Gender differences in screening for glucose perturbations, cardiovascular risk factor management and prognosis in patients with dysglycaemia and coronary artery disease: results from the ESC-EORP EUROASPIRE surveys.

BACKGROUND: Gender disparities in the management of dysglycaemia, defined as either impaired glucose tolerance (IGT) or type 2 diabetes (T2DM), in coronary artery disease (CAD) patients are a medical challenge. Recent data from two nationwide cohorts of patients suggested no gender difference as regards the risk for diabetes-related CV complications but indicated the presence of a gender disparity in risk factor management. The aim of this study was to investigate gender differences in screening for dysglycaemia, cardiovascular risk factor management and prognosis in dysglycemic CAD patients. METHODS: The study population (n = 16,259; 4077 women) included 7998 patients from the ESC-EORP EUROASPIRE IV (EAIV: 2012-2013, 79 centres in 24 countries) and 8261 patients from the ESC-EORP EUROASPIRE V (EAV: 2016-2017, 131 centres in 27 countries) cross-sectional surveys. In each centre, patients were investigated with standardised methods by centrally trained staff and those without known diabetes were offered an oral glucose tolerance test (OGTT). The first of CV death or hospitalisation for non-fatal myocardial infarction, stroke, heart failure or revascularization served as endpoint. Median follow-up time was 1.7 years. The association between gender and time to the occurrence of the endpoint was evaluated using Cox survival modelling, adjusting for age. RESULTS: Known diabetes was more common among women (32.9%) than men (28.4%, p < 0.0001). OGTT (n = 8655) disclosed IGT in 17.2% of women vs. 15.1% of men (p = 0.004) and diabetes in 13.4% of women vs. 14.6% of men (p = 0.078). In both known diabetes and newly detected dysglycaemia groups, women were older, with higher proportions of hypertension, dyslipidaemia and obesity. HbA1c was higher in women with known diabetes. Recommended targets of physical activity, blood pressure and cholesterol were achieved by significantly lower proportions of women than men. Women with known diabetes had higher risk for the endpoint than men (age-adjusted HR 1.22; 95% CI 1.04-1.43). CONCLUSIONS: Guideline-recommended risk factor control is poorer in dysglycemic women than men. This may contribute to the worse prognosis in CAD women with known diabetes.

INTERASPIRE: an International Survey of Coronary Patients; Their Cardiometabolic, Renal and Biomarker Status; and the Quality of Preventive Care Delivered in All WHO Regions : In Partnership with the World Heart Federation, European Society of Cardiology, Asia Pacific Society of Cardiology, InterAmerican Society of Cardiology, and PanAfrican Society of Cardiology.

PURPOSE OF REVIEW: To describe the INTERASPIRE scientific protocol-an international survey of secondary prevention of coronary heart disease (CHD). RECENT FINDINGS: This international survey is being conducted through National Societies of Cardiology in selected countries from each of the six WHO regions and has the following overall aims: (i) describe prevalence of cardiometabolic and renal risk factors together with biomarkers in CHD patients; (ii) describe current risk factor management through lifestyle changes and cardioprotective drug therapies; (iii) provide an objective assessment of clinical implementation of preventive care by comparison with the lifestyle and risk factor targets defined in international and national guidelines; (iv) investigate the reasons for variation in preventive cardiology practice between regions and countries; and (v) promote the principles of best preventive cardiology practice. This international survey will provide a unique picture of CHD patients; their cardiometabolic, renal and biomarker status; lifestyle and therapeutic management; and the quality of preventive care provided in all WHO regions.

EQ-5D in coronary patients: what are they suffering from? Results from the ESC EORP European Survey of Cardiovascular Disease Prevention and Diabetes (EUROASPIRE IV) Registry.

OBJECTIVE: Coronary patients often suffer from an impaired health, hence the aim of this study is to assess how coronary patients score on the different EQ-5D dimensions. METHODS: Analyses are based on the EUROASPIRE IV survey, conducted across 24 European countries. 7567 patients with stable coronary heart disease (mean age = 64.1 (SD = 9.6); males = 75.8%) completed the EQ-5D-5L instrument, 6 months to 3 years after their index hospitalization. Descriptive statistics and multilevel logistic regression was used to assess the differences between patient groups in reported problems on the EQ-5D dimensions. Furthermore, age-standardized country-specific outcomes were reported. RESULTS: About one out of four patients reported to have no problems on all five dimensions (57.9% reported no problems on mobility, 88.4% reported no problems on self-care, 67.1% reported no problems on usual activities, 41.1% reported no problems on pain/discomfort, and 56.2% reported no problems on anxiety/depression). Elderly patients and females reported more problems. Patients with behavioral risk factors and patients with comorbidities were more likely to have severe or extreme problems. Comparison across countries showed major differences in reported problems. CONCLUSIONS: Whether or not coronary patients have problems on one or more EQ-5D dimension, as well as the severity of the problems reported is largely associated with the patient profile. The least problems are seen on the self-care dimension and most problems are reported on the pain/discomfort dimension.

Incidence of cardiovascular events in patients with stabilized coronary heart disease: the EUROASPIRE IV follow-up study.

The EUROASPIRE surveys (EUROpean Action on Secondary Prevention through Intervention to Reduce Events) demonstrated that most European coronary patients fail to achieve lifestyle, risk factor and therapeutic targets. Here we report on the 2-year incidence of hard cardiovascular (CV) endpoints in the EUROASPIRE IV cohort. EUROASPIRE IV (2012-2013) was a large cross-sectional study undertaken at 78 centres from selected geographical areas in 24 European countries. Patients were interviewed and examined at least 6 months following hospitalization for a coronary event or procedure. Fatal and non-fatal CV events occurring at least 1 year after this baseline screening were registered. The primary outcome in our analyses was the incidence of CV death or non-fatal myocardial infarction, stroke or heart failure. Cox regression models, stratified for country, were fitted to relate baseline characteristics to outcome. Our analyses included 7471 predominantly male patients. Overall, 222 deaths were registered of whom 58% were cardiovascular. The incidence of the primary outcome was 42 per 1000 person-years. Comorbidities were strongly and significantly associated with the primary outcome (multivariately adjusted hazard ratio HR, 95% confidence interval): severe chronic kidney disease (HR 2.36, 1.44-3.85), uncontrolled diabetes (HR 1.89, 1.50-2.38), resting heart rate ≥ 75 bpm (HR 1.74, 1.30-2.32), history of stroke (HR 1.70, 1.27-2.29), peripheral artery disease (HR 1.48, 1.09-2.01), history of heart failure (HR 1.47, 1.08-2.01) and history of acute myocardial infarction (HR 1.27, 1.05-1.53). Low education and feelings of depression were significantly associated with increased risk. Lifestyle factors such as persistent smoking, insufficient physical activity and central obesity were not significantly related to adverse outcome. Blood pressure and LDL-C levels appeared to be unrelated to cardiovascular events irrespective of treatment. In patients with stabilized CHD, comorbid conditions that may reflect the ubiquitous nature of atherosclerosis, dominate lifestyle-related and other modifiable risk factors in terms of prognosis, at least over a 2-year follow-up period.

Adverse effects of statin therapy: perception vs. the evidence - focus on glucose homeostasis, cognitive, renal and hepatic function, haemorrhagic stroke and cataract.

Aims: To objectively appraise evidence for possible adverse effects of long-term statin therapy on glucose homeostasis, cognitive, renal and hepatic function, and risk for haemorrhagic stroke or cataract. Methods and results: A literature search covering 2000-2017 was performed. The Panel critically appraised the data and agreed by consensus on the categorization of reported adverse effects. Randomized controlled trials (RCTs) and genetic studies show that statin therapy is associated with a modest increase in the risk of new-onset diabetes mellitus (about one per thousand patient-years), generally defined by laboratory findings (glycated haemoglobin ≥6.5); this risk is significantly higher in the metabolic syndrome or prediabetes. Statin treatment does not adversely affect cognitive function, even at very low levels of low-density lipoprotein cholesterol and is not associated with clinically significant deterioration of renal function, or development of cataract. Transient increases in liver enzymes occur in 0.5-2% of patients taking statins but are not clinically relevant; idiosyncratic liver injury due to statins is very rare and causality difficult to prove. The evidence base does not support an increased risk of haemorrhagic stroke in individuals without cerebrovascular disease; a small increase in risk was suggested by the Stroke Prevention by Aggressive Reduction of Cholesterol Levels study in subjects with prior stroke but has not been confirmed in the substantive evidence base of RCTs, cohort studies and case-control studies. Conclusion: Long-term statin treatment is remarkably safe with a low risk of clinically relevant adverse effects as defined above; statin-associated muscle symptoms were discussed in a previous Consensus Statement. Importantly, the established cardiovascular benefits of statin therapy far outweigh the risk of adverse effects.

Lifestyle behaviour and risk factor control in coronary patients: Belgian results from the cross-sectional EUROASPIRE surveys.

OBJECTIVE: The aim of this study was to assess lifestyle behaviour as well as risk factor management across Belgian coronary patients who participated in the cross-sectional European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) surveys. METHODS: Analyses are based on a series of coronary patients by combining data from the Belgian participants in the EUROASPIRE III (328 patients; in 2006-2007) and EUROASPIRE IV (343 patients; in 2012-2013) surveys. Four hospitals located in the Ghent area participated in the surveys. Patients included in the analyses were ≥18 years old and had been hospitalised for a coronary event. Information on cardiovascular risk factors, lifestyle behaviour and medical treatment were obtained. RESULTS: Overall, the proportion of smokers was 11% with 40% persistent smokers. Adequate physical activity levels were reported by 17%, 28% of patients were obese, 47% was central obese and known diabetes was prevalent in 21% of patients. Hypertension was observed in 46% of patients and 20% had a total cholesterol ≥5 mmol/L. About 80% had participated in a cardiac rehabilitation programme and the majority of patients were treated with blood pressure (92%) or lipid-lowering drugs (92%). Anxiety and depressive symptoms were reported by 30% and 24%, respectively. Differences between EUROASPIRE III and IV were limited. CONCLUSIONS: Compared to the overall EUROASPIRE results in Europe, Belgian CHD patients seem to do slightly better. However, tackling obesity, physical inactivity, hypertension and psychosocial distress remains an important challenge in the management of coronary patients.

Undetected dysglycaemia common in primary care patients treated for hypertension and/or dyslipidaemia: on the need for a screening strategy in clinical practice. A report from EUROASPIRE IV a registry from the EuroObservational Research Programme of the European Society of Cardiology.

BACKGROUND: Dysglycaemia defined as type 2 diabetes (T2DM) and impaired glucose tolerance (IGT), increases the risk of cardiovascular disease (CVD). The negative impact is more apparent in the presence of hypertension and/or dyslipidaemia. Thus, it seems reasonable to screen for dysglycaemia in patients treated for hypertension and/or dyslipidaemia. A simple screening algorithm would enhance the adoption of such strategy in clinical practice. OBJECTIVES: To test the hypotheses (1) that dysglycaemia is common in patients with hypertension and/or dyslipidaemia and (2) that initial screening with the Finnish Diabetes Risk Score (FINDRISC) will decrease the need for laboratory based tests. METHODS: 2395 patients (age 18-80 years) without (i) a history of CVD or TDM2, (ii) prescribed blood pressure and/or lipid lowering drugs answered the FINDRISC questionnaire and had an oral glucose tolerance test (OGTT) and HbA1c measured. RESULTS: According to the OGTT 934 (39%) had previously undetected dysglycaemia (T2DM 19%, IGT 20%). Of patients, who according to FINDRISC had a low, moderate or slightly elevated risk 20, 34 and 41% and of those in the high and very high-risk category 49 and 71% had IGT or T2DM respectively. The OGTT identified 92% of patients with T2DM, FPG + HbA1c 90%, FPG 80%, 2hPG 29% and HbA1c 22%. CONCLUSIONS: (1) The prevalence of dysglycaemia was high in patients treated for hypertension and/or dyslipidaemia. (2) Due to the high proportion of dysglycaemia in patients with low to moderate FINDRISC risk scores its initial use did not decrease the need for subsequent glucose tests. (3) FPG was the best test for detecting T2DM. Its isolated use is limited by the inability to disclose IGT. A pragmatic strategy, decreasing the demand for an OGTT, would be to screen all patients with FPG followed by OGTT in patients with IFG.

Prevalence and treatment of atherogenic dyslipidemia in the primary prevention of cardiovascular disease in Europe: EURIKA, a cross-sectional observational study.

BACKGROUND: Atherogenic dyslipidemia is associated with poor cardiovascular outcomes, yet markers of this condition are often ignored in clinical practice. Here, we address a clear evidence gap by assessing the prevalence and treatment of two markers of atherogenic dyslipidemia: elevated triglyceride levels and low levels of high-density lipoprotein cholesterol. METHODS: This cross-sectional observational study assessed the prevalence of two atherogenic dyslipidemia markers, high triglyceride levels and low high-density lipoprotein cholesterol levels, in the study population from the European Study on Cardiovascular Risk Prevention and Management in Usual Daily Practice (EURIKA; N = 7641; of whom 51.6% were female and 95.6% were White/Caucasian). The EURIKA population included European patients, aged at least 50 years with at least one cardiovascular risk factor but no history of cardiovascular disease. RESULTS: Over 20% of patients from the EURIKA population have either triglyceride or high-density lipoprotein cholesterol levels characteristic of atherogenic dyslipidemia. Furthermore, the proportions of patients with one of these markers were higher in subpopulations with type 2 diabetes mellitus or those already calculated to be at high risk of cardiovascular disease. Approximately 55% of the EURIKA population who have markers of atherogenic dyslipidemia are not receiving lipid-lowering therapy. CONCLUSIONS: A considerable proportion of patients with at least one major cardiovascular risk factor in the primary cardiovascular disease prevention setting have markers of atherogenic dyslipidemia. The majority of these patients are not receiving optimal treatment, as specified in international guidelines, and thus their risk of developing cardiovascular disease is possibly underestimated. TRIAL REGISTRATION: The present study is registered with ClinicalTrials.gov (ID: NCT00882336).

One-year and longer dual antiplatelet therapy after an acute coronary syndrome: a Belgian position paper.

Acute coronary syndrome patients receive DAPT up to one year after their initial event. Exceptions to the guideline-recommended one-year rule, however, are not uncommon. The reasoning behind shorter treatments, such as unacceptable bleeding risk or urgent surgery, should be well documented in the patient's charts and discharge letter. Based on recent evidence, patients at high risk for repetitive events should continue on low-dose ticagrelor without a significant interruption at one year and indefinitely in the absence of excess bleeding risk. As there is currently no reimbursement, policy makers and insurers should be made aware of the continuing risk and unmet clinical need in this patient population. Nevertheless, many unsolved questions need to be answered, both through additional analyses from recent trials such as PEGASUS-TIMI 54 or DAPT, as well as new carefully designed clinical studies.

Do psychosocial job resources buffer the relation between physical work demands and coronary heart disease? A prospective study among men.

PURPOSE: Increasing evidence shows the detrimental impact of high physical work demands for cardiovascular health and mortality. The aim of this study was to investigate the buffering effects of social support at work and job control in the relation between physical work demands and incidence of coronary events. METHODS: The study included 14,337 middle-aged men free from coronary heart disease (CHD) at baseline. The sample consisted of a mixed occupational group recruited within 18 organizations from the manufacturing, service, and public sector. Data were collected through standardized questionnaires and clinical examinations. The incidence of clinical coronary events was monitored during a mean follow-up time of 3.15 years. Multilevel Cox proportional hazard regression modeling was used, adjusting for socio-demographic and classical coronary risk factors. RESULTS: Social support at work buffered the impact of physical work demands on CHD risk: Only among workers with low social support at work did physical work demands significantly increase the risk for CHD incidence (fully adjusted HR 2.50: 95 % CI 1.13-5.50), while this harmful effect completely disappeared in case of high level of workplace social support (fully adjusted HR 0.40; 95 % CI 0.09-1.70). No interaction or buffering effect with job control was observed. CONCLUSIONS: The results of our study suggest that supportive relationships at work may be a useful resource for reducing the cardiovascular risk associated with physical work demands in men. Future studies are needed to confirm this moderating role of workplace social support and to unravel the underlying mechanisms.

Screening for dysglycaemia in patients with coronary artery disease as reflected by fasting glucose, oral glucose tolerance test, and HbA1c: a report from EUROASPIRE IV--a survey from the European Society of Cardiology.

AIMS: Three methods are used to identify dysglycaemia: fasting plasma glucose (FPG), 2-h post-load plasma glucose (2hPG) from the oral glucose tolerance test (OGTT), and glycated haemoglobin A1c (HbA1c). The aim was to describe the yield and concordance of FPG, HbA1c, and 2hPG alone, or in combination, to identify dysglycaemia in patients with coronary artery disease. METHODS AND RESULTS: In EUROASPIRE IV, a cross-sectional survey of patients aged 18-80 years with coronary artery disease in 24 European countries, 4004 patients with no reported history of diabetes had FPG, 2hPG, and HbA1c measured. All participants were divided into different glycaemic categories according to the ADA and WHO criteria for dysglycaemia. Using all screening tests together, 1158 (29%) had undetected diabetes. Out of them, the proportion identified by FPG was 75%, by 2hPG 40%, by HbA1c 17%, by FPG + HbA1c 81%, and by OGTT (=FPG + 2hPG) 96%. Only 7% were detected by all three methods FPG, 2hPG, and HbA1c. The ADA criteria (FPG + HbA1c) identified 90% of the population as having dysglycaemia compared with 73% with the WHO criteria (OGTT = FPG + 2hPG). Screening according to the ADA criteria for FPG + HbA1c identified 2643 (66%) as having a 'high risk for diabetes', while the WHO criteria for FPG + 2hPG identified 1829 patients (46%). CONCLUSION: In patients with established coronary artery disease, the OGTT identifies the largest number of patients with previously undiagnosed diabetes and should be the preferred test when assessing the glycaemic state of such patients.

Statin-associated muscle symptoms: impact on statin therapy-European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management.

Statin-associated muscle symptoms (SAMS) are one of the principal reasons for statin non-adherence and/or discontinuation, contributing to adverse cardiovascular outcomes. This European Atherosclerosis Society (EAS) Consensus Panel overviews current understanding of the pathophysiology of statin-associated myopathy, and provides guidance for diagnosis and management of SAMS. Statin-associated myopathy, with significant elevation of serum creatine kinase (CK), is a rare but serious side effect of statins, affecting 1 per 1000 to 1 per 10 000 people on standard statin doses. Statin-associated muscle symptoms cover a broader range of clinical presentations, usually with normal or minimally elevated CK levels, with a prevalence of 7-29% in registries and observational studies. Preclinical studies show that statins decrease mitochondrial function, attenuate energy production, and alter muscle protein degradation, thereby providing a potential link between statins and muscle symptoms; controlled mechanistic and genetic studies in humans are necessary to further understanding. The Panel proposes to identify SAMS by symptoms typical of statin myalgia (i.e. muscle pain or aching) and their temporal association with discontinuation and response to repetitive statin re-challenge. In people with SAMS, the Panel recommends the use of a maximally tolerated statin dose combined with non-statin lipid-lowering therapies to attain recommended low-density lipoprotein cholesterol targets. The Panel recommends a structured work-up to identify individuals with clinically relevant SAMS generally to at least three different statins, so that they can be offered therapeutic regimens to satisfactorily address their cardiovascular risk. Further research into the underlying pathophysiological mechanisms may offer future therapeutic potential.

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology.

BACKGROUND: In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines. METHODS: A total of 6187 patients (18-80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012-2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys. RESULTS: A total of 2846 (46%) patients had no diabetes, 1158 (19%) newly diagnosed diabetes and 2183 (35%) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60%, respectively. A blood pressure target of <140/90 mmHg was achieved in 68, 61, 54% and a LDL-cholesterol target of <1.8 mmol/L in 16, 18 and 28%. Patients with newly diagnosed and previously known diabetes reached an HbA1c <7.0% (53 mmol/mol) in 95 and 53% and 11% of those with previously known diabetes had an HbA1c >9.0% (>75 mmol/mol). Of the patients with diabetes 69% reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40 %) and only 27% of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets. CONCLUSIONS: Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.

The combined relationship of occupational and leisure-time physical activity with all-cause mortality among men, accounting for physical fitness.

The aim of this study was to assess the combined relationship of occupational physical activity and leisure-time physical activity with all-cause mortality among men, while accounting for physical fitness. The prospective Belgian Physical Fitness Study included 1,456 male workers aged 40-55 years who were free of coronary heart disease at baseline. Baseline data were collected through questionnaires and clinical examinations from 1976 to 1978. To estimate physical fitness, a submaximal graded exercise test was performed on a bicycle ergometer. Total mortality was registered during a mean follow-up period of 16.9 years. Main results were obtained through Cox proportional hazards regression analysis. A total of 145 deaths were registered during follow-up. After adjustment for confounders, a significantly increased mortality rate was observed in workers who had low levels of both physical activity types (hazard ratio = 2.07, 95% confidence interval: 1.03, 4.19) but also in workers combining high occupational physical activity and low leisure-time physical activity (hazard ratio = 2.04, 95% confidence interval: 1.07, 3.91); the latter finding was particularly pronounced among workers with a low physical fitness level. The present results confirm the existence of a complex interplay among different physical activity settings and fitness levels in predicting mortality.

New risk markers for cardiovascular prevention.

The importance of total cardiovascular (CV) risk estimation before management decisions are taken is well established. Models have been developed that allow physicians to stratify the asymptomatic population in subgroups at low, moderate, high, and very high total CV risk. Most models are based on classical CV risk factors: age, gender, smoking, blood pressure, and lipid levels. The impact of additional risk factors is discussed here, looking separately at the predictive increments of novel biomarkers and of indicators of subclinical atherosclerotic disease. The contribution of biomarkers to the total CV risk estimation is generally modest, and their usage should be limited to subjects at intermediate total CV risk. Detection of subclinical vascular damage may improve total CV risk estimation in asymptomatic subjects who are close to a threshold that could affect management decisions and in whom the chances of re-classification in a different risk category are great. There is, however, an urgent need for trials in which the value of using total CV risk estimation models is tested.

C-reactive protein levels in patients at cardiovascular risk: EURIKA study.

BACKGROUND: Elevated C-reactive protein (CRP) levels are associated with high cardiovascular risk, and might identify patients who could benefit from more carefully adapted risk factor management. We have assessed the prevalence of elevated CRP levels in patients with one or more traditional cardiovascular risk factors. METHODS: Data were analysed from the European Study on Cardiovascular Risk Prevention and Management in Usual Daily Practice (EURIKA, ClinicalTrials.gov Identifier: NCT00882336), which included patients (aged ≥50 years) from 12 European countries with at least one traditional cardiovascular risk factor but no history of cardiovascular disease. Analysis was also carried out on the subset of patients without diabetes mellitus who were not receiving statin therapy. RESULTS: In the overall population, CRP levels were positively correlated with body mass index and glycated haemoglobin levels, and were negatively correlated with high-density lipoprotein cholesterol levels. CRP levels were also higher in women, those at higher traditionally estimated cardiovascular risk and those with greater numbers of metabolic syndrome markers. Among patients without diabetes mellitus who were not receiving statin therapy, approximately 30% had CRP levels ≥3 mg/L, and approximately 50% had CRP levels ≥2 mg/L, including those at intermediate levels of traditionally estimated cardiovascular risk. CONCLUSIONS: CRP levels are elevated in a large proportion of patients with at least one cardiovascular risk factor, without diabetes mellitus who are not receiving statin therapy, suggesting a higher level of cardiovascular risk than predicted according to conventional risk estimation systems. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00882336.

Cardiovascular risk factors: Belgian target achievement.

OBJECTIVE: The objective of this study was to evaluate the level of target achievement for key modifiable cardiovascular disease (CVD) risk factors (dyslipidaemia, arterial hypertension, hyperglycaemia, smoking, and physical inactivity) in Belgium. METHODS AND RESULTS: This non-systematic review of Belgian data from four recent studies assessed the control of CVD risk factors in clinical settings: the European Study on Cardiovascular Risk Prevention and Management in Usual Daily Practice (EURIKA), the Optimal Type 2 Diabetes Management Including Benchmarking and Standard Treatment Study (OPTIMISE), the European Action on Secondary and Primary Prevention by Intervention to Reduce Events Survey (EUROASPIRE III), and data from a general practice-based morbidity registration network (INTEGO). For each study, target achievement levels were evaluated using the guidelines that were applicable at the time of the study. The overall results show that the main CVD risk factors are poorly controlled in patients with established CVD and in patients at high CVD risk. Therapeutic targets may be incompletely reached because of the suboptimal implementation of European guidelines for CVD prevention in routine clinical practice (insufficient lifestyle and dietary adaptations; poor applications of drug therapy to control blood pressure, dyslipidaemia and hyperglycaemia) or the insufficient efficacy of the currently available treatments options in some patients. CONCLUSIONS: This review provides clear and updated evidence for non-target achievement for all major risk factors, with four different study designs and inclusion criteria, and highlights the need for more comprehensive and intensive application of European guidelines recommendations for CVD prevention in Belgium.

No shorter telomeres in subjects with a family history of cardiovascular disease in the Asklepios study.

OBJECTIVE: Shorter telomere length is associated with the occurrence of cardiovascular events, but the question of causality is complicated by the intertwined effects of inheritance, aging, and lifestyle factors on both telomere length and cardiovascular disease (CVD). Some studies indicated that healthy offspring of coronary artery disease patients exhibited shorter telomeres than subjects without a family history. Importantly, this result would imply that inheritance of shorter telomeres is a primary abnormality associated with an increased risk of CVD, the so-called Telomere Hypothesis of CVD. Therefore, we aimed at further validating the latter results in the large, population-representative Asklepios Study. METHODS AND RESULTS: Peripheral blood leukocyte telomere length was measured using telomere restriction fragment analysis in the young to middle-aged (≈ 35-55 years old) Asklepios study population, free from overt CVD, and could be successfully combined with data from the Asklepios Family History Database for 2136 subjects. No shorter telomere length could be found in healthy subjects with a family history of CVD compared with those without. CONCLUSIONS: These findings cast serious doubt on the hypothesis that telomere length is shorter in families with an increased risk of CVD and do not support the Telomere Hypothesis of CVD.

The association between leisure time physical activity and coronary heart disease among men with different physical work demands: a prospective cohort study.

The interplay of occupational and leisure time physical activity (LTPA) in affecting cardiovascular health is subject to debate. This study aimed to examine the independent and interacting associations of leisure time and occupational physical activity (OPA) with the incidence of coronary events within the BELSTRESS cohort. The study included 14,337 middle-aged men free from coronary heart disease at baseline. Standardized questionnaires and clinical examinations were used to assess socio-demographic factors, level of physical activity, job strain and classical coronary risk factors. The incidence of clinical coronary events was monitored during a mean follow-up time of 3.15 years. Results demonstrated overall a beneficial relation of LTPA and an adverse relation of physical work demands with cardiovascular health. However, an interaction effect between both physical activity types was observed, showing that men with high physical job demands who also engaged in physical activity during leisure time had an almost four times increased incidence of coronary events after adjusting for socio-demographic and classical coronary risk factors (HR 3.82; 95% CI 1.41-10.36). Stratified analyses revealed that moderate to high physical activity during leisure time was associated with a 60% reduced incidence rate of coronary events in men with low OPA (age adjusted HR 0.40; 95% CI 0.21-0.76), while this protective association was not observed in workers being exposed to high physical work demands (age adjusted HR 1.67; 95% CI 0.63-4.48). These findings suggest that recommendations regarding LTPA should be tailored according to the level of occupational physical activity.