Challenges in secondary prevention after acute myocardial infarction: A call for action

Aerobic training attenuates cardiac remodeling in mice post-myocardial infarction by inhibiting the p300/CBP-associated factor

Aerobic training (AT), an effective form of cardiac rehabilitation, has been shown to be beneficial for cardiac repair and remodeling after myocardial infarction (MI). The p300/CBP-associated factor (PCAF) is one of the most important lysine acetyltransferases and is involved in various biological processes. However, the role of PCAF in AT and AT-mediated cardiac remodeling post-MI has not been determined. Here, we found that the PCAF protein level was significantly increased after MI, while AT blocked the increase in PCAF. AT markedly improved cardiac remodeling in mice after MI by reducing endoplasmic reticulum stress (ERS). In vivo, similar to AT, pharmacological inhibition of PCAF by Embelin improved cardiac recovery and attenuated ERS in MI mice. Furthermore, we observed that both IGF-1, a simulated exercise environment, and Embelin protected from H2O2-induced cardiomyocyte injury, while PCAF overexpression by viruses or the sirtuin inhibitor nicotinamide eliminated the protective effect of IGF-1 in H9C2 cells. Thus, our data indicate that maintaining low PCAF levels plays an essential role in AT-mediated cardiac protection, and PCAF inhibition represents a promising therapeutic target for attenuating cardiac remodeling after MI.

More People, More Active, More Often for Heart Health - Taking Action on Physical Activity

Physical inactivity is a leading contributor to increased cardiovascular morbidity and mortality. Almost 500 million new cases of preventable noncommunicable diseases (NCDs) will occur globally between 2020 and 2030 due to physical inactivity, costing just over US$300 billion, or around US$ 27 billion annually (WHO 2022). Active adults can achieve a reduction of up to 35% in risk of death from cardiovascular disease. Physical activity also helps in moderating cardiovascular disease risk factors such as high blood pressure, unhealthy weight and type 2 diabetes. For people with cardiovascular disease, hypertension, type 2 diabetes and many cancers, physical activity is an established and evidence-based part of treatment and management. For children and young people, physical activity affords important health benefits. Physical activity can also achieve important cross-sector goals. Increased walking and cycling can reduce journeys by vehicles, air pollution, and traffic congestion and contribute to increased safety and liveability in cities.

The Essence of Lipoproteins in Cardiovascular Health and Diseases Treated by Photodynamic Therapy

Lipids, together with lipoprotein particles, are the cause of atherosclerosis, which is a pathology of the cardiovascular system. In addition, it affects inflammatory processes and affects the vessels and heart. In pharmaceutical answer to this, statins are considered a first-stage treatment method to block cholesterol synthesis. Many times, additional drugs are also used with this method to lower lipid concentrations in order to achieve certain values of low-density lipoprotein (LDL) cholesterol. Recent advances in photodynamic therapy (PDT) as a new cancer treatment have gained the therapy much attention as a minimally invasive and highly selective method. Photodynamic therapy has been proven more effective than chemotherapy, radiotherapy, and immunotherapy alone in numerous studies. Consequently, photodynamic therapy research has expanded in many fields of medicine due to its increased therapeutic effects and reduced side effects. Currently, PDT is the most commonly used therapy for treating age-related macular degeneration, as well as inflammatory diseases, and skin infections. The effectiveness of photodynamic therapy against a number of pathogens has also been demonstrated in various studies. Also, PDT has been used in the treatment of cardiovascular diseases, such as atherosclerosis and hyperplasia of the arterial intima. This review evaluates the effectiveness and usefulness of photodynamic therapy in cardiovascular diseases. According to the analysis, photodynamic therapy is a promising approach for treating cardiovascular diseases and may lead to new clinical trials and management standards. Our review addresses the used therapeutic strategies and also describes new therapeutic strategies to reduce the cardiovascular burden that is induced by lipids.

Lipoprotein(a) and Long-Term Recurrent Infarction After an Acute Myocardial Infarction

Lipoprotein(a) (Lp[a]) is an emerging risk factor for incident ischemic heart disease. However, its role in risk stratification in in-hospital survivors to an index acute myocardial infarction (AMI) is scarcer, especially for predicting the risk of long-term recurrent AMI. We aimed to assess the relation between Lp(a) and very long-term recurrent AMI after an index episode of AMI. It is a retrospective analysis that included 1,223 consecutive patients with an AMI discharged from October 2000 to June 2003 in a single-teaching center. Lp(a) was assessed during index admission in all cases. The relation between Lp(a) at discharge and total recurrent AMI was evaluated through negative binomial regression. The mean age of the patients was 67.0 ± 12.3 years, 379 (31.0%) were women, and 394 (32.2%) were diabetic. The index event was more frequently non-ST-segment elevation myocardial infarction (66.0%). The median Lp(a) was 28.8 (11.8 to 63.4) mg/100 ml. During a median follow-up of 9.9 (4.6 to 15.5) years, 813 (66.6%) deaths and 1,205 AMI in 532 patients (43.5%) occurred. Lp(a) values were not associated with an increased risk of long-term all-cause mortality (p = 0.934). However, they were positively and nonlinearly associated with an increased risk of total long-term reinfarction (p = 0.016). In the subgroup analysis, there was no evidence of a differential effect for the most prevalent subgroups. In conclusion, after an AMI, elevated Lp(a) values assessed during hospitalization were associated with an increased risk of recurrent reinfarction in the very long term. Further prospective studies are warranted to evaluate their clinical implications.

New Biomarkers for Cardiovascular Disease

Cardiovascular disease is the leading cause of death and disability worldwide. Early detection and treatment of cardiovascular disease are crucial for patient survival and long-term health. Despite advances in cardiovascular disease biomarkers, the prevalence of cardiovascular disease continues to increase worldwide as the global population ages. To address this problem, novel biomarkers that are more sensitive and specific to cardiovascular diseases must be developed and incorporated into clinical practice. Exosomes are promising biomarkers for cardiovascular disease. These small vesicles are produced and released into body fluids by all cells and carry specific information that can be correlated with disease progression. This article reviews the advantages and limitations of existing biomarkers for cardiovascular disease, such as cardiac troponin and cytokines, and discusses recent evidence suggesting the promise of exosomes as cardiovascular disease biomarkers.

Factors associated with diet quality among Brazilian individuals with cardiovascular diseases

BACKGROUND

An individual's dietary pattern contributes in different ways to the prevention and control of recurrent cardiovascular events. However, the quality of the diet is influenced by several factors. The present study aimed to evaluate the quality of the diet of individuals with cardiovascular diseases and determine whether there is an association between sociodemographic and lifestyle factors.

METHODS

This is a cross-sectional study carried out with individuals with atherosclerosis (coronary artery disease, cerebrovascular disease or peripheral arterial disease) recruited from 35 reference centres for the treatment of cardiovascular disease in Brazil. Diet quality was assessed according to the Modified Alternative Healthy Eating Index (mAHEI) and stratified into tertiles. For comparing two groups, the Mann-Whitney or Pearson's chi-squared tests were used. However, for comparing three or more groups, analysis of variance or Kruskal-Wallis was used. For the confounding analysis, a multinomial regression model was used. p < 0.05 was considered statistically significant.

RESULTS

In total, 2360 individuals were evaluated: 58.5% male and 64.2% elderly. The median (interquartile range [IQR]) of the mAHEI was 24.0 (20.0-30.0), ranging from 0.4 to 56.0 points. When comparing the odds ratios (ORs) for the low (first tertile) and medium (second tertile) diet quality groups with the high-quality group (third tertile), it was observed that there was an association between diet quality with a family income of 1.885 (95% confidence intervals [CI] = 1.302-2.729) and 1.566 (95% CI = 1.097-2.235), as well as physical activity of 1.391 (95% CI = 1.107-1.749) and 1.346 (95% CI = 1.086-1.667), respectively. In addition, associations were observed between diet quality and region of residence.

CONCLUSIONS

A low-quality diet was associated with family income, sedentarism and geographical area. These data are extremely relevant to assist in coping with cardiovascular disease because they enable an assessment of the distribution of these factors in different regions of the country.

Dietary modulation of advanced glycation end products metabolism on carotid intima-media thickness in type 2 diabetes patients: From the CORDIOPREV study

BACKGROUND

Advanced glycation end products (AGEs) are pro-oxidant and cytotoxic compounds involved in the progression of chronic diseases as cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). The total body burden of AGEs also depend of those consume through the diet. Our aim was to analyze whether the reduction of AGE levels, after the consumption of two-healthy diets were associated with a greater decrease of intima-media thickness of both common carotid arteries (IMT-CC) in patients with T2DM and coronary heart disease (CHD).

METHODS

540 CHD patients with T2DM, at baseline, from the CORDIOPREV study, were divided into two groups: (1) Responders, patients whose IMT-CC was reduced or not changed after dietary intervention and (2) Non-responders, patients whose IMT-CC was increased after dietary intervention. A total of 423 completed baseline and the 5-year follow-up carotid ultrasounds were analyzed in this study.

RESULTS

Our data showed that Responders, despite had a higher baseline IMT-CC and serum methylglyoxal (MG) levels than Non-responders, showed a reduction of serum levels of this glycotoxin after dietary intervention. Conversely, in patients whose IMT-CC was increased after dietary intervention (Non-responders), serum MG levels were increased. Moreover, an increase of circulating level of AGEs (and in particular, MG), after dietary intervention, could be considered a risk factor for the progression of atherosclerosis in patients with T2DM and CHD.

CONCLUSION

These results support the importance of identifying underlying mechanisms in the context of secondary prevention of CVD that would provide therapeutic targets to reduce the high risk of cardiovascular events of these patients.

CLINICAL TRIAL REGISTRATION-URL

https://clinicaltrials.gov/ct2/show/NCT00924937. Unique Identifier: NCT00924937.

Negative health outcomes in depressed cardiac patients are associated with both low and high psychological well-being dimensions

Literature supports the positive effects of psychological well-being (P.W.B.) on health. However, most studies focused on the unitary construct of P.W.B., neglecting the different role played by distinct P.W.B. dimensions on health-related outcomes. The aim of this study was to determine whether unbalanced (i.e. low or high) levels of P.W.B. dimensions could differentially affect cardiac course after acute coronary syndrome (A.C.S.), in terms of participation in secondary prevention (S.P.) and/or survival. The sample included 136 depressed and/or demoralized A.C.S. patients referred for a S.P. program on lifestyle modification, in addition to routine cardiac visits provided by the hospital where they were admitted. Psychological assessment included validated interviews on depression and demoralization, Symptom Questionnaire and Psychological Well-Being scales. 100 patients joined the S.P. program, 36 did not. Logistic regression revealed that older age (B = 0.051; p < 0.05), higher autonomy (B = 0.070; p < 0.05) and lower personal growth (B = -0.073; p < 0.05) levels were associated with non-participation in S.P. Moreover, only among patients who did not join the program, those presenting with an impaired level of P.W.B. 'positive relations' dimension (i.e. below the 25^th percentile) showed a worse cardiac prognosis (Log Rank: χ²₍₁₎ = 4.654; p = 0.031). Negative health outcomes in depressed cardiac patients, such as non-participation in S.P. and worse cardiac course, are associated with both high and low levels of certain P.W.B. dimensions. Psychotherapeutic approaches geared to a balance in P.W.B. dimensions could represent promising new additions to S.P. programs.

Lipid-Lowering Therapy Utilization and Dosage Among Patients with Acute Coronary Syndrome Events: A Retrospective Cohort from 12 Community Hospitals

Introduction

Clinical practice guidelines recommend initiating a high-intensity LLT and continued monitoring of low-density lipoprotein cholesterol (LDL-C) following acute coronary syndrome (ACS). We used real-world data to describe LLT utilization after discharge and 1-year adherence. The reduction in LDL-C was also evaluated.

Methods

Data were extracted from electronic health records (EHRs) from 12 hospitals in a large community healthcare system in midwestern United States between 2013 and 2019. Data on eligible patients recently discharged with an ACS event were linked to pharmacy claims data to describe LLT fill rates and 1-year post-discharge adherence. Adherence was reported as the proportion of days covered ≥80%.

Results

Of the 10,589 eligible patients, 49% filled a high-intensity statin at discharge and only 36% were adherent at 1 year. The mean (SD) age was 66.1±13.3, 39.3% were females, 58.8% were Caucasian, and 53.0% had Medicare. There was a clear trend for greater fill rates at discharge among patients with higher LDL-C values than those with lower values (p<0.01). Key predictors of high-intensity (versus medium-intensity) LLT use within 21 days after an ACS event included ACS type (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.52-0.67 for NSTEMI versus STEMI), age group (OR: 0.59; 95% CI: 0.48-0.72 for >75 years versus <65 years), and statin use before index ACS event (OR: 1.56; 95% CI: 1.23-1.88).

Conclusion

This real-world study found that despite recommendations in clinical practice guidelines, high-intensity LLT fill rates at discharge and 1-year adherence to LLT remain suboptimal. Clinical characteristics, including ACS type and LDL-C values, were strong predictors of filling and adherence to guideline-recommended therapy. Age, sex, and race/ethnicity disparities were observed in discharge fill rates and 1-year adherence. These results highlight the need for continued efforts at the patient and provider levels to improve LLT adherence among ACS patients.

European Physician Survey Characterizing the Clinical Pathway and Treatment Patterns of Patients Post-Myocardial Infarction

INTRODUCTION

The 2019 European Society of Cardiology and European Atherosclerosis Society (2019 ESC/EAS) guidelines stress the importance of managing low-density lipoprotein cholesterol (LDL-C) after myocardial infarction (MI) to reduce the risk of cardiovascular events. Information on guideline implementation is limited. The aim of this survey was to describe current clinical practice regarding LDL-C management in the first year post-MI across Europe, improving understanding of the role of ESC/EAS guidelines on clinical practice.

METHODS

A qualitative web-based cross-sectional physician survey about the patient pathway and LDL-C management post-MI was conducted in 360 physicians from France, Italy, Germany, The Netherlands, Spain, and the UK (n = 60/country) between December 2019 and June 2020. Secondary and primary care physicians (SCPs/PCPs) described their experiences treating patients post-MI over the preceding 2 months.

RESULTS

Physicians reported that on average 90.7% of patients not prescribed lipid-lowering therapy (LLT) before an MI initiated LLT as inpatients; for patients already taking LLT, treatment was intensified for 64.7% of inpatients post-MI. SCPs reported prescribing higher-intensity statins and/or ezetimibe for between 72.3% (Italy) and 88.6% (UK) of patients post-MI. More than 80.0% of SCPs and 51.2% of PCPs stated that they would initiate a change in LLT immediately if patients did not achieve their LDL-C treatment goal by 12 weeks post-MI; 82.0% of SCPs and 55.1% of PCPs reported referring to 2019 ESC/EAS guidelines for management of patients post-MI. Barriers to initiating PCSK9 inhibitors (PCSK9is) included prior prescription of a maximally tolerated dose of statin (49.4%) and/or ezetimibe (38.9%), requirement to reach threshold LDL-C levels (44.9%), and pre-authorization requirements (30.4%).

CONCLUSION

Differences in clinical practice post-MI were reported across the countries surveyed, including divergence between 2019 ESC/EAS and local guidelines. Increased use of innovative medicines to achieve LDL-C goals should reduce risk of subsequent cardiovascular events in very high-risk patients post-MI.

Comparison of management and outcomes of ST-segment elevation myocardial infarction patients in Estonia, Hungary, Norway and Sweden according to national ongoing registries

AIM

Describe the characteristics, management and outcomes of hospitalized ST-segment elevation myocardial infarction (STEMI) patients according to national ongoing myocardial infarction registries in Estonia, Hungary, Norway and Sweden.

METHODS AND RESULTS

Country-level aggregated data was used to study baseline characteristics, use of in-hospital procedures, medications at discharge, in-hospital complications, 30-day and 1-year mortality for all patients admitted with STEMI during 2014-2017 using data from EMIR (Estonia; n = 4584), HUMIR (Hungary; n = 23685), NORMI (Norway; n = 12414, data for 2013-2016) and SWEDEHEART (Sweden; n = 23342). Estonia and Hungary had a higher proportion of women, patients with hypertension, diabetes and peripheral artery disease compared to Norway and Sweden. Rates of reperfusion varied from 75.7% in Estonia to 84.0% in Sweden. Rates of recommendation of discharge medications were generally high and similar. However, Estonia demonstrated the lowest rates of dual antiplatelet therapy (78.1%) and statins (86.5%). Norway had the lowest rates of beta-blockers (80.5%) and angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (61.5%). The 30-day mortality rates ranged between 9.9-13.4% remaining lowest in Sweden. 1-year mortality rates ranged from 14.8% in Sweden and 16.0% in Norway to 20.6% in Hungary and 21.1% in Estonia. Age-adjusted lethality rates were highest for Hungary and lowest for Sweden.

CONCLUSION

This inter-country comparison of data from four national ongoing European registries provide new insights into the risk factors, management and outcomes of patients with STEMI. There are several possible reasons for the findings, including coverage of the registries and variability of baseline-characteristics' definitions that need to be further explored.

Reliability of the Swedish version of the multidimensional outcome expectations for exercise scale (MOEES-SW) in a cardiac population

Purpose: Translate and adapt the Multidimensional Outcome Expectations for Exercise Scale (MOEES) into Swedish language and to explore psychometric properties, in terms of test-retest reliability, internal consistency as well as factor structure and floor and ceiling effects, of the Swedish version of MOEES in cardiac patients.Materials and methods:This prospective psychometrical study set in a Swedish cardiac rehabilitation outpatient clinic included 74 patients; age ³18 years after acute coronary syndrome or that had undergone cardiac surgery. Translation and adaptation procedure of the MOEES followed established international guidelines. To evaluate test-retest reliability, relative (intra-class correlation coefficient ICC, 2.1)and absolute reliability (standard error of measurement (SEM) standard error of measurement % (SEM%), percentage of absolute agreement and Kappa coefficient for each item were calculated. Internal consistency was assessed with Cronbach´s alpha. The original 3-factor structure was tested with a confirmatory factor analysis. Floor and ceiling effects were calculated. Results: In total, 60 patients, mean age 65 years, were included in the study. The test-retest showed for the three outcome expectations subscales (Physical, Self-evaluative and Social) ICC-values of 0.40 (CI 95% 0.20-0.58), 0.57 (0.39-0.71) and 0.72 (0.57-0.83), respectively. In general, the Kappa coefficients were low and varied between 0.11 and 0.44. Two questions had low loadings in the confirmatory factor analysis (<0.5) , contributing to a weak fit of the model. There was no floor effect, but the subscales physical and self-evaluative outcome expectation showed ceiling effects. Conclusion:This is the first study to analyse test-retest reliability of the translated version of MOEES into Swedish in cardiac patients and shows need for further development of the instrument before use in clinical practice and research.

Participation in disease management programs and major adverse cardiac events in patients after acute myocardial infarction: a longitudinal study based on registry data

Background

Cardiovascular diseases are still the main cause of death in the western world. However, diminishing mortality rates of acute myocardial infarction (AMI) are motivating the need to investigate the process of secondary prevention after AMI. Besides cardiac rehabilitation, disease management programs (DMPs) are an important component of outpatient care after AMI in Germany. This study aims to analyze outcomes after AMI among those who participated in DMPs and cardiac rehabilitation (CR) in a region with overall increased cardiovascular morbidity and mortality.

Methods

Based on data from a regional myocardial infarction registry and a 2-year follow-up period, we assessed the occurrence of major adverse cardiac events (MACE) in relation to participation in CR and DMP, risk factors for complications and individual healths well as lifestyle characteristics. Multivariable Cox regression was performed to compare survival time between participants and non-participants until an adverse event occurred.

Results

Of 1094 observed patients post-AMI, 272 were enrolled in a DMP. An association between DMP participation and lower hazard rates for MACE compared to non-enrollees could not be proven in the crude model (hazard ratio = 0.93; 95% confidence interval = 0.65–1.33). When adjusted for possible confounding variables, these results remained virtually unchanged (1.03; 0.72–1.48). Furthermore, smokers and obese patients showed a distinctly lower chance of DMP enrollment. In contrast, those who participated in CR showed a lower risk for MACE in crude (0.52; 0.41–0.65) and adjusted analysis (0.56; 0.44–0.71).

Conclusions

Participation in DMP was not associated with a lower risk of MACE, but participation in CR showed beneficial effects. Adjustment only slightly changed effect estimates in both cases, but it is still important to consider potential effects of additional confounding variables.

Quality indicators for cardiac rehabilitation after myocardial infarction in China: a consensus panel and practice test

OBJECTIVES

Cardiac rehabilitation (CR) improves outcomes after myocardial infarction (MI), but it is underused in China. The purpose of this study was to develop a set of quality indicators (QIs) to improve clinical practices and to confirm the measurability and performance of the developed QIs for CR in Chinese patients after MI.

DESIGN AND SETTING

The QIs were developed by a Chinese expert consensus panel during in-person meetings. The five QIs most in need of improvement were selected using a national questionnaire. Finally, the completion rate and feasibility of the QIs were verified in a group of MI survivors at university hospitals in China.

PARTICIPANTS

Seventeen professionals participated in the consensus panel, 89 personnel in the field of CR participated in the national questionnaire and 165 MI survivors participated in the practice test.

RESULTS

A review of 17 eligible articles generated 26 potential QIs, among which 17 were selected by the consensus panel after careful evaluation. The 17 QIs were divided into two domains: (1) improving participation and adherence and (2) CR process standardisation. Nationwide telephone and WeChat surveys identified the five QIs most in need of improvement. A multicenter practice test (n=165) revealed that the mean performance value of the proposed QIs was 43.9% (9.9%-86.1%) according to patients with post-MI.

CONCLUSIONS

The consensus panel identified a comprehensive set of QIs for CR in patients with post-MI. A nationwide questionnaire survey was used to identify the QIs that need immediate attention to improve the quality of CR. Although practice tests confirmed the measurability of the proposed QIs in clinical practice, the implementation of the QIs needs to be improved.

TRIAL REGISTRATION NUMBER

This study is part of a study registered in ClinicalTrials.gov (NCT03528382).

Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

Dietary measures among patients with coronary heart disease in Europe. ESC EORP Euroaspire V

OBJECTIVE

Assess the dietary recommendations provided to patients hospitalized for a coronary heart disease (CHD) event.

DESIGN

Cross-sectional, multicentre observational study (ESC EORP Euroaspire V).

METHODS

8261 participants (25.8% women, 9.3% aged<50 years) from 27 countries, 6 to 24 months after hospitalization for a CHD event were included. Participants were asked if they had been advised to reduce salt, fat or sugar intake, change type of fat consumed, and increase consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish. Self-reported changes were recorded.

RESULTS

Advice to reduce energy intake, salt, fat and sugar was provided to 64.5% [range: 9.2-90.5], 73.2% [38.6-95.2], 77.3% [42.3-95.6] and 67.0% [39.4-93.3] of patients, respectively. Advice to change fat type, increase consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish was provided to 68.3% [33.7-92.3], 36.7% [0.6-75.2], 73.2% [39.2-93.6], 66.5% [8.0-90.8] and 53.5% [3.7-83.3] of patients, respectively. Advices were more frequently provided to patients aged 50 to 69, with a high educational level, or obesity. One-eighth [0-55.0] of patients reported having consulted a dietician. Reductions in energy intake, salt, fat and sugar were reported by 57.7% [4.9-81.0], 69.9% [32.1-85.9], 71.8% [40.4-88.4] and 61.2% [29.0-84.0] of patients, respectively. Changes in fat type and increased consumption of plant stanols/sterols, fruit & vegetables, fish and oily fish were reported by 60.9% [4.9-81.0], 25.8% [0.6-54.1], 69.2% [27.7-88.4], 54.8% [4.0-80.1] and 40.4% [2.0-66.8] of patients, respectively.

CONCLUSION

Dietary advice is not systematically provided to patients with CHD, and considerable differences exist between European countries.

Medication adherence, biological and lifestyle risk factors in patients with myocardial infarction: a ten-year follow-up on socially differentiated cardiac rehabilitation

Objective: There is strong evidence that medication adherence and lifestyle changes are essential in patients undergoing secondary cardiovascular disease prevention. Cardiac rehabilitation (CR) increases medication adherence and improves lifestyle changes. Patients with cardiac diseases and a low educational level and patients with little social support are less responsive to improve medication adherence and to adapt lifestyle changes. The aim of the present study was to investigate the long-term effects of a socially differentiated CR intervention on medication adherence as well as changes in biological and lifestyle risk factors at two- five- and ten-year follow-up. Design: A prospective cohort study. Setting: The cardiac ward at Aarhus University Hospital, Denmark. Intervention: A socially differentiated CR intervention in addition to the standard CR program. Subjects: Patients admitted with first-episode myocardial infarction between 2000 and 2004, N = 379. Patients were defined as socially vulnerable or non-socially vulnerable according to their educational level and extent of social network. Main outcome measures: Primary outcome was medication adherence to antithrombotics, beta-blockers, statins and angiotensin-converting enzyme inhibitors. Secondary outcomes were biological and lifestyle risk factors defined as; total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, glycated hemoglobin, blood pressure and smoking status. Results: No significant long-term effect of the intervention was found. Conclusions: The results indicate a non-significant effect of the intervention. However, it was found that equality in health was improved in the study population except concerning smoking. General practitioners manage to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status. Key points The socially differentiated intervention did not significantly improve medication adherence or biological and lifestyle risk factors. Despite the non-significant effect of the intervention, equality in health was improved except concerning smoking. General practitioners managed to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status.

The functional effect of atorvastatin dose-dependent via inflammation factors on acute ST segment elevation myocardial infarction after emergency percutaneous coronary intervention

OBJECTIVE

To investigate the effect of different doses of atorvastatin on patients with acute ST segment elevation myocardial infarction (MI) after emergency percutaneous coronary intervention (PCI).

METHODS

A total of 265 patients with acute ST segment elevation MI who underwent emergency PCI were enrolled, 133 in high-dose atorvastatin administration (40 mg/day) and 132 in moderate-dose atorvastatin administration (20 mg/day). All the patients continued treatment for 1 year. The incidences of major adverse cardiovascular events (MACE) were recorded, including cardiovascular death, spontaneous MI, and unplanned revascularization. The association between clinical incidences and different doses of atorvastatin treatment was studied.

RESULTS

Through tracking 1 year's treatment, the level of low-density lipoprotein cholesterol was lower in high-dose atorvastatin administration than in moderate treatment (1.6 ± 0.6 vs. 1.8 ± 0.6, P = 0.041). MACE significantly decreased in high-dose atorvastatin administration than in moderate treatment (9.8 vs. 18.2%, P = 0.03). Spontaneous MI was significantly more attenuated in high-dose treatment than in moderate treatment (6.8 vs. 12.8%, P = 0.03). Unplanned revascularization robustly decreased in patients with high-dose administration than those with moderate-dose treatment (5.2 vs. 8.3%, P = 0.03). There was no difference in the rate of adverse events between the two groups.

CONCLUSION

For patients with acute ST segment elevation MI who underwent emergency PCI, high-dose atorvastatin could provide better performance than moderate-dose in our long-term tracking.

Upregulation of miR-29b-3p protects cardiomyocytes from hypoxia-induced apoptosis by targeting TRAF5

Background

MicroRNAs (miRNAs) are pivotal regulators in regulating hypoxia-induced cardiomyocyte injury. This study was designed to evaluate the effects of miR-29b-3p on hypoxic cardiomyocytes.

Methods

Human AC16 cells were cultured under normoxic or hypoxic conditions. Hypoxic injury was confirmed based on alterations in cell viability using CCK-8 assay and apoptosis using flow cytometry and Hoechst staining. Bioinformatics analyses and the dual-luciferase reporter assay were performed to predict and validate the target gene of miR-29b-3p.

Results

We found that hypoxia suppressed cell viability and promoted apoptosis. TNF receptor-associated factor 5 (TRAF5) was a potential target gene of miR-29b-3p. Our in vitro experiments revealed that miR-29b-3p overexpression or TRAF6 knockdown significantly protected cardiomyocytes against hypoxia-induced injury. Moreover, knockdown of TRAF5 knockdown potentiated the protective effects of miR-29b-3p against hypoxia-induced cell injury.

Conclusion

These findings suggest that upregulation of miR-29b-3p could protect cardiomyocytes against hypoxia-induced injury through downregulation of TRAF5. Targeting TRAF5 with miR-29b-3p might be a potential therapeutic method for AMI.

Integrin β3 inhibits hypoxia-induced apoptosis in cardiomyocytes

Hypoxia-induced apoptosis plays an important role in cardiovascular diseases. Integrin β3 is one of the main integrin heterodimer receptors on the surface of cardiac myocytes. However, despite the important role that integrin β3 plays in the cardiovascular disease, its exact role in the hypoxia response remains unclear. Hence, in the present investigation we aimed to study the role of integrin β3 in hypoxia-induced apoptosis in H9C2 cells and primary rat myocardial cells. MTT assay, flow cytometry and TUNEL assay results showed that hypoxia inhibited cardiomyocyte proliferation and induced cardiomyocyte apoptosis. The expression levels of integrin β3 and HIF1α were upregulated in hypoxia-induced cardiomyocytes as revealed by real-time PCR and western blot analysis. Furthermore, knockdown of integrin β3 expression by siRNA increased hypoxia-induced cardiomyocyte apoptosis. In addition, integrin β3 overexpression weakened hypoxia-induced cardiomyocyte apoptosis. The protein expressions of integrin β3 and HIF1α were upregulated in acute myocardial infarction rat cardiac tissues compared with the control rat cardiac tissues. Our data suggest that integrin β3 plays a protective role in cardiomyocytes during hypoxia-induced apoptosis.

Cardiac arrest as an age-dependent prognosticator for long-term mortality after acute myocardial infarction: the potential impact of infarction size

BACKGROUND:

The development of cardiac arrhythmias resulting in cardiac arrest represents a severe complication in patients with acute myocardial infarction. While the worsening of the prognosis in this vulnerable patient collective is well known, less attention has been paid to its age-specific relevance from a long-term perspective.

METHODS:

Based on a clinical acute myocardial infarction registry we analysed 832 patients with acute myocardial infarction within the current analysis. Patients were stratified into equal groups ( n=208 per group) according to age in less than 45 years, 45-64 years, 65-84 years and 85 years and older via propensity score matching. Multivariate Cox regression analysis was used to assess the age-dependent influence of cardiac arrest on mortality.

RESULTS:

The total number of cardiac arrests differed significantly between age groups, demonstrating the highest incidence in the youngest population with 18.8% ( n=39), and a significantly lower incidence by increasing age (-11.6%; P=0.01). After a mean follow-up time of 8 years, a total of 264 patients (31.7%) died due to cardiovascular causes. While cardiac arrest was a strong and independent predictor for mortality within the total study population with an adjusted hazard ratio of 3.21 (95% confidence interval 2.23-4.61; P<0.001), there was no significant association with mortality independently in very young patients (<45 years; adjusted hazard ratio of 1.73, 95% confidence interval 0.55-5.53; P=0.35).

CONCLUSION:

We found that arrhythmias resulting in cardiac arrest are more common in very young acute myocardial infarction patients (<45 years) compared to their older counterparts, and were able to demonstrate that the prognostic value of cardiac arrest on long-term mortality in patients with acute myocardial infarction is clearly age dependent.

A randomized controlled trial to evaluate utilization of physical activity recommendations among patients of cardiovascular healthcare centres in Eastern Slovakia: study design and rationale of the AWATAR study

Background

Guidelines on modifiable risk factors regarding cardiological patients are poorly implemented in clinical practice perhaps due to low health literacy. Several digital tools for improving lifestyle and behavioural intervention were developed. Our primary aim is to evaluate the effectiveness of a digital exercise prescription tool on the adherence to physical activity recommendations among patients with cardiovascular diseases.

Methods

A randomized controlled trial will be realized in cooperation with Cardiovascular Health Centres in Eastern Slovakia. Patients recruited through their cardiologists, will be randomised at 1:1 ratio to the three-months’ experimental condition or control condition. The experimental group will receive standard lifestyle consultation leading to individually optimized prescription of physical activity. The control group will receive standard, usual-cardio-care lifestyle counselling, also in the domain of physical activity. The digital system will be used for optimized exercise prescription. The primary outcome is a change in the patient’s adherence to exercise recommendations. Data will be collected in both groups prior to consultation and after 3 months.

Discussion

This study protocol presents background and design of a randomized control trial to investigate the effectiveness of a digital system-provide exercise prescription tool on the adherence to physical activity recommendations. An optimized exercise prescription that better reflects patient’s diagnosis, comorbidities and medication can have a significant impact on secondary prevention of cardiovascular disease. This trial can provide important evidence about the effectiveness of digital exercise guidance in everyday practice of cardiovascular healthcare.

Trial registration

The study was registered on 1st November, 2017 and is available online at ClinicalTrials.gov (ID:NCT03329053).

Physical Training and Cardiac Rehabilitation in Heart Failure Patients

Regardless of advances in medical and interventional treatment of cardiovascular disease (CVD), a limited number of patients attend a cardiac rehabilitation (CR) programme on a regular basis. Due to modern therapies more individuals will be surviving an acute cardiovascular event, but the expected burden of chronic heart failure will be increasing worldwide.However, both in high- and low-income countries, secondary prevention after an acute myocardial infarction or stroke has been implemented in less than a half of eligible patients.Combined interventions are still needed to reduce decompensations, hospitalizations and mortality in heart failure patients from any origin. In addition to medical treatments, regular exercise has been demonstrated to improve metabolic and hemodynamic conditions in both asymptomatic risk factor carriers and cardiac patients. Risk factor control and exercise should gather together for an effective management of patients.Exercise-based training is a core component of primary and secondary prevention. It should involve healthy carriers of cardiovascular risk factors, and patients with cardiomyopathy as well. The supposed attenuated effect of CR in the era of advanced revascularization and structural interventions is due to the heterogeneity of training models and physical training in the literature. Moreover, lifestyle modification, psycho-social challenges and patient's compliance are potential confounders.In this chapter the most recent evidences about training modalities and potential benefit of CR in heart failure patients are discussed.