Trends in risk factors for coronary heart disease in the Netherlands

Comparing cardiovascular disease incidence and prevalence between depressed and non-depressed older persons over time: Cohort differences in the Longitudinal Aging Study Amsterdam

OBJECTIVE

Previous studies suggest that prevention of cardiovascular disease (CVD) is more difficult in depressed persons. Although the prevalence and incidence of CVD decreased over the past decades, it is uncertain whether this is also true for depressed persons. This study examined whether changes in the prevalence and incidence of CVD differ between depressed and non-depressed older persons.

METHODS

Longitudinal data from three community-based representative birth cohorts aged 55-65 years of the Longitudinal Aging Study Amsterdam were used; N = 1070 born in 1926-1937, N = 995 born in 1938-1947, N = 1019 born in 1948-1957. The outcome included fatal and non-fatal CVD. Depression was defined as ≥16 points on the Center for Epidemiological Studies Depression Scale or a general practitioner's diagnosis of depression. Data were analysed with for age and sex adjusted logistic regression and cox regression models.

RESULTS

Comparing cohort 2 and 3 with cohort 1 in the complete sample, the prevalence of CVD decreased by 2% (OR = 0.98, 95%CI = 0.76-1.26) and 32% (OR = 0.68, 95%CI = 0.52-0.89), respectively, and the three-year incidence of CVD decreased by 6% (OR = 0.94, 95%CI = 0.63-1.41) and 26% (OR = 0.74, 95%CI = 0.48-1.15), respectively. The 13-year incidence of CVD decreased by 19% (HR = 0.81, 95%CI = 0.67-0.99) in cohort 2 compared to cohort 1. These decreases did not differ statistically significantly between depressed and non-depressed respondents (p-values of interaction terms: 0.35-0.98).

CONCLUSION

Substantial decreases in the prevalence and incidence of CVD were observed in depressed and non-depressed older persons. Although this is encouraging, cardiovascular risk remained higher in depressed persons over time, warranting tailored prevention programs for depressed older persons.

The use of free versus in situ right internal mammary artery in coronary artery bypass grafting

INTRODUCTION

Coronary artery bypass grafting (CABG) continues to be the most commonly performed cardiac surgical procedure in the world. The use of multiarterial grafting may confer a long-term survival benefit over the use of vein grafts. However, there is a paucity of data comparing the use of in situ versus free right internal mammary artery (RIMA) in isolated CABG.

METHODS

Patients that underwent isolated CABG between 2010 and 2018 where RIMA was used in addition to a left internal mammary artery graft. Patients with prior cardiac surgery or percutaneous coronary intervention were excluded. Propensity matching was used for subanalysis. Mortality and major adverse cardiac and cerebrovascular events (MACCE) were analyzed with Kaplan-Meier survival curves and Cox multivariable regression. Heart failure-specific readmissions were assessed with cumulative incidence curves with Fine and Gray competing risk regression.

RESULTS

A total of 667 patients underwent isolated CABG. Of those, 422 had free RIMA and 245 had in situ RIMA utilized. Mortality was similar between cohorts (p = 0.199) with 5-year mortality rates of 6.6% (free) and 4.1% (in situ). MACCE was similar between cohorts, with 5-year event rates of 33.6% and 33.9% (p = 0.99). RIMA style was not a significant predictor of any outcome.

CONCLUSION

There was no difference in long-term mortality, complications, MACCE, or heart failure readmissions when comparing a contemporary cohort of patients undergoing isolated CABG utilizing RIMA as a conduit. These data may allow surgeons to consider using RIMA either as an in situ or a free conduit.

Development of a cost-effective CVD prediction model using lifestyle factors. A cohort study in Pakistan

Background:

Cardiovascular diseases (CVD) such as hypertension and ischemic heart diseases cause 35 to 40% of deaths every year in Pakistan. Several lifestyle factors such as dietary habits, lack of exercise, mental stress, body habitus (i.e., body mass index, waist), personal habits (smoking, sleep, fitness) and clinical conditions (i.e., diabetes, dyslipidemia and hypertension) have been shown to be strongly associated with the etiology of CVD. Epidemiological studies in Pakistan have shown poor adherence of people to healthy lifestyle and lack of knowledge in adopting healthy alternatives. There are well validated cardiovascular risk estimation tools (QRISK model) that cn predict the probability of future cardiac events. The existing tools are based on laboratory investigations of biochemical test but there is no widely accepted tool available that predicts the CVD risk probability based on lifestyle factors.

Aims:

Aim of the current study was to develop alternative CVD risk estimation model based on lifestyle factors and physical attributes (without using laboratory investigation) using QRISK model as the gold standard.

Study Design:

Clinical and lifestyle data of one hundred and sixty subjects were collected to formulate a regression model for predicting CVD risk probability.

Methods:

Lifestyle factors as independent variables (IV) include BMI, waist circumference, physical activities (stamina, strength, flexibility, posture), smoking, general illnesses, dietary intake, stress and physical characteristics. CVD risk probability of QRISK Intervention computed through clinical variables was used as a dependent variable (DV) in present research. Chronological age was also included in analysis in addition to selected lifestyle factors. Regression analysis, principal component analysis and bivariate correlations were applied to assess the relationship among predictor variables and cardiovascular risk score.

Results:

Chronological age, waist circumference, BMI and strength showed significant effect on CVD risk probability. The proposed model can be used to calculate CVD risk probability with 72.9% accuracy for the targeted population.

Conclusion:

The model involves only those features which can be measured without any clinical test. The proposed model is rapid and less costly hence appropriate for use in developing countries like Pakistan.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Chronic health conditions and work-related stress in older adults participating in the Dutch workforce

The proportion of workers with chronic health conditions (CHCs) will increase over the years as pension reform is increasing the age of retirement in many European countries. This will increase the percentage of older adults with CHCs performing highly demanding work. This study sought to examine the association between common CHCs [cardiovascular disease (CVD), diabetes, arthritis, respiratory and sleep disorders] and three domains of work stress in older Dutch workers. This study used data from the first wave of the NIDI Pension Panel Study for working adults aged 60–65 years (n = 6793). Logistic regression models examined the strength of association between CHCs and (1) general work stress, (2) emotional, and (3) physical demands. All five CHC were independently associated with one or more domains of stress. After including all CHCs in the model, CVD, sleep disorders, and arthritis were significantly associated with general stress. Respiratory disorders, sleep disorders, and arthritis were significantly associated with physical demands. Diabetes (1.25, 95% CI 1.01–1.53), sleep disorders (1.99, 95% CI 1.72–2.31), and arthritis (1.18, 95% CI 1.06–1.31) were significantly associated with emotional demands. Our findings demonstrate that work stress is associated with prevalent CHCs, and these conditions are differentially associated with several domains of work stress in adults approaching retirement. More research is needed to understand the causal relationship between CHCs and work stress. Such research may provide insights for effective workplace and public health interventions to ensure that older workers remain physically and mentally healthy, and productive through their working years.

A cost-effectiveness threshold based on the marginal returns of cardiovascular hospital spending

Traditionally, threshold levels of cost-effectiveness have been derived from willingness-to-pay studies, indicating the consumption value of health (v-thresholds). However, it has been argued that v-thresholds need to be supplemented by so-called k-thresholds, which are based on the marginal returns to health care. The objective of this research is to estimate a k-threshold based on the marginal returns to cardiovascular disease (CVD) hospital care in the Netherlands. To estimate a k-threshold for hospital care on CVD, we proceed in two steps: First, we estimate the impact of hospital spending on mortality using a Bayesian regression modelling framework, using data on CVD mortality and CVD hospital spending by age and gender for the period 1994-2010. Second, we use life tables in combination with quality of life data to convert these estimates into a k-threshold expressed in euros per quality-adjusted life year gained. Our base case estimate resulted in an estimate of 41,000 per quality-adjusted life year gained. In our sensitivity analyses, we illustrated how the incorporation of prior evidence into the estimation pushes estimates downwards. We conclude that our base case estimate of the k-threshold may serve as a benchmark value for decision making in the Netherlands as well as for future research regarding k-thresholds.

An unfavorable body composition is common in early arthritis patients: A case control study

BACKGROUND

An unfavorable body composition is often present in chronic arthritis patients. This unfavorable composition is a loss of muscle mass, with a stable or increased (abdominal) fat mass. Since it is unknown when this unfavorable composition develops, we compared body composition in disease-modifying antirheumatic drugs (DMARD)-naive early arthritis patients with non-arthritis controls and explored the association, in early arthritis patients, with disease activity and traditional cardiovascular risk factors.

METHODS

317 consecutive early arthritis patients (84% rheumatoid arthritis according to 2010 ACR/EULAR criteria) and 1268 age-/gender-/ethnicity-matched non-arthritis controls underwent a Dual-energy X-ray absorptiometry scan to assess fat percentage, fat mass index, fat mass distribution and appendicular lean (muscle) mass index. Additionally, disease activity, health assessment questionnaire (HAQ), acute phase proteins, lipid profile and blood pressure were evaluated.

RESULTS

Loss of muscle mass (corrected for age suspected muscle mass) was 4-5 times more common in early arthritis patients, with a significantly lower mean appendicular lean mass index (females 6% and males 7% lower, p<0.01). Patients had more fat distributed to the trunk (females p<0.01, males p = 0.07) and females had a 4% higher mean fat mass index (p<0.01). An unfavorable body composition was associated with a higher blood pressure and an atherogenic lipid profile. There was no relationship with disease activity, HAQ or acute phase proteins.

CONCLUSION

Loss of muscle mass is 4-5 times more common in early arthritis patients, and is in early arthritis patients associated with a higher blood pressure and an atherogenic lipid profile. Therefore, cardiovascular risk is already increased at the clinical onset of arthritis making cardiovascular risk management necessary in early arthritis patients.

Historical trends in modifiable indicators of cardiovascular health and self-rated health among older adults: Cohort differences over 20 years between the Berlin Aging Study (BASE) and the Berlin Aging Study II (BASE-II)

Background

The last decades have seen great advances in the understanding, treatment, and prevention of cardiovascular disease (CVD). Although mortality rates due to CVD have declined significantly in the last decades, the burden of CVD is still high, particularly in older adults. This raises the question whether contemporary populations of older adults are experiencing better or worse objective as well as subjective health than earlier-born cohorts. The aim of this study was to examine differences in modifiable indicators of cardiovascular health (CVH), comparing data obtained 20 years apart in the Berlin Aging Study (BASE, 1990–93) and the Berlin Aging Study II (BASE-II, 2009–2014).

Methods

Serial cross-sectional analysis of 242 propensity-score-matched participants of BASE (born 1907–1922) and BASE-II (born 1925–1942). Body mass index (BMI), blood pressure, total cholesterol, glycated hemoglobin (HbA1c), diet, smoking and physical activity were operationalized according to the “Life’s simple 7“(LS7) criteria of the American Heart Association.

Results

121 matched pairs were identified based on age, sex, and education. In the later-born BASE-II sample, the mean LS7 score was significantly higher than in the earlier-born sample (7.8±1.8 vs. 6.4±2.1, p<0.001), indicating better CVH. In detail, diet, physical activity, smoking, cholesterol, and HbA1c were more favorable, whereas blood pressure was significantly higher in individuals from the later-born cohort. BMI did not differ significantly between the two matched samples. Notably, despite better CVH, later-born individuals (BASE-II) reported lower self-rated health, presumably because of higher health expectations.

Conclusions

Overall, cardiovascular health was significantly better in the later-born cohort, but several notable exceptions exist.

Cardiovascular and all-cause mortality in patients with intermittent claudication and critical limb ischaemia

BACKGROUND

The aim of this study was to evaluate absolute mortality risks and to determine whether changes in mortality risk occurred in patients with intermittent claudication (IC) or critical limb ischaemia (CLI) in the Netherlands between 1998 and 2010.

METHODS

Data for patients treated between 1998 and 2010 were obtained from Dutch nationwide registers: the Hospital Discharge Register, Population Register and Cause of Death Register. The registers were used to obtain information regarding IC and CLI hospitalizations, co-morbidities, demographic factors, and date and cause of death. The cohort was split into two time intervals for comparison: 1998-2004 (period 1) and 2005-2010 (period 2). Thirty-day mortality was excluded to eliminate per-admission complications. One- and 5-year cardiovascular and all-cause mortality rates were compared with those of a representative sample of the general Dutch population (28 494 persons) by Cox proportional hazards models.

RESULTS

Some 47 548 patients were included, 34 078 with IC and 13 470 with CLI. In patients with IC, the age-adjusted 5-year mortality risk for cardiovascular disease decreased significantly in period 2 (14·1 per cent) compared with that in period 1 (16·1 per cent) in men only (5-year adjusted hazard ratio (HR) 0·76, 95 per cent c.i. 0·69 to 0·83; P < 0·001). In patients with CLI, the cardiovascular mortality risk decreased significantly only in women, with the 5-year risk reducing from 31·2 per cent in period 1 to 29·2 per cent in period 2 (adjusted HR 0·84, 0·74 to 0·94; P = 0·004). Compared with the general population, the mortality risk in patients with IC was increased between 1·70 (1·58 to 1·83) and 3·20 (2·69 to 3·81) times, and in those with CLI the risk was increased between 2·24 (2·09 to 2·40) and 5·19 (4·30 to 6·26) times.

CONCLUSION

The risk of premature death in patients with IC and CLI declined significantly in the Netherlands, in a sex-specific manner, over the period from 1998 to 2010. The absolute risk of cardiovascular mortality remains high in these patients.