2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR)

Associations of Dietary Patterns and Metabolic-Hormone Profiles with Breast Cancer Risk: A Case-Control Study

Breast cancer is the most diagnosed cancer in women worldwide. Studies regarding complex breast cancer aetiology are limited and the results are inconclusive. We investigated the associations between dietary patterns (DPs), metabolic-hormone profiles (M-HPs), and breast cancer risk. This case-control study involved 420 women aged 40⁻79 years from north-eastern Poland, including 190 newly-diagnosed breast cancer cases. The serum concentration of lipid components, glucose, and hormones (oestradiol, progesterone, testosterone, prolactin, cortisol, insulin) was marked in 129 post-menopausal women (82 controls, 47 cases). The food frequency consumption was collected using a validated 62-item food frequency questionnaire. A posteriori DPs or M-HPs were derived with a Principal Component Analysis (PCA). Three DPs: 'Non-Healthy', 'Prudent', and 'Margarine and Sweetened Dairy' and two M-HPs: 'Metabolic-Syndrome' and 'High-Hormone' were identified. The 'Polish-adapted Mediterranean Diet' ('Polish-aMED') score was calculated. The risk of breast cancer risk was three-times higher (odds ratio (OR): 2.90; 95% confidence interval (95% Cl): 1.62⁻5.21; p < 0.001) in the upper tertile of the 'Non-Healthy' pattern (reference: bottom tertile) and five-times higher (OR: 5.34; 95% Cl: 1.84⁻15.48; p < 0.01) in the upper tertile of the 'High-Hormone' profile (reference: bottom tertile). There was a positive association of 'Metabolic-Syndrome' profile and an inverse association of 'Polish-aMED' score with the risk of breast cancer, which disappeared after adjustment for confounders. No significant association between 'Prudent' or 'Margarine and Sweetened Dairy' DPs and cancer risk was revealed. Concluding, a pro-healthy diet is insufficient to reduce the risk of breast cancer in peri- and postmenopausal women. The findings highlight the harmful effect of the 'High-Hormone' profile and the 'Non-Healthy' dietary pattern on breast cancer risk. In breast cancer prevention, special attention should be paid to decreasing the adherence to the 'Non-Healthy' pattern by reducing the consumption of highly processed food and foods with a high content of sugar and animal fat. There is also a need to monitor the concentration of multiple sex hormones in the context of breast cancer risk.

Exercise participation has increased in patients with Rheumatoid Arthritis: A cross-sectional comparison between two Dutch RA cohorts

Objective:

This study evaluates exercise participation in patients with rheumatoid arthritis (RA) and the percentage of patients that meet the recommended level of physical activity (at least 150 minutes per week moderate-intensity physical activity) in two cross-sectional questionnaires in 2013 and 2016 in two Dutch RA cohorts.

Methods:

In 2013, a cross-sectional study was performed among 740 patients with RA from seven outpatient clinics from the Dutch DREAM registry. Subsequently in 2016, 498 patients with RA of the outpatient clinic of the Bernhoven Hospital (member of the DREAM registry) participated in a similar study. In both years, patients filled in an identical questionnaire about exercise participation (frequency and duration). In 2016, items about self-efficacy to become more physically active were added to the questionnaire.

Results:

In 2016, patients with RA spent significantly more minutes per week in exercise activities compared to 2013: 180 (150–450) and 120 (60–225) minutes per week, respectively (P<0.001). The percentage of patients with RA who met the recommended physical activity level increased from 25% in 2013 to 57% in 2016. Almost half (44%) of the non-exercisers reported feeling confident to become more physically active.

Conclusion:

Compared to 2013, RA patients participated in 2016 more frequently and spent more minutes per week in exercise activities. This resulted in a higher percentage of patients who met the recommended physical activity level. A personalized physical activity program, with a focus on identifying barriers and setting personal goals, might further increase the physical activity level of patients with RA.

Relationship between serum cholesterol and Graves' orbitopathy (GO): a confirmatory study

BACKGROUND

It has been suggested that high cholesterol represents a risk factor for Graves' orbitopathy (GO). In a recent cross-sectional study, a correlation between cholesterol and the presence of GO was found in patients with a Graves' disease (GD) of recent onset. To confirm this observation, we conducted a retrospective investigation in consecutive patients with GD. The primary outcome was the relationship between the presence of GO and low-density lipoprotein (LDL)-cholesterol.

METHODS

The design entailed the inclusion of consecutive patients with a GD of recent onset, with or without GO, who came to our observation to receive radioiodine over a period of 6 months, and a stratification aimed at having two homogeneous group of patients in terms of thyroid function. A total of 86 patients fulfilled the inclusion and evaded the exclusion criteria. All patients underwent an ophthalmological assessment and serum lipids were measured.

RESULTS

Serum levels of LDL-cholesterol were significantly higher in patients with GO (135.3 ± 41.3 mg/dL) compared with those without GO (106.6 ± 23.9 mg/dL, P = 0.0007). In a similar manner, serum levels of total cholesterol were higher in patients with GO (211.6 ± 44.0 mg/dL) than in those without GO (176.0 ± 27.2 mg/dL, P = 0.0001). There was no relationship between GO severity and activity and cholesterol. There was no relationship between GO and high-density lipoprotein-cholesterol or triglycerides.

CONCLUSIONS

Our study confirms a relationship between the presence of GO and cholesterol in patients with GD of recent onset. Whether lowering of cholesterol ameliorates, GO remains to be established.

A randomized controlled trial in Norwegian pharmacies on effects of risk alert and advice in people with elevated cardiovascular risk

We investigated if alerting subjects to elevated total cholesterol (TC), hemoglobin A1c (HbA1c) and blood pressure (BP) (cardiovascular disease (CVD) risk factors that are usually asymptomatic), and if providing advice would result in reduced risk. We conducted a multicenter (50 community pharmacies) parallel three-arm 8-week randomized controlled trial (RCT) with a 52-week follow-up visit. During six days of screening, TC, HDL- and LDL-cholesterol, triglycerides, HbA1c, BP and body mass index (BMI) were assessed in 1318 individuals. Of these, 582 with a measured and predefined elevated ad hoc CVD risk score were randomized to either Alert/advice (n = 198) (immediately alerted of their screening result and received healthy lifestyle-advice), Advice-only (n = 185) (received only advice) or Control (n = 199) (not alert, no advice). Changes in risk score and self-reported health-related behaviors (diet, alcohol, physical activity) were assessed in pharmacies after 8 weeks (N = 543; 93%). Although the primary analysis showed no significant difference between groups, the Control group had the largest reduction in risk score of 14%. The total (uncontrolled) sample (N = 543) reduced the risk score by 3.2% beyond estimated regression towards the mean and improved their health-related behaviors. Among the 65% (n = 377) who returned 52 weeks after baseline, 14% reported started using CVD preventive medication after the screening. The study demonstrated that while assessing risk factors and behaviors in pharmacies proved efficient and possibly led to a small risk decrease, alerting people to their screening result did not seem to be more effective than a self-directed approach. ClinicalTrials.gov identifier: NCT02223793.

Lipids: a personal view of the past decade

The past decade has witnessed considerable progress in the field of lipids. New drugs have been "rapidly" developed and some of these drugs have already been evaluated in event-based large trials. This evidence has led to the guidelines recommending new, more aggressive treatment goals for low-density lipoprotein cholesterol (LDL-C) levels. Although LDL-C remains the principal goal for cardiovascular disease (CVD) risk reduction, there has also been considerable interest in other lipid variables, such as high-density lipoprotein cholesterol, triglycerides, and lipoprotein(a). Statin intolerance is now considered a very important topic in daily clinical practice. This has resulted in more attention focusing on non-statin drugs [e.g., ezetimibe and proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors] and statin-related side effects. The latter mainly involve muscles, but there is also a need to consider other adverse effects associated with statin use (e.g., new onset diabetes). New specific areas of statin use have attracted interest. For example, statin-loading before procedures (e.g., coronary stenting), the prevention of stroke, and the treatment of non-alcoholic fatty liver disease (NAFLD). Statins will remain the most widely used drugs to treat dyslipidaemia and decrease CVD risk. However, we also need to briefly consider some other lipid-lowering drugs, including those that may become available in the future.

Impact of baseline left ventricular ejection fraction on outcome after transfemoral transcatheter aortic valve implantation in patients with and without low-gradient aortic stenosis

OBJECTIVES

To evaluate the impact of baseline left ventricular ejection fraction (LVEF) and its interaction with low-gradient aortic stenosis (LGAS) on all-cause mortality after transfemoral aortic valve implantation (TF-TAVI).

METHODS

We reviewed mortality data of 624 consecutive single center TF-TAVI patients and categorized LVEF according to current ASE/EACVI recommendations (normal, mildly-, moderately-, and severely abnormal).

RESULTS

Baseline LVEF was normal in 336 (53.8%), mildly abnormal in 160 (25.6%), moderately abnormal in 91 (14.6%), and severely abnormal in 37 (5.9%) patients, and 1-year mortality was 19%, 17%, 23%, and 43% (P = 0.002), respectively. Patients with LGAS had a similar 1-year mortality compared to those without LGAS in groups with normal (19% vs 19%, P = 0.899) and mildly abnormal LVEF (16% vs 17%, P = 0.898). One-year mortality of patients with LGAS was significantly greater than in those without LGAS in presence of moderately abnormal LVEF (31% vs 11%, P = 0.022), and it was numerically greater than in those without LGAS in presence of severely abnormal LVEF (48% vs 25%, P = 0.219). In multivariate analysis, only the combination of moderately/severely abnormal LVEF and LGAS predicted increased 1-year mortality (HR: 2.12, 95% CI: 1.4-3.2, P < 0.001). Other variables, including EuroSCORE I did not affect this result.

CONCLUSIONS

Moderately/severely abnormal LVEF (≤40%) at baseline is associated with increased mortality after TF-TAVI, especially when the mean transvalvular aortic gradient is <40 mm Hg (LGAS), while outcomes in patients with normal and mildly abnormal LVEF are comparable regardless of the pressure gradient across the native aortic valve. (DRKS00013729).

Risk classification in primary prevention of CVD according to QRISK2 and JBS3 'heart age', and prevalence of elevated high-sensitivity C reactive protein in the UK cohort of the EURIKA study

Objectives

This study assessed cardiovascular disease (CVD) risk classification according to QRISK2, JBS3 'heart age' and the prevalence of elevated high-sensitivity C reactive protein (hsCRP) in UK primary prevention patients.

Method

The European Study on Cardiovascular Prevention and Management in Usual Daily Practice (EURIKA) (NCT00882336) was a cross-sectional study conducted in 12 European countries. 673 UK outpatients aged ≥50 years, without clinical CVD but with at least one conventional CVD risk factor, were recruited. 10-year CVD risk was calculated using QRISK2. JBS3 'heart age' and hsCRP level were assessed according to risk category.

Results

QRISK2 and JBS3 heart age was calculated for 285 of the 305 patients free from diabetes mellitus and not receiving a statin. QRISK2 classified 28%, 39% and 33% of patients as low (<10%), intermediate (10% to <20%) and high (≥20%) risk, respectively. Two-thirds of low-risk patients and half of intermediate-risk patients had a heart age ≥5 years and ≥10 years higher than their chronological age, respectively. Half of low-risk patients had hsCRP levels ≥2 mg/L and approximately 40% had levels ≥3 mg/L. Approximately 80% of low-risk patients had both elevated hsCRP and heart age relative to their chronological age.

Conclusions

Almost 40% more patients in this 'at risk' group would be eligible for statin therapy following the lowering of the National Institute for Health and Care Excellence treatment threshold to ≥10% 10-year risk. Of patients falling below this treatment threshold, almost all were at increased lifetime risk as measured by JBS3, and of these, the majority had elevated hsCRP levels. These patients with high absolute risk may benefit from early primary CVD prevention.

“Obesity paradoxes”: main causes of an “inverse” cardiovascular epidemiology

Taken the continuous increase of obesity prevalence, most countries in the world deal with an epidemy, one of the main healthcare concerns. In the structure of nosology associated with overweight and obesity, cardiovascular is leading. Also, in the recent trials and meta analyses there is negative correlation found for body mass index and clinical outcomes characterizing better survival and lower events rate in those with higher BMI, as less chronic diseases. Such facts facilitated a number of discussions on the predictive value of overweight and obesity and consideration whether to correct those in cardiovascular patients as secondary prevention. Current article is focused on the main causes for an “inverse” cardiovascular epidemiology in overweight and obesity.

ω-6 Polyunsaturated Fatty Acids and Cardiometabolic Health: Current Evidence, Controversies, and Research Gaps

The 2015 Dietary Guidelines for Americans recommend limiting the intake of saturated fatty acids (SFAs) to <10% of energy/d and replacing dietary SFAs with unsaturated fatty acids. A Presidential Advisory from the American Heart Association recently released its evaluation of the relation between dietary fats and cardiovascular disease (CVD), and also recommended a shift from SFAs to unsaturated fatty acids, especially polyunsaturated fatty acids (PUFAs), in conjunction with a healthy dietary pattern. However, the suggestion to increase the intake of PUFAs in general, and omega-6 (n-6) PUFAs in particular, continues to be controversial. This review was undertaken to provide an overview of the evidence and controversies regarding the effects of ω-6 PUFAs on cardiometabolic health, with emphasis on risks and risk factors for CVD (coronary heart disease and stroke) and type 2 diabetes mellitus (T2D). Results from observational studies show that higher intake of ω-6 PUFAs, when compared with SFAs or carbohydrate, is associated with lower risks for CVD events (10-30%), CVD and total mortality (10-40%), and T2D (20-50%). Findings from intervention studies on cardiometabolic risk factors suggest that ω-6 PUFAs reduce concentrations of LDL cholesterol and non-HDL cholesterol in a dose-dependent manner compared with dietary carbohydrate, and have a neutral effect on blood pressure. Despite the concern that ω-6 fatty acids increase inflammation, current evidence from studies in humans does not support this view. In conclusion, these findings support current recommendations to emphasize consumption of ω-6 PUFAs as a replacement of SFAs; additional randomized controlled trials with cardiometabolic disease outcomes will help to more clearly define the benefits and risks of this policy.

Childhood prediction models for hypertension later in life: a systematic review

BACKGROUND

Hypertension, even during childhood, increases the risk of developing atherosclerosis and cardiovascular disease. Therefore, starting prevention of hypertension early in the life course could be beneficial. Prediction models might be useful for identifying children at increased risk of developing hypertension, which may enable targeted primordial prevention of cardiovascular disease.

OBJECTIVE

To provide an overview of childhood prediction models for future hypertension.

METHODS

Embase and Medline were systematically searched. Studies were included that were performed in the general population, and that reported on development or validation of a multivariable model for children to predict future high blood pressure, prehypertension or hypertension. Data were extracted using the CHARMS checklist for prediction modelling studies.

RESULTS

Out of 12 780 reviewed records, six studies were included in which 18 models were presented. Five studies predicted adulthood hypertension, and one predicted adolescent prehypertension/hypertension. BMI and current blood pressure were most commonly included as predictors in the final models. Considerable heterogeneity existed in timing of prediction (from early childhood to late adolescence) and outcome measurement. Important methodological information was often missing, and in four studies information to apply the model in new individuals was insufficient. Reported area under the ROC curves ranged from 0.51 to 0.74. As none of the models were validated, generalizability could not be confirmed.

CONCLUSION

Several childhood prediction models for future hypertension were identified, but their value for practice remains unclear because of suboptimal methods, limited information on performance, or the lack of external validation. Further validation studies are indicated.

Standardization of laboratory and lipid profile evaluation: A call for action with a special focus in 2016 ESC/EAS dyslipidaemia guidelines - Full report

Even with the improvement in lifestyle interventions, a better control of cardiovascular (CV) risk factors, and improvements in CV outcomes, cardiovascular disease (CVD) still persists as the leading cause of morbidity and mortality in Portugal and Europe. Atherogenic dyslipidaemias, namely hypercholesterolaemia, have a crucial and causal role in the development of atherosclerotic CVD. The clinical approach of a patient with dyslipidaemia involves a watchful diagnosis, sustained in lipid and lipoprotein laboratory procedures, which must be harmonized and standardized. Standardization of lipid test results and reports, incorporating the total CV risk and the respective target and goals of treatment approach, guarantees that clinical guidelines and good clinical practices are followed and respected, increasing the reliability of lipid disorders screening, producing more accurate diagnoses and CV risk stratification, and improving the CV prevention and the achievement the desirable treatment goals.

Consumption of individual saturated fatty acids and the risk of myocardial infarction in a UK and a Danish cohort

BACKGROUND

The effect of individual saturated fatty acids (SFAs) on serum cholesterol levels depends on their carbon-chain length. Whether the association with myocardial infarction (MI) also differs across individual SFAs is unclear. We examined the association between consumption of individual SFAs, differing in chain lengths ranging from 4 through 18 carbons, and risk of MI.

METHODS

We used data from 22,050 and 53,375 participants from EPIC-Norfolk (UK) and EPIC-Denmark, respectively. Baseline SFA intakes were assessed through validated, country-specific food frequency questionnaires. Cox regression analysis was used to estimate associations between intakes of individual SFAs and MI risk, for each cohort separately.

RESULTS

During median follow-up times of 18.8 years in EPIC-Norfolk and 13.6 years in Denmark, respectively, 1204 and 2260 MI events occurred. Mean (±SD) total SFA intake was 13.3 (±3.5) en% in EPIC-Norfolk, and 12.5 (±2.6) en% in EPIC-Denmark. After multivariable adjustment, intakes of C12:0 (lauric acid) and C14:0 (myristic acid) inversely associated with MI risk in EPIC-Denmark (HR upper versus lowest quintile: 0.80 (95%CI: 0.66, 0.96) for both SFAs). Intakes in the third and fourth quintiles of C4:0-C10:0 also associated with lower MI risk in EPIC-Denmark. Moreover, substitution of C16:0 (palmitic acid) and C18:0 (stearic acid) with plant proteins resulted in a reduction of MI risk in EPIC-Denmark (HR per 1 energy%: 0.86 (95%CI: 0.78, 0.95) and 0.87 (95%CI: 0.79, 0.96) respectively). No such associations were found in EPIC-Norfolk.

CONCLUSION

The results from the present study suggest that the association between SFA and MI risk depends on the carbon chain-length of the SFA.

Effects of gaseous and solid constituents of air pollution on endothelial function

Ambient air pollution is a leading cause of non-communicable disease globally. The largest proportion of deaths and morbidity due to air pollution is now known to be due to cardiovascular disorders. Several particulate and gaseous air pollutants can trigger acute events (e.g. myocardial infarction, stroke, heart failure). While the mechanisms by which air pollutants cause cardiovascular events is undergoing continual refinement, the preponderant evidence support rapid effects of a diversity of pollutants including all particulate pollutants (e.g. course, fine, ultrafine particles) and gaseous pollutants such as ozone, on vascular function. Indeed alterations in endothelial function seem to be critically important in transducing signals and eventually promoting cardiovascular disorders such as hypertension, diabetes, and atherosclerosis. Here, we provide an updated overview of the impact of particulate and gaseous pollutants on endothelial function from human and animal studies. The evidence for causal mechanistic pathways from both animal and human studies that support various hypothesized general pathways and their individual and collective impact on vascular function is highlighted. We also discuss current gaps in knowledge and evidence from trials evaluating the impact of personal-level strategies to reduce exposure to fine particulate matter (PM2.5) and impact on vascular function, given the current lack of definitive randomized evidence using hard endpoints. We conclude by an exhortation for formal inclusion of air pollution as a major risk factor in societal guidelines and provision of formal recommendations to prevent adverse cardiovascular effects attributable to air pollution.

Should Cushing's Syndrome be Considered as a Disease with High Cardiovascular Risk in Relevant Guidelines?

A considerable amount of data supports a 1.8-7.4-fold increased mortality associated with Cushing's syndrome (CS). This is attributed to a high occurrence of several cardiovascular disease (CVD) risk factors in CS [e.g. adiposity, arterial hypertension (AHT), dyslipidaemia and type 2 diabetes mellitus (T2DM)]. Therefore, practically all patients with CS have the metabolic syndrome (MetS), which represents a high CVD risk. Characteristically, despite a relatively young average age, numerous patients with CS display a 'high' or 'very high' CVD risk (i.e. risk of a major CVD event >20% in the following 10 years). Although T2DM is listed as a condition with a high CVD risk, CS is not, despite the fact that a considerable proportion of the CS population will develop T2DM or impaired glucose tolerance. CS is also regarded as a risk factor for aortic dissection in current guidelines. This review considers the evidence supporting listing CS among high CVD risk conditions.

Ten-year incidence of hypertension in a Swiss population-based sample Incidence of hypertension in Switzerland

Few studies assessed incidence and determinants of hypertension. We assessed the incidence and determinants of hypertension in a cohort of healthy adults aged 35-75 years living in Lausanne, Switzerland. Baseline data were collected from 2003 to 2006. Follow-ups were conducted in 2009-2012 and 2014-2017. Incident hypertension, defined as a systolic BP ≥140 mm Hg or a diastolic BP ≥90 mm Hg or anti-hypertensive medication, was assessed at 1) second follow-up only; 2) first and/or second follow-up. After 10.9 years, incident hypertension was 26.8% (analysis 1, N = 3299) and 30.3% (analysis 2, N = 3728). After multivariate adjustment, the variables associated with increased hypertension incidence were male gender [incident-rate ratio (IRR) and (95% confidence interval)]: 1.20 (1.07-1.35) and 1.24 (1.13-1.37) for analyses 1 and 2, respectively; increasing age (p for trend < 0.001) and body mass index (p for trend < 0.001) and history of cardiovascular disease (CVD). Being physically active was negatively associated with incident hypertension: 0.88 (0.78-0.98) and 0.92 (0.83-1.01) for analyses 1 and 2, respectively. Except for male gender, these associations remained after adjusting for baseline BP levels, with incident rate ratios for physical activity of 0.86 (0.77-0.96) and 0.91 (0.83-0.99) for analyses 1 and 2, respectively. No association was found for education, alcohol consumption or smoking status. We conclude that over 10.9 years, between 1/4 and 1/3 of the Swiss population aged 35-75 developed hypertension. Male gender, history of CVD, increasing age and higher BMI increase the risk of hypertension, while being physically active reduces the risk.

Efficacy of zofenopril in combination with amlodipine in patients with acute myocardial infarction: a pooled individual patient data analysis of four randomized, double-blind, controlled, prospective studies

OBJECTIVE

In the four SMILE (Survival of Myocardial Infarction Long-Term Evaluation) studies, early administration of zofenopril in acute myocardial infarction (AMI) showed beneficial effects as compared to placebo and other angiotensin converting enzyme inhibitors (ACEIs). This study investigated whether the concomitant administration of the dihydropyridine calcium channel-blocker amlodipine may improve zofenopril efficacy to prevent cardiovascular events in post-AMI patients.

METHODS

This was a post-hoc analysis of pooled individual patient data from the four large randomized SMILE studies. The primary endpoint was the 1-year combined occurrence of death or hospitalization for cardiovascular causes.

RESULTS

In total, 3488 patients were considered, 303 (8.7%) treated with concomitant amlodipine. Baseline systolic blood pressure and prevalence of metabolic syndrome were higher in amlodipine treated patients. The 1-year occurrence of major cardiovascular outcomes was significantly reduced in patients receiving concomitant treatment with amlodipine (hazard ratio, HR = 0.66; and 95% confidence interval, CI = 0.44-0.98; p = .039). After accounting for treatment with amlodipine, the risk of cardiovascular events was significantly reduced with zofenopril compared to placebo (HR = 0.78; 95% CI = 0.63-0.97; p = .026]. Among ACEI-treated patients, the zofenopril plus amlodipine combination reduced the risk of cardiovascular events by 38%, compared to the combination of other ACEIs plus amlodipine [HR = 0.76; 95% CI = 0.61-0.94); p = .013). The prognostic benefit of concomitant treatment with zofenopril plus amlodipine was independent from blood pressure lowering.

CONCLUSIONS

Zofenopril had a positive impact on prognosis in post-AMI patients, compared to other ACEIs. Concomitant administration of amlodipine may help to reduce the risk of cardiovascular events at 1 year.

Main Approaches to Assessing the Quality of Drug Therapy in Cardiology

A competent choice of drug therapy in a specific clinical situation is a difficult and important task that a practical doctor must regularly solve in everyday practice, and the consequences of errors in this decision can be quite serious. Therefore, evaluation of the quality of the prescribed therapy is extremely important.

In the treatment of cardiovascular diseases, medicines that have a proven effect on the outcomes of the disease, primarily on mortality rates (so-called "life-saving drugs") acquire special significance. There are several classes of such drugs, and in different situations, their positive impact on the prognosis of the disease may be different. On the other hand, one should remember the so-called "drug-related problems" (DRP), which include contraindications to the prescription of certain drugs in a particular patient, the possibility of developing side effects of drug therapy, aggravated by polypharmacy, inter-drug interaction, improper dosage of drugs, etc.

In this publication, an attempt is made to identify the main components by which the quality of the prescribed therapy can be evaluated in the treatment of cardiovascular diseases: compliance of prescriptions with official instructions for preparations, modern clinical guidelines, adequate selection of a specific drug within the class, drug formulation, salt of the drug, evaluation of important safety parameters and efficacy of the prescribed drug. In addition, a review of the methods and scales of the composite evaluation of the quality of drug therapy developed to date has been conducted, as well as attempts to improve them and create new ones that continue to the present day. Nevertheless, none of the currently known methods for assessing the quality of therapy is not universal or devoid of shortcomings.

Most likely, a universal method of assessing the quality of the prescribed treatment may not exist. In its most general form, it can be said that treatment should be based on modern evidence-based medicine, which is usually reflected in the clinical guidelines, without contradicting the official instruction on the use of the drug, considering the presence of concomitant diseases, that are often the reasons of contraindications to prescribing those or other medicines.

[Bone and metabolism]

Bone is now considered as a particular endocrine organ. Its endocrine function is not yet fully understood and has been the subject of several conferences at the European Society of Endocrinology Congress 2018. Bone regulates phosphate metabolism by secreting fibroblast growth factor 23; it also regulates glucose metabolism via osteocalcin and energy metabolism, thanks to lipocalin 2, a new hormone acting on the brain. In addition, the incidence of diabetes continues to grow, and its impact on bone has been demonstrated, with an increased risk of fractures regardless the type of diabetes. The mechanism of bone fragility in this disease is not fully known but it involves a decrease in bone turnover and bone demineralization. Recent findings on the role of bone on glucose and mineral metabolism could open therapeutic perspectives, especially for the treatment of diabetes or obesity.

Self-Management of Cardiac Pain in Women: A Meta-Summary of the Qualitative Literature

Symptom recognition and self-management is instrumental in reducing the number of deaths related to coronary artery disease (CAD) in women. The purpose of this study was to synthesize qualitative research evidence on the self-management of cardiac pain and associated symptoms in women. Seven databases were systematically searched, and the concepts of the Individual and Family Self-Management Theory were used as the framework for data extraction and analysis. Search strategies yielded 22,402 citations, from which 35 qualitative studies were included in a final meta-summary, comprising data from 769 participants, including 437 (57%) women. The available literature focused cardiac pain self-management from a binary sex and gender perspective. Ethnicity was indicated in 19 (54%) studies. Results support individualized intervention strategies that promote goal setting and action planning, management of physical and emotional responses, and social facilitation provided through social support.

Psoriasis is an independent predictor of increased risk of allergic reaction during percutaneous coronary interventions. Big data analysis from the Polish National PCI Registry (ORPKI)

BACKGROUND

The presence of psoriasis is currently considered by the European Society of Cardiology cardiovascular prevention guidelines of 2016 as one possible cardiovascular risk factor. Patients with psoriasis and concomitant coronary artery disease treated by means of percutaneous coronary interven-tion (PCI) are a fairly large subgroup of patients that have been usually omitted in mainstream research. The aim herein, was to identify the incidence of psoriasis, baseline characteristics and periprocedural outcome with a special focus on procedural complications in patients undergoing percutaneous coronary procedures.

METHODS

All consecutive patients who had either coronary angiography or coronary angiography with immediate PCI in Poland in 2014 and 2015 were included. Patients were assigned to two groups based on previous diagnosis: with psoriasis and without psoriasis. Clinical outcome was defined as any periprocedural death.

RESULTS

There were 405,078 patients included in this analysis. Psoriasis (moderate or severe) was di-agnosed in 1507 (0.4%) of them. Psoriasis was an independent predictor of allergic reaction occurrence (odds ratio [OR] 6.02; 95% confidence interval [CI] 1.44-25.22; p = 0.014). After propensity score adjustment, psoriasis remained a significant predictor of allergic reaction (OR 5, 95% CI 1.2-20.7; p = 0.0245). There were no differences in rates of periprocedural deaths in patients with or without psoriasis (death: 0.95% vs. 0.62%, p > 0.05).

CONCLUSIONS

Severe or moderate psoriasis is an independent risk factor for the occurrence of allergic reaction during percutaneous coronary procedures. There were no differences in periprocedural mortal-ity and complications in patients with versus those without psoriasis.

New graduate doctors' preparedness for practice: a multistakeholder, multicentre narrative study

OBJECTIVE

While previous studies have begun to explore newly graduated junior doctors' preparedness for practice, findings are largely based on simplistic survey data or perceptions of newly graduated junior doctors and their clinical supervisors alone. This study explores, in a deeper manner, multiple stakeholders' conceptualisations of what it means to be prepared for practice and their perceptions about newly graduated junior doctors' preparedness (or unpreparedness) using innovative qualitative methods.

DESIGN

A multistakeholder, multicentre qualitative study including narrative interviews and longitudinal audio diaries.

SETTING

Four UK settings: England, Northern Ireland, Scotland and Wales.

PARTICIPANTS

Eight stakeholder groups comprising n=185 participants engaged in 101 narrative interviews (27 group and 84 individual). Twenty-six junior doctors in their first year postgraduation also provided audio diaries over a 3-month period.

RESULTS

We identified 2186 narratives across all participants (506 classified as 'prepared', 663 as 'unprepared', 951 as 'general'). Seven themes were identified; this paper focuses on two themes pertinent to our research questions: (1) explicit conceptualisations of preparedness for practice; and (2) newly graduated junior doctors' preparedness for the General Medical Council's (GMC) outcomes for graduates. Stakeholders' conceptualisations of preparedness for practice included short-term (hitting the ground running) and long-term preparedness, alongside being prepared for practical and emotional aspects. Stakeholders' perceptions of medical graduates' preparedness for practice varied across different GMC outcomes for graduates (eg, Doctor as Scholar and Scientist, as Practitioner, as Professional) and across stakeholders (eg, newly graduated doctors sometimes perceived themselves as prepared but others did not).

CONCLUSION

Our narrative findings highlight the complexities and nuances surrounding new medical graduates' preparedness for practice. We encourage stakeholders to develop a shared understanding (and realistic expectations) of new medical graduates' preparedness. We invite medical school leaders to increase the proportion of time that medical students spend participating meaningfully in multiprofessional teams during workplace learning.

Nutraceutical Approach to Non-Alcoholic Fatty Liver Disease (NAFLD): The Available Clinical Evidence

Non-alcoholic fatty liver disease (NAFLD) is a clinical condition characterized by lipid infiltration of the liver, highly prevalent in the general population affecting 25% of adults, with a doubled prevalence in diabetic and obese patients. Almost 1/3 of NAFLD evolves in Non-Alcoholic SteatoHepatitis (NASH), and this can lead to fibrosis and cirrhosis of the liver. However, the main causes of mortality of patients with NAFLD are cardiovascular diseases. At present, there are no specific drugs approved on the market for the treatment of NAFLD, and the treatment is essentially based on optimization of lifestyle. However, some nutraceuticals could contribute to the improvement of lipid infiltration of the liver and of the related anthropometric, haemodynamic, and/or biochemical parameters. The aim of this paper is to review the available clinical data on the effect of nutraceuticals on NAFLD and NAFLD-related parameters. Relatively few nutraceutical molecules have been adequately studied for their effects on NAFLD. Among these, we have analysed in detail the effects of silymarin, vitamin E, vitamin D, polyunsaturated fatty acids of the omega-3 series, astaxanthin, coenzyme Q10, berberine, curcumin, resveratrol, extracts of Salvia milthiorriza, and probiotics. In conclusion, Silymarin, vitamin E and vitamin D, polyunsaturated fatty acids of the omega-3 series, coenzyme Q10, berberine and curcumin, if well dosed and administered for medium–long periods, and associated to lifestyle changes, could exert positive effects on NAFLD and NAFLD-related parameters.

Impact of cognitive performance on disease-related knowledge six months after multi-component rehabilitation in patients after an acute cardiac event

Background

Although associations between cardiovascular diseases and cognitive impairment are well known, the impact of cognitive performance on the success of patient education as a core component of cardiac rehabilitation remains insufficiently investigated so far.

Design

Prospective observational study in two inpatient cardiac rehabilitation centres between September 2014 and August 2015 with a follow-up six months after cardiac rehabilitation.

Method

At admission to and discharge from cardiac rehabilitation, the cognitive performance of 401 patients (54.5 ± 6.3 years, 80% men) following an acute coronary syndrome and/or coronary artery bypass graft was tested using the Montreal Cognitive Assessment. Patients’ disease-related knowledge was determined using a quiz (22 items for medical knowledge and 12 items for healthy lifestyle and behaviour) at both times and at follow-up. The change in knowledge after cardiac rehabilitation was analysed in multivariable regression models. Potentially influencing parameters (e.g. level of education, medication, cardiovascular risk factors, coronary artery bypass graft, comorbidities, exercise capacity) were considered.

Results

During cardiac rehabilitation, disease-related knowledge was significantly enhanced in both scales. At follow-up, the average level of medical knowledge was significantly reduced, while lifestyle knowledge remained at a stable level. The maintenance of knowledge after cardiac rehabilitation was predominantly predicted by prior knowledge, cognitive performance at discharge from cardiac rehabilitation and, in the case of medical knowledge, by coronary artery bypass graft.

Conclusion

Patient education in cardiac rehabilitation led to enhanced disease-related knowledge, but the maintenance of this essentially depended on patients’ cognitive performance, especially after coronary artery bypass graft. Therefore, patient education concepts in cardiac rehabilitation should be reconsidered and adjusted as needed.

THE ROLE OF GROUP EDUCATIONAL PROGRAMS IN MODIFICATION OF THE CARDIOVASCULAR RISK MAIN FACTORS

Aim – to study the influence of Healthy Schools "Healthy Lifestyle Basis" education on modifying of cardiovascular risk main factors. Materials and methods. 57 patients with cardiovascular diseases were examined. General clinical examination, anthropometric examinations (body weight, height, body mass index, and body composition), blood pressure measurement, and cholesterol determination, as well as its fractions in blood, were carried out before and after training course. The educational cycle included 9 lessons. Results. It was found that Healthy Schools education contributes to better both systolic and diastolic blood pressure monitoring. Thus, initially target blood pressure levels (<140/90 mmHg for patients without diabetes mellitus and <140/85 mmHg in case of diabetes) were observed in 49 % of patients, at the end of the training cycle – in 67 %. At the same time, the patients’ anthropometric parameters (BMI, fat and muscle tissue content, visceral fat) as well as cholesterol and its atherogenic serum fractions, did not change significantly. The patients’ education did not affect motivation level for their lifestyle improvement. So the number of patients consuming less than5 grams of table salt per day and over400 grams of vegetables and fruit did not change significantly. The level of physical activity between the examined patients did not change. Conclusion. The training course “Healthy Schools: Healthy Lifestyle Basis" contributes to improvement of blood pressure level monitoring, but does not significantly affect behavioral risk factors and does not lead to improvement of lipid metabolism monitoring in patients with cardiovascular disease. It is necessary to search for new more effective preventive care models for patients with high cardiovascular risk.

Efficacy of zofenopril in combination with thiazide diuretics in patients with acute myocardial infarction: a pooled individual data analysis of four randomized, double-blind, controlled, prospective studies

Background

In the Survival of Myocardial Infarction Long-Term Evaluation (SMILE) studies, early administration of zofenopril after acute myocardial infarction (AMI) was prognostically beneficial as compared to placebo and other angiotensin-converting enzyme inhibitors (ACEIs), such as lisinopril and ramipril. Here, we investigated whether zofenopril efficacy could be affected by a concomitant use of thiazide diuretics (TDs).

Methods

This was a post hoc analysis of pooled individual patient data from the SMILE studies. Patients treated with other diuretics than TDs were excluded. The primary study endpoint was the 1-year combined occurrence of death or hospitalization for CV causes, with or without TD.

Results

Among 2,995 patients, 263 (8.8%) were treated with a combination including a TD (TD+), whereas 2,732 (91.2%) were not treated with any diuretic (TD−). Proportions of subjects who were treated with TD were equally distributed (p=0.774) within the placebo, zofenopril, and other ACEIs groups. The 1-year risk of major cardiovascular events was similar in TD+ (18.3%) and TD− (16.8%) patients (hazard ratio [HR] 1.04; 95% CI 0.74–1.45; p=0.838). After stratifying per concomitant treatment and TD, the 1-year risk of CV events was significantly lower with zofenopril than with placebo (HR 0.70; 95% CI 0.55–0.88; p=0.002) and other ACEIs (HR 0.58; 95% CI 0.46–0.74; p=0.0001). Treatment with ACEIs and TD as concomitant therapy was associated with a larger blood pressure (BP) reduction (p=0.0001 for systolic BP and p=0.045 for diastolic BP).

Conclusion

In post AMI patients, zofenopril maintained its positive impact on prognosis compared to placebo or other ACEIs, regardless concomitant TD administration. In this setting, TD shows advantages in managing the most difficult hypertensive patients.

Association between progestin-only contraceptive use and cardiometabolic outcomes: A systematic review and meta-analysis

Aims The association between progestin-only contraceptive (POC) use and the risk of various cardiometabolic outcomes has rarely been studied. We performed a systematic review and meta-analysis to determine the impact of POC use on cardiometabolic outcomes including venous thromboembolism, myocardial infarction, stroke, hypertension and diabetes. Methods and results Nineteen observational studies (seven cohort and 12 case-control) were included in this systematic review. Of those, nine studies reported the risk of venous thromboembolism, six reported the risk of myocardial infarction, six reported the risk of stroke, three reported the risk of hypertension and two studies reported the risk of developing diabetes with POC use. The pooled adjusted relative risks (RRs) for venous thromboembolism, myocardial infarction and stroke for oral POC users versus non-users based on the random effects model were 1.06 (95% confidence interval (CI) 0.70-1.62), 0.98 (95% CI 0.66-1.47) and 1.02 (95% CI 0.72-1.44), respectively. Stratified analysis by route of administration showed that injectable POC with a RR of 2.62 (95% CI 1.74-3.94), but not oral POCs (RR 1.06, 95% CI 0.7-1.62), was associated with an increased risk of venous thromboembolism. A decreased risk of venous thromboembolism in a subgroup of women using an intrauterine levonorgestrel device was observed with a RR of 0.53 (95% CI 0.32-0.89). No effect of POC use on blood pressure was found, but there was an indication for an increased risk of diabetes with injectable POCs, albeit non-significant. Conclusions This systematic review and meta-analysis suggests that oral POC use is not associated with an increased risk of developing various cardiometabolic outcomes, whereas injectable POC use might increase the risk of venous thromboembolism.

Developing nurses’ skills in motivational interviewing to promote a healthy lifestyle in patients with coronary artery disease

Background:

If nurses have the communication skills and the time, they can play an important role in increasing the intrinsic motivation of patients with coronary artery disease (CAD) to change their lifestyle. Motivational Interviewing (Mo-Int) can be used to further support this role. However, few nurses are sufficiently proficient in applying Mo-Int skills. Increasing these complex communication skills may contribute significantly to achieve lifestyle changes in CAD patients.

Aims:

The aim of this study was to evaluate the coaching of nurses to skilfully use Mo-Int in a secondary prevention programme for CAD patients.

Methods:

The design was a before–after study of a learning strategy as a follow-up on a short Mo-Int workshop. At (on average) four-monthly intervals, the nurses received, three times, feedback and coaching by telephone and email on their use of Mo-Int skills in audio-recorded conversations on lifestyle change with CAD patients. The Mo-Int consistency of the nurses’ communication skills was scored using the Motivational Interviewing Target Scheme 2.1 (range 0–32).

Results:

Of the 24 nurses, 13 completed all audio recordings. The mean change in Mo-Int consistency of these completers between the first and the last audio recording was 6.4 (95% confidence interval 3.2 to 9.5). This change indicates an improvement from ‘a small part of Motivational Interviewing practice’ to ‘a mainly sufficient degree of Motivational Interviewing practice’.

Conclusion:

A one-year follow-up on a Mo-Int workshop with feedback and coaching improves Mo-Int skills of nurses. Healthcare professionals should be aware of the importance of a follow-up on training in complex communication skills, to develop and preserve competency.

Further options for treating lipids in people with diabetes: targeting LDL-cholesterol and beyond

Diabetes is associated with increased cardiovascular disease (CVD) risk. Previous studies with statins have established that a 1 mmol/l reduction in LDL-cholesterol reduces CVD events by 21% over 5 years in people with diabetes. More recently, trials in people with acute coronary syndromes showed that ezetimibe reduced CVD events by 6% at 5 years and achieved a LDL-cholesterol of 1.6 mmol/l with better results in people with Type 2 diabetes. Several novel lipid-lowering therapies have recently been developed. Most data have been accumulated with proprotein convertase subtilisin kexin-9 (PCSK-9) inhibitors, which reduce LDL-cholesterol by 50-55%. A large CVD outcome trial with evolocumab, in which 40% of participants had diabetes, achieved a LDL-cholesterol of 0.8 mmol/l and showed a consistent 20% relative risk reduction within 2 years, including in people with diabetes. Trials to increase HDL-cholesterol using cholesterol ester transfer protein (CETP) inhibitors have generally underwhelmed. Although anacetrapib reduced coronary ischaemic events by 7% in a population with chronic CVD, more expansive CVD endpoints were not improved. The complex nature of CETP inhibitor trial outcomes means that these compounds are not being developed further. Trials targeting inflammation-associated lipids have been generally unsuccessful but recent data on the interleukin-1B receptor antagonist canakinumab have shown a reduction in acute coronary intervention, validating this target although at the cost of increased infections. The ability to achieve low LDL-cholesterol with off-patent medications and the costs of novel therapies will confine the use of novel agents to subgroups of people at highest risk of CVD.

A low-fat spread with added plant sterols and fish omega-3 fatty acids lowers serum triglyceride and LDL-cholesterol concentrations in individuals with modest hypercholesterolaemia and hypertriglyceridaemia

Purpose

The primary and secondary objectives were to investigate the triglyceride (TG) and LDL-cholesterol (LDL-C) lowering effects of a spread with added plant sterols (PS) and fish oil as compared to a placebo spread.

Methods

This study had a randomized, double-blind, placebo-controlled, parallel group design with two intervention arms. Following a 2-week placebo run-in period, 260 healthy individuals with modestly elevated blood TG (≥ 1.4 mmol/L) and LDL-C (≥ 3.4 mmol/L) concentrations consumed either the placebo or intervention spread for 4 weeks. The intervention spread contained 2.0 g/day PS and 1.0 g/day eicosapentaenoic acid (EPA) + docosahexanoic acid (DHA) from fish oil. Fasting serum lipids and apolipoproteins (Apo) (exploratory) were measured at the end of the run-in and intervention phases.

Results

Four-week consumption of the intervention spread resulted in significantly lower TG (− 10.6%, 95% CI − 16.0 to − 4.9%; P < 0.001) and LDL-C concentrations (− 5.2%; 95% CI − 7.8 to − 2.4%) as compared to placebo. Total cholesterol (− 3.9%; 95% CI − 6.1 to − 1.5%), non-HDL-C (− 5.4%; 95% CI − 8.1 to − 2.7%), remnant-cholesterol (− 8.1%; 95% CI − 3.4 to − 12.5%), ApoAII (− 2.9%; 95% CI − 5.5 to − 0.2%), ApoCIII (− 7.7%; 95% CI − 12.1 to − 3.1%) and ApoB (− 3.2%; 95% CI − 5.9 to − 0.4%) concentrations were also significantly lower, as compared to placebo. No significant treatment effects were found for HDL-cholesterol, ApoAI, ApoCII, Apo E or ApoB/ApoAI.

Conclusions

Four-week consumption of the intervention spread led to significant and clinically relevant decreases in serum TG, LDL-C and other blood lipid concentrations. The study was registered at clinicaltrials.gov (NCT 02728583).

Electronic supplementary material

The online version of this article (10.1007/s00394-018-1706-1) contains supplementary material, which is available to authorized users.

Risk prediction in stable cardiovascular disease using a high-sensitivity cardiac troponin T single biomarker strategy compared to the ESC-SCORE

Objective

To evaluate the prognostic performance of high-sensitivity cardiac troponin T (hs-cTnT) compared with the ESC-SCORE.

Methods

We included low-risk outpatients with stable cardiovascular (CV) disease categorised into need for non-secondary and secondary prevention. The prognostication of hs-cTnT at index visit was compared with the European Society of Cardiology-Systematic COronary Risk Evaluation (ESC-SCORE) with respect to all-cause mortality (ACM) and two composite endpoints (ACM, acute myocardial infarction (AMI) and stroke and ACM, AMI, stroke and rehospitalisation for acute coronary syndrome (ACS) and decompensated heart failure (DHF)).

Results

Within a median follow-up of 796 days, a total of 16 deaths, 32 composite endpoints of ACM, AMI and stroke and 83 composite endpoints of ACM, AMI, stroke, rehospitalisation for ACS and DHF were observed among 693 stable low-risk outpatients. Using C-statistics, measurement of hs-cTnT alone outperformed the ESC-SCORE for the prediction of ACM in the entire study population (Δarea under the curve (AUC) 0.221, p=0.0039) and both prevention groups (non-secondary: ΔAUC 0.164, p=0.0208; secondary: ΔAUC 0.264, p=0.0134). For the prediction of all other secondary endpoints, hs-cTnT was at least as effective as the ESC-SCORE, both in secondary and non-secondary prevention. Using continuous and categorical net reclassification improvement and integrated discrimination improvement, hs-cTnT significantly improved reclassification regarding all endpoints in the entire population and in the secondary prevention cohort. In non-secondary prevention, hs-cTnT improved reclassification only for ACM. The results were confirmed in an independent external cohort on 2046 patients.

Conclusions

Hs-cTnT is superior to the multivariable ESC-SCORE for the prediction of ACM and a composite endpoint in stable outpatients with and without relevant CV disease.

Trial registration number

NCT01954303; Pre-results.

Evolocumab and lipoprotein apheresis combination therapy may have synergic effects to reduce low-density lipoprotein cholesterol levels in heterozygous familial hypercholesterolemia: A case report

A 49 years old woman (weight 68 kg, BMI 27.3 kg/m² ) with heterozygous familial hypercholesterolemia (HeFH) and multiple statin intolerance with muscle aches and creatine kinase elevation, presented at the Outpatient Lipid Clinic of Verona University Hospital in May 2015. Hypercholesterolemia was firstly diagnosed during adolescence, followed in adulthood by a diagnosis of Cogan's syndrome, a rheumatologic disorder characterized by corneal and inner ear inflammation. No xanthomas, corneal arcus, or vascular bruits were detectable at physical examination. Screening for macrovascular complications did not reveal relevant damages. Ongoing medical therapy included salicylic acid, methylprednisolone, methotrexate, and protonic-pump inhibitor. In the absence of specific lipid-lowering therapy, plasma lipid levels at first visit were: total-cholesterol = 522 mg/dL, LDL-cholesterol = 434 mg/dL, HDL-cholesterol = 84 mg/dL, triglycerides = 120 mg/dL, Lp(a) = 13 mg/dL. On December 2015, evolocumab 140 mg sc every 2 weeks was initiated. After a 24-week treatment, the LDL-cholesterol levels decreased by an average of 21.2% to 342 ± 22 mg/dL (mean ± SD). On May 2016, LDL-apheresis (H.E.L.P.system) was started as add-on therapy. Compared to the average levels obtained during the evolocumab monotherapy period, the LDL-cholesterol was reduced by 49.4%, thus reaching an inter-apheresis level (mean ± SD) of 173 ± 37 mg/dL. This report suggests that a combination therapy with evolocumab and lipoprotein-apheresis may have synergic effects on circulating lipid levels. Its relevance as a highly effective treatment option for hyperlipidemia in HeFH patients warrants further investigation in larger datasets.

Reduction of Vascular Inflammation, LDL-C, or Both for the Protection from Cardiovascular Events?

BACKGROUND

Low density lipoprotein cholesterol (LDL-C) and low grade arterial inflammation are key pathogenic factors for atherosclerosis and its manifestation, cardiovascular disease (CVD).

OBJECTIVE

In this narrative review we assessed if decreasing LDL-C levels or inflammation or both is more effective in reducing CVD events.

RESULTS

In the Scandinavian Simvastatin Survival Study (4S), all statin trials of the 90s' and the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) the benefit came from the LDL-C reduction. In the GREak and Atorvastatin Coronary heart disease Evaluation (GREACE), the Treating to New Targets (TNT), and the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trials both mechanisms in combination produced significant benefits. In the Atorvastatin for Reduction of MYocardial Damage during Angioplasty (ARMYDA) trials and the Canakinumab Antiinflammatory Thrombosis Outcome Study (CANTOS) with a human antibody targeting IL-1β with no lipid lowering effect, the reduction in arterial inflammation played the only beneficial role because there was no change in lipids levels.

CONCLUSION

Both LDL-C and inflammation reduction are beneficial to the reduction of CVD risk. However, canakinumab is a very expensive drug that only induced a 15% reduction in CVD events, thus drastically reducing the possibility for it to be used in clinical practice. Besides, canakinumab is associated with increased infections, some fatal. A potent statin with anti-inflammatory effects is probably the best choice for the majority of those needing hypolipidaemic drug therapy.

The "cholesterol paradox" among inpatients - retrospective analysis of medical documentation

Introduction

There is evidence of positive relationships between cholesterol concentration and risk of cardiovascular diseases. However, higher mortality in patients with a low cholesterol level has been reported (the “cholesterol paradox”).

Material and methods

Medical records of 34 191 inpatients between 2014 and 2016 were reviewed and the relationships between total (TC), low-density lipoprotein (LDL-C) and high-density lipoprotein (HDL-C) cholesterol and triglyceride blood concentrations and all-cause in-hospital death and readmission within 14 and 30 days and 1 year were determined in univariate and multivariate analyses.

Results

Patients with TC in the lower quartile and LDL-C < 70 mg/dl had greater risk of the outcomes measured than individuals with a TC level in the remaining quartiles and LDL-C ≥ 70 mg/dl. Moreover, patients with TC in the highest quartile, OR (95% CI): 0.36 (0.13–0.99), p < 0.05, and LDL-C ≥ 115 mg/dl, OR (95% CI): 0.53 (0.37–0.77), p < 0.05, had the lowest all-cause in-hospital mortality. However, multivariate analysis using logistic regression and a Cox proportional hazard model showed no significant influence of blood lipid levels on the occurrence of the outcomes measured.

Conclusions

A significant effect of a “cholesterol paradox” linking better prognosis with higher blood lipid concentration was found only in univariate analysis but, after adjustment for clinical characteristics in multivariate analysis, the plasma lipid level had a neutral influence on the occurrence of the measured outcomes. This suggests that a low cholesterol level should be interpreted as a biomarker of illness severity.

Diabetes Drugs and Cardiovascular Event Reduction: A Paradigm Shift

This review article summarizes the recent cardiovascular outcome data for sodium–glucose cotransporter-2 inhibitors and glucagon-like peptide-1 analogues, which have been found to reduce cardiovascular events. We also detail the implications these new medications will have on clinical practice through a review of recent diabetes guidelines and cost-effectiveness data.

Vitamin D supplementation and lipoprotein metabolism: A randomized controlled trial

BACKGROUND

Vitamin D deficiency is associated with an unfavorable lipid profile, but whether and how vitamin D supplementation affects lipid metabolism is unclear.

OBJECTIVE

To examine the effects of vitamin D supplementation on lipid and lipoprotein parameters.

METHODS

This is a post hoc analysis of the single-center, double-blind, randomized, placebo-controlled Styrian Vitamin D Hypertension Trial (2011-2014). Two hundred individuals with arterial hypertension and 25-hydroxyvitamin D concentrations of <75 nmol/L were randomized to 2800 IU of vitamin D daily or placebo for 8 weeks.

RESULTS

One hundred sixty-three participants (62.2 [53.1-68.4] years of age; 46% women) had available lipid data and were included in this analysis. Vitamin D supplementation significantly increased total cholesterol, triglycerides, very-low-density lipoprotein (VLDL) triglycerides, low-density lipoprotein (LDL) triglycerides, high-density lipoprotein (HDL) triglycerides, apolipoprotein B (ApoB), LDL-ApoB, ApoCII, ApoCIII, phospholipids, and ApoE (P < .05 for all). Except for ApoCII and ApoCIII and HDL-triglycerides, all other treatment effects remained statistically significant after adjustment for multiple testing with the Benjamini and Hochberg false discovery rate method. There was a nonsignificant increase in LDL cholesterol. Furthermore, no significant effects were seen on free fatty acids, lipoprotein (a), ApoAI, ApoAII, VLDL cholesterol, VLDL-ApoB, HDL cholesterol, LDL diameter, and VLDL diameter.

CONCLUSIONS

The effects of vitamin D on lipid metabolism are potentially unfavorable. They require further investigation in view of the wide use of vitamin D testing and treatment.

Association of depression and anxiety with cardiovascular co-morbidity in a primary care population in Latvia: a cross-sectional study

BACKGROUND

Cardiovascular (CV) diseases (CVDs) are the leading cause of mortality worldwide. Globally, there is a growing interest in understanding and addressing modifiable psychosocial risk factors, particularly depression and anxiety, to prevent CVDs and to reduce morbidity and mortality. Despite the high premature mortality rate from CVDs in Latvia, this is the first Latvian study to examine the association of depression and anxiety with CVD morbidity in a primary care population.

METHODS

This cross-sectional study was carried out in 2015 within the framework of the National Research Program BIOMEDICINE at 24 primary care facilities throughout Latvia. Consecutive adult patients during a one-week time period at each facility were invited to join the study. Assessments onsite included a 9-item Patient Health Questionnaire (PHQ-9) and a 7-item Generalized Anxiety Disorder scale (GAD-7) followed by a socio-demographic questionnaire and measurements of height, weight, waist circumference, blood pressure, and total cholesterol. The diagnostic Mini International Neuropsychiatric Interview (MINI) was conducted over the telephone within 2 weeks after the visit to the general practitioner. A multivariate model was developed using binary logistic regression.

RESULTS

From the 1565 subjects (31.2% male), CVD was detected in 17.1%. Depression screening was positive (PHQ-9 ≥ 10) for 14.7%, and anxiety screening was positive (GAD-7 ≥ 10) for 10.1% of the study subjects. According to the MINI, 10.3% had current and 28.1% had lifetime depressive episode, and 16.1% had an anxiety disorder. Depression, not anxiety, was statistically significantly related to CVDs with an odds ratio (OR) of 1.52 (p = 0.04) for current depressive symptoms (PHQ-9 ≥ 10) and 2.08 (p = 0.002) for lifetime depressive episode (MINI).

CONCLUSIONS

Current depressive symptoms (PHQ-9 ≥ 10) and a lifetime depressive episode (according to the MINI) were significantly associated with increased risk of CV morbidity. Therefore, CV patients should be screened and treated for depression to potentially improve the prognosis of CVDs. Enhanced training and integration of mental health treatment in Latvian primary care settings may improve clinical outcomes.