All-cause mortality of patients with dyslipidemia up to 19 years after a multidisciplinary lifestyle modification programme: a randomized trial

Oxidative balance score and associations with dyslipidemia and mortality among US adults: A mortality follow-up study of a cross-sectional cohort

BACKGROUND

Oxidative stress has been implicated in the pathogenesis and progression of dyslipidemia. We aimed to investigate the association between the oxidative balance score, and dyslipidemia, as well as to assess the mortality risk associated with oxidative balance score in patients with dyslipidemia.

METHODS

We performed a mortality follow-up study of a cross-sectional cohort of 26,118 adults from the National Health and Nutrition Examination Survey 1999-2018. The total oxidative balance score was calculated by 16 dietary nutrients (dietary oxidative balance score) and four lifestyle factors (lifestyle oxidative balance score). Weighted Cox proportional hazard model was applied to determine the relationship between oxidative balance score and all-cause or cardiovascular disease (CVD) mortality within the dyslipidemia group.

RESULTS

During a median follow-up of 118 months, 2448 all-cause deaths (766 CVD-related) occurred. A significant negative correlation was observed between total oxidative balance score, dietary oxidative balance score, lifestyle oxidative balance score, and dyslipidemia. The multivariable-adjusted odds ratios and 95% CIs for dyslipidemia were 0.86 (0.77-0.97), 0.80 (0.72-0.91), and 0.63 (0.56-0.70), respectively, when comparing the second, third, and fourth quartiles of total oxidative balance score to the reference lowest quartile (P for trend <0.0001). Increasing total oxidative balance score was inversely associated with all-cause (hazard ratio [HR] = 0.98, 95% CI 0.98-0.99) and CVD-specific mortality (HR = 0.98, 95% CI 0.97-0.99) in participants with dyslipidemia.

CONCLUSIONS

Oxidative balance score is inversely associated with dyslipidemia and linked to all-cause and CVD-related mortality, highlighting the potentially protective role of an antioxidant-rich diet against dyslipidemia.

Obesity, smoking habits, and serum phosphate levels predicts mortality after life-style intervention

Background

Life-style interventions, including smoking cessation and weight control are of importance for managing future escalating prevalence of obesity. Smoking habits and obesity have jointly great impact on mortality, however mechanisms behind the effect and variables involved in the obesity paradox is still unknown.

Objectives

This study examines risk factors for all-cause, cardiovascular, and cancer mortality in males and females with high cardiovascular risk, mediated by smoking habits, body mass index (BMI, kg/m²), and serum phosphate (S-P) levels.

Methods

Patients were admitted to the Vindeln Patient Education Center in groups of 30 for a four-week residential comprehensive program (114 hours) focusing on smoking cessation, stress reduction, food preferences and selections, and physical exercise. The follow-up, in years from 1984 to 2014 corresponds to 30 years. This study included 2,504 patients (1,408 females and 1,096 males). Cox regression analysis was used to assess mortality risk associated with smoking habits, low and high BMI, and low and high S-P levels.

Results

High BMI (>34,2 kg/m²), current smoking, type 2 diabetes mellitus (T2DM), high serum calcium (S-Ca), mmol/L and high systolic blood pressure (SBP, mmHg) were associated with all-cause mortality irrespective of sex. Former and current smoking females had a high all-cause mortality (adjusted hazard ratio [HR] 1.581; 95% CI 1.108–2.256, adjusted hazard ratio [HR] 1.935; 95% CI 1.461–2.562, respectively) while current smoking and high BMI increased risk for cardiovascular mortality (adjusted hazard ratio [HR] 3.505; 95% CI 2.140–5.740 and [HR] 1.536; 95% CI 1.058–2.231, respectively). Neither low nor high levels of S-P predicted all-cause, cardiovascular disease (CVD) and cancer mortality in males or females while low levels of S-P predicted all-cause mortality in smokers (adjusted hazard ratio [HR] 1.713; 95% CI 1.211–2.424). In non-smokers, low BMI (<27.6 kg/m²) was protecting and high BMI a risk for all-cause mortality. In males, ischemic heart disease (IHD), and low serum albumin (S-Alb) were associated with all-cause mortality. In females, an interaction between high BMI and smoking (HbmiSM) decreased the cardiovascular mortality (adjusted hazard ratio [HR] 0.410; 95% CI 0.179–0.937, respectively).

Conclusions

High BMI and current smoking were associated with all-cause mortality in both males and females in the present high cardiovascular-risk cohort. In current smokers and non-smokers, T2DM and high S-Ca were associated with an increase in all-cause mortality, while low S-P was associated with all-cause mortality in smokers. Interaction between high BMI and smoking contribute to the obesity paradox by being protective for cardiovascular mortality in females.

The Contribution of Individual Exercise Training Components to Clinical Outcomes in Randomised Controlled Trials of Cardiac Rehabilitation: A Systematic Review and Meta-regression

BACKGROUND

While the clinical benefits of exercise-based cardiac rehabilitation are well established, there is extensive variation in the interventions used within these trials. It is unknown whether variations in individual components of these exercise interventions provide different relative contributions to overall clinical outcomes. This study aims to systematically examine the relationship between individual components of the exercise intervention in cardiac rehabilitation (such as intensity and frequency) and clinical outcomes for people with coronary heart disease.

METHODS

In this systematic review, eligible trials were identified via searches of databases (PubMed, Allied and Complementary Medicine, EMBASE, PEDro, Science Citation Index Expanded, CINAHL, The Cochrane Library, SPORTDiscus) from citation tracking and hand-searching. Studies were included if they were randomised trials of a structured exercise intervention (versus usual care) for participants with coronary heart disease and reported at least one of cardiovascular mortality, total mortality, myocardial infarction or revascularisation outcomes. Each included trial was assessed using the Cochrane Risk of Bias Tool. Authors were also contacted for missing intervention details or data. Random effects meta-analysis was performed to calculate a summary risk ratio (RR) with 95% confidence interval (CI) for the effect of exercise on outcomes. Random effects meta-regression and subgroup analyses were conducted to examine the association between pre-specified co-variates (exercise components or trial characteristics) and each clinical outcome.

RESULTS

Sixty-nine trials were included, evaluating 72 interventions which differed markedly in terms of exercise components. Exercise-based cardiac rehabilitation was effective in reducing cardiovascular mortality (RR 0.74, 95% CI 0.65 to 0.86), total mortality (RR 0.90, 95% CI 0.83 to 0.99) and myocardial infarction (RR 0.80, 95% CI 0.70 to 0.92). This effect generally demonstrated no significant differences across subgroups of patients who received various types of usual care, more or less than 150 min of exercise per week and of differing cardiac aetiologies. There was however some heterogeneity observed in the efficacy of cardiac rehabilitation in reducing total mortality based on the presence of lipid lowering therapy (I 2 = 48%, p = 0.15 for subgroup treatment interaction effect). No single exercise component was identified through meta-regression as a significant predictor of mortality outcomes, although reductions in both total (RR 0.81, p = 0.042) and cardiovascular mortality (RR 0.72, p = 0.045) were observed in trials which reported high levels of participant exercise adherence, versus those which reported lower levels. A dose-response relationship was found between an increasing exercise session time and increasing risk of myocardial infarction (RR 1.01, p = 0.011) and the highest intensity of exercise prescribed and an increasing risk of percutaneous coronary intervention (RR 1.05, p = 0.047).

CONCLUSIONS

Exercise-based cardiac rehabilitation is effective at reducing important clinical outcomes in patients with coronary heart disease. While our analysis was constrained by the quality of included trials and missing information about intervention components, there appears to be little differential effect of variations in exercise intervention, particularly on mortality outcomes. Given the observed effect between higher adherence and improved outcomes, it may be more important to provide exercise-based cardiac rehabilitation programs which focus on achieving increased adherence to the exercise intervention.

Mind-Body Medicine in the Secondary Prevention of Coronary Heart Disease

BACKGROUND

In mind-body medicine (MBM), conventional lifestyle modification measures such as dietary counseling and exercise are supplemented with relaxation techniques and psychological motivational elements. This review studied the effect of MBM on cardiac events and mortality in patients with coronary heart disease (CHD).

METHODS

This review is based on publications up to and including January 2015 that were retrieved by a systematic search in PubMed, the Cochrane Library, and Scopus. Randomized controlled trials of the effect of MBM programs (versus standard treatment) on cardiac events, overall mortality, and/or cardiac mortality were analyzed. Atherosclerosis, blood pressure, LDL cholesterol, and the body mass index (BMI) were chosen as secondary outcomes. Random-effects meta-analyses were performed. The risk of bias was assessed with the Cochrane tool.

RESULTS

Twelve trials, performed on a total of 1085 patients, were included in the analysis. Significant differences between groups were found with respect to cardiac events (odds ratio [OR]: 0.38; 95% confidence interval [CI]: 0.23-0.61; p<0.01; heterogeneity [I2]: 0%), but not overall mortality (OR: 0.82; 95% CI: 0.46-1.45; p = 0.49; I2: 0%) or cardiac mortality (OR: 0.98; 95% CI: 0.43-2.25; p = 0.97; I2: 0%). Significant differences between groups were also found with respect to atherosclerosis (mean difference [MD] = -7.86% diameter stenosis; 95% CI: -15.06-[-0.65]; p = 0.03; I2: 0%) and systolic blood pressure (MD = -3.33 mm Hg; 95% CI: -5.76-[-0.91]; p<0.01; I2: 0%), but not with respect to diastolic blood pressure, LDL cholesterol, or BMI.

CONCLUSION

In patients with CHD, MBM programs can lessen the occurrence of cardiac events, reduce atherosclerosis, and lower systolic blood pressure, but they do not reduce mortality. They can be used as a complement to conventional rehabilitation programs.

Lifestyle interventions in patients with coronary heart disease: a systematic review

CONTEXT

Coronary heart disease (CHD) is responsible for about 15% of all deaths worldwide and is identified as a top priority for decision makers. Both primary and secondary prevention are considered key strategies in the prevention of CHD. The aim of this study was to assess the efficacy of nonpharmacologic interventions with multiple lifestyle components in patients with established CHD in comparison to usual care. For this reason, a systematic review and meta-analysis of RCTs were performed.

EVIDENCE ACQUISITION

The Cochrane Library, MEDLINE, and EMBASE databases were examined until March 31, 2012 (without start date) in order to identify studies addressing patient-tailored multifactorial lifestyle interventions aimed at reducing more than one cardiovascular risk factor in patients with established CHD. Primary endpoints were fatal and nonfatal cardiovascular events. Secondary outcomes were overall mortality and cardiovascular disease-associated hospital readmissions.

EVIDENCE SYNTHESIS

The search strategy yielded 14 unique RCTs, which were considered in the qualitative analysis. Nine of them contributed to the meta-analysis. A random effects model was used to pool the data. The meta-analysis showed a significant risk reduction of 18% (relative risk 0.82, 95% CI=0.69, 0.98) of fatal cardiovascular events in patients undergoing multifactorial lifestyle interventions. Further, a nonsignificant reduction of nonfatal events, overall mortality and hospital readmissions was found.

CONCLUSIONS

Multifactorial lifestyle interventions aimed at improving modifiable risk factors in patients with established CHD reduce the risk for fatal cardiovascular events. Therefore, they may have added value in secondary prevention of CHD.

Dyslipidaemia in patients with established cardiovascular disease in Sub-Saharan Africa: a systematic review and meta-analysis

Dyslipidaemia has been recognized as a major risk factor for cardiovascular diseases. Our objectives were to conduct a systematic review and meta-analysis of published studies to determine the prevalence of dyslipidaemia among hospitalized adult patients with cardiovascular disease in sub-Saharan Africa and to compare between the various cardiovascular disease types. We searched Internet-based search tools and other sources for studies on dyslipidaemia or hypercholesterolaemia among hospitalized adult patients with established cardiovascular disease in sub-Saharan Africa, from 1985 to May 2011. Established cardiovascular disease was defined as ischaemic heart disease, heart failure, stroke or chronic kidney disease. We then assessed for between-study heterogeneity and carried out sensitivity analyses. Study quality was assessed using Downs and Black Checklist and publication bias was considered present when positive in both Egger's and Begg's tests. Restricted analyses were then performed on data from studies on ischaemic heart disease, heart failure and stroke separately. A total of 451 studies were screened and eventually 16 studies were included with a total of 2584 persons. The overall estimate of dyslipidaemia was 38.38% (95% confidence intervals = 26.75-50.0; I(2 )= 96.878; p < 0.001). The prevalence was highest among those with ischaemic heart disease (49.64%) than among those with stroke (26.53%) or heart failure (15.4%; p-values for all comparisons<0.001). Prevalence of dyslipidaemia in subjects with cardiovascular disease including ischaemic heart disease, stroke and heart failure in sub-Saharan Africa was high and similar to what was obtained in Western Europe and North America; highest in subjects with ischaemic heart disease, followed by those with stroke and heart failure.

A structural equation model for assessment of links between changes in serum triglycerides, -urate, and -glucose and changes in serum calcium, -magnesium and -phosphate in type 2 diabetes and non-diabetes metabolism

Background

This study investigates the associations between changes in serum Triglycerides (S-TG), -Urate (S-Urate), and -Glucose (S-Glu) and changes in serum Calcium (S-Ca), -Magnesium (S-Mg), and -Phosphate (S-P) in patients with type 2 diabetes compared with non-diabetic patients.

Methods

The analysis is based on data collected from a secondary prevention population of women and men (W/M) at risk for cardiovascular disease (type 2 diabetes, 212/200; non-diabetes 968/703). The whole population (n = 2083) had a mean age of 51.0 (9.7) years and was stratified for sex and according to type 2 diabetes or non-diabetes. The patients were followed for, either half a year or one year and changes in risk factors were calculated from follow-up to baseline, the time when patients were admitted to the health center. The pattern of relationships was evaluated using a structural equation model.

Results

Higher S-TG and S-Glu but lower S-Urate was revealed at baseline in type 2 diabetes women and men as compared to their counterparts, non-diabetes patients. Women with type 2 diabetes had higher S-Ca and lower S-Mg than non-diabetes women. Changes in S-Glu were associated with changes in S-Ca (+), baseline S-Ca (+), and S-Urate (-) in type 2 diabetes men. Changes in S-Urate were associated with changes in S-Mg (+) in type 2 diabetes women and non-diabetes men. In men with non-diabetes, changes in S-Glu were associated with changes in S-Mg (-). In women with non-diabetes, changes in S-Glu were associated with changes in S-P (-) and changes in S-Urate with changes in S-Ca (+).

Conclusion

With respect to metabolic disturbances in non-diabetes and the awareness of risk for type 2 diabetes, changes in S-Glu and changes in S-Ca, S-Mg, and S-P should be considered as risk factors for cardiovascular disease. Increased early detection and corrections of high S-Ca, low S-Mg, and S-P in obese patients may improve their metabolism and reduce the risk of CVD in patients with type 2 diabetes.

Trial registration number

ISRCTN: ISRCTN79355192

Diabetic dyslipidaemia in Asian populations in the Western Pacific Region: what we know and don't know

Approximately 77 million persons with diabetes reside in the Western Pacific Region. This number is estimated to rise to 113 million in 2030 with increasing burden of cardio-renal disease, affecting an increasingly young population. Randomized clinical trials have confirmed the benefits of using statins to reduce low-density lipoprotein cholesterol in preventing cardiovascular disease (CVD) in Caucasians, although similar data are lacking in Asia. Experts from the Western Pacific Region met and reviewed evidence regarding risk association of diabetic dyslipidaemia with cardio-renal disease, effects of lipid lowering, recommended guidelines and clinical practices in Asian populations. There is strong evidence supporting the role of diabetic dyslipidaemia in cardio-renal disease and the benefits of lipid lowering in these populations. The high rate of diabetic kidney disease, its close links with CVD, and the benefits of lipid lowering on renal function are particularly relevant to this population. While most national guidelines use criteria similar to the West in management of diabetic dyslipidaemia, there are consistently low rates of use of lipid-lowering drugs and attaining treatment goals in the region. The group recommends conducting randomized studies, strengthening of the health care system to promote early detection, and intervention of diabetic dyslipidaemia to prevent end organ damage.