Executive summary of the Hellenic Atherosclerosis Society guidelines for the diagnosis and treatment of dyslipidemias - 2023

Atherosclerotic cardiovascular disease (ASCVD) remains the main cause of death worldwide, and thus its prevention, early diagnosis and treatment is of paramount importance. Dyslipidemia represents a major ASCVD risk factor that should be adequately managed at different clinical settings. 2023 guidelines of the Hellenic Atherosclerosis Society focus on the assessment of ASCVD risk, laboratory evaluation of dyslipidemias, new and emerging lipid-lowering drugs, as well as diagnosis and treatment of lipid disorders in women, the elderly and in patients with familial hypercholesterolemia, acute coronary syndromes, heart failure, stroke, chronic kidney disease, diabetes, autoimmune diseases, and non-alcoholic fatty liver disease. Statin intolerance is also discussed.

Evaluation of the usability of the digital platform navigator KardioUp for the journey of patients with chronic heart failure

INTRODUCTION

Digital health interventions constitute a promising supplementary approach for further improvement of the quality and experience of cardiovascular care in patients with heart failure (HF). However, concerns about privacy, security, and quality may arise additionally to lack of personal motivation and accessibility to digital resources. Therefore, the proposed system aims to implement innovative technological trends in HF monitoring by recording clinical, biological, and biometric parameters.

METHODS

The availability and feasibility of the digital platform KardioUp was evaluated in a group of 25 patients with HF (mean age: 60 years) and 15 medical doctors (mean age 40 years) in two University Cardiology Clinics of the country. Connectivity of platform with the application and Android devices, use of alerts in clinical measurements, educational material provided, and total satisfaction by both patients and physicians were also evaluated. Patients with health barriers to understand the use of digital platforms or low eHealth ≤8 (digital unawareness) were excluded.

RESULTS

All patients answered that the upload of measurements of blood pressure, blood glucose, and weight into the application were feasible. Patients mean eHealth score was 32,7. Additionally, the graphics of the application were friendly and educational material was also easily approached. Patients felt that this application can enable real patient-empowerment and self-management support.

CONCLUSIONS

KardioUp was evaluated as a non-pharmacological intervention that could promote autonomous living of patients. Thus, possible alterations in daily activities and other parameters will be continuously evaluated providing metrics' monitoring on patients' performance, adherence to their treatment plan, avoidance of rehospitalizations, and overall health metrics.

Peak oxygen consumption is associated with the inotropic reserve in patients with heart failure with reduced ejection fraction undergoing cardiopulmonary testing

Background

The role of cardiopulmonary exercise testing (CPET) in the prognostic evaluation of heart failure with reduced ejection fraction (HFrEF) is powerful and well-established. Nevertheless, the value of CPET in predicting left ventricular inotropic reserve in HFrEF remains unknown.

Purpose

The investigation of possible associations between CPET variables and left ventricular contractile reserve in patients with HFrEF.

Methods

Consecutive patients aged ≥18 years old with a diagnosis of heart failure and a left ventricular ejection fraction ≤40%, as assessed by echocardiography, were prospectively enrolled. Demographic and clinical data were recorded. All subject underwent CPET with either a Bruce or a modified Bruce protocol. Peak oxygen consumption (VO2), carbondioxide production (VCO2), minute ventilation to carbon dioxide production (VE/VCO2) slope, minute ventilation (VE), and VO2/heart rate (HR) values were calculated, while hemodynamic parameters during the test were also measured.

Results

In total, 191 patients with HFrEF were included in the analysis. The mean age was 58.8±11.8 years and 30 (15.7%) patients were women. Ischemic heart disease was the etiology of HFrEF in 101 (52.9%) patients, whereas 90 (47.1%) patients had a history of dilated cardiomyopathy. The mean exercise time was 7.6±.3 minutes. Mean peak VO2 and VE/VCO2 slope values were calculated at 19.1±6.1 ml kg–1 min–1 and 43.7±10.1, respectively. According to peak VO2 values, 70 patients (37.2%) were in Weber class A, 57 (29.8%) in class B, 48 (25.1%) in class C and 15 (7.9%) in class D. In univariate analysis, the change between rest and peak systolic blood pressure (ΔSBP), which is considered to reflect the left ventricular inotropic reserve, was positively correlated to the peak VO2 (p<0.001), the total pulmonary ventilation (VE) (p<0.001) and the peak heart rate during exercise (p=0.02). In multivariable analysis, peak VO2 was independently, linearly associated with the ΔSBP during CPET (Figure 1) (β=0.661, p=0.022). In Roc analysis, it was found that a cut-off value for peak VO2 of 16 ml kg–1 min–1 exhibits 64% sensitivity and 60% specificity in predicting a ΔSBP>40mmHg during exercise (area under the curve: 0.657, p<0.001 – Figure 2).

Conclusion

The peak oxygen consumption during cardiopulmonary testing represents an acceptable predictor of inotropic reserve in patients with HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Low muscle mass is linked with presence of non-alcoholic fatty liver disease irrespective to central obesity: highlights from a prospective epidemiological study in Greece

Background/Introduction

The association between sarcopenia and nonalcoholic fatty liver (NAFL) is highlighted in recent epidemiological studies, although results remain inconsistent.

Purpose

This study aimed to examine the association of low skeletal muscle mass with NAFL as well as the potential mediating effect of waist circumference on the examined association.

Methods

At baseline, 3,042 participants from the Attica region of Greece were recruited. NAFL was assessed through hepatic steatosis index (HSI). Skeletal muscle mass index (SMI) was indirectly calculated using a standard validated procedure.

Results

Ranking from 1st to 3rd SMI tertiles NAFL rate was 45%, 33% and 22%, respectively (p<0.001). Multi-adjusted logistic regression analysis revealed that participants assigned in the 2nd (Odds Ratio (OR): 0.50, 95% Confidence Interval (95% CI): 0.41–0.61)) and 3rd SMI tertile had 50% and 76% (OR: 0.24, 95% CI: 0.19–0.29) lower likelihood to have NAFL compared with their 1st tertile counterparts. This association remained robust after multiple adjustments; however, significance was marginally lost, when waist circumference was added to the model. Subsequently, a multi-adjusted dose-response analysis between SMI and NAFL was performed in the total sample, as well as in the subcategories of normal and abnormal waist circumference. In the total sample, a significant inverse association between SMI and NAFL was observed [OR (per 2 points increase in SMI) = 0.94 (95% CI: 0.92–0.95); p=0.001]. When categorized by waist circumference, participants with moderate/high SMI and normal waist circumference had the lowest NAFL rates (24.3%). Those with low SMI and normal waist circumference and those with moderate/high SMI and abnormal waist circumference had similar rates of NAFL (47.4% and 50.3%, respectively; p=0.25). Participants with both low SMI and abnormal waist circumference presented the highest NAFL rate (60.5%), which was significantly higher compared with the rest subgroups (p<0.001). These findings were confirmed in multi-adjusted analysis to assess NAFL odds per case: participants with adnormal waist, [OR (per 2 points increase in SMI) = 0.97 (95% CI: 0.94–1.00)] vs. participants with normal waist [OR (per 2 points increase in SMI) = 0.89 (95% CI: 0.84–0.95)].

Conclusions

Increasing SMI was associated with lower rates of NAFL independently to abdominal obesity, whereas the two interact as key determinants of NAFL.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Hellenic Society of Cardiology

Optimization of biventricular cardiac resynchronization improves cardiac power and atrial kinetics in patients with systolic heart failure with often hospitalizations for decompensation

 

Cardiac resynchronization therapy (CRT) reduces symptoms and improves left ventricular function in patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. In this work the biochemical, clinical and echocardiographic outcome of optimizing CRT (optCRT) function by the optimal VTI value of left ventricular outflow track.

Methods

80 NYHA III patients (68±10 years; 75% men; 53% ischemic cardiomyopathy-ICM), under optimal tolerated medical therapy, with standard BVP indication, having been implanted with a CRT system. Echocardiographic measurements, including aortoventricular coupling (VAC) calculation, 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months on optCRT. Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451.

Results

End-systolic volume of left ventricle was reduced (p=0.001) in both ischemic and non-ICM; while max left atrial volume was reduced only in non-ICM patients (72.1±32 to 65.8±30, p=0.04). Global longitudinal strain was improved in non ICM patients (p=0.015). Systolic strain of right ventricle was improved in non-ICM (9.4±2.2 to 10.7±2.3 vs. 8.7±3 to 8.9±3.2, p=0.03 for non-ICM); while left atrial function and the ratio E to E TDI of mitral annulus were not improved in either group. Non-ICM patients improved VAC (baseline: 1,36±0,3; CRT: 1.11±0.2; p=0.01) and CP (baseline 660±160 to 782±260, p=0.001); while no significant improvement was detected to ICM patients. 6-min-walk test was improved up to 30% (p=0.05). NtproBNP levels were decreased only in non-ICM patients (1759±1060.9 to 1015±650 vs. 2063,8±1800 to 1950.7±2342, p=0.001). MLHFQ improved in non-ICM patients (p=0.015); while non-significant improvement was detected in ICM patients.

Conclusion

Optimization of cardiac resynchronization therapy based on stroke volume maximization benefits quality of life and exercise tolerance, mainly in non-ICM. GLPS and aorto-ventricular coupling was improved in non-ischemic patients, reflecting the better adaptation of CRT in this population. Thus, CRT optimization by echocardiographic evaluation may be useful in improve clinical status and quality of life in CRT non-responder patients.

Funding Acknowledgement

Type of funding sources: None.

Ultra-processed foods and ten-year cardiovascular disease incidence in a Mediterranean population: results from a population-based cohort study

Background/Introduction

Although cardiovascular disease (CVD) guidelines emphasize consuming minimally processed foods, such as fruits, vegetables, whole grain products, nuts and seeds, less attention has been given to the importance of minimizing ultra-processed foods, probably due to the paucity of studies that exist.

Purpose

The aim of the present work was to investigate the association between the consumption of ultra-processed foods and ten-year first fatal/non fatal CVD event in a sample from Greece.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 men and n=1,528 women (>18 years old) free of CVD. Baseline dietary assessment was based on a validated semi-quantitative food frequency questionnaire. Ultra-processed foods were defined according to a standardized procedure and included among others sweets and desserts, beverages, salty snacks, breakfast cereals and fast foods. Follow-up assessment of first fatal/non fatal CVD event (2011–2012) was achieved in n=2,020 participants (n=317 cases). Cox proportional hazards models were constructed to determine the multiadjusted association between ultra-processed food intake (energy-adjusted servings per week) and incident fatal/non fatal CVD.

Results

On average, participants consumed about 15 servings of ultra-processed foods per week. Ranking from 1st to 3rd ultra-processed food consumption tertile (low to high level of intake) CVD incidence was 8.1%, 12.2%, 16.6% (p=0.006). Each additional weekly serving of ultra-processed food was associated with 10% higher CVD risk within the decade (Hazard Ratio (HR)=1.10, 95% Confidence Interval (95% CI) (1.02, 1.21), p=0.04). This association was reexamined according to participants' level of adherence to a cardiac friendly dietary pattern i.e. Mediterranean diet (defined through MedDietScore, range 1–55). In particular, the aggravating effect of ultra-processed foods was retained and only slightly attenuated even in the subset of participants with moderate to high level of adherence to Mediterranean diet (defined as MedDietScore>27) (HRper 1 serving/week=1.08, 95% CI (0.98, 1.19), p=0.09). On the other side, it became even stronger in case of low level of adherence to this pattern (HRper 1 serving/week=1.19, 95% CI (1.12, 1.25), p=0.02).

Conclusions

Current findings support that even in a population with Mediterranean origins and easy access to healthy least processed choices, systematic consumption of ultra-processed foods on a weekly basis was associated with increased risk of hard CVD events. Tailor-made public health initiatives and nutrition policies are demanded to promote healthy and sustainable dietary patterns with less-processed foods of high nutritional value.

Funding Acknowledgement

Type of funding sources: None.

The quality of plant-based dietary patterns affects the ten-year cardiovascular disease risk of participants with non-alcoholic fatty liver disease: highlights from a population-based cohort study

Background/Introduction

Some plant-based diets like the Mediterranean diet have been suggested to have a beneficial impact on liver disease. However, the quality of plant-based diets – in general – varies.

Purpose

The association between plant-based diet indices and non-alcoholic fatty liver disease (NAFLD) as well as their interaction on ten-year cardiovascular disease incidence was examined.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 males and n=1,528 females (aged >18 years old) free of CVD. Healthy metabolic status was defines as absence of all NCEP ATP III (2005) metabolic syndrome components (excluding waist circumference). Follow-up CVD assessment (2011–2012) was achieved in n=2,020 participants (n=317 cases). Overall, healthful and unhealthful plant-based dietary indices (PDI, hPDI and uPDI) were created through a standard procedure; hPDI was principally characterized by increased consumption of fruits/vegetables, whole grains, nuts, legumes, oils, tea/coffee while uPDI was related with increased intake of juices, sweetened beverages, refined grains, potatoes and sweets. NAFLD was defined according to validated liver steatosis indices.

Results

In total, n=707 (35%) participants presented NAFLD at baseline. Ranking from 1st to 3rd PDI tertile, NAFLD prevalence was 40.3%, 35.6% and 30.9%, respectively (p=0.04). Multiadjusted analysis revealed significant inverse associations between PDI and NAFLD prevalence [Odds Ratio (OR) (3rd vs. 1st tertile)=0.60 95% Confidence Interval (95% CI) (0.35, 0.92)] as well as hPDI [OR (3rd vs. 1st tertile) = 0.75 95% CI (0.64, 0.89)]. On the other side, increased uPDI had a positive association with NAFLD prevalence [OR (3rd vs. 1st hPDI tertile) = 1.22 95% CI (1.05, 1.34)]. NAFLD predicted CVD in multi-adjusted model [Hazard Ratio (HR) = 1.35, 95% CI (1.08, 2.10)]. Subgroup analyses according to participants' adherence to overall, healthy and unhealthy plant-based patterns revealed that this observation remained significant in the following cases: participants in the 1st PDI tertile, [HR=1.40, 95% CI (1.15, 2.09)] and participants in the 1st hPDI tertile [HR=1.47, 95% CI (1.22, 2.12)].

Conclusions

Lower adherence to plant-based diet was associated with substantially higher long-term CVD risk for a NAFLD individual. Most importantly, the healthy or unhealthy food choices within this pattern seemed to determine liver steatosis progression and in turn cardiometabolic health.

Funding Acknowledgement

Type of funding sources: None.

Peritoneal dialysis as a therapeutic solution in elderly patients with cardiorenal syndrome and heart failure: a case-series report

Background

The aim of this work was to evaluate the impact of peritoneal dialysis (PD) on venous congestion, right ventricle function, systolic arterial pulmonary pressure and clinical functional status in elderly patients with cardiorenal syndrome (CRS) and chronic heart failure (HF).

Methods

A case series of 21 (17 males, 70±11 years) consecutive pts with diuretic-resistance heart failure and right ventricular dysfunction (median renal failure duration (RF) 60 months, range 13–287 months, mean ejection fraction 36±11%) having been engaged in PD (median of 12.5 months, range 2–28); 77% of the pts were under Automated Peritoneal Dialysis (APD), whereas the rest were under Continuous Ambulatory PD (CAPD). Patients' Pulmonary Artery Systolic Pressure (PASP), Central Venus Pressure (CVP) – through compression sonography – and body weight were evaluated in 6 intermediate clinical visits.

Results

During the follow-up period, the mortality rate was 8 deaths out of 21 pts (38%) (or 3 deaths/100 person-months).A significant reduction by 29.9% in PASP levels (p=0.013)and by 42% in CVP levels (p<0.001), and in right ventricular function was observed; whereas pts weight increased by 3.7% (p=0.001). NYHA class improved in 12 pts; whereas, in the rest pts remained constant (p=0.046). In 8 pts complications were reported (mainly presence of staphylococcus. aureus).

Conclusion

PD seems to confer a substantial benefit in clinical status, in line with improvement in venous congestion and right ventricle systolic pressure among elderly HF patients with CRS.

Funding Acknowledgement

Type of funding sources: None.

A-posteriori protein-rich dietary patterns and their association with ten-year transition to metabolically unhealthy status: highlights from a population-based cohort study

Background/Introduction

The role of dietary protein on cardiometabolic health remains complex influenced by concomitant changes in overall diet composition. The quality of protein sources is currently suggested as more detrimental than the level of consumption itself.

Purpose

The association between different protein-rich dietary patterns and 10-year transition to metabolically unhealthy status in a sample from Greece was evaluated.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 men and n=1,528 women (>18 years old) free of CVD. Healthy metabolic status was defined as absence of all NCEP ATP III (2005) metabolic syndrome components. Baseline dietary assessment was based on a validated semi-quantitative food frequency questionnaire. Dietary protein was calculated through standardized food database. Follow-up cardiometabolic assessment (2011–2012) was achieved in n=2,020 participants. Protein-rich dietary patterns were derived through factor analysis in the subsample of participants with high daily protein intake (>15% of total energy intake corresponding to the median consumption level). Patterns were named according to food scores that correlated most with the factor (scores>0.5).

Results

Overall, six of ten participants lost their metabolically healthy status within a decade. Multiadjusted analysis revealed an inverse yet non-significant association between total energy-standardized protein intake and transition to metabolically unhealthy status [Odds ratio (OR) (high vs. low protein intake)=0.59, 95% Confidence Interval (95% CI) (0.32, 1.10), p=0.09]. Factor analysis extracted three protein-rich dietary patterns, explained 55% of the total variation in intake. Factor A was characterized by increased consumption of processed meet, unprocessed red meat and eggs, factor B was characterized by increased consumption of nuts and seeds, legumes, whole grain products and fish while factor C was characterized by increased consumption of dairy products, poultry and vegetables. Multiadjusted logistic regression analysis revealed that factor B had the strongest protective effect against 10-year transition to metabolically unhealthy status [ORper 1 point increase in factor B score=0.74, 95% CI (0.60, 0.85), p=0.01] followed by a marginally protective effect of factor C [ORper 1 point increase in factor C score=0.89, 95% CI (0.73, 1.05), p=0.07]. Participants with higher adherence to factor A had an increased likelihood to lose their metabolically healthy status [ORper 1 point increase in factor A score=1.15, 95% CI (1.02, 1.30), p=0.04].

Conclusions

The present work confirms that within an increased level of dietary protein intake, different cardiometabolic outcomes were observed according to the quality of protein food sources consumed.

Funding Acknowledgement

Type of funding sources: None.

Multipoint left ventricular pacing effects on hemodynamic parameters and functional status: HUMVEE single-arm clinical trial

Objectives

The aim of this study was to assess the capacity of optimized multipoint pacing (MPP) over optimized cardiac resynchronization therapy (CRT), in terms of clinical, functional, and echocardiographic parameters among dyssynchronous heart failure patients.

Methods

Eighty patients (Caucasian, 77.5% male, 68.4±10.1 years, 53.8% ischemic cardiomyopathy) sequentially received optimized CRT and optimized MPP over 6 and 12-month periods, in a single-arm clinical trial. Clinical, laboratory and echocardiographic assessment was conducted at baseline and following completion of each step.

Results

Significant additive effects of optimized MPP over optimized CRT were noted regarding 6-minute walking distance (baseline/optCRT/optMPP: 293±120m vs 367±94m vs 405±129m, p<0.001), NYHA class (2.36 vs 2.19 vs 1.45, p<0.001), VTIlvot (14.25±3.2cm vs 16.2±4cm vs 17.5±3.4cm, p<0.001), stroke volume (48±13.5ml vs 55±15ml vs 59±15ml, p<0.001), LVEF (29%±7.1% vs 33%±7.3% vs 37%±7.7%, p<0.001), maximal left atrial volume (77.2±34.2ml vs 74.2±39.5ml vs 67.7±32ml, p=0.02), pulmonary artery systolic pressure (35.9mmHg vs 33.5mmHg vs 31mmHg, p<0.001), and right ventricular strain (−8.3%±6.9% vs −8.8%±6.6% vs −11.8%±6.1%, p=0.022). Regarding VAC SW and CP as percentages of maximal, there was significant difference detected compared to baseline for both CRT and MPP. Additive effects persisted only if suitable MPP dipoles were present. Exploratory analysis revealed that ischemic cardiomyopathy continued to exhibit significant differences favoring MPP, whereas nonischemic cardiomyopathy had similar findings regarding total left atrial strain and quality of life.

Conclusions

Optimized MPP showed significant improvements on hemodynamic parameters and ventricular function, in heart failure patients over optimized CRT. The beneficial effect was more prominent in men and in those with rather reduced LVEF, consistent with findings suggesting a beneficial trend in VAC and CP with the more homogenous depolarization offered by optimized MPP

Funding Acknowledgement

Type of funding sources: None.

Liver steatosis, metabolically healthy obesity and ten-year cardiovascular disease risk: results from a population based cohort study

Background/Introduction

Inclusion of non-alcoholic fatty liver disease (NAFLD) as a component of metabolic syndrome (MetS) and/or a criterion for defining metabolically healthy vs. unhealthy obese (MHO vs MUO) status remains to be decided.

Purpose

The present work evaluated the role of NAFLD at baseline in the transition of MHO to MUO status, and its role in predicting cardiovascular disease (CVD) incidence ten years later.

Methods

A prospective longitudinal study was performed between 2001 and 2012 studying 1,514 (49·8%) men and 1,528 (50.2%) women (>18 years old) free of CVD at baseline and residing in the greater Athens area, Greece. Follow-up assessment of first fatal/non fatal CVD event (2011–2012) was achieved in n=2,020 participants (n=317 cases). Healthy metabolic status was defined as absence of all NCEP ATP III (2005) metabolic syndrome components. NAFLD was defined according to validated liver steatosis indices.

Results

Among obese participants, MHO prevalence was 9.8% (n=277). Only half of the MHO subjects retained their metabolically healthy status one decade later. NAFLD was an important predictor of this transition; MHO participants with NAFLD at baseline had about two times higher odds to develop unhealthy metabolic status compared with their non-NAFLD counterparts. Subsequently, MHO status accompanied by NAFLD was associated with increased CVD risk (Hazard Ratio=2.90 95%Confidence Interval (1.35, 5.40)) in contrast to their non-NAFLD MHO counterparts. C-statistics revealed that NAFLD significantly increased the discriminative ability of the standardly defined metabolic status (p for C-index change=0.002), yet in the total sample its contribution to the model seemed to be similar with the common metric of central obesity i.e. waist circumference (CNAFLD=0.711 vs. Cwc=0.710). When the analysis was restricted to the obese subset, it was revealed that the discriminative ability of the model adjusted for NAFLD was significantly higher compared with the one adjusted for waist circumference (CNAFLD=0.719 vs. Cwc=0.702).

Conclusions

Taking under consideration NAFLD – via validated indices – in the clinical assessment of an apparently healthy obese individual contributes to better defining future risk of conversion to metabolically unhealthy obesity and future cardiometabolic risk.

Funding Acknowledgement

Type of funding sources: None.

Primary prevention of acute coronary events through the adoption of a Mediterranean-style diet

We evaluated the role of a Mediterranean-style diet in preventing acute coronary syndromes [ACS]. Data from CARDIO2000, a multi-centre retrospective case-control study investigating the association between ACS and demographic, nutritional, lifestyle and medical risk factors were used. We studied 661 patients hospitalized for a first ACS event and 661 matched controls without clinical suspicion of cardiovascular disease. The Mediterranean diet significantly reduced [by 16%] the risk of developing ACS. The association remained significant in the presence of hypertension, hypercholesterolaemia, sedentary lifestyle, diabetes mellitus or a combination of two of these cardiovascular risk factors. Our findings illustrate the importance of the Mediterranean diet in the primary prevention of acute coronary events

A diet-related microsimulation modelling approach in the context of cardiovascular disease prevention: the ATTICA and GREECS epidemiological studies

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

Background/Introduction: Among all behaviors, nutrition makes the largest contribution to cardiovascular disease (CVD) morbidity across Europe. Purpose: The aim of the present work was to quantify the changes in 10-year CVD onset or recurrence or mortality, in relation to transitioning from low to higher level of adherence to Mediterranean diet. Methods: An individual-level microsimulation was created based on ATTICA (2002-2012, n = 3042 subjects free-of-CVD) and GREECS (2004-2014, n = 2172 patients with acute coronary syndrome (ACS)) studies (in total n = 5214). Eight scenarios regarding the proportion of participants and the size of improvement of level of adherence to Mediterranean diet were compared in terms of relative change in CVD incidence and mortality, as well as, the number of preventable CVD events and deaths. Results: Improving the level of adherence to the Mediterranean diet, even in 10% of the population, a significant relative percentage reduction was observed in the 10-year risk for CVD onset, recurrence and mortality, with the observed reductions being higher among women. In particular, at least 851 first CVD events, 374 recurrent CVD events and 205 CVD deaths per 100,000 of population could be averted or delayed. Additionally, Mediterranean diet clustering revealed that high consumption of fruits, vegetables, whole wheat products and legumes was more important than low consumption of meat and full fat dairy products against CVD. Conclusion: This microsimulation process confirms the added value of Mediterranean diet in primary and secondary CVD prevention having great achievements even with small modifications on a population basis, while challenges the orientation of a Mediterranean-diet intervention giving higher weights to plant-based part.

Application of non-HDL cholesterol for cardiovascular risk prediction in apparently healthy men and women: Results from the ATTICA prospective epidemiological study

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

Background/Introduction: Consistent evidence exists for a causal association between blood cholesterol and cardiovascular disease (CVD) yet alternative lipid markers are still discussed. To this issue, non-High Density Lipoprotein (non-HDL) cholesterol offers a simple way to analyze the total amount of pro-atherogenic lipoproteins containing apolipoprotein B100. Purpose: The aim of the present work was to evaluate the 10-year first fatal/non fatal CVD incidence related to non-HDL cholesterol on the basis of existing thresholds suggested by the European Society of Cardiology (ESC) in a sample with prevalent CVD. Methods: ATTICA study was conducted during 2001-2012 including n = 1,514 men and n = 1,528 women (aged >18 years old) from the greater Athens area, Greece. Baseline serum blood lipids profile was measured. Non-HDL cholesterol was evaluated according to the formula "total cholesterol minus HDL cholesterol" and the following categories were used: <100 mg/dL; 100 to <145 mg/dL; 145 to <185 mg/dL; 185 to <220 mg/dL, and ≥220 mg/dL. Ten-year follow up was performed (2011-12) in 2,020 participants (n = 317 cases, man-to-woman CVD incidence ratio = 1.66). Results: About 42% of women had non-HDL values within the range of 100 to <145 mg/dL while in case of men about one third of them had non-HDL values within the range of 100 to 185mg/dL. Ranking from low to high non-HDL cholesterol CVD incidence was 5.3%, 13.3%, 18.0%, 20.0% and 28.9%. The man-to-woman age-standardized CVD incidence ratio was 1.50, 1.93, 1.37, 1.24, 1.64, respectively; indicating a steep rise in CVD incidence rate in favor of men when non-HDL cholesterol levels reached the 2nd category levels (i.e. 100 to <145 mg/dL) while women seemed to present CVD incidence rates closer to their men counterparts in case of higher non-HDL cholesterol values (i.e. 145 to <220 mg/dL). Multi-adjusted Cox regression analysis revealed that 30mg/dL increase in non-HDL cholesterol values corresponded to 34% higher risk to develop CVD within the decade (Hazard ratio (HR)=1.34, 95% Confidence Interval (95%CI) (1.00, 1.81)). The association remained significant only in case of men (p for gender interaction = 0.01); HR = 1.45, 95%CI (1.09, 1.95). Additionally, when the categorical non-HDL variable was used, its independent aggravating effect on CVD outcome reached the level of significance only for non-HDL cholesterol values >220mg/dL; HR5th vs. 1st category = 1.95, 95%CI (1.10, 4.30). Sex-based stratified analysis revealed significance only in men and particularly HR5th vs. 1st category = 3.14, 95%CI (1.26, 5.10). In case of women the aggravating effect was retained yet without reaching the level of significance. Conclusion: Even if non-HDL cholesterol concentrations in blood are strongly associated with long-term risk of atherosclerotic CVD, its use in daily clinical practice is challenged. These outcomes could be useful for physician–patient communication about primary prevention strategies.

Healthful and unhealthful plant-based dietary patterns and their role on 10-year transition to metabolically unhealthy status in obese participants of the ATTICA prospective (2002–2012) study

Background/Introduction

Plant-based diets have been widely promoted for their protective role on cardiometabolic health. However, in the recent literature it is highly suggested that the quality of plant-based diets varies.

Purpose

The association between plant-based diet indices and 10-year transition to metabolically unhealthy status in metabolically healthy obese (MHO) individuals was assessed.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 males and n=1,528 females (aged >18 years old) free of CVD. Healthy metabolic status was defines as absence of all NCEP ATP III (2005) metabolic syndrome components (excluding waist circumference). Follow-up CVD assessment (2011–2012) was achieved in n=2,020 participants (n=317 cases). Overall, healthful and unhealthful plant-based dietary indices (PDI, hPDI and uPDI) were created through a standard procedure; hPDI was principally characterized by increased consumption of fruits/vegetables, whole grains, nuts, legumes, oils, tea/coffee while uPDI was related with increased intake of juices, sweetened beverages, refined grains, potatoes and sweets.

Results

MHO prevalence reached 4.8% (n=146) (4.9% in men and 4.7% in women, p=0.198). 28.2% of obese participants presented a metabolically benign status. Within the decade, almost half of MHO participants resulted as metabolically unhealthy obese (45% in men and 54% in women, p=0.04). Ranking from 1st to 3rd PDI tertile, transition to metabolically unhealthy status was for men, 63%, 48% and 22% (p<0.001) and for women 67%, 58% and 34% (p<0.001). Multiadjusted analysis revealed significant inverse associations between PDI and 10-year transition to metabolically unhealthy status for men [Hazard Ratio (HR) (3rd vs. 1st tertile)=0.63 95% Confidence Interval (95% CI) (0.41, 0.95)] yet –borderline significantly– for women [HR (3rd vs. 1st PDI tertile) = 0.82 95% CI (0.67, 1.09)]. When the indices for quality of plant-based patterns were used (hPDI and uPDI), only participants assigned to the higher level of adherence to healthful plant-based pattern retained their metabolically healthy profile with this relation being stronger in women; [HR (3rd vs. 1st hPDI tertile) = 0.55 95% CI (0.37, 0.84), for women] and [HR (3rd vs. 1st hPDI tertile) = 0.79 95% CI (0.64, 1.03), for men]. Similarly, the aggravating effect of high adherence to less healthful plant-based food choices was higher for women [HR (3rd vs. 1st uPDI tertile) = 1.68 95% CI (1.23, 1.99)].

Conclusions

Higher adherence to plant-based diet was associated with substantially higher likelihood for an obese individual to long-term retain its healthy metabolic status. Most importantly, the healthy or unhealthy food choices within this pattern seemed to determine cardiometabolic status with stronger remarks in women.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by a research grant from Hellenic Atherosclerosis Society. The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

The role of triglycerides-glucose index to predict 10-year first and recurrent cardiovascular disease events: a sex-based analysis from ATTICA and GREECS prospective studies

Background/Introduction

Triglycerides-glucose index (TyG) has been used in apparently healthy individuals to define insulin resistance and liver steatosis. Additionally, findings from very recent studies challenge the use of this index as a predictor of cardiovascular disease (CVD) onset as well as a marker of atherosclerosis in patients with established CVD.

Purpose

To evaluate the association between TyG and 10-year first or recurrent fatal/non fatal CVD event.

Methods

The samples from two prospective epidemiological studies implemented in Greece were used. In particular, in ATTICA study, in 2001–02, 1,514 men and 1,528 women (>18 years) free of CVD, at baseline, living in greater Athens area, Greece, were enrolled and 10-year follow up was performed (2011–12) in 2,020 participants (n=317 cases). In GREECS study, in 2003–04 almost all consecutive 2,172 acute coronary syndrome (ACS) patients of 6 Greek hospitals were enrolled. In 2013–14, 10-year follow-up was performed in 1,918 participants. TyG was assessed at baseline using a standard formula.

Results

In ATTICA, ranking from 1st (i.e. <8.0) to 3rd TyG tertile (i.e. >8.6), 10-year first CVD incidence was 5.6%, 14.2% and 24.1% (p<0.001); the respective man-to-woman incidence ratio was 1.86, 1.17 and 1.19. In GREECS, ranking from 1st (i.e. <8.7) to 3rd TyG tertile (i.e. >9.3), 10-year recurrent CVD incidence was 35.3%, 43.2% and 35.9% (p=0.11); the respective man-to-woman incidence ratio was 1.08, 0.99 and 1.23. Multi-adjusted Cox regression analysis in ATTICA study revealed that participants assigned in the 3rd TyG tertile had about 77% higher CVD risk compared with their 1st tertile counterparts [Hazard Ratio (HR)=1.77, 95% Confidence Interval (95% CI) (1.06, 2.96), p=0.02]; sex-based stratified analysis revealed that this association remained significant only in women [HR=2.29 95% CI (1.20, 4.38), p=0.01] while in case of men this association was borderline significant [HR=1.70 95% CI (0.95, 3.35), p=0.10]. The total correct classification rate was around 83–85% in all models and similar with models adjusted separately for triglycerides or glucose levels. Using the area under the Receiver Operation Characteristic ROC) curve (AUC) analysis TyG had the best discriminative ability in both sexes with a small advantage in favor of women and minor discrepancies with the commonly used –triglycerides and glucose– biomarkers (Women: AUCTyG=0.694, AUCtriglycerides=0.678, AUCglucose=0.601 / Men: AUCTyG=0.662, AUCtriglycerides=0.634, AUCglucose=0.623). In case of GREECS study, no significant trends were observed.

Conclusions

The findings here suggest a predictive role of TyG against long-term CVD onset which comes in line with recent works; yet its added value against conventional markers such as glucose and triglycerides was not confirmed. Additionally, no significant prognostic effect of TyG against CVD recurrence was observed challenging its clinical use in secondary prevention spectrum.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by a research grant from Hellenic Atherosclerosis Society. The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

Optimization in cardiac resynchronization therapy with quadripolar leads offer improvement in cardiac energetics in heart failure patients compared with bipolar leads: HUMVEE Clinical Trial

Background

Cardiac resynchronization therapy (CRT) is a well-established technique for symptomatic heart failure (HF) patients, producing significant clinical benefits. Recent studies have revealed the potential role of multipoint pacing (MPP) in improving response and clinical outcomes. The aim of this work from the Heart failUre study of Multisite pacing effects on VEntriculoartErial coupling (HUMVEE) trial was to evaluate the association between MPP of the left ventricle vs those of optimized biventricular pacing (optBVP) on: a) ventriculoarterial coupling (VAC) and energy efficiency of the failing heart. Both BVP and MPP mode were optimized according to the optimal VTI value of left ventricular outflow track.

Methods

HUMVEE is a single-center, prospective (13 months) trial (clinicaltrials.gov identifier NCT03189368), of 80 NYHA III patients (68±10 years; 75% men; 53% ischemic cardiomyopathy), under optimal tolerated therapy, with standard BVP indication, having being implanted with a CRT system able to deliver both modes of pacing. Echocardiographic measurements, including VAC calculation, 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months post BVP optimization (right before MPP activation) and at the end of follow-up (6 months post MPP optimization). Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451.

Results

23 patients (30%), due to inability to deliver MPP, remained in optBVP. Those in MPP had 45% ischemic cardiomyopathy vs. 65% in optBVP patients, (p=0.056); ejection fraction 26.5%, vs. 29.5%, p=0.05; while there was no significant difference in gender, age and baseline NYHA class. Both optBVP and MPP patients improved VAC (baseline: 1,26±0,3; CRT: 1.18±0.4; MPP: 1.07±0.06, p=0.07); but only MPP patients significant improved from baseline to 12-months (p=0.02); CP was improved in both groups (p=0.02 in optBVD and p=0.01 in MPP), with MPP patients showing improvement in CP by 30% vs 12% in optBVP (p=0.001); 6-min-walk test was improved in MPP patients by 42% from baseline (p=0.0001), compared to optBVP patients who showed improvement up to 30% (p=0.05) and during the first 6 months only. NtproBNP levels were decreased in all patients (p=0.05 for MPP and p=0.07 for optBVP). Only patients who achieved MPP showed improvement in the Quality of life score (baseline: 31.6±23; optBVD:20.1±17; MPP:15.8±12, p=0.002; while those remained in optBVP showed no significant improvement.

Conclusions

MPP is a new, promising biventricular pacing modality offering additive effects on myocardial energy balance, cardiac power, systolic and diastolic ventricular function and aortoventricular coupling. HUMVEE trial illustrates those clinical, imaging and biochemical divergences of MPP from even opt BVP that confer significant improvement in quality of life reflecting better myocardial energy handling in patients with advanced HF and cardiac dysychronization.

Funding Acknowledgement

Type of funding source: None

Mediterranean diet is inversely associated with steatosis and fibrosis and decreases ten-year diabetes and cardiovascular risk in NAFLD subjects: Results from the ATTICA prospective cohort study

BACKGROUND AND AIMS

We assessed the association of Mediterranean diet with NAFLD and their interaction in predicting ten-year diabetes onset and first fatal/non-fatal cardiovascular disease (CVD) incidence.

METHODS

The ATTICA prospective observational study in Athens, Greece included 1,514 men and 1,528 women (>18 years old) free-of-CVD at baseline. Liver steatosis and fibrosis indices were calculated. Mediterranean diet adherence was assessed through MedDietScore. At the ten-year follow-up visit, CVD evaluation was performed in an a priori specified subgroup of n = 2,020 participants and diabetes onset in n = 1,485 free-of-diabetes participants.

RESULTS

MedDietScore was inversely associated with steatosis and fibrosis; e.g. in the case of the TyG index the Odds Ratio (OR) of the 3rd vs. 1st MedDietScore tertile was = 0·53, [95% Confidence Interval (95% CI) (0·29, 0·95)] and the associations persisted in multi-adjusted models. NAFLD predicted incident diabetes prospectively over a ten year period [HR = 1·87, 95% CI (0·75, 4·61)] and the association remained significant only in subjects with low MedDietScore (below median) whereas diabetes onset among subjects with higher MedDietScore was not influenced by NAFLD. Similarly, NAFLD predicted CVD [Hazard Ratio (HR) = 3·01, 95%CI(2·28, 3·95)]; the effect remained significant only in subjects with MedDietScore below median [HR = 1·38, 95% CI (1·00, 1·93)] whereas it was essentially null [HR = 1·00,95% CI (0·38, 2·63)] among subjects with higher score. Mediation analysis revealed that adiponectin and adiponectin-to-leptin ratio were the strongest mediators.

CONCLUSIONS

We report an inverse association between Mediterranean diet and NAFLD. Mediterranean diet protected against diabetes and CVD prospectively among subjects with NAFLD.

Central pulse load and coronary flow benefit in relation to endogenous testosterone and the Mediterranean regime in hypertensive males with erectile dysfunction

Background

Central pulse pressure (cPP) is an important parameter of target organ damage (TOD) in essential hypertension. Coronary flow reserve (CFR) displays the ability of both macro and microcirculation to augment flow to the myocardium while endogenous total testosterone (TT) exhibits vasodilator effects. The Mediterranean diet (Med-diet) benefits cardiovascular health and erectile dysfunction (ED) often coexists with the decline of endogenous testosterone in the aging male population.

Purpose

To investigate the possible benefits of the Med-diet in central PP, CFR and erectile ability in relation to endogenous TT in the primary hypertensive population with ED.

Methods

247 male hypertensive patients (mean age 57 yo) with ED enrolled the study. Significant coronary artery disease was formerly excluded by a dobutamine stess echo test. We measured the CFR of the left anterior descending artery by performing an adenosine protocol (maximum dose 140 μg/kg/min over 6 minutes). Measurements by the PW Doppler were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was validated as ratio between peak diastolic flow velocity following drug infusion and rest. Ratios ≥2 are considered as non-ischemic response and higher values indicate microvascular coronary integrity. TT was measured in all patients on blood samples taken before 09:00 am. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values indicate a better erectile ability and Med-diet compliance respectively. Finally, cPP and augmentation index (AIx) were estimated as parameters of central hemodynamic load and wave reflection amplification respectively (sphygmocor device).

Results

In bivariate analysis Med-diet was favorably related to CFR (p=0.24, r=0.48), TT (p=0.01, r=0.57) and the SHIM-5 score (p=0.01, r=0.45). On the contrary, it was negatively related to cPP (p=0.15, r=−0.60) and AIx (p=0.31, r=−0.45). CFR was strongly related to TT (p=0.001, r=0.8) and the SHIM-5 score (p=0.01, r=0.41). By multiple linear regression analysis the relation of CFR, SHIM-5 and Med-diet score remained significant after adjustment for age, BMI, systolic arterial blood pressure and smoking habits. We further subdivide our population according to the mean Med-diet value (26) into high and low Med-diet adherence groups. Only in the group with the greater Med-diet adherence (n=153, 62%) there were still positive relation with the CFR, TT and SHIM-5 score as well as negative correlation to cPP and AIx (p=0.04).

Conclusion

In essential hypertensive males with erectile dysfunction the Med-diet regime lessens central pulse pressure while enhancing coronary flow, testosterone levels and so peripheral vascular physiology. We strongly recommend this dietary pattern as a life-style option and strategic component of holistic therapeutic approach.

Funding Acknowledgement

Type of funding source: None

The role of dietary vitamin D intake on 10-year cardiovascular disease incidence, intermediate cardiometabolic risk factors and surrogate markers: highlights from ATTICA prospective study

Background/Introduction

Increasing vitamin D intake through food supplements or fortification is far from revealing strong contribution to cardiac health. On the other side, the separate evaluation of dietary vitamin D intake with cardiac health is limited.

Purpose

The aim of the present work was to evaluate the association between dietary vitamin D intake and 10-year first fatal/non fatal CVD, conventional CVD risk factors and surrogate markers related with inflammation, coagulation, insulin resistance, liver and renal function.

Methods

ATTICA prospective study was conducted during 2001–2012 and included n=1,514 men and n=1,528 women (aged >18 years old) from the greater Athens area, Greece. Dietary assessment was based on a validated semi-quantitative food frequency questionnaire. Daily intake of vitamin D was calculated through standardized food database. Follow-up assessment of CVD (2011–2012) was achieved in n=2,020 participants (n=317 cases).

Results

Ranking from 1st to 3rd vitamin D tertile, CVD event was for men 24%, 17% and 12% (p=0.002) and for women 14%, 10% and 11% (p=0.59), respectively. Multiadjusted analysis revealed inverse associations between vitamin D and CVD in total sample [Hazard Ratio (HR)=0.76 95% Confidence Interval (95% CI) (0.60, 0.97)] and in men [HR=0.66 95% CI (0.49, 0.89)], lost after adjusting for inflammation/coagulation markers; for women no significant trends against hard CVD endpoints were observed. Regarding 10-year onset of conventional risk factors, inverse associations of vitamin D with hypertension in men [HR=0.62 95% CI (0.39, 0.99)] and transition to metabolically unhealthy status in women [HR=0.69 95% CI (0.51, 0.93)] were observed. Multiadjusted analyses revealed significant inverse associations for C-reactive protein, interleukin-6 and fibrinogen in both sexes while only in women for insulin resistance.

Conclusions

Contradicting the neutral/modest associations in vitamin D supplementation trials, the present work revealed that increased food-generated vitamin D may protect against hard and intermediate CVD endpoints implying the existence of different paths between sexes.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by a research grant from Hellenic Atherosclerosis Society. The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

A U-shape trend between total and red meat consumption and depressive symptomatology in apparently healthy women: highlights from the ATTICA prospective (2002–2012) study

Background/Introduction

Increasing amount of evidence currently suggests that in the context of vegetarianism, where meat is completely excluded from daily diet, the risk to develop depression-related symptoms is impressively high.

Purpose

The aim of the present work was to evaluate the association of meat consumption with prevalent depressive symptomatology in apparently healthy individuals.

Methods

ATTICA study was conducted during 2001–2012 including n=1,514 men and n=1,528 women (aged >18 years old) from the greater of our region in Greece. At baseline, depressive symptomatology through Zung Self-Rating Depression Scale (range 20–80) and meat consumption (total meat, red, white and processed meat) through validated semi-quantitative food frequency questionnaire were assessed. Follow-up (2011–2012) was achieved in n=2,020 participants (n=317 cases); n=845 participants with complete psychological metrics were used for the primary analysis.

Results

Ranking from 1st to 3rd total meat consumption (low to high) tertiles, participants assigned in 2nd tertile had the lowest depressive-symptomatology scoring (p<0.001). This trend was retained in multi-adjusted logistic regression analysis; participants reporting moderate total and red meat consumption had ∼20% lower likelihood to be depressed (i.e. Zung scale<45) compared with their 1st tertile counterparts (Odds Ratio (OR)total meat 0.82, 95% Confidence Interval (95% CI) (0.60, 0.97) and ORred meat 0.79 95% CI (0.45, 0.96)). Non-linear associations were revealed; 2–3 serving/week total meat and 1–2 servings/week red meat presented the lowest odds of depressive symptomatology (all ps<0.05). All aforementioned associations were more evident in women (all ps for sex-related interaction<0.05).

Conclusions

The present findings generate the hypothesis that moderate total meat consumption and impressively, red meat may be more beneficial to prevent depressed mood and probably in turn hard CVD endpoints.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by a research grant from Hellenic Atherosclerosis Society. The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

Non-alcoholic fatty liver disease, Mediterranean diet and 10-year cardiovascular disease incidence: the mediating role of adiponectin. Highlights from the ATTICA prospective (2002–2012) study

Background/Introduction

The most updated set of guidelines (EASL-EASD-EASO 2016) suggests Mediterranean diet as a promising dietary pattern for non-alcoholic fatty liver disease (NAFLD) management.

Purpose

The association between NAFLD and adherence to Mediterranean diet as well as their interaction on 10-year fatal/non fatal cardiovascular disease incidence were evaluated.

Methods

Study population included 1,514 men and 1,528 women (>18 years old) in our city in Greece, free of CVD recruited during the 2001–2002 period. Liver steatosis and fibrosis assessment indices were calculated at baseline and specific cut-offs were used to capture NAFLD. Level of adherence to Mediterranean diet was assessed through MedDietScore. National and international food databases were used to estimate total daily carbohydrate intake. The cut-off point of 35% of total daily energy intake was set to define low vs. high carbohydrate intake. Circulating adiponectin level was measured at baseline (4.0 (2.0) μg/mL).

Results

MedDietScore was inversely associated with NAFLD indices of both steatosis and fibrosis yet only in Triglycerides-Glucose index [Odds Ratio (OR)3rd vs. 1st MedDietScore tertile = 0.53, 95% Confidence Interval (95% CI) (0.29, 0.95)] persisted in multi-adjusted models including adjustments for metabolic syndrome components, energy intake and overall and central obesity. This was more evident in men (p for sex interaction = 0.03). The protective role of Mediterranean diet was retained irrespective to the total carbohydrate content; however, sex-based stratified analysis revealed that in woman subsample only Mediterranean diet with low carbohydrate content (i.e. <35%) had an independent protective role against NAFLD presence [OR3rd vs. 1st MedDietScore tertile = 0.79, 95% CI (0.40, 0.96)]. NAFLD predicted CVD [Hazard Ratio (HR) = 3.01, 95% CI (2.28, 3.95)] in crude model as well as in multi-adjusted model [HR=1.37, 95% CI (1.10, 2.10)]. NAFLD effect on CVD remained significant only in MedDietScore below median [HR=1.38, 95% CI (1.00, 1.93)] whereas it was essentially null [HR=1.00, 95% CI (0.38, 2.63)] among subjects with lower score. Mediation analysis revealed that adiponectin was the strongest mediator of the examined associations. In particular, per 1 mg/dL serum adiponectin about 21% lower likelihood to have NAFLD was observed. Stratified analysis using the median value of adiponectin level (4.1 mg/dL) revealed that the inverse association between Mediterranean diet and NAFLD reached the level of significance only in case of adiponectin levels over the median values (OR (3rd vs. 1st MedDietScore tertile) = 0.69 95% CI (0.35, 0.98)).

Conclusion

Beyond the inverse association between Mediterranean diet and NAFLD several novelties were revealed; low-carbohydrate Mediterranean diet was more protective against NAFLD in women while an adiponectin-related mechanism was revealed.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by a research grant from Hellenic Atherosclerosis Society. The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003]

The combined effect of Sacubitril-valsartan treatment on right ventricular function and cardiorespiratory response in patients with chronic heart failure

 

Cardiorespiratory response, right ventricular and global diastolic function is known to deteriorate the clinical course of patients with chronic heart failure with reduced ejection fraction (HFrEF), even under optimal treatment. In this work we sought to evaluate the impact of sacubitril/valsartan initiation in patients with chronic HFrEF in NYHA clinical status II-III, under optimal medical and invasive treatment. Methods 180 patients (85% male, mean age 62±9 years old, 60% ischemic heart failure, 73% with ICD, 45%with CRT and 45% with diabetes mellitus) in NYHA classification II-III-, who were prescribed Sacubitril-Valsartan were evaluated.

Clinical status, biochemical parameters, cardiorespiratory exercise response and bi-ventricular Doppler indices were evaluated at first visit and 6 months after. The pulsed tissue Doppler imaging of the systolic and diastolic function of mitral and tricuspid annulus was characterized by the systolic waves Smv and Stv, and the diastolic waves: Emv and Amv; E was the early filling wave in transmitral velocity. Left atrial maximal volume and global longitudinal strain of the left ventricle (GLPS) were measured. In cardiorespiratory exercise Vo2max, VE/VCO2 and Mets achieved were evaluated. All of them received b-blockers, 90% eplerenone or spironolactone, 25% ivabradine and 90% diuretic treatment. Seventy percent of them started with the dose of 50mg of sacubitril/valsartan; while 80% finally received the full dose of 200 mg bid. One third of them were on clinical status NYHA III.

Results

Eight of the patients discontinued the medication due to hypotension or renal function worsening. All patients expressed improvement in clinical status; while diuretic therapy was down titrated in all of them and discontinued in 30%. As compared with the initial examination, tricuspid annulus systolic wave velocity increased by 5% (p=0.04); maximum volume of left atrium was decreased by 6% (p=0.004); GLPS average was improved by 41% (p=0.001) and E/Emv ratio was decreased by 22% (p=0.04). Moreover, improvement in Stv was more prominent in DCM as compared to IHF patients; In cardio respiratory exercise VE/VCO2 decreased by 5% (p=0.05); while VO2 max showed a trend in improvement (p=0.06), with no difference detected between DCM and ICM patients; although there was a significant increase (47%) in METS achieved (p=0.02).

Conclusion

Sacubitril/valsartan initiation was associated with improved left diastolic function and right ventricular function, along with functional status improvement in patients with HFrEF. These finding underline the beneficial role of sacubitril/valsartan initiation on the hemodynamic course of patients with systolic heart failure and clinical status deterioration.

Funding Acknowledgement

Type of funding source: None

The gender-specific role of prediabetes on 10-year cardiovascular disease incidence: highlights from the ATTICA prospective (2002–2012) study

Background/Introduction

Prediabetes in terms of impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) are highly discussed for their aggravating effect on cardiac health and their potential inclusion in risk prediction to achieve earlier prevention.

Purpose

The aim of the present work was to evaluate the association between prediabetes and 10-year first fatal/non fatal cardiovascular disease (CVD) incidence in a sample without prevalent CVD, taking into account the stability of this condition or the transition to type II diabetes.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 males and n=1,528 females (aged >18 years old) free of CVD. According to American Diabetes Association Diagnosis, prediabetes in terms of IFG was defined as fasting glucose levels 100–125 mg/dl while type 2 diabetes as fasting blood glucose >125 mg/dl or the use of antidiabetic medication. Ten-year follow-up was performed in n=2,020 participants (n=317 CVD cases); the working sample here was n=1,485 (n=249 CVD cases) (without baseline diabetes and with available data on diabetes status at follow-up).

Results

Of the 1,485 participants, n=279 had IFG, at baseline. Ten-year CVD incidence was 19.3% in IFG subgroup and 12.3% in normoglycemic subgroup (p<0.001); the IFG-to-normoglycemic CVD incidence ratio in men was 1.22 while in women 1.60. Multi-adjusted analysis revealed that IFG was an independent predictor of CVD within the decade (Hazard ratio (HR)=1.39, 95% Confidence Interval (95% CI) (1.00, 1.95)). Significant interacting effect of gender on the examined association was revealed (p for interaction=0.001); in stratified analysis, IFG was independently associated with increased CVD risk only in women (HR=1.47, 95% CI (1.10, 2.68)). Within the decade, transition to diabetes status was observed in about one out of four participants with prediabetes (25.1%) while the respective rate in normoglycemic participants was 10% (n=191 diabetes cases, in total). Interestingly, sensitivity analysis revealed that when this category (with diabetes onset within the decade) was excluded from the analysis prediabetes retained its independent aggravating –even weaker– effect on 10-year CVD risk in total sample (HR=1.18, 95% CI (1.01, 1.91)) as well as in women (HR=1.25, 95% CI (1.03, 2.97)).

Conclusion

Here, it was suggested that IFG independently predicted long-term CVD onset, even without transition to a more serious cardiometabolic condition (i.e. diabetes) with more evident outcomes in case of women. Considering the increasing interest for early CVD risk prediction, prediabetes condition in terms of IFG may be a useful predictor towards this perspective.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by a research grant from Hellenic Atherosclerosis Society. The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

P4401Depressive symptomatology, sex and 10-year cardiovascular disease; revealing the mediation ranking of lifestyle, sociodemographic and clinical factors in primary and secondary prevention spectrum

Background/Introduction

Brain and heart interplay is highly discussed in healthy yet even more in cardiac population with inconclusive evidence regarding the sex-related interactions.

Purpose

The sex-specific effect of depressive symptomatology (DS) on 10-year first and recurrent cardiovascular disease (CVD) events was evaluated.

Methods

The samples of two cohorts were used; n=845 free of CVD males and females (2002–2012) and n=2,172 males and females with acute coronary syndrome (ACS) (2004–2014) with baseline psychological assessments (Zung Self-Rating Depression Scale and Centre of Epidemiological Studies-Depressive symptoms scale, respectively) were used. The percentage of excess mediated risk (PEMR) and the corresponding 95% Confidence Interval (95% CI) were used to evaluate the mediating effect of various factors on the examined association.

Results

ACS as well as free-of-CVD females scored significantly higher for DS. Males exceeded females against first (19.7% vs. 11.7%, p<0.001) and subsequent CVD events (38.8% vs. 32.9%, p=0.016) while in participants with DS a male-to-female first and recurrent CVD event rate ratio below -1- was noticed. Multivariate Cox regression analysis revealed that DS remained an independent aggravating factor for first (Hazard Ratio (HR) = 2.72, 95% Confidence Interval (95% CI) 1.50, 9.12, p=0.01) and recurrent (HR=1.31, 95% CI 1.01, 1.69, p<0.001) CVD events only in females. Mediation analysis in females revealed that 35% (23%, 44%) of excess first-CVD-event risk of DS was attributed to lifestyle, sociodemographic, clinical, anthropometric factors as well as lipid and inflammatory markers. The respective number for recurrent events was 46% (23%, 53%). In free-of-CVD females, factors mostly accounted for excess DS risk, close to the overall, were C-reactive protein [38% (31%, 51%)], waist-to-hip ratio [35% (31%, 42%)] and diabetes [32% (27%, 36%)]. Among lipid markers, the biggest mediating effect was observed for high density lipoprotein [28% (25%, 32%)] and triglycerides [26% (22%, 33%)]. As for non-clinical factors, financial status [23% (15%, 31%)] presented the biggest mediating effect followed by educational status, adherence to Mediterranean diet and sleep duration. In ACS females, diabetes [40% (27%, 51%)] and adherence to medication [40% (29%, 53%)] had the biggest mediating effect followed by hypertension [38% (27%, 48%)]. Patients' CVD history and discharge status, presented a very low mediating effect size (∼10%). Among the examined lifestyle factors, current smoking was revealed the strongest mediator, accounting for 33% (19%, 39%) of DS aggravating effect. Anthropometric parameters in terms of body mass index seemed to modestly mediate the examined association (∼29%).

Conclusions

The present work augments prior evidence that psychological stressors possess important drivers of CVD onset and progression mainly in females while it gives rise to research towards unidentified paths behind this claim.

Acknowledgement/Funding

The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

P4534The Mediterranean diet benefit in chronic heart failure by decoding central and peripheral vessel rheology, atheroma formation and serum prolactin levels

Background

Central hemodynamics and especially wave reflection amplification exhibit a vital parameter of chronic heart failure (CHF) physiology. Erectile dysfunction (ED) displays a poor peripheral vessel rheology and serum prolactin role is still debated in CHF mechanisms. The Mediterranean diet (Med-diet) is famous for its vasoprotective and wellbeing properties.

Purpose

To investigate the effect of the Med-diet in central hemodynamics, erectile status, atheroma formation and serum prolactin levels in male patients with chronic heart failure.

Methods

123 CHF male patients under optimal medical therapy enrolled the study (mean age: 65±8 yo, NYHA class II, ejection fraction <40%). All underwent evaluation of the carotid – femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) as parameter of wave reflection amplification (sphygmocor device). Ejection fraction (EF) of the left ventricle was estimated by using 2D echocardiography (Simpson method). ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values point to better erectile function and a great Med-diet compliance respectively. Detection of atheroma was based on the intima- media thickness (IMT) of the common carotid artery. Prolactin levels were assessed in morning blood samples taken before 09:00 am.

Results

The SHIM −5 score (mean: 12±4) was associated to the AIx (p=0,03, r=0,75) and both positively and strongly related to the Med-diet score (p=0,01, r=0,8 and p=0,01, r=0,75 respectively). Med-diet compliance was negatively associated to IMT (p=0,02, r=−0,8) and serum prolactin levels (p=0,03, r=−0,6).Moreover, we notice a positive association between prolactin and the IMT (p=0,04, r=0,7). By multiple linear regression analysis the relation of SHIM-5 and Med-diet score remained significant (p=0,04) after adjustment for BMI, central pulse and mean arterial pressures. We further subdivide our population according to the mean Med-diet value (28) into high and low Med-diet adherence groups. Only in the group with the greater Med-diet adherence (n=73, 60%) AIx was strongly associated to the SHIM-5 score (p=0,02) even after adjustment for PWV, age and BMI. Prolactin levels there were still related to IMT (p=0,04) after adjustment for PWV, AIx, BMI and central pulse pressure. All statistics remained significant when adjusting for ejection fraction of the left ventricle.

Conclusion

High adherence to the Med-diet benefits CHF hemodynamics by enforcing wave reflection amplification, thus generating a stronger pulse signal to peripheral vasculature. Moreover suppresses serum prolactin levels that relates to atheroma formation. Both actions enhance erectile performance independently of the EF of the left ventricle. It is important to advise CHF patients to adopt this dietary pattern in order to improve hemodynamic status and the sense of wellbeing.

P4410Normal weight central obesity and 10-year cardiovascular disease onset in apparently healthy males and females: the interacting effect of sex

Background/Introduction

The notion that standard weight–height tables are the proper way to determine high-risk groups for obesity-related disorders has been largely challenged, yet scarce data exist from the standpoint of sex.

Purpose

To evaluate the effect of combined weight and waist-circumference (WC) status on 10-year first fatal/non fatal cardiovascular disease (CVD) event in apparently healthy males and females.

Methods

A prospective study (2001–2012) was conducted in Greece with n=1,514 males and n=1,528 females (aged >18 years old) free of CVD. Follow-up assessment of CVD event (2011–2012) was achieved in n=2,020 participants (317 cases). Normal weight (NW) status was defined as body mass index (BMI) from 18.5kg/m2 to 25kg/m2 while central obesity as WC≥102cm for males and ≥88cm for females. NW central obesity (NWO) was defined as BMI within the normal range and abnormal WC.

Results

The prevalence of NWO reached 10% (n=302) with female:male ratio being close to 4:1 (p<0.001). Within NW group ∼25% of participants presented increased WC. Ten-year CVD incidence in NWO subjects reached 14.1% which was twice as high as the respective rate for NW participants without central obesity (7.4%) and followed by the 15.4% and 24.1% in overweight/obese participants without or with central obesity, respectively (p<0.001). The female:male CVD event rate ratio was 0.37, 0.77, 0.42, 0.64 ranking from NW participants without central obesity to NWO and overweight/obese without or with central obesity (p<0.001). Cox regression analysis revealed that NWO status was independently associated with 10-year CVD event (Hazard Ratio (HR)=1.87, 95% Confidence Interval (95% CI) 1.04, 3.37, p=0.03) when compared with their NW counterparts with normal WC, after adjusting for sociodemographic, clinical, lifestyle and biochemical factors (i.e. insulin resistance and systemic inflammation). When NWO subjects were set as reference group and compared with their overweight/obese counterparts with or without central obesity, no significant trends were observed (all ps>0.05). A significant interaction between sex and the combined weight and central obesity status was observed (p for interaction<0.001). Stratified analysis revealed that the aforementioned associations were retained only in NWO females (HR=2.35, 95% CI 1.15, 4.79, p=0.01) when compared with their NW counterparts without central obesity; in males the association did not reach the level of significance. C-statistics [C-index (95% CI)] revealed that within the NW range, WC-adjusted model had a better discriminative ability in females [0.810 (0.778, 0.842)] compared with males [0.789 (0.763, 0.810)] while a BMI-adjusted model seemed to discriminate better the CVD event in males [0.801 (0.772, 0.831)] than in females [0.762 (0.731, 0.798)].

Conclusion

Studies addressing the complex interaction between fat and BMI as well as its effect on CVD are demanded, yet with the potential to highlight sex-specific remarks.

Acknowledgement/Funding

The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

P5295Stable and temporal metabolically benign obesity and cardiovascular disease onset in males and females: the missing link with adiponectin

Background/Introduction

Metabolically healthy obesity (MHO) status has been recently conferred to be a transient condition with cohorts revealing that a considerable proportion, from 33% to 52%, lose their status over time.

Purpose

To evaluate the stability of MHO, its effect on 10-year first fatal/non fatal CVD onset and the mediating effect of adiponectin.

Methods

A prospective study was conducted during 2001–2012 studying n=1,514 males and n=1,528 females (aged >18 years old) free of CVD. Follow-up CVD assessment (2011–2012) was achieved in n=2,020 participants; of them, n=317 incident cases were identified. Obesity was defined as body mass index≥30kg/m2 and healthy metabolic status as absence of all NCEP ATP III (2005) metabolic syndrome components (excluding waist circumference). Circulating adiponectin level was measured at baseline (4.0 (2.0) μg/mL).

Results

MHO prevalence reached 4.8% (n=146) (4.9% in males and 4.7% in females, p=0.198). 28.2% of obese participants presented a metabolically benign status at baseline. In the 5-year follow-up period, transition to metabolically unhealthy status was observed for 33% of MHO participants. Within the decade, almost half of MHO participants resulted as metabolically unhealthy obese. Unadjusted analysis revealed that stable vs. temporal MHO subjects had better lifestyle (i.e. higher adherence to Mediterranean diet and better physical activity status) at the recruitment (all ps<0.05). Temporal MHO subjects presented lower adiponectin values (2.8 (1.1) μg/mL) compared with their stable MHO counterparts (4.1 (1.9) μg/mL) (p<0.05). Multivariate Cox regression analysis revealed no significant discrepancies on 10-year CVD risk between MHO and metabolically healthy non-obese subjects (Hazard Ratio (HR)=0.95, 95% Confidence Interval (95% CI) 0.37, 2.08, p=0.32). Only the subset of temporal MHO subjects reached the level of significance (HR=1.43, 95% CI 1.02, 2.01, p=0.04). Stable MHO status was not independently associated with 10-year CVD risk (p>0.05). Low vs. high adiponectin level was associated with ∼1.3 times higher 10-year risk to move from MHO to metabolically unhealthy obesity status (HR=1.33 95% CI 1.10, 4.02). Sensitivity analyses revealed that adiponectin had a significant interacting effect on the examined associations (p for interaction=0.01); stratified analysis using the mean value of adiponectin to define the strata revealed that MHO (stable or temporal) status was positively associated with 10-year CVD event only in participants with low adiponectin levels i.e. below the mean value of 4.1 μg/mL (HR=1.45 95% CI 1.19, 3.68).

Conclusions

Weight management is needed to prevent cardiometabolic features even in participants with increased weight status with healthy metabolic status. It is noteworthy that adiponectin may be an underlying path of the stability and CVD risk corresponding to this intermediate condition probably related with insulin resistance and other relevant paths.

Acknowledgement/Funding

The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

P4529Atrioventricular optimization in cardiac resynchronization therapy with quadripolarleads, improves energy handling and quality of life in heart failure patients: HUMVEE Trial

Background

Cardiac resynchronization therapy (CRT) is a well-established technique for symptomatic heart failure (HF) patients, producing significant clinical benefits. Recent studies have revealed the potential role of multipoint pacing (MPP) in improving response and clinical outcomes. The aim of Heart failUre study of Multisite pacing effects on VEntriculoartErial coupling (HUMVEE) trial was to evaluate the association between MPP of the left ventricle vs those of standard biventricular pacing (BVP) on: a) ventriculoarterial coupling (VAC) and energy efficiency of the failing heart, b) diastolic function, c) quality of life, and d) NT-proBNP levels.

Methods

HUMVEE is a single-center, prospective (13 months) trial (clinicaltrials.gov identifier NCT03189368), of 54 NYHA III patients (69±9 years; 79% men; 50% dilated cardiomyopathy), under optimal tolerated medical therapy, with standard BVP indication, having being implanted with a CRT system able to deliver both modes of pacing. Creatinine and NT-proBNP levels and echocardiographic measurements (VAC calculation, strain rate, diastolic function assessment), as well as 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months post BVP optimization (right before MPP activation) and at the end of follow-up (6 months post MPP optimization). Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451.

Results

Both CRT and MPP improved 6-min-walk (differences at baseline/6 mo/end of FU: 277±27 vs. 345±27 vs 363±27 m, p=0.07); left ventricular ejection fraction (24,2% vs 30,6%vs, 32%, p=0.05); end -diastolic diameters of left ventricle (65±1,4 vs. 63±1.7 vs. 61±1.1, p=0.03); end-systolic volume (150±15 vs. 140±10 vs. 131±13, p=0.08); stroke volume (41.6±9 vs. 53.6±14 vs. 62±9, p=0.0001 for MPP); left atrial volume (76±5 vs. 74±10 vs 61±6, p=0.001 for MPP), E/Emv (14±5 vs. 12±4 vs. 11±3, p=0.05 for MPP); NtproBNP (2782±1000 vs. 2080±2500 vs. 2000±1000, p=0.05 for MPP). VAC was reduced from 1.14±0.27 to 1.1±0.17 (p=0.1) while CP increased from 564.2±142 to 768±103 (p=0.009). Quality of life score (the lower the better) improved from 23.75±17 at baseline to 17.25±10 at end of FU (p=0.05).

Conclusions

MPP is a new, promising pacing modality with the potential to improve HF patients' outcome, offering additive effects on myocardial energy balance, cardiac power, systolic and diastolic ventricular function and aortoventricular coupling, especially in ischemic patients. HUMVEE trial illustrates those clinical, imaging and biochemical divergences of MPP from standard BVP that reflect significant improvement in quality of life in patients with advanced HF and cardiac dysychronization.

P301Preserved global longitudinal strain predicts left ventricular reverse remodeling one year after edge-to-edge mitral valve repair in functional mitral regurgitation

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has emerged as an effective treatment modality for high surgical risk patients with severe functional mitral regurgitation (FMR). Novel echocardiographic parameters, such as deformation imaging and their predictive significance have not been analyzed in this group of patients.

Purpose

The purpose of this study is to identify echocardiographic predictors of response in patients with FMR undergoing PMVR.

Methods

We retrospectively analyzed 44 consecutive patients with ischemic or dilated cardiomyopathy, reduced ejection fraction and severe functional MR (FMR), aged 71±9 years, 71% males, LVEF 30.9±8.7%, mitral valve effective regurgitant orifice area (EROA)>20mm2, regurgitant volume (RV) >30ml and logistic EuroSCORE 22±14.7%. At baseline and 1-year after PMVR we assessed echocardiographic parameters such as LV longitudinal strain (LVGLS) and peak left atrial longitudinal strain (PALS) using speckle tracking echocardiography, LV end-systolic and end-diastolic volumes (LVESV, LVEDV), LA volume, MR severity by Doppler echocardiography along with BNP levels, NYHA class and 6 minute walking distance.

Results

One year after edge-to-edge repair there was a significant reduction of MR (74.2% had mild to moderate MR, 22.6% moderate-to-severe MR and 3.2% severe MR) and BNP levels (933±943pg/ml to 669±824pg/ml), improvement of NYHA class (3.11±0.55 to 2.0±0.6, P<0.05) and increase of the 6 minute walking distance (251±141 to 296±148m, P<0.05). LA volume was reduced (132.5±62.1ml to 115.2±57.7ml) and PALS was improved (6.89±3.47 to 7.94±5.27) (P<0.05 for all comparisons). Baseline LVGLS did not change significantly post intervention (−8.8±4.1 vs. −8.8±3.9, P=0.7) but the baseline value predicted the percentage difference in LVEDV (r=−0.61, P<0.01), LVESV (r=−0.47, P=0.03), BNP (r=0.45, P=0.04) and NYHA class (r=0.63, P<0.01). The best reverse LV remodeling was found in patients with GLS better than −10% and the trend was that the better the GLS the greater the LVEDV and LVESV reduction post-intervention. Additionally, patients with GLS between −10% and −5% had the largest improvement in BNP (P<0.05) and NYHA class (P=0.005).

Conclusions

Edge-to-edge repair is effective in reducing MR in patients with severe functional MR and has a positive impact in patients' clinical status at one year follow up. A preserved LVGLS seems to be a good predictor of reverse modeling and clinical improvement post intervention.

P1674High intensity interval exercise program in heart failure patients seems to benefit cardiac power along with aorto-ventricular mechanical pump capacity and cardiorespiratory indices

Background

Cardiac power has been suggested as the most power predictor of mortality in heart failure (HF) patients. In those patients aorta elastic properties and compensation is lost, systolic (and pulse) pressure are therefore reduced and associated with a decrease in ejection duration and pump efficiency. Cardiac rehabilitation programs have showed enhancement in cardiac performance and quality of life in HF patients.

Aim

Aim of this work was to evaluate the effect of high-intensity interval exercise (i.e., 30 sec at 100% of max workload, followed by 30 sec at rest, on a day-by-day 30 minutes working-out schedule for 12 weeks), on cardiac power, diastolic function indices, right ventricle performance and cardiorespiratory parameters among chronic HF patients.

Methods

72 consecutive HF patients (NYHA class II-IV, ejection fraction <50%) who completed the study (exercise training group, n=33, 63±9 years, 88% men, and control group, n=39, 56±11 years, 82% men), underwent cardiopulmonary stress test, non-invasive high-fidelity tonometry of the radial artery, pulse wave velocity measurement using a SphygmoCor device, and echocardiography before and after completion of the training program. Cardiac power output (CPO) (W) was calculated as mean arterial pressure × CO/451, where mean arterial pressure = [(systolic blood pressure − diastolic blood pressure)/3] + diastolic blood pressure.

Results

Both groups reported similar medical characteristics and physical activity status. General mixed effects models revealed that the intervention group increased 6MWT (by 13%, p<0.05); increased cycle ergometry WRpeak (by 25%, p<0.01), showed higher O2max by 31% (p<0.001) and lower VE/VCO2 (p=0.05), whereas patients in the control group showed nosignificant changes in the aforementioned indices. Also, in the intervention group Emv/Vp was decreased by 14% (p=0.06); E to A ratio by 24% (p=0.004) and E to Emv ratio by 8% (p=0.05); while Stv increased by 25% (p=0.01). Most importantly, the intervention group reduced pulse wave velocity by 9% (p=0.05) and increased augmentation index by 26%; and VTI by 4% (p=0.05); Those parameters were not significantly changed on control group (all p>0.05).

Conclusion

Hight intensity exercise rehabilitation program revealed beneficial effect on left ventricular diastolic indices and right ventricle performance. As, in those patients compensation of the aorta is also lost and the LV cannot generate the extra force necessary to completely overcome the late systolic augmented pressure, the increase in the augmented pressure (AIa) observed in the intervention group reflects the benefit in aorto-ventricular coupling and cardiac power that boosts systolic pressure and restores a positive influence in pressure, like in early stages of HF.

Acknowledgement/Funding

None

P6197The effect of lipoprotein (a) on primary prevention of cardiovascular disease and the interaction with conventional lipid markers: a sex-based sensitivity analysis from a 10-year cohort study

Background/Introduction

In the context of novel risk factors in cardiovascular disease (CVD) spectrum, lipoprotein (a) (Lp(a)) is a highly discussed biomarker with promising evidence.

Purpose

The association between Lp(a) and 10-year first fatal/non fatal CVD event in free of CVD males and females was evaluated.

Methods

A longitudinal prospective study was conducted during 2001–2012, studying 1,514 males and 1,528 females (aged >18 years old). Follow-up assessment of CVD (2011–2012) was achieved in n=2,020 participants (n=317 cases). Of them, baseline Lp(a) was measured in n=1,890 participants. The recommended threshold of 50mg/dL was used to define abnormal Lp(a) status (≥50mg/dL). Effect-size of Lp(a) on CVD was evaluated through Cox-regression analysis while its discrimination ability through C-statistics.

Results

Ten-year CVD event rate was 14% and 24% in participants with Lp(a)<50 mg/dL and Lp(a)≥50 mg/dL, respectively (p=0.05). In multivariate analysis those with Lp(a)≥50 mg/dL had two times higher risk to develop CVD compared with participants with normal Lp(a) (Hazard Ratio (HR)=2.18, 95% Confidence Interval (95% CI) 1.11, 4.28, p=0.04). Sex-based stratified analysis revealed that the independent Lp(a)-effect on CVD was retained only in males (HR=2.00, 95% CI 1.19, 2.56, p=0.05); while in females significance was lost when adjusting for low and high density lipoprotein (LDL-C, HDL-C), triglycerides and statins use (p for sex interaction=0.01). Sensitivity analyses revealed that Lp(a) significantly increased CVD risk only in case of abnormal HDL-C, apolipoprotein A1 and triglycerides; interestingly, the interaction between these lipid markers, sex and Lp(a) was significant (p for interaction=0.001) implying that this observation could be sex-mediated. C-indexes and correct classification rates of a standard model with three different levels of adjustment (i.e. Lp(a) or conventional lipid markers or combined lipid markers) were evaluated per sex. In females, the highest total correct classification rate was higher in model adjusted for conventional lipid markers (89.6%) with the rate corresponding to CVD cases being more than twice as high in Lp(a)-adjusted model (19.6% vs. 8.5%) and lower than in fully adjusted model (15.7%). A similar ranking was observed in case of C-indexes (0.831 vs. 0.820 vs. 0.829). Males presented the best total correct classification rate in fully adjusted model (96.5%). Case-related correct classification rate was about 3 times higher in Lp(a)-adjusted model compared with the respective rate in females (24.7% vs. 8.5%). C-index after Lp(a) adjustment in the model with conventional lipid markers increased by 0.01 (i.e. 0.772 vs. 0.784).

Conclusion

While ever increasing efforts have sought to elucidate Lp(a) as a therapeutic target or risk-prediction biomarker in CVD prevention clinical recommendations remain to be guided with appropriate conclusive evidence, mostly from a sex-centered standpoint.

Acknowledgement/Funding

The ATTICA study is supported by research grants from the Hellenic Cardiology Society [HCS2002] and the Hellenic Atherosclerosis Society [HAS2003].

Skeletal muscle mass in acute coronary syndrome prognosis: Gender-based analysis from Hellenic Heart Failure cohort

BACKGROUND AND AIMS

Predictive and prognostic ability of muscle mass in CVD settings is increasingly discussed. The gender-specific effect of skeletal muscle mass index (SMI) on 10-year recurrent fatal/non fatal cardiovascular disease (CVD) event of acute coronary syndrome (ACS) patients was evaluated.

METHODS AND RESULTS

In 2006-2009, n = 1000 consecutive patients (n = 222 women), hospitalized at the First Cardiology Clinic of Athens with ACS diagnosis and with symptoms and left ventricular function indicative of heart failure were selected. SMI was created to reflect skeletal muscle mass through appendicular skeletal muscle mass (indirectly calculated through population formulas) divided by body mass index (BMI). In the 10-year follow-up (2016), 55% of ACS patients experienced recurrent fatal/non fatal CVD events (53% in women vs.62% in men, p = 0.04). Patients in the 2nd SMI tertile (mostly overweight) had 10% lower risk for CVD recurrence (women:men rate ratio = 0.87) over their counterparts in the 1st (mostly normalweight) and 3rd tertile (mostly obese). Multivariate analysis revealed that ACS patients in the 2nd SMI tertile presented 46% and 85% lower CVD event risk over their counterparts in the 1st tertile (Hazard Ratio (HR) = 0.54, 95% Confidence Interval (95% CI) 0.30, 0.96, p = 0.002) and 3rd tertile (HR = 1.85, 95%CI 1.05, 2.94, p = 0.03). Gender-based analysis revealed that this trend remained significant only in women. Inflammatory markers had strong confounding effect.

CONCLUSION

A U-shape association between SMI and 10-year CVD event especially in women was highlighted. This work reveals gender-specific remarks for "obesity-lean paradox" in secondary prevention, implying that high muscle mass accompanied by obesity and excess adiposity may not guarantee better prognosis.

Visceral adiposity index and 10-year cardiovascular disease incidence: The ATTICA study

BACKGROUND AND AIMS

Visceral adiposity index (VAI) has been proposed as a marker of visceral adipose tissue accumulation/dysfunction. Our aim was to evaluate potential associations between the VAI and the 10-year cardiovascular disease (CVD) incidence.

METHODS AND RESULTS

During 2001-2002, 3042 Greek adults (1514 men; age: ≥18 years) without previous CVD were recruited into the ATTICA study, whilst the 10-year study follow-up was performed in 2011-2012, recording the fatal/non-fatal CVD incidence in 2020 (1010 men) participants. The baseline VAI scores for these participants were calculated based on anthropometric and lipid variables, while VAI tertiles were extracted for further analyses. During the study follow-up a total of 317 CVD events (15.7%) were observed. At baseline, the participants' age and the prevalence of hypertension, diabetes, hypercholesterolemia and metabolic syndrome increased significantly across the VAI tertiles. After adjusting for multiple confounders, VAI exhibited a significantly independent positive association with the 10-year CVD incidence (OR = 1.05, 95%CI: 1.01, 1.10), whereas the association of the body mass index (HR = 1.03, 95%CI: 0.99, 1.08), or the waist circumference (HR = 1.01, 95%CI: 0.99, 1.02) was less prominent. Sex-specific analysis further showed that VAI remained significantly predictive of CVD in men alone (HR = 1.06, 95%CI: 1.00, 1.11) but not in women (HR = 1.06, 95%CI: 0.96, 1.10).

CONCLUSIONS

Our findings show for the first time in a large-sample, long-term, prospective study in Europe that the VAI is independently associated with elevated 10-year CVD risk, particularly in men. This suggests that the VAI may be utilized as an additional indicator of long-term CVD risk for Caucasian/Mediterranean men without previous CVD.

Arterial aging mediates the effect of TNF-α and ACE polymorphisms on mental health in elderly individuals: insights from IKARIA study

BACKGROUND

Aging is characterized by an insidious decline in cognitive function. Several genetic and lifestyle factors have been implicated in the increased risk or early onset of dementia.

AIM

We sought to assess the role of tumor necrosis factor (TNF) and angiotensin-converting enzyme (ACE) polymorphisms on the development of impaired mental health in respect to indices of arterial aging in nonagenarian individuals.

DESIGN

178 consecutive subjects above 75 years that permanently inhabit in the island of IKARIA, Greece were recruited.

METHODS

Aortic distensibility (AoD) was calculated and genetic evaluation was performed on the ACE Insertion/Deletion gene polymorphism (intron 16) and the G/A transition (position -308) of the TNF gene. Cognitive function was evaluated using the Mini-mental State Examination (MMSE).

RESULTS

The DD genotype for ACE was independently associated ( b  = -0.44, P = 0.007) with AD while AoD remained an independent determinant of mental status (OR = 1.82, P = 0.036). Interestingly though, when a combined genetic index (GI) was calculated for both genes (ACE and TNF), subjects being double homozygous (DD for ACE and GG for TNF) for these loci presented significantly decreased MMSE (adjusted OR = 0.259, P = 0.033). This GI independently associated with AD (beta coefficient = -0.785, P = 0.002). When AoD was included, GI lost its predictive role (OR = 0.784, P = 0.783) towards MMSE. AoD has marginal indirect mediating effect in the association of the GI with MMSE ( P = 0.07).

CONCLUSION

Vascular aging may modulates the genetic substrate of elderly subjects on the risk for developing dementia.