European Journal of Cardiovascular Prevention & Rehabilitation

Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation

2010-02-01

Increasing awareness of the importance of cardiovascular prevention is not yet matched by the resources and actions within health care systems. Recent publication of the European Commission's European Heart Health Charter in 2008 prompts a review of the role of cardiac rehabilitation (CR) to cardiovascular health outcomes. Secondary prevention through exercise-based CR is the intervention with the best scientific evidence to contribute to decrease morbidity and mortality in coronary artery disease, in particular after myocardial infarction but also incorporating cardiac interventions and chronic stable heart failure. The present position paper aims to provide the practical recommendations on the core components and goals of CR intervention in different cardiovascular conditions, to assist in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of CR. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, national or individual centre level, need to consider where and how structured programmes of CR can be delivered to all patients eligible. Thus a novel, disease-oriented document has been generated, where all components of CR for cardiovascular conditions have been revised, presenting both well-established and controversial aspects. A general table applicable to all cardiovascular conditions and specific tables for each clinical disease have been created and commented.

Improvement of cardiovascular risk prediction: time to review current knowledge, debates, and fundamentals on how to assess test characteristics

2010-02-01

Cardiovascular risk assessment might be improved with the addition of emerging, new tests derived from atherosclerosis imaging, laboratory tests or functional tests. This article reviews relative risk, odds ratios, receiver-operating curves, posttest risk calculations based on likelihood ratios, the net reclassification improvement and integrated discrimination. This serves to determine whether a new test has an added clinical value on top of conventional risk testing and how this can be verified statistically. Two clinically meaningful examples serve to illustrate novel approaches. This work serves as a review and basic work for the development of new guidelines on cardiovascular risk prediction, taking into account emerging tests, to be proposed by members of the ‘Taskforce on Vascular Risk Prediction’ under the auspices of the Working Group ‘Swiss Atherosclerosis’ of the Swiss Society of Cardiology in the future.

Does IQ predict cardiovascular disease mortality as strongly as established risk factors? Comparison of effect estimates using the West of Scotland Twenty-07 cohort study

G. David Batty, Ian J. Deary, Michaela Benzeval, Geoff Der — 2010-02-01

Objective: To compare the strength of the association between intelligence quotient (IQ) and cardiovascular disease (CVD) mortality with the predictive power for established risk factors.Design: Population-based cohort study of 1145 men and women with IQ test scores, a range of established risk factors, and 20-year mortality surveillance.Results: When CVD mortality was the outcome of interest, the relative index of inequality (sex-adjusted hazard ratio, 95% confidence interval) for the most disadvantaged relative to the advantaged persons was (in descending order of magnitude for the top five risk factors): 5.58 (2.89, 10.8) for cigarette smoking; 3.76 (2.14, 6.61) for IQ; 3.20 (1.85, 5.54) for income; 2.61 (1.49, 4.57) for systolic blood pressure and 2.06 (1.07, 3.99) for physical activity. Mutual adjustment led to some attenuation of these relationships. Similar observations were made in the analyses featuring all deaths where, again, IQ was the second most powerful predictor of mortality risk.Conclusion: In this cohort, lower intelligence scores were associated with increased rates of CVD and total mortality at a level of magnitude greater than most established risk factors.

PTPN1 polymorphisms are associated with total and low-density lipoprotein cholesterol

2010-02-01

Background: The protein tyrosine phosphatase nonreceptor type 1 (PTPN1) gene encodes for the protein tyrosine phosphatase 1B, which suppresses the signaling pathway of insulin. Variations in PTPN1 may lead to changes in insulin sensitivity and consequent changes in protein tyrosine phosphatase 1B activity may also contribute to the development of metabolic endophenotypes. Our aim was to investigate the association between single nucleotide polymorphisms (SNPs) of the PTPN1 gene and metabolic endophenotypes and insulin sensitivity.Design and methods: We used data from a population-based cross-sectional study of 382 Dutch Caucasian men aged between 40–80 years, in whom we genotyped and analyzed four tag SNPs in PTPN1.Results: We show that the minor alleles of three tag SNPs of the PTPN1 gene (rs6067484, rs6020611, rs1060402) are associated with higher levels of total plasma cholesterol and low-density lipoprotein (LDL) cholesterol in men with a body mass index (BMI) below 26kg/m2 (P<0.05). We also show that men with a BMI below 26kg/m2 and carrying the rs3487348T allele tend to have a more beneficial profile for total plasma cholesterol and LDL cholesterol (P<0.05). Haplotypes that comprised these alleles were also borderline statistically significant associated with higher levels of LDL and total cholesterol in men with BMI below 26kg/m2.Conclusion: Our results suggest that SNPs in the PTPN1 gene are associated with total plasma and LDL cholesterol levels.

Self-reported compliance to home-based resistance training in cardiac patients

Susan Marzolini, Donald J. Mertens, Paul I. Oh, Michael J. Plyley — 2010-02-01

Purpose: To retrospectively identify factors influencing long-term compliance to home-based resistance training (RT) in a cardiac rehabilitation (CR) programme.Methods: Five hundred and eighteen patients (447 males, 71 females) attending a CR programme consisting of aerobic exercise, education and lifestyle counselling were also offered RT exercises, which they performed over a 72-month period. These patients were sent a questionnaire to examine ongoing participation in RT and perceptions around RT.Results: Sixty-nine percent of the surveys were returned. The mean follow-up time was 38.7±25.9 months post-RT prescription (about 2.5 years postgraduation from on-site CR). Among respondents, 50% (50.6% males, 42.9% females) were continuing RT at the time of the survey (compliers), and 50% (49.4% males, 57.1% females) had discontinued RT (dropouts). Compliers perceived greater support for RT participation than dropouts (41.3 and 22.5% perceived strong support, respectively, from family/friends and physicians, P<0.005). Dropouts had a higher percentage of body fat at baseline than compliers (32% of dropouts and 20% of compliers had a body fat >25%, P<0.025). Men participated mainly to ‘improve appearance’ and women to ‘prevent osteoporosis’. Weight reduction was a greater motivator to participate for dropouts than for compliers. The main reason for discontinuing RT was ‘lack of motivation’. The most common injuries occurred in one shoulder or the lower back. Only 3% discontinued RT because of injury.Conclusion: One-half of patients starting an RT home-based programme were still under training at the time of the survey (mean 38.7 months). A lower percentage of body fat and support from family/friends and physicians seem to increase long-term compliance. There were sex differences in reasons for participation and dropout. Emphasizing achievable benefits that motivate men and women to participate may help to reduce dropout.

Food and vessels: the importance of a healthy diet to prevent cardiovascular disease

2010-02-01

Aim: We attempted to quantify the burden of cardiovascular disease that can be prevented by broader adherence to recommendations on dietary intake of key nutrients.Methods: A computer model capturing the epidemiology of chronic disease and risk factors in the Dutch population was used to simulate differences in the occurrence of cardiovascular disease under various scenarios defined by levels of intake of saturated and trans fatty acids, fruit, vegetables and fish. The following scenarios were compared with the current situation: (i) the whole population adhering to recommendations (optimum scenario); (ii) a moderate improvement and (iii) increased intake of fruit as has been achieved in an actual intervention (‘fruit at work’). Other outcome measures assessed were (differences in) life expectancy and healthy life expectancy for a 40-year-old individual.Results: In the optimum scenario, cumulative incidence prevented over a period of 20 years was 240000 cases for acute myocardial infarction, or 30% of the expected number of cases, 328000 (16%) for other coronary heart disease and 215000 (21%) for stroke. For the moderate improvement scenario, the corresponding figures were 119000 (14%), 163000 (8%) and 105000 (10%), respectively. The individual contributions of each of the separate dietary factors were greatest for fish, followed in decreasing order by fruit, vegetables, saturated and trans fatty acids. Only fish and fruit contributed to a decrease in strokes. In the optimum scenario, 1 year was added to the life expectancy of a 40-year-old individual and half a year in the moderate improvement scenario.Conclusion: Broader adherence to recommendations for daily intake of fruit, vegetables, fish and fatty acid composition may take away as much as 20–30% of the burden of cardiovascular disease and result in approximately 1 extra life year for a 40-year-old individual. Promotion of a healthy diet should be given more emphasis in the prevention of cardiovascular disease.

Reduced risk of myocardial infarction related to active commuting: inflammatory and haemostatic effects are potential major mediating mechanisms

2010-02-01

Background: Regular physical activity is inversely associated with risk of coronary heart disease, but the precise mechanisms remain unclear. Active commuting is an environmental friendly way to achieve the recommended 30min of daily physical activity. The aim of this study was to explore the relative contribution of markers from different potential mediating pathways on the association between active commuting and risk of myocardial infarction (MI) in a general population.Design: Prospective incident nested case–control study.Methods: Commuting habits, traditional risk factors and biomarkers were assessed at baseline and compared in 204 MI cases and 327 matched controls.Results: Car commuting was significantly associated with MI risk, even after adjusting for potential confounders (odds ratio: 1.77, 95% confidence interval: 1.05–2.99). When potential mediators were included in the model, the risk was substantially attenuated. Among the traditional risk factors, apolipoprotein B/apolipoprotein A-1 ratio seemed to be the largest mediator (26.0%), followed by body mass index (18.7%). The inflammatory and haemostatic markers similarly dampened the effect, with tissue plasminogen activator/plasminogen activator inhibitor-1 complex and IL-6 explaining 33.6 and 27.6% of MI risk, respectively. Combined, the potential mediators investigated seemed to explain 40.1% of MI risk related to car commuting.Conclusion: Overall, the traditional, inflammatory and haemostatic markers seemed to explain a substantial proportion of the reduction in MI risk related to active commuting in this study population. The predominant effect of the inflammatory and haemostatic markers supports the hypothesis that regular physical activity may work through additional biological mechanisms to reduce coronary risk beyond traditional risk factors. However, these findings need to be confirmed in larger studies.

Hypertension and its identification among current, past and never smokers in an English population sample

Lion Shahab, Jennifer Mindell, Neil R. Poulter, Robert West — 2010-02-01

Background: Clinical guidelines recommend prioritizing efforts to treat hypertension in people with other cardiovascular risk factors, including smoking, but few contemporary data are available on awareness of hypertension among smokers. This study aimed to determine the prevalence of hypertension awareness in hypertensive smokers and its association with receiving and acting on advice to stop smoking.Design: Cross-sectional surveys in 2003 and 2006.Methods: Data, including socio-demographic, lifestyle and smoking characteristics and provision of advice to stop smoking were collected from 20202 adults participating in the Health Survey for England. Self-report was used to determine awareness of hypertension; blood pressure readings were taken by a trained nurse to identify hypertension objectively.Results: Current smokers with objectively defined hypertension were less aware of their hypertension than hypertensive past or never smokers: only half of hypertensive smokers reported having received a diagnosis with hypertension [51.3%, 95% confidence interval (CI): 48.8–53.8]. After adjustment for confounding, this difference in awareness between current and past smokers remained significant [odds ratio (OR): 1.32, 95% CI: 1.12–1.55] but became nonsignificant when comparing current and never smokers (OR: 1.05, 95% CI: 0.88–1.25). However, hypertension awareness increased between 2003 and 2006 irrespective of smoking status. After adjusting for confounders, smokers aware of their hypertension were more likely to have received advice to stop smoking (OR: 3.29, 95% CI: 2.59–4.18) and to have stopped smoking (OR: 1.58, 95% CI: 1.32–1.89) than smokers unaware of their hypertension.Conclusion: The diagnosis of hypertension is picked up less frequently among smokers than nonsmokers. This is particularly important because receiving a diagnosis seems to motivate cessation.

Assessing overall duration of cardiovascular medicines in veterans with established cardiovascular disease

2010-02-01

Background: This study aimed to determine persistence, adherence, and time without therapy with cardiovascular medicines over all episodes of use among veterans following hospitalization for ischemic heart disease.Methods: Retrospective cohort study using Department of Veterans' Affairs database including 9635 veterans with a hospitalization for acute myocardial infarction, angina, or ischemic heart disease, and who had been dispensed cardiovascular medicines in the 3 months posthospitalization. The main outcome measures were duration of first treatment episode, duration of overall treatment episode, and adherence with recommended therapies: angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), lipid-lowering therapy, calcium channel blockers (CCBs), β-blockers, and antiplatelet therapy.Results: The median duration of overall treatment was 6.2 years [95% confidence interval (CI): 6.0–6.4] for lipid-lowering therapy, 5.4 years (95% CI: 5.1–5.5) for ACE inhibitors/ARBs, 5.0 years (95% CI: 4.8–5.1) for antiplatelets, 3.4 years (95% CI: 3.3–3.6) for β-blockers, and 2.8 years (95% CI: 2.6–3.0) for CCBs. Adherence was 72% for CCBs, 75% for ACE inhibitors/ARBs, 84% for lipid-lowering therapy, and 84% for antiplatelets other than aspirin. The median time without therapy was 4.5 months or less for ACE inhibitors/ARBs, antiplatelets, and lipid-lowering therapy.Conclusion: Problems with medication adherence can relate to either persistence or compliance during treatment. This novel method provides a way to determine which of these factors is most problematic when considering chronic therapies. We found that Australian veterans with established cardiovascular disease are persistent with their cardiovascular therapy, with only small gaps in therapy.

Trends in referral to outpatient cardiac rehabilitation in the Hunter Region of Australia, 2002–2007

Natalie A. Johnson, Kerry J. Inder, Steven J. Bowe — 2010-02-01

Background: Cardiac rehabilitation (CR) is an underutilized evidence-based treatment. We described trends in referral to outpatient CR (OCR) and the factors associated with referral.Design: Cross-sectional survey data provided by Hunter residents aged 20 years or older discharged from public hospitals in the region between 2002 and 2007 with an OCR eligible diagnosis were extracted from the Hunter New England Heart and Stroke Register database.Methods: Trends in referral were determined using the χ2 test for trend. Factors associated with referral were examined using multiple logistic regression.Results: Sixty-five percent (4971 of 7678) of patients provided sufficient data for inclusion in the analysis. Approximately half of the patients reported being referred to OCR. No increase over time was observed. Factors associated with referral were age less than 70 years, male sex, being married, urban residence, at least one admission to the tertiary referral hospital for cardiology, at least one admission for acute myocardial infarction, revascularization, no admissions for congestive heart failure, a self-reported history of high cholesterol, and no history of stroke or atrial fibrillation.Conclusion: Access to this treatment of proven benefit remained suboptimal despite the provision of new programs and expansion of existing programs. Automatic referral, which is recommended in Australia, should be standard practice.

A valid and reproducible protocol for testing maximal oxygen uptake in rabbits

Svein Erik Gaustad, Natale Rolim, Ulrik Wisløff — 2010-02-01

Background: Physiological studies of long-term cardiovascular adaptation to exercise require adequate testing procedures to quantify the outcome. Such test procedures are well established in rats and mice. However, the use of these species may have limitations, and to study several physiological parameters mimicking ‘the human adaptation’ larger animal models may be preferable. Here, we established a valid and reproducible exercise test protocol for measuring maximal oxygen uptake (VO2max) in rabbits.Methods and results: The VO2max protocol was studied in six adult female New Zealand White rabbits running on a treadmill at inclinations ranging from 0 to 20°. VO2max was reached at all inclinations indicating that the rabbits reach exhaustion independent of inclination. Average VO2max for test and retest were 35.1±4.2 and 35.8±4.0ml/kgpermin, respectively. Oxygen uptake and heart rate increased linearly with increased running speed. Average running speed at VO2max was 0.51±0.09m/s, and there was an increase oxygen pulse up to the intensity corresponding to VO2max, where it leveled off and declined.Conclusion: This study shows that rabbit is a suitable species for studying responses to training and could be of great importance for showing novel cellular cardiac adaptations to training.

HMGCR gene polymorphism is associated with stroke risk in the EPIC-Norfolk study

2010-02-01

Background: Earlier, a G/T single nucleotide polymorphism (SNP) in the HMGCR gene was shown to significantly reduce the overall serum lipids response to pravastatin. This study aimed to investigate the relationship of the rs17238540 SNP with coronary heart disease, stroke and cardiovascular disease risk.Design: Cross-sectional study from the European Prospective Investigation into Cancer and Nutrition-Norfolk cohort.Methods: Genotype was determined by pyrosequencing 23011 participants, for whom clinical and biochemical data were available. Baseline risk factors according to genotype were evaluated, and the risk for fatal and nonfatal stroke, ischaemic heart disease and all types of cardiovascular diseases were assessed by logistic regression after approximately 11 years of follow-up.Results: The G allele carriers presented 1.4mmHg higher systolic blood pressure and 0.8mmHg higher diastolic blood pressure than those who were TT carriers. They also presented higher risk of prevalent total (odds ratio: 1.44, 95% confidence interval: 1.05–1.97, P=0.025) and nonfatal (odds ratio: 1.56, 95% confidence interval: 1.12–2.17, P=0.009) stroke events compared with the TT individuals in the multivariate models.Conclusion: An association between the rs17238540 SNP and stroke risk was observed, independent of the effect of the SNP on the blood pressure. The possible mechanisms involved, besides the effect on blood pressure, might be related to pleiotropic functions of the HMGCR, and remain to be explored.

Diabetes as a coronary artery disease risk equivalent: before a change of paradigm?

2010-02-01

Background: Current guidelines consider diabetes per se as a coronary artery disease (CAD) risk equivalent. We aimed at investigating the contribution of baseline coronary atherosclerosis to the risk of diabetic patients for future vascular events.Design: Prospective cohort study.Methods: Vascular events were recorded over 4 years in 750 consecutive patients undergoing coronary angiography for the evaluation of stable CAD.Results: From our patients, 244 had neither type 2 diabetes (T2DM) nor significant CAD (i.e. coronary stenoses ≥50%) at the baseline angiography, 50 had T2DM but not significant CAD, 342 did not have T2DM but had significant CAD, and 114 had both T2DM and significant CAD. Nondiabetic patients without significant CAD had an event rate of 9.0%. The event rate was similar in T2DM patients without significant CAD (8.0%, P=0.951), but higher in nondiabetic patients with significant CAD (24.9%, P<0.001). Patients with T2DM and significant CAD had the highest event rate (43.0%). Importantly, T2DM patients without significant CAD had a significantly lower event rate than nondiabetic patients with significant CAD (P=0.008).Conclusion: T2DM per se is not a CAD risk equivalent. Moderate-risk diabetic patients without significant CAD and very high-risk diabetic patients with significant CAD add up to a grand total of high-risk diabetic patients, this is why diabetes seems to be a CAD risk equivalent in many epidemiological studies.

High prevalence of atrial fibrillation in long-term endurance cross-country skiers: echocardiographic findings and possible predictors – a 28–30 years follow-up study

Jostein Grimsmo, Irene Grundvold, Sverre Maehlum, Harald Arnesen — 2010-02-01

Background: Lone atrial fibrillation (LAF) seems to be more common in endurance-trained male athletes than in men in the general population. The reason for this has not been found.Aim: To determine the prevalence of LAF in long-term endurance cross-country skiers and to examine possible predictors.Methods: Of 149 healthy, long-term trained cross-country skiers from three different age groups who were invited, 122 and 117 participated in the studies in 1976 and 1981, respectively. At follow-up in 2004–2006, 78 men participated, with 33 in age group I (54–62 years), 37 in group II (72–80 years) and eight in group III (87–92 years), whereas 37 individuals had died and seven could not be tracked. The examination programme applied in 1976, 1981 and 2004–2006 consisted of an electrocardiographic monitoring during rest and exercise and a maximal exercise test. Echocardiography was performed in 2004–2006.Results: A high prevalence (12.8%) of LAF was found. The only predictor from both 1976 and 1981 associated with LAF was a long PQ time (r=0.38, P=0.001 and r=0.27, P=0.02, respectively), whereas bradycardia was another predictor from 1981 (r=0.29, P=0.012). At follow-up, left atrial enlargement was a marker associated with LAF (P<0.001).Conclusion: Long PQ time, bradycardia and left atrial enlargement seem to be important risk factors for LAF among long-term endurance cross-country skiers.

What is the predictive value of established risk factors for total and cardiovascular disease mortality when measured before middle age? Pooled analyses of two prospective cohort studies from Scotland

Linsay Gray, Carole L. Hart, George Davey Smith, G. David Batty — 2010-02-01

Aims: To examine the association of physiological, behavioural and social characteristics in pre-middle age with future total and cardiovascular disease (CVD) mortality.Methods and results: Risk factor data on 1503 individuals aged 16–35 years at baseline were collected in two prospective cohort studies using standard protocols. Their association with total and CVD mortality ascertained during 40 years of follow-up was summarized using Cox proportional hazards regression. A median follow-up of 39.6 years gave rise to 255 deaths (103 from CVD). In age-adjusted and sex-adjusted analyses, impaired lung function [one standard deviation increases in forced expiratory volume in 1s: hazards ratio 0.69; 95% confidence interval 0.55, 0.86; and in forced vital capacity: 0.76; 0.59, 0.98], current cigarette smoking (4.16; 2.22, 7.80) and higher alcohol consumption (one standard deviation increase in standard units consumed: 1.20; 1.02, 1.41) were associated with CVD. In fully adjusted analyses associations generally held. For total mortality, these factors and obesity and socioeconomic disadvantage were predictive.Conclusion: A range of risk factors measured before middle age were related to risk of total and CVD mortality up to four decades later, indicating that public health interventions should be implemented earlier in the life course than is currently the case.

Major life events increase the risk of stroke but not of myocardial infarction: results from the Copenhagen City Heart Study

2010-02-01

Background: More attention has been paid to psychosocial conditions as possible risk factors for cardiovascular disease (CVD) and the impact of accumulated major life events (MLE) on the development of CVD has received little attention.Design: The aim of this study was to explore the influences of MLE on CVD risk in a large cohort study.Methods: The study population consisted of 9542 randomly selected adults free of CVD examined in the Copenhagen City Heart Study in 1991–1994 and followed up for CVD defined as myocardial infarction or ischaemic stroke until 2001. MLE were analysed using an 11-item questionnaire and hazard ratios (HR) were calculated using the Cox proportional hazards model.Results: During follow-up there were 443 myocardial infarctions (MI) and 350 ischaemic strokes. Financial problems in both childhood and adulthood were associated with risk of stroke with an HR of 1.71 (95% CI: 1.29–2.26) and 1.60 (1.12–2.30), respectively. Accumulation of MLE was also associated with risk of stroke with HR reaching a maximum of 1.41 (95% CI: 1.06–1.90) for more than one event in childhood and 1.49 (95% CI: 1.09–2.04) for more than one event in adulthood. MLE accumulated over a life course showed a dose–response relationship with stroke. Associations were somewhat attenuated by adjustment for vital exhaustion suggesting a mediating role, but not by adjustment for behavioural risk factors. There were no associations between MLE and MI.Conclusion: In this population-based cohort study, we found that MLE conveyed a moderately increased risk of stroke partly mediated through vital exhaustion. We found no association between MLE and the risk of MI.

Alcohol consumption and risk of cardiovascular disease among hypertensive women

2010-02-01

Aim: This study investigated the relation between alcohol consumption and the risk of cardiovascular disease (CVD) among 10530-hypertensive women from the EPIC-NL cohort.Methods and results: Alcohol consumption was assessed using a validated food-frequency questionnaire and participants were followed for occurrence of CVD. During 9.4 years follow-up, we documented 580 coronary heart disease (CHD) events and 254 strokes, 165 of which were ischemic. An inverse association (Ptrend=0.009) between alcohol consumption and risk of CHD was observed with a multivariate-adjusted hazard ratio of 0.72 (95% confidence interval: 0.52–1.01) for those consuming 70–139.9g alcohol/week compared to lifetime abstainers. Of different beverages, only red wine consumption was associated with a reduced risk of CHD. A U-shaped relation (P=0.08) was observed for total stroke with a hazard ratio of 0.65 (0.44–0.95) for consuming 5–69.9g alcohol/week compared with lifetime abstainers. Similar results were observed for ischemic stroke with a hazard ratio of 0.56 (0.35–0.89) for consuming of 5–69.9g alcohol/week.Conclusion: We conclude that moderate alcohol consumption is associated with a reduced risk of CHD among hypertensive women. Light alcohol consumption tended to be related to a lower risk of stroke. Current guidelines for alcohol consumption in the general population also apply to hypertensive women.