European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts)

Relationship of musculoskeletal pain and well-being at work - Does pain matter?

BACKGROUND AND AIMS

Musculoskeletal pain is a common symptom and many people even with chronic pain continue to work. The aim of our study is to analyze how musculoskeletal pain affects work well-being by comparing work engagement in employees with or without pain, and how pain-related risk of disability is associated with work engagement. In a separate analysis, we also studied, how psychosocial factors are related to work engagement.

METHODS

This is a cross-sectional study of Finnish female employees of the city of Pori, Finland (PORi To Aid Against Threats (PORTAAT) study). Data was collected by trained study nurses and self-administrated questionnaires. Work well-being was measured by work engagement using Utrecht Work Engagement Scale (UWES-9) questionnaire and the burden of pain was measured by using the short version of Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ). Study population was divided into four groups: those without pain and the groups with low (I), medium (II) or high (III) ÖMPSQ score, reflecting increasing risk of long term disability due to musculoskeletal pain. The study nurse assessed psychosocial risk factors using defined core questions.

RESULTS

We evaluated 702 female employees, 601 (86%) had suffered from musculoskeletal pain over the past 12 months, whereas 101 (14%) reported no pain at all. Pain was chronic (duration at least 3 months) in 465/601 (77%) subjects. Subjects with musculoskeletal pain were older, had higher BMI and were on sick leave more often than subjects without pain. Of the psychosocial risk factors, depression, type D personality, anxiety and hostility were significantly more common among subjects with musculoskeletal pain. Hypertension and the use of non-steroidal anti-inflammatory drugs were significantly more frequent in the musculoskeletal pain group. Quality of sleep and working capability were significantly better among persons without pain. Average weekly working hours were slightly higher among those with musculoskeletal pain. In crude analysis, work engagement (UWES-9) was similar in women without pain and those with musculoskeletal pain (4.96 vs. 4.79; p=0.091). After adjustment for age, education years, BMI, working hours and financial satisfaction, the difference between the groups became statistically significant (p=0.036). Still, there was no difference between the groups of no-pain and low burden of pain (p=0.21, after adjustment). Work engagement was significantly lower in the groups of medium (p=0.024, after adjusted) and high (p<0.001, after adjustment) burden of pain. Linearity across the Linton tertiles was significant (p<0.001). In univariate and multivariate ordered logistic regression analyses relating study variables to the work engagement musculoskeletal pain per se did not enter in the model to explain work engagement. Work and family stress, type D personality and duration of sick leave due to pain reduced work engagement, whereas financial satisfaction, moderate and high leisure time physical activity and higher BMI improved it.

CONCLUSIONS

Among women with musculoskeletal pain psychosocial and lifestyle factors significantly correlate with work engagement, while the pain itself does not.

IMPLICATIONS

Special attention should be paid to the psychosocial aspects in female employees with musculoskeletal pain to improve work well-being and maintain work ability.

Risk factor paradox in the occurrence of cardiac arrest in acute coronary syndrome patients

Objective:

To compare patients without previously diagnosed cardiovascular risk factors) and patients with one or more risk factors admitted with acute coronary syndrome.

Methods:

This was a retrospective analysis of patients admitted with first episode of acute coronary syndrome without previous heart disease, who were included in a national acute coronary syndrome registry. The patients were divided according to the number of risk factors, as follows: 0 risk factor (G0), 1 or 2 risk factors (G1 - 2) and 3 or more risk factors (G ≥ 3). Comparative analysis was performed between the three groups, and independent predictors of cardiac arrest and death were studied.

Results:

A total of 5,518 patients were studied, of which 72.2% were male and the mean age was 64 ± 14 years. G0 had a greater incidence of ST-segment elevation myocardial infarction, with the left anterior descending artery being the most frequently involved vessel, and a lower prevalence of multivessel disease. Even though G0 had a lower Killip class (96% in Killip I; p < 0.001) and higher ejection fraction (G0 56 ± 10% versus G1 - 2 and G ≥ 3 53 ± 12%; p = 0.024) on admission, there was a significant higher incidence of cardiac arrest. Multivariate analysis identified the absence of risk factors as an independent predictor of cardiac arrest (OR 2.78; p = 0.019). Hospital mortality was slightly higher in G0, although this difference was not significant. By Cox regression analysis, the number of risk factors was found not to be associated with mortality. Predictors of death at 1 year follow up included age (OR 1.05; p < 0.001), ST-segment elevation myocardial infarction (OR 1.94; p = 0.003) and ejection fraction < 50% (OR 2.34; p < 0.001).

Conclusion:

Even though the group without risk factors was composed of younger patients with fewer comorbidities, better left ventricular function and less extensive coronary disease, the absence of risk factors was an independent predictor of cardiac arrest.

Effects of low molecular weight procyanidin rich extract from french maritime pine bark on cardiovascular disease risk factors in stage-1 hypertensive subjects: Randomized, double-blind, crossover, placebo-controlled intervention trial

BACKGROUND

Oligopin^ۚ (OP) is a quantified extract from French Maritime Pine bark (FMPB) with low molecular weight procyanidins. The cardioprotective effects of OP need to be tested in human clinical intervention trials with an appropriate design.

PURPOSE

The aim of the present study was to assess the effect of subchronic consumption of OP on cardiovascular disease risk factors such as lipid profile, systolic blood pressure (BP) and oxidized-Low Density Lipoprotein (ox-LDL) in stage-1-hypertensive subjects.

METHODS

Between February 14 and May 31, 2014, eligible subjects were recruited from the outpatient clinics of Hospital Universitari Sant Joan (Reus, Spain). A total of 24 participants (mean age ± DS; 57.36 ± 11.25; 17 men) with stage-1-hypertension who were not receiving BP-lowering medication and LDL cholesterol < 4.88 mmol/l were randomized in a double-blind, placebo-controlled, crossover study. The subjects received 2 capsules/day with 75 mg of OP or placebo for 5-weeks.

RESULTS

At 5-weeks, compared to the placebo, OP raised High Density Lipoprotein-cholesterol (HDL-c) by 14.06% (p = 0.012) and apolipoprotein A-1 by 8.12% (p = 0.038) and reduced the ratio of apolipoprotein B-100/A-1 by 10.26% (p = 0.046). Moreover, at 5-weeks, compared to the baseline, OP reduced the systolic BP by 6.36 mmHg (p = 0.014), and decreased ox-LDL concentrations by 31.72 U/l (p = 0.015).

CONCLUSION

At 5-weeks, the consumption of 150 mg/day of OP improve lipid cardiovascular profile and represents one of the scarce ways to increase HDL-c in stage-1-hypertensive subjects.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02063477.

[Chronic kidney disease and dyslipidaemia]

Chronic kidney disease (CKD) has to be considered as a high, or even very high risk cardiovascular risk condition, since it leads to an increase in cardiovascular mortality that continues to increase as the disease progresses. An early diagnosis of CKD is required, together with an adequate identification of the risk factors, in order to slow down its progression to more severe states, prevent complications, and to delay, whenever possible, the need for renal replacement therapy. Dyslipidaemia is a factor of the progression of CKD that increases the risk in developing atherosclerosis and its complications. Its proper control contributes to reducing the elevated cardiovascular morbidity and mortality presented by these patients. In this review, an assessment is made of the lipid-lowering therapeutic measures required to achieve to recommended objectives, by adjusting the treatment to the progression of the disease and to the characteristics of the patient. In CKD, it seems that an early and intensive intervention of the dyslipidaemia is a priority before there is a significant decrease in kidney function. Treatment with statins has been shown to be safe and effective in decreasing LDL-Cholesterol, and in the reduction of cardiovascular events in individuals with CKD, or after renal transplant, although there is less evidence in the case of dialysed patients.

[Using plant sterols in clinical practice: From the chemistry to the clinic]

This paper describes what are plant sterols, the chemical structure to understand their mechanism of cholesterol-lowering action, and indications and contraindications in clinical practice.

Severity of statin-induced adverse effects on muscle and associated conditions: data from the DAMA study

BACKGROUND

Statins are generally well tolerated, but muscular adverse effects appear to be the most common obstacle limiting their use. Our objective was to describe the severity of muscle injury (myalgia, myositis and rhabdomyolysis) and associated conditions related to statin therapy that may be clinically significant.

METHODS

A cross-sectional one-visit, non-interventional, national multicenter study including patients of both sexes over 18 years of age referred for past or present muscle symptoms associated with statin therapy was conducted. Clinical, biochemical and drug therapy characteristics were obtained at the initial evaluation.

RESULTS

3,845 patients were recruited from a one-day record from 2,001 physicians. Myalgia was present in 78.2% of patients, myositis in 19.3% and rhabdomyolysis in 2.5%. The prevalence of different comorbidities such as diabetes, hypertension, atrial fibrillation, and coronary heart disease increased as the severity of myopathy rose. High-intensity statin therapy was used in 33.4% of patients. Concomitant drugs metabolized by the CYP450 3A4 pathway were taken by 9.3% of patients, and statins with this metabolic route by 75%. Independent variables associated with myositis or rhabdomyolysis compared with myalgia alone in the multivariate model were excessive alcohol consumption and pravastatin therapy.

CONCLUSION

Myalgia was the most common muscle adverse effect associated with statin therapy. Excessive alcohol consumption and pravastatin were independently associated with myositis or rhabdomyolysis.

A Bayesian Network analysis of the probabilistic relations between risk factors in the predisposition to type 2 diabetes

In order to better understand the relations between different risk factors in the predisposition to type 2 diabetes, we present a Bayesian Network analysis of a large dataset, composed of three European population studies. Our results show, together with a key role of metabolic syndrome and of glucose after 2 hours of an Oral Glucose Tolerance Test, the importance of education, measured as the number of years of study, in the predisposition to type 2 diabetes.

Statin non-adherence and residual cardiovascular risk: There is need for substantial improvement

Although statin therapy has proven to be the cornerstone for prevention and treatment of cardiovascular disease (CVD), there are many patients for whom long-term therapy remains suboptimal. The aims of this article are to review the current complex issues associated with statin use and to explore when novel treatment approaches should be considered. Statin discontinuation as well as adherence to statin therapy remain two of the greatest challenges for lipidologists. Evidence suggests that between 40 and 75% of patients discontinue their statin therapy within one year after initiation. Furthermore, whilst the reasons for persistence with statin therapy are complex, evidence shows that low-adherence to statins negatively impacts clinical outcomes and residual CV risk remains a major concern. Non-adherence or lack of persistence with long-term statin therapy in real-life may be the main cause of inadequate low density lipoprotein cholesterol lowering with statins. There is a large need for the improvement of the use of statins, which have good safety profiles and are inexpensive. On the other hand, in a non-cost-constrained environment, proprotein convertase subtilisin/kexin type 9 inhibitors should arguably be used more often in those patients in whom treatment with statins remains unsatisfactory.

Hypertension awareness, treatment, and control among diabetic and nondiabetic individuals in a multiethnic population in the Netherlands: the HELIUS study

OBJECTIVES

There is a paucity of data on hypertension awareness, treatment and control among diabetic adults from different ethnic backgrounds. We assessed ethnic differences in prevalence, awareness, treatment, and control of hypertension among diabetic adults and how they are compared with individuals without diabetes.

METHODS

Baseline data from the Healthy Life in an Urban Setting study were used including 12 ,633 adults aged 18-70 years from six ethnic backgrounds in Amsterdam, the Netherlands. Age-sex-adjusted prevalence ratios were used to explore ethnic differences.

RESULTS

Among diabetic individuals, African-Surinamese (80.2%; 1.26, 95% confidence interval 1.06-1.51) and Ghanaians (81.7%; 1.40, 1.17-1.68) were more likely than Dutch (69.6%) to have hypertension. There were no significant ethnic differences in the rates of awareness and treatment, but blood pressure (BP) control rates among treated hypertensives were significantly lower in Ghanaians (41.7%; 0.66, 0.45-0.96) and African-Surinamese (28.7%; 0.53, 0.34-0.84) than Dutch (54.1%). Among nondiabetic adults, except Moroccans, all the ethnic minorities had higher prevalence rates of hypertension, awareness (except South-Asian Surinamese and Turks) and treatment than Dutch people. By contrast, BP control rates among treated hypertensives were lower in all ethnic minorities, with the differences being significant for African-Surinamese (42.5%; 0.68, 0.57-0.80), South-Asian Surinamese (41.8%; 0.68, 0.57-0.82), and Ghanaians (35.2%; 0.54, 0.45-0.65).

CONCLUSION

Hypertension awareness and treatment rates are similar among ethnic groups in both diabetics and nondiabetics. Adequate BP control remains low among ethnic minorities, particularly among diabetic African origin people. Major effort is needed to improve BP control among diabetic people given the cardiovascular complications associated with uncontrolled BP in this group.

Model-observational bridging study on the effectiveness of ezetimibe on cardiovascular morbidity and mortality in France: A population-based study

BACKGROUND

To evaluate the real-life impact of ezetimibe on cardiovascular (CV) morbidity and mortality in France.

OBJECTIVE

To estimate the number of non-fatal and fatal CV events that could be prevented and corresponding number of patients needed to treat (NNT) with ezetimibe to prevent one CV event over 5 years.

METHODS

Non-interventional 48-month follow-up cohort conducted in hypercholesterolemic patients starting on ezetimibe <3 months at study entry, either as monotherapy or combined with statins. Prediction modeling using discrete event simulation with calibrated Framingham CV risk equations was applied to data from pivotal clinical trials on ezetimibe and real-life data derived from the cohort.

RESULTS

A total of 3215 patients in the cohort accumulated 9314 person-years of follow-up for an average of 2.9 years. Mean age was 61.5 (standard deviation [SD] = 10.7), 54.6% were males, and 27.0% had a history of CV disease. Baseline LDL-cholesterol averaged 4.1 mmol/L (159 mg/dL; SD = 1.0) and HDL-C 1.6 mmol/L (62 mg/dL; SD = 0.5). LDL-C decreased in the first 12 months in ezetimibe-LLT (lipid-lowering therapy) initiators, switchers (monotherapy), and combination therapy with a statin by respectively 21.3%, 6.4%, and 29.1%. The corresponding predicted rate reductions of CV events (non-fatal and fatal) compared to no treatment or to a statin (combination therapy) were respectively 8, 2, and 12 per 1000 patients treated over 5 years, with a global NNT of 143 patients over 5 years.

CONCLUSION

These results, accounting for observed CV event rates, risk factors evolution over time and adherence to treatment in real life, were consistent with those from clinical trials.

The activity of 11β-hydroxysteroid dehydrogenase type 2 enzyme and cortisol secretion in patients with adrenal incidentalomas

In adrenal incidentaloma (AI) patients, beside the cortisol secretion, a different 11β-hydroxysteroid dehydrogenase type 2 (HSD11B2) activity, measurable by 24-h urinary cortisol/cortisone ratio (R-UFF/UFE) (the higher R-UFF/UFE the lower HSD11B2 activity), could influence the occurrence of the subclinical hypercortisolism (SH)-related complications (hypertension, type 2 diabetes, obesity). We evaluated whether in AI patients, UFF levels are associated to UFE levels, and the HSD11B2 activity to the complications presence. In 156 AI patients (93F, age 65.2 ± 9.5 years), the following were measured: serum cortisol after 1 mg-dexamethasone test (1 mg-DST), ACTH, UFF, UFE levels, and R-UFF/UFE (by liquid chromatography-tandem mass spectrometry), the latter was also evaluated in 63 matched-controls. We diagnosed SH (n = 22) in the presence of ≥2 among ACTH <2.2 pmol/L, increased UFF levels, and 1 mg-DST >83 nmol/L. Patients showed higher UFF levels and R-UFF/UFE than controls (75.9 ± 43.1 vs 54.4 ± 22.9 nmol/24 h and 0.26 ± 0.12 vs 0.20 ± 0.07, p < 0.005, respectively) but comparable UFE levels (291 ± 91.1 vs 268 ± 61.5, p = 0.069). The R-UFF/UFE was higher in patients with high (h-UFF, n = 28, 0.41 ± 0.20) than in those with normal (n-UFF, 0.22 ± 0.10, p < 0.005) UFF levels and in patients with SH than in those without SH (0.30 ± 0.12 vs 0.25 ± 0.12, p = 0.04). UFF levels were associated with R-UFF/UFE (r = 0.849, p < 0.001) in n-UFF, but not in h-UFF patients. Among h-UFF patients, the complications prevalence was not associated with R-UFF/UFE values. In AI patients, the UFF increase is not associated with a UFE increase. The HSD11B2 activity is inversely associated with UFF levels in n-UFF patients but not in h-UFF patients, and it is not associated with the SH complications.

Risk factor indicators in offspring of patients with premature coronary heart disease in Banja Luka region/Republic of Srpska/Bosnia and Herzegovina

INTRODUCTION

Risk factor differences among offspring of patients with premature coronary heart disease (CHD) have not been widely studiem.

MATERIAL AND METHODS

We examined 161 persons from the region of Banja Luka, including 81 children (mean age: 25.9 years, 45.7% female) with a history of CHD and a control group of 80 persons (mean age: 24.1, 50% female). Medical history interviews and risk factor measurements were performed.

RESULTS

There were differences in mean body amss index (BMI) (26.1 kg/m(2) vs. 23.1 kg/m(2), p < 0.0001), waist circumference (87.7 cm vs. 83.9 cm, p = 0.002), hip circumference (99.3 cm vs. 95.84 cm, p < 0.002), systolic blood pressure (BP) (128.09 mm Hg vs. 122.7 mm Hg, p = 0.007), and diastolic BP (99.3 mm Hg vs. 95.8 mm Hg, p = 0.07). Moreover, HDL-cholesterol was significantly lower (1.1 mmol/l vs. 1.4 mmol/l, p = 0.0001), triglycerides significantly higher (2.2 mmol/l vs. 1.6 mmol/l, p = 0.001), and TC/HDL-ratio was significantly higher (5.1 vs. 4.0, p < 0.001) comparing cases and controls, respectively, adjusted for age, gender, and standard CHD risk factors total cholesterol, LDL and HDL cholesterol, smoking, systolic and diastolic BP, and BMI, those with HDL-C > 1.0 mmol/l in men and 1.2 mmol/l in women had a reduced odds (OR = 0.08, 95% CI: 0.02-0.34 of CHD as well as those with change of fat type (OR = 0.26, 95% CI: 0.11-0.60).

CONCLUSIONS

Children of parents with premature CHD have a significantly greater burden of CHD risk factors, with low HDL-C, in particular, being associated with an increased likelihood of being a child of a parent with premature CHD.

Guidelines for Management of Hyperlipidemia: Implications for Treatment of Patients with Stroke Secondary to Atherosclerotic Disease

After careful review of randomized cardiovascular outcomes trial data, the 2013 ACC/AHA cholesterol guideline focused on using the appropriate intensity of statin therapy to reduce atherosclerotic cardiovascular disease (ASCVD) risk and moved away from recommending specific low-density lipoprotein cholesterol (LDL-C) treatment targets. In patients who have had a stroke or other clinical ASCVD event, a high-intensity statin should be initiated up to age 75 years unless there are safety concerns, including a history of hemorrhagic stroke. A moderate-intensity statin is recommended if there are safety concerns or age is greater than 75 years. Atorvastatin 40-80 mg and rosuvastatin 20-40 mg are considered high-intensity statins. These new guidelines avoid unnecessary usage of non-statins to achieve specific LDL-C values, thus avoiding potential adverse effects or use of an inadequate statin intensity in patients who are "at goal." When non-statins are considered for additional LDL-C lowering, ezetimibe is the only non-statin clearly shown to further reduce ASCVD risk when added to background statin therapy.

Current status of carotid ultrasound in atherosclerosis

Cardiovascular disease (CVD) primarily caused by atherosclerosis is a major cause of death and disability in developed countries. Sonographic carotid intima-media thickness (CIMT) is widely studied as a surrogate marker for detecting subclinical atherosclerosis for risk prediction and disease progress to guide medical intervention. However, there is no standardized CIMT measurement methodology in clinical studies resulting in inconsistent findings, thereby undermining the clinical value of CIMT. Increasing evidences show that CIMT alone has weak predictive value for CVD while CIMT including plaque presence consistently improves the predictive power. Quantification of plaque burden further enhances the predictive power beyond plaque presence. Sonographic carotid plaque characteristics have been found to be predictive of cerebral ischaemic events. With advances in ultrasound technology, enhanced assessment of carotid plaques is feasible to detect high-risk/vulnerable plaques, and provide risk assessment for ischemic stroke beyond measurement of luminal stenosis.

CORonary Diet Intervention with Olive oil and cardiovascular PREVention study (the CORDIOPREV study): Rationale, methods, and baseline characteristics: A clinical trial comparing the efficacy of a Mediterranean diet rich in olive oil versus a low-fat diet on cardiovascular disease in coronary patients

Coronary heart disease (CHD) represents a major global health burden. However, despite the well-known influence that dietary habits exert over the progression of this disease, there are no well-established and scientifically sound dietary approaches to prevent the onset of clinical outcomes in secondary prevention. The objective of the CORonary Diet Intervention with Olive oil and cardiovascular PREVention study (CORDIOPREV study, clinical trials number NCT00924937) is to compare the ability of a Mediterranean diet rich in virgin olive oil versus a low-fat diet to influence the composite incidence of cardiovascular events after 7 years in subjects with documented CHD at baseline. For this purpose, we enrolled 1,002 coronary patients from Spain. Baseline assessment (2009-2012) included detailed interviews and measurements to assess dietary, social, and biological variables. Results of baseline characteristics: The CORDIOPREV study in Spain describes a population with a high body mass index (37.2% overweight and 56.3% obesity) and with a median of low-density lipoprotein cholesterol of 88.5 mg/dL (70.6% of the patients having <100 mg/dL and 20.3% patients <70 mg/dL). A total of 9.6% of the participants were active smokers, and 64.4% were former smokers. Metabolic syndrome was present in 58% of this population. To sum up, we describe here the rationale, methods, and baseline characteristics of the CORDIOPREV study, which will test for the first time the efficacy of a Mediterranean diet rich in extra virgin olive oil as compared with a low-fat diet on the incidence of CHD recurrence in a long-term follow-up study.

Time trend in depression diagnoses among acute coronary syndrome patients and a reference population from 2001 to 2009 in Denmark

Introduction In the last decade a range of recommendations to increase awareness of depression in acute coronary syndrome patients have been published. To test the impact of those recommendations we examine and compare recent time trends in depression among acute coronary syndrome patients and a reference population. Methods 87 218 patients registered with acute coronary syndrome from 2001-2009 in Denmark and a match reference population were followed through hospital registries and medication prescriptions for early (≤30 days), intermediate (31 days to 6 months) and later (6 months to 2 years) depression in the acute coronary syndrome population and overall depression in the reference population. Cox regression models were used to compare hazard ratios (HRs) for depression over calendar years. Results During the study period, 11.0% and 6.2% were diagnosed with depression in the acute coronary syndrome population and in the reference population, respectively. For the acute coronary syndrome population, the adjusted HRs increased for early (HR (95% CI) 1.04 (1.01-1.06)) and intermediate depression (HR (95% CI) 1.01 (1.00-1.03)), whereas the adjusted HRs did not change for later depression (HR (95% CI) 0.99 (0.98-1.00)). For the reference population the adjusted HRs for depression increased through the study period (HR (95% CI) 1.01 (1.01-1.03)). Conclusion Increase in diagnoses of depressions within 6 months of acute coronary syndrome may be explained by increased focus on depression in this patient group in combination with increased awareness of depression in the general population.

Predictive Value of Arterial Stiffness and Subclinical Carotid Atherosclerosis for Cardiovascular Disease in Patients with Rheumatoid Arthritis

Objective.

We evaluated the predictive value of these vascular biomarkers for cardiovascular disease (CVD) events in patients with rheumatoid arthritis (RA): aortic pulse wave velocity (aPWV), augmentation index (AIx), carotid intima-media thickness (cIMT), and carotid plaques (CP). They are often used as risk markers for CVD.

Methods.

In 2007, 138 patients with RA underwent clinical examination, laboratory tests, blood pressure testing, and vascular biomarker measurements. Occurrence of CVD events was recorded in 2013. Predictive values were assessed in Kaplan-Meier plots, log-rank, and crude and adjusted Cox proportional hazard (PH) regression analyses.

Results.

Baseline median age and disease duration was 59.0 years and 17.0 years, respectively, and 76.1% were women. CVD events occurred in 10 patients (7.2%) during a mean followup of 5.4 years. Compared with patients with low aPWV, AIx, cIMT, and without CP, patients with high aPWV (p < 0.001), high AIx (p = 0.04), high cIMT (p = 0.01), and CP (p < 0.005) at baseline experienced more CVD events. In crude Cox PH regression analyses, aPWV (p < 0.001), cIMT (p < 0.001), age (p = 0.01), statin (p = 0.01), and corticosteroid use (p = 0.01) were predictive of CVD events, while AIx was nonsignificant (p = 0.19). The Cox PH regression estimates for vascular biomarkers were not significantly altered when adjusting individually for demographic variables, traditional CVD risk factors, RA disease-related variables, or medication. All patients who developed CVD had CP at baseline.

Conclusion.

CP, aPWV, and cIMT were predictive of CVD events in this cohort of patients with RA. Future studies are warranted to examine the additive value of arterial stiffness and carotid atherosclerosis markers in CVD risk algorithms. Regional Ethical Committee approval numbers 2009/1582 and 2009/1583.

Determinants of prevalence, awareness, treatment and control of high LDL-C in Turkey

Objective:

High blood cholesterol is one of the main modifiable risk factors for cardiovascular diseases (CVDs). The aim of the study is to determine the factors associated with the prevalence, awareness, treatment, and control of high “low-density lipoprotein-cholesterol” (LDL-C) among adults aged ≥20 years in Turkey.

Methods:

We used data from Chronic Diseases and Risk Factors Survey conducted in 2011–2012. The presence of high LDL-C, lipid-lowering treatment eligibility, and achievement of target LDL-C were defined according to the third Adult Treatment Panel guidelines on treatment of high cholesterol. Multivariate logistic regression analyses were performed to determine the associations between participant characteristics and high LDL-C prevalence, awareness, treatment, and control.

Results:

Framingham risk score categorization was performed for 13121 individuals aged ≥20 years. Approximately, 28% of the participants presented with high LDL-C. Among those with high LDL-C, 55.8% were aware of their situation; among those aware of high LDL-C, 46.9% were receiving lipid-lowering medication, and 50.6% of individuals who were receiving treatment achieved target LDL-C levels on the basis of their coronary heart disease (CHD) risk. Control of high LDL-C was negatively associated with the presence of diabetes mellitus (odds ratio: 0.36, 95% CI: 0.27–0.49, p<0.001).

Conclusion:

Despite the high awareness rates, there was a high proportion of adults who did not receive treatment or achieve recommended levels of LDL-C during treatment. The low treatment and control levels among individuals based on their CHD risk levels call for a better application of recommendations regarding personal preventive measures and treatments in Turkey.

Biomarkers, erectile dysfunction, and cardiovascular risk prediction: the latest of an evolving concept

A number of circulating and imaging biomarkers are robustly associated with cardiovascular (CV) risk. The overall expectation from a biomarker in the erectile dysfunction (ED) setting is to enhance the optimal management of a man with this disorder but no clinical atherosclerosis. Evidence demonstrating that these biomarkers enhance risk prediction for individuals with ED is at this stage still limited for most of them. A better identification of the subsets of the ED population that require further risk stratification, as well as the initiation of randomized trials that will formally test the ability of biomarkers to predict CV risk, could make biomarker-guided prevention an attainable goal.

Ideal cardiovascular health and risk of cardiovascular events in the EPIC-Norfolk prospective population study

BACKGROUND

The American Heart Association has prioritised seven cardiovascular health metrics to reduce the cardiovascular burden, including: body mass index, healthy diet, physical activity, smoking status, blood pressure, glycated haemoglobin A1c and total cholesterol. The aim of the current study was to assess the association between the American Heart Association-defined health metrics and the risk of cardiovascular events in the EPIC-Norfolk prospective study.

DESIGN

Prospective cohort study.

METHODS

An overall cardiovascular health score was calculated based on the number of health metrics including ideal, intermediate or poor. Cox proportional hazards models were used to describe the association of the seven metrics separately and the overall health score with risk of coronary heart disease, stroke and cardiovascular disease. A total of 10,043 participants was included in the analysis (follow-up 1993-2008). For all individual health metrics a more ideal status was associated with a lower risk of cardiovascular events.

RESULTS AND CONCLUSION

As for the overall cardiovascular health score, those in the highest (i.e. healthiest) category (score 12-14) had an adjusted hazard ratio for coronary heart disease of 0.07 (95% confidence interval (CI) 0.02-0.29, P < 0.001), for stroke of 0.16 (95% CI 0.02-1.37, P = 0.09) and for cardiovascular disease of 0.07 (95% CI 0.02-0.23, P < 0.001), compared to people in the lowest (i.e. unhealthiest) category (score 0-2). The overall cardiovascular health score was strongly and inversely associated with risk of coronary heart disease, stroke and cardiovascular disease. Our data suggest that even small improvements in modifiable risk factors may lead to substantial reductions in the risks of cardiovascular events.

Cardiovascular risk stratification in familial hypercholesterolaemia

Familial hypercholesterolaemia (FH) is a common autosomal-dominant disorder in most European countries. Patients with FH are characterised by a raised level of low-density lipoprotein cholesterol and a high risk of premature coronary heart disease (CHD). Currently there is no consensus regarding the clinical utility to predict future coronary events or testing for the presence of subclinical atherosclerotic disease in asymptomatic patients with FH. Family screening of patients with FH as recommended by the UK National Institute of Health and Care Excellence guideline would result in finding many young individuals with a diagnosis of FH who are clinically asymptomatic. The traditional CHD risk scores, that is, the Framingham score, are insufficient in risk prediction in this group of young individuals. In addition, a better understanding of the genetic aetiology of the FH phenotype and CHD risk in monogenic FH and polygenic hypercholesterolaemia is needed. Non-invasive imaging methods such as carotid intima-media thickness measurement might produce more reliable information in finding high-risk patients with FH. The potential market authorisation of novel therapeutic agents such as PCSK9 monoclonal inhibitors makes it essential to have a better screening programme to prioritise the candidates for treatment with the most severe form of FH and at higher risk of coronary events. The utility of new imaging techniques and new cardiovascular biomarkers remains to be determined in prospective trials.

Cholesterol absorption and synthesis markers in Portuguese hypercholesterolemic adults: A cross-sectional study

OBJECTIVE

The dynamics of cholesterol homeostasis and the development of cardiovascular disease (CVD) are complex and multifactorial, to which adds individual variability in the proportion of cholesterol from exogenous versus endogenous sources. The aim of this study was to undertake the first characterization of cholesterol absorption and synthesis profiles in Portuguese hypercholesterolemic adults through the quantification of surrogate markers, and the analysis of the predictive value of age and sex on the cholesterol homeostasis biomarkers.

METHODS

Serum samples for the measurement of lipid profiles and cholesterol homeostasis markers were obtained for 100 men and 112 women, aged 30-65, with TC ≥ 5.2 mmol/L (~200mg/dL) and/or LDL-C ≥ 2.6 mmol/L (~100mg/dL), none of whom were on any lipid-lowering therapy.

RESULTS

Overall, sex-specific significant differences were observed in the cholesterol homeostasis markers and lipid profiles; women had lower cholesterol synthesis marker concentrations (P<0.01 for lathosterol) and lipid parameters (except for HDL-C concentrations). Age-related significant differences were also found, including higher concentrations of cholesterol absorption markers in association with increasing age.

CONCLUSION

In our study, the predictors of higher levels of cholesterol absorption markers were higher age and female gender.

LDL cholesterol is not a good marker of cardiovascular risk in Type 1 diabetes

AIM

LDL cholesterol (LDL-C) is considered an important cardiovascular disease (CVD) risk factor. Less is known in Type 1 diabetes. We assessed LDL-C and total cholesterol to HDL cholesterol ratio (TC/HDL-C) as predictors of CVD in Type 1 diabetes.

METHODS

The study monitored 30 778 people with Type 1 diabetes, baseline 2003-2006, to 31 December 2011. Cox regression analyses were performed with LDL-C and TC/HDL-C as predictors of fatal/non-fatal CVD. Models were adjusted for traditional CVD risk factors.

RESULTS

Hazard ratios (HR) (with 95% CI) per 1 mmol/l increase in LDL-C for CVD were 1.09 (1.01-1.18) in people without lipid-lowering medication and 1.02 (0.95-1.09) in people with lipid-lowering medication (P = 0.02 and 0.65). In people aged 40 years or older having a CVD risk factor, and in people with a history of CVD, HR was 1.07 (0.99-1.16) and 1.02 (0.92-1.13) (P = 0.07 and 0.66). HR per 1 unit increase in TC/HDL-C was 1.12 (1.05-1.20) in people without lipid-lowering medication and 1.08 (1.02-1.15) in people with lipid-lowering medication (P < 0.001 and 0.01). For people aged 40 or older and people with a history of CVD, HR was 1.16 (1.09-1.24) and 1.04 (0.95-1.14) (P < 0.001 and 0.43). Broken down into octiles, LDL-C was not a significant predictor of CVD in any group. Higher octiles of TC/HDL-C were significant predictors for CVD in people without lipid-lowering medication and in those aged 40 years or older.

CONCLUSION

In this study of people with Type 1 diabetes in clinical practice, LDL-C was not a good predictor of CVD. We found no support for an LDL-C cut-off point < 2.6 mmol/l. TC/HDL-C seems more reliable as a marker for CVD risk when considering primary prevention.

Adrenalectomy reduces the risk of vertebral fractures in patients with monolateral adrenal incidentalomas and subclinical hypercortisolism

OBJECTIVE

Subclinical hypercortisolism (SH) is associated with increased risk of vertebral fractures (VFx). The effect on bone following recovery from SH is unknown.

DESIGN

Of the 605 subjects consecutively referred for monolateral adrenal incidentalomas (AIs) to our outpatient clinics, 55 SH patients (recruited on the basis of the exclusion criteria) were enrolled. We suggested to all patients to undergo adrenalectomy, which was accepted by 32 patients (surgical group, age 61.3±8.1 years) and refused by 23 patients, who were followed with a conservative management (non-surgical group, age 65.4±7.1 years).

METHODS

We diagnosed SH in patients with serum cortisol after 1  mg dexamethasone suppression test (1  mg-DST) >5.0  μg/dl or with greater than or equal to two criteria among 1  mg-DST >3.0  μg/dl, urinary free cortisol >70  μg/24  h and ACTH <10  pg/ml. We assessed: bone mineral density (BMD) at lumbar spine (LS) and femoral neck (as Z-score) by dual-energy X-ray absorptiometry and the VFx presence by X-ray at baseline and at the end of follow up (surgical group 39.9±20.9 months and non-surgical group 27.7±11.1 months).

RESULTS

The LS Z-score (ΔZ-score/year) tended to increase in the surgical group (0.10±0.20) compared with the non-surgical group (-0.01±0.27, P=0.08) and in the former, the percentage of patients with new VFx was lower (9.4%) than in the latter (52.2%, P<0.0001). Surgery in AI patients with SH was associated with a 30% VFx risk reduction (odds ratio 0.7, 95% CI 0.01-0.05, P=0.008) regardless of age, gender, follow up duration, 1  mg-DST, LS BMD, and presence of VFx at baseline.

CONCLUSION

In patients with monolateral AI and SH, adrenalectomy reduces the risk of VFx.

Gender differences in quality of life perception and cardiovascular risk in a community sample

INTRODUCTION

Self-reported heath and quality of life is an independent predictor of overall and cardiovascular morbidity and mortality, and incident coronary heart disease. However, less is known regarding how gender differences in cardiovascular risk factors impact quality of life perception.

METHODS

Primary healthcare users (n=261, 158 women) were screened for cardiovascular risk factors and completed the Medical Outcomes Study Short Form (SF-36).

RESULTS

Women had significantly lower alcohol consumption, body mass index and exercise frequency than men, but more prevalent psychiatric history, depressive and anxiety symptoms, and negative affectivity. Prevalences of hypertension, diabetes, dyslipidemia and type D personality were similar between genders. Women reported significantly worse quality of life on most SF-36 subscales and gender differences were apparent in predictors of quality of life. Moreover, high negative affectivity was an independent predictor of worse general health for women, whereas high social inhibition and high anxiety had a comparable role for men.

CONCLUSION

Gender specifics in cardiovascular risk factors should be considered in prevention strategies. Women reported significantly worse quality of life, putting them at higher risk for cardiovascular morbidity and mortality. Therefore, gender differences in predictors of quality of life warrant further investigation.

Systemic T Cells and Monocyte Characteristics in Patients with Denture Stomatitis

PURPOSE

Chronic inflammatory disorders of the oral cavity, such as periodontitis, were recently linked to systemic immune activation. Since fungal oral infections have not yet been studied in this respect, the aim of our study is to determine whether the local inflammation caused by oral fungal infection of the palatal tissue (denture stomatitis-DS) is associated with the systemic inflammatory response. This question is becoming essential as the population ages.

MATERIALS AND METHODS

Peripheral blood of DS patients (n = 20) and control patients (n = 24) was assessed with flow cytometry to determine lymphocyte and monocyte profiles. Intracellular cytometric analysis was carried out to establish cytokine production by T cells. DS was diagnosed based on clinical symptoms of DS such as swelling and redness of oral mucosa, confirmed by microbiological swabs for fungal colonization with Candida species. The control group was recruited from denture users without clinical and microbiological signs of oral infections.

RESULTS

Percentages of peripheral lymphocytes, T cells, monocytes, and their subpopulations were similar in both studied groups. The exception was median percentages of CD25+ T cell subsets, which were significantly lower in DS patients than in control subjects. This reduction was observed in both CD4 T cell subset (16.7% and 28.1%; p = 0.0006) and CD8 T cell subset (4.6% and 7.0%; p = 0.007) CONCLUSIONS: While DS and associated local fungal infection do not overtly affect activation of monocytes or lymphocytes, the number of CD 25+ T cells is significantly lower in the DS patients, possibly indicating limited potential for the infection clearance in denture-using aging patients.

Parathyroid hormone, cardiovascular and all-cause mortality: A meta-analysis

BACKGROUND

Inconsistent findings have reported on parathyroid hormone (PTH) concentration and cardiovascular or all-cause mortality.

OBJECTIVE

To investigate whether elevated PTH concentration was an independent predictor for cardiovascular or all-cause mortality in the general population by conducting a meta-analysis based on prospective studies.

METHOD

We searched Cochrane Library, Pubmed, and Embase databases up to June 2015. Only prospective studies evaluating serum PTH concentration and cardiovascular or all-cause mortality were included. Pooled adjust risk ratio (RR) and corresponding 95% confidence intervals (CI) were calculated for the highest vs. lowest PTH concentration.

RESULTS

Ten studies with 31,616 subjects were identified and analyzed. Compared the highest to the lowest PTH concentration, elevated serum PTH concentration increased the risk of all-cause mortality (RR 1.19; 95% CI 1.08-1.30) but not for cardiovascular mortality (RR 1.26; 95% CI 0.96-1.66). Subgroup analyses indicated that cardiovascular mortality risk appeared to be more pronounced among men (RR 1.68; 95% CI 1.05-2.67).

CONCLUSIONS

Elevated PTH concentration is an independent predictor of all-cause mortality. Elevated serum PTH concentration appears to increase risk of cardiovascular mortality among men.

Role of peripheral vascular resistance for the association between major depression and cardiovascular disease

Major depression and cardiovascular diseases are 2 of the most prevalent health problems in Western society, and an association between them is generally accepted. Although the specific mechanism behind this comorbidity remains to be elucidated, it is clear that it has a complex multifactorial character including a number of neuronal, humoral, immune, and circulatory pathways. Depression-associated cardiovascular abnormalities associate with cardiac dysfunctions and with changes in peripheral resistance. Although cardiac dysfunction in association with depression has been studied in detail, little attention was given to structural and functional changes in resistance arteries responsible for blood pressure control and tissue perfusion. This review discusses recent achievements in studies of depression-associated abnormalities in resistance arteries in humans and animal experimental models. The changes in arterial structure, contractile and relaxing functions associated with depression symptoms are discussed, and the role of these abnormalities for the pathology of major depression and cardiovascular diseases are suggested.

Prediction of Cardiovascular Disease Risk by Cardiac Biomarkers in 2 United Kingdom Cohort Studies: Does Utility Depend on Risk Thresholds For Treatment?

We tested the predictive ability of cardiac biomarkers N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T, and midregional pro adrenomedullin for cardiovascular disease (CVD) events using the British Regional Heart Study (BRHS) of men aged 60 to 79 years, and the MIDSPAN Family Study (MFS) of men and women aged 30 to 59 years. They included 3757 and 2226 participants, respectively, and during median 13.0 and 17.3 years follow-up the primary CVD event rates were 16.6 and 5.3 per 1000 patient-years, respectively. In Cox models adjusted for basic classical risk factors, 1 SD increases in log-transformed NT-proBNP, high-sensitivity troponin T, and midregional pro adrenomedullin were generally associated with increased primary CVD risk in both the studies (P<0.006) except midregional pro adrenomedullin in MFS (P=0.10). In BRHS, QRISK2 risk factors yielded a C-index of 0.657, which was improved by 0.017 (P=0.005) by NT-proBNP, but not by other biomarkers. Using 28% 14-year risk as a proxy for 20% 10-year risk, NT-proBNP improved risk classification for primary CVD cases (case net reclassification index, 5.9%; 95% confidence interval, 2.8%-9.2%), but only improved classification of noncases at a 14% 14-year risk threshold (4.6%; 2.9%-6.3%). In MFS, ASSIGN risk factors yielded a C-index of 0.752 for primary CVD; none of the cardiac biomarkers improved the C-index. Improvements in risk classification were only seen using NT-proBNP and high-sensitivity troponin T among cases using the 28% 14-year risk threshold (4.7%; 1.0%-9.2% and 2.6%; 0.0%-5.8%, respectively). In conclusion, the improvement in treatment allocation gained by adding cardiac biomarkers to risk scores seems to depend on the risk threshold chosen for commencing preventative treatments.

Vascular Health in American Football Players: Cardiovascular Risk Increased in Division III Players

Studies report that football players have high blood pressure (BP) and increased cardiovascular risk. There are over 70,000 NCAA football players and 450 Division III schools sponsor football programs, yet limited research exists on vascular health of athletes. This study aimed to compare vascular and cardiovascular health measures between football players and nonathlete controls. Twenty-three athletes and 19 nonathletes participated. Vascular health measures included flow-mediated dilation (FMD) and carotid artery intima-media thickness (IMT). Cardiovascular measures included clinic and 24 hr BP levels, body composition, VO2 max, and fasting glucose/cholesterol levels. Compared to controls, football players had a worse vascular and cardiovascular profile. Football players had thicker carotid artery IMT (0.49 ± 0.06 mm versus 0.46 ± 0.07 mm) and larger brachial artery diameter during FMD (4.3 ± 0.5 mm versus 3.7 ± 0.6 mm), but no difference in percent FMD. Systolic BP was significantly higher in football players at all measurements: resting (128.2 ± 6.4 mmHg versus 122.4 ± 6.8 mmHg), submaximal exercise (150.4 ± 18.8 mmHg versus 137.3 ± 9.5 mmHg), maximal exercise (211.3 ± 25.9 mmHg versus 191.4 ± 19.2 mmHg), and 24-hour BP (124.9 ± 6.3 mmHg versus 109.8 ± 3.7 mmHg). Football players also had higher fasting glucose (91.6 ± 6.5 mg/dL versus 86.6 ± 5.8 mg/dL), lower HDL (36.5 ± 11.2 mg/dL versus 47.1 ± 14.8 mg/dL), and higher body fat percentage (29.2 ± 7.9% versus 23.2 ± 7.0%). Division III collegiate football players remain an understudied population and may be at increased cardiovascular risk.

The Framingham Score and the Systematic Coronary Risk Evaluation at Low Cutoff Values Are Useful Surrogate Markers of High-risk Subclinical Atherosclerosis in Patients with Rheumatoid Arthritis

Objective.

We determined the performance of the Framingham score and the Systematic COronary Risk Evaluation (SCORE) in assessing high-risk atherosclerosis in patients with rheumatoid arthritis (RA).

Methods.

We assembled 330 cases without established cardiovascular disease (CVD), diabetes, and moderate or severe chronic kidney disease among 451 consecutive Spanish patients who underwent CVD risk screening and carotid ultrasound-determined plaque assessment. The findings were validated in 90 black and 97 white African patients.

Results.

When sensitivity for the Framingham score was set at 80% in receiver-operator curve analysis [area under the curve (AUC) = 0.799], the corresponding cutoff value and specificity were 7.3% and 63%, respectively. At a specificity of 80%, the cutoff value and sensitivity were 10.8% and 65%, respectively. When sensitivity for SCORE (AUC = 0.747) was set at 80%, the cutoff value and specificity were 0.5% and 58%, respectively. At a specificity of 80%, the cutoff value and sensitivity were 1.5% and 50%, respectively. Upon applying a cutoff value of 7.3% for the Framingham and 0.5% for SCORE in African white patients with RA, the corresponding sensitivities and specificities were 67% and 72%, and 67% and 55%, respectively. CVD risk equations did not discriminate between black African patients with and without plaque (AUC = 0.544 and 0.549 for Framingham score and SCORE, respectively).

Conclusion.

The Framingham score and SCORE at markedly low cutoff values of 7.3% to 10.8% and 0.5% to 1.5%, respectively, can usefully estimate plaque presence in RA. Effective population-specific CVD risk assessment strategies are needed in black African patients with RA.

Factors associated with lipid goal attainment among acute coronary syndrome patients

BACKGROUND

The incidence of acute coronary syndrome (ACS), one of the most common cardiovascular diseases, is high. Lipid goal attainment is one of the important factors to reduce the risk of recurrent heart attack. Identification of factors influencing lipid goal attainment such as age, female, race, underlying comorbidities, intensity of lipid-lowering therapy, patients' knowledge, and patients' belief about medicine would be beneficial in achieving the lipid goal. This study is aimed to determine lipid profile attainment and prescribing pattern of lipid-lowering therapy as well as to identify factors influencing lipid profile attainment among ACS patients.

PATIENTS AND METHODS

This researcher-assisted cross-sectional survey was carried out at a cardiology clinic in a tertiary hospital from March to May 2015.

RESULTS

A total of 101 ACS patients were involved in this study. The mean values for low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol levels were 2.75 (0.82) mmol/L and 1.14 (0.27) mmol/L, respectively, while the median value for triglyceride level was 2.75 (0.82) mmol/L. Only 15.8% of our participants achieved the targeted LDL-C. Simvastatin 20 mg was the most common regimen prescribed. Predictors for better LDL-C attainment were younger age (β=-0.228; P=0.032) and higher knowledge score (β=-0.255; P=0.049), while predictors for high-density lipoprotein cholesterol attainment were male (β=0.268; P=0.006), smoking (β=-0.192; P=0.045), and higher knowledge score (β=-0.195; P=0.039). Smoking (β=-0.361; P<0.0001) was the only predictor for higher triglyceride level.

CONCLUSION

Younger age, female, lower knowledge score, and smoking status are good predictors for lipid attainment among ACS patients.

Heterogeneous impact of classic atherosclerotic risk factors on different arterial territories: the EPIC-Norfolk prospective population study

AIMS

Particular atherosclerotic risk factors may differ in their association with atherosclerosis across vascular territories. Few studies have compared the associations between multiple risk factors and cardiovascular disease (CVD) manifestations in one population. We studied the strength of the associations between traditional risk factors including coronary artery disease (CAD), ischaemic and haemorrhagic stroke, abdominal aortic aneurysms (AAAs), and peripheral arterial disease (PAD).

METHODS AND RESULTS

This analysis included 21 798 participants of the EPIC-Norfolk population study, without previous CVD. Events were defined as hospitalization or mortality, coded using ICD-10. The associations between the risk factors, such as low-density lipoprotein cholesterol, systolic blood pressure (SBP), and smoking, and the various CVD manifestations were compared using competing risk analyses. During 12.1 years, 3087 CVD events were recorded. The associations significantly differed across CVD manifestations. Low-density lipoprotein cholesterol was strongly associated with CAD [adjusted hazard rate (aHR) highest vs. lowest quartile 1.63, 95% CI 1.44-1.86]. Systolic blood pressure was a strong risk factor for PAD (aHR highest vs. lowest quartile 2.95, 95% CI 1.78-4.89) and ischaemic stroke (aHR highest vs. lowest quartile 2.48, 95% CI 1.55-3.97), but not for AAA. Smoking was strongly associated with incident AAA (aHR current vs. never 7.66, 95% CI 4.50-13.04) and PAD (aHR current vs. never 4.66, 95% CI 3.29-6.61), but not with haemorrhagic stroke.

CONCLUSION

The heterogeneity in the risk factor-CVD associations supports the concept of pathophysiological differences between atherosclerotic CVD manifestations and could have implications for CVD prevention.