Prognostic value of exercise tolerance test for predicting cardiovascular disease in asymptomatic individuals with heterozygous familiar hypercholesterolemia.

Heterozygous familiar hypercholesterolemia (hFH) is an autosomal dominant inherited dyslipidemia, associated with premature cardiovascular disease (CVD). Aim of the study was to define prognostic factors for cardiovascular events (CVE) in asymptomatic individuals with hFH. All participants with recent diagnosis of hFH were recruited from the outpatient lipid clinic from 1987 to 2016, without any previous clinical evidence of CVD. A detailed clinical evaluation and laboratory investigation was obtained. Exercise tolerance test (ETT) was performed until maximum exercise capacity was achieved, without evidence of ischemia. Primary endpoint of the study was the first CVE. Four hundred fifty one participants were followed up for 10 ± 8 years, with 68 recorded cases of CVD (15%). Cumulative incidence of CVD was 15%, 24% and 32% for the 3 decades, respectively. In univariate analysis, male gender (p = 0.016), progression of age (p < 0.001), menopause (p = 0.030), waist-hip ratio (p = 0.043) and increased levels of Lp(α) (p = 0.014) were significantly associated with increased CVD incidence; whereas, exercise capacity (p = 0.025), low variation of heart rate (HR) during all stages of ETT compared to resting state (p = 0.020), maximum systolic (p = 0.014) and diastolic (p < 0.001) blood pressure were inversely associated with CVD. In multi-adjusted analysis, male gender (p < 0.001), duration of ETT (p = 0.023), estimated HR (p = 0.029), variation of HR during ETT compared to resting state (p < 0.05) and maximum diastolic pressure (p = 0.044) were significantly associated with CVD. Parameters of ETT in asymptomatic individuals with hFH, without any evidence of ischemia, may predict CVD in these high-risk patients after decades of observation.

Q Fever Severe Pericarditis With Cardiac Tamponade: A Case Report.

Q fever can present in acute or chronic form with a wide range of clinical symptoms and presentations. Here we report severe pericarditis with cardiac tamponade due to a chronic Coxiella burnetii (C. burnetii) infection. Our report emphasizes and justifies the importance of serological testing for chronic Q fever in patients with unexplained pericarditis, particularly in areas where C. burnetii is endemic.

Myocardial fibrosis after COVID-19 infection and severe sinus arrest episodes in an asymptomatic patient with mild sleep apnea syndrome: A case report and review of the literature.

COVID-19 infection is a new disease mainly affecting the respiratory system but is also accompanied by many extra-pulmonary manifestations. A case of a 47-year old male with unique myocardial fibrosis after COVID-19 infection involving the left ventricular wall, intraventricular septum and almost complete damage of interatrial septum, in combination with asymptomatic severe sinus arrest episodes related to mild obstructive sleep apnea syndrome is described here.

Effects of Mediterranean diet on hospital length of stay, medical expenses, and mortality in elderly, hospitalized patients: A 2-year observational study.

OBJECTIVES: The Mediterranean diet (MedDiet) has been related to reduced overall mortality and improved disease outcome. The aim of this study was to estimate the effects of the MedDiet on hospital length of stay (LOS), financial cost, and mortality (from hospitalization up to 24 mo afterward) in hospitalized patients >65 y of age. METHODS: Participating in this observational study were 183 patients >65 y of age, who were urgently admitted for any cause to the Internal Medicine Department of Argolidos General Hospital. Hospital LOS and its financial cost, mortality (during hospitalization, 6 and 24 mo after discharge), physical activity, and medical and anthropometric data were recorded and correlated with the level of adherence to the MedDiet (MedDiet score). RESULTS: In multivariate analyses, hospital LOS decreased by 0.3 d for each unit increase of MedDiet score (P < 0.0001), 2.1 d for each 1 g/dL increase of albumin (P = 0.001) and increased 0.1 d for each day of previous admissions (P < 0.0001). Extended hospitalization (P < 0.0001) and its interaction with MedDiet score (P = 0.01) remained the significantly associated variables for financial cost. Mortality risk increased 3% per each year increase of age (hazard ratio [HR], 1.03; P = 0.02) and 6% for each previous admission (HR, 1.06; P = 0.04); whereas it decreased 13% per each unit increase of MedDiet score (HR, 0.87; P < 0.0001). CONCLUSION: Adoption of the MedDiet decreases duration of admission and long-term mortality in hospitalized patients >65 y of age, with parallel reduction of relevant financial costs.

Real-world direct healthcare costs of treating recurrent high-grade serous ovarian cancer with cytotoxic chemotherapy.

Aim: To describe the direct healthcare costs associated with repeated cytotoxic chemotherapy treatments for recurrent high-grade serous cancer (HGSC) of the ovaries. Patients & methods: Retrospective review of 66 women with recurrent stage III/IV HGSC ovarian cancer treated with repeated lines of cytotoxic chemotherapy in a Canadian University Tertiary Center. Results: Mean cost of treatment of first relapse was CAD$52,227 increasing by 38% for two, and 86% for three or more relapses with median overall survival of 36.0, 50.7 and 42.8 months, respectively. In-hospital care accounted for 71% and chemotherapy drugs accounted for 17% of the total costs. Conclusion: After the third relapse of HGSC, cytotoxic chemotherapy did not prolong survival but was associated with substantially increased healthcare costs.

Weil's disease with haemoptysis and acute respiratory distress syndrome.

A 35-year-old male patient reached the emergency department after an episode of massive haemoptysis a few hours ago. Fever and dyspnea were mentioned to be present the last 5 days. His medical history included only malaria, successfully treated 2 years ago. Clinical examination revealed high fever, jaundice, cyanosis, tachypnea and bilateral rales on pulmonary auscultation. Laboratory investigation showed high erythrocyte sedimentation rate and C reactive protein, leucocytosis, anaemia, mild thrombocytopaenia, renal impairment, hyperbilirubinaemia and abnormal liver function tests; arterial blood gas analysis showed respiratory alkalosis with severe hypoxia. Thoracic X-ray revealed bilateral pulmonary infiltrates, whereas abdominal and heart ultrasound detected hepatomegaly and small pericardial infusion, respectively. The diagnosis of leptospirosis along with acute respiratory distress syndrome was confirmed by positive IgM Leptospira antibodies. Empirical treatment with triple antibiotic therapy and corticosteroids was applied. The patient was discharged after 1 week, without any symptoms and with almost normal laboratory tests.

Exercise capacity and heart rate recovery as predictors of coronary heart disease events, in patients with heterozygous Familial Hypercholesterolemia.

BACKGROUND: Several clinical and observational studies have established that exercise capacity and activity status are strong predictors of cardiovascular and overall mortality. We aimed to evaluate the relationship between exercise tolerance test (ETT) indices and occurrence of coronary heart disease (CHD), in patients with heterozygous Familial Hypercholesterolemia (eFH). METHODS: During 1987-1997, we enrolled 639 cardiovascular disease-free patients with heterozygous eFH; 58 (9%) patients were excluded since they had a positive ETT. A fatal or non-fatal CHD event was the end point. Cox proportional hazards models were applied to evaluate the association between the investigated outcome and ETT indices. RESULTS: During the follow-up (1987-2002), 53 (18%) men and 34 (10%) women developed a CHD event (11 were fatal). The age-adjusted event rate was 87 events per 2915 person-years (3%). Statistical analysis revealed that exercise capacity (hazard ratio = 0.82, P < 0.001), heart rate recovery at 1 min (hazard ratio = 0.91, P < 0.05), and peak pulse pressure levels (hazard ratio = 1.03, P < 0.001), were predictors of CHD, after controlling for several potential confounders. CONCLUSION: Decreased exercise capacity, a delayed decrease in heart rate during the first minute of graded exercise, and increased peak pulse pressure are strong predictors of coronary events in patients with eFH. Physical activity should be strongly recommended in these patients.

The effect of Mediterranean diet on the risk of the development of acute coronary syndromes in hypercholesterolemic people: a case-control study (CARDIO2000).

BACKGROUND: Hypercholesterolemia has been identified as a major risk factor for the development of coronary artery disease. The aim of this study was to assess the effect of a Mediterranean diet on the development of non-fatal acute coronary syndromes (ACS) in hypercholesterolemic people, with or without statin treatment. METHODS: During 2000-2001, 848 randomly selected patients with a first event of coronary heart disease and 1078 cardiovascular disease-free people, matched to the patients by sex, age and region, were studied. Treatment of hypercholesterolemia with statin and the adoption of a Mediterranean diet were recorded. RESULTS: Hypercholesterolemia was present in 534 (63%) out of 848 coronary patients and 399 (37%) out of 1078 control participants. One hundred and seventy-one (32%) of the hypercholesterolemic patients and 168 (42%) of the hypercholesterolemic control participants were treated with statins and also followed a Mediterranean diet. The analysis showed that the combination of a Mediterranean diet and statin medical therapy is associated with an additional reduction of the coronary risk (odds ratio = 0.57, P < 0.01), independently from cholesterol levels and the other cardiovascular factors. CONCLUSION: The adoption of a Mediterranean diet by hypercholesterolemic people seems to reinforce the benefits from statin treatment on lipid levels and reduces the risk of developing ACS. However, it is hard to claim that our findings suggest causal evidence, and in order to explain the potential common mechanism between diet and statin treatment much remains to be learned.

Effect of leisure time physical activity on blood lipid levels: the ATTICA study.

OBJECTIVE: We aimed to evaluate the effect of leisure time physical activity on blood lipid levels, in a random sample of cardiovascular disease-free individuals from the Attica basin. DESIGN AND METHODS: The ATTICA study is a population-based cohort, which during 2001-2002 randomly enrolled 2772 men (n = 1376, 45 +/- 12 years old) and women (n = 1396, 45 +/- 13 years old). Physical activity status was evaluated through intensity (kcal/min expended per day), frequency (per week) and duration (min). Multivariate data analysis evaluated the association of blood lipids with physical activity levels. RESULTS: 578 (42%) men and 584 (40%) women were physically active. Compared to sedentary women, physically active women had lower levels of total cholesterol (P < 0.05), low-density lipoprotein (LDL) (P < 0.05), oxidized LDL-cholesterol (P < 0.05), triglycerides (P < 0.05) and apolipoprotein B (P < 0.05) and higher levels of high-density lipoprotein (HDL)-cholesterol (P < 0.05) and apolipoprotein A1 (P < 0.05). Similar associations were observed in men, but they did not reach statistical significance. However, after adjustments for age, smoking habits, body mass index and dietary intake were made, the effect of physical activity on blood lipids remained statistically significant only for HDL-cholesterol (P < 0.05) and apolipoprotein A1 (P < 0.05) levels in women. Moreover, physical activity was associated with lower total cholesterol levels both in nonsmoker men (-7%, P = 0.032) and nonsmoker women (-2%, P = 0.064) and lower triglyceride levels in nonsmoker men (-15%, P = 0.086) and nonsmoker women (-9%, P = 0.036). CONCLUSIONS: Although almost all blood lipids were inversely associated with physical activity status, only HDL-cholesterol and apolipoprotein A1 concentrations were significantly affected by exercise in women.

The association of Mediterranean diet with lower risk of acute coronary syndromes in hypertensive subjects.

BACKGROUND: The elevation of blood pressure levels has been recognised as a determinant of the risk for several common cardiovascular diseases. In this work we examined the effect of Mediterranean type of diet on coronary risk in subjects with hypertension. METHODS: CARDIO2000 consisted of 848 randomly selected hospitalised patients (695 males, 58 +/- 10 years old; 153 females, 65 +/- 9 years old) for first event of coronary heart disease (CHD) and 1078 paired, by sex-age, hospitalised controls without CHD. The adoption of the Mediterranean diet was assessed through a validated questionnaire developed by the National School of Public Health. RESULTS: 418 (49%) of the patients and 303 (28%) of the controls were hypertensive. Of them 21 (5%) patients and 36 (12%) controls were unaware of their condition, 94 (22%) and 34 (11%) were untreated, 148 (35%) and 111 (36%) were uncontrolled and 155 (38%) and 122 (41%) were controlled (P<0.01). One hundred and sixty-two (19%) of the patients and 265 (25%) of the controls (P<0.01) adopted the Mediterranean type of diet. Our results suggest that the adoption of Mediterranean diet reduces the risk of developing acute coronary syndromes by 17% (odds ratio=0.83, 95% CI 0.73--0.88, P<0.01) in controlled hypertensive subjects, by 8% (odds ratio=0.92, 95% CI 0.87-0.95, P<0.05) in unaware, by 7% (odds ratio=0.93, 95% CI 0.88-0.95, P<0.05) in acknowledged but uncontrolled and by 20% (odds ratio=0.80, 95% CI 0.71-0.89, P<0.01) in normotensive subjects. CONCLUSION: According to our findings the adoption of the Mediterranean diet is associated with the reduction of coronary risk in hypertensive subjects.

The adoption of Mediterranean diet attenuates the development of acute coronary syndromes in people with the metabolic syndrome.

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.

Physical activity, high density lipoprotein cholesterol and other lipids levels, in men and women from the ATTICA study.

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.

The association between secondhand smoke and the risk of developing acute coronary syndromes, among non-smokers, under the presence of several cardiovascular risk factors: The CARDIO2000 case-control study.

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.

Cervical epidural abscess caused by brucellosis.

A 70-year-old Greek lady presented with fever, arthralgias of knees, cervical and lumbar pain during the last month. On clinical examination the patient was found to have tenderness of the cervical and the lumbar spine with great motion restriction. The blood tests revealed high erythrocyte sedimentation rate and C-reactive protein, abnormal liver function tests and a positive rheumatoid factor. Serological test for Brucella was positive while cervical MRI revealed epidural abscess and spondylodiscitis. Conservative treatment with streptomycin (it was substituted by rifampicin after the third week) and doxycyclin for 4 months significantly improved her symptoms. The frequency as well as the diagnosis and management of this manifestation are discussed.

Osteoporosis--a risk factor for cardiovascular disease?

Osteoporosis is a serious health problem worldwide that is associated with an increased risk of fractures and mortality. Vascular calcification is a well-defined independent risk factor for cardiovascular disease (CVD) and mortality. Major advances in our understanding of the pathophysiology of osteoporosis and vascular calcification indicate that these two processes share common pathogenetic mechanisms. Multiple factors including proteins (such as bone morphogenetic proteins, receptor activator of nuclear factor κB ligand, osteoprotegerin, matrix Gla protein and cathepsins), parathyroid hormone, phosphate, oxidized lipids and vitamins D and K are implicated in both bone and vascular metabolism, illustrating the interaction of these two, seemingly unrelated, conditions. Many clinical studies have now confirmed the correlation between osteoporosis and vascular calcification as well as the increased risk of CVD in patients with osteoporosis. Here, we explore the proposed mechanistic similarities between osteoporosis and vascular calcification and present an overview of the clinical data that support the interaction between these conditions.

Effects of chronic alcohol consumption on lipid levels, inflammatory and haemostatic factors in the general population: the 'ATTICA' Study.

BACKGROUND: Epidemiological studies suggest an unclear effect of alcohol consumption on cardiovascular risk. This ambiguity is likely related to the quantity of alcohol consumed in populations studied. The aim of this work was to evaluate the association between chronic alcohol consumption and several clinical and biochemical parameters related to coronary risk, in cardiovascular disease free men and women. METHODS: The 'ATTICA' study is a population-based cohort, which randomly enrolled 750 men and 883 women (18-88 years old) from area around Athens, during 2001-2002. We investigated the association between alcohol consumption and arterial blood pressure, fibrinogen levels, glucose concentration, total cholesterol, HDL and LDL, apolipoprotein A1 and B, Lp(a), uric acid, leucocyte count, triglycerides, C-reactive protein and homocysteine levels. RESULTS: Multivariate analysis, after controlling for several potential confounders, revealed a J-shaped association between alcohol intake (none, 1-2, 3-4, 5+ wine glasses/day) and uric acid, C-reactive protein, homocysteine, fibrinogen, triglycerides, apolipoproteins A1 and B, HDL and total cholesterols, blood glucose levels, leucocyte count and arterial blood pressure levels (only in males). The most beneficial values of all these biochemical and clinical parameters were found in alcohol intake of 100-200 ml (12% alcohol), even after adjustment for various potential confounders. CONCLUSIONS: The controversial association between alcohol intake and cardiovascular disease seems to be partially explained by the J-shaped relation of several biochemical parameters related to atherosclerosis and the amount of alcoholic beverages consumed.

Association between passive cigarette smoking and the risk of developing acute coronary syndromes: the CARDIO2000 study.

Although the effect of smoking on human health has been established as a major risk factor, the effect of passive smoking is controversial. The purpose of this study was to investigate the association between passive smoking and the risk of acute coronary syndromes (ACS) among nonsmokers. Eight hundred and forty-eight patients with the first event of ACS and 1078 cardiovascular disease-free matched controls completed a detailed questionnaire regarding their exposure to environmental smoke. Two hundred and ninety-seven (35%) of the patients and 259 (24%) of the controls were defined as nonsmokers and passive smokers, respectively. After controlling for several potential confounders, the results showed that nonsmokers exposed to cigarette smoke increased the risk of ACS by 51% (odds ratio = 1.51, 95% confidence interval 1.21-2.99) compared with nonsmokers not exposed to smoke. It was estimated that 34 coronary events per 134 subjects would occur as a result of passive smoking during their lifetime. Consequently, this study supports the hypothesis that passive smoking increases the risk of developing acute coronary syndromes. Given the high prevalence of cigarette smoking in many developing societies, the public health consequences of passive smoking with regard to coronary heart disease may be important.