Search

Introduction: The NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) conducts independent investigations of selected fire fighter line-of-duty deaths (LODD) and offers recommendations to prevent similar deaths. The purpose of the current study was to provide information on more recent FFFIPP recommendations and to determine if recommendations have changed over time., Methods: Fatality investigations completed from 2006 to 2014 were selected for this study with recommendations being assigned into twelve major categories when possible. The most frequently occurring recommendations were then rank ordered overall and then by medical and traumatic fire fighter LODD., Results: There were 1,067 total recommendations made in the published fire fighter investigative reports for both medical and trauma-related fire fighter fatalities for the period 2006-2014. Of these, 784 (73%) could be placed within one of the 12 categories noted previously. The top 10 recommendation categories overall were: 1. Medical screening, 2. Fitness and wellness program, 3. Training, 4. Medical clearance, 5. Standard Operating Procedures/Standard Operating Guidelines (SOPs/SOGs), 6. Incident command, 7. Strategy and tactics, 8. Communications, 9. Personal protective equipment and 10. Staffing., Conclusions: The leading recommendations from the NIOSH FFFIPP medical investigations between 2006 and 2014 did not change compared to those made between 1998 and 2005, with the exception of the addition of "medical clearance for duty". There were changes for the traumatic injury leading recommendations for 2006-2014, with the major change being "training", which was the leading FFFIPP recommendation for traumatic injuries for this time period. Practical applications: The intent of the FFFIPP is to influence fire departments and fire fighters to critically assess and evaluate situations/circumstances similar to those identified by NIOSH investigations and implement the recommendations offered to prevent additional fire fighter fatalities., (Published by Elsevier Ltd.)

Background and Aims: Constipation is one of the most frequent symptoms encountered in daily clinical practice and is implicated in the development of atherosclerosis, potentially through altered gut microbiota. However, little is known about its association with incident cardiovascular events., Methods: In a nationally representative cohort of 3,359,653 US veterans with an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m 2 between October 1, 2004 and September 30, 2006 (baseline period), with follow-up through 2013, we examined the association of constipation status (absence or presence; defined using diagnostic codes and laxative use) and laxative use (none, one, or ≥2 types of laxatives) with all-cause mortality, incident coronary heart disease (CHD), and incident ischemic stroke., Results: Among 3,359,653 patients, 237,855 (7.1%) were identified as having constipation. After multivariable adjustments for demographics, prevalent comorbidities, medications, and socioeconomic status, patients with (versus without) constipation had 12% higher all-cause mortality (hazard ratio [HR], 1.12; 95% CI, 1.11-1.13), 11% higher incidence of CHD (HR, 1.11; 95% CI, 1.08-1.14), and 19% higher incidence of ischemic stroke (HR, 1.19; 95% CI, 1.15-1.22). Patients with one and ≥2 (versus none) types of laxatives experienced a similarly higher risk of all-cause mortality (HRs [95% CI], 1.15 [1.13-1.16] and 1.14 [1.12-1.15], respectively), incident CHD (HRs [95% CI], 1.11 [1.07-1.15] and 1.10 [1.05-1.15], respectively) and incident ischemic stroke (HRs [95% CI], 1.19 [1.14-1.23] and 1.21 [1.16-1.26], respectively)., Conclusions: Constipation status and laxative use are independently associated with higher risk of all-cause mortality and incident CHD and ischemic stroke., (Published by Elsevier B.V.)

Background: The health outcomes associated with extremely low or high plasma concentrations of high-density lipoprotein cholesterol (HDL-C) are not well documented mainly because of the small numbers of participants with such values included in the clinical trials., Objective: We prospectively investigated the association between extremely low and high HDL-C with: 1) the risk of overall, coronary heart disease (CHD), cerebrovascular and cancer mortality, and, 2) their link with inflammatory factors., Methods: Analysis was based on subjects ≥18 years old from the National Health and Nutrition Examination Surveys (NHANES). We categorized HDL-C levels as follows: [low HDL-C group ≤30 (extremely low), 30-40 (low), and ≥40 (reference)] [high HDL-C group = 40-80 (reference), 80-100 (high) and ≥100 mg/dl (extremely high). Cox proportional hazard regression models and analysis of covariance accounted for survey design, masked variance and sample weights., Results: After adjustment for age, race and sex, we found that the very low HDL-C category (<30 mg/dl) had a greater risk of total mortality (risk ratio [RR]: 3.00, 95%CI: 2.20-4.09). RR for CHD and stroke mortality was 2.00 and 2.53, respectively; there was no link between cancer and level of HDL-C (p = 0.235). The association between total mortality, CHD and stroke with the level of HDL-C attenuated but remained significant even after adjustment for demographics, dietary, cardiovascular risk factors and treatment for dyslipidemia (all p < 0.001). After adjustments, subjects with extremely high HDL-C levels had a higher risk of mortalities (all p < 0.001). Mexican-American ethnicity, subjects in the low level of HDL-C (30-40 mg/dl) category had higher risk of mortalities than those with a very low level (all p < 0.001). Concentration of C-reactive protein, fibrinogen and white blood count significantly decreased as the level of the HDL-C increased; these findings were robust after adjustment for demographics, dietary, cardiovascular risk factors and treatment for dyslipidemia (all p < 0.001); further subjects with extremely high HDL-C levels have a greater levels of inflammatory factors (all p < 0.001)., Conclusions: Both extremely low and high HDL-C levels were associated with greater risk of mortalities (total, CHD and stroke) and higher level of inflammatory factors, while there was no link between level of HDL-C and risk of cancer. Moreover, we found evidence of an HDL-C paradox in Mexican-American ethnicity participants., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Life satisfaction is increasingly recognized as an important determinant of health; however, prospective population-based studies on this topic are limited. We estimated the risk of chronic disease and death according to life satisfaction among a population-based cohort in Ontario, Canada (n = 73,904). The cohort included 3 pooled cycles of the Canadian Community Health Survey (2003-2008) linked to 6 years of follow-up (to 2015), using population-based health databases and validated disease-specific registries. The databases capture incident and prevalent cases of diabetes, cancer, chronic obstructive pulmonary disease, heart disease, and death. Multivariable Cox proportional hazard models were used to estimate hazards of incident chronic disease and death, and were adjusted for sociodemographic, behavioral, and clinical confounders, including age, sex, comorbidity, mood disorder, smoking, alcohol consumption, physical activity, body mass index, immigrant status, education, and income. In the fully adjusted models, risk of both death and incident chronic disease was highest for those most dissatisfied with life (for mortality, hazard ratio = 1.59, 95% confidence interval: 1.15, 2.19; for chronic disease, hazard ratio = 1.70, 95% confidence interval: 1.16, 2.51). In this population-based cohort, poor life satisfaction was an independent risk factor for incident chronic disease and death, supporting the idea that interventions and programs that improve life satisfaction will affect population health.

Object: The purpose of this study was to fully assess the role of statins in the primary prevention of coronary heart disease (CHD)., Methods: We searched six databases (PubMed, the Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Database, and Chinese Scientific Journal Database) to identify relevant randomized controlled trials (RCTs) from inception to 31 October 2017. Two review authors independently assessed the methodological quality and analysed the data using Rev Man 5.3 software. Risk ratios and 95% confidence intervals (95% CI) were pooled using fixed/random-effects models. Funnel plots and Begg's test were conducted to assess publication bias. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach., Results: Sixteen RCTs with 69159 participants were included in this review. Statins can effectively decrease the occurrence of angina (RR=0.70, 95% CI: 0.58~0.85, I 2 =0%), nonfatal myocardial infarction (MI) (RR=0.60, 95% CI: 0.51~0.69, I 2 =14%), fatal MI (RR=0.49, 95% CI: 0.24~0.98, I 2 =0%), any MI (RR=0.53, 95% CI: 0.42~0.67, I 2 =0%), any coronary heart events (RR=0.73, 95% CI: 0.68~0.78, I 2 =0%), coronary revascularization (RR=0.66, 95% CI: 0.55~0.78, I 2 = 0%), and any cardiovascular events (RR=0.77, 95% CI: 0.72~82, I 2 = 0%). However, based on the current evidence, there were no significant differences in CHD deaths (RR=0.82, 95% CI: 0.66~1.02, I 2 =0%) and all-cause mortality (RR=0.88, 95% CI: 0.76 ~1.01, I 2 =58%) between the two groups. Additionally, statins were more likely to result in diabetes (RR=1.21, 95% CI: 1.05~1.39, I 2 =0%). There was no evidence of publication biases, and the quality of the evidence was considered moderate., Conclusion: Statins seemed to be beneficial for the primary prevention of CHDs but have no effect on CHD death and all-cause mortality.

Background: The combination pharmacotherapy of antiplatelet agents, lipid-modifiers, ACE inhibitors/ARBs and beta-blockers are recommended by international guidelines. However, data on effectiveness of the evidence-based combination pharmacotherapy (EBCP) is limited., Objectives: To determine the effect of EBCP on mortality and Cardiovascular events in patients with Coronary Heart Disease (CHD) or cerebrovascular disease., Methods: Publications in EMBASE and Medline up to October 2018 were searched for cohort and case-control studies on EBCP for the secondary prevention of cardiovascular disease. The main outcomes were all-cause mortality and major cardiovascular events. Meta-analyses were performed based on random effects models., Results: 21 studies were included. Comparing EBCP to either monotherapy or no therapy, the pooled risk ratios were 0.60 (95% confidence interval 0.55 to 0.66) for all-cause mortality, 0.70 (0.62 to 0.79) for vascular mortality, 0.73 (0.64 to 0.83) for myocardial infarction and 0.79 (0.68 to 0.91) for cerebrovascular events. Optimal EBCP (all 4 classes of drug prescribed) had a risk ratio for all-cause mortality of 0.50 (0.40 to 0.64). This benefit became more dilute as the number of different classes of drug comprising EBCP was decreased-for 3 classes of drug prescribed the risk ratio was 0.58 (0.49 to 0.69) and for 2 classes, the risk ratio was 0.67 (0.60 to 0.76)., Conclusions: EBCP reduces the risk of all-cause mortality and cardiovascular events in patients with CHD or cerebrovascular disease. The different classes of drugs comprising EBCP work in an additive manner, with optimal EBCP conferring the greatest benefit., Competing Interests: The authors have declared that no competing interests exist.

Background: Cardiac surgery waitlist recommendations, which were developed based on expert opinion, poorly predict preoperative mortality. Studies reporting risk factors for waitlist mortality have not evaluated the risks including nonadherence to waitlist benchmarks., Methods: In patients who underwent cardiac surgery or died on the waitlist between 2005 and 2015, we used a Fine and Gray competing risk model to identify independent predictors of waitlist mortality in 12,106 patients scheduled for urgent, semiurgent, or nonurgent surgery. The predictive variables were compared with Canadian Cardiovascular Society (CCS) waitlist recommendations using the Akaike information criterion., Results: A total of 101 (0.8%) patients died awaiting surgery. The median wait times and frequency waitlist deaths among emergent, urgent, semi-urgent, and nonurgent surgery were 0.6, 7.4, 69.0, 55.5 days (P < 0.001) and 6.3%, 0.8%, 0.3%, 0.6% (P < 0.001), respectively. Adherence to CCS waitlist recommendations was higher in patients who died on the waitlist (51.6% vs 70.8%, P = 0.001) and was not predictive of waitlist mortality (hazard ratio 1.48, 95% confidence interval 0.62-0.56). Independent predictors of waitlist mortality were age, aortic surgery, ejection fraction < 35%, urgent surgery, prior myocardial infarction, haemodynamic instability during cardiac catheterization, hypertension, and dyslipidemia. These variables were superior to current CCS guidelines (Akaike information criterion 1251 vs 1317, likelihood ratio test P < 0.001)., Conclusions: CCS waitlist recommendations were poorly predictive of waitlist mortality and the majority of waitlist deaths occur within recommended benchmarks. We identified variables associated with waitlist mortality with improved clinical performance. Our findings suggest a need to re-evaluate cardiac surgical triage criteria using evidence-based data., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to compare the incidence of cancer and all-cause and cause-specific mortality rates among a cohort of patients with severe PsA receiving TNF inhibitor (TNFi) with those of the general UK population., Methods: Cancers and deaths were identified from the national cancer and the national death registers in patients with PsA included in the British Society for Rheumatology Biologics Register from start of TNFi until 31 December 2012. Standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) were calculated using published cancer and death rates for the general population. SIRs were calculated for both overall cancer risk and non-melanoma skin cancer. SMRs were calculated for (1) all-cause mortality, (2) death from malignancy and (3) death from circulatory disease. Gender-specific analyses were also performed., Results: Thirty-four cancers and 41 deaths among 709 patients were observed. The risk of malignancy overall was not increased (SIR 0.94; 95% CI: 0.65, 1.34). However, there was a significantly increased incidence of non-melanoma skin cancer (SIR 2.12; 95% CI: 1.19, 3.50). The all-cause mortality rate in our cohort was increased (SMR 1.56; CI: 1.12, 2.11). Death from malignancy was not increased, but death from coronary heart disease was increased (SMR 2.42; 95% CI: 1.11, 4.59)., Conclusion: In our cohort of patients with severe PsA, the overall incidence of malignancy was similar to that of the general population, although the incidence of non-melanoma skin cancer was increased. All-cause mortality was significantly increased, in part due to excess of deaths attributed to coronary heart disease.

Background: Chemical, physical and psychological stressors due to the 2010 Deepwater Horizon oil spill may impact coronary heart disease (CHD) among exposed populations. Using longitudinal information from two interviews in the Gulf Long Term Follow-up (GuLF) STUDY, we assessed CHD among oil spill workers and community members., Objective: To assess the associations between duration of oil spill clean-up work, residential proximity to the oil spill, and incidence of self-reported myocardial infarction or fatal CHD., Methods: Among respondents with two GuLF STUDY interviews (n = 21,256), there were 395 first incident heart disease events (self-reported myocardial infarction or fatal CHD) across 5 years. We estimated hazard ratios (HR) and 95% confidence intervals (95%CI) for associations with duration of oil spill clean-up work and residential proximity to the oil spill. To assess potential impacts of non-response, we compared covariate distributions for those who did (n = 21,256) and did not (n = 10,353) complete the second interview and used inverse probability (IP) of censoring weights to correct for potential non-response bias., Results: Living in proximity to the oil spill (vs. living further away) was associated with heart disease, with [HR(95%CI) = 1.30(1.01-1.67)] and without [1.29(1.00-1.65)] censoring weights. For work duration, hazard of heart disease appeared to be higher for those who worked > 180 days (vs. 1-30 days), with and without censoring weights [1.43(0.91-2.25) and 1.36(0.88-2.11), respectively]. Associations persisted throughout the 5-year follow-up., Conclusions: Residential proximity to the spill and duration of clean-up work were associated with a suggested 29-43% higher hazard of heart disease events. Associations were robust to censoring., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Coarse particulate matter with aerodynamic diameter between 2.5 and [Formula: see text] ([Formula: see text]) air pollution is a severe environmental problem in developing countries, but its challenges to public health were rarely evaluated., Objective: We aimed to investigate the associations between day-to-day changes in [Formula: see text] and cause-specific mortality in China., Methods: We conducted a nationwide daily time-series analysis in 272 main Chinese cities from 2013 to 2015. The associations between [Formula: see text] concentrations and mortality were analyzed in each city using overdispersed generalized additive models. Two-stage Bayesian hierarchical models were used to estimate national and regional average associations, and random-effect models were used to pool city-specific concentration-response curves. Two-pollutant models were adjusted for fine particles with aerodynamic diameter [Formula: see text] ([Formula: see text]) or gaseous pollutants., Results: Overall, we observed positive and approximately linear concentration-response associations between [Formula: see text] and daily mortality. A [Formula: see text] increase in [Formula: see text] was associated with higher mortality due to nonaccidental causes [0.23%; 95% posterior interval (PI): 0.13, 0.33], cardiovascular diseases (CVDs; 0.25%; 95% PI: 0.13, 0.37), coronary heart disease (CHD; 0.21%; 95% PI: 0.05, 0.36), stroke (0.21%; 95% PI: 0.08, 0.35), respiratory diseases (0.26%; 95% PI: 0.07, 0.46), and chronic obstructive pulmonary disease (COPD; 0.34%; 95% PI: 0.12, 0.57). Associations were stronger for cities in southern vs. northern China, with significant differences for total and cardiovascular mortality. Associations with [Formula: see text] were of similar magnitude to those for [Formula: see text] in both single- and two-pollutant models with mutual adjustment. Associations were robust to adjustment for gaseous pollutants other than nitrogen dioxide and sulfur dioxide. Meta-regression indicated that a larger positive correlation between [Formula: see text] and [Formula: see text] predicted stronger city-specific associations between [Formula: see text] and total mortality., Conclusions: This analysis showed significant associations between short-term [Formula: see text] exposure and daily nonaccidental and cardiopulmonary mortality based on data from 272 cities located throughout China. Associations appeared to be independent of exposure to [Formula: see text], carbon monoxide, and ozone. https://doi.org/10.1289/EHP2711.

Background: In patients with chronic heart failure, there is a positive linear relationship between skeletal muscle mass (SMM) and peak oxygen consumption ( V ˙ O 2peak ); an independent predictor of all-cause mortality . We investigated the association between SMM and V ˙ O 2peak in patients with coronary heart disease (CHD) without a diagnosis of heart failure., Methods: Male patients with CHD underwent maximal cardiopulmonary exercise testing and dual X-ray absorptiometry assessment. V ˙ O 2peak, the ventilatory anaerobic threshold and peak oxygen pulse were calculated. SMM was expressed as appendicular lean mass (lean mass in both arms and legs) and reported as skeletal muscle index (SMI; kg m -2 ), and as a proportion of total body mass (appendicular skeletal mass [ASM%]). Low SMM was defined as a SMI <7·26 kg m -2 , or ASM% <25·72%. Five-year all-cause mortality risk was calculated using the Calibre 5-year all-cause mortality risk score., Results: Sixty patients were assessed. Thirteen (21·7%) had low SMM. SMI and ASM% correlated positively with V ˙ O 2peak (r = 0·431 and 0·473, respectively; P<0·001 for both). SMI and ASM% predicted 16·3% and 12·9% of the variance in V ˙ O 2peak , respectively. SMI correlated most closely with peak oxygen pulse (r = 0·58; P<0·001). SMI predicted 40·3% of peak V ˙ O 2 /HR variance. ASM% was inversely associated with 5-year all-cause mortality risk (r = -0·365; P = 0·006)., Conclusion: Skeletal muscle mass was positively correlated with V ˙ O 2peak in patients with CHD. Peak oxygen pulse had the strongest association with SMM. Low ASM% was associated with a higher risk of all-cause mortality. The effects of exercise and nutritional strategies aimed at improving SMM and function in CHD patients should be investigated., (© 2018 The Authors. Clinical Physiology and Functional Imaging published by John Wiley & Sons Ltd on behalf of Scandinavian Society of Clinical Physiology and Nuclear Medicine.)

Aims: Relatively little is known about the health outcomes associated with very low plasma concentrations of high-density lipoprotein cholesterol (HDL-C) mainly because of the small numbers of individuals with such extreme values included in clinical trials. We, therefore, investigated the association between low and very low HDL-C concentration at baseline and incident all-cause-mortality, death from malignant disease (i.e. cancer), and with fatal or non-fatal incident coronary heart disease (CHD) in individuals from the Reasons for Geographical And Racial Differences in Stroke (REGARDS) study., Methods and Results: Analysis was based on 21 751 participants from the REGARDS study who were free of CHD, other cardiovascular disease, and cancer at baseline and were categorized by baseline HDL-C into <30 mg/dL (very low), 30-<40 mg/dL (low), and ≥40 mg/dL (reference). A series of incremental Cox proportional hazards models were employed to assess the association between the HDL-C categories and outcomes. Statistical analysis was performed using both complete case methods and multiple imputations with chained equations. After adjustment for age, race, and sex, the hazard ratios (HRs) comparing the lowest and highest HDL-C categories were 1.48 [95% confidence interval (CI) 1.28-1.73] for all-cause mortality, 1.35 (95% CI 1.03-1.77) for cancer-specific mortality and 1.39 (95% CI 0.99-1.96) for incident CHD. These associations became non-significant in models adjusting for demographics, cardiovascular risk factors, and treatment for dyslipidaemia. We found evidence for an HDL paradox, whereby low HDL (30-<40 mg/dL) was associated with reduced risk of incident CHD in black participants in a fully adjusted complete case model (HR 0.63; 95% CI 0.46-0.88) and after multiple imputation analyses (HR 0.76; 95% CI 0.58-0.98). HDL-C (<30 mg/dL) was significantly associated with poorer outcomes in women for all outcomes, especially with respect to cancer mortality (HR 2.31; 95% CI 1.28-4.16) in a fully adjusted complete case model, replicated using multiple imputation (HR 1.81; 95% CI 1.03-3.20)., Conclusion: Low HDL-C was associated with reduced risk of incident CHD in black participants suggesting a potential HDL paradox for incident CHD. Very low HDL-C in women was significantly associated with cancer mortality in a fully adjusted complete case model.

Lifetime risk (LTR) provides an absolute risk assessment during the remainder of one’s life. Few studies have focused on the LTRs of stroke and coronary heart disease (CHD), categorized by fine blood pressure in Asian populations. We aimed to assess it using a large database of a meta-analysis with the individual participant data. The present metaanalysis included 107 737 Japanese (42.4% men; mean age, 55.1 years) from 13 cohorts. During the mean follow-up of 15.2±5.3 years (1 559 136 person-years), 1922 died from stroke and 913 from CHD. We estimated risks after adjusting for competing risk of death other than the outcome of interest. The 10-year risk of stroke and CHD deaths at index age of 35 years was ≤1.9% and ≤0.3%, respectively. The LTRs of stroke death at the index age of 35 years (men/women) were 6.1%/4.8% for optimal, 5.7%/6.3% for normal, and 6.6%/6.0% for high-normal blood pressure groups, and 9.1%/7.9% for grade 1, 14.5%/10.3% for grade 2, and 14.6%/14.3% for grade 3 hypertension groups. The LTRs of CHD death similarly elevated with an increase in blood pressure but were lower (≤7.2%) than those of stroke death. In conclusion, blood pressure was clearly associated with an elevated LTR of stroke or CHD death, although the LTR of CHD death was one-half of that of stroke death in an Asian population. These results would help young people with hypertension to adopt a healthy lifestyle or start antihypertensive therapy early., (© 2018 American Heart Association, Inc.)

We sought to assess the prevalence of polyvascular disease in patients with type 2 diabetes mellitus (T2DM) and its impact on ischemic events. Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR)-Thrombolysis in Myocardial Infarction (TIMI) 53, a large contemporary, randomized trial, evaluated the effect of saxagliptin versus placebo in 16,492 patients with T2DM and a history of or at risk for cardiovascular (CV) events. Polyvascular disease was defined as a history of clinical events involving 2 or more vascular beds (coronary, peripheral, or cerebrovascular system) at the time of randomization. The primary composite endpoint of CV death, myocardial infarction, or ischemic stroke was compared according to the number of diseased arterial beds. At the time of randomization, 3,667 (22.2%) patients had risk factors for CV events; 11,423 (69.3%) had established 1 arterial bed disease; 1,298 (7.9%) had 2 bed disease; and 104 (0.6%) had 3 bed disease. Compared with diabetic patients with no established atherosclerosis, the adjusted hazard ratio for the composite primary end point in 1, 2, or 3 diseased beds was 1.95, 3.54, and 4.64, respectively (trend p < 0.0001). The adjusted risk for overall mortality increased in a similar stepwise fashion from 1.47 to 2.33 to 3.12, respectively (trend p = 0.0001) with each additional diseased arterial territory. In conclusion, in patients with confirmed atherosclerosis enrolled in SAVOR-TIMI 53, 11% had polyvascular disease; and compared with diabetic patients with single bed disease, the risk of ischemic events and overall mortality was substantially higher in patients with T2DM and polyvascular disease., (Copyright © 2018. Published by Elsevier Inc.)

Background: Screening for depression in patients with coronary heart disease (CHD) remains controversial. There is limited data on the actual depression management need in routine care. The aim of this study was to examine the prevalence, treatment rates, prognosis, and management need of clinical and subclinical depression in CHD patients according to the American Heart Association recommendations and the National Institute for Health and Care Excellence (NICE) guideline "Depression in Adults with a Chronic Physical Health Problem"., Methods: Patients were recruited at 2 German university clinics between 2012 and 2014. Depressive disorders were assessed according to the DSM-IV and depressive symptom severity at baseline and during follow-up was evaluated with the Patient Health Questionnaire (PHQ-9). Depression management need was determined by the severity and longitudinal course of depression symptoms., Results: Of 1,024 patients (19% women), 12% had clinical depression (depressive disorder) and 45% had subclinical depression (PHQ-9 score ≥5) at baseline. Among those with clinical depression, 46% were in treatment at least once during 12 months; 26% were continuously in treatment during follow-up. Depressive disorder and depressive symptoms were significant risk factor-adjusted predictors of the 12-months mortality (adjusted HR = 3.19; 95% CI 1.32-7.69, and adjusted HR = 1.09; 95% CI 1.02-1.16, respectively). Depressive symptoms persisted in 85% of the clinically depressed and in 47% of the subclinically depressed patients. According to current recommendations, 29% of all CHD patients would require depression management within 1 year., Conclusions: There is a need for enhanced recognition, referral, and continuous and improved clinical management of depression in CHD patients., (© 2019 S. Karger AG, Basel.)

Objective: We aimed to investigate age-specific clinical characteristics in patients aged >60 years with large hemispheric infarction (LHI)., Methods: We prospectively enrolled consecutive patients with LHI. Patients were divided into two groups: ≤60 vs. >60 years, and demographics, vascular risk factors, clinical feature, in-hospital treatment, 3-month mortality, and unfavorable outcome (defined as a mRS score of 4-6) rate were compared., Results: Of the 256 cases included, 140 (54.7%) were older than 60 years. Compared with the younger, the older patients had higher rates of hypertension (66.4% vs. 31.0%), coronary heart disease (19.3% vs. 2.6%), atrial fibrillation (53.6% vs. 31.0%; all p < 0.001), more history of stroke (21.4% vs. 5.2%, p < 0.001), less history of rheumatic heart disease (16.4% vs. 30.1%, p = 0.009), and alcohol consumption (12.1% vs. 21.6%, p = 0.043). Cardio-embolism is the most common stroke etiology regardless of age (55.7% and 38.8%, respectively). Furthermore, the elderly less frequently received decompressive hemicraniectomy (4.3% vs. 15.5%, p = 0.005) and mechanical ventilation (7.9% vs. 16.4%, p = 0.035) and had a higher frequency of stroke-related complication (83.6% vs. 66.4%, p = 0.001). A total of 26 (18.6%) older patients and 15 (12.9%) younger patients died during hospitalization (p = 0.221), and 59 (42.1%) older patients and 35 (30.2%) younger patients died at 3 months (p = 0.061). Patient aged >60 years had significantly higher unfavorable outcome rate at 3 months (adjusted odds ratio, OR 4.30, 95% confidence interval [CI] 2.08-8.88; p < 0.05]. However, older age is not independently associated with 3-month mortality (42.1% vs. 30.2%, p = 0.095 [log-rank test])., Conclusions: Large hemispheric infarction patients over 60 years old were a little more than those aged ≤60 years and constitute more than half of those suffered from malignant brain edema and two thirds of in-hospital death and 3-month mortality. The elderly had more cardio-origin risk factors, received less aggressive hospital treatment, and showed higher risk of unfavorable outcome than the younger., (© 2018 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.)

Background: Sleep duration has been shown to be associated with all-cause mortality; however, its relationship with cause-specific fatal events remains uncertain. We examined the relationship between sleep duration and risk of fatal coronary heart disease, sudden cardiac death, cancer-related death, and all-cause mortality., Methods: Sleep duration was self-reported at baseline examinations performed between March 20, 1984, and December 5, 1989, in 2361 men aged 42-61 years from the Kuopio Ischemic Heart Disease study. Of these, 1734 (73.4%) men were free from coronary heart disease and cancer at baseline., Results: A total of 802 all-cause deaths, 202 fatal coronary heart disease events, 141 sudden cardiac events, and 229 cancer-related deaths were reported during a median follow-up of 25.9 (interquartile range, 20.6-28.2) years. Multivariable adjusted hazard ratios comparing the top quartile (>10 hours) of sleep duration vs the bottom quartile (<8 hours) was 1.19 (95% confidence interval [CI], 1.01-1.43) for all-cause mortality, 1.27 (95% CI, 0.88-1.84) for fatal coronary heart disease, 1.20 (95% CI, 0.78-1.86) for sudden cardiac death, and 1.29 (95% CI, 0.92-1.80) for cancer death. No differences in association of sleep duration with outcomes were found in clinically relevant subgroups, including age, history of coronary heart disease, body mass index, physical activity, and C-reactive protein levels., Conclusions: Longer duration of sleep was associated with significantly increased all-cause mortality. The mechanistic link between these findings remains to be explored further., (Copyright © 2018. Published by Elsevier Inc.)

Review Objective: The objective of this review was to investigate the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on patients' health-related quality of life and hospital readmission., Introduction: Coronary heart disease is a major cause of death and disability worldwide, putting a great strain on healthcare resources. For the past two decades, population-wide primary prevention and individual healthcare approaches have resulted in a dramatic decline in overall cardiac mortality. Over the intervening years, surgical techniques in cardiology have also improved substantially. As a result, long-term outcomes in patients treated with coronary artery bypass graft surgery have established the treatment's effectiveness and survival benefit. Furthermore, participating in cardiac rehabilitation following coronary artery bypass graft surgery has also demonstrated a significant decrease in all-cause cardiac mortality in these patients., Inclusion Criteria: This review included studies with participants aged 18 years and over, post coronary artery bypass graft surgery that evaluated nurse-led cardiac rehabilitation (CR) programs compared with usual care or other forms of CR. The outcomes of interest were the health-related quality of life and hospital readmissions following coronary artery bypass graft surgery and measured using validated scales. Randomized controlled trials reported in English between 2000 to June 2017 were considered for inclusion., Methods: The search strategy aimed to find both published and unpublished studies using a three-step search strategy. An initial search of MEDLINE, CINAHL and Scopus was undertaken, followed by a search for unpublished studies including Dissertation Abstracts International, ProQuest Dissertations and Theses, Google Scholar, MedNar and ClinicalTrials.gov. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal tools from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Quantitative data was extracted from papers included in the review using the standardized data extraction tool from JBI-SUMARI. No meta-analysis was undertaken due to heterogeneity of the outcome measures. All results were subject to double data entry. Effect sizes expressed as risk ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis., Results: Three trials involving 329 patients were included in the final review. The trials that investigated the effect of home based cardiac rehabilitation programs compared to usual care at six weeks, three months and six months follow-up demonstrated no statistically significant difference in health-related quality of life at any of the follow-up periods. However, one study demonstrated significantly higher scores related to health-related quality of life among those who received nurse-led home based cardiac rehabilitation (154.93 ± 4.6) compared to those who received usual care (134.20 ± 8.2) at two months follow-up. No trials were identified that compared the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on readmissions to hospital., Conclusion: There is not enough evidence to support or discourage nurse-led cardiac rehabilitation programs on health-related quality of life in patients following coronary artery bypass graft surgery. However, the sparse data available suggests improvements in health-related quality of life at two months follow-up among those who received a nurse-led program. Further large-scale multicenter trials with standardized methodology are needed to determine the effect of nurse-led cardiac rehabilitation programs on health-related quality of life and rates of readmission to hospital following coronary artery bypass graft surgery.

We attempted to estimate the mortality risk of radiation-associated coronary heart disease (CHD) by using a model in which radiation was assumed to participate in the atherosclerotic process jointly with ageing. Model parameters were determined by fitting the Life Span Study data of atomic bomb survivors. According to the model, the excess relative risk (ERR) varies depending on the baseline risk; when applied to the death statistics of Japan and the USA, the estimated ERR was consistently higher in the Japanese population. The absolute risk showed an opposite trend, such that the estimated lifetime attributable risk was approximately two times higher in the US population. Excess cases were expected to appear in old age almost synchronously with spontaneous cases; in contrast, the risk is practically unnoticeable for those young to middle aged. Our model suggests that the radiation dose-response curve for CHD, as well as the latency in epidemiological studies, could be modified by the baseline risk.

Background: In the risk assessment of patients considered for non-cardiac surgery and with recent coronary stent implantation, coronary drug-eluting stent implantation procedure characteristics may be taken into account. We aimed to evaluate associations between coronary drug-eluting stent implantation procedure characteristics and the risk of myocardial infarction and all-cause death within 30 days after non-cardiac surgery., Design: Patients with coronary drug-eluting stents were identified using the Western Denmark Heart Registry. Surgical procedures performed after stent implantation were detected using the Danish National Patient Registry. We used registry-based detection of myocardial infarction and all-cause death., Results: Of 22 590 patients treated with drug-eluting stents between 2005 and 2012, 4046 underwent non-cardiac surgery within 1 and 12 months after stent implantation. We found no significant association between the risk of myocardial infarction or all-cause death within 30 days after surgery and number of arteries treated (1 [reference] vs more), number of lesions treated (1 [reference] vs more), segments treated (left main and proximal left anterior descending artery vs other [reference]), total stent length (<20 mm [reference] vs ≥20 mm), number of stents (1 [reference] vs >1) and largest balloon diameter (≥3 mm [reference] vs <3 mm). All-cause death, but not myocardial infarction, risk was lower among patients treated with first-generation vs second-generation stents (odds ratio 0.58)., Conclusions: We identified no significant associations between stent implantation procedure characteristics and risk of myocardial infarction or all-cause death among patients undergoing non-cardiac surgery. All-cause death was lower with first- vs second-generation drug-eluting stents., (© 2018 Stichting European Society for Clinical Investigation Journal Foundation.)

Background: As mortality due to cardiovascular disease increases throughout the world, accurate data on risk factors such as hyperlipidemia are required. This is lacking in the Asia-Pacific region., Design: The observational Dyslipidemia International Study (DYSIS) II was established to quantify the extent of hyperlipidemia in adults with acute and stable coronary heart disease globally., Methods: Patients with stable coronary heart disease or hospitalised with an acute coronary syndrome were enrolled across nine Asia-Pacific countries from July 2013 to October 2014. Lipid-lowering therapy and low-density lipoprotein cholesterol target attainment (<70 mg/dL) were assessed. The acute coronary syndrome cohort was followed up 4 months post-discharge., Results: Of the 4592 patients enrolled, 2794 had stable coronary heart disease and 1798 were admitted with an acute coronary syndrome. In the coronary heart disease cohort, the mean low-density lipoprotein cholesterol level was 86.9 mg/dL, with 91.7% using lipid-lowering therapy and 31% achieving low-density lipoprotein cholesterol of less than 70 mg/dL. In the acute coronary syndrome cohort at admission, the corresponding values were 103.2 mg/dL, 63.4% and 23.0%, respectively. Target attainment was significantly higher in lipid-lowering therapy-treated than non-treated patients in each cohort (32.6% vs. 12.9% and 31.1% vs. 9.0%, respectively). Mean atorvastatin-equivalent dosages were low (20 ± 15 and 22 ± 18 mg/day, respectively), with little use of non-statin adjuvants (13.0% and 6.8%, respectively). Low-density lipoprotein cholesterol target attainment had improved by follow-up for the acute coronary syndrome patients, but remained low (41.7%)., Conclusions: Many patients in Asia at very high risk of recurrent cardiovascular events had a low-density lipoprotein cholesterol level above the recommended target. Although lipid-lowering therapy was common, it was not used to its full potential.

Objective: Evaluation of the hypertensive disease (HD) and coronary heart disease (CHD) progress in the ChornobylNPP (ChNPP) accident clean-up workers (ACUW) and persons not exposed to ionizing radiation depending on gen-der and genotype of the phosphodiesterase 4D (PDE4D) gene rs966221 polymorphism., Materials and Methods: There were male ACUW (ACUWm; n=515) and female ACUW (ACUWf; n=145) involved in thestudy since 2013 till 2018. Participation in the clean-up works took place in 1986-1987. The control group includ-ed male (CGm; n=162) and female (CGf; n=120) persons not exposed to ionizing radiation. All study subjects havehad neither signs nor symptoms of HD or CHD before the ChNPP accident., Results: Review of the Kaplan-Meier survival tables indicated that according to median survival the HD emerged inACUWm and ACUWf in a younger age (47.5 ± 0.6 and 50.7 ± 0.7 years old, respectively) vs. CGm or CGf (54.9 ± 1.1 and54.4 ± 1.1 years, respectively). The same was true for CHD where the median values were (56.8 ± 0.5), (61.2 ± 0.8),(61.6 ± 1.0) and (64.2 ± 1.4) years respectively. Review of cumulative incidence of HD and CHD revealed no associ-ation of the PDE4D gene rs966221 polymorphism with the diseases of concern. The TT gene carrier state comparedto the CC or CT genes features an increased risk of myocardial infarction (MI) 2.9 times in ACUWm, 4-fold in CGm, and5.5 times in CGf (p < 0.05). No any gene carrier state was associated with MI in the ACUWf. Onset of menopause wasfollowed by an increase in HD incidence vs. males., Conclusions: The male and female ChNPP ACUW were developing HD and CAD at a younger age compared with cor-responding non-irradiated control. In male ACUW in comparison with female ACUW the cumulative morbidity ratefor MI was higher in any age range, whereas for CAD it was higher from 23 to 74 years, and for HD from 25 to 53 yearsof age. In male and female ACUW as well as in non-irradiated control the HD developed much earlier than CHD. Thecarrier state of TT genotype of PDE4D gene rs966221 polymorphism increases the risk of MI in males of all ages, inthe non-irradiated controls it is increased in 65 years for men and in 60 years for women. No data on association ofthe genotype of the described gene polymorphism with MI were found in female ACUW., (D. О. Bilyi, O. M. Nastina, G. V. Sydorenko, N. I. Bilous, N. V. Kursina, G. V. Pleskach, O. D. Bazyka, O. M. Makarevysh, O. S. Kovaliov, A. A. Chumak, I. V. Abramenko.)

Background: Researchers have suggested that omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this., Objectives: To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids., Search Methods: We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors., Selection Criteria: We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake., Data Collection and Analysis: Two review authors independently assessed studies for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression., Main Results: We included 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5g/d LCn3 to > 5 g/d (16 RCTs gave at least 3g/d LCn3).Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20, 19,327 participants; 459 deaths, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs) and ALA may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence with greater effects in trials at low summary risk of bias), and probably reduces risk of arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, except LCn3 reduced triglycerides by ˜15% in a dose-dependant way (high-quality evidence)., Authors' Conclusions: This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event and arrhythmia risk.

Background: Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega-3 PUFA and plant oils in omega-6 PUFA. Evidence suggests that increasing PUFA-rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear., Objectives: To assess effects of increasing total PUFA intake on cardiovascular disease and all-cause mortality, lipids and adiposity in adults., Search Methods: We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews., Selection Criteria: We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all-cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions., Data Collection and Analysis: Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta-analyses used random-effects analysis, sensitivity analyses included fixed-effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence., Main Results: We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA.Increasing PUFA intake probably has little or no effect on all-cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate-quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) andstroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low-quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality.Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD -0.12 mmol/L, 95% CI -0.20 to -0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) -0.12 mmol/L, 95% CI -0.23 to -0.02, 26 trials, 8072 participants), high-density lipoprotein (HDL) (MD -0.01 mmol/L, 95% CI -0.02 to 0.01, 18 trials, 4674 participants) or low-density lipoprotein (LDL) (MD -0.01 mmol/L, 95% CI -0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants).Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality., Authors' Conclusions: This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all-cause or cardiovascular disease mortality. The mechanism may be via TG reduction.

Objectives: To investigate the association of alkaline phosphatase (ALP) levels with the risk of the composite end point of cardiovascular disease (CVD), and all-cause mortality as well as each of them separately., Design: Prospective cohort study., Setting: Within the framework of the Tehran Lipid and Glucose Study (TLGS) cohort, participants were followed from baseline examination (1999-2001) until March 2014., Participants: A total of 2578 participants, aged ≥30 years free of prevalent CVD at baseline examination., Primary Outcome: The main outcome measures were composite end point of coronary heart disease (CHD), stroke, all-cause mortality and each per se., Results: During a median follow-up of 11.3 years, 369, 68, 420, 170 and 495 participants experienced CHD, stroke, CVD, all-cause mortality and the composite outcome, respectively. In the multivariable Cox regression models, the adjusted HRs (95% CI) for mentioned events per one SD increase in ALP level after full adjustment were 1.11 (1.01 to 1.22), 1.20 (0.97 to 1.49, p=0.058), 1.10 (1.01 to 1.21), 1.16 (1.01 to 1.33) and 1.11 (1.02 to 1.21), respectively. Furthermore, participants with ALP levels in the highest tertile had significant adjusted HRs (95% CI) for stroke (1.88 (1.00 to 3.61)), CVD (1.30 (1.01 to 1.68)) and composite outcome (1.27 (1.00 to 1.61)). The cut-off value of ALP ≥199 IU/L for predicting composite outcome was derived using Youden's index, based on which this cut-off point was associated with significant risk of 80%, 26%, 43% and 26% for incident stroke, CVD, all-cause mortality and composite outcome. Additionally, no improvement was seen in the predictive ability of traditional risk factors models after adding ALP values, considering the levels of Akaike information criterion, C-index and Net Reclassification Index., Conclusion: Independent associations between ALP levels and the risks of CVD and mortality events were shown, despite the fact that adding the data of ALP to known risk factors did not improve the prediction of these events., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study sought to compare the clinical outcomes of percutaneous coronary interventions (PCIs) performed by sleep deprived and non-sleep deprived operators., Background: Interventional cardiologists are at risk for sleep deprivation as they often have to perform emergent procedures at night, but the effects of sleep deprivation on clinical outcomes have received limited study., Methods: We examined the frequency, clinical characteristics, and outcomes of daytime PCIs performed by sleep deprived and non-sleep deprived operators at a tertiary medical center. Operators were considered sleep deprived when performing a daytime (7 am-11:59 pm) procedure preceded by a nighttime (12 am-6:59 am) procedure on the same date., Results: Of the 12,680 daytime PCIs performed from 6/29/09 to 12/30/2016, 367 (2.9%) were performed by sleep deprived operators. Patients undergoing PCI performed by a sleep deprived operator were more likely to be younger, white, and to present with ST-elevation acute myocardial infarction (STEMI). The incidence of in-hospital death (1.1% vs. 1.3%, P = 1.0) and bleeding within 72 hr (3.9% vs. 2.9%, P = 0.29) were similar for procedures performed by sleep-deprived and non-sleep deprived operators. When the sleep deprived group was further stratified based on degree of sleep deprivation or length of sleep interruption, differences in mortality and total bleeding remained non-significant., Conclusions: In this large single center study, operator sleep deprivation did not appear to adversely impact PCI outcomes., (© 2018 Wiley Periodicals, Inc.)

Previous studies suggest that reduced leukocyte telomere length (LTL) is related to higher risk of mortality and several chronic conditions, including coronary heart disease (CHD) and stroke. However, the consistency of this association differs across populations. We investigated the relationship of LTL with CHD, stroke and all-cause mortality together with non-fatal CHD and stroke events in a Russian cohort with a mean age of 58 years at baseline. Data from 1,144 individuals in the Russian subset of the Health Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) cohort study were used. The associations between LTL at baseline and fatal/non-fatal outcomes during 12 years of follow-up were assessed using multivariable Cox regression models, which yielded adjusted hazard ratios (HR). Compared to individuals in the shortest tertile, those in the longest tertile of LTL had a 42% lower risk of death from all-causes (HR 0.58; 95% CI: 0.39-0.88) and 58% lower risk of death from CHD (HR 0.42; 95%CI: 0.19-0.97). Similar patterns of association were identified for non-fatal and combined fatal/non-fatal CHD and stroke events but the associations were weaker. Consistent with results of previous studies in Western populations, this cohort of elderly Russian adults found an inverse association between LTL and CHD and all-cause mortality. These findings reinforce the hypothesis that LTL may play (or be a marker of) an aetiological role in human health across diverse populations.

Purpose of Review: To review recent literature on associations between habitual physical activity and mortality in general populations and patients with stable coronary heart disease., Recent Findings: There are substantial decreases in cardiovascular and all-cause mortality between people who take little or no exercise and those who take regular light or moderate physical activity. The benefits associated with increasing high-intensity exercise are smaller, and an increase in mortality risk is possible. Meta-analyses of trials of exercise-based cardiac rehabilitation suggest a small mortality benefit from supervised exercise training, but because of a high risk of bias, the impact on cardiovascular mortality and hospitalizations is uncertain., Summary: Modest habitual physical activity is likely to lower mortality in most patients with stable coronary heart disease.

Background In the large-scale ADAPT-DES study (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents), drug-eluting stent implantation with intravascular ultrasound (IVUS) guidance was associated with a reduction in 1-year rates of stent thrombosis, myocardial infarction (MI), and major adverse cardiac events (cardiac death, MI, or stent thrombosis) compared with angiography guidance alone. We assessed whether the benefits of IVUS guidance were maintained, reduced, or increased at 2 years. Methods and Results ADAPT-DES was a prospective, multicenter, nonrandomized all-comers study of 8582 consecutive patients at 11 US and German sites designed to determine the frequency, timing, and correlates of adverse events after drug-eluting stents. Propensity-adjusted multivariable analysis was performed to examine the impact of IVUS guidance on 2-year outcomes. IVUS guidance (n=3361; 39%) compared with angiography guidance (n=5221; 61%) was associated with reduced 2-year adjudicated rates of (1) major adverse cardiac events (cardiac death, MI, or stent thrombosis; 4.9% versus 7.5%; adjusted hazard ratio, 0.72; 95% CI, 0.59-0.89; P=0.003), (2) definite/probable stent thrombosis (0.55% versus 1.16%; adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P=0.003), and (3) MI (3.5% versus 5.6%; adjusted hazard ratio, 0.65; 95% CI, 0.51-0.83; P=0.0006). By landmark analysis, IVUS guidance compared with angiography guidance was also associated with significantly reduced rates of major adverse cardiac events, MI, stent thrombosis, and clinically driven target lesion revascularization between 1 and 2 years after drug-eluting stent implantation. The number needed to treat with IVUS guidance to prevent 1 major adverse cardiac event was reduced from 64 (42-137) at 1 year to 41 (29-69) at 2 years. Conclusions In ADAPT-DES, the early improvement in event-free survival after drug-eluting stent implantation with IVUS guidance compared with angiography guidance was further increased with longer term follow-up to 2 years. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00638794.

Study Objective: Patients with coronary heart disease (CHD) frequently use the combination of a statin and renin-angiotensin-aldosterone system (RAAS) blocker, an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), to control lipid levels and blood pressure, respectively, and the use of ARBs is increasing in Korean patients. Few studies are available, however, that have compared combination therapy with statin-ACEIs versus statin-ARBs. The objective of this study was to evaluate whether ARBs are associated with a reduced risk of major adverse cardiovascular and cerebrovascular events (MACCEs) compared with ACEIs when used in combination with statins in patients with established CHD., Design: Population-based retrospective cohort study., Data Source: Korean National Health Insurance Service-National Sample Cohort database., Patients: A total of 6577 adults who started statin-RAAS blocker combination therapy (1870 in the statin-ACEI cohort and 4707 in the statin-ARB cohort) after being diagnosed with CHD between January 2003 and December 2013 were included. Of these, 3676 propensity score-matched patients (1838 in the statin-ACEI cohort and 1838 in the statin-ARB cohort) were included in the final analyses., Measurements and Main Results: The primary outcome was MACCE (major adverse cardiovascular and cerebrovascular events), a composite of cardiovascular mortality, nonfatal myocardial infarction (MI), ischemic stroke, and revascularization. Incidences and incidence rates of MACCE were calculated to estimate the differences between the two cohorts. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by using a Cox proportional hazard model. The incidence of MACCE was 19.9% and 14.7%, and incidence rates were 11.7 and 8.1 per 100 person-years in the statin-ACEI and statin-ARB cohorts, respectively. The risk of MACCE was significantly lower in the statin-ARB cohort (adjusted HR 0.69, 95% CI 0.59-0.81)., Conclusion: A MACCE was less likely to occur in patients who received a statin-ARB than in those who received a statin-ACEI. Similar trends were seen in cardiovascular mortality and the occurrence of recurrent MI but not stroke. The availability of statin-ARB fixed-dose combinations may have contributed to the improved outcomes in the statin-ARB cohort by reducing pill burden and improving medication adherence. Further research is warranted to validate our findings and to address whether a particular statin-ARB combination is more effective than other combinations., (© 2018 Pharmacotherapy Publications, Inc.)

Objective: Evaluate the impact of anxiety and depression on morbidity and mortality of patients with acute coronary syndrome., Method: Retrospective cohort study, with follow-up of two years, conducted with 94 patients. The morbidity and mortality (readmission, myocardial revascularization, and death) was evaluated immediately after discharge and after one and two years. Anxiety and depression were evaluated by the State-Trait Anxiety Inventory and by Beck's Depression Inventory. The Kaplan-Meier estimator and the Logrank test were used. The significance level adopted was 0.05., Results: We observed that 76.6% of the patients did not present symptoms of depression or had mild signs, while 78.8% had low to moderate anxiety. The symptoms of depression and anxiety were not related to morbidity (need for MR p=0.098 and 0.56, respectively; readmission p=0.962 and 0.369, respectively) and mortality (p=0.434 and 0.077, respectively)., Conclusion: No relationship was found between levels of anxiety and depression with the morbidity and mortality of patients.

Background Mortality from cardiovascular diseases is particularly high in Russia compared with the European average. The National Priority Project 'Health', launched in 2005, aimed to promote prevention of non-communicable diseases, particularly cardiovascular diseases, in primary care and to increase availability of state-of-art cardiovascular disease management. Methods This is a multiregional population based study with analysis of indicators for cardiovascular health and coronary heart disease in Moscow, St Petersburg, the Moscow region and across Russia, including a total population of 143.7 million inhabitants between 2005 and 2013. Data were collected using conventional methodology and originate from open statistical sources. Results The overall age-standardized coronary heart disease mortality decreased in 2005-2013 by 24.7% from 383.6 to 289.0 per 100000 population, but with substantial interregional differences: it declined from 306.1 to 196.9 per 100,000 in Moscow (-35.7%), from 362.1 to 258.9 per 100,000 in St Petersburg (-28.5%) and from 433.8 to 374.3 per 100,000 in the Moscow region (-13.7%). Income in Moscow exceeded the national average 2-3-fold, and Moscow had the highest availability of modern treatments and interventions. Although vegetables, fruits and fish consumption increased overall in Russia, this trend was most prominent in Moscow. Indicators for psychosocial well-being also were best in Moscow. Life expectancy in Moscow is almost six years higher than the Russian average. Conclusion Health policy interventions turned out to be successful but with substantial interregional differences. Lower coronary heart disease mortality and higher life expectancy in Moscow may be due to a more favourable socioeconomic and psychological environment, more healthy eating and greater availability of medical care.

Aims: Recent findings have demonstrated the important contribution of inflammation to the risk of cardiovascular disease (CVD) in individuals with optimally managed low density lipoprotein cholesterol (LDL-C). We explored relationships between LDL-C, high sensitivity C-reactive protein (hs-CRP), and clinical outcomes in a free-living US population., Methods and Results: We used data from the REasons for Geographical And Racial Differences in Stroke (REGARDS), and selected individuals at 'high risk' for coronary events with a Framingham Coronary Risk Score of ≥10% or atherosclerotic cardiovascular disease (ASCVD) risk ≥7.5% in order to explore relationships between low LDL-C [<70 mg/dL (1.8 mmol/L) in comparison to ≥70 mg/dL (1.8 mmol/L)]; hs-CRP <2 compared with ≥2 mg/L and clinical outcomes [all-cause mortality, incident coronary heart disease (CHD), and incident stroke]. To assess the association between the LDL-C and hs-CRP categories and each outcome, a series of incremental Cox proportional hazards models were employed on complete cases. To account for missing observations, the most adjusted model was used to interrogate the data using multiple imputation with chained equations (MICE). In this analysis, 6136 REGARDS high-risk participants were included. In the MICE analysis, participants with high LDL-C (≥70 mg/dL) and low hs-CRP (<2 mg/L) had a lower risk of incident stroke [hazard ratio (HR) 0.69, 0.47-0.997], incident CHD (HR 0.71, 0.53-0.95), and CHD death (HR 0.70, 0.50-0.99) than those in the same LDL-C category high hs-CRP (≥2 mg/L). In participants with high hs-CRP (≥2 mg/dL), low LDL-C [<70 mg/dL (1.8 mmol/L)] was not associated with additional risk reduction of any investigated outcome, but with the significant increase of all-cause mortality (HR 1.37, 1.07-1.74)., Conclusions: In this high-risk population, we found that low hs-CRP (<2 mg/L) appeared to be associated with reduced risk of incident stroke, incident CHD, and CHD death, whereas low LDL-C (<70 mg/dL) was not associated with protective effects. Thus, our results support other data with respect to the importance of inflammatory processes in the pathogenesis of CVD.

Objective: To evaluate if obstructive sleep apnoea (OSA) modifies the risk of coronary heart disease, type 2 diabetes (T2D) and diabetic complications in a gender-specific fashion., Design and Setting: A longitudinal population-based study with up to 25-year follow-up data on 36 963 individuals (>500 000 person years) from three population-based cohorts: the FINRISK study, the Health 2000 Cohort Study and the Botnia Study., Main Outcome Measures: Incident coronary heart disease, diabetic kidney disease, T2D and all-cause mortality from the Finnish National Hospital Discharge Register and the Finnish National Causes-of-Death Register., Results: After adjustments for age, sex, region, high-density lipoprotein (HDL) and total cholesterol, current cigarette smoking, body mass index, hypertension, T2D baseline and family history of stroke or myocardial infarction, OSA increased the risk for coronary heart disease (HR=1.36, p=0.0014, 95% CI 1.12 to 1.64), particularly in women (HR=2.01, 95% CI 1.31 to 3.07, p=0.0012). T2D clustered with OSA independently of obesity (HR=1.48, 95% CI 1.26 to 1.73, p=9.11×[Formula: see text]). The risk of diabetic kidney disease increased 1.75-fold in patients with OSA (95% CI 1.13 to 2.71, p=0.013). OSA increased the risk for coronary heart disease similarly among patients with T2D and in general population (HR=1.36). All-cause mortality was increased by OSA in diabetic individuals (HR=1.35, 95% CI 1.06 to 1.71, p=0.016)., Conclusion: OSA is an independent risk factor for coronary heart disease, T2D and diabetic kidney disease. This effect is more pronounced even in women, who until now have received less attention in diagnosis and treatment of OSA than men., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We aimed at comparing 2 a-priori -Mediterranean Adequacy Index (MAI), the Median Score (MED) - versus 2 a-posteriori, -Factor Analysis (FA2) and Principal Components analysis (PC2)- dietary scores in 1214 CHD-free men aged 45-64 belonging to the Italian Rural Areas of the Seven Countries Study examined in 1965 and followed-up for mortality during 40 years. CHD death was the end-point. Collection of dietary history allowed to define 17 main food groups expressed in gr/day and to compare dietary scores, each divided into 3 classes. Kaplan-Meier curves showed higher survival for classes 2 and 3 (healthy) versus class 1 (unhealthy), but the log-rank test was not significant for the 2 a-priori scores. Cox proportional hazards models showed similar significant findings comparing class 3 with class 1 in the a-posteriori scores FA2 and PC2, with hazards ratios of 0.48 and 0.43, that became 0.65 and 0.53 respectively after adjusting for six specific risk factors for CHD (age, cigarette smoking, systolic blood pressure, serum cholesterol, body mass index and physical activity). Food intake of class 3 in all 4 scores matched rather well the characteristics of the Mediterranean Diet. The poor performance of a-priori dietary scores was partly explained by the unexpected and direct relationship of fruit intake with CHD deaths. The superiority of a-posteriori dietary patterns could be in turn due to the specificity of the study population. External validations and comparisons of a-priori versus a-posteriori dietary patterns in larger cohorts, using the same 17 food groups explored here, are urgently needed.

Objectives: To use restricted mean survival time, which summarizes treatment effects in terms of event-free time over a fixed time period, to evaluate the benefit of pravastatin therapy for primary prevention of cardiovascular disease in older adults., Design: Secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial-Lipid-Lowering Trial (ALLHAT-LLT)., Setting: Ambulatory setting., Participants: Individuals aged 65 and older (mean aged 71, 49% female) free of cardiovascular disease (N=2,867)., Intervention: Pravastatin 40 mg/d (n=1,467) versus usual care (n=1,400)., Measurements: We estimated the difference in RMST for total and coronary heart disease (CHD)-free survival between the pravastatin and usual care groups over the 6-year trial period and used parametric survival models to estimate RMST differences projected over 10 years., Results: Over 6 years, individuals treated with pravastatin lived (RMST 2,008.1 days), on average, 33.7 fewer days than those receiving usual care (RMST 2,041.8 days) (difference -33.7 days, 95% confidence interval (CI)=-67.0 to -0.5 days, p=.047). Pravastatin-treated individuals lived RMST 2,088.1 days), on average, 18.7 more days free of CHD over 6 years than those receiving usual care (RMST 2,069.4 days), but this difference was not statistically significant (difference 18.7 days, 95% CI=-10.4-47.8 days, p=.21). The 10-year projection showed that pravastatin-treated individuals would live 108.1 fewer days (95% CI=-204.5 to -14.1, p=.03) than those receiving usual care, although treated individuals would gain 77.9 days (95% CI=3.8-159.6, p=.046) of CHD-free survival., Conclusion: RMST provides an intuitive and explicit way to express the effect of pravastatin therapy on CHD-free and overall survival in older adults free of cardiovascular disease. This measure allows a more personalized interpretation than hazard ratios of the benefits and risks of a medical intervention for decision-making., (© 2018, Copyright the Author Journal compilation © 2018, The American Geriatrics Society.)

Background: Unhealthy diet, especially consumption of trans fatty acids (TFAs), is a known risk factor for cardiovascular disease (CVD), a leading cause of death in Austria. In 2009, Austria introduced a law regulating the content of TFAs in foods. The aim of this study was to assess the impact of the TFA regulation on CVD-related outcomes., Methods: The study evaluated the TFA regulation as an intervention in a natural experiment. Two study periods were assessed: pre-intervention (1995-2009) and post-intervention (2010-14). The study compared the age-standardized death rates per 100 000 population for CVD outcomes with those of a 'synthetic' international comparator population, created from data of OECD countries where TFA regulation has not been implemented, but where the population is otherwise comparable., Results: There was a continuous decrease in CVD-related mortality throughout the study period in both the synthetic international comparator population, as well as in the adult Austrian population, with no significant change in this trend observed as an effect of TFA regulation., Conclusions: Whilst the results are counterintuitive, given the established link between TFA consumption and an increased risk of CVD, there are many possible explanations: high prevalence of tobacco smoking, changes in TFA content in foods due to international guidance as opposed to formal regulation and a beneficial impact of TFA regulation on sub-groups of the population that might not be detected with nationally aggregated data. However, reduction in TFAs should still be considered an important part of risk factor reduction for CVD and other non-communicable diseases.

Background: Novel cardiac biomarkers including soluble suppression of tumorigenicity 2, galectin-3, and the N-terminal prohormone of brain natriuretic peptide may be associated with long-term adverse outcomes after cardiac surgery. We sought to measure the association between cardiac biomarker levels and 1-year hospital readmission or mortality., Methods: Plasma biomarkers from 1,047 patients discharged alive after isolated coronary artery bypass graft surgery from 8 medical centers were measured in a cohort from the Northern New England Cardiovascular Disease Study Group between 2004 and 2007. We evaluated the association between preoperative and postoperative biomarkers and 1-year readmission or mortality using Kaplan-Meier estimates and Cox proportional hazards modeling, adjusting for covariates used in The Society of Thoracic Surgeons 30-day readmission model., Results: The median follow-up time was 365 days. After adjustment for established risk factors, above-median levels of postoperative galectin-3 (median 10.35 ng/mL; hazard ratio, 1.40; 95% confidence interval, 1.08 to 1.80; p = 0.010) and N-terminal prohormone of brain natriuretic peptide (median = 15.21 ng/mL, hazard ratio, 1.42; 95% confidence interval, 1.07 to 1.87; p = 0.014) were each significantly associated with 1-year readmission or mortality., Conclusions: In patients undergoing cardiac surgery, novel cardiac biomarkers were associated with readmission or mortality independent of established risk factors. Measurement of these biomarkers may improve our ability to identify patients at highest risk for readmission or mortality before discharge. This will also allow resource allocation accordingly, while implementing strategies for personalized medicine based on the biomarker profile of the patient., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice., Objective: The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources., Methods: Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results., Results: At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966)., Conclusions: At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.

Purpose: Serum calcium and phosphorus abnormalities are associated with cardiovascular disorders in general population, but evidence among patients with established coronary heart disease (CHD) is limited and controversial. This study aimed to investigate the associations of baseline serum calcium and phosphorus levels with long-term mortality risk among patients with CHD., Methods: We conducted a prospective cohort study among 3187 patients with CHD from October 2008 and December 2011 in China. Cox proportional hazards model was used to assess the associations of serum calcium and phosphorus at baseline with the risk of death., Results: During follow-up (mean, 4.9 years), 295 patients died, 193 of which resulted from cardiovascular causes. Multivariable-adjusted hazard ratios (HR) for each 1 mmol/L increase in serum calcium at baseline were 0.27 (95% confidence interval (CI) 0.14-0.51) for all-cause mortality and 0.26 (95% CI 0.12-0.54) for cardiovascular mortality. Patients in the highest compared to the lowest quartile of serum calcium were at lower risk of all-cause mortality (HR, 95% CI 0.57, 0.40-0.82) and cardiovascular mortality (0.50, 0.32-0.79) (both P trend  < 0.001). This inverse association between serum calcium and the risk of mortality did not change when participants were stratified by sex, age groups, level of overweight, types of CHD, and history of diabetes. We also observed a graded positive association between baseline serum phosphorus and the risks of mortality., Conclusions: The present study is the first to report that lower serum calcium at baseline is associated with an increased risk of all-cause and cardiovascular mortality in a Chinese coronary heart disease cohort. Further studies are required to investigate the causal relationship and actual mechanisms.

The Dietary Guidelines for Americans 2015⁻2020 (DGA) provides recommendations for consuming a specific amount and variety of vegetables, but no studies have assessed the relationship between DGA-recommended vegetable variety and risk of mortality. We prospectively assessed the relationship between vegetable amount and variety and the risk of mortality using nationally-representative survey data ( n = 29,133). Hazard ratios were estimated using survey-weighted, multivariate, Cox-proportional hazards models. Mean follow-up time was 6.5 years (12.8 years maximum). Total deaths from all causes were 2861, which included 829 deaths from cardiometabolic disease (556 coronary heart disease, 170 stroke, and 103 diabetes). Compared to individuals who reported consuming the greatest amount of vegetables daily, those with the least intake had a 78% greater risk of mortality from all causes (HR: 1.78, 95% CI: 1.29⁻2.47), a 68% greater risk of death from cardiovascular disease (1.68, 1.08⁻2.62), and an 80% greater risk of death from coronary heart disease (1.80, 1.09⁻2.08). No relationships were observed between vegetable variety and risk of all-cause or cause-specific mortality. Greater vegetable amount, but not variety, was associated with a reduced risk of mortality from all causes, cardiovascular disease, and coronary heart disease. Additional large-scale longitudinal studies with repeated measures of dietary exposure are needed.

Objective: We aimed to evaluate the criterion validity of the 2015 food-based Dutch dietary guidelines, which were formulated based on evidence on the relation between diet and major chronic diseases., Design: We studied 9,701 participants of the Rotterdam Study, a population-based prospective cohort in individuals aged 45 years and over., Method: Dietary intake was assessed at baseline with a food-frequency questionnaire. For all participants, we examined adherence (yes/no) to fourteen items of the guidelines: vegetables (≥200g/d), fruit (≥200g/d), whole-grains (≥90g/d), legumes (≥135g/wk), nuts (≥15g/d), dairy (≥350g/d), fish (≥100g/wk), tea (≥450mL/d), ratio whole-grains:total grains (≥50%), ratio unsaturated fats & oils:total fats (≥50%), red and processed meat (<300g/wk), sugar-containing beverages (<150mL/d), alcohol (<10 g/d) and salt (≤6g/d). Total adherence was calculated as sum-score of the adherence to the individual items (0-14). Information on disease incidence and all-cause mortality was collected during a median follow-up period of 13.5 years (range 0-27.0)., Results: Using Cox proportional-hazards models adjusted for confounders, we observed that every additional component adhered to was associated with a 3% lower mortality risk (HR=0.97,95% CI=0.95 - 0.98), lower risk of stroke (HR=0.95,95%CI 0.92;0.99), chronic obstructive pulmonary disease (HR=0.94,95%CI=0.91-0.98), colorectal cancer (HR=0.90,95%CI=0.84;0.96), and depression (HR=0.97,95%CI=0.95-0.999), but not with incidence of coronary heart disease, type 2 diabetes, heart failure, lung cancer, breast cancer, or dementia., Conclusion: Adherence to the Dutch dietary guidelines was associated with a lower mortality risk and a lower risk of developing some but not all of the chronic diseases on which the guidelines were based.

Background: Although coronary computed tomographic angiography (CTA) improves diagnostic certainty in the assessment of patients with stable chest pain, its effect on 5-year clinical outcomes is unknown., Methods: In an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years., Results: The median duration of follow-up was 4.8 years, which yielded 20,254 patient-years of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P=0.004). Although the rates of invasive coronary angiography and coronary revascularization were higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard-care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause., Conclusions: In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization. (Funded by the Scottish Government Chief Scientist Office and others; SCOT-HEART ClinicalTrials.gov number, NCT01149590 .).

Background/objectives: The Oslo diet and antismoking study showed that counselling for a healthy lifestyle reduced lifelong coronary mortality in high-risk men. We explored whether the same counselling reduced also cancer risk., Methods: The study randomly allocated males at high coronary risk to either a 5-year intervention for lifestyle changes (cholesterol-lowering dietary changes, weight loss and stopping smoking) or a control group (1 : 1) in 1972/73. We explored the incidence and mortality of all cancers and cancer forms related to smoking, BMI or diet up to 43 years after randomization., Results: A total of 595 men in the intervention and 621 in the control group were included. At inclusion median age was 45 years, 588 (48.4%) subjects were overweight (BMI > 25 kg m -2 ) and 925 (76.1%) current smokers. The intervention did not reduce the risk of cancer after 43 years (adjusted hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.80-1.15). In the first 25 years of follow-up, among the 1088 (89.5%) men who were overweight/obese and/or smokers, the intervention reduced the incidence of those cancer forms related to smoking, BMI or diet (including carcinoma of the respiratory, digestive and urinary tracts; adjusted HR 0.69; 95% CI 0.49-0.99). The intervention had no significant effect on incidence beyond 25 years, or on mortality., Conclusions: The 5-year counselling for a healthy lifestyle did not reduce the overall cancer risk in the very long term. However, in the first 25 years, the counselling reduced the risk of relevant cancer types in overweight/obese subjects and smokers., (© 2018 The Association for the Publication of the Journal of Internal Medicine.)

Objective: The obesity paradox in which overweight/obesity is associated with mortality benefits is believed to be explained by confounding and reverse causality rather than by a genuine clinical benefit of excess body weight. We aimed to gain deeper insights into the paradox through analyzing mortality relationships with several adiposity measures; assessing subgroups with type 2 diabetes, with coronary heart disease (CHD), with cancer, and by smoking status; and adjusting for several confounders., Research Design and Methods: We studied the general UK Biobank population ( N = 502,631) along with three subgroups of people with type 2 diabetes ( n = 23,842), CHD ( n = 24,268), and cancer ( n = 45,790) at baseline. A range of adiposity exposures were considered, including BMI (continuous and categorical), waist circumference, body fat percentage, and waist-to-hip ratio, and the outcome was all-cause mortality. We used Cox regression models adjusted for age, smoking status, deprivation index, education, and disease history., Results: For BMI, the obesity paradox was observed among people with type 2 diabetes (adjusted hazard ratio for obese vs. normal BMI 0.78 [95% CI 0.65, 0.95]) but not among those with CHD (1.00 [0.86, 1.17]). The obesity paradox was pronounced in current smokers, absent in never smokers, and more pronounced in men than in women. For other adiposity measures, there was less evidence for an obesity paradox, yet smoking status consistently modified the adiposity-mortality relationship., Conclusions: The obesity paradox was observed in people with type 2 diabetes and is heavily modified by smoking status. The results of subgroup analyses and statistical adjustments are consistent with reverse causality and confounding., (© 2018 by the American Diabetes Association.)

Objective: This study sought to characterise the main dyslipidaemic phenotypes present in chronic kidney disease (CKD) and their association with coronary heart disease (CHD) risk., Methods: Analyses included 6612 individuals in the multiethnic study of atherosclerosis free of CHD at baseline. CKD was defined as an estimated glomerular filtration rate (eGFR) of 15 to <60 mL/min/1.73 m 2 (stages 3-4). Principal component analyses were used to characterise the main dyslipidaemic phenotypes of CKD accounting for the correlation among different lipoproteins and lipoprotein particles. CHD was defined as incident myocardial infarction, angina followed by revascularisation, resuscitated cardiac arrest or CHD death., Results: CHD developed in 303 individuals (5%) with eGFR ≥60 and in 72 individuals (12%) with CKD (p for difference <0.001). A dyslipidaemic phenotype (principal component 1 (PC1)) consisting of elevations in triglycerides, triglyceride-rich lipoproteins (VLDL particles), small LDL particles and reductions in HDL particles, was more common in those with CKD, compared with those without CKD (p for difference <0.001). This phenotype was also more strongly associated with CHD in those with CKD: adjusted HRs (95% CIs) per SD increase in PC1 1.13 (95% CI 1.00 to 1.27; P=0.05) and 1.51 (95% CI 1.17 to 1.94; P<0.001) in eGFR ≥60 and CKD, respectively (P for interaction=0.05)., Conclusion: In individuals with mainly stage 3 CKD, a dominant lipid phenotype consisting of triglyceride-rich lipoproteins and other closely correlated lipoproteins is strongly associated with CHD risk. Future studies should investigate whether modification of the components of this phenotype leads to a reduction in the CHD burden in individuals with CKD., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

This study aims to evaluate the impact of co-morbidity burden on outcomes in patients who undergo percutaneous coronary intervention (PCI). We used the Nationwide Inpatient Sample to identify all PCI procedures undertaken in the United States from 2004 to 2014. We then determined co-morbidity burden for each patient record based on the Charlson Co-morbidity Score. Multivariable logistic regression models were used to examine the association between co-morbidity burden and in-hospital mortality other in-hospital complications. A total of 6,601,526 PCI procedures were included in the analysis. Overall co-morbidity burden increased over time, with severe co-morbidity burden (defined as a CCI score ≥3) increasing from 5.3% in 2004 to 14.2% in 2014 (p <0.0001). After adjustment for confounding factors increasing co-morbidity burden was independently associated with increased odds of in-hospital mortality, complications, length of hospital stay, and total cost of hospitalization post PCI. A CCI score of 1 was independently associated with an increase in the odds of in hospital mortality (odds ratio [OR] 1.19 [95% confidence interval [CI] 1.15 to 1.25]), a score of 2 associated with an almost 1.5-fold increase (OR 1.41 [95% CI 1.34 to 1.48]) and a score of ≥3 a 2-fold increase (OR 1.96 [95% CI 1.86 to 2.07]) compared with no co-morbid burden (CCI score of 0). In conclusion, our results show that co-morbid burden is independently associated with increased risk of in-hospital mortality, in-hospital complications, length of stay, and healthcare costs., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background Visceral adipose tissue ( VAT ) and other measures of central obesity predict incident atherosclerotic cardiovascular disease ( ASCVD ) events in middle-aged individuals, but these associations are less certain in older individuals age 70 years and older. Our objective was to estimate the associations of VAT and the android-gynoid fat mass ratio, another measure of central obesity, with incident ASCVD events among a large cohort of older men. Methods and Results Two thousand eight hundred ninety-nine men (mean [ SD ] age 76.3 [5.5] years) enrolled in the Outcomes of Sleep Disorders in Older Men study had rigorous adjudication of incident ASCVD events (myocardial infarction, coronary heart disease death, or fatal or nonfatal stroke). We used proportional hazards models to estimate the hazard ratios for incident ASCVD per SD increase of VAT or android-gynoid fat mass ratio (measured at baseline with dual-energy absorptiometry), adjusted for age, race, education, systolic blood pressure, smoking status, oxidized low-density lipoprotein level, treatment for hypertension, statin use, aspirin use, presence of diabetes mellitus, and study enrollment site. Over a mean ( SD ) follow-up period of 7.9 (3.4) years, 424 men (14.6%) had an incident ASCVD event. Neither VAT nor android-gynoid fat mass ratio were associated with incident ASCVD events, either unadjusted or after multivariable-adjustment (hazard ratios [95% confidence interval ] per SD increase 1.02 [0.92-1.13] and 1.05 [0.95-1.17], respectively). Conclusions Central adipose tissue, as measured by VAT or android-gynoid fat mass ratio, was not associated with incident ASCVD events in this study of older men.

Background: Mendelian randomization data suggest that the genetic determinants of lifetime higher triglyceride-rich lipoprotein-cholesterol (TRL-C) are causally related to cardiovascular disease and therefore a potential therapeutic target. The relevance of TRL-C among patients receiving statins is unknown. We assessed the relationship between TRL-C and cardiovascular risk, and whether this risk was modifiable among patients receiving statins in the TNT trial (Treating to New Targets)., Methods: Patients with coronary heart disease and low-density lipoprotein cholesterol (LDL-C) 130 to 250 mg/dL entered an 8-week run-in phase with atorvastatin 10 mg/d (ATV10). After this period, participants with LDL-C <130 mg/dL entered the randomized phase with ATV10 (n=5006) versus atorvastatin 80 mg/d (ATV80, n=4995). The primary end point was coronary heart disease death, nonfatal myocardial infarction, resuscitated cardiac arrest, or stroke (major adverse cardiovascular events [MACE]). TRL-C was calculated as total cholesterol minus high-density lipoprotein cholesterol minus LDL-C. The effect of atorvastatin on TRL-C was assessed during the run-in phase (ATV10) and randomized phase (ATV80 versus ATV10). The risk of MACE was assessed across quintiles (Q) of baseline TRL-C (and, for comparison, by baseline triglycerides and non-high-density lipoprotein cholesterol) during the randomized period. Last, the association between TRL-C changes with atorvastatin and cardiovascular risk was assessed by multivariate Cox regression., Results: ATV10 reduced TRL-C 10.7% from an initial TRL-C of 33.9±16.6 mg/dL. ATV80 led to an additional 15.4% reduction. Cardiovascular risk factors positively correlated with TRL-C. Among patients receiving ATV10, higher TRL-C was associated with higher 5-year MACE rates (Q1=9.7%, Q5=13.8%; hazard ratio Q5-versus-Q1, 1.48; 95% confidence interval, 1.15-1.92; P-trend<0.0001). ATV80 (versus ATV10) did not significantly alter the risk of MACE in Q1-Q2, but significantly reduced risk in Q3-Q5 (relative risk reduction, 29%-41%; all P<0.0250), with evidence of effect modification ( P-homogeneity=0.0053); results were consistent for triglycerides ( P-homogeneity=0.0101) and directionally similar for non-high-density lipoprotein cholesterol ( P-homogeneity=0.1387). Last, in adjusted analyses, a 1 SD percentage reduction in TRL-C with atorvastatin resulted in a significant lower risk of MACE (hazard ratio, 0.93; 95% confidence interval, 0.86-1.00; P=0.0482) independent of the reduction in LDL-C and of similar magnitude to that per 1 SD lowering in LDL-C (hazard ratio, 0.89; 95% confidence interval, 0.83-0.95; P=0.0008)., Conclusions: The present post hoc analysis from TNT shows that increased TRL-C levels are associated with an increased cardiovascular risk and provides evidence for the cardiovascular benefit of lipid lowering with statins among patients who have coronary heart disease with high TRL-C., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00327691.