Secular trends in cardiovascular disease mortality, incidence, and case fatality rates in adults in the United States

Stakeholder-led understanding of the implementation of digital technologies within heart disease diagnosis: a qualitative study protocol

INTRODUCTION

Cardiovascular diseases are highly prevalent among the UK population, and the quality of care is being reduced due to accessibility and resource issues. Increased implementation of digital technologies into the cardiovascular care pathway has enormous potential to lighten the load on the National Health Service (NHS), however, it is not possible to adopt this shift without embedding the perspectives of service users and clinicians.

METHODS AND ANALYSIS

A series of qualitative studies will be carried out with the aim of developing a stakeholder-led perspective on the implementation of digital technologies to improve holistic diagnosis of heart disease. This will be a decentralised study with all data collection being carried out online with a nationwide cohort. Four focus groups, each with 5-6 participants, will be carried out with people with lived experience of heart disease, and 10 one-to-one interviews will be carried out with clinicians with experience of diagnosing heart diseases. The data will be analysed using an inductive thematic analysis approach.

ETHICS AND DISSEMINATION

This study received ethical approval from the Sciences and Technology Cross Research Council at the University of Sussex (reference ER/FM409/1). Participants will be required to provide informed consent via a Qualtrics survey before being accepted into the online interview or focus group. The findings will be disseminated through conference presentations, peer-reviewed publications and to the study participants.

Time Trends of Cardiovascular Disease in the General Population and Inflammatory Arthritis

Cardiovascular diseases (CVDs) are the leading causes of death in the world, but declining trends for cardiovascular (CV) mortality and morbidity have been observed during the last decades. Reports on secular trends regarding the excess CV mortality and morbidity in rheumatoid arthritis show diverging results. Data support that also patients with inflammatory arthritis have benefited from improved treatment and prevention for CVD, which can be observed, for example, in decreased case fatality after CV event. However, several recent studies indicate a remaining excess CV risk in patients with inflammatory arthritis.

Identifying potential signatures for atherosclerosis in the context of predictive, preventive, and personalized medicine using integrative bioinformatics approaches and machine-learning strategies

Background

Atherosclerosis is a major contributor to morbidity and mortality worldwide. Although several molecular markers associated with atherosclerosis have been developed in recent years, the lack of robust evidence hinders their clinical applications. For these reasons, identification of novel and robust biomarkers will directly contribute to atherosclerosis management in the context of predictive, preventive, and personalized medicine (PPPM). This integrative analysis aimed to identify critical genetic markers of atherosclerosis and further explore the underlying molecular immune mechanism attributing to the altered biomarkers.

Methods

Gene Expression Omnibus (GEO) series datasets were downloaded from GEO. Firstly, differential expression analysis and functional analysis were conducted. Multiple machine-learning strategies were then employed to screen and determine key genetic markers, and receiver operating characteristic (ROC) analysis was used to assess diagnostic value. Subsequently, cell-type identification by estimating relative subsets of RNA transcript (CIBERSORT) and a single-cell RNA sequencing (scRNA-seq) data were performed to explore relationships between signatures and immune cells. Lastly, we validated the biomarkers' expression in human and mice experiments.

Results

A total of 611 overlapping differentially expressed genes (DEGs) included 361 upregulated and 250 downregulated genes. Based on the enrichment analysis, DEGs were mapped in terms related to immune cell involvements, immune activating process, and inflaming signals. After using multiple machine-learning strategies, dehydrogenase/reductase 9 (DHRS9) and protein tyrosine phosphatase receptor type J (PTPRJ) were identified as critical biomarkers and presented their high diagnostic accuracy for atherosclerosis. From CIBERSORT analysis, both DHRS9 and PTPRJ were significantly related to diverse immune cells, such as macrophages and mast cells. Further scRNA-seq analysis indicated DHRS9 was specifically upregulated in macrophages of atherosclerotic lesions, which was confirmed in atherosclerotic patients and mice.

Conclusions

Our findings are the first to report the involvement of DHRS9 in the atherogenesis, and the proatherogenic effect of DHRS9 is mediated by immune mechanism. In addition, we confirm that DHRS9 is localized in macrophages within atherosclerotic plaques. Therefore, upregulated DHRS9 could be a novel potential target for the future predictive diagnostics, targeted prevention, patient stratification, and personalization of medical services in atherosclerosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-022-00289-y.

The role of anti-inflammatory drugs and nanoparticle-based drug delivery models in the management of ischemia-induced heart failure

Ongoing advancements in the treatment of acute myocardial infarction (MI) have significantly decreased MI related mortality. Consequently, the number of patients experiencing post-MI heart failure (HF) has continued to rise. Infarction size and the extent of left ventricular (LV) remodeling are largely determined by the extent of ischemia at the time of myocardial injury. In the setting of MI or acute phase of post-MI LV remodeling, anti-inflammatory drugs including intravenous immunoglobulin (IVIG) and Pentoxifylline have shown potential efficacy in preventing post-MI remodeling in-vitro and in some clinical trials. However, systemic administration of anti-inflammatory drugs are not without their off-target side effects. Herein, we explore the clinical feasibility of targeted myocardial delivery of anti-inflammatory drugs via biodegradable polymers, liposomes, hydrogels, and nano-particle based drug delivery models (NDDM) based on existing pre-clinical and clinical models. We summarize the barriers to clinical application of targeted anti-inflammatory delivery post-MI, including challenges in achieving sufficient retention and distribution, as well as the potential need for multiple dosing. Collectively, we suggest that localized delivery of anti-inflammatory agents to the myocardium using NDDM is a promising approach for successful treatment of ischemic HF. Future studies will be instrumental in determining the most effective target and delivery modalities for orchestrating NDDM-mediated treatment of HF.

Magnetic resonance markers of bilateral neuronal metabolic dysfunction in patients with unilateral internal carotid artery occlusion

OBJECTIVES

To evaluate cerebral hemodynamic, metabolic and anatomic changes occurring in patients with unilateral occlusion of the internal carotid artery (ICA).

MATERIALS AND METHODS

Twenty-two patients with unilateral occlusion of ICA and twenty age and sex matched healthy subjects were included in the study. Single voxel proton magnetic resonance spectroscopy (¹H-MRS) of the centrum semiovale, semi-automated hippocampal volumetry in T1-weighted scans and transcranial Doppler examination (TCD) with calculation of Breath Holding Index (BHI) were performed in both groups. Metabolic, anatomic, and hemodynamic features were compared between the two groups.

RESULTS

The N-acetylaspartate (NAA)/choline (Cho) ratio was significantly lower in both hemispheres of enrolled patients compared to controls (p = 0.005 for the side with occlusion, p = 0.04 for the side without occlusion). The hippocampus volume was significantly reduced bilaterally in patients compared to healthy subjects (p = 0.049). A statistically significant difference in BHI values was observed between the side with occlusion and without occlusion (p = 0.037) of the patients, as well as between BHI values of the side with occlusion and healthy volunteers (p = 0.014).

DISCUSSION

Patients with unilateral ICA occlusion have reduced NAA/Cho ratio in the white matter of both hemispheres and have bilateral atrophy of hippocampus. The alteration of hemodynamics alone cannot explain these changes.

Outcome trends in people with heart failure, type 2 diabetes mellitus and chronic kidney disease in the UK over twenty years

BACKGROUND

Heart failure (HF) together with type 2 diabetes (T2D) and chronic kidney disease (CKD) are major pandemics of the twenty first century. It is not known in people with new onset HF, what the distinct and combined associations are between T2D and CKD comorbidities and cause-specific hospital admissions and death, over the past 20 years.

METHODS

An observational study using the UK Clinical Practice Research Datalink linked to the Hospital Episode Statistics in England (1998-2017). Participants were people aged ≥30 years with new onset HF. Exposure groups were HF with: (i) no T2D and no CKD (reference group); (ii) CKD-only (estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m²); (iii) T2D-only; (iv) T2D and CKD. CKD severity groups were: CKD-3a (eGFR 45-59); CKD-3b (30-44); CKD-4 (15-29); CKD-5 (<15). Outcomes were cardiovascular and non-cardiovascular hospitalisations and all-cause death.

FINDINGS

In 87,709 HF patients (mean age, 78 years; 49% female), 40% had CKD-only, 12% T2D-only, and 16% both. Age-standardised first-year CVD hospitalisation rates were significantly higher in HF patients with CKD-only (46.4; 95% CI 44.9,47.9 per 100 person years) and T2D-only (49.2; 46.7,58.8) than in the reference group (35.1; 34.0,36.1); the highest rate was in patients with T2D-CKD-5: 89.1 (65.8,112.4). Similar patterns were observed for non-CVD hospitalisations and deaths. Group differences remained significant after adjustment for potential confounders. Median survival was highest in the reference (4.4 years) and HF-T2D-only (4.1 years) groups, compared to HF-CKD-only (2.2 years). HF-T2D-CKD group survival ranged from 2.8 (CKD-3a) to 0.7 years (CKD-5). Over time, CVD hospitalisation rates significantly increased for HF-CKD-only (+26%) and reduced (-24%) for HF-T2D-only groups; no reductions were observed in any of the HF-T2D-CKD groups. Trends were similar for non-CVD hospitalisations and death: whilst death rates significantly reduced for HF-T2D-only (-37%), improvement was not observed in any of the T2D-CKD groups.

INTERPRETATION

In a cohort of people with new onset HF, hospitalisations and deaths are high in patients with T2D or CKD, and worst in those with both comorbidities. Whilst outcomes have improved over time for patients with HF and comorbid T2D, similar trends were not seen in those with comorbid CKD. Strategies to prevent and manage CKD in people with HF are urgently needed.

FUNDING

NIHR fellowship [reference: NIHR 30011].

Prevalence and incidence of hearing impairment among adults: a 13-year follow-up study

OBJECTIVE

The aim of this study was to investigate the prevalence and incidence of hearing impairment (HI) in a longitudinal setting among adults.

DESIGN

An unscreened, population-based epidemiological 13-year follow-up study. Study sample: 850 randomly sampled 54 to 66-year-old baseline participants, of whom 559 participated in the follow-up study at the age of 68 to 79 years. A questionnaire-based interview, an otological examination and pure-tone audiometry were performed.

RESULTS

The overall prevalence of HI was 70.3%, defined by better ear hearing level (BEHL)  ≥ 20 dB in the 0.5-4 kHz frequency range. The prevalence was higher among men (78.6%) than among women (63.7%). The overall incidence rate for HI was 45.8 per 1000 person years and the 13-year cumulative incidence was 60.9%. The incidence was higher among men and older participants.

CONCLUSION

HI is highly prevalent and incident among older adults in Northern Finland.

Trends in cardiovascular outcomes after acute coronary syndrome in New Zealand 2006-2016

OBJECTIVES

Characterisation of trends in acute coronary syndrome (ACS) outcomes are critical to informing clinical practice and quality improvement, but there are few recent population studies for ACS. We reviewed the recent trends in the outcomes of ACS in New Zealand (NZ).

METHODS

All patients with ACS admitted to NZ public hospitals in 2006-2016 were identified from hospital discharge records, and their first ACS hospitalisations per year extracted for analysis. Thirty-day and 1-year death, myocardial infarction, stroke, heart failure and bleeding rates were calculated for each calendar year. Trends in outcome rates were assessed using generalised linear mixed models.

RESULTS

Total annual ACS hospitalisations decreased from 685 to 424 per 100 000. Using first patient hospitalisations per year (n=1 55 060), we found significant annual declines in all major outcomes except for non-cardiovascular deaths. All-cause mortality fell from 10.5% to 9.1% at 30 days (adjusted OR 0.985 per year change, p<0.001) and from 21.8% to 18.7% at 1 year (OR=0.994, p=0.016). This was related to significant decreases in cardiovascular death at both time points (OR=0.982 and 0.987, respectively, p<0.001), outweighing a slight increase in non-cardiovascular death at 1 year (OR=1.009, p=0.014). One-year rates of myocardial infarction, heart failure, stroke and bleeding rates all decreased significantly over time.

CONCLUSION

ACS outcomes including all-cause mortality, cardiovascular death, myocardial infarction, stroke, heart failure and bleeding at 30 days and 1 year improved over the last decade in NZ, reflecting successful implementation and advances in prevention, medical and invasive management in ACS over time.

Contrasting Trends in Acute Coronary Syndrome Hospitalisation and Coronary Revascularisation in New Zealand 2006-2016: A National Data Linkage Study (ANZACS-QI 27)

BACKGROUND

Evaluating trends in acute coronary syndrome (ACS) and invasive coronary procedures, including coronary angiography, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) can identify areas for improvement in clinical care and inform future health planning. This national data-linkage study reports trends in ACS hospitalisations and procedure rates in New Zealand between 2006 and 2016.

METHODS

All adult ACS hospitalisations and associated angiography and revascularisation procedures were identified from hospital discharge codes. Crude and age-standardised ACS incidence and procedure rates were calculated for each calendar year.

RESULTS

Between 2006 and 2016 there were 188,264 ACS admissions. During this time, there was a steady decline in hospitalisation rates, from 685 to 424 per 100,000 per year. This decline was observed in both sexes and in all age groups. There were also significant increases in coronary angiography and revascularisation rates, from 29.8% to 54.3% and 20.6% to 37.3%, respectively, between 2006 and 2016. The rate of revascularisation by PCI increased from 16.0% to 31.0%, a greater increase than revascularisation by CABG, which increased from 4.6% to 6.5%. Increases in procedures were observed in all age groups and both sexes. The proportions of coronary angiograms that resulted in revascularisation each year consistently ranged from 67 to 70% throughout the period.

CONCLUSIONS

Acute coronary syndrome hospitalisation rates in New Zealand decreased by nearly 40% between 2006 and 2016, while the use of coronary angiography and revascularisation after ACS nearly doubled. The similar proportions of angiograms that resulted in revascularisation each year suggests that, despite the doubling of angiograms over the 10-year study period, they are not over-utilised.

Coronary Artery Disease: From Mechanism to Clinical Practice

In most developed countries, coronary artery disease (CAD), mostly caused by atherosclerosis of coronary arteries, is one of the primary causes of death. From 1990s to 2000s, mortality caused by acute MI declined up to 50%. The incidence of CAD is related with age, gender, economic, etc. Atherosclerosis contains some highly correlative processes such as lipid disturbances, thrombosis, inflammation, vascular smooth cell activation, remodeling, platelet activation, endothelial dysfunction, oxidative stress, altered matrix metabolism, and genetic factors. Risk factors of CAD exist among many individuals of the general population, which includes hypertension, lipids and lipoproteins metabolism disturbances, diabetes mellitus, chronic kidney disease, age, genders, lifestyle, cigarette smoking, diet, obesity, and family history. Angina pectoris is caused by myocardial ischemia in the main expression of pain in the chest or adjoining area, which is usually a result of exertion and related to myocardial function disorder. Typical angina pectoris would last for minutes with gradual exacerbation. Rest, sit, or stop walking are the usual preference for patients with angina, and reaching the maximum intensity in seconds is uncommon. Rest or nitroglycerin usage can relieve typical angina pectoris within minutes. So far, a widely accepted angina pectoris severity grading system included CCS (Canadian Cardiovascular Society) classification, Califf score, and Goldman scale. Patients with ST-segment elevated myocardial infarction (STEMI) may have different symptoms and signs of both severe angina pectoris and various complications. The combination of rising usage of sensitive MI biomarkers and precise imaging techniques, including electrocardiograph (ECG), computed tomography, and cardiac magnetic resonance imaging, made the new MI criteria necessary. Complications of acute myocardial infarction include left ventricular dysfunction, cardiogenic shock, structural complications, arrhythmia, recurrent chest discomfort, recurrent ischemia and infarction, pericardial effusion, pericarditis, post-myocardial infarction syndrome, venous thrombosis pulmonary embolism, left ventricular aneurysm, left ventricular thrombus, and arterial embolism.

Incidence and risk factors for recurrent cardiovascular disease in middle-eastern adults: a retrospective study

BACKGROUND

Individuals with established cardiovascular disease (CVD) and risk factors such as age, smoking, hypertension, and diabetes mellitus are at an increased risk of recurrent cardiovascular events and death. The incidence rate of recurrent CVD events varies between countries and populations. The United Arab Emirates (UAE) has one of the highest age-standardized death rates for CVD worldwide. The aim of our study was to estimate the incidence rates and determine the predictors of recurrent CVD events among UAE nationals.

METHODS

We investigated an outpatient-based cohort of patients with a history of CVD visiting Tawam Hospital between April 1, 2008 and December 31, 2008. They were followed-up until July 31, 2018. Univariable and multivariable Cox proportional hazards regression models were used to determine the association between major CVD risk factors and the risk of CVD recurrence.

RESULTS

A total of 216 patients (167 males, 49 females) with a history of CVD were included. They were followed for a median (interquartile range) of 8.1 (5.5-9.3) years, with a total of 1184 patient-years of follow-up. The overall incidence rate of recurrent CVD events was 92.1 per 1000 patient-years. The 8-year cumulative incidence was 73.7%. Age, female sex, and diabetes mellitus were significant predictors of recurrent CVD events, where females had a 1.96 times higher risk of recurrent CVD events than males.

CONCLUSION

Significant predictors of recurrent CVD events are older age, female sex, and diabetes mellitus. The incidence rate of recurrent CVD events was 92.1 per 1000 patient-years. Preventive measures, based on international guidelines for CVD management, may improve CVD morbidity and mortality in the UAE population.

Induction immunosuppression agents as risk factors for incident cardiovascular events and mortality after kidney transplantation

Low T cell counts and acute rejection are associated with increased cardiovascular events (CVEs); T cell-depleting agents decrease both. Thus, we aimed to characterize the risk of CVEs by using an induction agent used in kidney transplant recipients. We conducted a secondary data analysis of patients who received a kidney transplant and used Medicare as their primary insurance from 1999 to 2010. Outcomes of interest were incident CVE, all-cause mortality, CVE-related mortality, and a composite outcome of mortality and CVE. Of 47 258 recipients, 29.3% received IL-2 receptor antagonist (IL-2RA), 33.3% received anti-thymocyte globulin (ATG), 7.3% received alemtuzumab, and 30.0% received no induction. Compared with IL-2RA, there was no difference in the risk of CVE in the ATG (adjusted hazard ratio [aHR] 0.98, 95% confidence interval [CI] 0.92-1.05) and alemtuzumab group (aHR 1.01, 95% CI 0.89-1.16), but slightly higher in the no induction group (aHR 1.06, 95% CI 1.00-1.14). Acute rejection did not modify this association in the latter group but did increase CVE by 46% in the alemtuzumab group. There was no difference in the hazard of all-cause or CVE-related mortality. Only in the ATG group, a 7% lower hazard of the composite outcome of mortality and CVE was noted. Induction agents are not associated with incident CVE, although prospective trials are needed to determine a personalized approach to prevention.

Epidemiological trends of acute coronary syndrome in Shimla district of the hilly state of Northern India: Six-year data from the prospective Himachal Pradesh acute coronary syndrome registry

Objectives

The epidemiological trends of incidence, treatment practices, and outcomes are reported from Shimla district of the northern state of India.

Methods

The data of clinical characteristics, treatment practices, and outcomes of patients with acute coronary syndrome (ACS) diagnosed using standard criteria were collected systematically from the defined hilly geographical region of the northern state of India from January 2013 to December 2018 as the part of Himachal Pradesh acute coronary syndrome (HP ACS) registry. The year-wise trends of incidence, demographic, clinical characteristics, treatment practices, and in-hospital mortality are reported.

Results

The incidence of ACS shows declining trends. The mean age at incident ACS is increasing without change in gender predilection. The prevalence of overweight/obesity and diabetes has increased significantly since 2013 but tobacco consumption has not changed. The reperfusion therapy has increased significantly (20.9% in 2013 to 42.1% in 2018, p < 0.01) primarily because of an increased use of percutaneous coronary angioplasty. There is a trend of increasing use of beta blockers. The use of other oral secondary preventive drugs remained more than 90% since 2013. The in-hospital mortality rate is declining (9.0% in 2013 to 6.0% in 2018, p < 0.01).

Conclusions

Epidemiological characteristics of the ACS population in Shimla district are changing. The trends of use of reperfusion therapy in ST segment elevated myocardial infarction population has although increased but is still suboptimal, and there is a need for taking initiatives both at the system and population level to improve the reperfusion therapy.

Utility of Normal Findings on Electrocardiogram and Echocardiogram in Subjects ≥65 Years

The lack of abnormalities found on noninvasive cardiac testing possibly improves cardiovascular disease (CVD) risk stratification efforts and conveys reduced risk despite the presence of traditional risk factors. This analysis included 3,805 (95% white and 61% women) participants from the Cardiovascular Health Study (CHS) without baseline CVD. The combination of a normal electrocardiogram (ECG) and echocardiogram was assessed for the development of CVD. A normal ECG was defined as the absence of major or minor Minnesota code abnormalities. A normal echocardiogram was defined as the absence of contractile dysfunction, wall motion abnormalities, or abnormal left ventricular mass. Cox regression was used to compute the 10-year risk of developing coronary heart disease, stroke, and heart failure events. There were 1,555 participants (41%) with normal findings on both measures. After accounting for traditional CVD risk factors, a protective benefit was observed for all outcomes among participants who had normal ECG and echocardiographic findings (coronary heart disease: hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.46, 0.69; stroke: HR 0.57, 95% CI 0.43, 0.76; heart failure: HR 0.36, 95% CI 0.29, 0.41). The addition of this normal profile resulted in significant net reclassification improvement of the Framingham risk score for heart failure (net reclassification improvement 4.3%, 95% CI 1.0, 8.0). In conclusion, normal findings on routine noninvasive cardiac assessment identify subjects in whom CVD risk is low.

Exposure of Arctic populations to methylmercury from consumption of marine food: an updated risk-benefit assessment

Recent and powerful epidemiological studies have been used as a basis for revising international and domestic guidelines for human exposure to mercury. Long-range transport of mercury into the Arctic makes some Arctic peoples consuming traditional marine foods, especially newborns, children and pregnant women, very vulnerable to harmful exposures. The WHO, the USEPA and Health Canada have all recently revised their mercury intake guidelines as a result of neurological effects reported in children exposed in utero and adults. Guidance values are equivalent to 0.23 microg/kg-bw/d, 0.1 microg/kg-bw/d and 0.2 microg/kg-bw/d respectively. Differences between the numbers represent slight differences in the uncertainty factors applied, rather than in toxicological interpretation. More recent findings suggest that mercury may also be a factor in ischemic heart disease, which could lower guidance values in the future. Considering the benefits of marine fatty acids (n-3 fatty acids) and guidance that populations consume 300-400g fish/week, consumers face a reality that most open ocean and relatively 'unpolluted' fish species contain levels of mercury that would lead to exposures at current guidance levels. Clearly, there is no more room for further mercury pollution and there is an urgent need for international action to reduce mercury emissions. Concomitantly, while there may be a need for public health authorities to provide consumption advisories to some highly exposed populations, such as in the Arctic, there remains a need to better understand the interactions and benefits associated with marine foods that may reduce health risks associated with low-level mercury exposure.

Epidemiology of coronary heart disease and acute coronary syndrome

The aim of this review is to summarize the incidence, prevalence, trend in mortality, and general prognosis of coronary heart disease (CHD) and a related condition, acute coronary syndrome (ACS). Although CHD mortality has gradually declined over the last decades in western countries, this condition still causes about one-third of all deaths in people older than 35 years. This evidence, along with the fact that mortality from CHD is expected to continue increasing in developing countries, illustrates the need for implementing effective primary prevention approaches worldwide and identifying risk groups and areas for possible improvement.

No evidence of morbidity compression in Spain: a time series study based on national hospitalization records

OBJECTIVES

Compression of morbidity postulates that as the populations age, the age of onset of disease is postponed. The objective of this study is to test for evidence of compression of morbidity in Spain.

METHODS

We calculated the age and sex-specific incidence of myocardial infarction, heart failure, cerebrovascular disease, as well as bladder, prostate, breast, lung, and colon cancer among hospital discharges covering 99.5 % of the Spanish population, approximately 40 million inhabitants for two non-overlapping periods, 1997-2000 and 2007-2010, and estimated the length of life spent with disease using the Sullivan method.

RESULTS

We found that expansion of morbidity due to an earlier age-specific onset of incident disease and increase in life expectancy was the norm in Spain. Notable exceptions were cardiovascular disease in women (-0.2 % time spent with disease) and lung cancer for men (-0.9 % time spent with disease) from 1997-2000 to 2007-2010.

CONCLUSIONS

Compression of morbidity is often cited by policy makers when discussing adjustments to the health-care system. If morbidity is measured by age at onset of disease, the burden of morbidity has increased in Spain.

Midlife moderation-quantified healthy diet and 40-year mortality risk from CHD: the prospective National Heart, Lung, and Blood Institute Twin Study

It is unknown whether influences of midlife whole diet on the long-term CHD mortality risk are independent of genetic and common environmental factors or familial predisposition. We addressed this question prospectively using data from the National Heart, Lung, and Blood Institute Twin Study. We included 910 male twins who were middle-aged and had usual diet assessed with nutritionist-administered, cross-checked dietary history interview at baseline (1969-1973). Moderation-quantified healthy diet (MQHD), a dietary pattern, was created to evaluate a whole diet. Primary outcome was time-to-CHD death. Hazard ratios (HR) were estimated using frailty survival model. Known CHD risk factors were controlled. During the follow-up of 40 years through 31 December 2009, 113 CHD deaths, 198 total cardiovascular deaths and 610 all-cause deaths occurred. In the entire cohort, the multivariable-adjusted HR for the overall association (equivalent to a general population association) was 0·76 (95 % CI 0·66, 0·88) per 10-unit increment in the MQHD score for CHD, and the multivariable-adjusted HR for a twin with a MQHD score ten units higher than his co-twin brother was 0·79 (95 % CI 0·64, 0·96, P=0·02) for CHD independent of familial predisposition. Similar results were found for a slightly more food-specified alternative moderation-quantified healthy diet (aMQHD). The between-pair association (reflecting familial influence) was significant for CHD for both MQHD and aMQHD. It is concluded that associations of MQHD and aMQHD with a lower long-term CHD mortality risk are both nutritionally and familially affected, supporting their use for dietary planning to prevent CHD mortality.

Dementia in western Europe: epidemiological evidence and implications for policy making

Dementia is receiving increasing attention from governments and politicians. Epidemiological research based on western European populations done 20 years ago provided key initial evidence for dementia policy making, but these estimates are now out of date because of changes in life expectancy, living conditions, and health profiles. To assess whether dementia occurrence has changed during the past 20-30 years, investigators of five different studies done in western Europe (Sweden [Stockholm and Gothenburg], the Netherlands [Rotterdam], the UK [England], and Spain [Zaragoza]) have compared dementia occurrence using consistent research methods between two timepoints in well-defined geographical areas. Findings from four of the five studies showed non-significant changes in overall dementia occurrence. The only significant reduction in overall prevalence was found in the study done in the UK, powered and designed explicitly from its outset to detect change across generations (decrease in prevalence of 22%; p=0.003). Findings from the study done in Zaragoza (Spain) showed a significant reduction in dementia prevalence in men (43%; p=0.0002). The studies estimating incidence done in Stockholm and Rotterdam reported non-significant reductions. Such reductions could be the outcomes from earlier population-level investments such as improved education and living conditions, and better prevention and treatment of vascular and chronic conditions. This evidence suggests that attention to optimum health early in life might benefit cognitive health late in life. Policy planning and future research should be balanced across primary (policies reducing risk and increasing cognitive reserve), secondary (early detection and screening), and tertiary (once dementia is present) prevention. Each has their place, but upstream primary prevention has the largest effect on reduction of later dementia occurrence and disability.

Incidence and outcome of first myocardial infarction according to gender and age in Denmark over a 35-year period (1978-2012)

Aims

To examine temporal changes in incidence and 1-year mortality of first myocardial infarction (MI) in different age groups for both genders in Denmark over a 35-year period (1978-2012).

Methods and results

Patients aged 30 years or older admitted with first MI in Denmark from 1978 to 2012 were included (n = 316 790). Overall, first MI incidence per 100 000 person-years (/105 p.y.) decreased significantly from 500 to 297/105 p.y. for males and from 229 to 156/105 p.y. for females. The decline was greatest among men aged 70-79 from 1460 to 643/105 p.y. (-56%). The majority of age groups also experienced declining incidence. However, men aged 30-39 and ≥90 years as well as females aged 30-49 and ≥90 years had increasing incidence during the study period. Moreover, the incidence decreased from 1978 to 1996 among males aged 40-49 and females aged 50-59 years, but increased in the remainder of the study period. One-year case-fatality declined significantly from 50 to 9% of MI male patients, and from 53 to 15% of MI female patients when comparing 1978 to 2012. Statistical analysis with Poisson models demonstrated that the mortality rate increased with age and decreased with time and indicated no significant difference between genders.

Conclusions

During the period from 1978 to 2012, there was a significant decline in MI incidence among most age groups for both genders; however, an incidence increase was observed in men under 50 and women under 60 years, and ≥90 years for both genders. One-year case-fatality decreased constantly during the study period.

A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis

BACKGROUND & AIMS

Little is known about progression of ischemic colitis (IC) among unselected patients. We aimed to estimate the incidence, risk factors, and natural history of IC in a population-based cohort in Olmsted County, Minnesota.

METHODS

We performed a retrospective population-based cohort and nested case-control study of IC. Each IC case was matched to 2 controls from the same population on the basis of sex, age, and closest registration number. Conditional logistic regression, the Kaplan-Meier method, and proportional hazards regression were used to assess comorbidities, estimate survival, and identify characteristics associated with survival, respectively.

RESULTS

Four hundred forty-five county residents (median age, 71.6 years; 67% female) were diagnosed with IC from 1976 through 2009 and were matched with 890 controls. The age-adjusted and sex-adjusted incidence rates of IC nearly quadrupled from 6.1 cases/100,000 person-years in 1976-1980 to 22.9/100,000 in 2005-2009. The odds for IC were significantly higher among subjects with atherosclerotic diseases; odds ratios ranged from 2.6 for individuals with coronary disease to 7.9 for individuals with peripheral vascular disease. Of IC cases, 59% survived for 5 years (95% confidence interval, 54%-64%), compared with 90% of controls (95% confidence interval, 88%-92%). Age >40 years, male sex, right-sided colon involvement, concomitant small bowel involvement, and chronic obstructive pulmonary disease were all independently associated with mortality (P < .05).

CONCLUSIONS

The incidence of IC increased during the past 3 decades in a population-based cohort in Minnesota. IC typically presents in older patients with multiple comorbidities and is associated with high in-hospital mortality (11.5%) and rates of surgery (17%).

Ten-year (2002-2012) cardiovascular disease incidence and all-cause mortality, in urban Greek population: the ATTICA Study

AIM

The 10-year incidence of cardiovascular disease (CVD) and all-cause mortality, as well as its determinants, in a sample of men and women from Greece, was evaluated.

METHODS

From May 2001 to December 2002, 1514 men and 1528 women (>18y) without any clinical evidence of CVD or any other chronic disease, at baseline, living in greater Athens area, in Greece, were enrolled. In 2011-12, the 10-year follow-up was performed in 2583 participants (15% of the participants were lost to follow-up). Incidence of fatal or non-fatal CVD (coronary heart disease, acute coronary syndromes, stroke, or other CVD) was defined according to World Health Organization (WHO)-International Coding Diseases (ICD)-10 criteria.

RESULTS

The 10-year CVD incidence was 19.7% in men and 11.7% in women (p<0.001). Multi-adjusted analysis revealed that the determinants of CVD events were increased age (Hazard ratio (HR) per year=1.06, 95%Confidence Interval (CI): 1.04, 1.08), male sex (HR=1.40, 95%CI: 0.90, 2.19), smoking (HR=1.53, 95%CI: 1.03, 2.27), C-reactive protein levels (HR per 1mg/L=1.06, 95%CI: 1.02, 1.15), as well as adherence to Mediterranean diet (protective) (HR per 1/55 units=0.98, 95%CI: 0.95, 1.01).

CONCLUSION

The burden of CVD and its related risk factors is at emerging rates, in Greece, making the need for effective public health actions, more necessary than ever before.

Traditional games resulted in post-exercise hypotension and a lower cardiovascular response to the cold pressor test in healthy children

The present study aimed to verify if blood pressure (BP) reactivity could be reduced through a previous single session of active playing when compared to sedentary leisure. Sixteen pre-pubertal healthy children participated in this study. After familiarization with procedures and anthropometric evaluation, participants performed three sessions in randomized order: (1) 30 min of traditional Brazilian games (PLAY); (2) 30 min of video game playing (DDR); and (3) 30 min of watching TV (TV). Each session lasted 80 min, being 10 min of rest; 30 min of intervention activity; and 40 min of recovery. After recovery, the Cold Pressor Test (CPT) was used for the assessment of acute cardiovascular reactivity. BP was recorded at 30 s and 1 min during the CPT. Analysis of variance showed post-exercise hypotension (PEH) only after PLAY, and that systolic and diastolic BP were significantly increased in all conditions during CPT. However, the magnitude of the CPT-induced BP response was significantly less in PLAY compared to DDR and TV. The PEH observed during recovery and the reduced BP response to CPT following playing traditional games may be due its higher cardiovascular and metabolic demand as was indicated by the increased heart rate, oxygen consumption, and BP. It was concluded that BP reactivity to stress may be reduced through a previous single session of traditional games and that PEH was recorded only after this exercise form. This benefit indicates a potential role of playing strategies for cardiovascular health in childhood.

Epidemiology, traditional and novel risk factors in coronary artery disease

Coronary artery disease (CAD) mortality has been declining in the United States and in regions where health care systems are relatively advanced. Still, CAD remains the number one cause of death in both men and women in the United States, and coronary events have increased in women. Many traditional risk factors for CAD are related to lifestyle, and preventative treatment can be tailored to modifying specific factors. Novel risk factors also may contribute to CAD. Finally, as the risk for CAD is largely understood to be inherited, further genetic testing should play a role in preventative treatment of the disease.

Risk of cerebrovascular accidents and ischemic heart disease in patients with inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND & AIMS

Inflammatory bowel disease (IBD) is associated with an increased risk of venous thromboembolic disease. However, it is unclear whether IBD modifies the risk of arterial thromboembolic events, including cerebrovascular accidents (CVA) and ischemic heart disease (IHD).

METHODS

We performed a systematic review and meta-analysis of cohort and case-control studies that reported incident cases of CVA and/or IHD in patients with IBD and a non-IBD control population (or compared with a standardized population). We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We analyzed data from 9 studies (2424 CVA events in 5 studies, 6478 IHD events in 6 studies). IBD was associated with a modest increase in the risk of CVA (5 studies; OR, 1.18; 95% CI, 1.09-1.27), especially among women (4 studies; OR, 1.28; 95% CI, 1.17-1.41) compared with men (OR, 1.11; 95% CI, 0.98-1.25), and in young patients (<40-50 y old). The increase in risk was observed for patients with Crohn's disease and in those with ulcerative colitis. IBD also was associated with a 19% increase in the risk of IHD (6 studies; OR, 1.19; 95% CI, 1.08-1.31), both in patients with Crohn's disease and ulcerative colitis. This risk increase was seen primarily in women (4 studies; OR, 1.26; 95% CI, 1.18-1.35) compared with men (OR, 1.05; 95% CI, 0.92-1.21), in young and old patients. IBD was not associated with an increased risk of peripheral arterial thromboembolic events. Considerable heterogeneity was observed in the overall analysis.

CONCLUSIONS

IBD is associated with a modest increase in the risk of cardiovascular morbidity (from CVA and IHD)-particularly in women. These patients should be counseled routinely on aggressive risk factor modification.

Assessing progress in reducing the burden of cancer mortality, 1985-2005

PURPOSE

Measuring the effect of cancer interventions must take into account rising cancer incidence now that people live longer because of declines in mortality from cardiovascular disease (CVD). Cancer mortality rates in the population do not accomplish this objective. We sought a measure that would reveal the effects of changing mortality rates from other diseases.

METHODS

We obtained annual breast, colorectal, lung, and prostate cancer mortality rates from the Surveillance, Epidemiology, and End Results registries; we obtained noncancer mortality rates from national death certificates, 1975 to 2005. We used life-table methods to calculate the burden of cancer mortality as the average person-years of life lost (PYLL) as a result of cancer (cancer-specific PYLL) and quantify individual-and perhaps offsetting-contributions of the two factors that affect cancer-specific PYLL: mortality rates as a result of cancer and other-cause mortality.

RESULTS

Falling cancer mortality rates reduced the burden of mortality from leading cancers, but increasing cancer incidence as a result of decreasing other-cause mortality rates partially offset this progress. Between 1985 and 1989 and between 2000 and 2004, the burden of lung cancer in males declined by 0.1 year of life lost. This decline reflects the sum of two effects: decreasing lung cancer mortality rates that reduced the average burden of lung cancer mortality by 0.33 years of life lost and declining other-cause mortality rates that raised it by 0.23 years. Other common cancers showed similar patterns.

CONCLUSION

By using a measure that accounts for increased cancer incidence as a result of improvements in CVD mortality, we find that prior assessments have underestimated the impact of cancer interventions.

The epidemiology of coronary heart disease

Understanding the societal impact and trends of coronary heart disease through basic epidemiological measures is essential to evaluate treatment effectiveness and organize resource distribution. In the following narrative review, data are presented on the prevalence, incidence, and prognosis of coronary heart disease in general and of acute coronary syndrome in particular.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Epidemiology of diabetic foot infections in an eastern Caribbean population: a prospective study

INTRODUCTION

This study evaluates the epidemiology of diabetic foot infections in an Eastern Caribbean nation in order to direct public health preventive measures.

METHODS

We prospectively identified all patients with diabetic foot infections who were admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. A questionnaire was used to collect data on demographics, patient knowledge, avoidance of risk factors for chronic diseases (a proxy to unhealthy lifestyles), and glycosylated hemoglobin measurements on admission as an index of blood glucose control. The data were analyzed with statistical software.

RESULTS

There were 446 patients with diabetic foot infections (mean age = 56.9 years, standard deviation = 12.4 years). Most patients had Type 2 diabetes (93.3%) and were of Indo-Trinidadian (49.1%) or Afro-Trinidadian (41.7%) descent. There were preexisting complications of diabetes in 82.9% of patients with Type 2 diabetes: foot infections requiring hospitalization (70.2%), ischemic heart disease (32.5%), renal impairment (13.7%), and retinopathy (22.1%). Despite most patients claiming compliance with treatment, 75% had glycosylated hemoglobin levels above 7.1% at presentation, and 49.3% continued unhealthy lifestyles. Despite the high prevalence of diabetic complications at admission, and despite 70% having had previous hospitalization for treatment of foot infections, only 57.4% of patients reported ever being counseled or taught about foot care by medical personnel.

CONCLUSIONS

There is room for improvement in public health strategies to prevent diabetic foot complications in this setting. Such strategies should focus on patient education with emphasis on lifestyle modification and compliance with medical therapy.

Oxygen therapy for acute myocardial infarction

BACKGROUND

Oxygen (O₂) is widely used in people with acute myocardial infarction (AMI) although it has been suggested it may do more harm than good. Previous systematic reviews have concluded that there was insufficient evidence to know whether oxygen reduced, increased or had no effect on heart ischaemia or infarct size, as did our original Cochrane review on this topic in 2010. The wide dissemination of the lack of evidence to support this widely-used intervention since 2010 may stimulate the needed trials of oxygen therapy, and it is therefore important that this review is updated regularly.

OBJECTIVES

To review the evidence from randomised controlled trials to establish whether routine use of inhaled oxygen in acute myocardial infarction (AMI) improves patient-centred outcomes, in particular pain and death.

SEARCH METHODS

The following bibliographic databases were searched last in July 2012: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO) and Web of Science (ISI). LILACS (Latin American and Caribbean Health Sciences Literature) and PASCAL were last searched in May 2013. We also contacted experts to identify any studies. We applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials of people with suspected or proven AMI (ST-segment elevation myocardial infarction (STEMI) or non-STEMI), less than 24 hours after onset, in which the intervention was inhaled oxygen (at normal pressure) compared to air and regardless of cotherapies provided these were the same in both arms of the trial.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the titles and abstracts of identified studies to see if they met the inclusion criteria, and independently undertook the data extraction. The quality of studies and the risk of bias were assessed according to guidance in the Cochrane Handbook. The primary outcomes were death, pain and complications. The measure of effect used was the risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

The updated search identified one new trial. In total, four trials involving 430 participants were included and 17 deaths occurred. The pooled RR of death was 2.05 (95% CI 0.75 to 5.58) in an intention-to-treat analysis and 2.11 (95% CI 0.78 to 5.68) in participants with confirmed AMI. While suggestive of harm, the small number of deaths recorded means that this could be a chance occurrence. Pain was measured by analgesic use. The pooled RR for the use of analgesics was 0.97 (95% CI 0.78 to 1.20).

AUTHORS' CONCLUSIONS

There is no conclusive evidence from randomised controlled trials to support the routine use of inhaled oxygen in people with AMI. A definitive randomised controlled trial is urgently required, given the mismatch between trial evidence suggestive of possible harm from routine oxygen use and recommendations for its use in clinical practice guidelines.

Use of evidence-based therapy for the secondary prevention of acute coronary syndromes in Malaysian practice

RATIONALE

Despite the availability of various prevention guidelines on acute coronary syndrome (ACS), secondary prevention practice utilizing aspirin, beta-blockers, angiotensin converting enzyme inhibitors and statins still can be sub-optimal.

AIMS AND OBJECTIVES

To review and document the utilization of pharmacotherapy for the secondary prevention of ACS in patients discharged from a Malaysian hospital.

METHODS

A retrospective cross-sectional study was conducted at a tertiary hospital in Penang, Malaysia. Patients with a primary diagnosis of ACS were identified from medical records over a 4-month period. A range of clinical data was extracted from medical records, including medical history, clinical presentation and pharmacotherapy both on admission and at discharge. This audit focused on the use of four guideline-recommended therapies: aspirin ± clopidogrel, beta-blockers, statins and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blockers (ARBs).

RESULTS

Data pertaining to a total of 380 ACS patients was extracted and reviewed, the mean age of the study population was 57.49 years and 73.9% of population was males. Patients with unstable angina accounted for 56.6% of the admissions whereas 23.4% and 20% of the patients were admitted for ST-elevation myocardial infarction and non-ST-segment elevation infarct respectively. 95.7% of the patients received antiplatelets comprising of at least aspirin, and 82% received aspirin plus clopidogrel. Furthermore, 80.3% of the patients received a beta-blocker at discharge, 95% a statin and 69.7% received either an ACEI or ARB. Compared with patients who presented with myocardial infarction (with or without ST-segment elevation), those presenting with unstable angina were less likely to receive the combination of aspirin plus clopidogrel or an ACEI/ARB at discharge. Patients over 65 years of age were also less likely to receive a beta-blocker at discharge, compared with younger patients.

CONCLUSIONS

There is a good adherence to evidence-based guidelines for the secondary prevention of ACS in this local setting. However, there is some potential underutilization in the older population and patients presenting with unstable angina.

Time trends of incidence of age-associated diseases in the US elderly population: Medicare-based analysis

OBJECTIVES

time trends of age-adjusted incidence rates of 19 ageing-related diseases were evaluated for 1992-2005 period with the National Long Term Care Survey and the Surveillance, Epidemiology and End RESULTS Registry data both linked to Medicare data (NLTCS-Medicare and SEER-Medicare, respectively).

METHODS

the rates were calculated using individual medical histories (34,077 individuals from NLTCS-Medicare and 199,418 from SEER-Medicare) reconstructed using information on diagnoses coded in Medicare data, dates of medical services/procedures and Medicare enrolment/disenrolment.

RESULTS

increases of incidence rates were dramatic for renal disease [the average annual percent change (APC) is 8.56%, 95% CI = 7.62, 9.50%], goiter (APC = 6.67%, 95% CI = 5, 90, 7, 44%), melanoma (APC = 6.15%, 95% CI = 4.31, 8.02%) and Alzheimer's disease (APC = 3.96%, 95% CI = 2.67, 5.26%), and less prominent for diabetes and lung cancer. Decreases of incidence rates were remarkable for angina pectoris (APC = -6.17%, 95% CI = -6.96, -5.38%); chronic obstructive pulmonary disease (APC = -5.14%, 95% CI = -6.78,-3.47%), and ulcer (APC = -5.82%, 95% CI = -6.77,-4.86%) and less dramatic for carcinomas of colon and prostate, stroke, hip fracture and asthma. Incidence rates of female breast carcinoma, myocardial infarction, Parkinson's disease and rheumatoid arthritis were almost stable. For most diseases, an excellent agreement was observed for incidence rates between NLTCS-Medicare and SEER-Medicare. A sensitivity analysis proved the stability of the evaluated time trends.

CONCLUSION

time trends of the incidence of diseases common in the US elderly population were evaluated. The results show dramatic increase in incidence rates of melanoma, goiter, chronic renal and Alzheimer's disease in 1992-2005. Besides specifying widely recognised time trends on age-associated diseases, new information was obtained for trends of asthma, ulcer and goiter among the older adults in the USA.

Awareness, treatment, and control of major cardiovascular risk factors in a small-scale Italian community: results of a screening campaign

INTRODUCTION

Hypertension, hypercholesterolemia, and diabetes are the main causes of cardiovascular diseases in developed countries. However, these conditions are still poorly recognized and treated.

OBJECTIVE

This study aimed at estimating the prevalence, awareness, treatment, and control rates of major cardiovascular risk factors in an unselected sample of individuals of a small community located in northern Italy.

METHODS

We screened 344 sequential subjects in this study. Data collection included family and clinical history, anthropometric data, blood pressure, blood glucose, and serum cholesterol values. Individual cardiovascular risk profiles were assessed by risk charts of the Progetto Cuore.

RESULTS

Based on personal history and/or measured values, 78.2% of subjects had hypercholesterolemia (total cholesterol levels > 190 mg/dL), 61.0% had central obesity (waist circumference ≥ 94 cm for men and ≥80 cm for women), 51.2% had arterial hypertension (blood pressure ≥ 140/90 mmHg), 8.1% had diabetes (blood glucose ≥ 126 mg/dL), 22.7% had impaired fasting glucose (blood glucose 100-125 mg/dL), and 35.5% were overweight (body mass index 25-29 kg/m(2)). Alcohol drinkers and smokers accounted for 46.2% and 22.4% of subjects, respectively. Awareness of hypertension, hypercholesterolemia, and diabetes was poor, and control of these risk factors, except for diabetes, was even worse. Prevalence of high blood pressure, high serum cholesterol, overweight, and obesity significantly increased with aging. Hypercholesterolemia and obesity were significantly more common in women, while overweight and diabetes in men. In 15.4% of participants, the risk of a major cardiovascular event in the next 10 years was either high or very high.

CONCLUSION

In a small community in a wealthy region of Italy, the prevalence of major cardiovascular risk factors is high, while awareness, treatment, and control are poor. Such a result highlights the importance of screening campaigns as a strategy to improve early diagnosis and access to treatment, and thus effective prevention of cardiovascular diseases in the general population.

Upregulation of phase II enzymes through phytochemical activation of Nrf2 protects cardiomyocytes against oxidant stress

Increased production of reactive oxygen species has been implicated in the pathogenesis of cardiovascular disease (CVD), and enhanced endogenous antioxidants have been proposed as a mechanism for regulating redox balance. Nuclear factor (erythroid-derived 2)-like 2 (Nrf2) is a transcriptional regulator of phase II antioxidant enzymes, and activation of Nrf2 has been suggested to be an important step in attenuating oxidative stress associated with CVD. A well-defined combination of five widely studied medicinal plants derived from botanical sources (Bacopa monniera, Silybum marianum (milk thistle), Withania somnifera (Ashwagandha), Camellia sinensis (green tea), and Curcuma longa (turmeric)) has been shown to activate Nrf2 and induce phase II enzymes through the antioxidant response element. The purpose of these experiments was to determine if treatment of cardiomyocytes with this phytochemical composition, marketed as Protandim, activates Nrf2, induces phase II detoxification enzymes, and protects cardiomyocytes from oxidant-induced apoptosis in a Nrf2-dependent manner. In cultured HL-1 cardiomyocytes, phytochemical treatment was associated with nuclear accumulation of Nrf2, significant induction of phase II enzymes, and concomitant protection against hydrogen peroxide-induced apoptosis. The protection against oxidant stress was abolished when Nrf2 was silenced by shRNA, suggesting that our phytochemical treatment worked through the Nrf2 pathway. Interestingly, phytochemical treatment was found to be a more robust activator of Nrf2 than oxidant treatment, supporting the use of the phytochemicals as a potential treatment to increase antioxidant defenses and protect heart cells against an oxidative challenge.

The association of angina pectoris with heart disease mortality among men and women by diabetes status: the Rancho Bernardo Study

OBJECTIVE

To study the sex-specific association of angina pectoris with mortality in community-dwelling older adults with and without diabetes.

METHODS

Baseline prevalence of angina was evaluated in 822 men and 1184 postmenopausal women aged 50-89 years at the 1984-1987 Rancho Bernardo Study clinic visit, when an oral glucose tolerance test (OGTT) and the Rose angina questionnaire were administered. All-cause and coronary heart disease (CHD) mortality were assessed after an average follow-up period of 13.2 years. Sex-specific Cox proportional hazard models were used to examine the independent association of angina with mortality by glucose tolerance category.

RESULTS

At baseline, average age was 71 years for both sexes; 61 men (7.4%) and 142 women (12.0%) had angina. Overall, 129 men (15.9%) and 130 women (11.0%) had type 2 diabetes; 228 men (27.7%) and 357 women (30.2%) had impaired glucose tolerance (IGT). During follow-up, 485 men (59%) and 557 women (47%) died, of whom 103 men (21.2%) and 104 women (18.7%) had fatal CHD. Women with diabetes and angina had a 3-4-fold greater risk of dying from CHD than women with diabetes but without angina, independent of covariates. Women with angina and IGT had twice the risk of CHD mortality compared with women with IGT but without angina. A smaller increased risk of fatal CHD in men was not statistically significant.

CONCLUSIONS

Angina was associated with an increased risk of dying from CHD among women, especially among those who also had IGT or diabetes.

Higher immunoglobulin G antibody levels against cytomegalovirus are associated with incident ischemic heart disease in the population-based EPIC-Norfolk cohort

BACKGROUND

Cytomegalovirus (CMV) is associated with ischemic heart disease (IHD) among organ transplant recipients. The relationship between the levels of antibody for CMV with IHD in immunocompetent individuals is uncertain.

METHODS

We measured baseline CMV immunoglobulin G (IgG) levels in 12,574 participants without IHD from the population-based EPIC-Norfolk cohort, aged 40-70 years old at recruitment in 1993-1997. Underlying causes of death or hospitalization until 31 March 2008 were abstracted from death certificates and a database of hospital admissions, respectively.

RESULTS

Of the participants, 58% were seropositive for CMV. After a mean follow-up of 12 years (standard deviation, 2.2 years), 1356 first-time IHD events occurred. After adjustment for classic IHD risk factors, belonging to the highest antibody group was associated with an increased risk of incident IHD, compared with seronegativity (hazard ratio, 1.22; 95% confidence interval, 1.05-1.42). After additional adjustment for measures of social class, inflammation, and possible confounders, this association was unchanged (hazard ratio, 1.21; 95% confidence interval, 1.04-11.41).

CONCLUSIONS

This is the first population study to show that CMV IgG antibody levels are related to incident IHD compared to seronegativity. Studies correlating CMV antibody levels with direct measurements of active infection will be necessary.