European Journal of Preventive Cardiology

Limited research studies with a large sample size were performed to evaluate the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for in-hospital or long-term poor outcomes in patients with infective endocarditis.

A total of 703 patients with infective endocarditis were enrolled and divided into four groups according to admission NT-pro-BNP (pg/mL) quartiles: Q1 (<258), Q2 (258–1054), Q3 (1055–3522) and Q4 (>3522). Multivariate regression was used to determine independent risk of NT-proBNP for in-hospital and one-year death.

In-hospital death occurred in 9.0% of patients. The in-hospital mortality was increased from the lowest to the highest NT-proBNP quartiles (1.1%, 3.4%, 9.1% and 22.3%, P < 0.001, respectively). During the one-year follow-up period, 29 patients died: 0 in Q1, 7 (4.6%) in Q2, 8 (5.7%) in Q3 and 14 (12.0%) in Q4 (P < 0.001). Log-transformed (lg) NT-proBNP had a linear correlation with lg C-reactive protein (r = 0.308, P < 0.001). Multivariate analysis showed lgNT-proBNP was an independent predictor for both in-hospital (odds ratio 4.59, 95% confidence interval (CI) 2.45–8.61, P < 0.001) and one-year mortality (hazard ratio 3.11, 95% CI 1.65–5.87, P < 0.001). In addition, NT-proBNP had a higher predictive power for in-hospital death than C-reactive protein (area under the curve 0.797 vs. 0.670, P = 0.005). NT-proBNP > 2260 pg/mL had 76.2% sensitivity and 69.1% specificity for predicting in-hospital death. Kaplan–Meier analysis showed that patients with NT-proBNP > 2260 pg/ml had a worse prognosis than those without (log-rank test 18.84, P < 0.001).

Increased NT-proBNP was independently associated with in-hospital and one-year mortality in patients with infective endocarditis.

Aortic stenosis is a valvular heart disease characterised by fixed obstruction of the left ventricular outflow. It can be managed by surgical aortic valve replacement (sAVR) or transcatheter aortic valve implantation (TAVI). This review aimed to describe the evidence supporting a cardiac rehabilitation programme on functional capacity and quality of life in aortic stenosis patients after sAVR or TAVI.

The search was conducted on multiple databases from January to March 2016. All studies were eligible that evaluated the effects of a post-interventional cardiac rehabilitation programme in aortic stenosis patients. The methodological quality was assessed using the PEDro scale. Meta-analysis was performed separately by procedure and between procedures. The walked distance during the six-minute walk test (6MWD) and Barthel index were evaluated. The analysis was conducted in Review Manager.

Five studies were included (292 TAVI and 570 sAVR patients). The meta-analysis showed that a cardiac rehabilitation programme was associated with a significant improvement in 6MWD (0.69 (0.47, 0.91); P < 0.001) and Barthel index (0.80 (0.29, 1.30); P = 0.002) after TAVI and 6MWD (0.79 (0.43, 1.15); P < 0.001) and Barthel index (0.93 (0.67, 1.18); P < 0.001) after sAVR. In addition, the meta-analysis showed that the cardiac rehabilitation programme promoted a similar gain in 6MWD (4.28% (−12.73, 21.29); P = 0.62) and Barthel index (−1.52 points (−4.81, 1.76); P = 0.36) after sAVR or TAVI.

The cardiac rehabilitation programme improved the functional capacity and quality of life in aortic stenosis patients. Patients who underwent TAVI benefitted with a cardiac rehabilitation programme similar to sAVR patients.

While cardiac rehabilitation in patients with ischaemic heart disease and heart failure is considered cost-effective, this evidence may not be transferable to heart valve surgery patients. The aim of this study was to investigate the cost-effectiveness of cardiac rehabilitation following heart valve surgery.

We conducted a cost–utility analysis based on a randomised controlled trial of 147 patients who had undergone heart valve surgery and were followed for 6 months.

Patients were randomised to cardiac rehabilitation consisting of 12 weeks of physical exercise training and monthly psycho-educational consultations or to usual care. Costs were measured from a societal perspective and quality-adjusted life years were based on the EuroQol five-dimensional questionnaire (EQ-5D). Estimates were presented as means and 95% confidence intervals (CIs) based on bootstrapping. Costs and effect differences were presented in a cost-effectiveness plane and were transformed into net benefit and presented in cost-effectiveness acceptability curves.

No statistically significant differences were found in total societal costs (–1609 Euros; 95% CI: –6162 to 2942 Euros) or in quality-adjusted life years (–0.000; 95% CI –0.021 to 0.020) between groups. However, approximately 70% of the cost and effect differences were located below the x-axis in the cost-effectiveness plane, and the cost-effectiveness acceptability curves showed that the probability for cost- effectiveness of cardiac rehabilitation compared to usual care is at minimum 75%, driven by a tendency towards costs savings.

Cardiac rehabilitation after heart valve surgery may not have improved health-related quality of life in this study, but is likely to be cost-effective for society, outweighing the extra costs of cardiac rehabilitation.

The aim of the study was to evaluate the impact of compliance with lifestyle recommendations and medication on 1-year prevention of major adverse cardiovascular events (MACE) in patients with type 2 diabetes (T2D) after trans-femoral amputation (TFA).

In this prospective single-center interventional cohort study, 179 consecutive T2D patients with symptomatic coronary artery disease (CAD) underwent 1-year follow-up examination after TFA in 2013. Lower limb and coronary artery CT angiography were provided before surgery; physical examination and laboratory tests were performed at baseline and every month after TFA for 1 year. A total of 77 patients (43%) were defined as compliant. They followed all recommendations, including >80% drug intake (anti-diabetic, antihypertensive drugs, dual antiplatelet and statin treatment), healthy diet, smoking cessation, physical exercise ≥30 min/day. A total of 102 patients (57%) were non-compliant (drug intake ≤80%, and did not fully follow lifestyle change recommendations).

There were no significant differences at baseline between the two groups. Fuster-BEWAT score in 1 year was 9.83 ± 3.1 in compliant and 7.74 ± 2.9 in non-compliant patients (p = 0.0001). At 1-year follow-up, there were 43 myocardial infarctions (40 patients (93%) were non-compliant) and 28 deaths (26 cases (92.8%) were non-compliant). Patients from the non-compliant group with three- and two-vessel obstructive CAD had higher 1-year MACE rate than those with one-vessel obstructive and non-obstructive CAD (95.24% and 70.5% versus 17.2% and 8.6%; p < 0.0001); more proximal coronary lesions were related to a worse prognosis.

Non-compliant diabetic patients had a tenfold increased risk for MACE within 1 year after TFA.

Chronic Rheumatic Heart disease (RHD) continues to be a health problem in many low and middle income countries and especially in sub-Saharan Africa. Echocardiography has shown that the disease is far more widespread than may be detected by clinical assessment, but data are lacking on the prevalence and epidemiological features in rural Africa.

Community-based prevalence survey

We used transthoracic echocardiography to carry out a population-based study of RHD in a rural area of Ethiopia. A total of 987 participants aged 6 to 25 were selected by cluster sampling. The prevalence of RHD was assessed by the current consensus World Heart Federation criteria.

There were 37 definite cases of RHD and a further 19 borderline cases giving an overall prevalence of 37.5 cases per 1000 population (95% CI 26.9–51.8) rising to 56.7 (95% CI 43.9–73.5) if the borderline cases are included. The prevalence of definite disease rose to a peak of 60 cases per 1000 in those aged 16–20 years before falling to 11 cases per 1000 in subjects aged 21–25 years. Of the 37 with definite disease, 36 had evidence of mitral valve and seven evidence of aortic valve disease.

RHD has a high prevalence in rural Ethiopia. Although follow-up is needed to determine how the disease develops with advancing age, the data provide evidence that the disease is an important health problem in rural sub-Saharan Africa requiring urgent concerted action.

The high risk of recurrent events in patients with reduced renal function following an acute coronary syndrome (ACS) may in part be due to suboptimal secondary prevention. We aimed to describe the association between renal dysfunction and the prescription, initiation and persistent use of secondary prevention during the first year after a first ACS.

We identified all patients admitted to any Swedish coronary care unit for a first ACS between 2005 and 2010 (n = 77,432). In 75,129 patients, creatinine levels were available in order to obtain the estimated glomerular filtration rate (eGFR). Persistent use of prescribed drugs was determined for 1 year using the National Prescription Registry, with complete coverage of all prescribed and dispensed drugs in Sweden.

After adjustment for relative and absolute contraindications, compared to patients with eGFR ≥ 60 mL/min/1.73 m², patients with eGFR 30–59 had higher odds of not being prescribed acetylsalicylic acid (ASA; odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.47–1.67), statins (OR: 2.94, 95% CI: 2.86–3.13) or β-blockade (OR: 1.25, 95% CI: 1.18–1.32). Patients with eGFR 30–59 were more likely to discontinue treatment with ASA (hazard ratio [HR]: 1.59, 95% CI: 1.42–1.56), statins (HR: 1.35, 95% CI: 1.29–1.41), angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers (HR: 1.37, 95% CI: 1.31–1.43) or β-blockade (HR: 1.22, 95% CI: 1.18–1.27). Patients with eGFR < 30 showed a similar pattern in both prescription and discontinuation.

High-risk ACS patients with reduced renal function are less likely to be prescribed secondary prevention drugs at discharge, are less likely to initiate treatment when being prescribed these drugs, are less likely to be persistent in the use of these drugs and more often discontinue treatment.

The relationships between dietary intake of soy foods and risk of cardiovascular disease are uncertain. The aims of this study were to evaluate and summarize the evidence on the association between consumption of soy and risk of cardiovascular disease (including stroke and coronary heart disease).

We systematically searched the MEDLINE and EMBASE databases from their inception up to 22 February 2016. We included only observational studies, and used random-effects models to calculate summary relative risks (SRRs) and 95% confidence intervals (CIs).

A total of 10 prospective cohort and seven case-control studies met the inclusion criteria. There were a total of 17,269 cardiovascular disease events, including 6265 stroke events, 10,806 coronary heart disease events, and 198 other cardiovascular disease events. A significant negative association was shown between soy intake and risk of cardiovascular disease (SRR = 0.84 95% CI: 0.75–0.94; p_{heterogeneity}<0.001, I²= 71.4%). Subgroup meta-analyses indicated that a statistically significant protective effect was primarily observed in case-control studies and in Asian populations. There was a borderline significant association between intake of tofu and the risk of cardiovascular disease (SRR = 0.80, 95% CI: 0.64–1.00). A significant negative association was shown for the association between soy intake and risk of stroke (SRR = 0.82, 95% CI: 0.68–0.99) and coronary heart disease (SRR = 0.83, 95% CI: 0.72–0.95). There were no associations between soy isoflavones consumption and risk of cardiovascular disease, stroke, and coronary heart disease.

Overall evidence indicated that consumption of soy was negatively associated with the risk of cardiovascular disease, stroke, and coronary heart disease risk.

Resting heart rate is an established risk factor for cardiovascular disease, but long-term individual resting heart rate trajectories and their effect on cardiovascular disease morbidity and mortality have not yet been described.

This large population-based longitudinal study included 14,208 men and women aged 20 years or older, not pregnant and not using blood pressure medications, who attended at least two of the three Tromsø Study surveys conducted between 1986–2001. Resting heart rate was measured using an automated Dinamap device. Participants were followed up from 2001 to 2012 with respect to myocardial infarction, atrial fibrillation, ischaemic stroke, cardiovascular disease death and total death. The Proc Traj statistical procedure was used to identify resting heart rate trajectories.

Five common long-term resting heart rate trajectories were identified: low, moderate, decreasing, increasing and elevated. In men, an elevated resting heart rate trajectory was independently associated with an increased risk of myocardial infarction when low resting heart rate trajectory was used as a reference (hazard ratio 1.83, 95% confidence interval 1.11–3.02). Risk of total death in men was lowest in the low resting heart rate trajectory group and highest in the increasing and elevated resting heart rate trajectory groups. In women, the association between resting heart rate trajectories and myocardial infarction was similar to that in men, but it was not significant.

Among the five long-term resting heart rate trajectories we identified, increasing and elevated trajectories were associated with an increased risk of myocardial infarction and total death in men. Our results suggest that changes in long-term individual resting heart rate in the general population may provide additional prognostic information.

Patient activity (PA) has been demonstrated to predict all-cause mortality. However, the association between PA and cardiac death is unclear.

The aims of this study were to determine whether PA can predict cardiac death and what is the cut-off of PA to discriminate cardiac death, as well as the mechanism underlying the relationship between PA and survival in patients with home monitoring.

This study retrospectively analysed clinical and implantable cardioverter-defibrillator/cardiac resynchronization therapy defibrillator device data in 845 patients. Data regarding PA and PP variability during the first 30–60 days of home monitoring were collected, and mean values were calculated. The primary endpoint was cardiac death, and the secondary endpoint was all-cause mortality.

The mean PA percentage was 11 ± 5.8%. Based on receiver operating characteristic curve analysis, we determined that a PA cut-off value of 7.84% (113 min) can predict cardiac death. During a mean follow-up period of 31.1 ± 12.9 months (ranging from three to 60 months), PA ≤ 7.84% was associated with increased risks of cardiac death in an unadjusted analysis; after adjusting in a multivariate Cox model, the relationship remained significant between PA≤7.84% and cardiac death (hazard ratio = 3.644, 95% confidence interval = 2.424–5.477, p < 0.001). Moreover, a significant correlation was observed between PA and PP variability (r = 0.601, p < 0.001).

A baseline PA ≤ 7.84% was associated with a higher risk of cardiac death in patients who have survived more than three months after implantable cardioverter-defibrillator/cardiac resynchronization therapy defibrillator implantation. PA had a sizable effect on heart rate variability, reflecting autonomic function.

Guidelines for the prevention of cardiovascular disease recommend the estimation of an individual’s total risk. We have developed a new model for the prediction of the 10-year risk of incident acute myocardial infarction or cerebral stroke based on Norwegian data, NORRISK 2.

The model was based on 10-year follow-up of a large population-based cohort (CONOR) through linkage to the CVDNOR project, a database of cardiovascular disease hospital discharge diagnoses and mortality in Norway in 1994–2009.

We used the Fine and Gray regression model to estimate the 10-year risk adjusting for competing risk. The model population consisted of participants in 1994–1999 and the external validation population of participants in 2000–2003. We validated the model by area under the receiver operating characteristic curves, calibration plots and analyses of sensitivity and specificity.

The model population consisted of 31,445 men and 35,267 women aged 40–79 years with 3658 endpoints in men and 2459 in women. The external validation population consisted of 19,980 men and 19,309 women, of whom 1858 men and 874 women had an endpoint during follow-up. The area under the curve was 0.79 (0.79–0.80) in men and 0.84 (0.83–0.85) in women in the model population and was slightly lower in the external validation population. Calibration plots showed good agreement between observed and predicted risk. The sum of sensitivity and specificity was greatest around the suggested risk thresholds.

The NORRISK 2 model showed good validity in an external dataset and will be a valuable tool to guide decisions about preventive interventions in people without known previous cardiovascular disease.