European Journal of Preventive Cardiology

Vascular inflammation plays a key role in the development of atherosclerosis and acute coronary syndrome (ACS), and pentraxin 3 (PTX3) is one of several novel, promising markers of inflammation. In addition, D-dimer might serve as a marker of thrombogenesis and a hypercoagulable state following plaque rupture. The present study assesses the prognostic utility of these two biomarkers as compared to high-sensitivity C-reactive protein (hsCRP) and B-type natriuretic peptide (BNP), in addition to conventional clinical risk factors for coronary heart disease in patients with suspected ACS.

Chest pain patients with suspected ACS (n = 871) were consecutively included in a prospective, observational study with a follow-up time of 84 months.

At 7-year follow-up, 332 patients had died and 203 had suffered an adverse troponin T-positive, non-fatal cardiac event. In the multivariate analysis, levels of PTX3 above 5.88 ng/mL (median) and D-dimer above 436 µg/L (lower limit upper quartile) independently predicted mortality (HR 1.60 [95% CI 1.10–2.33]; p = 0.014 and HR 1.83 [95% CI 1.20–2.78]; p = 0.005, respectively). Also, BNP levels above 310.75 pg/mL (lower limit upper quartile) (HR 2.16 [95% CI 1.37–3.42]; p = 0.001), but not hsCRP, independently predicted mortality. Only hsCRP and BNP also predicted future myocardial infarction (HR 1.59 [95% CI 1.05–2.40]; p = 0.029 and HR 1.91 [95% CI 1.10–3.31]; p = 0.021, respectively).

High levels of PTX3, D-dimer and BNP were found to be independent, long-term predictors of all-cause mortality in chest pain patients with a suspected ACS. hsCRP and BNP also predicted future myocardial infarction.

Despite the compelling evidence of the benefits of cardiac rehabilitation (CR) on risk factor modification, quality of life and mortality reduction, a significant proportion of eligible patients are not referred or do not participate. Factors influencing CR referral and participation are complex and are likely patient, referral system and clinician-related. Little is known about clinician-related factors, which include attitudes, values and beliefs towards CR, or how these factors affect patient referral and attendance. This review examines the current evidence in the literature in relation to clinicians' attitudes, values and beliefs about CR.

A review of the literature was conducted on studies in relation to clinicians' attitudes, values and beliefs toward CR. An expert consensus methodology was used to develop the concepts presented in this paper.

Besides guidelines, a range of other factors influence clinicians' view about CR. This review suggests that clinicians lacking cardiac qualifications may have limited knowledge and awareness of CR and its benefits. Low agreement among clinicians on who is more likely to benefit from CR was also identified. Clinicians' personal lifestyle and health belief, the availability and quality of local the CR programme, and the lack of a standard administrative process of referral can also hinder the referral of patients to CR.

Clinician-related factors are important to consider in relation to CR referral and participation. Education for clinicians, discussion of local services and the support of an efficacious system at programme and organisation levels are essential.

Aerobic interval training (AIT) and aerobic continuous training (ACT) both improve physical fitness (peak VO₂) in coronary artery disease patients. However, little is known about the long-term effects of AIT and ACT on peak VO₂ and exercise adherence.

This study is a randomized clinical multicenter trial.

In total, 163 patients were assessed after 12 weeks of AIT or ACT and 12 months after their enrollment. Physical fitness and physical activity measures served as the primary outcomes, and peripheral endothelial function, cardiovascular risk factors and quality of life (QoL) served as the secondary outcomes.

Twenty-six patients dropped out during the intervention; 11 were lost during the follow-up period. Dropouts (n = 37) consisted of more women (p = 0.001) compared to completers (n = 163). Physical fitness (VO₂, heart rate and workload at peak and at thresholds) and physical activity (steps, active energy expenditure [kcal], physical activity duration [minutes]) were preserved at the 1-year follow-up (p-time > 0.05) after both AIT and ACT (p-interaction > 0.05). Forty percent of patients showed increased peak VO₂, 52% showed increased active energy expenditure and 91.2% met the recommended levels of 150 minutes/week of moderate physical activity (p-group > 0.05). Further, peripheral endothelial function, QoL and cardiovascular risk factors, except systolic blood pressure (p-time < 0.05), remained stable (p-time > 0.05) after both AIT and ACT (p-interaction > 0.05).

The short-term improvements of center-based AIT and ACT on physical fitness, physical activity, peripheral endothelial function, cardiovascular risk factors and QoL are sustained after a 1-year follow-up period. The majority of patients (>90%) met the recommended physical activity levels of 150 minutes/week.

The clinical use of carotid intima media thickness (cIMT) requires normal values, which may be subject to variation of geographical factors, ethnicity or measurement details. The influence of these factors has rarely been studied. The aim of this study was to determine whether normative cIMT values and their association with event risk are generalizable across populations.

Meta-analysis of individual participant data.

From 22 general population cohorts from Europe, North America and Asia we selected subjects free of cardiovascular disease. Percentiles of cIMT and cIMT progression were assessed separately for every cohort. Cox proportional hazards models for vascular events were used to estimate hazard ratios for cIMT in each cohort. The estimates were pooled across Europe, North America and Asia, with random effects meta-analysis. The influence of geography, ethnicity and ultrasound protocols on cIMT values and on the hazard ratios was examined by meta-regression.

Geographical factors, ethnicity and the ultrasound protocol had influence neither on the percentiles of cIMT and its progression, nor on the hazard ratios of cIMT for vascular events. Heterogeneity for percentiles of cIMT and cIMT progression was too large to create meaningful normative values.

The distribution of cIMT values is too heterogeneous to define universal or regional population reference values. CIMT values vary widely between different studies regardless of ethnicity, geographic location and ultrasound protocol. Prediction of vascular events with cIMT values was more consistent across all cohorts, ethnicities and regions.

HeartQoL is a recently developed core health-related quality of life instrument for patients with coronary heart disease. The current study aims to investigate its association with patients’ coronary risk profile and to provide reference values for patients with coronary heart disease across Europe.

Analyses are based on the EUROASPIRE IV (EUROpean Action on Secondary and Primary prevention through Intervention to Reduce Events) cross-sectional survey.

Patients with a diagnosis of coronary heart disease were examined and interviewed six months to three years after their coronary event. The HeartQoL questionnaire was completed by 7261 coronary heart disease patients. Reference values were calculated and the association with the coronary risk profile was assessed.

Significantly worse outcomes were observed in higher-risk patient groups. Both metabolic and behavioural risk factors were associated with worse HeartQoL outcomes. Further, the HeartQoL scores decreased as the number of risk factors increased. The mean global reference values in males were 2.27 ± 0.65 (<60 years), 2.30 ± 0.61 (between 60 and 69 years) and 2.19 ± 0.64 (≥70 years). Likewise, in females, the respective global HeartQoL reference values were 2.02 ± 0.67, 2.01 ± 0.66 and 1.83 ± 0.70. The ceiling effect in males was 11.4%, 10.4% and 7.4% for the three age classes respectively, whereas in females the ceiling effect was 5.2%, 3.5% and 1.9%, respectively.

HeartQoL scores were associated with patients’ coronary risk profile. The reference values may help other researchers to interpret HeartQoL scores. Further research should focus on the minimal important difference needed to evaluate the effect of therapies and lifestyle changes.

In recent clinical guidelines, individuals with chronic kidney disease are considered to have a similar 10-year absolute risk of cardiovascular death as individuals with diabetes or established cardiovascular disease. There is limited evidence to support this claim.

We investigated the 10-year risk for cardiovascular death in individuals with moderate or severe chronic kidney disease (glomerular filtration rate of 30–60 or <30 mL/min/1.73 m², respectively) in a cohort of primary care health check-ups in Stockholm, Sweden (n = 295,191, 46% women, 4290 cardiovascular deaths during 10 years follow-up). We also assessed the risk associated with diabetes or cardiovascular disease. The inclusion criteria, exposure, study outcome and follow-up period adhered strictly to the definitions of the European Society of Cardiology guidelines.

The absolute 10-year risk of cardiovascular death was 3.9% and 14.0% in individuals with moderate and severe chronic kidney disease, respectively, but was substantially lower in women and in younger individuals. The risk in individuals with prevalent diabetes and cardiovascular disease was approximately two and three times higher compared to the risk estimate for moderate chronic kidney disease (hazard ratio (HR) 4.1, 95% confidence interval (CI) 3.8–4.5 and HR 6.2, 95% CI 5.7–6.7 vs. HR 2.3 95% CI 2.0–2.6, respectively) while the risk for individuals with severe chronic kidney disease appeared more congruent to that of diabetes and cardiovascular disease (HR 5.5, 95% CI 3.3–8.9).

Although moderate chronic kidney disease is an independent predictor for an increased 10-year risk of cardiovascular death, only those with severe chronic kidney disease had similar risk to those with diabetes or cardiovascular disease.

In contrast to structured, integrated risk assessment in primary care, unstructured risk factor screening outside primary care and corresponding recommendations to consult a general practitioner (GP) are often based on one abnormal value of a single risk factor. This study investigates the advantages and disadvantages of unstructured screening of blood pressure and cholesterol outside primary care.

After the baseline visit of the Netherlands Epidemiology of Obesity study (population-based prospective cohort study in persons aged 45–65 years, recruited 2008–2012) all participants received a letter with results of blood pressure and cholesterol, and a recommendation to consult a GP if results were abnormal. Four years after the start of the study, participants received a questionnaire about the follow-up of their results.

The study population consisted of 6343 participants, 48% men, mean age 56 years, mean body mass index 30 kg/m². Of all participants 66% had an abnormal result and, of these, 49% had a treatment indication based on the risk estimation system SCORE-NL 2006. Of the 25% of the participants who did not consult a GP, 40% had a treatment indication. Of the participants with an abnormal result 19% were worried, of whom 60% had no treatment indication.

In this population 51% of the participants with an abnormal result had unnecessarily received a recommendation to consult a GP, and 10% were unnecessarily worried. GPs should be informed about the complete risk assessment, and only participants at intermediate or high risk should receive a recommendation to consult a GP.

To simplify the assessment of the recording and control of coronary heart disease risk factors in different countries and regions.

The SUrvey of Risk Factors (SURF) is an international clinical audit.

Data on consecutive patients with established coronary heart disease from countries in Europe, Asia and the Middle East were collected on a one-page collection sheet or electronically during routine clinic visits. Information on demographics, diagnostic category, risk factors, physical and laboratory measurements, and medications were included and key variables summarized in a Cardiovascular Health Index Score.

Coronary heart disease patients (N = 10,186; 29% women) were enrolled from 79 centres in 11 countries. Recording of risk factors varied considerably: smoking was recorded in over 98% of subjects, while about 20% lacked data on laboratory measurements relevant to cardiovascular disease risk. Sixteen per cent of participants reported smoking, 29% were obese, and 46% had abdominal obesity. Sixty per cent of participants had blood pressure <140/90 mmHg (140/80 mmHg for diabetics), 48% had HbA1c<7%, 30% had low-density lipoprotein <1.8 mmol/l and 17% had a good cardiovascular health index score. There were substantial regional variations. Less than 3% of patients attended cardiac rehabilitation in Asia or the Middle East, compared with 45% in Europe. In Asia, 15% of patients had low-density lipoprotein cholesterol <1.8 mmol/l compared with 33% in Europe and 36% in the Middle East. Variations in medications were noted, with lower use of statins in Asia.

SURF proved to be practical in daily practice. Results indicated poor control of risk factors with substantial variation between countries, calling for development and implementation of clinical standards of secondary prevention of coronary heart disease.

Inflammation and leukocyte infiltration are hallmarks of atherosclerosis. Clinically routine hematology analyzers mostly perform an entire differential blood count by default, irrespective of the requested parameter. We hypothesize that these normally unreported leukocyte characteristics associate with coronary artery disease (CAD) severity and can improve prediction of mortality in coronary angiography patients.

We studied coronary angiography patients suspected of CAD (n = 1015) from the Utrecht Coronary Biobank cohort. Leukocyte characteristics were routinely assessed in blood drawn directly prior to angiography using an automated hematology analyzer and extracted from the Utrecht patient oriented database (UPOD) database. Patients were followed up for a median duration of 805 days, during which 65 patients died. We evaluated the association of leukocyte characteristics with synergy between PCI with taxus and cardiac surgery (SYNTAX) score as a measure of CAD severity, all-cause and cardiovascular mortality and major adverse cardiovascular events (MACEs). In order to determine the improvement of risk prediction, we calculated continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI).

Monocyte percentage showed strong independent predictive value for all-cause mortality (hazard ratio (HR) 1.44 (1.19–1.74), p < 0.001), and the monocyte-to-lymphocyte ratio performed best for cardiovascular mortality (HR 1.42 (1.11–1.81), p = 0.005). The cNRIs and IDIs of leukocyte characteristics for all-cause mortality confirmed the improvement in mortality risk prediction. No significantly predictive leukocyte characteristics were found for MACEs.

Readily available yet unreported leukocyte characteristics from routine hematology analyzers significantly improved prediction of mortality in coronary angiography patients on top of clinical characteristics.

Cardiorespiratory fitness is a well-established independent predictor of cardiovascular health. However, the relevance of alternative exercise and non-exercise tests for cardiorespiratory fitness assessment in large cohorts has not been studied in detail. We aimed to evaluate the YMCA-step test and the Veterans Specific Activity Questionnaire (VSAQ) for the estimation of cardiorespiratory fitness in the general population.

One hundred and five subjects answered the VSAQ, performed the YMCA-step test and a maximal cardiopulmonary exercise test (CPX) and gave BORG ratings for both exercise tests (BORG_STEP, BORG_CPX). Correlations of peak oxygen uptake on a treadmill (VO_{2_PEAK}) with VSAQ, BORG_STEP, one-minute, post-exercise heartbeat count, and peak oxygen uptake during the step test (VO_{2_STEP}) were determined. Moreover, the incremental values of the questionnaire and the step test in addition to other fitness-related parameters were evaluated using block-wise hierarchical regression analysis.

Eighty-six subjects completed the step test according to the protocol. For completers, correlations of VO_{2_PEAK} with the age- and gender-adjusted VSAQ, heartbeat count and VO_{2_STEP} were 0.67, 0.63 and 0.49, respectively. However, using hierarchical regression analysis, age, gender and body mass index already explained 68.8% of the variance of VO_{2_PEAK}, while the additional benefit of VSAQ was rather low (3.4%). The inclusion of BORG_STEP, heartbeat count and VO_{2_STEP} increased R² by a further 2.2%, 3.3% and 5.6%, respectively, yielding a total R² of 83.3%.

Neither VSAQ nor the YMCA-step test contributes sufficiently to the assessment of cardiorespiratory fitness in population-based studies.

Sports-related sudden cardiac deaths (SrSCDs) occur most frequently in highly dynamic and/or static sports. We aimed to assess the incidence and characteristics of SrSCDs in Switzerland and to compare SrSCD occurrence according to sports categories with the sports participation behaviour in the general population.

Between 1999 and 2010, forensic reports of SrSCDs in young individuals (10–39 years of age) were retrospectively reviewed and categorised based on peak static (increasing from I to III) and dynamic sports components (increasing from A to C). Data were compared to the sports participation behaviour of the Swiss population.

Sixty-nine SrSCDs were identified. Forty-eight (69.6%) occurred during recreational sports (REC) and 21 (30.4%) during competitive sports (COMP). Incidences (per 100,000 athlete person-years) for COMP and REC were 0.90 and 0.52, respectively (p = 0.001). Most SrSCDs occurred in IC (23 cases, 33.3%), followed by IIC (13, 18.9%), IIIA and IIIC (11 each, 15.9%), IIIB (6, 8.7%), IIA (4, 5.8%) and IB sports categories (1, 1.5%). No SrSCDs were found in IA and IIB sports categories. Incidences between sports categories (IIIA 0.25, IB 0.25, IC 0.18, IIC 0.33 and IIIC 0.25) were not significantly different except to IIA (0.94, p < 0.001), due to the fact that few people were involved in this sports category. Coronary artery disease (CAD) was the most common underlying pathology of SrSCD.

In this Swiss cohort, incidence of SrSCD was very low and similar in all sports categories classified by their static and dynamic components. However, the incidence was higher in COMP compared to REC, and CAD proved to be the most common underlying cause of SrSCD.