Pulmonary artery pressure monitoring in chronic heart failure: effects across clinically relevant subgroups in the MONITOR-HF trial.

BACKGROUND AND AIMS: In patients with chronic heart failure (HF), the MONITOR-HF trial demonstrated the efficacy of pulmonary artery (PA)-guided HF therapy over standard of care in improving quality of life and reducing HF hospitalizations and mean PA pressure. This study aimed to evaluate the consistency of these benefits in relation to clinically relevant subgroups. METHODS: The effect of PA-guided HF therapy was evaluated in the MONITOR-HF trial among predefined subgroups based on age, sex, atrial fibrillation, diabetes mellitus, left ventricular ejection fraction, HF aetiology, cardiac resynchronisation therapy, and implantable cardioverter defibrillator. Outcome measures were based upon significance in the main trial and included quality of life, clinical, and PA pressure endpoints, and were assessed for each subgroup. Differential effects in relation to the subgroups were assessed with interaction terms. Both unadjusted and multiple testing adjusted interaction terms were presented. RESULTS: The effects of PA monitoring on quality of life, clinical events, and PA pressure were consistent in the predefined subgroups, without any clinically relevant heterogeneity within or across all endpoint categories (all adjusted interaction P-values were nonsignificant). In the unadjusted analysis of the primary endpoint quality-of-life change, weak trends towards a less pronounced effect in older patients (Pinteraction = 0.03; adjusted Pinteraction = 0.33) and diabetics (Pinteraction = 0.01; adjusted Pinteraction = 0.06) were observed. However, these interaction effects did not persist after adjusting for multiple testing. CONCLUSIONS: This subgroup analysis confirmed the consistent benefits of PA-guided HF therapy observed in the MONITOR-HF trial across clinically relevant subgroups, highlighting its efficacy in improving quality of life, clinical, and PA pressure endpoints in chronic HF patients.

Targeting residual inflammatory risk in coronary disease: to catch a monkey by its tail.

Patients with coronary disease remain at high risk for future cardiovascular events, even with optimal risk factor modification, lipid-lowering drugs and antithrombotic regimens. A myriad of inflammatory pathways contribute to progression of the atherosclerotic burden in these patients. Only in the last few years has the inflammatory biology of atherosclerosis translated into clinical therapeutic options. Low-dose colchicine can provide a clinically relevant reduction in the risk for composite and individual major cardiovascular outcomes in patients with acute and chronic coronary syndromes. Among others, its anti-inflammatory effects in atherosclerosis seem to be related to neutrophil recruitment and adhesion, inflammasome inhibition, and morphological changes in platelets and platelet aggregation. Future research is aimed at further elucidating its particular mechanism of action, as well as identifying patients with the highest expected benefit and evaluating efficacy in other vascular beds. These data will help to formulate the role of colchicine and other anti-inflammatory drugs in patients with coronary disease and atherosclerosis in general in the near future.

The challenge of choosing in cardiovascular risk management.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. For many years guidelines have listed optimal preventive therapy. More recently, novel therapeutic options have broadened the options for state-of-the-art CV risk management (CVRM). In the majority of patients with CVD, risk lowering can be achieved by utilising standard preventive medication combined with lifestyle modifications. In a minority of patients, add-on therapies should be considered to further reduce the large residual CV risk. However, the choice of which drug combination to prescribe and in which patients has become increasingly complicated, and is dependent on both the absolute CV risk and the reason for the high risk. In this review, we discuss therapeutic decisions in CVRM, focusing on (1) the absolute CV risk of the patient and (2) the pros and cons of novel treatment options.

Sodium-glucose cotransporter 2 inhibitors: a practical guide for the Dutch cardiologist based on real-world experience.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors include a relatively new class of glucose-lowering drugs that reduce plasma glucose concentrations by inhibiting proximal tubular reabsorption of glucose in the kidney, while increasing its excretion in urine. Recent large randomised controlled trials have demonstrated that many of these agents reduce the occurrence of major adverse cardiovascular events, hospitalisation for heart failure, cardiovascular death and/or chronic kidney disease progression in patients with and without type 2 diabetes mellitus (DM2). Given their unique insulin-independent mode of action and favourable efficacy and adverse-event profile, SGLT2 inhibitors are promising and they offer an interesting therapeutic approach for the cardiologist to incorporate into routine practice. However, despite accumulating data supporting this class of therapy, cardiologists infrequently prescribe SGLT2 inhibitors, potentially due to a lack of familiarity with their use and the reticence to change DM medication. Here, we provide an up-to-date practical guide highlighting important elements of treatment initiation based on real-world evidence and expert opinion. We describe how to change DM medication, including insulin dosing when appropriate, and how to anticipate any adverse events based on real-world experience in patients with DM2 in the Meander Medical Centre in Amersfoort, the Netherlands. This includes a simple algorithm showing how to initiate SGLT2 inhibitor treatment safely, while considering the consequence of the glucosuric effects of these inhibitors for the individual patient.

Training general practitioners to improve evidence-based drug treatment of patients with heart failure: a cluster randomised controlled trial.

AIMS: To assess whether a single training session for general practitioners (GPs) improves the evidence-based drug treatment of heart failure (HF) patients, especially of those with HF with reduced ejection fraction (HFrEF). METHODS AND RESULTS: A cluster randomised controlled trial was performed for which patients with established HF were eligible. Primary care practices (PCPs) were randomised to care-as-usual or to the intervention group in which GPs received a half-day training session on HF management. Changes in HF medication, health status, hospitalisation and survival were compared between the two groups. Fifteen PCPs with 200 HF patients were randomised to the intervention group and 15 PCPs with 198 HF patients to the control group. Mean age was 76.9 (SD 10.8) years; 52.5% were female. On average, the patients had been diagnosed with HF 3.0 (SD 3.0) years previously. In total, 204 had HFrEF and 194 HF with preserved ejection fraction (HFpEF). In participants with HFrEF, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers decreased in 6 months in both groups [5.2%; (95% confidence interval (CI) 2.0-10.0)] and 5.6% (95% CI 2.8-13.4)], respectively [baseline-corrected odds ratio (OR) 1.07 (95% CI 0.55-2.08)], while beta-blocker use increased in both groups by 5.2% (95% CI 2.0-10.0) and 1.1% (95% CI 0.2-6.3), respectively [baseline-corrected OR 0.82 (95% CI 0.42-1.61)]. For health status, hospitalisations or survival after 12-28 months there were no significant differences between the two groups, also not when separately analysed for HFrEF and HFpEF. CONCLUSION: A half-day training session for GPs does not improve drug treatment of HF in patients with established HF.

A randomised comparison of the effect of haemodynamic monitoring with CardioMEMS in addition to standard care on quality of life and hospitalisations in patients with chronic heart failure : Design and rationale of the MONITOR HF multicentre randomised clinical trial.

BACKGROUND: Assessing haemodynamic congestion based on filling pressures instead of clinical congestion can be a way to further improve quality of life (QoL) and clinical outcome by intervening before symptoms or weight gain occur in heart failure (HF) patients. The clinical efficacy of remote monitoring of pulmonary artery (PA) pressures (CardioMEMS; Abbott Inc., Atlanta, GA, USA) has been demonstrated in the USA. Currently, the PA sensor is not reimbursed in the European Union as its benefit when applied in addition to standard HF care is unknown in Western European countries, including the Netherlands. AIMS: To demonstrate the efficacy and cost-effectiveness of haemodynamic PA monitoring in addition to contemporary standard HF care in a high-quality Western European health care system. METHODS: The current study is a prospective, multi-centre, randomised clinical trial in 340 patients with chronic HF (New York Heart Association functional class III) randomised to HF care including remote monitoring with the CardioMEMS PA sensor or standard HF care alone. Eligible patients have at least one hospitalisation for HF in 12 months before enrolment and will be randomised in a 1:1 ratio. Minimum follow-up will be 1 year. The primary endpoint is the change in QoL as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Secondary endpoints are the number of HF hospital admissions and changes in health status assessed by EQ-5D-5L questionnaire including health care utilisation and formal cost-effectiveness analysis. CONCLUSION: The MONITOR HF trial will evaluate the efficacy and cost-effectiveness of haemodynamic monitoring by CardioMEMS in addition to standard HF care in patients with chronic HF. Clinical Trial Registration number NTR7672.

Cardiac imaging to detect coronary artery disease in athletes aged 35 years and older. A scoping review.

Sudden cardiac death (SCD) is a devastating event in athletes. Screening efforts that were first directed at athletes younger than 35 years are now focusing on the rapidly growing group of older sportspersons. Athletes aged ≥35 years have a 10-fold increased risk of exercise-related cardiac arrest, mostly due to coronary artery disease (CAD). Although cardiac imaging is pivotal in identifying CAD, the role of imaging modalities in screening asymptomatic older sportspersons remains unclear. We performed a scoping review to identify the role of cardiac imaging to detect CAD in older sportspersons and to identify gaps in the existing literature. We searched MEDLINE, EMBASE and the Cochrane library for studies reporting data on cardiac imaging of CAD in sportspersons ≥35 years. The systematic search yielded 1737 articles, and 14 were included in this scoping review. Imaging modalities included two echocardiography, one unenhanced computed tomography (CT) for coronary artery calcium scoring (CACS), three CACS and contrast-enhanced CT angiography (CCTA), two CACS and cardiac magnetic resonance (CMR), one CCTA with CMR and echocardiography, two CCTA, two CMR, and one myocardial perfusion imaging article. The low number of relevant articles and the selection bias introduced by studying specific groups, like veteran marathon runners, indicate the need for future research. Cardiac CT (CACS and CCTA) probably has the highest potential for pre-participation screening, with high diagnostic value to detect CAD and low radiation dose. However, currently there is insufficient evidence for incorporating routine cardiac imaging in the pre-participation screening of asymptomatic sportspersons over 35 years.

Pre-participation screening of asymptomatic athletes : "Don't do stupid stuff".

Catastrophic events, be it traffic accidents, natural disasters or homicides, always lead to scrutiny. Could we have seen the event coming and could it have been prevented? In the case of a sudden cardiac arrest of a seemingly healthy athlete the public outcry is not any different. Despite an intrinsic appeal for screening to prevent similar events, there is no evidence that justifies routine cardiovascular pre-participation screening of athletes. On balance, cardiovascular screening in athletes will most likely do more harm than good. Fatal exercise-related cardiac arrests do not occur very often. The true diagnostic yield of the pre-participation evaluation is not known and once a cardiac condition has been identified, the most appropriate intervention is often unclear. It follows that pre-participation screening of large groups of athletes without known cardiac disease will inevitably result in many false positive findings, while at the same time providing a false sense of security to those screened negative. Except for compelling reasons (e. g. cascade screening, research settings, professional athletes), physicians should not engage in routine examination of asymptomatic athletes to prevent cardiac events.

Nationwide claims data validated for quality assessments in acute myocardial infarction in the Netherlands.

INTRODUCTION: Since health insurance is compulsory in the Netherlands, the centrally registered medical claims data might pose a unique opportunity to evaluate quality of (cardiac) care on a national level without additional collection of data. However, validation of these claims data has not yet been assessed. DESIGN: Retrospective cohort study. METHODS: National claims data ('national registry') were compared with data collected by patient records reviews in four representative hospitals ('validation registry'). In both registries, we extracted the national diagnosis codes for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction of 2012 and 2013. Additionally, data on medication use at one year after acute myocardial infarction (AMI) was extracted from the Dutch pharmacy information systems and also validated by local patient records reviews. The data were compared at three stages: 1) validation of diagnosis and treatment coding; 2) validation of the hospital where follow-up has taken place; 3) validation of follow-up medical treatment after 365 days. RESULTS: In total, 3,980 patients ('national registry') and 4,014 patients ('validation registry') were compared at baseline. After one-year follow-up, 2,776 and 2,701 patients, respectively, were evaluated. Baseline characteristics, diagnosis and individual medication were comparable between the two registries. Of all 52,672 AMI patients in the Netherlands in 2012 and 2013, 81% used aspirin, 76% used P2Y12 inhibitors, 85% used statins, 82% used beta-blockers and 74% angiotensin converting enzyme inhibitors/angiotensin II antagonists. Optimal medical treatment was achieved in 49% of the patients with AMI. CONCLUSION: Nationwide routinely collected claims data in patients with an acute myocardial infarction are highly accurate. This offers an opportunity for use in quality assessments of cardiac care.

No psychological distress in sportsmen aged 45 years and older after cardiovascular screening, including cardiac CT: The Measuring Athlete's Risk of Cardiovascular events (MARC) study.

BACKGROUND: Psychological distress caused by cardiovascular pre-participation screening (PPS) may be a reason not to implement a PPS program. We assessed the psychological impact of PPS, including cardiac computed tomography (CT), in 318 asymptomatic sportsmen aged ≥45 years. METHODS: Coronary artery disease (CAD) was defined as a coronary artery calcium score ≥100 Agatson units and/or ≥50% luminal stenosis on contrast-enhanced cardiac CT. Psychological impact was measured with the Impact of Event Scale (IES) (seven items) on a six-point scale (grade 0-5). A sum score ≥19 indicates clinically relevant psychological distress. A Likert scale was used to assess overall experiences and impact on sports and lifestyle. RESULTS: A total of 275 participants (86.5% response rate, 95% CI 83-90%) with a mean age of 54.5 ± 6.4 years completed the questionnaires, 48 (17.5%, 95% CI 13-22%) of whom had CAD. The median IES score was 1 (IQR 0-2, [0-23]). IES was slightly higher in those with CAD (mean rank 175 vs. 130, p < 0.001). One participant (with CAD) experienced clinically relevant psychological distress (IES = 23). Participants reported numerous benefits, including feeling safer exercising (58.6%, 95% CI 53-65%) and positive lifestyle changes, especially in those with CAD (17.2 vs. 52.1%, p < 0.001). The majority were satisfied with their participation (93.8%, 95% CI 91-97%). CONCLUSION: Cardiovascular PPS, including cardiac CT, causes no relevant psychological distress in older sportsmen. Psychological distress should not be a reason to forego screening in sportsmen.

Rationale and design of the Measuring Athlete's Risk of Cardiovascular events (MARC) study : The role of coronary CT in the cardiovascular evaluation of middle-aged sportsmen.

BACKGROUND: More than 90 % of exercise-related cardiac arrests occur in men, predominantly those aged 45 years and older with coronary artery disease (CAD) as the main cause. The current sports medical evaluation (SME) of middle-aged recreational athletes consists of a medical history, physical examination, and resting and exercise electrocardiography. Coronary CT (CCT) provides a minimally invasive low radiation dose opportunity to image the coronary arteries. We present the study protocol of the Measuring Athlete's Risk of Cardiovascular events (MARC) study. MARC aims to assess the additional value of CCT to a routine SME in asymptomatic sportsmen ≥45 years without known CAD. DESIGN: MARC is a prospective study of 300 asymptomatic sportsmen ≥45 years who will undergo CCT if the SME does not reveal any cardiac abnormalities. The prevalence and determinants of CAD (coronary artery calcium score ≥100 Agatston Units (AU) or ≥50 % luminal stenosis) will be reported. The number needed to screen to prevent the occurrence of one cardiovascular event in the next 5 years, conditional to adequate treatment, will be estimated. DISCUSSION: We aim to determine the prevalence and severity of CAD and the additional value of CCT in asymptomatic middle-aged (≥45 years) sportsmen whose routine SME revealed no cardiac abnormalities.

Plasma extracellular vesicle protein content for diagnosis and prognosis of global cardiovascular disease.

Cardiovascular disease is a major public health problem worldwide. Its growing burden is particularly ominous in Asia, due to increasing rates of major risk factors such as diabetes, obesity and smoking. There is an urgent need for early identification and treatment of individuals at risk of adverse cardiovascular events. Plasma extracellular vesicle proteins are novel biomarkers that have been shown to be useful in the diagnosis, risk stratification and prognostication of patients with cardiovascular disease. Ongoing parallel biobank initiatives in European (the Netherlands) and Asian (Singapore) populations offer a unique opportunity to validate these biomarkers in diverse ethnic groups.

Relationship of ventricular and atrial dilatation to valvular function in endurance athletes.

OBJECTIVE: To establish cardiac magnetic resonance imaging (MRI) reference values for atrial adaptation to training in endurance athletes in comparison with matched non-athletes. In addition, to study the relationship of atrial size to ventricular and annular size and valvular function. DESIGN: Cross-sectional study. PARTICIPANTS: 180 healthy individuals aged 18-39 years (41% women): 60 elite endurance athletes (exercising > 18 h/week), 60 regular endurance athletes (9-18 h/ week), and 60 age and gender matched non-athletes (exercising ≤3 h/week) underwent cardiac MRI. Quantitative atrial dimensions and volumes, indexed for body surface area (BSA), were compared with ventricular and annular dimensions. Regurgitant fractions of all four valves and peak velocities of mitral and tricuspid valves were also assessed. RESULTS: BSA-corrected right and left atrial volumes and diameters were significantly larger for athletes compared with non-athletes (p<0.05-p<0.0005). Ventricular, annular and atrial ratios remained constant for all groups, suggesting balanced adaptation to exercise training. E/A ratios remained statistically unchanged in all groups. Regurgitant fractions of the four cardiac valves were all mild (≤15%) and not significantly different in athletes compared with non-athletes. CONCLUSIONS: Atrial remodelling in endurance athletes may be regarded as a balanced physiological adaptation to exercise training with preservation of valvular function.

Clopidogrel in noncarriers of CYP2C19 loss-of-function alleles versus ticagrelor in elderly patients with acute coronary syndrome: A pre-specified sub analysis from the POPular Genetics and POPular Age trials CYP2C19 alleles in elderly patients.

BACKGROUND: Patients with acute coronary syndrome (ACS) who are carrying CYP2C19 loss-of-function alleles derive less benefit from clopidogrel treatment. Despite this, in elderly patients, clopidogrel might be preferred over more potent P2Y12 inhibitors due to a lower bleeding risk. Whether CYP2C19 genotype-guided antiplatelet treatment in the elderly could be of benefit has not been studied specifically. METHODS: Patients aged 70 years and older with known CYP2C19*2 and *3 genotype were identified from the POPular Genetics and POPular Age trials. Noncarriers of loss-of-function alleles treated with clopidogrel were compared to patients, irrespective of CYP2C19 genotype, treated with ticagrelor and to clopidogrel treated carriers of loss-of-function alleles. We assessed net clinical benefit (all-cause death, myocardial infarction, stroke and Platelet Inhibition and Patient Outcomes (PLATO) major bleeding), atherothrombotic outcomes (cardiovascular death, myocardial infarction, stroke) and bleeding outcomes (PLATO major and minor bleeding). RESULTS: A total of 991 patients were assessed. There was no significant difference in net clinical benefit (17.2% vs. 15.1%, adjusted hazard ratio (adjHR) 1.05, 95% confidence interval (CI) 0.77-1.44), atherothrombotic outcomes (9.7% vs. 9.2%, adjHR 1.00, 95%CI 0.66-1.50), and bleeding outcomes (17.7% vs. 19.8%, adjHR 0.80, 95%CI 0.62-1.12) between clopidogrel in noncarriers of loss-of-function alleles and ticagrelor respectively. CONCLUSION: In ACS patients aged 70 years and older, there was no significant difference in net clinical benefit and atherothrombotic outcomes between noncarriers of a loss-of-function allele treated with clopidogrel and patients treated with ticagrelor. The bleeding rate was numerically; though not statistically significant, lower in patients using clopidogrel.

Age- and gender-specific risk of death after first hospitalization for heart failure.

BACKGROUND: Hospitalization for heart failure (HF) is associated with high-in-hospital and short- and long-term post discharge mortality. Age and gender are important predictors of mortality in hospitalized HF patients. However, studies assessing short- and long-term risk of death stratified by age and gender are scarce. METHODS: A nationwide cohort was identified (ICD-9 codes 402, 428) and followed through linkage of national registries. The crude 28-day, 1-year and 5-year mortality was computed by age and gender. Cox regression models were used for each period to study sex differences adjusting for potential confounders (age and comorbidities). RESULTS: 14,529 men, mean age 74 ± 11 years and 14,524 women, mean age 78 ± 11 years were identified. Mortality risk after admission for HF increased with age and the risk of death was higher among men than women. Hazard ratio's (men versus women and adjusted for age and co-morbidity) were 1.21 (95%CI 1.14 to 1.28), 1.26 (95% CI 1.21 to 1.31), and 1.28 (95%CI 1.24 to 1.31) for 28 days, 1 year and 5 years mortality, respectively. CONCLUSIONS: This study clearly shows age- and gender differences in short- and long-term risk of death after first hospitalization for HF with men having higher short- and long-term risk of death than women. As our study population includes both men and women from all ages, the estimates we provide maybe a good reflection of 'daily practice' risk of death and therefore be valuable for clinicians and policymakers.

[Beta-blockers after a myocardial infarction: when to discontinue safely?] / Bètablokkers na een hartinfarct.

For decades beta-blockers have been used in the treatment of patients after a myocardial infarction (MI). Current guidelines on the use of beta-blockers after myocardial infarction are based on studies that date back to 3 decades ago. Since then advances in the treatment of myocardial infarction have been made, thanks to the implementation of percutaneous coronary intervention, statins and ACE-inhibitors. This has resulted in increased survival and lower rates of post-MI heart failure. Long-term beta-blocker treatment is a cornerstone for treatment in patients with decreased left ventricular systolic function. However, the efficacy of the long-term treatment in post-MI patients with preserved ventricular function is unknown. Side-effects of beta-blockers can considerably impact patient's quality-of-life. This contribution reviews available data on the efficacy and possibilities for discontinuation of treatment with beta-blockers.

Plasma extracellular vesicle proteins are associated with stress-induced myocardial ischemia in women presenting with chest pain.

Diagnosing stable ischemic heart disease (IHD) is challenging, especially in females. Currently, no blood test is available. Plasma extracellular vesicles (EV) are emerging as potential biomarker source. We therefore aimed to identify stress induced ischemia due to stable IHD with plasma extracellular vesicle protein levels in chest pain patients. We analyzed 450 patients suspected for stable IHD who were referred for 82Rb PET/CT in the outpatient clinic. Blood samples were collected before PET/CT and plasma EVs were isolated in 3 plasma subfractions named: TEX, HDL, LDL. In total 6 proteins were quantified in each of these subfractions using immuno-bead assays. CD14 and CystatinC protein levels were independent significant predictors of stress-induced ischemia in the LDL and the HDL subfraction and SerpinC1 and SerpinG1 protein levels in the HDL fraction. Subgroup-analysis on sex revealed that these associations were completely attributed to the associations in women. None of the significant EV proteins remained significant in men. Plasma EV proteins levels are associated with the presence of stable IHD in females presenting with chest pain. This finding, if confirmed in larger cohort studies could be a crucial step in improving diagnostic assessment of women with suspected IHD.

Advances in cardiac imaging: the role of magnetic resonance imaging and computed tomography in identifying athletes at risk.

Advanced cardiac imaging, using cardiac magnetic resonance imaging (MRI) and multidetector computed tomography (CT), is increasingly used in the work-up of athletes with suspected abnormalities on screening. Both imaging modalities produce highly accurate and reproducible structural and functional cardiac information. Cardiac MRI has the advantage of imaging without radiation exposure or the use of iodine-containing contrast agents, but is sometimes not possible due to claustrophobia or other contraindications. Although cardiac MRI can rule out coronary artery anomalies, multidetector CT is superior to cardiac MRI for visualising the full extent of the coronary arteries and atherosclerotic coronary artery disease. For patients less than 35 years of age, cardiac MRI is the first option after initial echocardiography for further assessment of cardiomyopathies, myocarditis and coronary anomalies, which are major causes of sudden cardiac death in young athletes. For athletes over 35 years of age the most common cause of sudden cardiac death is coronary artery disease, whereby cardiovascular screening requires further diagnostic modalities and may include multidetector CT.

Risk factors for exercise-related acute cardiac events. A case-control study.

BACKGROUND: In spite of the benefits of physical activity, exercise may provoke acute cardiac events in susceptible individuals. Understanding risk factors of exercise-related acute cardiac events may identify opportunities for prevention. METHODS: A case-control study was conducted to examine determinants of acute cardiac events in athletes. The cases were athletes who suffered an acute cardiac event during or shortly after vigorous exercise. Athletes who visited a hospital because of a minor sports injury were selected as controls. Information on cardiovascular disease, family history of cardiovascular disease, cardiovascular symptoms and other potential risk factors was collected through questionnaires. RESULTS: 57 cases (mean age 41.8 years, range 11-73) and 57 controls (mean age 40.9 years, range 13-68) were included in the study. Athletes with a history of cardiovascular disease were at a markedly increased risk for cardiac events during exercise (OR = 32; 95% CI 7.4 to 143). Smoking (OR 5.9; 95% CI 1.9 to 18), fatigue (OR = 12; 95% CI 1.2 to 118) and flu-like symptoms (OR 13; 95% CI 1.4 to 131) in the month preceding the event were related to acute cardiac events in athletes. CONCLUSIONS: Prior cardiovascular disease, smoking, and a recent episode of fatigue or flu-like symptoms are associated with an increased risk of exercise-related acute cardiac events. Athletes and physicians should pay careful attention when these factors exist or occur.

One-year mortality after a first visit to a cardiology outpatient clinic: a useful performance indicator?

PURPOSE: In 2003 the Dutch Health Care Inspectorate introduced performance indicators to monitor and compare quality of care in Dutch hospitals. In 2007, the new performance indicator 'one-year mortality after a first visit to a cardiology outpatient clinic' was introduced. We set out to evaluate this new indicator in three Dutch teaching hospitals. METHODS: Using electronic medical records, information was collected retrospectively of patients aged >/=70 years who visited the cardiology outpatient clinic of Medical Centre Alkmaar, Meander Medical Centre Amersfoort and Deventer Hospital between 1 January 2006 and 31 January 2006. Diagnoses were based on the diagnosis treatment combination (DBC) coding system. RESULTS: 547 patients (mean age 78.0 years, 53% men) were included, 35 (6.4%) of whom had died after one year. Cardiovascular disease was the most frequent cause of death (22/35, 62.9%). The oneyear mortality among the three hospitals varied from 5.0 to 7.3% (NS). CONCLUSION: One-year mortality after the first visit to a cardiology outpatient clinic amounted to 6.4% in patients aged >/=70 years and did not differ significantly between the three Dutch teaching hospitals. The administrative load to obtain the necessary information was considerable. One-year mortality should be regarded as an 'outcome' parameter rather than a 'performance' indicator. (Neth Heart J 2009;17:52-5.).