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OBJECTIVE: As a measure of socioeconomic status, low educational level is positively associated with the risk of developing adverse health events. The aim of this study was to investigate the relationship between the level of education and the risk of developing non- fatal acute coronary syndromes. METHODS: During 2000 and 2001, 1619 randomly selected subjects from several regions of Greece were entered into a case-control study. Of these, 750 were patients with their first acute coronary heart syndrome event, and 869 were hospitalized controls with no cardiovascular disease in their medical history. Trends in cardiovascular risk factors were then examined across patient and control educational level by years of schooling. FINDINGS: In both patients and controls, education status was related to economic and occupation status, smoking habits, physical inactivity, alcohol consumption and non-compliance to treatment. After adjusting for these and other conventional risk factors, as well as for the effects of age and sex, we found that coronary risk increases by 82% (odds ratio (OR) = 1.82, P

Abstract Carcinoid is a rare malignancy originating from enterochromaffin cells and is clinically characterized by flushing, diarrhea and bronchospasm, due to secretion of vasoactive substances. A dreaded complication is carcinoid heart disease, which mainly affects right cardiac chambers, resulting in thickened, immobile and retracted tricuspid and pulmonary valves. In the current report, a case of a 60-year old female presenting with symptoms of right heart failure is described. Transthoracic two-dimensional and real-time three-dimensional echocardiography findings, as well as biochemical markers, including pro-BNP and NT-pro-BNP, were consistent with carcinoid syndrome. The histological diagnosis of carcinoid was confirmed after surgical resection of an ovarian mass.

Abstract Background Elevated liver enzymes are markers of liver steatosis and metabolic syndrome. We aimed to investigate the association of Mediterranean diet on the relationship between aminotransferases (i.e., AST, ALT, gGT) and the metabolic syndrome. Methods The ATTICA study has randomly enrolled 1514 adult males (18–87 yrs) and 1528 females (18–89 yrs) from the greater area of Athens. Adherence to Mediterranean diet was assessed through the MedDietScore. According to NCEP III criteria, participants were classified into those with or without the metabolic syndrome. Results Women with metabolic syndrome had higher γGT (p = 0.02) and lower AST/ALT levels (p = 0.018) than those without, and men with metabolic had a lower AST/ALT ratio (p = 0.01) compared to those without metabolic syndrome. The AST/ALT ratio was also positively correlated with MedDietScore (rho = 0.17, p < 0.001), while higher MedDietScore was associated with lower likelihood of having the metabolic syndrome in a multi-adjusted analysis (OR = 0.34, 95% CI: 0.16–0.73). Stratified analysis by the level of adherence to the Mediterranean diet, revealed that only in subjects away or with moderate adherence to the Mediterranean diet, an increase in the AST/ALT ratio was associated with lower likelihood of having the metabolic syndrome (OR = 0.33, p < 0.05 and OR = 0.34, p < 0.09, respectively); however, when we focused in those with greater adherence to the Mediterranean diet, AST/ALT ratio was not associated with the presence of the syndrome (OR = 0.51, p = 0.55). These findings remained similar in both genders, and even when the quantity of alcohol drinking was taken into account. Conclusion Aminotransferases ratio constitutes a marker of the metabolic syndrome among healthy adults; however, this relationship is moderated when individuals are close to the Mediterranean dietary pattern.

Abstract Background Lipoprotein-associated phospholipase A2 (Lp-PLA2) also known as serum platelet activating factor acetylhydrolase (PAF-AH) activity constitutes a novel risk marker for cardiovascular disease. Leukocytes constitute one main cellular source of circulating Lp-PLA2. The aim of the present study was to evaluate the association of both serum and leukocyte PAF-AH activities with fat distribution and lean tissue. One hundred healthy volunteers without cardiovascular disease history participated in this study (n = 52 men, 44 ± 13 years and n = 48 women, 43 ± 13 years). Body composition was assessed with dual-energy X-ray absorptiometry, while anthropometrical indices were also measured. The activity of Lp-PLA2 and levels of lipid and glycemic parameters were determined in fasting samples. Results Mean Lp-PLA2 activity was 24.8 ± 4.5 and 19.6 ± 5.0 nmol/min/mL in men and women, respectively (P < 0.001). Mean activity of PAF-AH in leukocyte homogenates was 386 ± 127 pmol/min/mg and 292 ± 92 pmol/min/mg in men and women, correspondingly (P < 0.001). In multiple regression models upper and total adiposity measures were positively associated with Lp-PLA2 activity in men after adjusting for LDL-cholesterol, age, smoking, hs-CRP and physical activity, whereas no associations were found with PAF-AH leukocyte homogenates activity. Hierarchical analysis revealed that the variables with the highest explanatory ability of Lp-PLA2 activity in men, were DXA deriving L1–L4 region of interest and arms fat (increase in R2 = 0.136, P = 0.005 and increase in R2 = 0.118, P = 0.009, respectively), followed by trunk fat and total fat. In women, no association of body composition variables with Lp-PLA2 nor PAF-AH leukocyte homogenates activity was found. Conclusion Lp-PLA2 activity is differentiated across levels of adiposity and topology of adipose tissue, whereas no association was found regarding PAF-AH leukocyte homogenates activity. Our findings suggest that Lp-PLA2 may compensate for the adiposity-associated increases in inflammatory and oxidative burden, in men.

Abstract Objective In this work we evaluated the 5-year incidence of hypercholesterolemia, in a sample of cardiovascular disease free adult men and women from Greece. We also evaluated the association of several socio-demographic, dietary and lifestyle habits on the incidence of this disorder. Methods 1514 men and 1528 women (>18 y) without any clinical evidence of cardiovascular disease, living in Attica area, Greece, were enrolled in the ATTICA study from May 2001 to December 2002. The sampling was random, multi-stage, and included information about various socio-demographic, lifestyle (diet, exercise, smoking etc), biological (lipids, and inflammatory markers), and clinical characteristics of the participants. In 2006, a group of experts performed the 5-year follow-up through telephone calls or personal visits (941 of the 3042 (31%) participants were lost to follow-up). Hypercholesterolemia, among people who had normal blood lipids at initial examination, was defined as fasting total cholesterol levels > 200 mg/dl or use of lipids lowering agents (NCEP ATPIII). Results The 5-year incidence of hypercholesterolemia was 23.7% (n = 127) in men and 17.7% (n = 110) in women (p for gender differences < 0.001). Multi-adjusted logistic regression analysis which revealed that increased age (odds ratio = 1.05, p < 0.001), waist circumference (odds ratio = 1.02, p = 0.03), fasting blood glucose (odds ratio = 1.01, p = 0.08) and apolipoprotein B (odds ratio = 1.02, p = 0.001) levels, were the most significant baseline predictors of developing hypercholesterolemia within a 5-year period. Conclusion Incidence of hypercholesterolemia was high in both genders, emphasizing the burden of this disorder at population level. Aging, increased waist circumference, fasting blood glucose and apolipoprotein B levels were the most significant baseline predictors of hypercholesterolemia.

Abstract Background We aimed to investigate if overweight and obese adults "close" to Mediterranean diet present better insulin, lipids profile and better pressure levels, compared to individuals close to a more Westernized diet. Methods The ATTICA study is a population-based cohort that has randomly enrolled 3042 adult men and women, stratified by age – gender, from the greater area of Athens, during 2001–2002. Of them, in this work were have studied 1762 participants with excess body weight, meaning overweight (BMI: 25–29.9 kg/m2) and obese (BMI>30 kg/m2). 1064 were men and 698 women (20–89 years old). Adherence to Mediterranean diet was assessed through a diet-score that was based on a validated food-frequency questionnaire. Blood pressure was measured and also fasting glucose, insulin and blood lipids. Insulin sensitivity was also assessed by the homeostasis model assessment (HOMA) approach (glucose × insulin/22.5). Results Individuals with excess bodyweight in the highest tertile of diet score, were more insulin sensitive than those in the lowest tertile (11.4% lower HOMA, p = 0.06), had 13% lower levels of total cholesterol (p = 0.001) and 3 mmHg decrease of systolic blood pressure levels (p < 0.001), when adjusted for age, sex and BMI. Multivariate analysis after taking into account several confounders demonstrated that insulin sensitivity, total cholesterol and systolic blood pressure were independently but only modestly correlated with Mediterranean diet in people with excess bodyweight. Conclusion Adherence to Mediterranean diet is modeslty associated with a better insulin sensitivity, lower levels of total cholesterol and lower levels of systolic blood pressure in overweight and obese subjects. This may suggest that compared to general population, the beneficial effect of this diet in cardiovascular system of excess body weight people is limited.

Abstract Background Hypertension leads to many degenerative diseases, the most common being cardiovascular in origin. This study has been designed to estimate the prevalence of self-reported hypertension in a random nationwide sample of adult Greek population, while focus was set to the assessment of participants' nutritional habits in relation to their hypertension status. Methods A random-digit dialed telephone survey. Based on a multistage, stratified sampling, 5003 adults (18 – 74 yr) participated (men: 48.8%, women: 51.2%). All participants were interviewed via telephone by trained personnel who used a standard questionnaire. The questionnaire included demographic and socioeconomic characteristics, medical history, lifestyle habits and nutritional assessment. Results The prevalence of self-reported hypertension was 13.3% in men and 17.7% in women (P < 0.001). Furthermore, women reported higher values of systolic blood pressure (180 ± 27 mmHg) than men (169 ± 24 mmHg). Positive relationships were found between hypertension status and the prevalence of the rest investigated health conditions (i.e. hypercholesterolaemia, diabetes mellitus, renal failure and obesity). Nutritional assessment showed that consumption of fish, fruits and juices, cereals, and low fat milk and yogurt was significantly higher among hypertensive subjects while the opposite was observed for food items as red meat, pork, egg, pasta and rice, full fat dairy products and desserts. Conclusion Hypertension seems to be a serious public health problem in Greece. It is encouraging that hypertensives may have started adopting some more healthy nutritional behaviour compared to normotensive ones. However, they can gain significant benefits regarding to blood pressure control, if they increase the level of compliance with dietary recommendations.

Abstract Background The strong causal role of hypercholesterolaemia on the progression of atherosclerosis and subsequently on the development of cardiovascular disease is well described. Main aim of this study was to evaluate the prevalence of self-reported hypercholesterolaemia and its relation to nutritional habits, in a representative nationwide sample of adult Greek population. Methods Cross sectional survey. Based on a multistage sampling, 5003 adults (18 – 74 yr) were enrolled (men: 48.8%, women: 51.2%). All participants were interviewed by trained personnel who used a standard questionnaire. The questionnaire included demographic and socioeconomic characteristics, medical history, lifestyle habits and nutritional assessment. Results The prevalence of self-reported hypercholesterolaemia was 16.4% in men and 21.8% in women (P < 0.001). Hypercholesterolaemic status was positively associated with the prevalence of hypertension, diabetes mellitus, renal failure, obesity and physical inactivity, and inversely with the prevalence of smoking. The analysis of reported food consumption patterns showed that consumption of fish, fruits and juices, cereals, and low fat milk and yogurt was significantly higher among hypercholesterolaemic participants while the opposite was observed for food items as red meat, pork, egg, full fat dairy products and desserts. Conclusion Hypercholesterolaemia seems to affect a large part of Greek population. It is hopeful that hypercholesterolaemics may have started adopting some more healthy nutritional behaviour compared to normocholesterolaemic ones.

Abstract Background We aimed to evaluate the prevalence, frequency and type of leisure-time physical activity (LTPA) among adults in Greece, as well as its relationship with socio-demographic, lifestyle and clinical characteristics of these people. Methods From May 2001 to December 2002 we randomly enrolled 1514 men and 1528 women, without any evidence of cardiovascular or any other chronic disease. The sampling was stratified by the age – gender distribution of (census 2001) of the greater area of Athens. Weekly energy expenditure assessed by considering frequency, duration (in minutes) and intensity of sports related physical activity during a usual week. Results 53% of men and 48% of women were classified as physically active. Men were more likely to be active as compared to women (p < 0.05), while the lowest activity rates were observed in 40 to 49 years old participants (p < 0.01). Physically active people had higher occupation skills, were more likely to live in rural areas, to be unmarried, non smokers and they were devoted to a healthier dietary pattern, as compared to sedentary, irrespective of age and sex (all p < 0.05). In addition, the cumulative risk factors score of obesity, hypertension, hypercholesterolemia and diabetes, was inversely associated with activity status (p < 0.001). Finally, physically active men and women were less likely to report depressive symptoms (p < 0.01), after various adjustments were made. Conclusion Half of the studied population reported physically inactive, indicating that sedentary lifestyle becomes a serious epidemic in Greece. High occupation skills, non-smoking, devotion to a healthier dietary pattern and a better cardiovascular risk factors profile were some of the determinants of physically active people.

Abstract Background The present study GREECS was conducted in order to evaluate the annual incidence of acute coronary syndromes (ACS) and to delineate the role of clinical, biochemical, lifestyle and behavioral characteristics on the severity of disease. In this work we present the design, methodology of the study and various baseline characteristics of people with ACS. Methods/Design A sample of 6 hospitals located in Greek urban and rural regions was selected. In these hospitals we recorded almost all admissions due to ACS, from October 2003 to September 2004. Socio-demographic, clinical, dietary, psychological and other lifestyle characteristics were recorded. 2172 patients were included in the study (76% were men and 24% women). The crude annual incidence rate was 22.6 per 10,000 people and the highest frequency of events was observed in winter. The in-hospital mortality rate was 4.3%. The most common discharged diagnosis for men was Q-wave MI, while for women it was unstable angina. Discussion This study aims to demonstrate current information about the epidemiology of patients who suffer from ACS, in Greece.

Abstract Background Epidemiological studies suggest a non-monotonic effect of alcohol consumption on cardiovascular risk, while there is strong evidence concerning the involvement of homocysteine levels on thrombosis. The aim of this work was to evaluate the association between usual ethanol consumption and homocysteine levels, in cardiovascular disease free adults. Methods From May 2001 to December 2002 we randomly enrolled 1514 adult men and 1528 women, without any evidence of cardiovascular disease, stratified by age – gender (census 2001), from the greater area of Athens, Greece. Among the variables ascertained we measured the daily ethanol consumption and plasma homocysteine concentrations. Results Data analysis revealed a J-shape association between ethanol intake (none, 48 gr per day) and total homocysteine levels (mean ± standard deviation) among males (13 ± 3 vs. 11 ± 3 vs. 14 ± 4 vs. 18 ± 5 vs. 19 ± 3 μmol/L, respectively, p < 0.01) and females (10 ± 4 vs. 9 ± 3 vs. 11 ± 3 vs. 15 ± 4 vs. 17 ± 3 μmol/L, respectively, p < 0.01), after controlling for several potential confounders. The lowest homocysteine concentrations were observed with ethanol intake of < 12 gr/day (Bonferroni α* < 0.05). No differences were observed when we stratified our analysis by type of alcoholic beverage consumed. Conclusion We observed a J-shape relationship between homocysteine concentrations and the amount of ethanol usually consumed.

Abstract Background Beta-thalassaemia major (b-TM) has been defined as a combination of chronic hemolytic anemia, iron storage disease and myocarditis, and it has been associated with premature death especially due to heart failure. To the best of our knowledge the status of blood lipids in these patients has rarely been investigated. Thus, we assessed the levels of lipids and lipoproteins in a sample of cardiovascular disease free adult men and women with b-TM. Methods During 2003 we enrolled 192 consecutive patients with b-TM that visited our Institution for routine examinations. The Institution is considered the major reference center for b-TM in Greece. Of the 192 patients, 88 were men (25 ± 6 years old) and 104 women (26 ± 6 years old). Fasting blood lipid levels were measured in all participants. Results Data analysis revealed that 4% of men and 2% of women had total serum cholesterol levels > 200 mg/dl, and 11% of men and 17% of women had triglyceride levels > 150 mg/dl. In addition, mean HDL cholesterol levels were 32 ± 11 mg/dl in men and 38 ± 10 mg/dl in women, lipoprotein-a levels were 8.3 ± 9 mg/dl in men and 8.8 ± 9 mg/dl in women, apolipoprotein-A1 levels were 111 ± 17 mg/dl in men and 123 ± 29 mg/dl in women, and apolipoprotein-B levels were 60 ± 20 mg/dl in men and 59 ± 14 mg/dl in women. Total-to-HDL cholesterol ratios were 3.7 ± 1.2 and 3.8 ± 1.5 in men and women, respectively. Conclusions The majority of the patients had blood lipid levels (by the exception of HDL-cholesterol) within the normal range, and consequently the prevalence of lipid and lipoprotein abnormalities was much lower as compared to the general population of the same age. Interestingly, is that the total – to HDL cholesterol ratio was high in our patients, and may underline the importance of this index for the prognosis of future cardiac events in these patients.

Abstract Background In an attempt to evaluate the levels of several cardiovascular risk factors in Greece we conducted a population-based health and nutrition survey, the "ATTICA study". In this work we present the design and the methodology of the study, as well as the status of various baseline characteristics of the participants. Methods From May 2001 to December 2002 we randomly enrolled 1514 adult men and 1528 adult women, stratified by age – gender (census 2000), from the greater area of Athens. More than 300 demographic, lifestyle, behavioral, dietary, clinical and biochemical variables have been recorded. Results Regarding the frequency of the classical cardiovascular risk factors we observed that 51% of men and 39% of women reported smokers (p < 0.05), 37% of men and 25% of women were defined as hypertensives (p < 0.05), 46% of men and 40% of women had total serum cholesterol levels above 200 mg/dl (p < 0.05) and 8% of men and 6% of women had history of diabetes mellitus. Moreover, 20% of men and 15% of women were obese (p < 0.05), while men were more physically active as compared to women (42% vs. 39%, p < 0.05). 19% of men and 38% of women had mild to severe depressive symptoms (p < 0.01). Finally, 72 men (5%) and 45 (3%) women reported history of coronary heart disease at entry evaluation. Conclusions The prevalence of the common cardiovascular risk factors in our population seems high. As a consequence a considerable proportion of Greek adults are at "high-risk" for future cardiovascular events.

Abstract Background Physical activity has long been associated with reduced risk of coronary heart disease (CHD). In this work we evaluated the effect of physical activity on lipid levels, in a sample of cardiovascular disease free people. Methods The ATTICA study is a population – based cohort that has randomly enrolled 2772 individuals, stratified by age – gender (according to the census 2001), from the greater area of Athens, during 2001–2002. Of them, 1376 were men (45 ± 12 years old, range: 18 – 86) and 1396 women (45 ± 13 years old, range: 18 – 88). We assessed the relationship between physical activity status (measured in kcal/min expended per day) and several lipids, after taking into account the effect of several characteristics of the participants. Results 578 (42%) men and 584 (40%) women were classified as physically active. Compared to sedentary physically active women had significantly lower levels of total serum cholesterol (p < 0.05), LDL (p < 0.05) and oxidized LDL cholesterol (p < 0.05), triglycerides (p < 0.05), apolipoprotein B (p < 0.05), and higher levels of HDL cholesterol (p < 0.05) and apolipoprotein A1 (p < 0.05). Similar associations were observed in men, but the benefits did not reach statistical significance. However, when we adjusted for age, smoking habits and body mass index, physical activity was only significantly associated with higher HDL-cholesterol (p < 0.05) and apolipoprotein A1 (p < 0.05) levels, in women, but not in men. Conclusions Substantial independent increases in HDL-cholesterol and apolipoprotein A1 concentrations were observed in women, but not in men, in a Mediterranean cohort.

Abstract Background The relation between diet and human health has long been investigated. The aim of this work is to evaluate the association between CHD risk and the consumption of fruit and vegetable, in a large sample of cardiac patients and controls. Methods Stratified sampling from all Greek regions, consisted of 848 (700 males, 58 ± 10 years old and 148 females, 65 ± 9 years old) randomly selected patients, admitted to the cardiology clinic for a first event of an acute coronary syndrome (ACS). In addition we selected 1078 frequency paired, by sex-age-region, controls in the same hospitals but without any clinical suspicion of CHD. Using validated food-frequency questionnaires we assessed total diet, including fruit and vegetable intake, on a weekly basis. Multiple logistic regression analysis estimated the relative risk of developing ACS by level of fruits and vegetables intake after taking into account the effect of several potential confounders. Results Data analysis revealed that the benefit of fruit or vegetable consumption increases proportionally by the number of servings consumed (P for trend < 0.001). After adjusting for the conventional cardiovascular risk factors, those in the upper quintile of fruit consumption (5 or more items/day) had 72% lower risk for CHD (odds ratio = 0.28, 95% CI 0.11 – 0.54, P < 0.001), compared with those in the lowest quintile of intake ( Conclusions Consumption of fruits and vegetables seems to offer significant protection against CHD.

Abstract Objectives In this work we investigated the effect of the consumption of the Mediterranean diet on coronary risk, in subjects with the metabolic syndrome. Methods During 2000–2002, we randomly selected, from all Greek regions, 848 hospitalised patients (695 males, 58 ± 10 & 153 females, 65 ± 9 years old) with a first event of acute coronary syndrome and 1078 frequency matched, by sex, age, region controls, without any suspicious for cardiovascular disease. Nutritional habits were evaluated through a validated questionnaire, while the metabolic syndrome was defined according to the NCEP ATP III criteria. Mediterranean diet was defined according to the guidelines of the Division of Nutrition/Epidemiology, of Athens Medical School. Results Of the 1926 participants, 307 (36.2%) of the patients and 198 (18.4%) of the controls (P < 0.001) met the ATP III criteria. This was related with 2fold adjusted coronary risk (odds ratio = 2.35, 95% 1.87 – 2.84) in subjects with the metabolic syndrome as compared with the rest of them. No differences were observed concerning the prevalence of the metabolic syndrome and sex of subjects, after adjustment for group of study (P > 0.1). Eighty (26%) of the patients and 70 (35%) of the controls (P < 0.01) with the metabolic syndrome were "closer" to the Mediterranean diet. Multivariate analysis revealed that the adoption of this diet is associated with a 35% (odds ratio = 0.65, 95% 0.44 – 0.95) reduction of the coronary risk in subjects with the metabolic syndrome, after adjusting for age, sex, educational and financial level and the conventional cardiovascular risk factors. Conclusion Consequently, the adoption of Mediterranean diet seems to attenuate the coronary risk in subjects with the metabolic syndrome.

Abstract Background The purpose of this study was to investigate the association between secondhand smoke and the risk of developing a first event of acute coronary syndromes (ACS), i.e. acute myocardial infarction or unstable angina, among non-smokers, in relation to the presence of several other cardiovascular risk factors. Methods Eight hundred and forty-eight patients with first event of ACS and 1078 cardiovascular disease-free matched controls completed a detailed questionnaire regarding their exposure to secondhand smoke, among other investigated parameters. Results Two hundred and ninety–seven (35%) of the patients and 259 (24%) of the controls were defined as secondhand smokers. After controlling for several potential confounders, the results showed that non-smokers occasionally (< 3 time per week) exposed to cigarette smoke were associated with 26% higher risk of ACS (OR = 1.26, P-value < 0.01) compared to non-smokers not exposed to smoke, while regular exposure is associated with 99% higher risk of developing ACS (OR = 1.99, P-value < 0.001). Moreover, the previous risk increases progressively from 15% to 256% if one or more of the classical cardiovascular risk factors (i.e. hypertension, hypercholesterolemia, diabetes mellitus, sedentary life and family history of premature coronary heart disease) are present. Conclusions Consequently, this study supports the hypothesis that even occasional secondhand smoke increases the risk of developing acute coronary syndromes, especially when other risk factors are present. Given the high prevalence of cigarette smoking, the public health consequences of passive smoking with regard to coronary heart disease are important.

The aim of this study was to evaluate the potential interplay between a carbohydrate diet and inflammation in atherosclerotic cardiovascular disease (ASCVD) development. ATTICA is a prospective observational study of 3042 adults free of cardiovascular disease (CVD) who were recruited in 2002 and followed for 20 years. Baseline data on carbohydrate intake and inflammatory biomarker levels were collected. Participants were stratified by carbohydrate intake (low vs. high: 190 g/day) and carbohydrate quality. At the 20-year follow-up in 2022, 1988 participants had complete data for CVD assessment. The overall quantity and quality of carbohydrate intake did not show a significant association with CVD incidence; inflammatory markers were positively correlated with an increased risk of CVD (p-values < 0.05). Chronic systemic inflammation seems to affect the CVD risk of participants who had a higher carbohydrate intake more substantially, as compared to those with low intake. Additionally, individuals with higher high carbohydrate/low fiber intake experienced a higher risk of inflammation-related CVD, compared to those with high carbohydrate/high fiber intake. The presented findings revealed that the effect of inflammation markers on the CVD risk is influenced both by the amount and quality of carbohydrate intake, irrespective of overall dietary habits and clinical and lifestyle characteristics. [ABSTRACT FROM AUTHOR]