroke risk with lower achieved low-density lipoprotein cholesterol levels.
Conclusion
In this meta-analysis of randomised controlled trials, the stroke risk monotonically reduced with lowering of low-density lipoprotein cholesterol to very low levels.

© The European Society of Cardiology 2019.

Eur J Prev Cardiol: 11 May 2021; epub ahead of print
Shin J, Chung JW, Jang HS, Lee J, ... Kim GM, Seo WK
Eur J Prev Cardiol: 11 May 2021; epub ahead of print | PMID: 33978157
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Impact:
Abstract

Sex differences on new-onset heart failure in patients with known or suspected coronary artery disease.

Núñez J, Lorenzo M, Miñana G, Palau P, ... Bayés-Genís A, Bodí V
Aims
The impact of sex in patients with CAD has been widely reported, but little is known about the influence of sex on the risk of new-onset HF in patients with known or suspected CAD. We aimed to examine sex-related differences and new-onset heart failure (HF) risk in patients with known or suspected coronary artery disease (CAD) undergoing vasodilator stress cardiac magnetic resonance (CMR).
Methods and results
We prospectively evaluated 5899 consecutive HF-free patients submitted to stress CMR for known or suspected CAD. Ischaemic burden (number of segments with stress-induced perfusion deficit) and left ventricular ejection fraction (LVEF) were assessed by CMR. The association between sex and new-onset HF (including outpatient diagnosis or acute HF hospitalization) was evaluated using a Cox proportional hazards regression model adjusted for competing events [death, myocardial infarction (MI), and revascularization]. A total of 2289 (38.8%) patients were women. During a median follow-up of 4.5 years, 610 (10.3%) patients died, 191 (3.2%) suffered an MI, 905 (15.3%) underwent revascularization, and 314 (5.3%) developed new-onset HF. Unadjusted new-onset HF rates were higher in women than in men (1.25 vs. 0.83 per 100 person-years, P = 0.001). After comprehensive multivariate adjustment, women showed an increased risk of new-onset HF (hazard ratio 1.58, 95% confidence interval 1.18-2.10; P = 0.002). We found a sex-differential effect along the continuum of LVEF (P-value for interaction = 0.007). At lower LVEF, there was an increased risk in both sexes. However, compared with men, the risk of new-onset HF was higher in women with LVEF >55%.
Conclusion
Women with known or suspected CAD are at a higher risk of new-onset HF. Further studies are needed to unravel the mechanisms behind these sex-related differences.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 09 May 2021; epub ahead of print
Núñez J, Lorenzo M, Miñana G, Palau P, ... Bayés-Genís A, Bodí V
Eur J Prev Cardiol: 09 May 2021; epub ahead of print | PMID: 33970216
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Impact:
Abstract

Burden of cardiovascular risk factors and disease in five Asian groups in Catalonia: a disaggregated, population-based analysis of 121 000 first-generation Asian immigrants.

Satish P, Vela E, Bilal U, Cleries M, ... Mauri J, Cainzos-Achirica M
Aims
To evaluate the burden of cardiovascular risk factors and disease (CVD) among five Asian groups living in Catalonia (Spain): Indian, Pakistani, Bangladeshi, Filipino, and Chinese.
Methods and results
Retrospective cohort study using the Catalan Health Surveillance System database including 42 488 Pakistanis, 40 745 Chinese, 21 705 Indians, 9544 Filipinos, and 6907 Bangladeshis; and 5.3 million native individuals (\'locals\'). We estimated the age-adjusted prevalence (as of 31 December 2019) and incidence (during 2019) of diabetes, hypertension, hyperlipidaemia, obesity, tobacco use, coronary heart disease (CHD), cerebrovascular disease, atrial fibrillation, and heart failure (HF). Bangladeshis had the highest prevalence of diabetes (17.4% men, 22.6% women) followed by Pakistanis. Bangladeshis also had the highest prevalence of hyperlipidaemia (23.6% men, 18.3% women), hypertension among women (24%), and incident tobacco use among men. Pakistani women had the highest prevalence of obesity (28%). For CHD, Bangladeshi men had the highest prevalence (7.3%), followed by Pakistanis (6.3%); and Pakistanis had the highest prevalence among women (3.2%). For HF, the prevalence in Pakistani and Bangladeshi women was more than twice that of locals. Indians had the lowest prevalence of diabetes across South Asians, and of CHD across South Asian men, while the prevalence of CHD among Indian women was twice that of local women (2.6% vs. 1.3%). Filipinos had the highest prevalence of hypertension among men (21.8%). Chinese men and women had the lowest prevalence of risk factors and CVD.
Conclusions
In Catalonia, preventive interventions adapted to the risk profile of different Asian immigrant groups are needed, particularly for Bangladeshis and Pakistanis.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 09 May 2021; epub ahead of print
Satish P, Vela E, Bilal U, Cleries M, ... Mauri J, Cainzos-Achirica M
Eur J Prev Cardiol: 09 May 2021; epub ahead of print | PMID: 33969397
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Impact:
Abstract

The impact of coronary heart disease prevention on work productivity: a 10-year analysis.

Savira F, Wang BH, Kompa AR, Ademi Z, ... Liew D, Zomer E
Aims
To determine the impact of preventing new (incident) cases of coronary heart disease (CHD) on years of life and productivity, using the novel measure \'productivity-adjusted life year\' (PALY), over the next 10 years.
Methods and results
A dynamic life table model was constructed for the total Australian working-age population (15-69 years) over 10 years (2020-2029), separated by CHD status. Productivity estimates were sourced from the literature. The PALY was ascribed a financial value in terms of gross domestic product (GDP) per equivalent full-time worker. The total number of years lived, PALYs, and economic burden (in terms of GDP per PALY) were estimated. The model simulation was repeated assuming incidence was reduced, and the differences represented the impact of CHD prevention. All outcomes were discounted by 5% per annum. Over 10 years, the total projected years lived and PALYs in the Australian working-age population (with and without CHD) were 133 million and 83 million, respectively, amounting to A$17.2 trillion in GDP. We predicted more than 290 000 new (incident) CHD cases over the next 10 years. If all new cases of CHD could be prevented during this period, a total of 4 000 deaths could be averted, resulting in more than 8 000 years of life saved and 104 000 PALYs gained, equivalent to a gain of nearly A$21.8 billion (US$14.8 billion) in GDP.
Conclusion
Prevention of CHD will prolong years of life lived and productive life years, resulting in substantial economic benefit. Policy makers and employers are encouraged to engage in preventive measures addressing CHD.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 07 May 2021; 28:418-425
Savira F, Wang BH, Kompa AR, Ademi Z, ... Liew D, Zomer E
Eur J Prev Cardiol: 07 May 2021; 28:418-425 | PMID: 33624015
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Impact:
Abstract

Epidemiological and clinical boundaries of heart failure with preserved ejection fraction.

Gentile F, Ghionzoli N, Borrelli C, Vergaro G, ... Passino C, Giannoni A
Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and is associated with relevant morbidity and mortality. However, an evidence-based treatment is still absent. The heterogeneous definitions, differences in aetiology/pathophysiology, and diagnostic challenges of HFpEF made it difficult to define its epidemiological landmarks so far. Several large registries and observational studies have recently disclosed an increasing incidence/prevalence, as well as its prognostic significance. An accurate definition of HFpEF epidemiological boundaries and phenotypes is mandatory to develop novel effective and rational therapeutic approaches.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur J Prev Cardiol: 07 May 2021; epub ahead of print
Gentile F, Ghionzoli N, Borrelli C, Vergaro G, ... Passino C, Giannoni A
Eur J Prev Cardiol: 07 May 2021; epub ahead of print | PMID: 33963839
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Impact:
Abstract

Profile and treatment of chronic coronary syndromes in European Society of Cardiology member countries: The ESC EORP CICD-LT registry.

Komajda M, Cosentino F, Ferrari R, Kerneis M, ... Gale CP, CICD investigators group
Background
International guidelines recommend pharmacotherapy combinations for chronic coronary syndromes (CCSs) but medical management remains suboptimal.
Design
The CICD-LT registry is investigating short- and long-term outcomes and management in patients in European Society of Cardiology (ESC) member countries, in a longitudinal ESC EURObservational Research Programme aimed at improving CCS management.
Methods
Between 1 May 2015 and 31 July 2018, 9174 patients with previous ST-elevation myocardial infarction (STEMI), non-STEMI or coronary revascularisation, or other CCS, were recruited during a routine ambulatory visit or elective revascularisation procedure. Baseline clinical data were recorded and prescribed medications analysed at initial contact and discharge, and according to patient gender and age (<75 vs. ≥75 years).
Results
Poorly controlled cardiovascular risk factors, including current smoking (18.5%), obesity (33.9%), diabetes (25.8%), raised low-density lipoprotein cholesterol (73.3%) and persistent hypertension (24.7%), were common across all cohorts. At ambulatory visit or admission, the guidelines-recommended combination of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, aspirin, statin and any antiplatelet agent was prescribed to 57.8% of patients with STEMI/NSTEMI. Differences in prescribing rates, including for combination therapies, were observed based on age and gender and persisted after adjustment for demographic factors.
Conclusions
Cardiovascular risk factors were common in contemporary CCS patients and secondary prevention prescribing was suboptimal. Patients aged ≥75 years and, to some extent, female patients were less likely to receive guidelines-recommended drug combinations than younger and male patients. One- and two-year follow-up will study prescribing changes and associations between baseline characteristics/prescribing and subsequent clinical outcomes.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 07 May 2021; 28:432-445
Komajda M, Cosentino F, Ferrari R, Kerneis M, ... Gale CP, CICD investigators group
Eur J Prev Cardiol: 07 May 2021; 28:432-445 | PMID: 33966083
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Impact:
Abstract

Impact of cardiorespiratory fitness on survival in men with low socioeconomic status.

Jae SY, Kurl S, Bunsawat K, Franklin BA, ... Kauhanen J, Laukkanen JA
Aims
Although both low socioeconomic status (SES) and poor cardiorespiratory fitness (CRF) are associated with increased chronic disease and heightened mortality, it remains unclear whether moderate-to-high levels of CRF are associated with survival benefits in low SES populations. This study evaluated the hypothesis that SES and CRF predict all-cause mortality and cardiovascular disease mortality and that moderate-to-high levels of CRF may attenuate the association between low SES and increased mortality.
Methods
This study included 2368 men, who were followed in the Kuopio Ischaemic Heart Disease Study cohort. CRF was directly measured by peak oxygen uptake during progressive exercise testing. SES was characterized using self-reported questionnaires.
Results
During a 25-year median follow-up, 1116 all-cause mortality and 512 cardiovascular disease mortality events occurred. After adjusting for potential confounders, men with low SES were at increased risks for all-cause mortality (hazard ratio 1.49, 95% confidence interval: 1.30-1.71) and cardiovascular disease mortality (hazard ratio1.38, 1.13-1.69). Higher levels of CRF were associated with lower risks of all-cause mortality (hazard ratio 0.54, 0.45-0.64) and cardiovascular disease mortality (hazard ratio 0.53, 0.40-0.69). In joint associations of SES and CRF with mortality, low SES-unfit had significantly higher risks of all-cause mortality (hazard ratio 2.15, 1.78-2.59) and cardiovascular disease mortality (hazard ratio 1.95, 1.48-2.57), but low SES-fit was not associated with a heightened risk of cardiovascular disease mortality (hazard ratio 1.09, 0.80-1.48) as compared with their high SES-fit counterparts.
Conclusion
Both SES and CRF were independently associated with subsequent mortality; however, moderate-to-high levels of CRF were not associated with an excess risk of cardiovascular disease mortality in men with low SES.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 07 May 2021; 28:450-455
Jae SY, Kurl S, Bunsawat K, Franklin BA, ... Kauhanen J, Laukkanen JA
Eur J Prev Cardiol: 07 May 2021; 28:450-455 | PMID: 33966081
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Abstract

Primary prevention efforts are poorly developed in people at high cardiovascular risk: A report from the European Society of Cardiology EURObservational Research Programme EUROASPIRE V survey in 16 European countries.

Kotseva K, De Backer G, De Bacquer D, Rydén L, ... Wood D, EUROASPIRE V Investigators
Background
European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V in primary care was carried out by the European Society of Cardiology EURObservational Research Programme in 2016-2018. The main objective was to determine whether the 2016 Joint European Societies\' guidelines on cardiovascular disease prevention in people at high cardiovascular risk have been implemented in clinical practice.
Methods
The method used was a cross-stional survey in 78 centres from 16 European countries. Patients without a history of atherosclerotic cardiovascular disease either started on blood pressure and/or lipid and/or glucose lowering treatments were identified and interviewed ≥ 6 months after the start of medication.
Results
A total of 3562 medical records were reviewed and 2759 patients (57.6% women; mean age 59.0 ± 11.6 years) interviewed (interview rate 70.0%). The risk factor control was poor with 18.1% of patients being smokers, 43.5% obese (body mass index ≥30 kg/m2) and 63.8% centrally obese (waist circumference ≥88 cm for women, ≥102 cm for men). Of patients on blood pressure lowering medication 47.0% reached the target of <140/90 mm Hg (<140/85 mm Hg in people with diabetes). Among treated dyslipidaemic patients only 46.9% attained low density lipoprotein-cholesterol target of <2.6 mmol/l. Among people treated for type 2 diabetes mellitus, 65.2% achieved the HbA1c target of <7.0%.
Conclusion
The primary care arm of the EUROASPIRE V survey revealed that large proportions of people at high cardiovascular disease risk have unhealthy lifestyles and inadequate control of blood pressure, lipids and diabetes. Thus, the potential to reduce the risk of future cardiovascular disease throughout Europe by improved preventive cardiology programmes is substantial.

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Eur J Prev Cardiol: 07 May 2021; 28:370-379
Kotseva K, De Backer G, De Bacquer D, Rydén L, ... Wood D, EUROASPIRE V Investigators
Eur J Prev Cardiol: 07 May 2021; 28:370-379 | PMID: 33966079
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Abstract

Socioeconomic disparities in the management of coronary heart disease in 438 general practices in Australia.

Mnatzaganian G, Lee CMY, Robinson S, Sitas F, ... Woodward M, Huxley RR
Background
This population-based cross-stional and panel study investigated disparities in the management of coronary heart disease (CHD) by level of socioeconomic status.
Methods
CHD patients (aged ≥18 years), treated in 438 general practices in Australia, with ≥3 recent encounters with their general practitioners, with last encounter being during 2016-2018, were included. Secondary prevention prescriptions and number of treatment targets achieved were each modelled using a Poisson regression adjusting for demographics, socioeconomic indicators, remoteness of patient\'s residence, comorbidities, lifetime follow-up, number of patient-general practitioner encounters and cluster effect within the general practices. The latter model was constructed using the Generalised Estimating Equations approach. Sensitivity analysis was run by comorbidity.
Results
Of 137,408 patients (47% women), approximately 48% were prescribed ≥3 secondary prevention medications. However, only 44% were screened for CHD-associated risk factors. Of the latter, 45% achieved ≥5 treatment targets. Compared with patients from the highest socioeconomic status fifth, those from the lowest socioeconomic status fifth were 8% more likely to be prescribed more medications for secondary prevention (incidence rate ratio (95% confidence interval): 1.08 (1.04-1.12)) but 4% less likely to achieve treatment targets (incidence rate ratio: 0.96 (0.95-0.98)). These disparities were also observed when stratified by comorbidities.
Conclusion
Despite being more likely to be prescribed medications for secondary prevention, those who are most socioeconomically disadvantaged are less likely to achieve treatment targets. It remains to be determined whether barriers such as low adherence to treatment, failure to fill prescriptions, low income, low level of education or other barriers may explain these findings.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 07 May 2021; 28:400-407
Mnatzaganian G, Lee CMY, Robinson S, Sitas F, ... Woodward M, Huxley RR
Eur J Prev Cardiol: 07 May 2021; 28:400-407 | PMID: 33966082
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Abstract

Trends in cardiovascular diseases burden and vascular risk factors in Italy: The Global Burden of Disease study 1990-2017.

Cortesi PA, Fornari C, Madotto F, Conti S, ... Mantovani LG, GBD 2017 Italy Cardiovascular Diseases Collaborators
Aims
An exhaustive and updated estimation of cardiovascular disease burden and vascular risk factors is still lacking in European countries. This study aims to fill this gap assessing the global Italian cardiovascular disease burden and its changes from 1990 to 2017 and comparing the Italian situation with European countries.
Methods
All accessible data sources from the 2017 Global Burden of Disease study were used to estimate the cardiovascular disease prevalence, mortality and disability-adjusted life years and cardiovascular disease attributable risk factors burden in Italy from 1990 to 2017. Furthermore, we compared the cardiovascular disease burden within the 28 European Union countries.
Results
Since 1990, we observed a significant decrease of cardiovascular disease burden, particularly in the age-standardised prevalence (-12.7%), mortality rate (-53.8%), and disability-adjusted life years rate (-55.5%). Similar improvements were observed in the majority of European countries. However, we found an increase in all-ages prevalence of cardiovascular diseases from 5.75 m to 7.49 m Italian residents. Cardiovascular diseases still remain the first cause of death (34.8% of total mortality). More than 80% of the cardiovascular disease burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high low density lipoprotein cholesterol, and impaired kidney function.
Conclusions
Our study shows a decline in cardiovascular mortality and disability-adjusted life years, which reflects the success in reducing disability, premature death and early incidence of cardiovascular diseases. However, the burden of cardiovascular diseases is still high. An approach that includes the cooperation and coordination of all stakeholders of the Italian National Health System is required to further reduce this burden.

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Eur J Prev Cardiol: 07 May 2021; 28:385-396
Cortesi PA, Fornari C, Madotto F, Conti S, ... Mantovani LG, GBD 2017 Italy Cardiovascular Diseases Collaborators
Eur J Prev Cardiol: 07 May 2021; 28:385-396 | PMID: 33966080
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Abstract

A cost-utility analysis of increasing percutaneous coronary intervention use in elderly patients with acute coronary syndromes in six European countries.

Forné C, Subirana I, Blanch J, Ferrieres J, ... Dégano IR, EUROTRACS Investigators
Aims
Percutaneous coronary intervention reduces mortality in acute coronary syndrome patients but the cost-utility of increasing its use in elderly acute coronary syndrome patients is unknown.
Methods
We assessed the efficiency of increased percutaneous coronary intervention use compared to current practice in patients aged ≥75 years admitted for acute coronary syndrome in France, Germany, Greece, Italy, Portugal and Spain with a semi-Markov state transition model. In-hospital mortality reduction estimates by percutaneous coronary intervention use and costs were derived from the EUROpean Treatment & Reduction of Acute Coronary Syndromes cost analysis EU project (n = 28,600). Risk of recurrence and out-of-hospital all-cause mortality were obtained from the Information System for the Development of Research in Primary Care (SIDIAP) database from North-Eastern Spain (n = 55,564). In-hospital mortality was modelled using stratified propensity score analysis. The 8-year acute coronary syndrome recurrence risk and out-of-hospital mortality were estimated with a multistate survival model. The scenarios analysed were to increase percutaneous coronary intervention use among patients with the highest, moderate and lowest probability of receiving percutaneous coronary intervention based on the propensity score analysis.
Results
France, Greece and Portugal showed similar total costs/1000 individuals (7.29-11.05 m €); while in Germany, Italy and Spain, costs were higher (13.53-22.57 m €). Incremental cost-utility ratios of providing percutaneous coronary intervention to all patients ranged from 2262.8 €/quality adjusted life year gained for German males to 6324.3 €/quality adjusted life year gained for Italian females. Increasing percutaneous coronary intervention use was cost-effective at a willingness-to-pay threshold of 10,000 €/quality adjusted life year gained for all scenarios in the six countries, in males and females.
Conclusion
Compared to current clinical practice, broadening percutaneous coronary intervention use in elderly acute coronary syndrome patients would be cost-effective across different healthcare systems in Europe, regardless of the selected strategy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur J Prev Cardiol: 07 May 2021; 28:408-417
Forné C, Subirana I, Blanch J, Ferrieres J, ... Dégano IR, EUROTRACS Investigators
Eur J Prev Cardiol: 07 May 2021; 28:408-417 | PMID: 33966078
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Abstract

Residual cardiovascular risk reduction guided by lifetime benefit estimation in patients with symptomatic atherosclerotic disease: effectiveness and cost-effectiveness.

Hageman SHJ, Dorresteijn JAN, Bots ML, Asselbergs FW, ... Visseren FLJ, Westerink J
Aims
To determine the (cost)-effectiveness of blood pressure lowering, lipid-lowering, and antithrombotic therapy guided by predicted lifetime benefit compared to risk factor levels in patients with symptomatic atherosclerotic disease.
Methods and results 
For all patients with symptomatic atherosclerotic disease in the UCC-SMART cohort (1996-2018; n = 7697) two treatment strategies were compared. The lifetime benefit-guided strategy was based on individual estimation of gain in cardiovascular disease (CVD)-free life with the SMART-REACH model. In the risk factor-based strategy, all patients were treated the following: low-density lipoprotein cholesterol (LDL-c) < 1.8 mmol/L, systolic blood pressure <140 mmHg, and antithrombotic medication. Outcomes were evaluated for the total cohort using a microsimulation model. Effectiveness was evaluated as total gain in CVD-free life and events avoided, cost-effectiveness as incremental cost-effectivity ratio (ICER). In comparison to baseline treatment, treatment according to lifetime benefit would lead to an increase of 24 243 CVD-free life years [95% confidence interval (CI) 19 980-29 909] and would avoid 940 (95% CI 742-1140) events in the next 10 years. For risk-factor based treatment, this would be an increase of 18 564 CVD-free life years (95% CI 14 225-20 456) and decrease of 857 (95% CI 661-1057) events. The ICER of lifetime benefit-based treatment with a treatment threshold of ≥1 year additional CVD-free life per therapy was €15 092/QALY gained and of risk factor-based treatment €9933/QALY gained. In a direct comparison, lifetime benefit-based treatment compared to risk factor-based treatment results in 1871 additional QALYs for the price of €36 538/QALY gained.
Conclusion 
Residual risk reduction guided by lifetime benefit estimation results in more CVD-free life years and more CVD events avoided compared to the conventional risk factor-based strategy. Lifetime benefit-based treatment is an effective and potentially cost-effective strategy for reducing residual CVD risk in patients with clinical manifest vascular disease.

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Eur J Prev Cardiol: 01 May 2021; epub ahead of print
Hageman SHJ, Dorresteijn JAN, Bots ML, Asselbergs FW, ... Visseren FLJ, Westerink J
Eur J Prev Cardiol: 01 May 2021; epub ahead of print | PMID: 34009323
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Abstract

Cardiovascular risk stratification by coronary computed tomography angiography imaging: current state-of-the-art.

Antonopoulos AS, Angelopoulos A, Tsioufis K, Antoniades C, Tousoulis D
Current cardiovascular risk stratification by use of clinical risk score systems or plasma biomarkers is good but less than satisfactory in identifying patients at residual risk for coronary events. Recent clinical evidence puts now further emphasis on the role of coronary anatomy assessment by coronary computed tomography angiography (CCTA) for the management of patients with stable ischaemic heart disease. Available computed tomography (CT) technology allows the quantification of plaque burden, identification of high-risk plaques, or the functional assessment of coronary lesions for ischaemia detection and revascularization for refractory angina symptoms. The current CT armamentum is also further enhanced by perivascular Fat Attenuation Index (FAI), a non-invasive metric of coronary inflammation, which allows for the first time the direct quantification of the residual vascular inflammatory burden. Machine learning and radiomic features\' extraction and spectral CT for tissue characterization are also expected to maximize the diagnostic and prognostic yield of CCTA. The combination of anatomical, functional, and biological information on coronary circulation by CCTA offers a unique toolkit for the risk stratification of patients, and patient selection for targeted aggressive prevention strategies. We hereby provide a review of the current state-of-the art in the field and discuss how integrating the full capacities of CCTA into clinical care pathways opens new opportunities for the tailored management of coronary artery disease.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permiss[email protected]

Eur J Prev Cardiol: 29 Apr 2021; epub ahead of print
Antonopoulos AS, Angelopoulos A, Tsioufis K, Antoniades C, Tousoulis D
Eur J Prev Cardiol: 29 Apr 2021; epub ahead of print | PMID: 33930129
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This program is still in alpha version.