Plasma amyloid-beta in relation to cardiac function and risk of heart failure in the general population

Background

Amyloid-β is a major hallmark of Alzheimer's disease, and its pathology has been hypothesized as a multiple organ syndrome that may also affect cardiac function. There are limited data on association of plasma amyloid-β with cardiac dysfunction and risk of HF in the general population.

Objective

To determine the association of plasma amyloid-β40 (Aβ40) and amyloid-β42 (Aβ42) with echocardiographic measurements of cardiac dysfunction, and with incident heart failure (HF) in the general population.

Methods

We included 4156 participants of the population-based cohort (mean age 71.4 years, 57.1% women), who had plasma amyloid-β measured between 2002 and 2005, and were free of dementia and HF at baseline. Multivariable linear regression models were used to explore the associations of plasma Aβ40 and Aβ42 with echocardiographic measures. Participants were followed for the occurrence of HF until December 2016. Cause-specific hazard models were used to assess the association of plasma amyloid-β with incident HF and competing risk event. Models were adjusted for cardiovascular risk factors.

Results

Higher plasma Aβ40 concentrations were associated with lower left ventricular ejection fraction (β, −0.39; 95% CI, −0.68 to −0.10) and larger left ventricular mass (β, 0.70; 95% CI, 0.06 to 1.34). Aβ42 was not significantly associated with echocardiographic measures cross-sectionally. During follow-up (median 10.2 years), 472 incident HF cases were identified. Higher plasma Aβ40 was associated with an increased risk of incident HF (HR, 1.32; 95% CI, 1.15 to 1.51), more profound in men than in women (P value for interaction: 0.022). One SD increase in Aβ40 was associated with a 31% increase in the hazard of HF in men (HR, 1.32; 95% CI, 1.14 to 1.54) but the association was not significant in women (HR, 1.06; 95% CI, 0.93 to 1.20). Higher plasma Aβ42 concentrations were associated with increased risk of HF (HR, 1.12; 95% CI, 1.02 to 1.24), while further adjustment for concomitant Aβ40 attenuated this association (HR, 1.03; 95% CI, 0.92 to 1.16).

Conclusion

Higher levels of plasma Aβ40 were independently associated with worse cardiac function and higher risk of new-onset HF in the general population, in particular among men.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Netherlands Organization for Health Research and Development (ZonMw); the Dutch Heart Foundation;This study is further funded by the European Union's Horizon 2020 research and innovation programme as part of the Common mechanisms and pathways in Stroke and Alzheimer's disease (CoSTREAM) project.

Aortic valve calcium in relation to subclinical cardiac dysfunction and risk of heart failure in the general population

Background

Emerging evidence suggests that aortic valve calcium (AVC) is associated with adverse cardiovascular outcomes, while the association of (early) AVC with subclinical cardiac dysfunction and with risk of heart failure (HF) remains unclear.

Purpose

To determine the association of CT-assessed AVC with echocardiographic measurements of cardiac dysfunction, and with HF in the general population.

Methods

We included 2,348 participants (mean age 68.5 years, 52% women) of the Rotterdam Study, who had AVC measured between 2003 and 2006, and without a history of HF at baseline. Linear regression models were used to explore cross-sectional associations of AVC with echocardiographic measures at baseline. All participants were followed for HF event until December 2016. Cox proportional hazard models were used to assess the association of AVC with incident HF. Models were adjusted for potential confounders.

Results

The presence of AVC was associated with 3.14 g/m2 (95% CI, 1.50 to 4.79) higher mean left ventricular mass indexed by body surface area. One-unit larger log (AVC+1) was associated with 0.01 mm (95% CI 0.01 to 0.02) larger mean left atrial size. During a median follow-up of 9.8 years, 182 incident HF cases were identified. Presence of AVC was associated with 37% greater risk for HF (HR, 1.37; 95% CI, 1.01 to 1.87). One-unit larger log (AVC+1) was associated with 11% larger risk of HF (HR, 1.11; 95% CI, 1.04 to 1.18). Compared with the AVC =0, AVC ≥100 had 1.70 folded risk of HF (HR, 1.70; 95% CI, 1.17 to 2.49).

Conclusions

The levels of AVC were associated with markers of left ventricular structure and with risk of HF, independent of traditional cardiovascular risk factors. Larger CT-assessed AVC is an indicative of increased risk for development of HF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Netherlands Organization for the Health Research and Development (ZonMw)Dutch Heart Foundation (03-004-2021-T050)

Tailor-made cardiac rehabilitation for patients with obesity: results of the OPTICARE-XL randomized controlled trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Organisation for Health Research and Development (ZonMW) and Capri Cardiac Rehabilitation

Background

More than a third of the patients referred to cardiac rehabilitation (CR) suffers from obesity, and this number is growing. However, in patients with obesity, standard CR is not effective in achieving the recommended physical activity levels and results achieved in weight loss and health related quality of life (HRQOL) are unsatisfactory.

Purpose

To describe the effectiveness of a new state of the art CR program designed for patients with obesity, OPTICARE XL, on weight, physical activity and HRQOL.

Methods

A total of 201 patients that were referred to CR after a diagnosis of coronary artery disease (CAD) or atrial fibrillation (AF) and a BMI≥30 were randomized to standard CR (n=99) or OPTICARE XL CR (n=102). Standard CR consists of a 6 till 12 week aerobic exercise program, supplemented with cardiovascular lifestyle education. OPTICARE XL CR is a one-year intervention including aerobic and strength exercise, behavioral coaching on diet and physical activity and an after-care program. Weight was measured with a calibrated weight scale, physical activity (steps/day) was measured with an Actigraph GT3X+, and HRQOL with the MacNew questionnaire. Data was analyzed by means of linear mixed-effect models.

Results

Included patients had a mean age of 59 years, were predominantly male (73%) and the majority was referred to CR after a CAD (66% CAD, 34% AF). Patients in the OPTICARE XL group showed on average greater weight loss three months after the start of CR (mean change -3.6 kg vs -1.8 kg, respectively, p=0.002). Six months post CR, changes in body weight were equal between groups (-2.5 kg in both groups, p=0.959). No significant between-group differences were seen in improvements in physical activity both three months after the start of CR (+880 steps/day for OPTICARE XL vs +481 steps/day for standard CR, p=0.169) and six months post CR (+331 steps/ day vs +283 steps/day, p=0.919). With regard to HRQOL score, also no significant between groups differences in improvements were seen both three months after the start of CR (+0.6 for OPTICARE XL vs +0.5 for standard CR, p=0.169) and six months post CR (+0.5 for both groups, p=0.907).

Conclusion

OPTICARE XL had added value on the short-term, but this did not sustain on the long-term. We suggest to re-evaluate the OPTICARE XL program to expand short-term effects.

Aortic coarctation in pregnancy: outcomes and predictors for cardiovascular and hypertensive complications. Data from the ESC Registry of Pregnancy and Cardiac disease (ROPAC)

Background

Pregnancy in women with repaired aortic coarctation (CoA) has a moderately increased risk (mWHO II-III) of an adverse cardiovascular, obstetric or fetal event, but prospective data to validate this estimated risk is scarce.

Purpose

We examined maternal and fetal outcomes in pregnant women with unrepaired and repaired CoA to identify predictors of adverse outcomes.

Methods

Pregnancies in women with CoA were selected from the worldwide prospective Registry of Pregnancy and Cardiac Disease (ROPAC, n=5739). The frequency and predictors of major adverse cardiac events (MACE, defined as maternal cardiac death, heart failure, atrial fibrillation/flutter, ventricular tachyarrhythmia, endocarditis, thromboembolic events, aortic dissection and acute coronary syndrome), and hypertensive complications (defined as pregnancy-induced hypertension, (pre)eclampsia or HELLP syndrome) were analyzed.

Results

Of 303 pregnancies in women with CoA (median age 30 years, median pregnancy duration 39 weeks), 10% were in women with unrepaired CoA and 27% in women with pre-existing hypertension. There were no maternal deaths. There were 4 neonatal deaths of which 3 occurred after a spontaneous extreme preterm birth. MACE occurred in 4.3% of pregnancies, predominantly involving heart failure (3.3%). MACE rate was similar in unrepaired vs repaired CoA (3.4% vs 4.4%, p=0.814). Predictors of MACE included pre-pregnancy clinical signs of heart failure (OR 31.8, 95% CI 6.8–147.7), LVEF <40% (OR 10.4, 95% CI 1.8–59.5), NYHA class >1 (OR 11.4, 95% CI 3.6–36.3), cardiac medication use (OR 4.9, 95% CI 1.3–18.3) and living in an emerging country (OR 4.88, 95% CI 1.58–15.07). Hypertensive complications occurred in 6.3%, more often in the subgroup with pre-existing hypertension (11% vs 5%, p=0.040). Pre-existing hypertension was the only predictor (OR 2.6, 95% CI 1.01–6.6). Caesarean section was performed in 50% of the total cohort.

Conclusions

Pregnancies in women with CoA are safe, well tolerated and MACE and hypertensive complication rates are low. These findings support mWHO risk score reevaluation to mWHO II for women with CoA without cardiac impairment.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): ESC EURObservational Research Programme (EORP)

Serially measured cytokines and cytokine receptors in relation to clinical outcome in patients with stable heart failure

Background

Activation of the inflammatory response in heart failure (HF) may initially serve as a compensatory mechanism. However, on the longer term, this physiological phenomenon can become disadvantageous. Temporal patterns of inflammatory proteins other than CRP have not yet been investigated in patients with stable HF.

Purpose

We aimed to evaluate the association of 17 serially measured cytokines and cytokine receptors with clinical outcome in patients with stable heart failure.

Methods

In 263 patients, 1984 serial, tri-monthly blood samples were collected during a median follow-up of 2.2 (IQR: 1.4–2.5) years. The primary endpoint (PE) composed of cardiovascular mortality, HF-hospitalization, heart transplantation, and LVAD. We selected baseline blood samples in all patients, as well as the two samples closest to the primary endpoint, and the last sample available in event-free patients. Thus, in 567 samples we measured 17 cytokines and cytokine receptors using the Olink Proteomics Cardiovascular III multiplex assay. Associations between biomarkers and PE were investigated by joint modelling.

Results

Median age was 68 (IQR: 59–76) years, with 72% men, 74% NYHA class I-II and a median ejection fraction of 30% (23–38%). 70 patients reached a PE. After adjustment for clinical characteristics (age, sex, diabetes, atrial fibrillation, NYHA class at baseline, diuretics and systolic blood pressure), 7 biomarkers were associated with the PE (Figure). Interleukin-1 receptor type 1 (IL1RT1) showed the strongest association: HR 2.65 [95% CI: 1.78–4.21]) per standard deviation change in level (NPX) at any point in time during follow-up, followed by Tumor necrosis factor receptor 1 (TNF-R1): 2.25 [1.66–3.08], and C-X-C motif chemokine 16 (CXCL16): 2.18 [1.59–3.04]. After adjustment for baseline N-terminal pro–B-type natriuretic peptide, high-sensitive troponin T and C-reactive protein however, only IL1RT1 and TNF-R1 remained significantly associated with the PE.

Conclusion

Repeatedly measured levels of several cytokines and cytokine receptors are independently associated with clinical outcome in stable HF patients. These results suggest that repeated measurements of these biomarkers, in addition to established cardiac biomarkers, may contribute to personalized risk assessment and herewith better identify high-risk patients.

Figure 1. Associations between levels of cytokines and cytokine receptors and the primary endpoint.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by the Jaap Schouten Foundation and the Noordwest Academie.

5948Circulating biomarkers of cell adhesion in relation to clinical outcomes in patients with chronic heart failure: the Bio-SHiFT study

Background

Cardiovascular inflammation and vascular endothelial dysfunction are present in chronic heart failure (CHF), and cellular adhesion molecules are considered to play a key role in these mechanisms. The temporal patterns of the blood biomarkers involved could provide further insights into these processes.

Purpose

We aimed to evaluate the prognostic value of the temporal patterns of blood biomarkers of cell adhesion in stable patients with CHF.

Methods

In 263 patients, a median of 9 (IQR: 5–10) serial, tri-monthly blood samples were collected during a median follow-up of 2.2 (IQR: 1.4–2.5) years. The composite primary endpoint (PE) of cardiovascular mortality, HF-hospitalization, heart transplantation and LVAD was reached in 70 patients. For efficiency, we selected all baseline samples, the two samples closest to a PE, and the last sample available for event-free patients. Thus, in 567 samples we measured twelve biomarkers of cell adhesion using the Olink Proteomics Cardiovascular III multiplex assay. Associations between biomarkers and first PE were investigated by combining linear mixed effect models and Cox regression (so-called joint model).

Results

Median age was 68 (IQR: 59–76) years, with 72% men and 74% NYHA class I-II. Levels of CD93 (Complement component C1q receptor), CDH5 (VE cadherin), CHI3L1 (Chitinase-3-like protein 1), EPHB4 (Ephrin type-B receptor 4) and JAM-A (Junctional adhesion molecule A) differed at baseline already. The average biomarker evolutions of these markers, and additionally of ICAM-2 (Intercellular adhesion molecule-2), showed different patterns in patients approaching the PE versus those who remained event-free (Figure 1). Repeatedly measured levels of these biomarkers were independently associated with the PE. Corresponding HRs [95% CI] per 1SD increase in log2 level (arbitrary unit) were: CD93: 1.85 [1.29–2.70], CDH5: 1.72 [1.23–2.44], CHI3L1: 2.45 [1.73–3.56], EPHB4: 1.83 [1.33–2.55], ICAM2: 1.74 [1.24–2.46] and JAM-A: 2.07 [1.39–3.18], adjusted for clinical characteristics (age, sex, diabetes, atrial fibrillation, baseline NYHA class, diuretics, systolic blood pressure and eGFR).

Figure 1. Average temporal patterns of cell adhesion biomarkers during follow-up.

Conclusion

CD93, CDH5, CHI3L1, EPHB4, ICAM2 and JAM-A show different patterns as adverse events approach in CHF patients, and their temporal patterns strongly predict clinical outcome. These findings demonstrate the incremental value of repeated measurements of biomarkers of cell adhesion in stable patients with CHF.

Acknowledgement/Funding

This work was supported by the Jaap Schouten Foundation and the Noordwest Academie.

4077Sex-specific aging effects on iliofemoral and carotid atherosclerotic plaque composition in vascular surgery patients

Introduction

Knowledge on factors that influence atherosclerotic plaque composition may allow improved risk stratification and treatment selection in iliofemoral and carotid atherosclerotic disease, since outcomes of different treatment strategies are influenced by the type of underlying lesions. The sex- and age-related differences in iliofemoral atherosclerotic plaque composition is largely unknown. Unravelling the intertwined relation between sex, age and plaque composition might provide important implications for the treatment of peripheral artery disease.

Purpose

We aimed to elucidate the associations between sex, age and plaque composition in a histopathological analysis of plaque specimens of patients undergoing iliofemoral endarterectomy. Given the systemic nature of atherosclerosis, analyses are replicated in atherosclerotic plaque specimens obtained from patients undergoing carotid surgery.

Methods

Peripheral atherosclerotic plaques of 790 patients who underwent iliofemoral endarterectomy were harvested between 2002 and 2014. A cohort of patients (n=2006) who underwent carotid endarterectomy was used to replicate analyses on sex-specific aging effects in plaques from a different vascular bed. The atherosclerotic plaques were semi-quantitatively analyzed for the presence of lipid cores, plaque calcifications, plaque hemorrhages and collagen, macrophage and smooth muscle cell content, and quantitatively for microvessel density. Patients were stratified by age tertiles and by sex.

Results

Men had a higher prevalence of lipid cores (25.7% versus 20.5%, odds ratio [OR] 1.62 and 95% confidence interval [CI] 1.06–2.45, P=0.025) and plaque hemorrhage (54.3% versus 42.9%, OR 1.62 and 95% CI 1.16–2.54, P=0.004) when compared to women. Women showed an increase in plaque calcifications, plaque hemorrhage and a decrease in macrophages with increasing age (figure panel B, D, E), whereas men only showed a decrease in collagen content (figure panel C). These sex-specific aging effects were replicated in plaques obtained from the carotid arteries.

s

Conclusion

Atherosclerotic iliofemoral plaques derived from men display more rupture-prone characteristics compared to women. However, advanced age was more often associated with an increase in the presence of vulnerable plaque characteristics in women as compared to men in both the iliofemoral and carotid atherosclerotic plaque.

P5620Clinical and hemodynamic determinants of coronary flow reserve in non-obstructed coronary arteries - A patient level pooled analysis of the DEBATE and ILIAS studies

Aim

Coronary Flow Reserve (CFR) is a valuable physiological index for the assessment of myocardial flow impairment due to focal or microcirculatory coronary artery disease (CAD). Coronary flow capacity (CFC) is another flow-based concept in diagnosing ischemic heart disease (IHD), based on hyperemic average peak velocity (hAPV) and CFR. We evaluated clinical and hemodynamic factors which potentially influence CFR and CFC in non-obstructed coronary arteries.

Methods

We analysed CFR and CFC of 396 non-obstructed vessels of patients from two large multi-center trials (DEBATE and ILIAS) with stable CAD who were scheduled for percutaneous coronary intervention (PCI). Doppler flow measurements were performed after inducing hyperemia with either intracoronary or intravenous infusion of adenosine.

Results

Akaike's Information Criterion (AIC) revealed the parameters age, female gender, a history of myocardial infarction, hypercholesterolemia, current or previous smoking and rate pressure product (RPP) as independent predictors in the best model of fit for CFR in an angiographically non-obstructed vessel. After multivariate regression analysis age, female gender and RPP remained as determinants of CFR in angiographically non-obstructed vessels. Subsequently, ordered logistic regression analysis revealed that age is associated with a worse CFC.

Conclusion

Clinical and hemodynamic parameters are associated with CFR and to a lesser extent CFC in an angiographically non-obstructed coronary artery. CFC is less sensitive to variations in clinical and hemodynamic parameters than CFR and therefore a promising tool in contemporary clinical decision making in the cardiac catheterization laboratory.

Acknowledgement/Funding

DEBATE: Cardiometrics INC. ILIAS: Dutch Health Insurance Board; RADI Medical Systems, Uppsala, Sweden; and Endosonics, Rancho Cordova, CA.

P1644Personalized screening intervals for measurement of n-terminal pro-b-type natriuretic peptide improve efficiency of prognostication in patients with chronic heart failure

Background

Predefined screening intervals and target levels do not account for variations in temporal patterns of biomarkers between individuals, which may hamper their potential use for therapy guidance. Conversely, a personalized screening approach with screening intervals and target levels based on the evolution of biomarkers in individual patients may further improve risk assessment and therapy guidance.

Purpose

We hypothesize that personalized screening intervals for N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements in patients with chronic heart failure (CHF) maximize information gain on the individual patient's disease progression, while minimizing the number of necessary measurements. We aim to compare such personalized scheduling of NT-proBNP measurements to a predefined fixed scheduling approach.

Methods

In 263 CHF patients from the Bio-SHiFT study, NT-proBNP was measured trimonthly according to a prespecified, fixed schedule [median: 9 (IQR: 5–10) measurements per patient].The primary composite endpoint (PE) comprised cardiac death, cardiac transplantation, left ventricular assist device implantation or heart failure hospitalization, and occurred in 70 patients (26.6%). Using joint models for time-to-event and longitudinal data, we modelled the association between repeated NT-proBNP measurements and the PE. Using the fitted joint model, for each patient at each follow-up visit, we determined the optimal time point of the next NT-proBNP measurement based on the patient's individual risk profile and the maximum information gain on the patient's prognosis as assessed by the Kullback-Leibler divergence. Personalized scheduling was compared to fixed (trimonthly) scheduling by means of a realistic simulation study, based on a replica of the study population included in the Bio-SHiFT study. In this simulation study, we stopped monitoring NT-proBNP to potentially enable appropriate timely intervention if the cumulative risk of PE exceeded an arbitrary risk threshold of 7.5% within 3-months. We compared personalized scheduling with fixed scheduling in terms of capability of identification of high-risk intervals (whether timely intervention was enabled before occurrence of PE), number of measurements needed, and costs.

Results

Compared to fixed scheduling, personalized scheduling saved on average 2 measurements [personalized; median: 7 (IQR: 7–8) vs. fixed; 9 (IQR: 8–10) measurements], while the start of the time-window identified for therapeutic intervention to avoid the occurrence of PE was similar in both approaches [personalized; median: 6.6 (IQR: 4.5–11.3) vs. fixed; 6.3 (IQR: 4.2–10.3) months before occurrence of PE]. Costs saved were €165 per patient per year.

Figure 1

Conclusion

Personalized scheduling of NT-proBNP measurements in CHF patients shows similar prognostic performance as fixed scheduling, but requires fewer NT-proBNP measurements. This may improve efficiency of natriuretic guided therapy, if the latter were to be installed.

Acknowledgement/Funding

Funding for this study was provided by the Jaap Schouten Foundation and Erasmus MC Efficiency Research grant

Alteration of Skull Dimensions in Aged Persons

Lateral radiographs of the heads of persons between the ages of 58 and 91 years were compared. Few statistically significant differences were found. Almost all linear dimensions in the women were smaller than those in the men.

Hyperglycemia at admission and during hospital stay are independent risk factors for mortality in high risk cardiac patients admitted to an intensive cardiac care unit

AIMS

Hyperglycemia is associated with increased mortality in cardiac patients. However, the predictive value of admission- and average glucose levels in patients admitted to an intensive cardiac care unit (ICCU) has not been described.

METHODS

Observational study of patients admitted to the ICCU of a tertiary medical center in whom glucose levels were measured at and during admission. Over a 19-month period, 1713 patients were included. Mean age was 63±14 years, 1228 (72%) were male, 228 (17%) had known diabetes. Median (interquartile) glucose levels at admission were 7.9 (6.5-10.1) mmol/l; median glucose levels during ICCU admission (873 patients with three or more measurements) were 7.3 (6.7-8.3) mmol/l. Cox regression analysis was performed including the variables age, gender, admission diagnosis, length of stay, prior (cardio)vascular disease and diabetes.

RESULTS

A 1 mmol/l increase in admission glucose level (above 9 mmol/l) was associated with a 10% (95% confidence interval (CI): 7 -13%) increased risk for all-cause mortality. A 1 mmol/l higher average glucose level (above 8 mmol/l) was an additional independent predictor of mortality (HR 1.11, 95% CI: 1.03 - 1.20). At 30 days, 16.8% (97/579) of the patients with an admission glucose level in the highest tertile (>9.8 mmol/L) had died vs 5.2% (59/1134) of those with a lower admission glucose level.

CONCLUSION

In a high risk ICCU population, both high admission glucose levels as well as high average glucose levels during hospitalization were independently associated with increased mortality, even when accounting for other risk factors and parameters of disease severity.

Characteristics of smokers and long-term changes in smoking behavior in consecutive patients with myocardial infarction

BACKGROUND

The prognosis of patients with estabLished coronary artery improves if smoking is stopped. Still, about half of patients who suffer a myocardial infarction continue smoking after that event. In order to predict to whom additional support should be offered, various baseline characteristics were compared with smoking status at short-term and long-term follow-up.

METHODS

Demographics, medical history, presence of coronary risk factors, psychological determinants, and the clinical course were recorded in a group of 530 unselected consecutive patients who had been admitted with a myocardial infarction and were smoking. Patients who were smoking at admission, and who were alive at 4-year follow-up, were studied to relate smoking status and baseline characteristics.

RESULTS

At 3 months, persistent smokers were younger than quitters, had shorter hospital stays, underwent revascularization procedures less often, smoked more cigarettes per day at baseline, and were more socially isolated. After 4 years, patients who stopped smoking had had a more serious myocardial infarction and had a lower displeasure score than those who continued smoking. Also, quitters received more support from their social environment.

CONCLUSIONS

Although the majority of the patients try to stop smoking after a myocardial infarction, about half smokes after 4 years. In the future, special support should be offered to smokers who suffer myocardial infarction, especially to those whose psychosocial profiles are less favorable.

Prospective study of early discharge after acute myocardial infarction (SHORT)

AIMS

To identify, without additional investigation, a large group of myocardial infarction patients at low risk who would qualify for early discharge.

METHODS

The decision rule was developed in 647 unselected patients with consecutively admitted myocardial infarction, and validated in 825 others. Daily event-rates were calculated for major (death, ventricular fibrillation, recurrent infarction, heart failure, advanced AV-block) and minor (unstable angina and rhythm-abnormalities) cardiac complications.

RESULTS

Patients free from major complications until day 7 (44% of all patients) were found to constitute a very low risk group and thus would qualify for discharge at day 7. Of the 39% of patients with an uncomplicated infarction (low risk) in the validation group, 31% were discharged at day 7, while 8% stayed longer because of non-cardiac co-morbidity, for social reasons or logistic problems. No major adverse event occurred within 7 days after hospital discharge and only 1.8% developed complications within 1 month. The median duration of hospital stay for all in-hospital survivors was 7 days compared to 10 days in the control group.

CONCLUSION

Prospective application of the early discharge decision rule, based upon simple clinical variables and without the need for additional non-invasive and/or invasive tests, resulted in a significant reduction of hospital stay. The decision rule correctly classified patients into high and low risk groups and appeared feasible and safe. Its efficacy was demonstrated by its ability to identify a large group of post infarction survivors at low risk for complications during follow-up.

Registration and management of smoking behaviour in patients with coronary heart disease. The EUROASPIRE survey

AIMS

To establish to what extent smoking status and its management is recorded in coronary patients' medical records, and to investigate their motivation to change smoking behaviour.

METHODS

In EUROASPIRE, a survey on secondary prevention in 21 hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, Slovenia and Spain, data were collected from records of 4863 consecutive patients =<70 years of age, with previous (>6 months) admission for coronary bypass operation, angioplasty, myocardial infarction or ischaemia. Of these, 3569 patients were interviewed 1.6 years following their index hospitalization.

RESULTS

Of the 82% of patients whose pre-hospitalization smoking behaviour was known, 34% were smokers. Documentation was significantly better in younger patients, in males and patients requiring angioplasty or bypass operation. In only 35% of 1364 smokers was the smoking habit recorded again after discharge from hospital At the time of the interview, 554 of the interviewed patients were still smoking. In over 90% of the smokers, advice to quit smoking was reported at interview. A positive relationship was found between receiving advice and seeking help to stop smoking, between receiving advice to stop smoking and attempting to stop, as well as between seeking help and attempting to stop.

CONCLUSION

In almost 20% of coronary patients, smoking habits are not documented in medical records, and in only 35% of the smoking patients is smoking status documented at the follow-up. After a cardiac event requiring hospitalization as many as 50% of patients continue their smoking habit and so there is further potential to reduce the risk of recurrent coronary disease. Advice to stop smoking motivates patients to seek help and to attempt to stop smoking. Physicians repeated advice to stop smoking is important and smoking status should always be documented at follow-up.