Abstract
The News and Notices section is published in every issue of the European Journal of Cardiovascular Prevention and Rehabilitation. It provides readers with details of current affairs, the best of what is being published in other journals and upcoming events for your diaries. Readers are invited to submit material, upcoming events and training opportunities to the News Editors.
Professor Pantaleo Giannuzzi
Salvatore Maugeri Foundation IRCCS, Cardiology Department Medical Centre of Veruno Via Revislate 131–28010 Veruno, Italy Tel: +39 0322 884711 Fax: 32 0322 884816 E-mail:
Professor Annika Rosengren
The Cardiovascular Institute Gr för kardiovascular forskn Medicin, plan 2 CK SU/Östra 416 85 Göteborg, Sweden Tel: +46 31 343 4086 Fax: +46 31 259 254 E-mail:
Newsworthy…
In western populations, high levels of HDL-cholesterol are associated with a lower risk of cardiovascular disease. Low levels of HDL are found in individuals with unfavourable risk factors such as abdominal obesity, hypertension, impaired glucose tolerance and diabetes. However, surprisingly, a case–control study of hypertension (339 hypertensive cases, 272 normotensive controls) conducted in a predominantly rural Chinese population, the Uygur, who also have a markedly low prevalence of hypertension (less than 10%) found that HDL levels of hypertensive participants were significantly higher than normotensive participants after adjustment for age and sex (1.15 versus 1.12 mmol/l, P = 0.001). After adjustment for related variables, the HDL levels increased slightly with age, body mass index and fasting glucose (all P < 0.001) in normotensive participants and increased with age among hypertensive participants (P < 0.0001). The authors could offer no explanation for this slightly perplexing finding, but concluded that further study is needed on the environmental and genetic determinants of the HDL distribution as well as their association with coronary heart disease in the Uygur population.
Yan W, et al. High-density lipoprotein cholesterol levels increase with age, body mass index, blood pressure and fasting blood glucose in a rural Uygur population in China. J Hypertens 2005;
Babies who are big or who grow rapidly may be at increased risk of adult obesity
Prevention is important in halting the increasing prevalence of obesity in the population. Some evidence has suggested that faster growth during childhood is associated with an increased risk of obesity in later life, and if so, this might be of importance in preventing adult obesity. A systematic review from the University of Southampton retrospectively reviewed data from 24 studies that had analysed the relationships between infant size or growth during the first 2 years of life and subsequent obesity. Of these, 18 assessed the relationship between infant size and subsequent obesity, most showing that infants who were defined as ‘obese’ or who were at the highest end of the distribution for weight or body mass index were at an increased risk of obesity. Compared with non-obese infants, in those who had been obese odds ratios or relative risks for subsequent obesity ranged from 1.35 to 9.38. Ten studies assessed the relationship of infant growth with subsequent obesity and most showed that infants who grew more rapidly were at an increased risk of obesity. Compared with other infants, in infants with rapid growth odds ratios relative risks of later obesity ranged from 1.17 to 5.70. The authors concluded that babies who are at the highest end of the distribution for weight or body mass index or who grow rapidly during infancy are at an increased risk of subsequent obesity. Future research needs to investigate the determinants of early growth, and whether these factors are amenable to change.
Baird J, et al. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ 2005;
Pulse pressure may best predict cardiovascular death
Pulse pressure may be more closely linked to cardiovascular mortality than either systolic or diastolic blood pressure. In yet another analysis from the classic Seven Countries Study the association of blood pressure measurements with mortality from among different male populations of the world was investigated. A total of 12 763 men, aged 40–59 years, from seven countries (United States, Japan, Italy, Greece, former Yugoslavia, Finland, and The Netherlands) were surveyed from 1958 to 1964. Follow-up for vital status and causes of death was carried out over 25 years. Men living in Japan had the lowest systolic and diastolic blood pressure, but also the highest pulse pressure, calculated as systolic minus diastolic blood pressure. All baseline blood pressure measurements were the best predictors of cardiovascular disease mortality, compared with other conventional risk factors. The age-adjusted hazard ratio per 10-mmHg increase in pulse pressure varied among cohorts from 1.19 in the United States to 1.29 in southern Europe. Differences among cohorts were not significant. In the pooled cohorts, pulse pressure measurements were also a significant predictor of coronary heart disease (hazard ratio per 10-mmHg increase, 1.15) as well as stroke death (hazard ratio per 10-mmHg increase, 1.32). For every 10-mmHg increase in pulse pressure a 22% increase in the hazard ratio of cardiovascular death was observed. Overall, the adjusted 25-year survival of men in the highest third of pulse pressure at baseline (> 60 mmHg) was less than 70%, whereas survival in those with lower values was approximately 80% (P = 0.007). The investigators concluded that pulse pressure followed by diastolic and systolic blood pressures were the best predictors of cardiovascular disease mortality among other blood pressures, as well as age, physical activity, total serum cholesterol level, anthropometric indices, and smoking habits. In addition, although mortality rates differed among populations, no significant interaction was observed between blood pressure level and region in the effect on mortality. The follow-up in the Seven Countries Study was terminated 15–20 years ago, so more recent data are needed, as are data in women.
Panagiotakos DB, et al. The relation between pulse pressure and cardiovascular mortality in 12 763 middle-aged men from various parts of the world: a 25-year follow-up of the Seven Countries Study. Arch Intern Med 2005;
The prognostic value of circulating endothelial progenitor cells
Endothelial progenitor cells derived from bone marrow are believed to support the integrity of the vascular endothelium. The number and function of endothelial progenitor cells correlate inversely with cardiovascular risk factors, but the prognostic value associated with circulating endothelial progenitor cells has not been defined.
The number of endothelial progenitor cells positive for CD34 and kinase insert domain receptor was determined with the use of flow cytometry in 519 patients with coronary artery disease as confirmed on angiography. After 12 months, the study investigated the association between baseline levels of endothelial progenitor cells and death from cardiovascular causes, the occurrence of a first major cardiovascular event (myocardial infarction, hospitalization, revascularization, or death from cardiovascular causes), revascularization, hospitalization, and death from all causes.
A total of 43 participants died, 23 from cardiovascular causes. A first major cardiovascular event occurred in 214 patients. The cumulative event-free survival rate increased stepwise across three increasing baseline levels of endothelial progenitor cells in an analysis of death from cardiovascular causes, a first major cardiovascular event, revascularization, and hospitalization. After adjustment for age, sex, vascular risk factors, and other relevant variables, increased levels of endothelial progenitor cells were associated with a reduced risk of death from cardiovascular causes [hazard ratio (HR) 0.31, 95% confidence interval (CI) 0.16–0.63, P = 0.001], a first major cardiovascular event (HR 0.74, 95% CI 0.62–0.89, P = 0.002), revascularization (HR 0.77, 95% CI 0.62–0.95, P = 0.02), and hospitalization (HR 0.76, 95% CI 0.63–0.94, P = 0.01). Endothelial progenitor cell levels were not predictive of myocardial infarction or of death from all causes.
Therefore, the level of circulating CD34 + KDR + endothelial progenitor cells predicts the occurrence of cardiovascular events and death from cardiovascular causes and may help to identify patients at increased cardiovascular risk.
Nikos Werner, et al. Circulating endothelial progenitor cells and cardiovascular outcomes. TV Engl J Med 2005;
Early invasive versus selectively invasive management for acute coronary syndromes
Current guidelines recommend an early invasive strategy for patients who have acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level. However, randomized trials have not shown an overall reduction in mortality, and the reduction in the rate of myocardial infarction in previous trials has varied depending on the definition of myocardial infarction.
This study randomly assigned 1200 patients with acute coronary syndrome without ST-segment elevation who had chest pain, an elevated cardiac troponin T level (> 0.03 μg/l), and either electrocardiographic evidence of ischemia at admission or a documented history of coronary disease to an early invasive strategy or to a more conservative (selectively invasive) strategy. Patients received aspirin daily, enoxaparin for 48 h, and abciximab at the time of percutaneous coronary intervention. The use of clopidogrel and intensive lipid-lowering therapy was recommended. The primary endpoint was a composite of death, non-fatal myocardial infarction, or rehospitalization for anginal symptoms within 1 year after randomization.
The estimated cumulative rate of the primary endpoint was 22.7% in the group assigned to early invasive management and 21.2% in the group assigned to selectively invasive management (relative risk 1.07, 95% confidence interval 0.87–1.33, P = 0.33). The mortality rate was the same in the two groups (2.5%). Myocardial infarction was significantly more frequent in the group assigned to early invasive management (15.0 versus 10.0%, P = 0.005), but rehospitalization was less frequent in that group (7.4 versus 10.9%, P = 0.04).
The study could thus not demonstrate that, given optimized medical therapy, an early invasive strategy was superior to a selectively invasive strategy in patients with acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level.
Robbert J. de Winter, et al. Early invasive versus selectively invasive management for acute coronary syndromes. TV Engl J Med 2005;
Fasting plasma glucose levels and type 2 diabetes in young men
The normal fasting plasma glucose level was recently defined as less than 100 mg/dl (5.55 mmol/l). Whether higher fasting plasma glucose levels within this range independently predict type 2 diabetes in young adults is unclear.
The authors obtained blood measurements, data from physical examinations, and medical and lifestyle information from men in the Israel Defence Forces who were 26–45 years of age.
A total of 208 incident cases of type 2 diabetes occurred during 74 309 person-years of follow-up (from 1992 to 2004) among 13 163 subjects who had baseline fasting plasma glucose levels of less than 100 mg/dl. A multivariate model, adjusted for age, family history of diabetes, body mass index (the weight in kilograms divided by the square of the height in meters), physical activity level, smoking status, and serum triglyceride levels, revealed a progressively increased risk of type 2 diabetes in men with fasting plasma glucose levels of 87 mg/dl (4.83 mmol/l) or more, compared with those whose levels were in the bottom quintile [less than 81 mg/dl (4.5 mmol/l), P for trend < 0.001]. In multivariate models, men with serum triglyceride levels of 150 mg/dl (1.69 mmol/l) or more, combined with fasting plasma glucose levels of 91–99 mg/dl (5.05–5.50 mmol/l), had a hazard ratio of 8.23 [95% confidence interval (CI) 3.6–19.0] for diabetes, compared with men with a combined triglyceride level of less than 150 mg/dl and fasting glucose levels of less than 86 mg/dl (4.77 mmol/l). The joint effect of a body mass index of 30 or more and a fasting plasma glucose level of 91–99 mg/dl resulted in a hazard ratio of 8.29 (95% CI 3.8–17.8), compared with a body mass index of less than 25 and a fasting plasma glucose level of less than 86 mg/dl.
Therefore, higher fasting plasma glucose levels within the normoglycemic range constitute an independent risk factor for type 2 diabetes among young men, and such levels may help, along with body mass index and triglyceride levels, to identify apparently healthy men at an increased risk of diabetes.
Amir Tirosh, et al. Normal fasting plasma glucose levels and type 2 diabetes in young men. N Engl J Med 2005;
Efficacy and safety of cholesterol-lowering treatment
The results of previous randomized trials have shown that interventions that lower LDL-cholesterol concentrations can significantly reduce the incidence of coronary heart disease and other major vascular events in a wide range of individuals. However, each separate trial has limited power to assess particular outcomes or particular categories of participant.
A prospective meta-analysis of data from 90 056 individuals in 14 randomized trials of statins was performed. Weighted estimates were obtained of the effects on different clinical outcomes per 1.0 mmol/l reduction in LDL-cholesterol.
During a mean of 5 years, there were 8186 deaths, 14 348 individuals had major vascular events, and 5103 developed cancer. Mean LDL-cholesterol differences at one year ranged from 0.35 to 1.77 mmol/l (mean 1.09) in these trials. There was a 12% proportional reduction in all-cause mortality per mmol/l reduction in LDL-cholesterol [rate ratio (RR) 0.88, 95% confidence interval (CI) 0.84–0.91, P < 0.0001]. This reflected a 19% reduction in coronary mortality (RR 0.81, 95% CI 0.76–0.85, P < 0.0001), and non-significant reductions in non-coronary vascular mortality (RR 0.93, 95% CI 0.83–1.03, P = 0.2) and nonvascular mortality (RR 0.95, 95% CI 0.90–1.01, P = 0.1). There were corresponding reductions in myocardial infarction or coronary death (RR 0.77, 95% CI 0.74–0.80, P < 0.0001), in the need for coronary revascularization (RR 0.76, 95% CI 0.73–0.80, P < 0.0001), in fatal or non-fatal stroke (RR 0.83, 95% CI 0.7–0.88, P < 0.0001), and, combining these, of 21% in any such major vascular event (RR 0.79, 95% CI 0.77–0.81, P < 0.0001). The proportional reduction in major vascular events differed significantly (P < 0.0001) according to the absolute reduction in LDL-cholesterol achieved, but not otherwise. These benefits were significant within the first year, but were greater in subsequent years. Taking all years together, the overall reduction of approximately one-fifth per mmol/l LDL-cholesterol reduction translated into 48 (95% CI 39–57) fewer participants having major vascular events per 1000 among those with pre-existing coronary heart disease at baseline, compared with 25 (95% CI 19–31) per 1000 among participants with no such history. There was no evidence that statins increased the incidence of cancer overall (1.00, 0.95–1.06, P = 0.9) or at any particular site.
Statin therapy can safely reduce the 5-year incidence of major coronary events, coronary revascularization, and stroke by approximately one-fifth per mmol/l reduction in LDL-cholesterol, largely irrespective of the initial lipid profile or other presenting characteristics. The absolute benefit relates chiefly to an individual's absolute risk of such events and to the absolute reduction in LDL-cholesterol achieved. These findings reinforce the need to consider prolonged statin treatment with substantial LDL-cholesterol reductions in all patients at high risk of any type of major vascular event.
Baigent C, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins. Lancet 2005;