Very late heart transplant rejection is associated with microvascular injury, complement deposition and progression to cardiac allograft vasculopathy

In heart transplants, the significance of very late rejection (after 7 years post-transplant, VLR) detected by routine endomyocardial biopsies (EMB) remains uncertain. Here, we assessed the prevalence, histopathological and immunological phenotype, and outcome of VLR in clinically stable patients. Between 1985 and 2009, 10 662 protocol EMB were performed at our institution in 398 consecutive heart transplants recipients. Among the 196 patients with >7-year follow-up, 20 (10.2%) presented subclinical ≥3A/2R-ISHLT rejection. The VLR group was compared to a matched control group of patients without rejection. All biopsies were stained for C4d/C3d/CD68 with sera screened for the presence of donor-specific antibodies (DSAs). In addition to cellular infiltrates with myocyte damage, 60% of VLR patients had evidence of intravascular macrophages. C4d and/or C3d-capillary deposition was found in 55% VLR EMB. All cases of VLR associated with microcirculation injury had DSAs (mean DSA(max) -MFI = 1751 ± 583). This entity was absent from the control group (p < 0.0001). Finally, after a similar follow-up postreference EMB of 6.4 ± 1 years, the mean of CAV grade was 0.76 ± 0.18 in the control group compared to 2.06 ± 0.26 in the VLR group respectively, p = 0.001). There was no difference in patient survival between study and control groups. In conclusion, VLR is frequently associated with complement-cascade activation, microvascular injury and DSA, suggesting an antibody-mediated process. VLR is associated with a dramatic progression to severe CAV in long-term follow-up.

Donor-specific antibodies accelerate arteriosclerosis after kidney transplantation

In biopsies of renal allografts, arteriosclerosis is often more severe than expected based on the age of the donor, even without a history of rejection vasculitis. To determine whether preformed donor-specific antibodies (DSAs) may contribute to the severity of arteriosclerosis, we examined protocol biopsies from patients with (n=40) or without (n=59) DSA after excluding those with any evidence of vasculitis. Among DSA-positive patients, arteriosclerosis significantly progressed between month 3 and month 12 after transplant (mean Banff cv score 0.65 ± 0.11 to 1.12 ± 0.10, P=0.014); in contrast, among DSA-negative patients, we did not detect a statistically significant progression during the same timeframe (mean Banff cv score 0.65 ± 0.11 to 0.81 ± 0.10, P=not significant). Available biopsies at later time points supported a rate of progression of arteriosclerosis in DSA-negative patients that was approximately one third that in DSA-positive patients. Accelerated arteriosclerosis was significantly associated with peritubular capillary leukocytic infiltration, glomerulitis, subclinical antibody-mediated rejection, and interstitial inflammation. In conclusion, these data support the hypothesis that donor-specific antibodies dramatically accelerate post-transplant progression of arteriosclerosis.

Resting heart rate, mortality and future coronary heart disease in the elderly: the 3C Study

OBJECTIVES

To investigate the association between resting heart rate (RHR) and mortality and incident coronary heart disease (CHD) in the elderly.

METHODS

Data derived from the Three-City Study, a French multicentre prospective study including 9294 community-dwelling elderly subjects aged ≥65 years at baseline examination between 1999 and 2001. The study population comprised 7147 participants (61% women) who were free of a pacemaker or any cardiac arrhythmias at baseline. RHR was measured twice at baseline in a seated position using an electronic tensiometer. Participants were then followed up bi-annually for vascular morbidity and mortality over 6 years. CHD events and cardiovascular death were adjudicated by an independent expert committee.

RESULTS

After 6 years of follow-up, 615 subjects died including 17.9% from cardiovascular causes. Subjects from the top quintile of RHR (>79 bpm) had respectively a 74% (95% CI, 1.3-2.3), a 87% (95% CI: 0.98-3.6, p = 0.06) and a 72% (95% CI, 1.3-2.3) increased risk of total, cardiovascular and non-cardiovascular mortality compared to those from the lowest quintile (<62 bpm), after adjustment for cardiovascular risk factors and beta-blocker (BB) use in a Cox regression analysis. Associations with total mortality were consistent according to age, gender, BB use, diabetes and hypertension status (all p values for interaction >0.10). Conversely, RHR was not predictive of incident CHD (n = 228 events; top vs lowest quintile: HR: 1.0; 95% CI: 0.6-1.5).

CONCLUSIONS

RHR is an independent risk marker of mortality but not of incident CHD events in community-dwelling elderly. Its routine measurement may help identify those who are at increased risk of mortality in the short term.

Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients?: insights from a large registry

BACKGROUND

Although the level of evidence of improvement is significant in cardiac arrest patients resuscitated from a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia [VF/Vt]), the use of therapeutic mild hypothermia (TMH) is more controversial in nonshockable patients (pulseless electric activity or asystole [PEA/asystole]). We therefore assessed the prognostic value of hypothermia for neurological outcome at hospital discharge according to first-recorded cardiac rhythm in a large cohort.

METHODS AND RESULTS

Between January 2000 and December 2009, data from 1145 consecutive out-of-hospital cardiac arrest patients in whom a successful resuscitation had been achieved were prospectively collected. The association of TMH with a good neurological outcome at hospital discharge (cerebral performance categories level 1 or 2) was quantified by logistic regression analysis. TMH was induced in 457/708 patients (65%) in VF/Vt and in 261/437 patients (60%) in PEA/asystole. Overall, 342/1145 patients (30%) reached a favorable outcome (cerebral performance categories level 1 or 2) at hospital discharge, respectively 274/708 (39%) in VF/Vt and 68/437 (16%) in PEA/asystole (P<0.001). After adjustment, in VF/Vt patients, TMH was associated with increased odds of good neurological outcome (adjusted odds ratio, 1.90; 95% confidence interval, 1.18 to 3.06) whereas in PEA/asystole patients, TMH was not significantly associated with good neurological outcome (adjusted odds ratio, 0.71; 95% confidence interval, 0.37 to 1.36).

CONCLUSIONS

In this large cohort of cardiac arrest patients, hypothermia was independently associated with an improved outcome at hospital discharge in patients presenting with VF/Vt. By contrast, TMH was not associated with good outcome in nonshockable patients. Further investigations are needed to clarify this lack of efficiency in PEA/asystole.

Predicting CHD risk in France: a pooled analysis of the D.E.S.I.R., Three City, PRIME, and SU.VI.MAX studies

BACKGROUND

We aimed to develop and validate a simple coronary heart disease (CHD) risk algorithm applicable to asymptomatic men and women in France, and to compare its accuracy with that of the last published version of the Framingham risk function for cardiovascular disease.

DESIGN

A pooled analysis of four French prospective general-population studies.

METHODS

The baseline and follow-up data from D.E.S.I.R., PRIME, Three City, and SU.VI.MAX studies were used. The 10-year CHD risk was estimated by the Cox proportional hazards model with candidate variables including age, gender, body mass index, waist circumference, family history of coronary heart disease, smoking status, diabetes status, systolic blood pressure, and total and high-density lipoprotein (HDL) cholesterol.

RESULTS

The study population included 22,256 subjects (61.4% men) aged (SD) 56.0 years (8.3) without a personal history of CHD at baseline. After a mean follow-up of 8.0 years (2.3), 788 first CHD events occurred, 726 in men and 62 in women. The final model included age, gender, age × gender interaction, current smoking status, diabetes status, systolic blood pressure, total and HDL cholesterol. Using this model, the number of predicted coronary events fitted that given by the 10-year Kaplan-Meier survival estimates within each decile of estimated risk (calibration). This model had fair discrimination: Harrell C-index, 0.7831 (95% CI: 0.7704-0.7957). For comparison, the recalibrated Framingham risk function had equivalent performances compared to the French risk equation.

CONCLUSION

Our 10-year French CHD risk equation based on traditional risk factors performed at least as well as the recalibrated Framingham cardiovascular disease risk function.

Significance of C4d Banff scores in early protocol biopsies of kidney transplant recipients with preformed donor-specific antibodies (DSA)

The significance of C4d-Banff scores in protocol biopsies of kidney transplant recipients with preformed donor-specific antibodies (DSA) has not been determined. We reviewed 157 protocol biopsies from 80 DSA+ patients obtained at 3 months and 1 year post-transplant. The C4d Banff scores (1,2,3) were associated with significant increments of microcirculation inflammation (MI) at both 3 months and 1 year post-transplant, worse transplant glomerulopathy and higher class II DSA-MFI (p < 0.01). Minimal-C4d had injury intermediate between negative and focal, while focal and diffuse-C4d had the same degree of microvascular injury. A total of 54% of patients had variation of C4d score between 3 months and 1 year post-transplant. Cumulative (3 month + 1 year) C4d scores correlated with long-term renal function worsening (p = 0.006). However, C4d staining was not a sensitive indicator of parenchymal disease, 55% of C4d-negative biopsies having evidence of concomitant MI. Multivariate analysis demonstrated that the presence of MI and class II DSA at 3 months were associated with a fourfold increased risk of progression to chronic antibody-mediated rejection independently of C4d (p < 0.05). In conclusion, the substantial fluctuation of C4d status in the first year post-transplant reflects a dynamic humoral process. However, C4d may not be a sufficiently sensitive indicator of activity, MI and DSA being more robust predictors of bad outcome.

Do lipids and apolipoproteins predict coronary heart disease under statin and fibrate therapy in the primary prevention setting in community-dwelling elderly subjects? The 3C Study

PURPOSE

To evaluate associations of standard lipids and apolipoproteins with incident coronary heart disease (CHD) in older adults according to lipid-lowering treatment (LLT) in the primary prevention setting.

METHODS

Within the 3C Study of men and women aged ≥ 65 years, standard lipids, apolipoproteins A-1 and B100 and hs-CRP were measured in baseline blood samples from 199 participants who developed a first CHD event over 4 years of follow-up and from 1081 subjects randomly selected from the initial cohort (case cohort study). Standardized hazard ratios (HRs) were estimated by the Cox proportional hazard model.

RESULTS

In the random sample, 75.3% were free of LLT (non-users), 11.5% received statins and 13.4% fibrates. Among the non-users, all lipid parameters were significantly associated with future CHD (n = 145) after adjustment for age, gender, study center and educational level, and their HRs were comparable. For instance, the HR for LDL-cholesterol was 1.38 (95% CI: 1.13-1.69). These associations also existed and were stronger among statin users (n = 27 CHD), as shown by an HR for LDL-cholesterol of 2.20 (95% CI: 1.27-3.81). Additional adjustment for traditional risk factors and hs-CRP marginally modified HR estimates in those receiving or not receiving statins. Among fibrate users (n = 27 CHD), significant associations were observed for triglycerides only (1.68; 95% CI = 1.04-2.72) in fully adjusted analyses.

CONCLUSION

In older adults, standard lipids and apolipoproteins are stronger predictors of CHD in those receiving statins than in those who are not in the primary prevention setting. Under fibrate treatment, only triglycerides were independent predictors of CHD.

C-reactive protein, interleukin 6, fibrinogen and risk of sudden death in European middle-aged men: the PRIME study

OBJECTIVE

To examine prospectively the association of high-sensitivity C-reactive protein, interleukin 6, and fibrinogen with sudden death in asymptomatic European men.

METHODS AND RESULTS

Among the 9771 men from the Etude PRospective de l'Infarctus du Myocarde (PRIME) Study, 664 had a first coronary heart disease over 10 years, including 50 sudden deaths, 34 nonsudden coronary deaths, and 580 nonfatal coronary heart disease events. For each outcome, 2 matched controls, who were free of coronary heart disease at the index date, were randomly selected from the initial cohort (nested case control study design). There was a 3-fold increased risk (95% CI, 1.20 to 7.81) of sudden death between the upper and the lower third of interleukin 6 after adjustment for baseline confounders in conditional logistic regression analysis. Neither high-sensitivity C-reactive protein (hazard ratio(third versus first tertile)=1.27; 95% CI, 0.51 to 3.17) nor fibrinogen (hazard ratio(third versus first tertile)=1.90; 95% CI, 0.76 to 4.75) was associated with sudden death. For comparison, there was a 6-fold increased risk of nonsudden coronary death from the highest compared with the lowest tertile of fibrinogen and a trend toward an association with higher C-reactive protein and higher interleukin 6. All 3 inflammatory biomarkers were moderately, but significantly, associated with nonfatal coronary heart disease.

CONCLUSIONS

Interleukin 6, but not high-sensitivity C-reactive protein or fibrinogen, is an independent predictor of sudden death in asymptomatic European men.

Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry

BACKGROUND

Acute coronary occlusion is the leading cause of cardiac arrest. Because of limited data, the indications and timing of coronary angiography and angioplasty in patients with out-of-hospital cardiac arrest are controversial. Using data from the Parisian Region Out of hospital Cardiac ArresT prospective registry, we performed an analysis to assess the effect of an invasive strategy on hospital survival.

METHODS AND RESULTS

Between January 2003 and December 2008, 714 patients with out-of-hospital cardiac arrest were referred to a tertiary center in Paris, France. In 435 patients with no obvious extracardiac cause of arrest, an immediate coronary angiogram was performed at admission followed, if indicated, by coronary angioplasty. At least 1 significant coronary artery lesion was found in 304 (70%) patients, in 128 (96%) of 134 patients with ST-segment elevation on the ECG performed after the return of spontaneous circulation, and in 176 (58%) of 301 patients without ST-segment elevation. The hospital survival rate was 40%. Multivariable analysis showed successful coronary angioplasty to be an independent predictive factor of survival, regardless of the postresuscitation ECG pattern (odds ratio, 2.06; 95% CI, 1.16 to 3.66).

CONCLUSIONS

Successful immediate coronary angioplasty is associated with improved hospital survival in patients with or without ST-segment elevation. Therefore, our findings support the use of immediate coronary angiography in patients with out-of-hospital cardiac arrest with no obvious noncardiac cause of arrest regardless of the ECG pattern.

Disability and incident coronary heart disease in older community-dwelling adults: the Three-City Study

OBJECTIVES

To prospectively assess the association between disability and incident fatal and nonfatal coronary heart disease (CHD) in older adults free of cardiovascular disease (CVD).

DESIGN

A French multicenter prospective population-based cohort of 9,294 subjects, aged 65 and older at baseline, recruited between 1999 and 2001 and followed for 6 years.

SETTING

Three cities in France: Bordeaux in the southwest, Dijon in the northeast, and Montpellier in the southeast.

PARTICIPANTS

Seven thousand three hundred fifty-four participants with no history of CVD and with available information on disability status. Subjects were categorized at baseline as having no disability, mild disability (mobility only), and moderate or severe disability (mobility plus activities of daily living or instrumental activities of daily living).

MEASUREMENTS

Incident fatal and nonfatal coronary events (angina pectoris, myocardial infarction, revascularization procedures, and CHD death).

RESULTS

At baseline, the mean level of the risk factors increased gradually with the severity of disability. After a median follow-up of 5.2 years, 264 first coronary events, including 55 fatal events, occurred. After adjustment for cardiovascular risk factors, participants with moderate or severe disability had a 1.7 times (95% confidence interval (CI)=1.0-2.7) greater risk of overall CHD than nondisabled subjects, whereas those with mild disability were not at greater CHD risk. An association was also found with fatal CHD, for which the risk increased gradually with the severity of disability (hazard ratio (HR)(mild disability)=1.7, 95% CI=0.8-3.6; HR(moderate/severe disability)=3.5, 95% CI=1.3-9.3; P for trend=.01).

CONCLUSION

In older community-dwelling adults, the association between disability and incident CHD is mostly due to an association with fatal CHD.

Framingham Stroke Risk Function in a Large Population-Based Cohort of Elderly People

Background and Purpose— External validation of the Framingham stroke risk function has been rarely performed. We assessed its predictive ability in a population-based cohort of French elderly.

Methods— The sample comprised 6913 subjects from the 3C Study, aged 65 to 84 at baseline, who were followed up to 6 years. Predictive accuracy of the original Framingham stroke risk function was assessed in a 3-step procedure: comparison between the Framingham and 3C cohorts of the prevalence of selected risk factors and the associated relative risks (RR) for stroke, comparison of the predicted to the observed number of stroke events (calibration), and ability to separate high-risk from low-risk participants (discrimination). We also compared predictive performances of the original Framingham, the recalibrated Framingham, and the local stroke risk functions.

Results— During follow-up, 110 incident strokes occurred. For most risk factors, RRs were comparable between the 2 cohorts, except for age in women. The original Framingham stroke risk function applied to the 3C cohort overestimated the 6-year absolute risk for stroke by a factor of 3.7 for men and 4.4 for women. However, the recalibrated Framingham and 3C functions did not show any over- or underestimation of stroke risk. The 3 stroke risk functions (original, recalibrated, and 3C) provided acceptable discrimination with areas under the ROC curve ranging from 0.67 to 0.73.

Conclusions— The original Framingham stroke risk function strongly overestimated the stroke risk for 3C participants. Derived Framingham stroke score sheets should not be directly used by physicians in the French elderly population.

Excessive daytime sleepiness is an independent risk indicator for cardiovascular mortality in community-dwelling elderly: the three city study

BACKGROUND AND PURPOSE

Excessive daytime sleepiness, one of the most frequent sleep complaints in the elderly, may affect survival, but inconsistent results have been observed in that population so far. We therefore estimated the risk of mortality for excessive daytime sleepiness (EDS) in community-dwelling elderly participating in the Three City Study.

METHODS

The Three City Study is a French population-based multicenter prospective study including 9294 subjects (60% women) aged >or=65 years at recruitment between 1999 to 2001. At baseline, 8269 subjects rated EDS and nocturnal sleep complaints as never, rare, regular, and frequent in response to an administered questionnaire and provided information on medication use for sleep or anxiety. Hazard ratios (HR) of EDS (regular or frequent) for mortality over 6 years were estimated by a Cox proportional hazard model.

RESULTS

At baseline, 18.7% of the study participants had regular or frequent EDS. After 6 years of follow-up, 762 subjects had died including 260 from cancer and 196 from cardiovascular disease. EDS was associated with a significant 33% increased risk of mortality (95% CI: 1.13 to 1.61) after adjustment for age, gender, study center, body mass index, previous cardiovascular disease, Mini Mental State Examination score, and cardiovascular risk factors. Further adjustment for current use of medication for sleep and for depressive symptoms slightly diminished the HRs. EDS was equally predictive of mortality in those who snored loudly and in those who did not. EDS was related to cardiovascular mortality but not to mortality attributable to cancer.

CONCLUSIONS

EDS might be independently associated with total and cardiovascular mortality in community-dwelling elderly.

Metabolic syndrome and risk for incident Alzheimer's disease or vascular dementia: the Three-City Study

OBJECTIVE

Associations between metabolic syndrome and its individual components with risk of incident dementia and its different subtypes are inconsistent.

RESEARCH DESIGN AND METHODS

The 7,087 community-dwelling subjects aged > or =65 years were recruited from the French Three-City (3C) cohort. Hazard ratios (over 4 years) of incident dementia and its subtypes (vascular dementia and Alzheimer's disease) and association with metabolic syndrome (defined according to the National Cholesterol Education Program Adult Treatment Panel III criteria) and its individual components (hypertension, large waist circumference, high triglycerides, low HDL cholesterol, and elevated fasting glycemia) were estimated in separate Cox proportional hazard models.

RESULTS

Metabolic syndrome was present in 15.8% of the study participants. The presence of metabolic syndrome increased the risk of incident vascular dementia but not Alzheimer's disease over 4 years, independent of sociodemographic characteristics and the apolipoprotein (apo) Eepsilon4 allele. High triglyceride level was the only component of metabolic syndrome that was significantly associated with the incidence of all-cause (hazard ratio 1.45 [95% CI 1.05-2.00]; P = 0.02) and vascular (2.27 [1.16-4.42]; P = 0.02) dementia, even after adjustment of the apoE genotype. Diabetes, but not impaired fasting glycemia, was significantly associated with all-cause (1.58 [1.05-2.38]; P = 0.03) and vascular (2.53 [1.15-5.66]; P = 0.03) dementia.

CONCLUSIONS

The observed relation between high triglycerides, diabetes, and vascular dementia emphasizes the need for detection and treatment of vascular risk factors in older individuals in order to prevent the likelihood of clinical dementia.

Contribution of the metabolic syndrome to sudden death risk in asymptomatic men: the Paris Prospective Study I

AIMS

To compare the risk of sudden death and non-sudden death from myocardial infarction associated with the metabolic syndrome (MetS) in asymptomatic men.

METHODS AND RESULTS

The mortality status of 6,678 middle-aged men from the Paris Prospective Study I, who were free of diabetes and coronary heart disease (CHD) at the baseline examination, has been investigated over 21 years of follow-up. The sagittal abdominal diameter was substituted for waist circumference, and HDL cholesterol was unavailable. The presence of three abnormalities and the presence of abdominal adiposity plus at least two abnormalities defined the MetS, using the NCEP-ATP III and IDF criteria, respectively. Frequency estimate of the MetS was 14.4 and 16.7%, using the NCEP-ATP III and IDF criteria, respectively. The MetS increased the risk of sudden death and non-sudden death by 68% [95% confidence interval (CI) 1.05-2.70] and 38% (95% CI 0.95-2.01), respectively, after adjustment for other CHD risk factors (P for the comparison of the hazard ratios = 0.25). Hazards ratio using the IDF criteria were 2.02 (95% CI 1.30-3.14) and 1.69 (95% CI 1.20-2.38), respectively, (P = 0.26).

CONCLUSION

In healthy middle-aged men, the MetS increased the risk of sudden death and, to a lesser extent, the risk of non-sudden death over 21 years independent of CHD risk factors.

The Metabolic Syndrome and the Carotid Artery Structure in Noninstitutionalized Elderly Subjects

Background and Purpose— In contrast to the young adult population, limited data are presently available regarding the epidemiology of the metabolic syndrome (MetS) and its relationship with cardiovascular disease risk in the elderly. We have investigated the frequency of the MetS and its association with the carotid artery structure in an elderly free-living population.

Methods— The study population consists of 5585 French noninstitutionalized elderly men and women aged 65 to 85 years, free of diabetes, who participated in the multicenter Three City Study and who underwent ultrasound examination of the carotid arteries at baseline examination between March 1999 and March 2001. The MetS was defined according to the National Cholesterol Education Program Adult Treatment Panel III criteria.

Results— The MetS was present in 12.1% of the study participants, with slightly higher rates in men. Subjects with the MetS had higher frequency of carotid plaques (odds ratio, 1.30; 95% CI, 1.09 to 1.55), higher intima-media thickness of the common carotid artery (odds ratio, 1.81; 95% CI, 1.37 to 2.41), and higher lumen diameter (odds ratio, 2.17; 95% CI, 1.61 to 2.94) (upper quintiles) after adjustment for other cardiovascular risk factors. This association was observed in both genders and in subjects without prevalent cardiovascular disease. Elevated blood pressure as defined in the MetS was the main determinant of the relations between the MetS and the carotid parameters, especially the lumen diameter.

Conclusions— The present data suggest that noninstitutionalized elderly subjects with the MetS have altered structure of the carotid arteries.

Clinical Depression and Risk of Out-of-Hospital Cardiac Arrest

BACKGROUND

The association of depression with coronary heart disease-related mortality has been widely recognized. This finding may partly reflect an association between depression and sudden death, in part because the imbalance between sympathetic and parasympathetic tone is altered in depressed subjects. We, thus, investigated whether the presence and severity of clinical depression was associated with a higher risk of sudden cardiac death.

METHODS

We used data from a population-based case-control study of risk factors for incident out-of-hospital cardiac arrest (CA) conducted among enrollees of a health maintenance organization in western Washington State. Cases (n = 2228) were aged 40 to 79 years and experienced CA between January 1, 1980, and December 31, 1994. Controls (n = 4164) were a stratified random sample of enrollees defined by calendar year, age, sex, and prior heart disease. Clinical depression was defined as physician diagnosis of depression or use of antidepressant treatment within the year before the event. Referral to mental health clinics or hospitalization for depression defined severe depression.

RESULTS

Clinically depressed patients had a higher odds ratio (OR) of CA (1.88; 95% confidence interval [CI], 1.59-2.23), which persisted after adjustment for confounders (OR, 1.43; 95% CI, 1.18-1.73). The association was observed in both sexes, in various age groups, and in subjects with prior physician-diagnosed heart disease (OR, 1.27; 95% CI, 1.01-1.60) and without prior physician-diagnosed heart disease (OR, 1.71; 95% CI, 1.22-2.41) (P = .13 for the interaction). Compared with nondepressed subjects, the risk of CA was increased in less severely depressed subjects (OR, 1.30; 95% CI, 1.04-1.63) and further increased in severely depressed subjects (OR, 1.77; 95% CI, 1.28-2.45) (P<.001 for trend).

CONCLUSION

Clinical depression may be associated with a higher risk of CA independently of established coronary heart disease risk factors.

[The best of epidemiology and cardiovascular prevention in 2005]

It is difficult to summarize in a few pages the wealth of information appeared during the year 2005 in the field of epidemiology and cardiovascular prevention. The general epidemiological data on the evolutionary tendencies of coronary mortality and morbidity make it possible to underline the effectiveness of the control of the great risk factors within the framework of the primary prevention. Although lipids and diabetes have still this year held the front of the scene through many trials, this analysis is also focused on smoking, subject more and more tackled in the cardiologic journals, and to which a larger attention should be paid in our daily practice. The Paris Prospective Study I brought new data concerning the early identification of the subjects at risk of sudden death, starting from the analysis of the evolution of heart rate profile during and after exercise. Is the concept of metabolic syndrome a phenomenon of mode or does it constitute in itself an autonomous prognostic factor beyond the risk related to the plurality of the factors which define it? The cardiologist will have to be interested more and more in the living conditions of his patients and in particular with the environmental factors such as the air pollution, who seems to have a considerable impact on the incidence of the acute coronary events. Lastly, the ADMA (asymmetric dimethylarginine), seems a possible new marker of cardiovascular risk, but its real prognostic interest remains to be defined.

Diabetes, glucose level, and risk of sudden cardiac death

AIMS

The prevalence of diabetes mellitus in industrialized countries is rapidly increasing, and diabetes is suspected to carry a particular high risk for sudden cardiac death (SCD).

METHODS AND RESULTS

We conducted a population-based case-control study at Group Health Cooperative. Cases (n=2040) experienced out-of-hospital cardiac arrest due to heart disease between 1980 and 1994. Controls (n=3800) were a stratified random sample of enrollees. Diabetes status was classified into four exclusive groups: (i) no diabetes, (ii) borderline, (iii) diabetes without microvascular disease (retinopathy or proteinuria), and (iv) diabetes with microvascular disease. When compared with no diabetes, we observed progressively higher risk of SCD associated with borderline diabetes [Odds ratio (OR)=1.24 (0.98-1.57)], diabetes without microvascular disease [OR=1.73 (1.28-2.34)], and diabetes with microvascular disease [OR=2.66 (1.84-3.85)], after adjustment for potential confounders (P-value for trend <0.001). Higher glucose levels were also associated with the risk of SCD both in the absence and in the presence of microvascular disease. However, subjects with microvascular complications but with glucose level <7.7 mmol/L were not at significant increased risk of SCD.

CONCLUSION

These results emphasize the role of diabetes as a strong risk factor for SCD and outline the importance of glucose level at every stage of diabetes severity.

Heart-rate profile during exercise as a predictor of sudden death

BACKGROUND

Changes in heart rate during exercise and recovery from exercise are mediated by the balance between sympathetic and vagal activity. Since alterations in the neural control of cardiac function contribute to the risk of sudden death, we tested the hypothesis that among apparently healthy persons, sudden death is more likely to occur in the presence of abnormal heart-rate profiles during exercise and recovery.

METHODS

A total of 5713 asymptomatic working men (between the ages of 42 and 53 years), none of whom had clinically detectable cardiovascular disease, underwent standardized graded exercise testing between 1967 and 1972. We examined data on the subjects' resting heart rates, the increase in rate from the resting level to the peak exercise level, and the decrease in rate from the peak exercise level to the level one minute after the termination of exercise.

RESULTS

During a 23-year follow-up period, 81 subjects died suddenly. The risk of sudden death from myocardial infarction was increased in subjects with a resting heart rate that was more than 75 beats per minute (relative risk, 3.92; 95 percent confidence interval, 1.91 to 8.00); in subjects with an increase in heart rate during exercise that was less than 89 beats per minute (relative risk, 6.18; 95 percent confidence interval, 2.37 to 16.11); and in subjects with a decrease in heart rate of less than 25 beats per minute after the termination of exercise (relative risk, 2.20; 95 percent confidence interval, 1.02 to 4.74). After adjustment for potential confounding variables, these three factors remained strongly associated with an increased risk of sudden death, with a moderate but significantly increased risk of death from any cause but not of nonsudden death from myocardial infarction.

CONCLUSIONS

The heart-rate profile during exercise and recovery is a predictor of sudden death.

Contributions of Depressive Mood and Circulating Inflammatory Markers to Coronary Heart Disease in Healthy European Men

Background— Data on the possible association between depressive disorders and inflammatory markers are scarce and inconsistent. We investigated whether subjects with depressive mood had higher levels of a wide range of inflammatory markers involved in coronary heart disease (CHD) incidence and examined the contribution of these inflammatory markers and depressive mood to CHD outcome.

Methods and Results— We built a nested case-referent study within the Prospective Epidemiological Study of Myocardial Infarction (PRIME) study of healthy middle-aged men from Belfast and France. We considered the baseline plasma sample from 335 future cases (angina pectoris, nonfatal myocardial infarction, coronary death) and 670 matched controls (2 controls per case). Depressive mood characterized men whose baseline depression score (13-item modification of the Welsh depression subscale) was in the fourth quartile (mean score, 5.75; range, 4 to 12). On average, men with depressive mood had 46%, 16%, and 10% higher C-reactive protein, interleukin-6, and intercellular adhesion molecule-1 levels, respectively, independently of case-control status, social characteristics, and classic cardiovascular risk factors; no statistical difference was found for fibrinogen. The odds ratios of depressive mood for CHD were 1.35 (95% CI, 1.05 to 1.73) in univariate analysis and 1.50 (95% CI, 1.04 to 2.15) after adjustment for social characteristics and classic cardiovascular risk factors. The latter odds ratio remained unchanged when each inflammatory marker was added separately, and in this analysis, each inflammatory marker contributed significantly to CHD event risk.

Conclusions— These data support an association of depressive mood with inflammatory markers and suggest that depressive mood is related to CHD even after adjustment for these inflammatory markers.

Sagittal abdominal diameter and risk of sudden death in asymptomatic middle-aged men: the Paris Prospective Study I

BACKGROUND

Abdominal (visceral) and overall obesity are both related to coronary heart disease mortality risk; however, the relative contribution of these 2 components of fat deposit in the etiology of sudden death is unknown.

METHODS AND RESULTS

We used the data from 7079 asymptomatic men of the Paris Prospective Study I who were free of ischemic heart disease and who were 43 to 52 years of age at first clinical examination between 1967 and 1972. Body mass index (BMI) and sagittal abdominal diameter (SAD) were measured at baseline and used as markers of overall and abdominal obesity. During a follow-up of 23 years, there were 118 sudden deaths and 192 fatal myocardial infarctions. After adjustment for baseline level of cardiovascular risk factors, trunk subcutaneous fat, and thoracic diameter, the ratio of the fifth over the first quintile of SAD was 2.6 (95% CI 1.0 to 6.7) and 2. 6 (95% CI 1.3 to 5.1) for sudden death and fatal myocardial infarction, respectively, and the risk of sudden death increased proportionally with SAD level. The corresponding ratios for BMI were 2.0 (95% CI 1.1 to 3.8) and 1.0 (95% CI 0.6 to 1.7), respectively. Compared with men with low SAD (first tertile) and normal BMI (<25 kg/m2), men with elevated SAD (third tertile) were at increased risk of sudden death but not of fatal myocardial infarction, whether they were of normal weight (multivariate adjusted relative risk 3. 0 [95% CI 1.3 to 6. 9]) or overweight (BMI > or =25 kg/m2; 1.9 [95% CI 1.0 to 3.9]).

CONCLUSIONS

In asymptomatic French middle-aged men, larger SAD was associated with a particularly increased risk of sudden death, independent of BMI level and known cardiovascular risk factors.

Antenatal corticosteroids policies in 14 European countries: factors associated with multiple courses. The EURAIL survey

AIM

To describe antenatal corticosteroids (ANCs) policies in European obstetric units and to determine factors that influence the use of multiple courses.

METHODS

641 obstetricians from obstetric departments covering a geographical area in 14 European countries responded to a questionnaire on ANCs policies. Logistic regression was used to identify factors that were related to the use of multiple ANCs courses.

RESULTS

The survey response rate was 76% (inter-country range 33-94%): 11% (0-50%) of the respondents started ANCs from 23 to 24 wk gestation, 82% from 24 to 28 wk (50-100%) and 7% from 28 to 36 wk (0-32%). Eighty-five percent of the units (63-100%) used multiple ANCs courses. After adjustment for country, number of infants delivered at 24-32 wk annually in the unit, NICU and maternal hypertension, maternal hypertension tended to be an explicative factor (OR 1.97; 95% CI: 0.75-5.17).

CONCLUSIONS

The high proportion of departments that initiated ANCs between 24 and 28 wk of gestation is consistent with the high incidence of neonatal morbidity and mortality in that age range. Multiple courses are overwhelmingly prescribed in Europe, although their risk/benefit ratio compared with a single dose is not yet known. The likelihood of using repeated courses of ANCs may be related to the presence of maternal hypertension, and this highlights the importance of closely monitoring women at risk of premature delivery.

Natural history and risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy

BACKGROUND

Management of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is complicated by the incomplete information on the natural history of the disease and by the lack of risk stratification for cardiovascular death. The aim of the study was the identification of risk factors related to long-term prognosis.

METHODS AND RESULTS

Data were collected from 130 patients (100 men; age at onset of symptoms, 31.8+/-14.4 years) from a tertiary center between 1977 and 2000 who fulfilled the international standardized diagnostic criteria for ARVD/C. Risk factors for cardiovascular death were determined by a logistic regression model. After a mean follow-up of 8.1+/-7.8 years, 24 deaths were recorded, with a mean age at death of 54+/-19 years (annual mortality rate, 2.3%). There were 21 deaths with a cardiovascular origin (progressive heart failure for 14 patients and sudden death for the remaining 7 patients). All patients who died had a history of ventricular tachycardia. Multivariate analysis showed that after adjustment for sex, history of syncope, chest pain, inaugural ventricular tachycardia, recurrence of ventricular tachycardia, and QRS dispersion, clinical signs of right ventricular failure and left ventricular dysfunction both remained independently associated with cardiovascular mortality. The combined presence of one of these risk factors and ventricular tachycardia identifies high-risk subjects for cardiovascular mortality, whereas patients without ventricular tachycardia displayed the best prognosis.

CONCLUSIONS

The information on the natural history of patients with ARVD allowed us to identify risks factors for cardiovascular mortality. An analysis of a large international registry is needed to refine these results.