Effects of Cardiac Rehabilitation and Diet Counselling on Adherence to the Mediterranean Lifestyle in Patients after Myocardial Infarction.

Adherence to the Mediterranean lifestyle­as captured by the Medlife Index Questionnaire (i.e., encompassing a Mediterranean diet as well as other aspects of healthy living, such as food preparation, physical activity, and socializing)­has been associated with reduced cardiovascular events in healthy individuals. In the present study, we sought to determine the adherence to, and the effect of comprehensive cardiac rehabilitation on, Mediterranean lifestyle adherence in patients after myocardial infarction. We included 121 patients (mean age, 55 years; women, 37%) undergoing comprehensive cardiac rehabilitation­i.e., exercise training 3 times per week for 12 weeks plus dedicated workshops promoting the Mediterranean lifestyle. Before and after cardiac rehabilitation, patients completed the Medlife Index Questionnaire. High baseline adherence was associated with favourable glucose (5.39 vs. 6.1 mmol/L; p < 0.001), triglycerides (1.1 vs. 1.5 mmol/L; p = 0.002), and HDL cholesterol levels (1.32 vs. 1.12 mmol/L; p = 0.032). More importantly, the Medlife Score significantly improved following comprehensive cardiac rehabilitation in patients with low baseline adherence (from 13.8 to 16.7 points; p < 0.001), but not in patients with high baseline adherence (from 19.4 to 18.8 points; p = 0.205). Our findings suggested that Mediterranean lifestyle promotion during cardiac rehabilitation improved adherence to the Mediterranean lifestyle, especially in low-adherence patients.

Potential for optimizing management of obesity in the secondary prevention of coronary heart disease.

AIMS: Prevention guidelines have identified the management of obese patients as an important priority to reduce the burden of incident and recurrent cardiovascular disease. Still, studies have demonstrated that over 80% of patients with coronary heart disease (CHD) fail to achieve their weight target. Here, we describe advice received and actions reported by overweight CHD patients since being discharged from hospital and how weight changes relate to their risk profile. METHODS AND RESULTS: Based on data from 10 507 CHD patients participating in the EUROASPIRE IV and V studies, we analysed weight changes from hospital admission to the time of a study visit ≥6 and <24 months later. At hospitalization, 34.9% were obese and another 46.0% were overweight. Obesity was more frequent in women and associated with more comorbidities. By the time of the study visit, 19.5% of obese patients had lost ≥5% of weight. However, in 16.4% weight had increased ≥5%. Weight gain in those overweight was associated with physical inactivity, non-adherence to dietary recommendations, smoking cessation, raised blood pressure, dyslipidaemia, dysglycaemia, and lower levels of quality of life. Less than half of obese patients was considering weight loss in the coming month. CONCLUSIONS: The management of obesity remains a challenge in the secondary prevention of CHD despite a beneficial effect of weight loss on risk factor prevalences and quality of life. Cardiac rehabilitation programmes should include weight loss interventions as a specific component and the incremental value of telehealth intervention as well as recently described pharmacological interventions need full consideration.

Have We Learnt all from IMPROVE-IT? Part I. Core Results and Subanalyses on the Effects of Ezetimibe Added to Statin Therapy Related to Age, Gender and Selected Chronic Diseases (Kidney Disease, Diabetes Mellitus and Non-Alcoholic Fatty Liver Disease).

IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial) was a randomized clinical trial (including 18,144 patients) that evaluated the efficacy of the combination of ezetimibe with simvastatin vs. simvastatin monotherapy in patients with acute coronary syndrome (ACS) and moderately increased low-density lipoprotein cholesterol (LDL-C) levels (of up to 2.6-3.2 mmol/L; 100-120 mg/dL). After 7 years of follow-up, combination therapy resulted in an additional LDL-C decrease [to 1.8 mmol/L, or 70 mg/dL, within the simvastatin (40 mg/day) monotherapy arm and to 1.4 mmol/L, or 53 mg/dL for simvastatin (40 mg/day) + ezetimibe (10 mg/day)] and showed an incremental clinical benefit [composite of cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization (≥30 days after randomization), or nonfatal stroke; hazard ratio (HR) of 0.936, and 95% CI 0.887-0.996, p=0.016]. Therefore, for very high cardiovascular risk patients "even lower is even better" regarding LDL-C, independently of the LDL-C reducing strategy. These findings confirm ezetimibe as an option to treat very-high-risk patients who cannot achieve LDL-C targets with statin monotherapy. Additional analyses of the IMPROVE-IT (both prespecified and post-hoc) include specific very-high-risk subgroups of patients (those with previous acute events and/or coronary revascularization, older than 75 years, as well as patients with diabetes mellitus, chronic kidney disease or non-alcoholic fatty liver disease). The data from IMPROVE-IT also provide reassurance regarding longer-term safety and efficacy of the intensification of lipid-lowering therapy in very-high-risk patients resulting in very low LDL-C levels. We comment on the results of several (sub) analyses of IMPROVE-IT.

Statin intolerance - an attempt at a unified definition. Position paper from an International Lipid Expert Panel.

Statins are one of the most commonly prescribed drugs in clinical practice. They are usually well tolerated and effectively prevent cardiovascular events. Most adverse effects associated with statin therapy are muscle-related. The recent statement of the European Atherosclerosis Society (EAS) has focused on statin-associated muscle symptoms (SAMS), and avoided the use of the term 'statin intolerance'. Although muscle syndromes are the most common adverse effects observed after statin therapy, excluding other side effects might underestimate the number of patients with statin intolerance, which might be observed in 10 - 15% of patients. In clinical practice, statin intolerance limits effective treatment of patients at risk of, or with, cardiovascular disease. Knowledge of the most common adverse effects of statin therapy that might cause statin intolerance and the clear definition of this phenomenon is crucial to effectively treat patients with lipid disorders. Therefore, the aim of this position paper was to suggest a unified definition of statin intolerance, and to complement the recent EAS statement on SAMS, where the pathophysiology, diagnosis and the management were comprehensively presented.