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Background and Aim: To study the relationships of an Atherogenicity Index (ATI) and a Thrombogenicity Index (THI), with 50-year mortality from coronary heart disease (CHD), other heart diseases of uncertain etiology (HDUE) and cerebrovascular disease or stroke (STR), in 16 international cohorts of middle-aged men., Methods and Results: Foods from a dietary survey in subsamples of men in each cohort of the Seven Countries Study (SCS) were chemically analyzed for several types of fatty acids that were converted into ATI and THI identifying each of 16 cohorts. Ecological correlations of the ATI and THI were calculated with the three fatal CVD conditions and with all-cause mortality at 25 and 50 years. Correlation coefficients (Rs) were positive and highly significant between ATI and THI versus CHD mortality, with levels ranging from 0.79 to 0.97, depending on the duration of follow-up and the choice of 10 or of 16 cohorts. This was not the case for HDUE and STR mortality for which Rs were variable and not significant. A strong direct association was also found with all-causes deaths at 25 and 50-years. ATI and THI were also directly related with dietary saturated fat and cholesterol levels and inversely with the Mediterranean Adequacy Index (a score identifying the Mediterranean diet)., Conclusion: These findings indicate that CHD has a different relationship with dietary lipids intake than HDUE and STR. This suggests that HDUE and STR have different underlying pathways or are different diseases., (Copyright © 2024 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Objectives: The aim of this study was to describe and interpret differences in major cardiovascular disease (CVD) mortality during 60 years between Northern European and Southern European cohorts of the Seven Countries Study of Cardiovascular Diseases., Material and Methods: Northern Europe included two cohorts from Finland and one from the Netherlands, and Southern Europe included two cohorts from Italy and two from Greece, for a total of 2360 and 2792 CVD-free men, respectively, at entry examination. Coronary heart disease (CHD), STROKE and other Heart Diseases of Uncertain Etiology (HDUE) deaths were the outcomes and Cox models were solved separately based on 12 risk factors., Results: In 60 years, overall death rates were 99.8% in both Northern and Southern Europe and the pooled CVD rates were 46.9% (significantly higher) and 42.2%, respectively: CHD mortality was higher in Northern Europe, whereas STROKE and HDUE mortality were higher in Southern Europe. Significant Cox coefficients for both areas (but not significantly different between areas) were age, smoking habits, SBP and serum cholesterol for CHD, and only age and SBP did so for STROKE and HDUE. Age at death was lower for CHD, intermediate for STROKE and higher for HDUE in both areas., Conclusion: The advantage for Southern Europe was small in terms of overall CVD death rates, but definitely larger in terms of expectancy of life due to the differences in age at death in the three types of CVD mortality. Mean entry levels of serum cholesterol, 50 mg/dl higher in Northern Europe than in Southern Europe are a major culprit of these outcomes., (Copyright © 2022 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Aims: In patients with coronary heart disease (CHD), we investigated whether it is possible to accurately assess the probability of short-term control of risk factors (blood pressure, cholesterol, smoking) based on individual and large-area residential characteristics., Methods and Results: We merged individual data of participants from EUROASPIRE V who were hospitalized for CHD (2014-2017) and interviewed and examined for risk factor control (2016-2017), with large-area residential data provided by Eurostat for Nomenclature of Territorial Units for Statistics (NUTS) regions using postal codes. Data from 2562 CHD patients in 16 countries were linked to data from 60 NUTS 2 and 121 NUTS 3 regions. The median time between hospitalization and interview was 14 months. We developed prediction models to assess the probability of risk factor control at interview using data from the time of hospitalization: (i) baseline models including 35 variables on patients' demographic, clinical, and socio-economic characteristics and (ii) extended models additionally considering nine variables on large-area residential characteristics. We calculated and internally validated c-indices to assess the discriminative ability of prediction models. Baseline models showed good discrimination with c-indices of 0.69, 0.70, and 0.76 for blood pressure control, cholesterol control, and smoking cessation, respectively. Extended models for blood pressure, cholesterol, and smoking yielded improved c-indices of 0.72, 0.71, and 0.78, respectively., Conclusion: Our results indicate that the probability of risk factor control in CHD patients can be accurately assessed using individual and large-area residential characteristics, allowing for an identification of patients who are less likely to achieve risk factor targets., Competing Interests: Conflict of interest: K.K. had research grant support from the European Society of Cardiology (paid to the Imperial College London). K.S.M. had a doctoral fellowship from the German Heart Foundation. All other authors declare that there is no conflict of interest., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background and Aims: Alcohol consumption is an important risk factor for cardiovascular morbidity and mortality worldwide. The highest levels of alcohol consumption are observed in Europe, where alcohol as contributing cause of coronary heart disease (CHD) is also most significant. We aimed to describe alcohol consumption patterns across European regions and adherence to the current guidelines in patients with a recent CHD event., Methods: The ESC-EORP survey (EUROASPIRE V) has been conducted in 2016-2017 at 131 centers in 27 European countries in 7350 patients with a recent CHD. Median alcohol consumption, as well as the proportion of abstainers and excessive drinkers (i.e. >70 g/week for women and >140 for men, as recommended by the European guidelines on cardiovascular prevention), was calculated for each region. To assess adherence to guidelines, proportions of participants who were advised to reduce excessive alcohol consumption and participants who were incorrectly not advised were calculated per region., Results: Mean age was 64 years (SD: 9.5), 75% were male. Abstention rates were 53% in males and 77% in females, whereas excessive drinking was reported by 9% and 5% of them, respectively. Overall, 57% of the participants were advised to reduce alcohol consumption. In the total population, 3% were incorrectly not advised, however, this percentage differed per region (range: 1%-9%). In regions where alcohol consumption was highest, participants were less often advised to reduce their consumption., Conclusion: In this EUROASPIRE V survey, the majority of CHD patients adhere to the current drinking guidelines, but substantial heterogeneity exists between European regions., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background and Aim: The association of serum cholesterol levels with the occurrence of coronary heart disease (CHD) mortality during a follow-up of 50 years was rarely investigated previously. Thus, we took advantage of results at hand in 10 pooled cohorts of men aged 40-59 years from the Seven Countries Study (9063 individuals and 2057 CHD fatal events) and we assessed this., Methods and Results: Cox proportional hazards models were run with CHD fatal events (as dependent variable) and cholesterol levels (as independent variables) at years 0, 10, and 25 (in 5 cohorts). Cumulative events during subsequent decades (cumulative approach: CA) and separately in each subsequent decade (partitioned approach: PA) were analyzed. The ecological correlation of average baseline serum cholesterol levels with CHD mortality was very high (R = 0.97). Serum cholesterol and CHD mortality for 50 years were associated at the individual level, and the association estimated by the Cox's coefficients (and related hazards ratios) was initially strong in both CA and PA, but slightly declined during later decades. Hazards ratios (for a difference of 40 mg/dl) ranged from 1.39 to 1.20 for CA and from 1.39 to 0.80 for PA. Coefficients were larger for CA than for PA and the decline was more evident for the latter. Partitioned coefficient became negative and significant in the last decade (from year 40-50). Coefficients derived from cholesterol levels measured at year 10 of follow-up showed similar trends but their magnitude was smaller., Conclusion: Thus, the relationship of serum cholesterol levels with CHD mortality remained relatively stable during at least 40 years after a single cholesterol measurement at baseline in middle-aged men., (Copyright © 2020 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Background and Aims: Despite the proven evidence of high glycemic index (GI) and glycemic load (GL) diets to increase cardiometabolic risks, knowledge about the meta-evidence for carbohydrate quality within world geographic regions is limited. We conducted a meta-analysis to synthesize the evidence of GI/GL studies and carbohydrate quality, gathering additional exposures for carbohydrate, high glycemic carbohydrate, total dietary fiber, and cereal fiber and risks for type 2 diabetes (T2DM), coronary heart disease (CHD), stroke, and mortality, grouped into the US, Europe, and Asia. Secondary aims examined cardiometabolic risks in overweight/obese individuals, by sex, and dose-response dietary variable trends., Methods and Results: 40-prospective observational studies from 4-Medline bibliographical databases (Ovid, PubMed, EBSCOhost, CINAHL) were search up to November 2019. Random-effects hazard ratios (HR) and 95% confidence intervals (CI) for highest vs. lowest categories and continuous form combined were reported. Heterogeneity (I 2 >50%) was frequent in US GI/GL studies due to differing study characteristics. Increased risks ((HR GI,T2DM,US =1.14;CI:1.06,1.21), HR GL,T2DM,US =1.02 (1.01, 1.03)), HR GI,T2DM,Asia =1.25;1.02,1.53), and HR GL,T2DM,Asia =1.37 (1.17, 1.60)) were associated with cardiometabolic diseases. GI/GL in overweight/obese females had the strongest magnitude of risks in US-and Asian studies. Total dietary fiber (HR T2DM,US  = 0.92;0.88,0.96) and cereal fiber (HR T2DM,US  = 0.83;0.77,0.90) decreased risk of developing T2DM. Among females, we found protective dose-response risks for total dietary fiber (HR 5g-total-dietary-fiber,T2DM,US  = 0.94;0.92,0.97) , but cereal fiber showed better ability to lower T2DM risk (HR 5g-cereal-fiber , T2DM,US  = 0.67;0.60,0.74). Total dietary-and cereal fibers' dose-response effects were nullified by GL, but not so for cereal fiber with GI., Conclusions: Overweight/obese females could shift their carbohydrate intake for higher cereal fiber to decrease T2DM risk, but higher GL may cancel-out this effect., Competing Interests: Declaration of Competing Interest All authors declare no competing conflicts of interests., (Copyright © 2020 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Background: DNA methylation is implicated in coronary heart disease (CHD), but current evidence is based on small, cross-sectional studies. We examined blood DNA methylation in relation to incident CHD across multiple prospective cohorts., Methods: Nine population-based cohorts from the United States and Europe profiled epigenome-wide blood leukocyte DNA methylation using the Illumina Infinium 450k microarray, and prospectively ascertained CHD events including coronary insufficiency/unstable angina, recognized myocardial infarction, coronary revascularization, and coronary death. Cohorts conducted race-specific analyses adjusted for age, sex, smoking, education, body mass index, blood cell type proportions, and technical variables. We conducted fixed-effect meta-analyses across cohorts., Results: Among 11 461 individuals (mean age 64 years, 67% women, 35% African American) free of CHD at baseline, 1895 developed CHD during a mean follow-up of 11.2 years. Methylation levels at 52 CpG (cytosine-phosphate-guanine) sites were associated with incident CHD or myocardial infarction (false discovery rate<0.05). These CpGs map to genes with key roles in calcium regulation (ATP2B2, CASR, GUCA1B, HPCAL1), and genes identified in genome- and epigenome-wide studies of serum calcium (CASR), serum calcium-related risk of CHD (CASR), coronary artery calcified plaque (PTPRN2), and kidney function (CDH23, HPCAL1), among others. Mendelian randomization analyses supported a causal effect of DNA methylation on incident CHD; these CpGs map to active regulatory regions proximal to long non-coding RNA transcripts., Conclusion: Methylation of blood-derived DNA is associated with risk of future CHD across diverse populations and may serve as an informative tool for gaining further insight on the development of CHD.

Background: Recent studies suggest that circulating concentrations of specific ceramide species may be associated with coronary risk and mortality. We sought to determine the relations between the most abundant plasma ceramide species of differing acyl chain lengths and the risk of coronary heart disease (CHD) and mortality in community-based samples., Methods and Results: We developed a liquid chromatography/mass spectrometry assay to quantify plasma C24:0, C22:0, and C16:0 ceramides and ratios of these very-long-chain/long-chain ceramides in 2642 FHS (Framingham Heart Study) participants and in 3134 SHIP (Study of Health in Pomerania) participants. Over a mean follow-up of 6 years in FHS, there were 88 CHD and 90 heart failure (HF) events and 239 deaths. Over a median follow-up time in SHIP of 5.75 years for CHD and HF and 8.24 years for mortality, there were 209 CHD and 146 HF events and 377 deaths. In meta-analysis of the 2 cohorts and adjusting for standard CHD risk factors, C24:0/C16:0 ceramide ratios were inversely associated with incident CHD (hazard ratio per average SD increment, 0.79; 95% confidence interval, 0.71-0.89; P <0.0001) and inversely associated with incident HF (hazard ratio, 0.78; 95% confidence interval, 0.61-1.00; P =0.046). Moreover, the C24:0/C16:0 and C22:0/C16:0 ceramide ratios were inversely associated with all-cause mortality (C24:0/C16:0: hazard ratio, 0.60; 95% confidence interval, 0.56-0.65; P <0.0001; C22:0/C16:0: hazard ratio, 0.65; 95% confidence interval, 0.60-0.70; P <0.0001)., Conclusions: The ratio of C24:0/C16:0 ceramides in blood may be a valuable new biomarker of CHD risk, HF risk, and all-cause mortality in the community., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Familial hypercholesterolaemia (FH) is a hereditary disorder predisposing to premature coronary heart disease (CHD) and is until now mainly diagnosed clinically on the basis of a classical phenotype. Its prevalence varies and is estimated around 1 in 200-500; in patients with established CHD the prevalence is less well documented., Methods and Results: In EUROASPIRE IV data were collected in coronary patients from 24 European countries by means of a standardized interview, bioclinical examination and venous blood sampling. Potential FH was estimated using an adapted version of the Dutch Lipid Clinic Network Criteria. Among the 7044 patients eligible for analysis, the prevalence of potential FH was 8.3%; 7.5% in men and 11.1% in women. The prevalence was inversely related to age with a putative prevalence of 1:5 in those with CHD <50 yrs of age in both sexes. Even among women aged 70 the prevalence was 1:10. Irrespective of age and gender, prevalence differed substantially between European regions; potential FH patients were more likely to smoke, had higher triglycerides levels and their blood pressure was less well controlled. The use of cardioprotective drugs and the prevalences of diabetes, obesity and central obesity were similar., Conclusions: The prevalence of potential FH in coronary patients is high; the results underscore the need to promote identification of FH in CHD patients and to improve their risk factor profile., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The relationships were explored of some cardiovascular risk factors to typical (TYP) and atypical (ATYP) fatal coronary events (CHD)., Material and Methods: Thirteen cohorts of 40-59 year-old men of the Seven Countries Study were followed-up for 40 years (N = 9704 heart disease free subjects). Fatal TYP-CHD were classified when manifested as myocardial infarction, other acute coronary syndromes, angina pectoris and sudden death; and as ATYP-CHD when manifested only as heart failure or arrhythmia in the absence of other clear etiologies. Death rates were computed for single countries separately for TYP and ATYP and for different lengths of follow-up. Cox models included: age, smoking habits, systolic blood pressure (SBP), serum cholesterol (CHOL), forced expiratory volume in ¾ sec (FEV) and diabetes., Results: TYP-CHD was more common in North American and Northern European countries, while ATYP-CHD were more common in Southern and Eastern Europe. Age at death was 5 years greater for ATYP-CHD than for TYP-CHD. Cox models in the pool of 13 cohorts showed that coefficient for age was significantly larger for ATYP-CHD (hazard ratio, HR: 2.36; confidence intervals CI: 2.18 - 2.26) versus TYP-CHD (HR 1.50, CI 1.43-1.58) while coefficients for CHOL was larger and significant for TYP-CHD (HR 1.29, CI 1.22-1.35) but not for ATYP-CHD (HR 0.93, CI 0.85-1.03). SBP, smoking habits, FEV and diabetes all predicted both conditions almost equally., Conclusion: The different relationships of CHOL and age with the two types of fatal CHD suggest that the two groups of manifestations may belong to different diseases., (© 2013.)

Background: The European Heart SCORE model constitutes the basis for national guidelines for primary prevention and treatment of cardiovascular disease (CVD) in several European countries. The model estimates individuals' 10-year CVD mortality risks from age, sex, smoking status, systolic blood pressure, and total cholesterol level. The SCORE model, however, is not mathematically consistent and does not estimate all-cause mortality. Our aim is to modify the SCORE model to allow consistent estimation of both CVD-specific and all-cause mortality., Methods: Using a competing risk approach, we first re-estimated the cause-specific risk of dying from cardiovascular disease, and secondly we incorporated non-CVD mortality. Finally, non-CVD mortality was allowed to also depend on smoking status, and not only age and sex. From the models, we estimated CVD-specific and all-cause 10-year mortality risk, and the expected residual lifetime together with corresponding expected effects of statin treatment., Results: The modified model provided CVD-specific 10-year mortality risks similar to those of the European Heart SCORE model. Incorporation of non-CVD mortality increased 10-year mortality risks, in particular for older individuals. When non-CVD mortality was assumed unaffected by smoking status, the absolute risk reduction due to statin treatment ranged from 0.0% to 3.5%, whereas the gain in expected residual lifetime ranged from 3 to 11 months. Statin effectiveness increased for non-smokers and declined for smokers, when smoking was allowed to influence non-CVD mortality., Conclusion: The modified model provides mathematically consistent estimates of mortality risk and expected residual lifetime together with expected benefits from statin treatment.

Aim: To describe lifestyle and risk-factor management in patients attending cardiac rehabilitation programmes (CRPs) compared to those who do not., Design: A cross-sectional survey., Methods: The EUROASPIRE III survey was conducted in 76 centres in 22 European countries. Consecutive patients having had a coronary event or revascularization before the age of 80 were identified and interviewed at least 6 months after hospital admission., Results: 13,935 medical records were reviewed and 8845 patients interviewed (participation rate 73%); 44.8% of patients reported being advised to attend a CRP and of these 81.4% did so (36.5% of all patients). There were wide variations between countries and diagnostic categories, ranging from 15.9% in the Ischaemia group to 68.1% in the CABG group. Characteristics associated with participation in a CRP included younger age, male sex, higher educational level and CABG as a recruiting index event, while smokers were less likely to attend a CRP. Patients who attended a CRP had a significantly lower prevalence of smoking, better control of total and LDL-cholesterol and higher use of beta-blockers, ACE inhibitors/ARBs and lipid-lowering drugs., Conclusions: CRPs in Europe are underused, with poor referral and low participation rate and wide variations between countries. Despite this heterogeneity, the control of smoking and cholesterol and the use of cardioprotective medication is better in those who attend a CPR. There is an urgent need for comprehensive, multidisciplinary rehabilitation programmes to integrate professional lifestyle interventions with effective risk-factor management, appropriately adapted to the medical, cultural and economic settings of a country.

Background: Cardiovascular patients are likely to have an impaired health-related quality of life (HRQoL) due to functional and psycho-social limitations. The main objective of this study was to assess the distribution of HRQoL scores in coronary heart disease (CHD) patients across 22 European countries and to identify factors associated with the variation between patients., Methods: Data from the EUROASPIRE III survey (European Action on Secondary and Primary Prevention by Intervention to Reduce Events), on 8734 patients, were used. Patients with a diagnosis of CHD (coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), acute myocardial infarction (AMI) or myocardial ischemia) were interviewed and examined at least 6 months after their acute coronary event. Quality of life of each patient was measured using 2 standardized questionnaires: the EuroQoL-5D (EQ-5D) and the 12-item short-form health survey (SF-12v2)., Results: HRQoL values differed significantly across countries. Lower HRQoL estimates were found in women, older patients, less educated patients, patients with myocardial infarction or ischemia as recruiting diagnosis, patients with a history of stroke and patients who suffered from a recurring CHD event. In addition, HRQoL was significantly associated with current smoking, central obesity, lack of exercise and inappropriate HbA1c control in patients with diabetes. Furthermore the number of risk factors is inversely associated with HRQoL., Conclusion: Overall, a large heterogeneity was observed in HRQoL values between countries and patient groups. There seems to be a significant association between quality of life and patient characteristics with lifestyle risk factors as important determinants of HRQoL., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: The EUROASPIRE I, II and III surveys revealed high prevalences of modifiable risk factors in the high priority group of coronary patients all over Europe. The potential to further reduce coronary heart disease (CHD) morbidity and mortality rates is still considerable. We report here on the relative risk of cardiovascular disease (CVD) death associated with common modifiable risk factor levels based on the mortality follow-up of patients participating in the first two EUROASPIRE surveys. We also present a novel simple risk classification system (ERC) that can be used in the management of patients with existing CHD., Methods: The study cohort consisted of a consecutive sample of CHD patients aged ≤ 70 years from 12 European countries. Baseline data gathered in 1995-2000 through standardized methods, were linked to cardiovascular mortality in 5216 patients according to an accelerated failure time model., Results: During 28,143 person-years of follow-up, 332 patients died from cardiovascular disease denoting a CVD mortality risk of 12.3 per 1000 person-years in men and 10.2 per 1000 person-years in women. In multivariate analysis, fasting glucose, total cholesterol and smoking emerged as the strongest independent modifiable predictors of cardiovascular mortality., Conclusions: The results of the mortality follow-up of the EUROASPIRE I and II CHD patients emphasize the continuing risk from elevated glucose and total cholesterol levels and underline the importance of smoking cessation in secondary prevention. The ERC risk tool that we developed may prove helpful to obtain these goals in the setting of secondary prevention., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To investigate the validity and reliability of the EuroQol-5D (EQ-5D), the 12-item Short-Form Health Survey (SF-12v2), and the Hospital Anxiety and Depression Scale (HADS) in a stable coronary population., Study Design: Cross-sectional study EUROASPIRE III., Setting: Quality of life data (QoL) were available on 8745 patients hospitalized for coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), acute myocardial infarction (AMI), or myocardial ischemia. They were interviewed and examined at least 6 months after their hospital admission. Reliability and validity of the 3 instruments were tested. Internal consistency, and discriminative, convergent, criterion and construct validity were assessed., Results: Cronbach's alpha indicated good internal consistency for all measures (0.73 to 0.87). Discriminative validity analyses confirmed significant QoL differences between known groups: age, gender, educational level. In addition, all hypothesized correlations between QoL constructs (convergent validity) and items (criterion validity) were confirmed with significant correlations. Confirmatory factor analyses indicated good construct validity for HADS and SF-12v2. On country-specific level, results were roughly similar., Conclusion: The EQ-5D as well as the SF-12v2 and the HADS are reliable and valid instruments for use in a stable coronary population, both on aggregate European level and on country-specific level. However, our results must be generalized with caution, because EUROASPIRE III patients might not be representative for all patients with stable coronary heart disease., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The aim of this observational, multicenter study was to describe the outcome of very elderly patients undergoing percutaneous coronary intervention (PCI)., Background: There is a paucity of data among nonagenarians undergoing PCI., Methods: All consecutive patients 90 years of age or older undergoing PCI with stent implantation between April 2002 and June 2009 were included in the study. The primary endpoint was the long-term rate of net adverse cardiac events (NACE), that is, death, myocardial infarction (MI), target lesion revascularization, and life-threatening or major bleedings., Results: One hundred forty-six nonagenarians were divided in three groups according to clinical setting: 27 (group A) stable angina or silent ischemia, 85 (group B) unstable angina or non-ST elevation MI, and 34 (group C) with ST elevation MI (STEMI). At 30 days, the incidence of NACE was significantly lower in patients in Group A vs. B or C (0% vs. 17.3% vs. 31.2%, P = 0.006), and the frequency of definite stent thrombosis was higher in Group C vs. A or B (9.4% vs. 0% vs. 0%, P = 0.007), respectively. Up to a median follow-up of 24 months, NACE rate was 33.3% in group A, 49.3% in group B, and 50% in group C (P = 0.32). There were no significant differences between groups in the individual components of the primary endpoint., Conclusions: PCI in nonagenarians is safe and feasible with acceptable major bleeding rates. However, long-term results show high mortality rates particularly in the STEMI group., (Copyright © 2013 Wiley Periodicals, Inc.)

The EUROASPIRE audits of risk factor control have indicated that, even in those with established coronary heart disease, risk factor control remains poor. We therefore analysed the EUROASPRE III data set to establish the factors associated with success or failure in risk factor control in order to inform future risk factor management strategies. University education, attendance at a specialist cardiology clinic, and participation in a cardiac rehabilitation programme were associated with improved risk factor control. Risk factor control was poorer in women, those with diabetes, and those undergoing coronary artery bypass surgery as opposed to medical therapy or percutaneous coronary intervention. Increasing age, depression, and anxiety were not associated with poorer risk factor control.

Objective: To assess in coronary heart disease (CHD) patients: (1) differences in the prevalence of depression and anxiety between samples selected from 22 countries; (2) the association of depression and anxiety with age, education, diagnostic category, favourable behaviours, use of cardioprotective drugs, and reaching the secondary prevention treatment targets., Design: Cross-sectional study., Methods: The study group consisted of 8580 patients from 22 European countries examined at least 6 months after hospitalization due to CHD. Depression and anxiety were assessed using Hospital Anxiety and Depression Scale (HADS)., Results: Prevalence of depression (HADS depression score ≥ 8) varied from 8.2% to 35.7% in men and from 10.3% to 62.5% in women. Prevalence of anxiety (HADS anxiety score ≥ 8) varied from 12.0% to 41.8% in men and from 21.5% to 63.7% in women. Older age, female sex, low education, and no history of invasive treatment were associated with more frequent depression and anxiety. Depression and anxiety were associated with less frequent modification of lifestyle. Depression was related with body mass index, waist circumference, fasting glucose, and more frequent self-reported diabetes but not with reaching the treatment targets for blood pressure and lipids., Conclusions: High prevalence of depression and anxiety in CHD patients, and relation with less frequent lifestyle modification, call to integrate methods of identification and minimizing unfavourable effects of depression and anxiety into the cardiac rehabilitation and prevention programmes.

Renal disease is highly prevalent in people with type 2 diabetes, and co-existence with hypertension increases the risk of cardiac events and mortality. Despite many large randomized trials, controversies remain regarding optimal antihypertensive therapy in diabetic patients, including whether some classes of antihypertensive drugs have specific renal protective properties, and the relationships between renal, cardiovascular and mortality endpoints. In this article, we review landmark antihypertensive drug trials from the last two decades in patient populations composed, or including substantial proportions, of patients with type 2 diabetes. Several points emerge. Firstly, treatment effects can vary widely among different renal, cardiovascular and mortality endpoints. Secondly, combinations of antihypertensive drugs vary in their ability to prevent major renal and cardiovascular events, even if they produce similar reductions in blood pressure. Thirdly, simply adding further antihypertensive drugs may not improve outcomes, even if it produces further reductions in blood pressure. In most trials, a reduction in microalbuminuria was associated with evidence of renal protection, but further evidence is needed relating changes in proteinuria with cardiovascular risk. The study that aligns best with the current reappraisal of ESH guidelines, with regard to blood pressure goals, use of an adequate combination and simultaneously protecting the kidney and the cardiovascular system, is the ADVANCE study.

Diabetes and cardiovascular disease are so intertwined with one another that the presence of one prompts a search for the other. Diabetes has been considered to be equivalent to coronary heart disease (CHD), and conversely many patients with known CHD have concomitant diabetes or its pre-states. This review has been compiled based on the guidelines of the American Diabetes Association, the Third Report of the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III), the European Society of Cardiology, and the European Association for the Study of Diabetes. A systematic approach was developed by the European Society of Cardiology and the European Association for the Study of Diabetes recently to help detect CHD in patients with diabetes and to detect metabolic diseases in patients with CHD.This article is intended for the clinician in everyday practice focusing on the impact of recent advances in the prevention and management of CHD in diabetic patients and the background behind it.

Familial hypercholesterolemia (FH) and familial defective apoB 100 (FDB) are characterized by increased plasma low-density lipoprotein cholesterol (LDLc) levels and risk of coronary heart disease (CHD). FDB is clinically indistinguishable from FH. The aims of this study were to evaluate clinical diagnosis criteria for FDB and to compare the lipoprotein phenotype between carriers of LDL receptor (LDLR) gene mutations that affect the ligand-binding domain and subjects with the R3500Q mutation in apoB gene. We studied 213 subjects (113 probands) with FH and 19 heterozygous FDB subjects. Genetic diagnosis was determined by following a protocol based on Southern blot and polymerase chain reaction-single strand conformation polymorphism (SSCP) analysis. Thirty FH carriers of LDLR gene missense mutations that affect ligand-binding domain were matched by age, gender, and body mass index to the 19 FDB subjects (R3500Q mutation). Lipoprotein phenotype comparison was conducted between the 2 groups. FH patients showed plasma total and LDL cholesterol levels significantly higher than those in FDB patients. Three FDB showed plasma total and LDLc values in the normal range. Using the 1999 clinical Med-Ped criteria for diagnosis of genetic hypercholesterolemia, no FDB subjects had a confirmed diagnosis; it was probable in 36% of the subjects, it was possible in 32% of the subjects, and it could be excluded in the remaining 32% of the subjects. We conclude that the FDB lipoprotein phenotype was significantly less severe than that observed in FH carriers of LDLR gene missense ligand-binding domain mutations. Clinical Med-Ped diagnosis criteria tend to under-diagnose FDB.

Background: There are few data on differences in exposure to risk factors for coronary heart disease (CHD) in relation to geographic areas, especially areas with large differences in terms of continental and Mediterranean climates. To study these differences in Croatia, we analyzed data from the Treatment and Secondary Prevention of Ischemic Coronary Events in Croatia V (TASPIC-CRO V) study, which recruited Croatian CHD patients in two principal regions (Mediterranean and continental) of the country., Methods: A total of 31 Croatian research centers participated in the study. We collected information on personal details, demographic characteristics and risk factor exposure from the hospital medical records of 3054 CHD patients. Risk factors included history of cigarette smoking, hypertension, hyperlipidemia (total cholesterol, triglycerides, HDL-cholesterol and LDL-cholesterol) and diabetes type 2., Results: Both univariate and multivariate analyses showed that the prevalence of hypertension in examined CHD patients was significantly higher in the continental part of Croatia than in the Mediterranean part (univariate analysis: P < 0.001; multivariate analysis: P = 0.003). Multivariate analysis revealed a higher prevalence of decreased HDL-cholesterol in continental Croatia (P = 0.006) and a higher prevalence of smokers in coastal Mediterranean Croatia (P = 0.007). A significant difference in total cholesterol levels was noted between hospitalized CHD patients in two Mediterranean subregions (P < 0.001). No significant differences between continental and coastal Mediterranean parts of Croatia were found for other CHD risk factors., Conclusions: Higher prevalences of both hypertension and decreased HDL-cholesterol were recorded in hospitalized CHD patients in the continental part of Croatia, but in coastal Mediterranean Croatia there was higher prevalence of smokers. Differences in total cholesterol, LDL-cholesterol and triglycerides between hospitalized CHD patients in continental and coastal Mediterranean Croatia did not follow the expected continental-Mediterranean pattern.

Aims: The purpose of this registry is to collect data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in newer revascularization approaches and its distribution in different regions in Europe., Methods and Results: Questionnaires distributed to delegates of the national societies of cardiology represented in the European Society of Cardiology to be completed by local institutions and operators yielded that 1637148 angiograms and 525983 coronary angioplasty (PTCAs) were performed in 2000. This is an increase of 15% and 23%, respectively, compared with 1999, particularly due to increases in eastern European countries. The population-adjusted PTCA rate rose from 714 procedures per 10(6) inhabitants in 1999 to approximately 800 procedures per 10(6) inhabitants in the year 2000. Coronary stenting increased by 26% to about 395000 stented cases in 2000. Complication rates remained unchanged, the need for emergency coronary artery bypass grafting (CABG) further decreased to 0.2% per percutaneous intervention., Conclusion: Interventional cardiology in Europe is still expanding, mainly due to rapid growth in countries with lower socioeconomical levels. Most central European countries reported only minor increases in procedures performed. Coronary stenting remains the only noteworthy adjunctive or alternative strategy to balloon angioplasty.

Unlabelled: Prognostic scoring helps doctors, patients and their families to weigh the risks and benefits of medical care and clarifies their expectations., Objective: We aimed to analyze the risk stratification performance of the EuroSCORE system because of its common use in Lithuania., Design: EuroSCORE performance is assessed in terms of sensitivity, specificity, accuracy and area under the receiver operating characteristic (ROC) curve (AUC). Logistic regression is carried out for modeling categorical data and odds ratio calculations of being a non-survivor case for each EuroSCORE risk group., Results: The study was completed on 1002 patients. Mean score for EuroSCORE was 4.77 +/- 2.8; ROC curve of 0.71; accuracy was 65.5%; 65.4% sensitivity and 67.2% specificity., Conclusions: EuroSCORE created a moderately predictive area under the ROC curve for our patient population. Probability of non-survival by logistic regression model for each EuroSCORE risk group is statistically significantly higher compared to the lower risk group. Predictions available from prognostic scoring systems could be useful in decision making when there is uncertainty in whether to carry out surgery or not.

Background: Oral treatments for diabetes mellitus (DM) may have a deleterious effect on acute coronary syndromes (ACS) outcomes., Aim: We aimed to examine in-hospital mortality among patients with ACS and DM and the impact of anti-DM treatment modalities., Methods and Results: The Euro Heart Survey ACS prospectively enrolled 10484 patients across Europe and the Mediterranean basin. Of the 10214 patients with recorded DM status, 2352 (23.0%) had DM, of whom 562 were on diet alone, 1112 received oral hypoglycaemics, 561 received insulin, and 117 received both. The in-hospital mortality for ST-elevation-ACS was 9.8 and 5.7% for patients with and without DM, respectively, with an adjusted risk (95% confidence interval) of in-hospital mortality of 1.6 (1.2, 2.1). The in-hospital mortality for non-ST-elevation-ACS was 2.8 and 2.0%, accordingly, with an adjusted risk (95% confidence interval) of in-hospital mortality of 1.2 (0.8, 1.9). The in-hospital mortality for undetermined-electrocardiographic-pattern-ACS was 11.5 and 10.9%, accordingly, with an adjusted risk of in-hospital mortality of 1.1 (0.6, 2.0). Among DM patients with ST-elevation-ACS, the adjusted risks of in-hospital mortality were 1.0 for diet therapy, 0.8 (0.4, 1.5) for oral hypoglycaemics, and 1.9 (1.0, 3.8) for insulin; for DM patients and non-ST-elevation-ACS, 1.0 for diet therapy, 2.2 (0.6, 7.8) for oral hypoglycaemics, and 3.5 (1.0, 12.5) for insulin; for DM patients and undetermined-electrocardiographic-pattern-ACS, the adjusted risks of in-hospital mortality were 1.0 for diet therapy, 0.9 (0.2, 4.6) for oral hypoglycaemics, and 2.1 (0.5, 9.5) for insulin., Conclusions: Acute coronary syndrome patients with DM, especially those with ST-elevation, had increased in-hospital mortality. Among ACS patients with DM, those receiving insulin had worse outcomes. Outcomes were similar for those on hypoglycaemics or on diet alone.

The recent technical developments in multislice computed tomography (MSCT), with ECG retro-gated image reconstruction, have elicited great interest in the possibility of accurate non-invasive imaging of the coronary arteries. The latest generation of MSCT systems with 8-16 rows of detectors permits acquisition of the whole cardiac volume during a single 15-20 s breath-hold with a submillimetric definition of the images and an outstanding signal-to-noise ratio. Thus the race which, between MSCT, electron beam computed tomography and cardiac magnetic resonance imaging, can best provide routine and reliable imaging of the coronary arteries in clinical practice has recommenced. Currently available MSCT systems offer different options for both cardiac image acquisition and reconstruction, including multiplanar and curved multiplanar reconstruction, three-dimensional volume rendering, maximum intensity projection, and virtual angioscopy. In our preliminary experience including 176 patients suffering from known or suspected coronary artery disease, MSCT was feasible in 161 (91.5%) and showed a sensitivity of 80.4% and a specificity of 80.3%, with respect to standard coronary angiography, in detecting critical stenosis in coronary arteries and artery or venous bypass grafts. These results correspond to a positive predictive value of 58.6% and a negative predictive value of 92.2%. The true role that MSCT is likely to play in the future in non-invasive coronary imaging is still to be defined. Nevertheless, the huge amount of data obtainable by MSCT along with the rapid technological advances, shorter acquisition times and reconstruction algorithm developments will make the technique stronger, and possible applications are expected not only for non-invasive coronary angiography, but also for cardiac function and myocardial perfusion evaluation, as an all-in-one examination.

Cardiovascular disease is the leading cause of morbidity and mortality with annual costs of care exceeding 300 billion US dollars. Although screening tools are advocated for many cancers, the use of subclinical disease tests for cardiovascular disease are considered controversial. Health care payers and many governmental agencies apply cost-effectiveness analysis for the evaluation of new technology being considered for routine application in the US and Europe. Cost-effectiveness analysis by definition provides a comparative analysis of clinical and economic outcome data when evaluating new technology in relation to existing modalities. The current report provides a description of the framework upon methods applied in cost-effectiveness analysis as well as available data on the subject of cardiovascular screening, most notably using the evaluation of coronary calcium screening with electron beam tomography. The current report will also present several decision analytic models on the cost of atherosclerotic imaging including the evaluation of serial monitoring for disease progression and the development of cost-effectiveness models employing intermediate outcomes. Based on this review, there is an unfolding body of evidence that explores both the clinical and economic consequences of screening for atherosclerotic diseases. Although further evidence is required from prospectively designed randomized controlled trials, it appears that the current evidence from small series and decision analytic models supports cardiovascular screening of asymptomatic individuals and that the current results reveal enhanced cost effectiveness when compared with the routine evaluation using a Framingham risk assessment.

Background: Assessment of the relative diagnostic accuracy of investigation strategies for patients with suspected acute coronary syndromes (ACS)., Methods: A prospective observational study followed two groups of patients over a 3-month period in a UK district general hospital. Group one: all admissions with suspected ACS (n = 576); group two: non-cardiac in-patients who were suspected of developing ACS (n = 87). Both were investigated by full clinical history, examination and serial electrocardiographs (ECGs). Conventional World Health Organization (WHO) criteria for myocardial damage were compared with diagnosis based on cardiac troponin T (cTnT). Clinical discharge diagnosis based on conventional WHO criteria was compared with the review diagnosis based on measurement of cTnT., Results: Diagnosis based on WHO criteria missed 58 patients (8.7%) admitted with suspected ACS who had high risk unstable angina. Thirty-three patients (5% of all admissions) who were diagnosed as non-Q wave acute myocardial infarction (AMI) were found to have normal troponin values and to have been incorrectly classified as AMI., Conclusions: Diagnostic strategies based on WHO criteria are inaccurate. The measurement of cTnT in all patients with suspected ACS would have increased the number of those with a diagnosis of AMI by 58 (8.7%), while avoiding inaccurate diagnosis in 33 (5%), therefore producing an absolute increase of 25/663 (3.8%) but a relative increase of 58/138 (42%). In patients with a primary diagnosis of suspected ACS, the overall increase in patients with a diagnosis of AMI will be 55 (9.5%), a relative increase of 55/118 (46.6%) but an absolute increase of 36/576 (6.3%).

The epidemic of atherosclerotic disease in wealthy countries had probably begun by 1900. Although a few physicians understood how atherosclerosis/thrombosis of the coronary arteries caused angina pectoris and myocardial infarction, the medical community did not accept that relationship until the 1920s. In wealthy countries, the epidemic peaked in mid-century, and it is now advancing in poor countries and in countries becoming affluent. Two recent developments in methods for disease detection, however, will profoundly affect not only our understanding of the epidemic of atherosclerotic disease, but also our management of patients. A redefinition of the clinical diagnosis of myocardial infarction, a well-used but imperfect measure of the epidemic, was published in September 2000. Criteria employed for about 50 years have now been replaced by criteria based on sensitive biochemical markers of necrosis of as little as 1 g of myocardium, accompanied by chest discomfort or electrocardiographic (ECG) changes, or following coronary artery intervention. The new criteria, adopted by the major societies of cardiology in Europe and the United States, is likely to increase the apparent incidence and prevalence of coronary heart disease (CHD). In the beginning of the twentieth century, diagnosis of CHD required an autopsy. In the end it was carried out by angiography as well, but it could not be applied to large proportions of the population. That has now been changed by new, non-invasive methods of computer tomography (CT) and magnetic resonance imaging (MRI), and patients, however, asymptomatic, will expect treatment for a disease that physicians have detected. Coronary artery disease (CAD) will be to CHD what occult cancer is to cancer.

Background: The heavy burden of the costs of medical care has brought changes in the public health policy. The changes are partly related to the health management factors, but several cultural, social and environmental factors have also had a significant impact on healthcare. The role of the laboratory is now considered amidst changes that have occurred in the American health model (free-trader) and in the European-Canadian model (universalistic). Moreover, costs and clinical decision-making in laboratories in Italy have also changed in response to the new focus on the pre- and post-analytical phases of the testing process., Methods: In the present study, we used the Laboratory Information System (LIS) to evaluate whether the time involved in stages in the turnaround time (TAT) (admission, performance of tests, validation and decision-making for treatment) were reduced following improvements made to the laboratory organization and management of the pre-analytical and post-analytical phases. In particular, an analysis was made of laboratory testing for myocardial markers in patients with acute coronary syndrome., Results: TAT for myocardial markers in an emergency setting was reduced by 30% following changes made in the laboratory organization and in the management of the pre-analytical and post-analytical phases of the testing process., Conclusions: Thanks to changes in healthcare service/system in Italy, laboratory services will now play a crucial role in cultural and socioeconomic changes, particularly where testing processes and techniques are concerned.

Unlabelled: INTRODUCTION, AIMS, METHODS: The databases of large multicentric trials dealing with acute coronary syndrome (OASIS Registry, CORE, PURSUIT, FRAX.I.S.) were analysed., Results: Significant differences were disclosed comparing the baseline and history characteristics of patients randomized from Eastern or Western Europe. In most investigations the patients from Eastern Europe had a higher prevalence of hypertension, diabetes, angina and myocardial infarction. Invasive diagnostics and revascularization therapy were less frequently used in Eastern than in Western Europe in all the trials. The prevalence of myocardial infarction and the case fatality rate were not uniformly different during the early days, but after 30 days the case fatality rate in Eastern Europe was significantly higher than in Western Europe., Conclusion: It is suggested that the differences in demographic and baseline characteristics were only partially responsible for the difference in mortality. The low intervention rate and delayed revascularization may contribute to the high rate of myocardial infarction and mortality in Eastern Europe.

Background: The working group Coronary Circulation of the European Society of Cardiology has been conducting a yearly survey on coronary interventions in Europe. The purpose of this study is to present the evolution of percutaneous transluminal coronary angioplasty (PTCA) with epidemiological and economic implications., Methods: Coronary interventions were polled by questionnaires distributed to all institutions performing cardiac catheterization. Aggregated country data of the years 1992-1996 on indication, type of procedure, technique, and outcome of coronary interventions were analysed., Results: Population-adjusted coronary angiographies and PTCA procedures increased by 76% and by 105%, respectively. The Percentage of coronary stenting increased from zero to almost half of all procedures. Analysis per country groups reveals considerable variation, ranging, e.g. for PTCA in 1996 from 157 procedures per million population in a group of eastern countries to 1138 in a central European group. Relating total revascularization (R) to standardized death rate for ischaemic heart disease (SDR) and to gross domestic product (GDP), there was an increase from 1.0 to 1.8 R/SDR and 40 to 61 R/GDP in the central European group compared with an increase from 0.06 to 0.18 R/SDR and 43 to 85 R/GDP in the eastern group., Conclusions: An overall increase in PTCAs at an annual rate between 15 and 25% was observed. The wide variation in the use of PTCA in Europe appears to be dependent mostly on economic factors and national health care policies., (Copyright 2001 The European Society of Cardiology.)

The Coronary Angioplasty vs. Bypass Revascularisation Investigation (CABRI) trial comparing percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass grafting did not show a difference in mortality with either procedure. Nonrandomized studies suggest that coronary artery disease (CAD) severity and distribution influences outcome. In the present study we explored the effect of prerevascularization CAD on 1-year mortality in the CABRI population, while adjusting for other baseline variables. Of the 1,054 patients recruited, there were sufficient angiographic results to derive the CAD scores in 974 (92.4%). Of these 974, there were 32 deaths. A number of CAD scores, both weighted for proximal disease (Duke and Leaman) and nonweighted, were used. These scores were then cross-tabulated against mortality. Demographic and clinical variables were also cross-tabulated against mortality and used to derive an initial logistic regression model to predict mortality. The effect of adding each of the CAD scores to this initial model was then assessed. After inclusion of the CAD scores, the best model was: (1) presence of peripheral vascular disease (odds ratio [OR] 3.89, p = 0.0025), (2) previous cerebrovascular accident (OR 2.86, p = 0.043), (3) older age (OR 1.05, p = 0.039), (4) a higher Duke score (OR 2.84, p = 0.0061), and (5) having undergone PTCA (OR 2.12, p = 0.047). In the CABRI population, adjustment for baseline variables, including prerevascularization CAD, revealed significantly higher mortality in those who underwent PTCA than in those who underwent coronary artery bypass grafting.

Biological, behavioral, and psychosocial contributions to the gender gap in coronary heart disease (CHD) are discussed. Although CHD is the Number 1 cause of death for both sexes in the industrialized world, CHD mortality rates between these countries are larger than those between men and women, suggesting that biological factors are not the sole influences on the gender gap in CHD. Traditional coronary risk factors cannot explain the rapid increase in CHD mortality among middle-aged men in many of the newly independent states of eastern Europe. However, eastern European men score higher on stress-related psychosocial coronary risk factors (e.g., social isolation, vital exhaustion) than men living in the West. Comparisons between the sexes also reveal gender differences in psychosocial and behavioral coronary risk factors, including excessive alcohol consumption and smoking, favoring women. Overall, it appears that men's coping with stressful events may be less adaptive physiologically, behaviorally, and emotionally, contributing to their increased risk for CHD.

Aims: Evaluation of angiographical and intracoronary Doppler-derived parameters of coronary stenosis severity., Methods and Results: A total of 225 patients with one-vessel disease were studied before PTCA and at 6 months follow-up. Exercise electrocardiography was performed to document presence (n = 157) or absence (n = 138) of an ST segment shift (> or =0.1 mV). Intracoronary blood flow velocity analysis was performed to determine the proximal/distal flow velocity ratio, the distal diastolic/systolic flow velocity ratio and coronary flow velocity reserve. Receiver operator characteristic curves were calculated to assess the predictive value of these variables compared with the exercise test. The distal coronary flow velocity reserve demonstrated the best linear correlation for both percentage diameter stenosis and minimum lumen diameter (r = 0.67 and r = 0.66; P<0.01), compared to the diastolic/systolic flow velocity ratio (r = 0.19 and r = 0.14; P<0.01) and the proximal/distal flow velocity ratio (r = 0.03 and r = 0.07; not significant). The areas under the curve were 0. 84+/-0.02; 0.82+/-0.03 and 0.83+/-0.03 for diameter stenosis, minimum lumen diameter and coronary flow velocity reserve, respectively. Logistic regression analysis revealed that the percentage diameter stenosis or minimum lumen diameter and coronary flow velocity reserve were independent predictors for the result of stress testing., Conclusions: The distal coronary flow velocity reserve is the best intracoronary Doppler parameter for evaluation of coronary narrowings. Angiographical estimates of coronary lesion severity and distal coronary flow velocity reserve are good and independent predictors for the assessment of functional severity of coronary stenosis, emphasizing the complementary role of these parameters for clinical decision making., (Copyright 2000 The European Society of Cardiology.)

This review concentrates on contributions from European centers to magnetic resonance (MR) imaging of the coronary arteries. Coronary MR angiography has developed rapidly over the last 10 years, and there has been considerable interaction between Europe and the United States in the technical and clinical developments during this time. The major problems of coronary imaging have been gradually overcome with the combined use of respiratory and cardiac gating, as well as three-dimensional imaging. The ultrafast techniques such as spiral and echoplanar methods are likely to play a larger role in the future, and flow measurements are becoming possible. The next millennium should see the adoption of these techniques into routine clinical practice to allow the safe non-invasive diagnosis of coronary artery disease.J. Magn. Reson. Imaging 1999;10:721-727., (Copyright 1999 Wiley-Liss, Inc.)

Background: Angiotensin-converting enzyme (ACE) inhibitors have an accepted place in the treatment of hypertension and heart failure. However, at present they have no specific role in the prevention or treatment of coronary artery disease: evidence from animal experiments and some of the large ACE inhibitor cardiac studies makes this effect well worth testing., Objective: The objective of EUROPA is to assess the effects of perindopril (an ACE inhibitor) on outcome in patients with stable coronary artery disease, but no clinical heart failure., Methods: This is a double-blind, placebo-controlled, multicentre study with a duration of 3.5 years. It is proposed to recruit 10500 patients from 24 countries in Europe. The primary end-point is a combined one: total mortality, non-fatal acute myocardial infarction, unstable angina pectoris and cardiac arrest with successful resuscitation are included; the outcome is studied in patients with proven coronary artery disease and no clinical heart failure. Secondary end-points consist of these events individually calculated. The first patient was recruited in October 1997, and it is planned to finish recruitment by the end of 1998.

The working group Coronary Circulation of the European Society of Cardiology conducts an annual survey of cardiac interventions in Europe with the support of the national societies of cardiology. A detailed questionnaire about cardiac interventions performed during 1994 was mailed to all members of the European Society of Cardiology. Incomplete or absent data from eight national members precluded their inclusion in the final analysis. Thus, this report summarizes the cardiac interventions performed during 1994 in 29 of 37 members of the European Society of Cardiology, representing a total population of approximately 490 million inhabitants., Coronary Angiography: A total of 922,687 coronary angiograms were reported during 1994, representing an increase of 22% compared with 1993 and of 35% compared with 1992. The mean incidence of coronary angiograms was 1881/10(6) inhabitants, ranging from 4417/10(6) inhabitants in Germany to 35/10(6) inhabitants in Romania, Germany, France, Great Britain, and Italy with 50% of the European population performed 73% of all cardiac interventions., Coronary Angioplasty: During 1994, a total of 224,722 coronary angioplasty (PTCA) procedures were reported in Europe, an increase of 22% compared with 1993 and of 52% compared with 1992. Adjusted per capita, the mean incidence of coronary angioplasty was 458/10(6) inhabitants, ranging from 1091/10(6) inhabitants in Germany to 6/10(6) inhabitants in Romania. On average, the ratio PTCA per coronary angiogram was 0.24, ranging from 0.37 in the Netherlands to 0.06 in Cyprus. Ad hoc PTCA accounted for 22% of all PTCA cases. The majority (81%) of PTCAs were restricted to a single vessel. Major complications were reported in 2% of patients undergoing PTCA, including death (0.3%), myocardial infarction (1.0%) and need for emergency coronary artery bypass grafting (0.7%)., Coronary Stenting: Coronary stents were utilized in 21,599 coronary interventions during 1994, an increase of 235% compared with 1993 and thus representing the fastest growth in interventional cardiology. The number of European countries employing stents during coronary angioplasty grew from 14 during 1993 to 24 during 1994. Elective use (38%) became the most frequent indication for coronary stenting during 1994, replacing bail-out stenting as the primary indication during 1993., Other New Devices: Other new interventional therapeutic devices were employed in 8827 cases. Only the Rotablator was used more frequently during 1994 as compared with 1993. All other new therapeutic devices showed a decline. Coronary ultrasound was utilized in 3032 interventions and coronary angioscopy in 304 cases during 1994. NON-CORONARY INTERVENTIONS: Valvuloplasty remained the most frequent non-coronary intervention in Europe during 1994 with a total of 2622 mitral. 609 pulmonary and 506 aortic valvuloplasties., Catheterization Facilities: The number of facilities per 10(6) inhabitants performing invasive cardiac procedures in Europe during 1994 ranged from 7.7 in Iceland to 0.2 in Romania (European mean 2.9). The number of trained operators per 10(6) inhabitants ranged from 24 in Germany to 0.4 in Romania (European mean 10). During 1994, a mean of 701 coronary angiograms and 170 PTCAs were performed per catheterization facility in Europe (range: 1052 coronary angiograms and 293 PTCAs per facility in Norway to 218 coronary angiograms and 37 PTCAs per facility in Romania)., Conclusions: The number of both coronary angiograms and coronary angioplasties continues to grow at an annual rate of approximately 20% in Europe. There is a wide range in the amount of revascularization procedures performed between western and eastern European countries. However, countries with the lowest numbers of coronary angiograms and coronary angioplasties, e.g. Romania, also show the fastest annual growth. About one quarter of all patients undergoing coronary angiography are subsequently revascularized by coronary angioplasty. (ABSTRACT TRUN

To determine whether metallic stent implantation within a coronary artery modifies the accuracy of angina or exercise test results in predicting stenosis, we studied 172 patients assigned to stent implantation and 153 patients assigned to balloon angioplasty enrolled in the Benestent trial comparing de novo stenting with conventional balloon angioplasty. Sensitivity and specificity curves were constructed for the prediction of percentage diameter stenosis and minimal lumen diameter. Receiver-operator curves were constructed for comparison of diagnostic accuracy. Identical exercise load and duration were achieved in the two groups, despite a better angiographic result in patients treated with a stent. Similarly, the diagnostic accuracy of clinical symptoms or exercise test results as a function of the angiographic results were similar in patients with and patients without a stent. The intersection points of the sensitivity and specificity curves for recurrent angina or ST-segment depression were 72% to 77%. The corresponding cut-off points for percentage diameter stenosis were, respectively, 52% and 50% for patients with and without a stent (1.35 and 1.50 mm for minimal lumen diameter). We conclude that the presence of an intracoronary stent does not affect the diagnostic accuracy of recurrent angina or exercise-induced ST depression in predicting residual stenosis. We also conclude that exercise tolerance is similar after balloon angioplasty, with or without stenting, despite a better angiographic outcome in the group receiving a stent, suggesting a minimal threshold beyond which the patient is no longer at risk for ischemia during exercise.

An annual survey on cardiac interventions in Europe is performed by the working group on Coronary Circulation of the European Society of Cardiology with the help of the national societies of cardiology. A questionnaire about cardiac interventions in 1993 was mailed to a representative of the national societies of 35 members of the European Society of Cardiology. The data collection of coronary interventions was delayed by slow backreporting and from 10 of the 35 national members data were missing or grossly incomplete. They were excluded from the analysis., Coronary Angiography: A total of 756,822 coronary angiograms were reported resulting in an incidence of 1146 +/- 1024 per 10(6) inhabitants, ranging from 24 (Romania) to 3499 (Germany). This represents an increase of 12% compared to 1992. Germany (279,882 cases), France (157,237), the United Kingdom (77,000), Italy (44,934) and Spain (37,591) registered 79% of all the coronary angiograms performed., Percutaneous Transluminal Coronary Angioplasty: A total of 183,728 percutaneous transluminal coronary angioplasty cases were reported in 1993, 24% more than in 1992. On average, they accounted for 18 +/- 7% (range 8 (Romania) to 35% (Sweden) of the coronary angiograms. Most of these percutaneous transluminal coronary angioplasties (82%) were confined to a single vessel. In 13% only, percutaneous transluminal coronary angioplasty took place immediately after the diagnostic study. Adjusted per capita. Germany ranks first with 873 percutaneous transluminal coronary angioplasties per 10(6) inhabitants, followed by France (737), Holland (725), Belgium (713), and Switzerland (665). The European mean of percutaneous transluminal coronary angioplasties per 10(6) inhabitants was 270 +/- 279, representing an increase of 14% compared with 1992. A major in-hospital complication was reported in 3.8% of the patients undergoing percutaneous transluminal coronary angioplasty: 0.6% hospital deaths, 1.5% emergency coronary artery bypass grafting, and 1.7% myocardial infarctions., New Devices: In 1993 stents were implanted in 6444 patients (3.5% of all percutaneous transluminal coronary angioplasty patients), equally distributed between bail-out situations (53%) and elective procedures. The 14 stent implanting countries showed a mean increase in incidence of coronary stenting of 53% compared with 1992. Other interventional devices were applied in 7045 cases, 3.8% of all percutaneous transluminal coronary angioplasty cases. Coronary ultrasound (2194 cases) and coronary angioscopy (380 cases) were performed infrequently. NON-CORONARY INTERVENTIONS: Valvuloplasties were most frequently performed non-coronary interventions European countries performed more than 300 valvuloplasties each in 1993. Most of them were mitral valvuloplasties in southern countries., Conclusions: Although partial backreporting might conclusions, several findings of this survey are noteworthy for the participating countries: The number of percutaneous taneous transluminal coronary angioplasties is universally increasing. There is an extremely wide range of coronary angiography and percutaneous translumina, coronary angioplasties performed per population. The most common additional procedure is a stent implantation while other new devices are only rarely applied. Mitral valvuloplasty is the most frequently performed non-coronary intervention.

Objective: To study the relationship between presence or absence of ischaemic events on Holter monitoring and occurrence of a hard or hard+soft endpoint., Design: A randomized double-blind parallel group study of atenolol, nifedipine and their combination, with ambulatory monitoring off-treatment and after 6 weeks of randomized treatment and prospective follow-up of 2 years on average., Setting: Europe., Subjects: 682 men and women with a diagnosis of chronic stable angina and who were not being considered for surgery., Main Outcome: Hard endpoints were cardiac death, nonfatal myocardial infarction and unstable angina; soft endpoints were coronary artery bypass surgery, coronary angioplasty and treatment failure., Results: The study showed no evidence of an association between the presence, frequency or total duration of ischaemic events on Holter monitoring, either on or off treatment, and the main outcome measures. There was a non-significant trend to a lower rate of hard endpoints in the group receiving combination therapy. Compliance, as measured by withdrawal from trial medication, was clearly poorest in the nifedipine group with similar withdrawal rates in the atenolol and combination therapy groups., Conclusion: The recording of ischaemic events in 48 h Holter monitoring failed to predict hard or hard+soft endpoints in patients with chronic stable angina.

Recent studies collected via Medline and Psychlit suggest that coronary heart disease is treated less aggressively in women than in men. Women have significantly less access to major diagnostic and therapeutic procedures such as thrombolytic therapy, coronary angiography, coronary angioplasty, and coronary artery bypass surgery. This holds for women with suspected coronary heart disease as well as for women with coronary heart disease documented by myocardial infarction or coronary angiography. Possible reasons for gender bias in the management of coronary heart disease are: 1) physicians may underestimate the prevalence of coronary heart disease in women, 2) because of the higher prevalence in men, physicians may consider coronary heart disease as more serious in men, 3) a general lack of knowledge concerning coronary heart disease in women, 4) physicians' perceptions of gender-specific differences in risks and benefits of certain procedures, 5) gender stereotypes of the physician, 6) presentation style of the patient.

On the basis of a market analysis on the part of industry, the cardiological and cardiosurgical investigation and treatment capacities in 13 West European countries and in the USA are examined. With 2.0 adult left-heart catheter centers per million inhabitants or about 500,000 inhabitants per center, West Germany takes fourth place behind the USA (4.0), the Netherlands (3.2) and Switzerland (2.3). With regard to cardiac surgery, West Germany takes last place in the European comparison with less than 0.6 cardiac surgery centers per million inhabitants. The widespread use of transluminal coronary angioplasty (PTCA) is limited by the fact that only 28% of all cardiological centers in West Germany can ensure preparedness for emergency cardiac surgery operations in the same hospital. However, experience in the United States shows that less a proliferation of cardiac surgery centers than additional instruments and staff in the available facilities in West Germany would be desirable for economic and medical reasons.