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Competing Interests: Conflict of interest: M.S. reports serving as a consultant or research support (or both) from CiVi, Resverlogix, Lexicon, Baxter, Esperion, Amarin, New Amsterdam, Tourmaline, Sanofi, and Regeneron Pharmaceuticals, Inc. E.R.: No disclosures. P.G.S. reports grants, personal fees, and non-financial support from Sanofi; grants and personal fees from Amarin, Servier, and Bayer; personal fees from Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Idorsia, Pfizer, and Novartis. J.W.J. receives research grants from The Netherlands Heart Foundation, the Interuniversity Cardiology Institute of The Netherlands, and the European Commission Seventh Framework Programme; and research support from Amgen, Astellas, AstraZeneca, Daiichi Sankyo, Lilly, Merck-Schering-Plough, Novartis, Pfizer, Roche, and Sanofi. M.Sc. is an employee of Roche and may hold shares in the company. D.L.B. discloses the following relationships: Advisory Board: Angiowave, Bayer, Boehringer Ingelheim, Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma, Regado Biosciences, and Stasys; Board of Directors: Angiowave (stock options), Boston VA Research Institute, Bristol Myers Squibb (stock), DRS.LINQ (stock options), High Enroll (stock), Society of Cardiovascular Patient Care, TobeSoft; Chair: Inaugural Chair, American Heart Association Quality Oversight Committee; Consultant: Broadview Ventures, Hims; Data Monitoring Committees: Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St Jude Medical, now Abbott), Boston Scientific (Chair, PEITHO trial), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical), Novartis, Population Health Research Institute; Rutgers University (for the NIH-funded MINT Trial); Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), CSL Behring (AHA lecture), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (Course Director, Comprehensive Review of Interventional Cardiology), Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees), Wiley (steering committee); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Patent: Sotagliflozin (named on a patent for sotagliflozin assigned to Brigham and Women's Hospital who assigned to Lexicon; neither I nor Brigham and Women's Hospital receive any income from this patent); Research Funding: Abbott, Acesion Pharma, Afimmune, Aker Biomarine, Alnylam, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CinCor, Cleerly, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Lilly, Medtronic, Merck, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Otsuka, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, Youngene, 89Bio; Royalties: Elsevier (Editor, Braunwald's Heart Disease); Site Co-Investigator: Author contributions Abbott, Biotronik, Boston Scientific, CSI, Endotronix, St Jude Medical (now Abbott), Philips, SpectraWAVE, Svelte, Vascular Solut.

Aims: This study aims to compare the preventive effect of low- or moderate-statin with ezetimibe combination therapy and high-intensity statin monotherapy on cardiovascular disease (CVD) and all-cause death in a real-world setting., Methods and Results: Using the Korean National Health Insurance Service datasets, two cohorts comparing high-intensity statin monotherapy with low- or moderate-intensity statin and ezetimibe combination were constructed by 1:1 propensity score matching procedure. Primary outcome was a composite of myocardial infarction (MI), stroke, and all-cause death. Secondary outcome was an individual event. The study population was followed from baseline until the date of events, or the last health check-ups, whichever came first. Compared to high-intensity statin monotherapy, moderate-intensity statin with ezetimibe combination significantly reduced the risk of composite outcome [hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.77-0.92, P < 0.001] as well as individual MI (HR 0.81, 95% CI 0.71-0.94, P = 0.005) and stroke (HR 0.78, 95% CI 0.65-0.93, P = 0.005), but not all-cause death. Low-intensity statin with ezetimibe also significantly reduced the risk of the composite outcomes (HR 0.80, 95% CI 0.66-0.97, P = 0.024) compared to high-intensity statin monotherapy, but the risk of individual outcome did not differ between two groups. Statin and ezetimibe combination demonstrated consistent effect across various subgroups., Conclusion: Among people without pre-existing CVD, moderate-intensity statin with ezetimibe combination was superior to high-intensity statin monotherapy in preventing composite outcomes as well as each of MI and stroke. In contrast, low-intensity statin with ezetimibe combination reduced the risk of composite but not individual outcomes., Competing Interests: Conflict of interest: J.E.J. reports research support from Kyung Hee University which is her institution. Y.-C.H. research funding from Celltrion Pharm Inc. However, the authors declare that they have no competing financial interests or personal relationships that could influence the work reported in this article., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Assessment of residual cardiovascular risk in statin-treated patients with atherosclerotic cardiovascular disease (ASCVD) is pivotal for optimizing secondary preventive therapies. This study investigates if non-high-density lipoprotein cholesterol (non-HDL-C) is associated with residual ASCVD risk in statin-treated ischaemic heart disease (IHD) patients with and without diabetes., Methods and Results: Using the Western Denmark Heart Registry, we identified statin-treated patients with IHD examined by coronary angiography (CAG) from 2011 to 2020. Non-HDL-C was assessed within 1 year after CAG. Outcomes were ASCVD (myocardial infarction, ischaemic stroke, and cardiovascular death) and all-cause death. Cox regression analyses obtained hazard ratios (HRs) adjusted for age, sex, smoking, and hypertension. A total of 42 057 patients were included: 8196 patients with diabetes and 33 861 without diabetes. During the median 4.6 years of follow-up, event rates per 1000 person-years of ASCVD were 28.8 (27.1-30.5) and 17.2 (16.5-17.8) among patients with and without diabetes. In patients with diabetes, the adjusted HRs of ASCVD as compared with non-HDL-C < 25th percentile were 1.0 (0.9-1.2), 1.3 (1.1-1.6), and 1.6 (1.2-2.1) for patients in the 25th-74th, 75th-94th, and ≥95th percentiles. In patients without diabetes, the corresponding adjusted HRs were 1.1 (0.9-1.1), 1.2 (1.1-1.4), and 1.7 (1.4-2.0). Results were consistent across sex, age, clinical presentation, and low-density lipoprotein cholesterol strata., Conclusion: In statin-treated IHD patients with and without diabetes, non-HDL-C, especially above the 75th percentile, is associated with residual cardiovascular risk. These results have implications for secondary prevention, targeting patients who may benefit most from intensified preventive therapy., Competing Interests: Conflict of interest: M.K.H. has received a research grant from the Novo Nordisk Foundation (grant number NNF22OC0074083). M.B.M. has achieved lecture fees from Novo Nordisk, AstraZeneca, Amarin, Sanofi, and Amgen. K.K.W.O. is supported by a grant from the Danish Cardiovascular Academy funded by the Danish Heart Association and Novo Nordisk. P.G.T.: none. RWT: the Department of Clinical Epidemiology, Aarhus University, receives funding for other studies in the form of institutional research grants to (and administered by) Aarhus University. None of these studies has any relation to the present study. M.M. is supported by a grant from the Novo Nordisk Foundation (grant number NNF22OC0074083), has received lecture and/or advisory board fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, and Novo Nordisk, has received research grants from Philips, Bayer, and Novo Nordisk, has received a travel grant from Novo Nordisk, has ongoing institutional research contracts with Janssen, Novo Nordisk, and Philips, and is a minor shareholder in Novo Nordisk, Eli Lilly and Company, and Verve Therapeutics., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Aims: Patients with cancer are at increased cardiovascular (CV) risk. We aimed to compare the recommended and observed statin use among individuals with and without cancer., Methods and Results: Using three 2-year cycles from the National Health and Nutrition Examination Survey (2013-18), we analysed data from 17 050 US adults. We compared the prevalence of Class 1 statin recommendations and use between individuals with and without cancer, overall, and among different demographic groups. Individuals with a history of cancer were older and had a higher burden of comorbidities. Stratified by age groups, they were more likely to have a secondary prevention indication compared with individuals without cancer but not a primary prevention indication for statin. Among individuals with an indication for statin therapy, the prevalence of statin use was higher in the cancer group compared with those without cancer (60.8% vs. 47.8%, P < 0.001), regardless of sex, type of indication (primary vs. secondary prevention), and education level. However, the higher prevalence of statin use in the cancer group was noted among younger individuals, ethnic minorities, and those with lower family income., Conclusion: Our finding highlights the importance of optimization of CV health in patients with cancer, as individuals with cancer were more likely to have a Class 1 indication for statin treatment when compared with individuals without cancer. Important differences in statin use among cohorts based on sex, age, ethnicity, and socioeconomic status were identified, which may provide a framework through which CV risk factor control can be targeted in this population., Key Findings: Higher statin use in cancer patients: Among those with Class 1 recommendation to take statins, 60.8% of cancer patients were using them, compared with 47.8% of non-cancer individuals, indicating a greater adherence to heart health recommendations in the cancer group. Demographic variations in statin use: The study found notable differences in statin use among younger individuals, ethnic minorities, and those with lower income within the cancer patient group, suggesting disparities in how these subgroups manage their cardiovascular health., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: The lack of effective pharmacotherapies for aortic aneurysms (AA) is a persistent clinical challenge. Lipid metabolism plays an essential role in AA. However, the impact of lipid-lowering drugs on AA remains controversial. The study aimed to investigate the genetic association between lipid-lowering drugs and AA., Methods and Results: Our research used publicly available data on genome-wide association studies (GWASs) and expression quantitative trait loci (eQTL) studies. Genetic instruments, specifically eQTLs related to drug-target genes and SNPs (single nucleotide polymorphisms) located near or within the drug-target loci associated with low-density lipoprotein cholesterol (LDL-C), have been served as proxies for lipid-lowering medications. Drug-Target Mendelian Randomization (MR) study is used to determine the causal association between lipid-lowering drugs and different types of AA. The MR analysis revealed that higher expression of HMGCR (3-hydroxy-3-methylglutaryl coenzyme A reductase) was associated with increased risk of AA (OR = 1.58, 95% CI = 1.20-2.09, P = 1.20 × 10-03) and larger lumen size (aortic maximum area: OR = 1.28, 95% CI = 1.13-1.46, P = 1.48 × 10-04; aortic minimum area: OR = 1.26, 95% CI = 1.21-1.42, P = 1.78 × 10-04). PCSK9 (proprotein convertase subtilisin/kexin type 9) and CETP (cholesteryl ester transfer protein) show a suggestive relationship with AA (PCSK9: OR = 1.34, 95% CI = 1.10-1.63, P = 3.07 × 10-03; CETP: OR = 1.38, 95% CI = 1.06-1.80, P = 1.47 × 10-02). No evidence to support genetically mediated NPC1L1 (Niemann-Pick C1-Like 1) and LDLR (low-density lipoprotein cholesterol receptor) are associated with AA., Conclusion: This study provides causal evidence for the genetic association between lipid-lowering drugs and AA. Higher gene expression of HMGCR, PCSK9, and CETP increases AA risk. Furthermore, HMGCR inhibitors may link with smaller aortic lumen size., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Elevated small dense LDL cholesterol (sd-LDL-C) increases atherosclerotic cardiovascular disease (CVD) risk. Although coronary artery calcification (CAC) is widely used for predicting CVD events, few studies have examined the relationship between sd-LDL-C and CAC., Methods and Results: This study included 4672 individuals with directly measured baseline sd-LDL-C and CAC from the Multi-Ethnic Study of Atherosclerosis [mean (standard deviation) age: 61.9 (10.4) years; 52.5% women; 47.3% with baseline CAC (mean score >0)]. We used multi-variable general linear models and restricted cubic splines with the goodness of fit testing to evaluate the association of sd-LDL-C with the presence of CAC. Odds ratios [OR (95% confidence interval)] were adjusted for demographics and cardiovascular risk factors, including estimated total LDL-C. Higher quartiles of sd-LDL-C were associated with the presence of CAC, even after accounting for total LDL-C. Compared with the lowest quartile of sd-LDL-C, participants in Quartiles 2, 3, and 4 had higher odds for the presence of baseline CAC [Quartile 2 OR: 1.24 (1.00, 1.53); Quartile 3 OR: 1.51 (1.19, 1.93); and Quartile 4 OR 1.59 (1.17, 2.16)]. Splines suggested a quadratic curvilinear relationship of continuous sd-LDL-C with CAC after adjustment for demographics and CVD risk factors (quadratic vs. first-order sd-LDL-C terms likelihood ratio test: P = 0.015), but not after accounting for total LDL-C (quadratic vs. first-order terms: P = 0.156)., Conclusion: In a large, multi-ethnic sample without known CVD, higher sd-LDL-C was associated with the presence of CAC, above and beyond total LDL-C. Whether selective direct measurement of sd-LDL-C is indicated to refine cardiovascular risk assessment in primary prevention warrants further investigation., Competing Interests: Conflict of interest: M.D.S. has participated in scientific advisory boards with the following entities: Amgen, Agepha, Ionis, Novartis, Precision BioScience, Novo Nordisk, and New Amsterdam; and has served as a consultant for Ionis, Novartis, Regeneron, Aidoc, Kaneka, and Shanghai Pharma Biotherapeutics. C.L.S. has received honoraria from the National Institutes of Health for service on grant review panels. All other authors have nothing to disclose., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Most studies of treatment adherence after acute coronary syndrome (ACS) are based on prescribed drugs and lack long-term follow-up or consecutive data on risk factor control. We studied the long-term treatment adherence, risk factor control, and its association to recurrent ACS and death., Methods and Results: We retrospectively included 3765 patients (mean age 75 years, 40% women) with incident ACS from 1 January 2006 until 31 December 2010 from the Swedish Primary Care Cardiovascular Database of Skaraborg. All patients were followed until 31 December 2014 or death. We recorded blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), recurrent ACS, and death. We used data on dispensed drugs to calculate the proportion of days covered for secondary prevention medications. Cox regressions were used to analyse the association of achieved BP and LDL-C to recurrent ACS and death. The median follow-up time was 4.8 years. The proportion of patients that reached BP of <140/90 mm Hg was 58% at Year 1 and 66% at Year 8. 65% of the patients reached LDL-C of <2.5 mmol/L at Year 1 and 56% at Year 8; however, adherence to statins varied from 43% to 60%. Only 62% of the patients had yearly measured BP, and only 28% yearly measured LDL-C. Systolic BP was not associated with a higher risk of recurrent ACS or death. Low-density lipoprotein cholesterol of 3.0 mmol/L was associated with a higher risk of recurrent ACS {hazard ratio [HR] 1.19 [95% confidence interval (CI) 1.00-1.40]} and death HR [1.26 (95% CI 1.08-1.47)] compared with an LDL-C of 1.8 mmol/L., Conclusion: This observational long-term real-world study demonstrates low drug adherence and potential for improvement of risk factors after ACS. Furthermore, the study confirms that uncontrolled LDL-C is associated with adverse outcome even in this older population., Competing Interests: Conflict of interest: S.B. reports research grants from Astra Zeneca and personal fees from Amarin, Amgen, Astra Zeneca, Sanofi, and Novo Nordisk. T.K. report research grants to Karolinska Institutet from Medtronic and ReCor Medical. These companies do not have access to the data and do not have the right to review manuscripts before publication., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Modifiable cardiovascular risk factors (RFs) play a key role in the development of coronary artery disease. We evaluated 20-year trends in RF prevalence among young adults hospitalized with acute coronary syndromes (ACS) in Switzerland., Methods and Results: Data were analysed from the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry from 2000 to 2019. Young patients were defined as those aged <50 years. Among 58 028 ACS admissions, 7073 (14.1%) were young (median 45.6 years, IQR 42.0-48.0), of which 91.6% had at least one modifiable RF and 59.0% had at least two RFs. Smoking was the most prevalent RF (71.4%), followed by dyslipidaemia (57.3%), hypertension (35.9%), obesity (21.7%), and diabetes (10.1%). Compared with older patients, young patients were more likely to be obese (21.7% vs. 17.4%, P < 0.001) and active smokers (71.4% vs. 33.9%, P < 0.001). Among young patients, between 2000 and 2019, there was a significant increase in the prevalence of hypertension from 29.0% to 51.3% and obesity from 21.2% to 27.1% (both Ptrend < 0.001) but a significant decrease in active smoking from 72.5% to 62.5% (Ptrend = 0.02). There were no significant changes in the prevalence of diabetes (Ptrend = 0.32) or dyslipidaemia (Ptrend = 0.067)., Conclusion: Young ACS patients in Switzerland exhibit a high prevalence of RFs and are more likely than older patients to be obese and smokers. Between 2000 and 2019, RF prevalence either increased or remained stable, except for smoking which decreased but still affected approximately two-thirds of young patients in 2019. Public health initiatives targeting RFs in young adults in Switzerland are warranted., Competing Interests: Conflict of interest All authors declare no conflict of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: To investigate sex differences in the association of metabolic syndrome (MetS) and/or low-density lipoprotein cholesterol (LDL-C) with the incidence of cardiovascular and cerebrovascular disease (CCVD)., Methods and Results: A total of 4 702 458 individuals, aged between 40 and 70, without a previous diagnosis of CCVD, underwent at least two health screenings between 2009 and 2011. Of them, 4 193 878 individuals (48.6% women) fulfilled the study requirements. The main outcome measured was the incidence of CCVD. By the end of 2017, 68 921 CCVD events occurred. Men in high LDL-C only, MetS only, and both MetS and high LDL-C groups had higher risks of CCVD. Women in MetS only and both MetS and high LDL-C groups, but not those in high LDL-C only group, had higher risks of CCVD than those in the reference group. The effect of the interaction between the presence of MetS and high LDL-C levels on the primary outcome was found among women (P for interaction 0.016) but not among men (P for interaction 0.897). A combination of MetS and LDL-C > 3.4 mmol/L increased the risk of CCVD as compared to MetS or LDL-C > 3.4 mmol/L alone in both men and women., Conclusions: Metabolic syndrome confers an increased risk of CCVD irrespective of sexes; LDL-C > 3.4 mmol/L alone has a greater influence on CCVD occurrence in men than in women. Metabolic syndrome and high LDL-C beget a synergistically detrimental impact on the incidence of CCVD in both men and women. Treatment of dyslipidaemia and metabolic syndrome should be tailored according to patient characteristics., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: We sought to evaluate physicians' opinions and practices in lipid management., Methods and Results: A web-based survey by the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) was distributed to 70 696 individuals at two time points, before and after publication of the 2019 ESC/EAS dyslipidaemia guidelines. Respondents (1271 in the first and 1056 in the second part) were most commonly cardiologists in Europe. More than 90% of participants reported that they regularly measure lipid levels and discuss lipid-lowering treatment with patients. More than 87% found the use of LDL-C goals useful or potentially useful, although it was acknowledged that recommended goals are frequently not achieved. Regarding the LDL-C goal according to the 2019 guidelines (<1.4 mmol/L for very high-risk patients), more than 70% of respondents felt that it is based on solid scientific evidence, but 31% noted that implementation should also consider available local resources and patient preferences. Statin intolerance was perceived as infrequent, affecting 1-5% of patients according to most respondents but was the main reason for not prescribing a statin to secondary-prevention patients, followed by patient non-adherence. Although most respondents reported that 11-20% of secondary-prevention patients have an indication to add a non-statin medication, fewer patients (<10% according to most respondents) receive these medications., Conclusions: This survey shows a high level of acceptance of the LDL-C treatment goals recommended by current ESC/EAS guidelines. Although patient-related factors were the main reported reasons for suboptimal lipid-lowering therapy, physician inertia to intensify treatment cannot be excluded as an additional contributing factor., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: Due to improving cancer treatment results, non-cancer mortality is an important issue for cancer survivors. Cardiovascular diseases are the leading causes of death in Korea and globally. In addition to lowering the risk of cardiovascular disease, the use of statins has led to an overall reduction in cancer mortality in recent observational studies. We investigated the status of current dyslipidemia management in cancer survivors with reference to 2018 guidelines., Methods: The study is a cross-sectional analysis of 1460 cancer survivors aged from 40 to 75 years who participated in the Korean National Health and Nutrition Examination Survey from 2007 to 2016. Dyslipidemia management status among cancer survivors was assessed according to 2018 American College of Cardiology/American Heart Association guidelines and Korean Coronary Heart Disease Risk Score guidelines., Results: The rate of treatment for dyslipidemia was 8.5% for males, 13.8% for females, and 11.9% overall. Among cancer survivors who were not receiving treatment for dyslipidemia, 59.6% of males, 34.2% of females and 43.9% of total cancer survivors would have been eligible for statin therapy under the 2018 American College of Cardiology/American Heart Association guidelines and Korean Coronary Heart Disease Risk Score guidelines. The rate of undertreatment of dyslipidemia increased with age and length of time since cancer diagnosis., Conclusion: Nearly 50% of cancer survivors remain untreated although they are eligible for statin therapy. This emphasizes the need for more attention to prevent atherosclerotic cardiovascular disease among cancer survivors., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: The recently updated European Society of Cardiology (ESC) dyslipidaemia guidelines recommend a lower low-density lipoprotein cholesterol (LDL-C) goal of <55 mg/dL for patients with atherosclerotic cardiovascular disease (ASCVD), with a concomitant Class IA upgrade for proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) for patients not reaching their LDL-C goal under conventional lipid-lowering therapy., Aims: We aim to quantify the need for PCSK9i and the related costs to achieve the revised LDL-C goal in ASCVD patients compared to former ESC recommendations, in particular the risk-based 2017 ESC consensus update., Methods and Results: We included patients with ASCVD from an observational cohort study ongoing since 2015. A Monte Carlo simulation incorporating a treatment algorithm adding sequentially a statin, ezetimibe, and a PCSK9i was applied with consideration of partial and total statin intolerance. The need for PCSK9i was calculated for three different ESC recommendations (2019 guidelines, 2016 guidelines, 2017 consensus update). Preventable events and treatment costs due to PCSK9i were calculated for a range of annual event rates from 2% to 8% and annual treatment costs of ca. 6050 €. We included 1780 patients (mean age 69.5 years). Median LDL-C at baseline was 85.0 mg/dL, with 61% of patients taking lipid-lowering medication. The need for PCSK9i was simulated to be 42.0% (ESC 2019), 31.9% (ESC 2016), and 5.0% (ESC 2017). The LDL-C goals were achieved in 97.9%, 99.1%, and 60.9% of patients, respectively. Annual treatment cost for PCSK9i per 1 000 000 ASCVD patients would be 2.54 billion € (ESC 2019) compared to 0.30 billion € (ESC 2017). Costs per prevented event due to PCSK9i initiation differed widely, e.g. 887 000 € for an event rate of 3% and a treatment goal of <55 mg/dL compared to 205 000 € for an event rate of 7% and risk-based use of PCSK9i., Conclusion: The revised LDL-C treatment goals increase the projected need for PCSK9i with a substantial increase in associated treatment cost. An allocation strategy based on residual LDL-C and clinical or angiographic risk factors leads to a more tailored target population for PCSK9i with a reasonable benefit/cost ratio., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: The relationship between high-density lipoprotein cholesterol and the severity of coronary artery disease beyond low-density lipoprotein cholesterol, the primary target of cholesterol-lowering therapy, remains uncertain. We evaluated the association between high-density lipoprotein cholesterol and obstructive coronary artery disease using parameters of any obstructive plaque, obstructive plaque in the left main coronary artery or proximal left anterior descending artery, and obstructive plaque in multi-vessels, according to low-density lipoprotein cholesterol levels., Methods and Results: We analyzed 5130 asymptomatic non-diabetics who underwent coronary computed tomography angiography for general health examination. Obstructive plaque was defined as a plaque with ≥50% luminal diameter stenosis. The participants were divided into three groups based on low-density lipoprotein cholesterol levels of ≤129, 130-159, and ≥160 mg/dl. The prevalence of any obstructive plaque (5.9% vs 6.4% vs 10.6%) and obstructive plaque in the left main coronary artery or proximal left anterior descending artery (2.1% vs 2.1% vs 4.3%) significantly increased with low-density lipoprotein cholesterol category (all p  < 0.05). Compared with subjects with high-density lipoprotein cholesterol level ≥40 mg/dl, those with high-density lipoprotein cholesterol level <40 mg/dl had a significantly higher prevalence of any obstructive plaque (10.4% vs 5.1%), obstructive plaque in the left main coronary artery or proximal left anterior descending artery (3.6% vs 1.8%), and obstructive plaque in multi-vessels (4.3% vs 1.1%), only in the group with low-density lipoprotein cholesterol level ≤129 mg/dl (all p  < 0.05). Multiple regression analysis showed that increased high-density lipoprotein cholesterol levels were associated with a reduced risk of all obstructive coronary artery disease parameters only in the group with low-density lipoprotein cholesterol level ≤129 mg/dl (all p  < 0.05)., Conclusion: Increased high-density lipoprotein cholesterol levels were independently associated with a lower risk of obstructive coronary artery disease in asymptomatic non-diabetics with low low-density lipoprotein cholesterol levels.

Aims: There is mixed evidence for an association between depression and/or anxiety and carotid intima-media thickness, and limited information on the related role of dyslipidaemia. Here we report associations between depression and/or anxiety and intima-media thickness in the Whitehall II cohort, considering the moderating effects of sex and dyslipidaemia., Methods: A total of 2822 men and 1112 women (61 ± 6 years) were studied during phase 7 (2002-2004) of the Whitehall II study. Intima-media thickness and lipid levels were assessed, and questionnaires (general health questionnaire and the Centre for Epidemiologic Studies depression scale) were completed. Linear regression was used to explore relationships between depression and/or anxiety and intima-media thickness and the moderating effects of sex and dyslipidaemia., Results: A total of 1461 participants were categorised with depression and/or anxiety. The association between depression and/or anxiety and intima-media thickness differed between men and women so analyses were undertaken separately by sex. In men, intima-media thickness was significantly associated with dyslipidaemia ( P  = 0.002) but not depression and/or anxiety ( P  = 0.29). In women, both dyslipidaemia and depression and/or anxiety were independently associated with intima-media thickness ( P  = 0.028 and P  = 0.031). The greatest intima-media thickness was in women with both depression and/or anxiety and dyslipidaemia. These results were replicated when the general health questionnaire score was substituted for depression and/or anxiety and non-high-density lipoprotein cholesterol for dyslipidaemia., Conclusions: Depression and/or anxiety is associated with increased intima-media thickness in women but not in men. Dyslipidaemia is associated with intima-media thickness in both men and women. Women with both depression and/or anxiety and dyslipidaemia are potentially at the greatest risk of cardiovascular disease.

Aims: Averaged measurements, but not the progression based on multiple assessments of carotid intima-media thickness, (cIMT) are predictive of cardiovascular disease (CVD) events in individuals. Whether this is true for conventional risk factors is unclear., Methods and Results: An individual participant meta-analysis was used to associate the annualised progression of systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol with future cardiovascular disease risk in 13 prospective cohort studies of the PROG-IMT collaboration ( n  = 34,072). Follow-up data included information on a combined cardiovascular disease endpoint of myocardial infarction, stroke, or vascular death. In secondary analyses, annualised progression was replaced with average. Log hazard ratios per standard deviation difference were pooled across studies by a random effects meta-analysis. In primary analysis, the annualised progression of total cholesterol was marginally related to a higher cardiovascular disease risk (hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.00 to 1.07). The annualised progression of systolic blood pressure, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol was not associated with future cardiovascular disease risk. In secondary analysis, average systolic blood pressure (HR 1.20 95% CI 1.11 to 1.29) and low-density lipoprotein cholesterol (HR 1.09, 95% CI 1.02 to 1.16) were related to a greater, while high-density lipoprotein cholesterol (HR 0.92, 95% CI 0.88 to 0.97) was related to a lower risk of future cardiovascular disease events., Conclusion: Averaged measurements of systolic blood pressure, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol displayed significant linear relationships with the risk of future cardiovascular disease events. However, there was no clear association between the annualised progression of these conventional risk factors in individuals with the risk of future clinical endpoints.

Aims: Few data are available on cardiovascular risk stratification in primary care patients treated for arterial hypertension. This study aimed at evaluating the cardiovascular risk profile of hypertensive patients included into the Swiss Hypertension Cohort Study according to the 2013 European Society of Hypertension/European Society of Cardiology Guidelines., Methods: The Swiss Hypertension Cohort Study is a prospective, observational study conducted by the Centre for Primary Health Care of the University of Basel from 2006 to 2013. Patients with a diagnosis of arterial hypertension (office blood pressure measurement ≥140/90 mmHg) were enrolled. Office blood pressure measurement, cardiovascular risk factors, subclinical organ damage, diabetes mellitus, and established cardiovascular and renal disease were recorded at baseline and at an annual interval during routine consultations by general practitioners in Switzerland., Results: In total, 1003 patients were eligible for analysis (55.6% male, mean age: 64.0 ± 13.2 years). At baseline, 78.5% of patients presented with either more than three additional cardiovascular risk factors, diabetes mellitus or subclinical organ damage, while 44.4% of patients had a high or very high overall cardiovascular risk. Cardiovascular risk factors and information about diabetes mellitus, established cardiovascular disease and renal disease were recorded mostly completely, whereas substantial gaps were revealed regarding the assessment of subclinical organ damage., Conclusion: The present findings demonstrate that the majority of primary care patients with arterial hypertension bear a substantial number of additional cardiovascular risk factors, subclinical and/or established organ damage. This emphasizes the need for continuous cardiovascular risk stratification and adequate treatment of arterial hypertension in Switzerland.

Regulation of pro-protein convertase subtilisin/kexin type 9 (PCSK9) by drugs has led to the development of a still small number of agents with powerful activity on low-density lipoprotein cholesterol levels, associated with a significant reduction of cardiovascular events in patients in secondary prevention. The Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) and Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) studies, with the two available PCSK9 antagonists, i.e. evolocumab and alirocumab, both reported a 15% reduction in major adverse cardiovascular events. Regulation of PCSK9 expression is dependent upon a number of factors, partly genetic and partly associated to a complex transcriptional system, mainly controlled by sterol regulatory element binding proteins. PCSK9 is further regulated by concomitant drug treatments, particularly by statins, enhancing PCSK9 secretion but decreasing its stimulatory phosphorylated form (S688). These complex transcriptional mechanisms lead to variable circulating levels making clinical measurements of plasma PCSK9 for cardiovascular risk assessment a debated matter. Determination of total PCSK9 levels may provide a diagnostic tool for explaining an apparent resistance to PCSK9 inhibitors, thus indicating the need for other approaches. Newer agents targeting PCSK9 are in clinical development with a major interest in those with a longer duration of action, e.g. RNA silencing, allowing optimal patient compliance. Interest has been expanded to areas not only limited to low-density lipoprotein cholesterol reduction but also investigating other non-lipid pathways raising cardiovascular risk, in particular inflammation associated to raised high-sensitivity C-reactive protein levels, not significantly affected by the present PCSK9 antagonists.

Aims: The PATIENT CARE registry aimed to document clinical characteristics of patients during cardiac rehabilitation after myocardial infarction, including the current pharmacological treatment, risk factor modification and achievement of treatment targets for low-density lipoprotein cholesterol (LDL-C)., Methods: Multicentre, prospective non-interventional study at 20 cardiac rehabilitation in-patient centres across Germany., Results: A total of 1408 patients post myocardial infarction were analysed. Patients' mean age was 62 ± 11 years and 27.0% were women. ST elevation myocardial infarction ( n = 657; 48.7%), and non-ST elevation myocardial infarction ( n = 617; 45.8%) were equally balanced causes for hospitalization, while previous coronary artery bypass grafting was reported in n = 134 patients (9.9%). On average, cardiac rehabilitation began 19 ± 10 days after the index event and lasted for 22 ± 4 days. At discharge, 96.7% of patients received statins, 13.0% another lipid-lowering medication in addition to a statin, 98.5% antithrombotic drugs and 22.3% antidiabetic medication. The rate of patients with LDL-C on target according to the European Society of Cardiology/European Atherosclerosis Society dyslipidaemia guidelines 2011 (<70 mg/dl (1.8 mmol/l) or at least 50% reduction of baseline value) was increased from 21.4% at admission to cardiac rehabilitation to 41.9% at discharge after cardiac rehabilitation. Most patients (95.2%) completed the cardiac rehabilitation and 88% returned to their former work at full time., Conclusion: During cardiac rehabilitation, the modifiable cardiovascular risk factors, in particular the LDL-C, were substantially improved in patients after myocardial infarction. The great majority were able to return to work. However, less than 50% reached the LDL-C guideline targets during short-term cardiac rehabilitation.

Background: Patients with coronary heart disease (CHD) and survivors of acute coronary syndrome (ACS) are at very high risk for adverse cardiovascular events. Lowering low-density lipoprotein cholesterol (LDL-C) can reduce the risk, with effective lipid-lowering therapy (LLT) readily available; however, dyslipidemia remains prevalent throughout Europe., Design: The observational Dyslipidemia International Study II (DYSIS II) aimed to identify unmet treatment needs in adult ACS and CHD patients. Data for the seven participating European countries are presented herein., Methods: The study was carried out from December 2012 to November 2014. Use of LLT and attainment of European-guideline-recommended LDL-C targets were assessed. For ACS patients, changes in lipid levels and LLT were evaluated 4 months post-hospitalization., Results: Of the 4344 patients enrolled, 2946 were attending a physician visit for the assessment of stable CHD, while 1398 had been hospitalized for an ACS event. In both patient sets, mean LDL-C levels were high (89.5 and 112.5 mg/dl, respectively) and <70 mg/dl target attainment extremely poor. The mean daily statin dosage (normalized to atorvastatin potency) was 27 ± 20 mg for CHD and 22 ± 17 mg for ACS patients. Treatment was intensified slightly for ACS subjects after hospitalization, with the dosage reaching 35 ± 24 mg/day. LDL-C target attainment was higher by the end of the 4-month follow up (30.9% and 41.5% for patients on LLT and without LLT at baseline, respectively; p < 0.05)., Conclusion: Elevated blood cholesterol levels are highly prevalent across Europe, with low numbers of coronary patients reaching their recommended LDL-C target. While use of LLT is widespread, there is significant scope for intensifying treatment.

Background Little is known about the achievement of low density lipoprotein cholesterol (LDL-C) targets in patients at cardiovascular risk receiving stable lipid-lowering therapy (LLT) in countries outside Western Europe. Methods This cross-sectional observational study was conducted in 452 centres (August 2015-August 2016) in 18 countries in Eastern Europe, Asia, Africa, the Middle East and Latin America. Patients ( n = 9049) treated for ≥3 months with any LLT and in whom an LDL-C measurement on stable LLT was available within the previous 12 months were included. Results The mean±SD age was 60.2 ± 11.7 years, 55.0% of patients were men and the mean ± SD LDL-C value on LLT was 2.6 ± 1.3 mmol/L (101.0 ± 49.2 mg/dL). At enrolment, 97.9% of patients were receiving a statin (25.3% on high intensity treatment). Only 32.1% of the very high risk patients versus 51.9% of the high risk and 55.7% of the moderate risk patients achieved their LDL-C goals. On multivariable analysis, factors independently associated with not achieving LDL-C goals were no (versus lower dose) statin therapy, a higher (versus lower) dose of statin, statin intolerance, overweight and obesity, female sex, neurocognitive disorders, level of cardiovascular risk, LDL-C value unknown at diagnosis, high blood pressure and current smoking. Diabetes was associated with a lower risk of not achieving LDL-C goals. Conclusions These observational data suggest that the achievement of LDL-C goals is suboptimal in selected countries outside Western Europe. Efforts are needed to improve the management of patients using combination therapy and/or more intensive LLTs.

Objective An interleukin-beta antagonist reduces the risk of subsequent cardiovascular events in coronary patients with high-sensitivity C-reactive protein (hs-CRP) ≥2 mg/L. It remains to be defined how large the coronary population at inflammatory risk is, and what the predictors of elevated risk are. Methods A cross-sectional study investigated the proportion of patients with elevated hs-CRP (i.e. ≥2 mg/L) and the respective demographic and clinical predictors in 971 patients without concomitant inflammatory diseases who had been hospitalized with myocardial infarction (80%) and/or a revascularization procedure. Data were collected from hospital records, a self-report questionnaire and a clinical examination with blood samples. Results After 2-36 month follow-up, 39% ( n = 378) had hs-CRP ≥ 2 mg/L, among whom 64% ( n = 243) had low-density lipoprotein cholesterol (LDL-C) ≥1.8 mmol/L and 47% ( n = 176) used a low-intensity statin regime. Only 24% had both LDL and hs-CRP at target range, 27% had elevation of both, whereas 12% had hs-CRP ≥ 2 mg/L and LDL-C < 1.8 mmol/L. Somatic comorbidity (odds ratio (OR) 1.3/1.0 point on the Charlson score), ≥1 previous coronary event (OR 2.4), smoking (OR 2.2), higher body mass index (OR 1.2/1.0 kg/m 2 ), high LDL-C (OR 1.4/1.0 mmol/L) and higher anxiety scores (OR 1.1/1.0 point increase on the Hospital Anxiety and Depression Scale-Anxiety subscale score) were significantly associated with hs-CRP ≥2 mg/L in adjusted analyses. Conclusions Elevated hs-CRP was frequently observed after a coronary event and associated with unfavourable LDL-C and unhealthy lifestyles and psychosocial distress. Intensified statin therapy and strategies to target these modifiable factors are the encouraged first steps to reduce inflammation and improve LDL-C in these patients.

Aims The aim of this study was to evaluate the performance of the US Preventive Services Task Force (USPSTF) cholesterol recommendations in a contemporary non-US cohort. Methods and results This is a historical cohort analysis of electronic records from Israel's largest health provider. All patients in the Tel Aviv district eligible for primary cardiovascular prevention were followed between January 2005 and December 2015. Risk was estimated by the pooled cohort equations. Statin eligibility was determined by USPSTF and American College of Cardiology and American Heart Association (ACC/AHA) recommendations. Atherosclerotic cardiovascular disease events were retrieved from electronic registration. The mean ± standard deviation age of the 10,889 (98,258 person-years) participants was 60.3 ± 9.4 years, and 69.1% were women. Outcome events were recorded for 1351 patients (12.4%). Treatment recommendations were discordant in 901 patients (8.3%) whose treatment was indicated only by the ACC/AHA guidelines, implying a 26% reduction in newly eligible patients for statin treatment had the USPSTF recommendations been implemented. Among the statin-naive patients, the pooled cohort equations underestimated the risk, with a predicted-to-observed event ratio of 0.88. The recommended treatment thresholds provided excellent calibration, with ratios of 1.0 for USPSTF and 0.98 for ACC/AHA-eligible patients. Both models showed similar discrimination (Harrel's C = 0.63 (0.62-0.65) for USPSTF vs. 0.64 (0.63-0.66) for ACC/AHA, P = 0.26). The USPSTF recommendations were less sensitive and more specific for the detection of outcome events than the ACC/AHA recommendations (61% vs. 75% and 68% vs. 55%, respectively). The net reclassification index was -0.01. Conclusions Calibration, discrimination and net reclassifications were very similar for USPSTF and ACC/AHA recommendations. Applying the USPSTF recommendations could reduce over-treatment.

Background The comparative effects of statins, ezetimibe with or without statins and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors remain unassessed. Design Bayesian network meta-analysis was conducted to compare treatment groups. Methods Thirty-nine randomized controlled trials were selected using MEDLINE, EMBASE, and CENTRAL (inception - September 2017). Results In network meta-analysis of 189,116 patients, PCSK9 inhibitors were ranked as the best treatment for prevention of major adverse cardiovascular events (Surface Under Cumulative Ranking Curve (SUCRA), 85%), myocardial infarction (SUCRA, 84%) and stroke (SUCRA, 80%). PCSK9 inhibitors reduced the risk of major adverse cardiovascular events compared with ezetimibe + statin (odds ratio (OR): 0.72; 95% credible interval (CrI), 0.55-0.95; Grading of Recommendation Assessment, Development and Evaluation (GRADE) criteria: moderate), statin (OR: 0.78; 95% CrI: 0.62-0.97; GRADE: moderate) and placebo (OR: 0.63; 95% CrI: 0.49-0.79; GRADE: high). The PCSK9 inhibitors were consistently superior to groups for major adverse cardiovascular event reduction in secondary prevention trials (SUCRA, 95%). Statins had the highest probability of having lowest rates of all-cause mortality (SUCRA, 82%) and cardiovascular mortality (SUCRA, 84%). Compared with placebo, statins reduced the risk of all-cause mortality (OR: 0.88; 95% CrI: 0.83-0.94; GRADE: moderate) and cardiovascular mortality (OR: 0.84; 95% CrI: 0.77-0.90; GRADE: high). For cardiovascular mortality, PCSK9 inhibitors were ranked as the second best treatment (SUCRA, 78%) followed by ezetimibe + statin (SUCRA, 50%). Conclusion PCSK9 inhibitors were ranked as the most effective treatment for reducing major adverse cardiovascular events, myocardial infarction and stroke, without having major safety concerns. Statins were ranked as the most effective therapy for reducing mortality.

Introduction The benefits of alcohol consumption for cardiovascular and metabolic health may have been overstated due to inappropriate comparisons with abstainers and inadequate control for confounding factors including physical activity and mental health. We examined alcohol consumption and cardio-metabolic health in a cohort of young Australian adults overcoming these limitations. Methods Cross-sectional data of a cohort of 2200 participants (age range 25-36 years) from the 2004-06 Childhood Determinants of Adult Health were used. Alcohol consumption was assessed from questionnaire and cardio-metabolic risk factors were measured in clinics. Linear and log binomial regression were used to examine total alcohol consumption (categories: none 0 g/day; light >0-10 g/day [reference]; moderate >10-20 g/day; heavy >20-30 g/day; very heavy >30 g/day) against dichotomous metabolic syndrome and its components: waist circumference, triglycerides, high-density lipoprotein cholesterol, blood pressure and glucose. Covariates included socio-demographics, smoking, diet, physical activity, fitness, depression and anxiety. Results Of the 2220 participants (48% males, mean (standard deviation) age 29.5 (2.5) years), most were classified in the 'light drinking' group (54.2%), less were in the 'non-drinking' (13.2%), 'heavy' (5.2%) or 'very heavy' (5.5%) drinking groups. Only moderate drinking was associated with a significantly lower prevalence of metabolic syndrome (prevalence ratio = 0.64, p < 0.05) compared with light drinking. Higher levels of alcohol consumption were associated with higher high-density lipoprotein cholesterol (β = 0.05, p trend  < 0.001). Very heavy compared to light drinkers had higher systolic (β = 3.01 mm Hg, p < 0.01) and diastolic (β = 2.07 mm Hg, p < 0.05) blood pressure. Conclusion Moderate alcohol consumption was associated with a lower prevalence of MetS, and more favourable levels of lipids but not glucose or blood pressure even when compared to light consumption and with account for a range of confounding factors.

Background Early detection of risk factors for left ventricular (LV) dysfunction may be useful in patients with high blood pressure (HBP). Methods Patient from an outpatient HBP clinic underwent a two-dimensional Doppler-coupled echocardiography with determination of LV global longitudinal strain (GLS) by speckle-tracking. Results Among 200 patients (mean age 61.7 ± 9.7 years), 155 were overweight, 93 had diabetes, 83 had dyslipidemia, and 109 had uncontrolled HBP. LV hypertrophy (LVH) was found in 136 patients (68%), including concentric ( n = 106) and eccentric ( n = 30) LVH. Diastolic dysfunction patterns were observed in 178 patients (89%), and increased filling pressures were observed in 37 patients (18.5%). GLS ranged from -25% to -11.6% (mean -16.9 ± 3.2%). Low GLS values (>-17%) were found in 91 patients (45.5%), 68 with and 23 without LVH. In univariate analysis, a reduced GLS was associated with HBP lasting for >10 years (odds ratio (OR) = 3.51, 95% confidence interval (CI) 1.73-7.09; p = 0.002), uncontrolled HBP (OR = 3.55, 95% CI 1.96-6.43; p < 0.0001), overweight (OR = 2.01, 95% CI 0.93-4.31; p = 0.0028), diabetes (OR = 2.21, 95% CI 1.25-3.90; p = 0.006), dyslipidemia (OR = 2.16, 95% CI 1.22-3.84; p = 0.008), renal failure (OR = 4.27, 95% CI 1.80-10.10; p = 0.001), an increased Cornell index (OR = 3.70, 95% CI 1.98-6.90; p < 0.0001), concentric LVH (OR = 9.26, 95% CI 2.62-32.73; p = 0.001), remodeling (OR = 8.51, 95% CI 2.18-33.23; p = 0.002), and filling pressures (OR = 7.1, 95% CI 2.9-17.3; p < 0.0001). In multivariable analysis, duration of HBP ( p = 0.038), uncontrolled BP ( p = 0.006), diabetes ( p = 0.023), LVH ( p = 0.001), and increased filling pressures ( p = 0.003) remained associated with GLS decline. Conclusion Early impairment of LV function, detected by a reduced GLS, is associated with long-lasting, uncontrolled HBP, overweight, related metabolic changes, and is more pronounced in patients with LVH.

Background Statin treatment in association with physical exercise can substantially reduce mortality in dyslipidaemic individuals. However, the available data to compare the efficacy and safety of statins and exercise combination therapy with statin monotherapy are limited. Design Systematic review and meta-analysis. Methods We systematically searched PubMed, Embase and the Cochrane Library from database inception until December 2016. We included randomised and non-randomised studies that compared the efficacy and safety of statins and exercise combination therapy with statin monotherapy in patients with dyslipidaemia. Standardised mean differences were calculated and pooled by means of fixed effects models. The risk of bias and heterogeneity among trials was also assessed. Seven articles were assessed in terms of the efficacy of therapy and 13 from the viewpoint of therapeutic safety. Results In terms of efficacy, statins and exercise combination decreased the incidence of diabetes mellitus, improved insulin sensitivity and inflammation, but caused no change in lipid profile compared to statins alone. In terms of safety, statins and exercise combination increased peak oxygen uptake (standardised mean difference 1.01, 95% confidence interval 0.46 to 1.57) compared to statins alone. In contrast to statin-induced myopathy, chronic exercise training prior to statin treatment could counteract statin-induced adverse effects in skeletal muscle. Conclusion Statins and exercise combination therapy is more effective than statin monotherapy in terms of insulin sensitivity, inflammation and exercise capacity. The small number of studies warrants the need for more randomised controlled trials evaluating the efficacy and safety of combination therapy.

Background Lifestyle and dietary advice typically precedes or accompanies the prescription of statin medications. However, evidence for adherence to this advice is sparse. The objective was to compare saturated fat intake, exercise, alcohol consumption and smoking between statin users and non-users in Australia. Methods Data were analysed for 4614 participants aged ≥37 years in the Australian Diabetes, Obesity and Lifestyle study in 2011-2012. Statin use, smoking status and physical activity were self-reported. Saturated fat and alcohol intake were measured via a food frequency questionnaire. Multinomial logistic regression was used to compute adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between statin use and the four lifestyle factors. All models were adjusted for age, sex, education, number of general practitioner visits, body mass index, hypertension, diabetes and prior cardiovascular diseases. Results In total 1108 (24%) participants used a statin. Statin users were 29% less likely to be within the highest quartile versus the lowest quartile of daily saturated fat intake compared to non-users (OR 0.71, 95% CI 0.54-0.94). There were no statistically significant associations between statin use and smoking, physical activity or alcohol consumption. Conclusions Smoking status, alcohol consumption and exercise level did not differ between users and non-users of statins. However, statin users were less likely to consume high levels of saturated fat than non-users. We found no evidence that people took statins to compensate for a poor diet or lifestyle.

Background Cognitive ability (CA) is positively related to later health, health literacy, health behaviours and longevity. Accordingly, a lower CA is expected to be associated with poorer adherence to medication. We investigated the long-term role of CA in adherence to prescribed statins in male patients after a first myocardial infarction (MI). Methods CA was estimated at 18-20 years of age from Military Conscript Register data for first MI male patients (≤60 years) and was related to the one- and two-year post-MI statin adherence on average 30 years later. Background and clinical data were retrieved through register linkage with the unselected national quality register SWEDEHEART for acute coronary events (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) and secondary prevention (Secondary Prevention after Heart Intensive Care Admission). Previous and present statin prescription data were obtained from the Prescribed Drug Register and adherence was calculated as ≥80% of prescribed dispensations assuming standard dosage. Logistic regression was used to estimate crude and adjusted associations. The primary analyses used 2613 complete cases and imputing incomplete cases rendered a sample of 4061 cases for use in secondary (replicated) analyses. Results One standard deviation increase in CA was positively associated with both one-year (OR 1.15 (CI 1.01-1.31), P < 0.05) and two-year (OR 1.14 (CI 1.02-1.27), P < 0.05) adherence to prescribed statins. Only smoking attenuated the CA-adherence association after adjustment for a range of > 20 covariates. Imputed and complete case analyses yielded very similar results. Conclusions CA estimated on average 30 years earlier in young adulthood is a risk indicator for statin adherence in first MI male patients aged ≤60 years. Future research should include older and female patients and more socioeconomic variables.

Background: Although South Asians experience cardiovascular disease (CVD) and risk factors at an early age, the distribution of CVD risks across the socioeconomic spectrum remains unclear., Methods: We analysed the 2011 Centre for Cardiometabolic Risk Reduction in South Asia survey data including 16,288 non-pregnant adults (≥20 years) that are representative of Chennai and Delhi, India, and Karachi, Pakistan. Socioeconomic status (SES) was defined by highest education (primary schooling, high/secondary schooling, college graduate or greater); wealth tertiles (low, middle, high household assets) and occupation (not working outside home, semi/unskilled, skilled, white-collar work). We estimated age and sex-standardized prevalence of behavioural (daily fruit/vegetables; tobacco use), weight (body mass index; waist-to-height ratio) and metabolic risk factors (diabetes, hypertension, hypercholesterolaemia; hypo-HDL; and hypertriglyceridaemia) by each SES category., Results: Across cities, 61.2% and 16.1% completed secondary and college educations, respectively; 52.8% reported not working, 22.9% were unskilled; 21.3% were skilled and 3.1% were white-collar workers. For behavioural risk factors, low fruit/vegetable intake, smoked and smokeless tobacco use were more prevalent in lowest education, wealthy and occupation (for men only) groups compared to higher SES counterparts, while weight-related risks (body mass index 25.0-29.9 and ≥30 kg/m(2); waist-to-height ratio ≥0.5) were more common in higher educated and wealthy groups, and technical/professional men. For metabolic risks, a higher prevalence of diabetes, hypertension and dyslipidaemias was observed in more educated and affluent groups, with unclear patterns across occupation groups., Conclusions: SES-CVD patterns are heterogeneous, suggesting customized interventions for different SES groups may be warranted. Different behavioural, weight, and metabolic risk factor prevalence patterns across SES indicators may signal on-going epidemiological transition in South Asia., (© The European Society of Cardiology 2015.)

Aims: We aimed to clarify the associations of high-density lipoprotein cholesterol (HDL-C) subclasses with incident coronary heart disease (CHD) in two large primary prevention cohorts., Methods: We measured cholesterol at baseline from the two major HDL subfractions (larger, more buoyant HDL2 and smaller, denser HDL3) separated by density gradient ultracentrifugation in 4114 (mean age 53.8 years; 64% female) African American participants from the Jackson Heart Study and 818 (mean age 57.3 years, 52% female) predominantly Caucasian participants from the Framingham Offspring Cohort Study. Multivariable adjusted hazard ratios (HRs) for HDL-C and its subclasses were derived from Cox proportional hazards regression models to estimate associations with incident CHD events including myocardial infarction, CHD death, and revascularization. Analyses were performed for each cohort separately and as a combined population., Results: In models adjusted for cardiovascular risk factors for the combined population, HDL3-C (HR 0.76 per SD increase; 95% confidence interval (CI), 0.62-0.94; p = 0.01), rather than HDL2-C (HR 0.88 per SD; 95% CI, 0.72-1.09; p = 0.24) drove the inverse association of HDL-C (HR 0.79 per SD; 95% CI, 0.64-0.98; p = 0.03) with CHD. Similar associations were seen in multivariable analyses within each cohort including after adjusting for apolipoprotein A1 in the Jackson Heart Study., Conclusion: Smaller, denser HDL3-C levels are primarily responsible for the inverse association between HDL-C and incident CHD in this diverse group of primary prevention subjects. These findings have important implications ranging from considerations of HDL biology to interpretations of clinical trials utilizing HDL-C therapeutics., (© The European Society of Cardiology 2014.)

Aims: Analyses using conventional statistical methodologies have yielded conflicting results as to whether low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non-HDL-C) or apolipoprotein B (apoB) is the best marker of the apoB-associated risk of coronary heart disease. The aim of this study was to determine the additional value of apoB beyond LDL-C or non-HDL-C as a predictor of coronary heart disease., Methods and Results: For each patient from the Framingham Offspring Cohort aged 40-75 years (n = 2966), we calculated the extent to which the observed apoB differed from the expected apoB based on their LDL-C or non-HDL-C. We added this difference to a Cox model predicting new onset coronary heart disease over a maximum of 20 years adjusting for standard risk factors plus LDL-C or non-HDL. The difference between observed and expected apoB over LDL-C or non-HDL-C was highly prognostic of future coronary heart disease events: adjusted hazard ratios 1.26 (95% confidence interval: 1.15, 1.37) and 1.20 (1.11, 1.29), respectively, for each standard deviation increase beyond expected apoB levels. When this difference between observed and expected apoB was added to standard coronary heart disease prediction models including LDL-C or non-HDL-C, prediction improved significantly (likelihood ratio test p-values <0.0001) and discrimination c-statistics increased from 0.72 to 0.73. The corresponding relative integrated discrimination improvements were 11% and 8%, respectively., Conclusions: apoB improves risk assessment of future coronary heart disease events over and beyond LDL-C or non-HDL-C, which is consistent with coronary risk being more closely related to the number of atherogenic apoB particles than to the mass of cholesterol within them., (© The European Society of Cardiology 2015.)

Background: Studies investigating the relation between risk profiles and cardiovascular disease have measured risk at baseline only. We investigated maintenance and changes of risk profiles over time and their potential impact on incident cardiovascular disease., Design: Population-based cohort study., Methods: Risk factors were measured at baseline (1987-1991) among 5574 cardiovascular disease-free adults aged 20-59 years. They were classified into four risk categories according to smoking status, presence of diabetes and widely accepted cut-off values for blood pressure, total cholesterol/HDL-ratio and body mass index. Categories were subdivided (maintenance, deterioration, improvement) based on risk factor levels at six and 11 years of follow-up. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for cardiovascular disease incidence 5-10 years following the risk-change period were fitted using Cox proportional hazards models., Results: Only 12% of participants were low risk at baseline, and only 7% maintained it. Participants who maintained a low risk profile over 11 years had seven times lower risk of cardiovascular disease (HR: 0.14, 95% CI: 0.05-0.41) than participants with long-term high risk profile, whereas those low risk at baseline whose profile deteriorated had three times lower risk (HR: 0.36, 95% CI: 0.18-0.71). Our results suggest that, within each baseline risk profile group, compared with a stable profile, improving profiles may be associated with up to two-fold lower HRs, and deteriorating profiles with about two-fold higher HRs., Conclusions: Our study, using long-term risk profiles, demonstrates the full benefits of low risk profile. These findings underscore the importance of achieving and maintaining low risk from young adulthood onwards., (© The European Society of Cardiology 2014.)

Background: Surveillance of and monitoring trends for cardiovascular diseases and risk factors are relevant when we consider that these diseases and conditions are largely preventable. The aim of this paper is to assess time trends of cardiovascular diseases, lifestyles, risk factors and high risk conditions in different socioeconomic levels., Methods: Paired but independent population samples of men and women aged 35-74 years located in all 20 Italian regions were examined in 1998-2002 (n = 9612) and in 2008-2012 (n = 8141). Time trends of lifestyles, cardiovascular risk factors, prevalence of high-risk conditions and cardiovascular diseases are shown for two different socioeconomic levels, as assessed by educational level., Results: Over 10 years, in both genders and socioeconomic classes, the prevalence of smoking decreased (from 32% to 23% in men) as well as mean levels of blood pressure (systolic from 136 mmHg to 133 mmHg in men and from 132 mmHg to 127 mmHg in women), while the prevalence of dyslipidemia and obesity increased reaching 35% and 25% of the population respectively; the prevalence of myocardial infarction remained stable (1.6% in men; about 0.5% in women), that of stroke decreased in men (from 1.2% to 0.7%); the prevalence of diabetes did not change (12% in men; 8% in women). In the low educational class, cardiovascular risk factors and diseases remained unfavourable compared with the high educational class., Conclusions: The burden of cardiovascular diseases and their risk factors remain high and require continuous appropriate action at the community and individual levels, as suggested by the European Guidelines for Cardiovascular Prevention., (© The European Society of Cardiology 2015.)

Background: Cardiac rehabilitation (CR) is an evidence-based recommendation for patients with coronary artery disease (CAD). However, CR is dramatically underutilized. Telehealth interventions have the potential to overcome barriers and may be an innovative model of delivering CR. This review aimed to determine the effectiveness of telehealth intervention delivered CR compared with center-based supervised CR., Method: Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library and the Chinese BioMedical Literature Database (CBM), were searched to April 2014, without language restriction. Existing randomized controlled trials, reviews, relevant conference lists and gray literature were checked. Randomized controlled trials that compared telehealth intervention delivered CR with traditional center-based supervised CR in adults with CAD were included. Two reviewers selected studies and extracted data independently. Main clinical outcomes including clinical events, modifiable risk factors or other endpoints were measured., Results: Fifteen articles reporting nine trials were reviewed, most of which recruited patients with myocardial infarction or revascularization. No statistically significant difference was found between telehealth interventions delivered and center-based supervised CR in exercise capacity (standardized mean difference (SMD) -0.01; 95% confidence interval (CI) -0.12-0.10), weight (SMD -0.13; 95% CI -0.30-0.05), systolic and diastolic blood pressure (mean difference (MD) -1.27; 95% CI -3.67-1.13 and MD 1.00; 95% CI -0.42-2.43, respectively), lipid profile, smoking (risk ratio (RR) 1.03; 95% CI 0.78-1.38), mortality (RR 1.15; 95% CI 0.61-2.19), quality of life and psychosocial state., Conclusions: Telehealth intervention delivered cardiac rehabilitation does not have significantly inferior outcomes compared to center-based supervised program in low to moderate risk CAD patients. Telehealth intervention offers an alternative deliver model of CR for individuals less able to access center-based cardiac rehabilitation. Choices should reflect preferences, anticipation, risk profile, funding, and accessibility to health service., (© The European Society of Cardiology 2014.)

Background: Metabolic syndrome (MetS) remains a controversial entity. Specific clusters of MetS components - rather than MetS per se - are associated with accelerated arterial ageing and with cardiovascular (CV) events. To investigate whether the distribution of clusters of MetS components differed cross-culturally, we studied 34,821 subjects from 12 cohorts from 10 European countries and one cohort from the USA in the MARE (Metabolic syndrome and Arteries REsearch) Consortium., Methods: In accordance with the ATP III criteria, MetS was defined as an alteration three or more of the following five components: elevated glucose (G), fasting glucose ≥110 mg/dl; low HDL cholesterol, < 40mg/dl for men or <50 mg/dl for women; high triglycerides (T), ≥150 mg/dl; elevated blood pressure (B), ≥130/≥85 mmHg; abdominal obesity (W), waist circumference >102 cm for men or >88 cm for women., Results: MetS had a 24.3% prevalence (8468 subjects: 23.9% in men vs. 24.6% in women, p < 0.001) with an age-associated increase in its prevalence in all the cohorts. The age-adjusted prevalence of the clusters of MetS components previously associated with greater arterial and CV burden differed across countries (p < 0.0001) and in men and women (p < 0.0001). In details, the cluster TBW was observed in 12% of the subjects with MetS, but was far more common in the cohorts from the UK (32.3%), Sardinia in Italy (19.6%), and Germany (18.5%) and less prevalent in the cohorts from Sweden (1.2%), Spain (2.6%), and the USA (2.5%). The cluster GBW accounted for 12.7% of subjects with MetS with higher occurrence in Southern Europe (Italy, Spain, and Portugal: 31.4, 18.4, and 17.1% respectively) and in Belgium (20.4%), than in Northern Europe (Germany, Sweden, and Lithuania: 7.6, 9.4, and 9.6% respectively)., Conclusions: The analysis of the distribution of MetS suggested that what follows under the common definition of MetS is not a unique entity rather a constellation of cluster of MetS components, likely selectively risky for CV disease, whose occurrence differs across countries., (© The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Dyslipidaemia has been recognized as a major risk factor for cardiovascular diseases. Our objectives were to conduct a systematic review and meta-analysis of published studies to determine the prevalence of dyslipidaemia among hospitalized adult patients with cardiovascular disease in sub-Saharan Africa and to compare between the various cardiovascular disease types. We searched Internet-based search tools and other sources for studies on dyslipidaemia or hypercholesterolaemia among hospitalized adult patients with established cardiovascular disease in sub-Saharan Africa, from 1985 to May 2011. Established cardiovascular disease was defined as ischaemic heart disease, heart failure, stroke or chronic kidney disease. We then assessed for between-study heterogeneity and carried out sensitivity analyses. Study quality was assessed using Downs and Black Checklist and publication bias was considered present when positive in both Egger's and Begg's tests. Restricted analyses were then performed on data from studies on ischaemic heart disease, heart failure and stroke separately. A total of 451 studies were screened and eventually 16 studies were included with a total of 2584 persons. The overall estimate of dyslipidaemia was 38.38% (95% confidence intervals = 26.75-50.0; I(2 )= 96.878; p < 0.001). The prevalence was highest among those with ischaemic heart disease (49.64%) than among those with stroke (26.53%) or heart failure (15.4%; p-values for all comparisons<0.001). Prevalence of dyslipidaemia in subjects with cardiovascular disease including ischaemic heart disease, stroke and heart failure in sub-Saharan Africa was high and similar to what was obtained in Western Europe and North America; highest in subjects with ischaemic heart disease, followed by those with stroke and heart failure., (© The European Society of Cardiology 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: The association of insulin resistance (IR) with other cardiometabolic risk (CMR) factors in sub-Saharan Africans is poorly documented. This study examined the links between IR and the evolution of blood pressure (BP), glycaemia, serum lipids and abdominal obesity in the population of Benin., Design: Population-based longitudinal study., Methods: This study initially included 541 apparently healthy Beninese adults (50% women) aged 25-60 years who were randomly selected in a large city, a small town and a rural area. After a baseline survey, our subjects were followed up after 2 years, and again at 4 years. IR based on homeostasis model assessment (HOMA), blood glucose, BP, waist circumference (WC), triglycerides, total cholesterol and HDL-cholesterol were measured. Complete data at the end of the follow-up periods was available for 416 subjects., Results: IR was more prevalent in women than in men (33.2% versus 17.8%) and it was generally associated with more adverse values of CMR factors, excepting BP. In controlling for baseline age, sex, WC, diet, lifestyle variables and WC changes; the relative risk (RR) of hyperglycemia over 4 years was as least 3-fold in IR subjects, compared to normal subjects. The RR of abdominal obesity was 5.3 (1.04-26.93) in IR women, compared to non-IR. The association of IR with the evolution of dyslipidemia was inconsistent, but IR tended to exacerbate low HDL-cholesterol., Conclusion: Over 4 years, IR exacerbated hyperglycemia in both men and women, and abdominal obesity in women, but IR did not affect blood pressure. Further research on the link found between IR and dyslipidemia, particularly low HDL-C, is needed in sub-Saharan Africa.

Background: Cardiac rehabilitation programmes are strongly recommended for all forms of coronary artery disease to reduce recurrent events and mortality. Few patients seem to participate in these programmes after elective percutaneous coronary intervention (PCI). The aim of this study was to assess changes in lifestyle and risk factors after PCI for patients with stable disease and not included in cardiac rehabilitation programmes., Methods: We prospectively enrolled 207 consecutive patients with stable disease who underwent a first elective PCI. Follow up was performed at 13.0 ± 3.2 months for 94.7%; 28 patients were excluded due to participation in a cardiac rehabilitation programme. Baseline values from admission sheets were compared to follow up values collected from the treating physician., Results: At follow up, systolic and diastolic blood pressures dropped (p = 0.001) as well as the prevalence of hypertension (p < 0.001). Significant reductions in cholesterol (p < 0.001) and blood glucose (p = 0.004) were also noted. Low-density lipoprotein levels stayed outside target in 47.2% and high-density lipoprotein levels in 75.0% of patients initially presenting with lipid disorders. Obesity prevalence remained high at follow up. Only 45.6% were performing regular physical exercise and 8.3% of smokers quit smoking. Only 13.3% attended any form of dietary advice programme. HADS-A score was 5.1 ± 3.9 and the HADS-D score was 3.8 ± 3.6. SF 36 questionnaire revealed a good quality of life with a mean value of 45.6 for physical and 42.9 for mental wellbeing., Conclusion: A considerable percentage of patients receiving PCI for stable angina do not achieve lifestyle and risk factor goals and therefore remain at increased risk for recurrent events. Efforts should be initiated to better implement guidelines that strongly recommend secondary prevention through cardiac rehabilitation after elective PCI.

Background: Type D personality is associated with an increased morbidity and mortality risk in cardiovascular disease patients, but the mechanisms explaining this risk are unclear. We examined whether Type D was associated with coronary artery disease (CAD) risk factors, estimated risk of developing CAD, and previous cardiac events., Design: Cross-sectional study in the general Icelandic population., Methods: A random sample of 4753 individuals (mean age 49.1 ± 12.0 years; 49% men) from the REFINE-Reykjavik study completed assessments for Type D personality and conventional CAD risk factors. Ten-year risk of developing CAD was estimated with the Icelandic risk calculator., Results: Type D personality (22% of sample) was associated with a higher prevalence of hypertension (35 vs. 31%, p = 0.009), but less use of hypertension medication (58 vs. 65%, p = 0.013) in hypertensives, more diabetes (6 vs. 4%, p = 0.023), wider waist circumference (p = 0.007), and elevated body mass index (p = 0.025) and blood lipids (p < 0.05). Type D individuals reported less physical exercise (p = 0.000) and more current (26 vs. 21%, p = 0.003) and former smoking (48 vs. 44%, p = 0.036). Estimates of 10-year risk of CAD were higher in Type D individuals (12.4%, 95% CI 1.9 to 23.8%), and Type Ds reported more previous cardiac events than non-Type Ds (5 vs. 3%, p < 0.01; OR 1.71, 95% CI 1.21 to 2.42)., Conclusions: In the general Icelandic population, Type D personality was associated with differences in lifestyle-related CAD risk factors, a higher estimated risk of developing CAD, and higher incidence of previous cardiac events. Unhealthy lifestyles may partly explain the adverse cardiovascular effect of Type D personality.

Background: Urban middle-socioeconomic status (SES) subjects have high burden of cardiovascular risk factors in low-income countries. To determine secular trends in risk factors among this population and to correlate risks with educational status we performed epidemiological studies in India., Methods: Five cross-sectional studies were performed in middle-SES urban locations in Jaipur, India from years 1992 to 2010. Cluster sampling was performed. Subjects (men, women) aged 20-59 years evaluated were 712 (459, 253) in 1992-94, 558 (286, 272) in 1999-2001, 374 (179, 195) in 2002-03, 887 (414, 473) in 2004-05, and 530 (324, 206) in 2009-10. Data were obtained by history, anthropometry, and fasting blood glucose and lipids estimation. Response rates varied from 55 to 75%. Mean values and risk factor prevalence were determined. Secular trends were identified using quadratic and log-linear regression and chi-squared for trend., Results: Across the studies, there was high prevalence of overweight, hypertension, and lipid abnormalities. Age- and sex-adjusted trends showed significant increases in mean body mass index (BMI), fasting glucose, total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides (quadratic and log-linear regression, p < 0.001). Systolic blood pressure (BP) decreased while insignificant changes were observed for waist-hip ratio and low-density lipoprotein (LDL) cholesterol. Categorical trends showed increase in overweight and decrease in smoking (p < 0.05); insignificant changes were observed in truncal obesity, hypertension, hypercholesterolaemia, and diabetes. Adjustment for educational status attenuated linear trends in BMI and total and LDL cholesterol and accentuated trends in systolic BP, glucose, and HDL cholesterol. There was significant association of an increase in education with decline in smoking and an increase in overweight (two-line regression p < 0.05)., Conclusion: In Indian urban middle-SES subjects there is high prevalence of cardiovascular risk factors. Over a 20-year period BMI and overweight increased, smoking and systolic BP decreased, and truncal obesity, hypercholesterolaemia, and diabetes remained stable. Increasing educational status attenuated trends for systolic BP, glucose and HDL cholesterol, and BMI.

Background: Knowledge of the hypertensive patient's characteristics is an important aspect to improve its clinical handling. Because of the burden that the patients of advanced age suppose in primary care, few data exist about the youngest patient's cardiovascular profile., Objective: To describe the cardiovascular profile of the young hypertensive patient (<55 years) in primary care in Spain., Design and Methods: Cross-sectional multicentre study that was carried out in centres of primary care of the whole Spanish territory. At total of 2108 doctors participated and 6815 patients diagnosed with high blood pressure were included. We used a survey of risk factors, subclinical organ damage, and cardiovascular or renal established disease according to the European Society of Hypertension and the European Society of Cardiology 2007 guidelines to evaluate the cardiovascular risk., Results: Of the hypertensive patients, 5.8% did have not another cardiovascular risk factor (CVRF), 23.2% had one risk factor associated with high blood pressure, 32.8% two, 24.7% three, 11.3% four, and 2.3% had five risk factors. The most prevalent cardiovascular risk factor was dyslipidaemia, found in 80.4% (37.9% with treatment), followed by abdominal obesity, in 45.9% of the hypertensive patients. The prevalence of metabolic syndrome was 44.4%. The cardiovascular risk was average in 0.2% of the sample, low in 5%, moderate in 26.1%, high in 47.3%, and very high in 21.4%., Conclusions: Our study demonstrates that newly diagnosed young hypertensive patients have an intense association of CVRF and a high cardiovascular risk.

Aims: To investigate changes in cardiovascular risk factors over 14 years in relation to diabetes status., Methods: The study is based on 10,327 subjects who attended the Tromsø Study in 1994 and were screened again in 2007-8. At baseline there were 79 prevalent cases, and 397 incident cases of type 2 diabetes mellitus (DM2) were diagnosed between 1994 and 2008., Results: Cases with DM2 had decreasing levels of high-density lipoprotein cholesterol (HDL-C), total cholesterol and blood pressure (BP) and increasing levels of triglycerides, body mass index (BMI), and anti-hypertensive treatment during 14 years of follow-up. Despite decreasing BP, more than 75% of the treated cases had BP above 135/80 at the end of follow-up. Similarly, less than 35% of incident cases using statins had low-density lipoprotein cholesterol (LDL-C) below the recommended threshold value of 2.6 mmol/l., Conclusions: Despite greater relative reduction in cardiovascular risk factors among people with DM2 compared to those without, treatment targets were met in less than 50% of subjects with DM2. Thirteen percent reached the combined targets for glucose, BP and LDL-C control. This indicates a need for more effective strategies to control cardiovascular risk factors especially among individuals with DM2.