Screening of sarcomere gene mutations in young athletes with abnormal findings in electrocardiography: identification of a MYH7 mutation and MYBPC3 mutations.

There is an overlap between the physiological cardiac remodeling associated with training in athletes, the so-called athlete's heart, and mild forms of hypertrophic cardiomyopathy (HCM), the most common hereditary cardiac disease. HCM is often accompanied by unfavorable outcomes including a sudden cardiac death in the adolescents. Because one of the initial signs of HCM is abnormality in electrocardiogram (ECG), athletes may need to monitor for ECG findings to prevent any unfavorable outcomes. HCM is caused by mutations in genes for sarcomere proteins, but there is no report on the systematic screening of gene mutations in athletes. One hundred and two genetically unrelated young Japanese athletes with abnormal ECG findings were the subjects for the analysis of four sarcomere genes, MYH7, MYBPC3, TNNT2 and TNNI3. We found that 5 out of 102 (4.9%) athletes carried mutations: a heterozygous MYH7 Glu935Lys mutation, a heterozygous MYBPC3 Arg160Trp mutation and another heterozygous MYBPC3 Thr1046Met mutation, all of which had been reported as HCM-associated mutations, in 1, 2 and 2 subjects, respectively. This is the first study of systematic screening of sarcomere gene mutations in a cohort of athletes with abnormal ECG, demonstrating the presence of sarcomere gene mutations in the athlete's heart.

Cardiorespiratory fitness and the incidence of type 2 diabetes: a cohort study of Japanese male athletes.

BACKGROUND: In Japan, although the incidence of overweight (BMI ≥ 25) is still low compared with that in Europe and the United States, the prevalence of type 2 diabetes has increased over the last 15 years,. In both Japanese and Caucasian populations it has been reported that a high level of cardiorespiratory fitness protects against the development of type 2 diabetes. However, there are no reports focused specifically on athletes that investigate whether high cardiorespiratory fitness at a young age can prevent disease later in life. We examined the relationship between cardiorespiratory fitness at a young age and the development of type 2 diabetes in Japanese athletes using a cohort study. METHODS: The cardiorespiratory fitness of male alumni of the physical education department of Juntendo University, as measured by stored data of a 1,500-m endurance run in college (1971-1991) was compared with their incidence of type 2 diabetes as determined by follow-up questionnaires (2007-2009). This study used Cox's proportional hazards models and adjusted for age, year of graduation, BMI, smoking, and sports club participation at college age. RESULTS: We collected data on cardiorespiratory fitness at college age and medical history survey data during 2007-2009 from 570 male alumni. The median follow-up period was 26 years (IQR: 23-29 years), and 22 men had developed type 2 diabetes. An inverse relationship was observed between incidence of type 2 diabetes and level of cardiorespiratory fitness at time of college after adjustment for age, year of graduation, BMI, smoking, and sports participation. The adjusted hazards ratio and 95% CI by category (low, medium, and high) were 1.00 (reference), 0.40 (0.14-1.13) and 0.26 (0.07-1.00) (p = 0.03 for trend). CONCLUSIONS: A high level of cardiorespiratory fitness at a young age can help prevent type 2 diabetes later in life.

Basal cardiomyopathy develops in rabbits with ventricular tachyarrhythmias induced by a single injection of adrenaline.

We have recently demonstrated that basal cardiomyopathy develops in rabbits with ventricular tachyarrhythmias that have been induced by electrical stimulation of the cervical vagus. This study investigated whether similar basal cardiomyopathy would develop in rabbits with ventricular tachyarrhythmias induced by a single injection of adrenaline. Adrenaline was intravenously infused for 10-360 seconds in anesthetized rabbits. Colloidal carbon was injected after adrenaline infusion. Wall movement velocity of the left ventricular base was assessed by tissue Doppler echocardiography. Animals were killed either 1 week or 3-4 weeks later. Pathological lesions were identified by deposits of carbon particles. Animals were divided into two groups according to the infused dose of adrenaline. The small-dose group (group S, n = 15) received 1-10 µg and the large-dose group (group L, n = 23) received 15-60 µg of adrenaline. Adrenaline infusion induced premature ventricular contractions followed by monomorphic ventricular tachycardias in 22 of 23 animals in group L, but in only 1 of 15 animals in group S. Wall movement velocity of the left ventricular base decreased just after adrenaline infusion, remained low after 1 week, and recovered to near-baseline levels after 3-4 weeks in group L. Unique cardiac lesions identified by deposits of carbon particles were frequently observed on the left ventricular basal portion, almost always associated with the mitral valve and papillary muscles, but were never observed in the apical area. Lesions involving all areas of the left ventricular basal portion were observed in 22 of 23 animals in group L, but in only 2 of 15 animals in group S. Basal cardiomyopathy developed in rabbits with ventricular tachycardias induced by a single injection of adrenaline.

Consumption of yogurt fermented with Lactobacillus delbrueckii ssp. bulgaricus OLL1073R-1 augments serum antibody titers against seasonal influenza vaccine in healthy adults.

Seasonal influenza is a major upper respiratory tract infection occurring in winter. Vaccination is the best method for preventing this infection. We conducted two randomized, double-blind, placebo-controlled trials to examine whether consumption of yogurt fermented with Lactobacillus delbrueckii ssp. bulgaricus OLL1073R-1, which has been reported to reduce the risk of catching the common cold, augments serum antibody titers against seasonal influenza vaccines. In the first trial, which included university students, serum antibody titers against influenza A (H3N2) and B viruses were significantly higher in the yogurt group than in the placebo group. According to the guidelines established by the European Medicines Agency (EMA) for the assessment of vaccines, the seroconversion rate and mean geometric increase of influenza A (H3N2) and seroprotection of influenza B met the criteria only in the yogurt group. In the second trial, which included healthy adults, serum antibody titers against influenza A (H1N1) and B viruses were significantly higher in the yogurt group than in the placebo group. The seroconversion rate and mean geometric increase of influenza B met the EMA criteria only in the yogurt group. Furthermore, the cumulative days of ill health, such as throat complaints, upper respiratory inflammation, and cold, were significantly lower in the yogurt group than in the placebo group. Therefore, daily intake of yogurt fermented with L. bulgaricus OLL1073R-1 could reduce the duration of symptoms caused by respiratory infections and act as a mucosal adjuvant enhancing acquired immune responses against vaccines, leading to the improvement of public health.

Dilated cardiomyopathy-associated BAG3 mutations impair Z-disc assembly and enhance sensitivity to apoptosis in cardiomyocytes.

Dilated cardiomyopathy (DCM) is characterized by dilation of left ventricular cavity with systolic dysfunction. Clinical symptom of DCM is heart failure, often associated with cardiac sudden death. About 20-35% of DCM patients have apparent family histories and it has been revealed that mutations in genes for sarcomere proteins cause DCM. However, the disease-causing mutations can be found only in about 17% of Japanese patients with familial DCM. Bcl-2-associated athanogene 3 (BAG3) is a co-chaperone protein with antiapoptotic function, which localizes at Z-disc in the striated muscles. Recently, BAG3 gene mutations in DCM patients were reported, but the functional abnormalities caused by the mutations are not fully unraveled. In this study, we analyzed 72 Japanese familial DCM patients for mutations in BAG3 and found two mutations, p.Arg218Trp and p.Leu462Pro, in two cases of adult-onset DCM without skeletal myopathy, which were absent from 400 control subjects. Functional studies at the cellular level revealed that the DCM-associated BAG3 mutations impaired the Z-disc assembly and increased the sensitivities to stress-induced apoptosis. These observations suggested that BAG3 mutations present in 2.8% of Japanese familial DCM patients caused DCM possibly by interfering with Z-disc assembly and inducing apoptotic cell death under the metabolic stress.

Effects of phase III cardiac rehabilitation on mortality and cardiovascular events in elderly patients with stable coronary artery disease.

BACKGROUND: Cardiac rehabilitation (CR) has numerous benefits, including reduction of mortality and cardiovascular events, in patients with coronary artery disease (CAD). However, the long-term effect of phase III CR in elderly patients with stable CAD is still unknown. METHODS AND RESULTS: The 111 elderly male CAD patients (>or=65 years), including 37 subjects participating in supervised CR for 6 months and 74 age-matched controls, were analyzed. The patients were followed for up to 3,500 days, until the occurrence of death or 1 of the following major adverse cardiovascular events (MACE): cardiovascular death, acute coronary syndrome, refractory angina requiring revascularization, admission for congestive heart failure, or stroke. All-cause mortality tended to be lower in the CR group than in the Control group (14% vs 28%, P=0.081). The MACE incidence was significantly lower in the CR group than in the Control group (30% vs 62%, P=0.001). Multivariate Cox proportional hazard analysis showed that the MACE incidence was significantly lower in the CR group than in the Control group [adjusted hazard ratio 0.43 (95% confidence interval 0.20-0.91), P=0.027]. CONCLUSIONS: Phase III CR has the beneficial effect of reducing cardiovascular events even in elderly patients with stable CAD.

A body mass index over 22 kg/m2 at college age is a risk factor for future diabetes in Japanese men.

BACKGROUND: There is a high incidence of type 2 diabetes in Asian adults, even those with a normal body mass index (BMI) (<25.0 kg/m2). For example, it has been shown that a slightly increased BMI (>23 kg/m2) at middle age is a risk factor for type 2 diabetes in Asians. In this historical cohort study, we investigated whether a slightly increased BMI at college age was also a risk factor for future diabetes in Japanese men. METHODS: Six hundred and sixty-one male alumni who graduated from a physical education school between 1971 and 1991 and who responded to follow-up investigation between 2007 and 2017 were included in this study. Participants were categorized into four categories: college BMI of <21.0 kg/m2, 21.0-22.0 kg/m2, 22.0-23.0 kg/m2, and ≥23.0 kg/m2, and the incidence and risk ratio of diabetes were compared between groups. RESULTS: The median follow-up period was 32 years (interquartile range, IQR: 27-36), which included 20,983 person-years of observation. Subjects were 22 (22-22) years old at college graduation, and 55 (50-59) years old at the final follow-up investigation. During the study period, 56 men developed diabetes; the prevalence rates for the lowest to highest BMI categories were 4.4%, 7.6%, 10.5%, and 11.3%, respectively, and their adjusted hazard ratios were 1.00 (reference), 1.77 (95% CI: 0.68-4.30), 2.42 (1.00-5.84), and 2.53 (1.06-6.07), respectively (p = 0.03 for trend). CONCLUSION: Our data suggest that a BMI over 22.0 kg/m2 at college age is a risk factor for diabetes later in life in Japanese men.

Slightly increased BMI at young age is a risk factor for future hypertension in Japanese men.

BACKGROUND: Hypertension is developed easily in Asian adults with normal body mass index (BMI) (~23 kg/m2), compared with other ethnicities with similar BMI. This study tested the hypothesis that slightly increased BMI at young age is a risk factor for future hypertension in Japanese men by historical cohort study. METHODS: The study participants were 636 male alumni of the physical education school. They had available data on their physical examination at college age and follow-up investigation between 2007 and 2011. The participants were categorized into six categories: BMI at college age of <20.0 kg/m2, 20.0-21.0kg/m2, 21.0-22.0kg/m2, 22.0-23.0kg/m2, 23.0-24.0kg/m2, and ≥24.0kg/m2, and the incidence of hypertension was compared. RESULTS: This study covered 27-year follow-up period (interquartile range: IQR: 23-31) which included 17,059 person-years of observation. Subjects were 22 (22-22) years old at graduated college, and 49 (45-53) years old at first follow-up investigation. During the period, 120 men developed hypertension. The prevalence rates of hypertension for lowest to highest BMI categories were 9.4%, 14.6%, 16.1%, 17.5%, 30.3%, and 29.3%, respectively (p<0.001 for trend), and their hazard ratios were 1.00 (reference), 1.80 (95%CI: 0.65-4.94), 2.17 (0.83-5.64), 2.29 (0.89-5.92), 3.60 (1.37-9.47) and 4.72 (1.78-12.48), respectively (p<0.001 for trend). This trend was similar after adjustment for age, year of graduation, smoking, current exercise status and current dietary intake. CONCLUSION: Slightly increased BMI at young age is a risk factor for future hypertension in Japanese men.

Association Between Visceral Fat Accumulation and Exercise Tolerance in Non-Obese Subjects Without Diabetes.

BACKGROUND: We examined the associations between visceral fat accumulation, presence of the components of metabolic syndrome (MetS), and exercise tolerance in non-obese subjects without diabetes. METHODS: Seventy-four non-obese, non-diabetic Japanese men were enrolled. The subjects were divided into the following two groups: non-obese subjects without any MetS risk factors (n = 38, Group A) and non-obese subjects with one or two MetS risk factors (n = 36, Group B). Anthropometric and metabolic parameters were measured. The response of heart rate (HR) and blood pressure (BP), and exercise tolerance were also evaluated with a cardiopulmonary exercise test using a bicycle ergometer. RESULTS: The body mass index, abdominal circumference, visceral fat area, and homeostasis model assessment-insulin resistance, were significantly higher, while levels of anaerobic threshold and maximal oxygen uptake were significantly lower in Group B than in Group A. The levels of resting HR, resting BP, and BP at maximal exercise were significantly higher in Group B than in Group A. There were no significant differences in the HR at maximal exercise as well as the HR and BP after exercise between the two groups. The visceral fat area was significantly and negatively correlated with exercise tolerance. Multivariate linear regression analyses demonstrated that visceral fat area, but not abdominal circumference, was significantly and independently associated with maximal oxygen uptake. CONCLUSIONS: These data suggest that the visceral fat area is a significant determinant for exercise tolerance even in non-obese subjects without diabetes.

Level of serum undercarboxylated osteocalcin correlates with bone quality assessed by calcaneal quantitative ultrasound sonometry in young Japanese females.

The diagnostic criteria of osteoporosis were established based on bone mineral density (BMD). Therefore, BMD measured by dual energy X-ray absorptiometry has been recognized as the gold standard to diagnose osteoporosis. However, discrepancies between fracture risk and BMD have been recognized. Bone is composed of collagen scaffold reinforced by hydroxyapatite. Both protein scaffold and hydroxyapatite are involved in bone quality. BMD may indicate bone mineralization but potentially fail to assess the protein scaffold. Vitamin K contributes to bone mineralization and as a protein scaffold. A deficiency of vitamin K upregulates the level of serum undercarboxylated osteocalcin (ucOC), and serum ucOC correlates with fracture risk. However, direct association of ucOC and bone quality has not been demonstrated. For the present study, a total of 49 healthy young Japanese female college students underwent calcaneal; quantitative ultrasound sonometry (QUS) and determination of serological bone metabolic markers. QUS parameters were significantly correlated with serum 25-hydroxyvitamin D (25-OH-D) concentrations (P<0.05). A significant negative correlation was also identified between log transformed serum ucOC concentrations [Ln(ucOC)] and a QUS parameter, speed of sound (SOS) (P<0.05). Stepwise multiple regression analysis indicated that Ln(ucOC) was an independent determinant of SOS, and 25-OH-D was an independent determinant of the other two QUS parameters, transmission index (TI) and synthetic parameter osteo-sono-assessment index. As vitamin D is involved in bone mineralization, TI may reflect the mineralization. Correlation of vitamin K status, indicated by ucOC, with SOS may clarify the correlation between vitamin K status and bone quality, although the material factors that connect them have not been identified.

Association between Yogurt Consumption and Intestinal Microbiota in Healthy Young Adults Differs by Host Gender.

Human intestinal microbiota are influenced by various factors viz. diet, environment, age, gender, geographical, and socioeconomic situation, etc. among which diet has the most profound impact. However, studies investigating this impact have mostly included subjects from diverse geographic/socioeconomic backgrounds and hence the precise effects of dietary factors on gut microbiota composition remain largely confounded. Herein, with an aim to evaluate the association between dietary habits, specifically yogurt consumption, and the gut microbiota in healthy young adults sharing similar age, lifestyle routine, geographical setting, etc., we conducted a cross-sectional study wherein 293 collegiate freshmen answered a questionnaire about their frequency of yogurt consumption over the last 2 months and provided stool specimens for microbiota analysis. Fecal microbiota were analyzed by highly sensitive reverse-transcription-quantitative-PCR assays targeting bacterial 16S rRNA molecules. Fecal organic acids were measured by HPLC. Overall, the gut microbiota were predominated (97.1 ± 8.6%) by Clostridium coccoides group, Clostridium leptum subgroup, Bacteroides fragilis group, Bifidobacterium and Atopobium cluster. Interestingly, after adjusting the data for yogurt consumption, females were found to have higher total bacterial (P = 0.013) and Bifidobacterium (P = 0.046) count and fecal pH (P = 0.007) and lower fecal concentration of total organic acids (P = 0.030), succinic acid (P = 0.007) and formic acid (P = 0.046) as compared to males. Altogether, yogurt consumption showed positive linear association with Lactobacillus and Lactobacillus gasseri subgroup in both male and female subjects; however, several gender-specific disparities were also detected in this yogurt-microbiota association. Yogurt consumption demonstrated a negative association with L. sakei subgroup, Enterobacteriaceae and Staphylococcus in males but shared a positive association with L. casei subgroup and succinic acid in female subjects. The study manifests the association between yogurt consumption and gut microbiota in a healthy homogeneous cohort and show how this association can differ by host gender. The findings should be helpful for prospective studies investigating the diet-microbiome interaction in human health and disease.

[Systematic review of fall-related factors among the house-dwelling elderly in Japan].

BACKGROUND: Fall-related factors and individual characteristics of the elderly who have had fall are necessary to develop practical fall prevention programs, and life support management. However, no nation-wide meta-analysis of the fall-related factors of elderly has been performed in Japan. OBJECTIVES: To conduct a meta-analysis concerning fall-related factors among the house-dwelling elderly in Japan. DATA SOURCES: Japana Centra Revuo Medicina, version 3 (systematic literature search system for Japanese literature), and Pub Med (a service of the National Library of Medicine) from January 1994 to December 2003. METHODS: Study search terms included the following: retrograde case-control, prospective cohort, and retrospective cohort study with falls. Search terms included older adults (60 years and over), falls and humans. Thirty-two fall-related factors were meta-analyzed. RESULTS: Among 32 fall-related factors, only nine factors were statistically proven to be related to falls. These factors were female gender, age over 70 years old, fall experience, past history of cerebrovascular disease, grip strength, knee extensor strength, one foot standing time with eyes open, one foot standing time with eyes closed, and skinfold thickness (female). Eleven factors: presence of a spouse, past medical history of hypertension, complaints of dizziness, numbness of the extremities, 10 meter maximum walking velocity, tendency to stumble, use of supportive equipment, standing postural sway. sitting trunk flexion, skinfold thickness (male), and body mass index, were not statistically proven to be related to falls. CONCLUSIONS: More studies are necessary to determine the efficacy of fall-related factors among the Japanese elderly.

Severe infundibular pulmonary stenosis and coronary artery stenosis with ventricular tachycardia 24 years after mediastinal irradiation.

A 28-year-old man developed severe infundibular pulmonary stenosis (PS), coronary artery stenosis with sustained ventricular tachycardia (VT) 24 years after mediastinal irradiation (total amount of 40 Gray) for non-Hodgkin's lymphoma. Repair of right ventricular outflow tract and coronary artery bypass graft procedure were performed. Infundibular PS was successfully relieved after operation and VT was also controlled by medication. Mediastinal irradiation often causes various cardiac complications after a latent period. Therefore, continuous careful observation is mandatory in patients with the history of mediastinal irradiation.

[Pathology of sudden cardiac death].

Sudden unexpected cardiac death generally occurs in persons with previously unrecognized heart disease. It has become evident that it occurs often enough in patients without any identifiable structural abnormality. Although mechanical cardiac function may seem normal, such patients might have certain discrete anatomic abnormalities, such as myocarditis, focal myocardial fibrosis, hypertrophy of Purkinje-like myocytes, and myocardial disarray. The pathophysiology in patients with acute myocardial infarction (atherothrombosis of the coronary arteries) was discussed.

Expression of tumor necrosis factor ligand superfamily costimulatory molecules CD27L, CD30L, OX40L and 4-1BBL in the heart of patients with acute myocarditis and dilated cardiomyopathy.

BACKGROUND: T-cell-mediated myocardial damage is known to be involved in acute myocarditis and dilated cardiomyopathy. Recently, we found that tumor necrosis factor (TNF) ligand superfamily costimulatory molecules, especially 4-1BBL, played an important role in the myocardial damage of murine acute viral myocarditis. METHODS AND RESULTS: To investigate the roles for CD27L, CD30L, OX40L and 4-1BBL, which belong to TNF ligand superfamily, in the development of acute myocarditis and dilated cardiomyopathy, we analyzed the expression of these antigens in the myocardial tissues of patients with acute myocarditis and dilated cardiomyopathy. We also examined expression of the receptors for these molecules, CD27, CD30, OX40 and 4-1BB, which belong to TNF receptor superfamily, on the infiltrating cells. Strong expression of CD27L, CD30L and 4-1BBL and weak to moderate expression of OX40L was found in the cardiac myocytes of patients with acute myocarditis. Moderate expression of CD27L, CD30L and 4-1BBL and weak expression of OX40L was found on the cardiac myocytes of patients with dilated cardiomyopathy. Most of the infiltrating cells expressed CD27, CD30 and 4-1BB and a part of the infiltrating cells expressed OX40. CONCLUSIONS: Our findings suggest that expression of TNF ligand superfamily costimulatory molecules on cardiac myocytes may play a role in the cell-mediated myocardial damage in patients with acute myocarditis and dilated cardiomyopathy as in murine viral myocarditis.

Multiple cutaneous rhabdomyomas in a child.

We recently encountered a 4 year-old male patient with congenital, multiple, corporeal, cutaneous rhabdomyomas. Pathological examination of the excised tumors showed lobular structures in the dermis. The tumor cells contained spherical and polygonal eosinophilic cytoplasm with peripherally dislocated nuclei, and were positive for myogloblin staining. Extra-cardiac rhabdomyoma is an extremely rare condition, and our case might be considered the first of its kind in Japan.

Milk fortified with vitamin D could reduce the prevalence of vitamin D deficiency among Japanese female college students.

SUMMARY: The mean serum 25-OH-D was 23.1 ng/mL in 49 female Japanese college students, and concentrations in 33% of them were ≤20 ng/mL. Subsequently, they consumed milk fortified with 2 µg of vitamin D daily for 8 weeks. Then, 25-OH-D increased to 36.0 ng/mL and all values were ≥20 ng/mL. PURPOSE: Commercial milk in the USA is fortified with vitamin D (VD), whereas food fortified with VD is unpopular in Japan even though dietary sources of this vitamin are limited. Therefore, young Japanese females might be VD deficient. This study assesses the effects of ingesting milk fortified with VD among Japanese female college students. METHODS: Forty-nine female college students consumed 180 mL of milk fortified with 2 µg of VD daily for 8 weeks. This amount of VD in the milk was similar to that in commercial milk sold in the USA. Serum concentrations of 25-OH-D were measured in venous blood collected before and after the ingestion period. RESULTS: The initial serum 25-OH-D concentration was 23.1 ng/mL and concentrations in 33% of the participants were ≤20 ng/mL. After 8 weeks, serum 25-OH-D increased to 36.0 ng/mL and all values were ≥20 ng/mL. Serum Ca and FGF-23 also increased and PTH, NTX, and BAP significantly decreased. CONCLUSIONS: The high prevalence of VD deficiency in Japanese female college students was decreased by consuming VD-fortified milk.

Evidence-based new service package vs. routine service package for smoking cessation to prevent high risk patients from cardiovascular diseases (CVD): study protocol for randomized controlled trial.

BACKGROUND: Smoking cessation is a high-priority intervention to prevent CVD events and deaths in developing countries. While several interventions to stop smoking have been proved successful, the question of how to increase their effectiveness and practicality in developing countries remains. In this study, a newly devised evidence-based smoking cessation service package will be compared with the existing service in a randomized controlled trial within the community setting of Thailand. METHOD/DESIGN: This randomized control trial will recruit 440 current smokers at CVD risk because of being diabetic and/or hypertensive. Informed, consented participants will be randomly allocated into the new service-package arm and the routine service arm. The study will take place in the non-communicable disease clinics of the Maetha District Hospital, Lampang, northern Thailand. The new smoking-cessation service-package comprises (1) regular patient motivation and coaching from the same primary care nurse over a 3-month period; (2) monthly application of piCO + smokerlyzer to sustain motivation of smoker's quitting attempt and provide positive feedback over a 3-month period; (3) assistance by an assigned family member; (4) nicotine replacement chewing gum to relieve withdrawal symptoms. This new service will be compared with the traditional routine service comprising the 5A approach in a 1-year follow-up. Participants who consent to participate in the study but refuse to attempt quitting smoking will be allocated to the non-randomized arm, where they will be just followed up and monitored. Primary outcome of the study is smoking cessation rate at 1-year follow-up proven by breath analysis measuring carbomonoxide in parts per million in expired air. Secondary outcomes are smoking cessation rate at the 6-month follow-up, blood pressure and heart rate, CVD risk according to the Framingham general cardiovascular risk score, CVD events and deaths at the 12-month follow-up, and the cost-effectiveness of the health service packages. Intention-to-treat analysis will be followed. Factors influencing smoking cessation will be analyzed by the structure equation model. DISCUSSION: This multicomponent intervention, accessible at primary healthcare clinics, and focusing on the individual as well as the family and social environment, is unique and expected to work effectively. TRIAL REGISTRATION: Current Controlled Trials ISRCTN89315117.