Changes in life expectancy 1950-2010: contributions from age- and disease-specific mortality in selected countries.

BACKGROUND: Changes of life expectancy over time serve as an interesting public health indicator for medical, social and economic developments within populations. The aim of this study was to quantify changes of life expectancy between 1950 and 2010 and relate these to main causes of death. METHODS: Pollard's actuarial method of decomposing life expectancy was applied to compare the contributions of different age- and disease-groups on life expectancy in 5-year intervals. RESULTS: From the 1960 to 70s on, declines in cardiovascular disease (CVD) mortality play an increasing role in improving life expectancy in many developed countries. During the past decades gains in life expectancy in these countries were mainly observed in age groups ≥65 years. A further consistent pattern was that life expectancy increases were stronger in men than in women, although life expectancy is still higher in women. In Japan, an accelerated epidemiologic transition in causes of death was found, with the highest increases between 1950 and 1955. Short-term declines and subsequent gains in life expectancy were observed in Eastern Europe and the former states of the Union of Soviet Socialist Republics (USSR), reflecting the changes of the political system. CONCLUSIONS: Changes of life years estimated with the decomposing method can be directly interpreted and may therefore be useful in public health communication. The development within specific countries is highly sensitive to changes in the political, social and public health environment.

German nationwide data on current trends and management of acute myocardial infarction: discrepancies between trials and real-life.

AIMS: Recent guidelines on acute myocardial infarction (AMI) are based on randomized clinical trials (RCTs) and registries with selected patients, and may therefore not represent 'real-life'. This analysis shows for the first time nationwide trends in AMI from Germany. METHODS AND RESULTS: We were provided with data on all in-patient hospitalizations by the Federal Statistical Office. All hospitalized cases with AMI (onset of symptoms <28 days) from the years 2005, 2007, and 2009 were analysed regarding morbidity, in-hospital mortality, treatments, and costs. Analysis of a total of 16.1, 16.6, and 17.2 million hospitalizations showed the proportion of coded AMI to remain relatively constant (1276, 1272, and 1181 per 100 000 hospitalizations in 2005, 2007, and 2009). The proportion of ST-elevation AMI decreased over time (STEMI; 631, 546, and 454 per 100 000 hospitalizations),while non-ST-elevation AMI increased (NSTEMI; 645, 726, and 727 per 100 000 hospitalizations). The proportion of older patients >75 years (+4.6%), of comorbidities such as hypertension (+5.8%), diabetes (+17.7%), left ventricular failure (+19.8%), peripheral artery disease (+13.3%), and chronic kidney disease (+165.4%) increased as well. In-hospital mortality remained relatively stable during this period in AMI cases overall (11.1, 10.7, 10.8%) but changed slightly in STEMI (11.2, 11.9, 12.2%) and NSTEMI (11.0, 9.9, 9.9%). Causing about 1.2% of hospitalizations, AMI accounted for 2.5% (1.2 billion €) of in-hospital health expenses. CONCLUSION: This hospitalization-based analysis revealed a marked increase of NSTEMI among constant AMI frequency. Despite all current efforts, in-hospital mortality was stagnating on a high level compared with data of RCTs.

Passive smoking and smoking cessation among patients with coronary heart disease across Europe: results from the EUROASPIRE III survey.

AIMS: Passive smoking is the inhalation of environmental tobacco smoke (ETS) and is a risk factor for coronary heart disease (CHD). We aimed to describe the frequency of passive smoking among patients with CHD and to investigate the association between ETS exposure and smoking cessation. METHODS AND RESULTS: The EUROASPIRE III survey was conducted in 2006-07 among CHD patients up to 80 years of age from 22 European regions. Patients were interviewed and examined on average 15 months after hospital admission for CHD. Information was obtained on smoking prior to hospital admission, smoking at interview, and ETS exposure at home, at work, and at other locations. Breath carbon monoxide was measured to validate self-reported non-smoking. Among 8729 patients, 6060 (69.4%) were non-smokers prior to hospital admission, of whom 10.3% reported ETS exposure at home, 7.2% at work, and 13.8% at other locations. Overall, 24.2% of non-smokers were exposed to ETS at any place. Among the 2669 patients who were smoking prior to hospital admission, the likelihood of cessation at interview was lower in those with ETS exposure at home than in those without [25.3 vs. 58.1%; adjusted odds ratio (OR) 0.26, 95% confidence interval (CI) 0.20-0.33]. This finding applied also to ETS exposure at work (32.2 vs. 52.7%; adjusted OR 0.56, 95% CI 0.42-0.76) and at other locations (38.0 vs. 52.8%; adjusted OR 0.63, 95% CI 0.48-0.84). CONCLUSION: A noteworthy proportion of non-smokers with CHD are exposed to ETS. Passive smoking may jeopardize smoking cessation among CHD patients.

Do fast foods cause asthma, rhinoconjunctivitis and eczema? Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) phase three.

BACKGROUND: Certain foods may increase or decrease the risk of developing asthma, rhinoconjunctivitis and eczema. We explored the impact of the intake of types of food on these diseases in Phase Three of the International Study of Asthma and Allergies in Childhood. METHODS: Written questionnaires on the symptom prevalence of asthma, rhinoconjunctivitis and eczema and types and frequency of food intake over the past 12 months were completed by 13-14-year-old adolescents and by the parents/guardians of 6-7-year-old children. Prevalence ORs were estimated using logistic regression, adjusting for confounders, and using a random (mixed) effects model. RESULTS: For adolescents and children, a potential protective effect on severe asthma was associated with consumption of fruit ≥3 times per week (OR 0.89, 95% CI 0.82 to 0.97; OR 0.86, 95% CI 0.76 to 0.97, respectively). An increased risk of severe asthma in adolescents and children was associated with the consumption of fast food ≥3 times per week (OR 1.39, 95% CI 1.30 to 1.49; OR 1.27, 95% CI 1.13 to 1.42, respectively), as well as an increased risk of severe rhinoconjunctivitis and severe eczema. Similar patterns for both ages were observed for regional analyses, and were consistent with gender and affluence categories and with current symptoms of all three conditions. CONCLUSIONS: If the association between fast foods and the symptom prevalence of asthma, rhinoconjunctivitis and eczema is causal, then the findings have major public health significance owing to the rising consumption of fast foods globally.

The association between tobacco and the risk of asthma, rhinoconjunctivitis and eczema in children and adolescents: analyses from Phase Three of the ISAAC programme.

BACKGROUND: Exposure to parental smoking is associated with wheeze in early childhood, but in 2006 the US Surgeon General stated that the evidence is insufficient to infer a causal relationship between exposure and asthma in childhood and adolescents. AIMS: To examine the association between maternal and paternal smoking and symptoms of asthma, eczema and rhinoconjunctivitis. METHODS: Parents or guardians of children aged 6-7 years completed written questionnaires about symptoms of asthma, rhinoconjunctivitis and eczema, and several risk factors, including maternal smoking in the child's first year of life, current maternal smoking (and amount) and paternal smoking. Adolescents aged 13-14 years self completed the questionnaires on these symptoms and whether their parents currently smoked. RESULTS: In the 6-7-year age group there were 220 407 children from 75 centres in 32 countries. In the 13-14-year age group there were 350 654 adolescents from 118 centres in 53 countries. Maternal and paternal smoking was associated with an increased risk of symptoms of asthma, eczema and rhinoconjunctivitis in both age groups, although the magnitude of the OR is higher for symptoms of asthma than the other outcomes. Maternal smoking is associated with higher ORs than paternal smoking. For asthma symptoms there is a clear dose relationship (1-9 cigarettes/day, OR 1.27; 10-19 cigarettes/day, OR 1.35; and 20+ cigarettes/day, OR 1.56). When maternal smoking in the child's first year of life and current maternal smoking are considered, the main effect is due to maternal smoking in the child's first year of life. There was no interaction between maternal and paternal smoking. CONCLUSIONS: This study has confirmed the importance of maternal smoking, and the separate and additional effect of paternal smoking. The presence of a dose-response effect relationship with asthma symptoms suggests that the relationship is causal, however for eczema and rhinoconjunctivitis causality is less certain.

Relationships between body mass index, cardiovascular mortality, and risk factors: a report from the SCORE investigators.

BACKGROUND: Although cardiovascular disease (CVD) is the biggest global cause of death, CVD mortality is falling in developed countries. There is concern that this trend may be offset by increasing levels of obesity. DESIGN: We used the Systematic Coronary Risk Evaluation (SCORE) data set to examine relationships between body mass index (BMI), conventional risk factors and CVD mortality. METHODS: The SCORE data set comprises data from 12 European cohort studies. The relationship between BMI and CVD mortality was examined in each BMI category using univariable and multivariable (Cox) analyses. The SCORE population was also divided into gender and age strata: under 40, 40-49, 50-59, and over 60. The rate of CVD mortality in each BMI category was calculated within each gender and age stratum. Relationships between BMI and other CVD risk factors were also examined. RESULTS: There was a strong, graded but J-shaped univariable relationship between BMI and CVD mortality in both genders. Each 5-unit increase in BMI was associated with an increase in CVD mortality of 34% in men and 29% in women. The hazard ratios remained significant when adjusted for age, self-reported smoking status, total cholesterol, and systolic blood pressure (SBP). On additional adjustment for diabetes and high-density lipoprotein cholesterol (HDL), the association between BMI and CVD mortality did not persist. In all age groups except those over 60 there were significant relationships between increased BMI and CVD mortality. In the over-60 age group the only significant relationships with mortality were in underweight and severely overweight women and mildly obese men. After adjustment for age, each 1-unit increase in BMI was associated with a 1.14 mmHg increase in SBP, 0.055 mmol/l increase in total cholesterol, and a 0.024 mmol/l decrease in HDL in men. Figures were slightly lower in women. CONCLUSIONS: Overall, overweight and obesity relate to CVD mortality in a strong and graded manner. The effects are greater in women and markedly so in younger persons. It is likely that a substantial part of the BMI-associated risk of CVD mortality is mediated through other known CVD risk factors. This increases the public health importance of BMI as both a simple indicator and mediator of CVD risk.

Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries.

BACKGROUND: The first and second EUROASPIRE surveys showed high rates of modifiable cardiovascular risk factors in patients with coronary heart disease. The third EUROASPIRE survey was done in 2006-07 in 22 countries to see whether preventive cardiology had improved and if the Joint European Societies' recommendations on cardiovascular disease prevention are being followed in clinical practice. METHODS: EUROASPIRE I, II, and III were designed as cross-sectional studies and included the same selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, and Slovenia. Consecutive patients (men and women /=30 kg/m(2)) increased from 25.0% in EUROASPIRE I, to 32.6% in II, and 38.0% in III (p=0.0006). The proportion of patients with raised blood pressure (>/=140/90 mm Hg in patients without diabetes or >/=130/80 mm Hg in patients with diabetes) was similar (58.1% in EUROASPIRE I, 58.3% in II, and 60.9% in III; p=0.49), whereas the proportion with raised total cholesterol (>/=4.5 mmol/L) decreased, from 94.5% in EUROASPIRE I to 76.7% in II, and 46.2% in III (p<0.0001). The frequency of self-reported diabetes mellitus increased, from 17.4%, to 20.1%, and 28.0% (p=0.004). INTERPRETATION: These time trends show a compelling need for more effective lifestyle management of patients with coronary heart disease. Despite a substantial increase in antihypertensive and lipid-lowering drugs, blood pressure management remained unchanged, and almost half of all patients remain above the recommended lipid targets. To salvage the acutely ischaemic myocardium without addressing the underlying causes of the disease is futile; we need to invest in prevention.

EUROASPIRE III. Management of cardiovascular risk factors in asymptomatic high-risk patients in general practice: cross-sectional survey in 12 European countries.

OBJECTIVE: To determine whether the 2003 Joint European Societies' guidelines on cardiovascular disease prevention in people at high cardiovascular risk have been followed in general practice. DESIGN: Cross-sectional survey. METHODS: The EUROASPIRE survey was carried out in 2006-2007 in 66 general practices in 12 European countries. Patients without a history of coronary or other atherosclerotic disease either started on antihypertensive and/or lipid-lowering and/or antidiabetes treatments were identified retrospectively, interviewed and examined at least 6 months after the start of medication. RESULTS: Four thousand, three hundred and sixty-six high-risk individuals (57.7% females) were interviewed (participation rate 76.7%). Overall, 16.9% smoked cigarettes, 43.5% had body mass index ≥30 kg/m, 70.8% had blood pressure ≥140/90 mmHg (≥130/80 in people with diabetes mellitus), 66.4% had total cholesterol ≥5.0 mmol/l (≥4.5 mmol/l in people with diabetes) and 30.2% reported a history of diabetes. The risk factor control was very poor, with only 26.3% of patients using antihypertensive medication achieving the blood pressure goal, 30.6% of patients on lipid-lowering medication achieving the total cholesterol goal and 39.9% of patients with self-reported diabetes having haemoglobin A1c ≤6.1%. The use of blood pressure-lowering medication in people with hypertension was: ß-blockers 34.1%, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 60.8%, calcium channel blockers 26.3%, diuretics 36.9%. Statins were prescribed in 47.0% of people with hypercholesterolemia. About 22.0% of all patients were on aspirin or other antiplatelet medication. CONCLUSION: The EUROASPIRE III survey in general practice shows that the lifestyle of people being treated as high cardiovascular risk is a major cause of concern with persistent smoking and high prevalence of both obesity and central obesity. Blood pressure, lipid and glucose control are completely inadequate with most patients not achieving the targets defined in the prevention guidelines. Primary prevention needs a systematic, comprehensive, multidisciplinary approach, which addresses lifestyle and risk factor management by general practitioners, nurses and other allied health professionals, and a health care system which invests in prevention.

Management of overweight and obese patients with coronary heart disease across Europe.

AIMS: Several studies have reported increasing obesity rates in the general population. Using data from the EUROASPIRE III survey, we investigated as to what extent the obesity epidemic affects the high priority group of coronary heart disease patients. METHODS AND RESULTS: Data from 8924 patients, who had experienced a recent coronary acute event, from 22 countries in Europe participating in the EUROASPIRE III study were gathered in 2006-2007. Eight centres had also participated in the earlier two EUROASPIRE surveys carried out in 1994-1995 and 1999-2000. In these eight centres, obesity prevalence in coronary patients had increased from 25 to 38% during the past decade. The most recent survey shows that obesity is more prevalent in women (45 vs. 32% in men) and is a major health problem across all the 22 countries. Only 18% of all the patients were found to reach a body mass index below 25 kg/m whereas 53% were diagnosed with central obesity. Since their hospital discharge, only half of the obese patients reported to have followed the dietary recommendations and 48% reported engagement in more physical activity. Only 13% of the patients who were overweight at the time of the coronary event reached the target of >or=5% weight loss whereas 21% of them presented with a weight gain of 5% or more. CONCLUSION: The prevalence of obesity is still increasing and reaching epidemic proportions in the high priority group of coronary patients all over Europe. Patients' awareness and current management of obesity seems inadequate. More intensive programs focusing on diet and especially physical activity are urgently required.

Association between degenerative aortic valve disease and long-term exposure to cardiovascular risk factors: results of the longitudinal population-based KORA/MONICA survey.

AIMS: Degenerative aortic valve disease (DAVD), a common finding in the elderly, is associated with an increased risk of death due to cardiovascular causes. Taking advantage of its longitudinal design, this study evaluates the prevalence of DAVD and its temporal associations with long-term exposure to cardiovascular risk factors in the general population. METHODS AND RESULTS: We studied 953 subjects (aged 25-74 years) from a random sample of German residents. Risk factors had been determined at a baseline investigation in 1994/95. At a follow-up investigation, 10 years later, standardized echocardiography determined aortic valve morphology and aortic valve area (AVA) as well as left ventricular geometry and function. At the follow-up study, the overall prevalence of DAVD was 28%. In logistic regression models adjusting for traditional cardiovascular risk factors at baseline age (OR 2.0 [1.7-2.3] per 10 years, P < 0.001), active smoking (OR 1.7 [1.1-2.4], P = 0.009) and elevated total cholesterol levels (OR 1.2 [1.1-1.3] per increase of 20 mg/dL, P < 0.001) were significantly related to DAVD at follow-up. Furthermore, age, baseline status of smoking, and total cholesterol level were significant predictors of a smaller AVA at follow-up study. In contrast, hypertension and obesity had no detectable relationship with long-term changes of aortic valve structure. CONCLUSIONS: In the general population we observed a high prevalence of DAVD that is associated with long-term exposure to elevated cholesterol levels and active smoking. These findings strengthen the notion that smoking cessation and cholesterol lowering are promising treatment targets for prevention of DAVD.

EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries.

AIM: The aim of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events III (EUROASPIRE III) survey was to determine whether the Joint European Societies' guidelines on cardiovascular prevention are being followed in everyday clinical practice and to describe the lifestyle, risk factor and therapeutic management in patients with coronary heart disease (CHD) in Europe. METHODS: The EUROASPIRE III survey was carried out in 2006-2007 in 76 centres from selected geographical areas in 22 countries in Europe. Consecutive patients, with a clinical diagnosis of CHD, were identified retrospectively and then followed up, interviewed and examined at least 6 months after their coronary event. RESULTS: Thirteen thousand nine hundred and thirty-five medical records (27% women) were reviewed and 8966 patients were interviewed. At interview, 17% of patients smoked cigarettes, 35% were obese and 53% centrally obese, 56% had a blood pressure >or=140/90 mmHg (>or=130/80 in people with diabetes mellitus), 51% had a serum total cholesterol >or=4.5 mmol/l and 25% reported a history of diabetes of whom 10% had a fasting plasma glucose less than 6.1 mmol/l and 35% a glycated haemoglobin A1c less than 6.5%. The use of cardioprotective medication was: antiplatelets 91%; beta-blockers 80%; angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers 71%; calcium channel blockers 25% and statins 78%. CONCLUSION: The EUROASPIRE III survey shows that large proportions of coronary patients do not achieve the lifestyle, risk factor and therapeutic targets for cardiovascular disease prevention. Wide variations in risk factor prevalences and the use of cardioprotective drug therapies exist between countries. There is still considerable potential throughout Europe to raise standards of preventive care in order to reduce the risk of recurrent disease and death in patients with CHD.

How much does HDL cholesterol add to risk estimation? A report from the SCORE Investigators.

BACKGROUND: Systematic COronary Risk Evaluation (SCORE), the risk estimation system recommended by the European guidelines on cardiovascular disease prevention, estimates 10-year risk of cardiovascular disease mortality based on age, sex, country of origin, systolic blood pressure, smoking status and either total cholesterol (TC) or TC/high-density lipoprotein cholesterol (HDL-C) ratio. As, counterintuitively, these two systems perform very similarly, we have investigated whether incorporating HDL-C and TC as separate variables improves risk estimation. METHODS: The study consisted of 57,302 men and 47,659 women. Cox proportional hazards method was used to derive the function including HDL-C and an identical function without HDL-C for comparison. Risk charts were developed to illustrate the results. RESULTS: Inclusion of HDL-C resulted in a modest but statistically significant improvement in risk estimation, based on the area under receiver operating characteristic curve (AUROC); 0.814 versus 0.808, P value less than 0.0001, for the functions with and without HDL-C, respectively. Addition of HDL-C also resulted in a significant and important improvement in risk estimation as measured by net reclassification index, which is highly clinically relevant. Improvement in risk estimation was greatest in women from high-risk countries, in terms of both AUROC and net reclassification index. CONCLUSION: For the general population, the inclusion of HDL-C in risk estimation results in only a modest improvement in overall risk estimation based on AUROC. However, when using the more clinically that examines reclassification of individuals, clinically useful improvements occur. Inclusion of HDL may be particularly useful in women from high-risk countries and individuals with unusually high or low HDL-C levels. Addition of HDL-C is particularly applicable to electronic, interactive risk estimation systems such as HeartScore.

Implications of persistent prehypertension for ageing-related changes in left ventricular geometry and function: the MONICA/KORA Augsburg study.

BACKGROUND: It is unclear whether persistent prehypertension causes structural or functional alterations of the heart. METHODS: We examined echocardiographic data of 1005 adults from a population-based survey at baseline in 1994/1995 and at follow-up in 2004/2005. We compared individuals who had either persistently normal (<120 mmHg systolic and <80 mmHg diastolic, n = 142) or prehypertensive blood pressure (120-139 mmHg or 80-89 mmHg, n = 119) at both examinations using multivariate regression modeling. RESULTS: Over 10 years, left ventricular end-diastolic diameters were stable and did not differ between the two groups. However, the prehypertensive blood pressure group displayed more pronounced ageing-related increases of left ventricular wall thickness (+4.7 versus +11.9%, P < 0.001) and left ventricular mass (+8.6 versus +15.7%, P = 0.006). Prehypertension was associated with a raised incidence of left ventricular concentric remodeling (adjusted odds ratio 10.7, 95% confidence interval 2.82-40.4) and left ventricular hypertrophy (adjusted odds ratio 5.33, 1.58-17.9). The ratio of early and late diastolic peak transmitral flow velocities (E/A) decreased by 7.7% in the normal blood pressure versus 15.7% in the prehypertensive blood pressure group (P = 0.003) and at follow-up the ratio of early diastolic peak transmitral flow and early diastolic peak myocardial relaxation velocities (E/EM) was higher (9.1 versus 8.5, P = 0.031) and left atrial size was larger (36.5 versus 35.3 mm, P = 0.024) in the prehypertensive blood pressure group. Finally, the adjusted odds ratio for incident diastolic dysfunction was 2.52 (1.01-6.31) for the prehypertensive blood pressure group. CONCLUSIONS: Persistent prehypertension accelerates the development of hypertrophy and diastolic dysfunction of the heart.

Predicted 10-year risk of cardiovascular mortality in the 40 to 69 year old general population without cardiovascular diseases in Germany.

AIMS: To estimate the 10-year risk of fatal cardiovascular disease (CVD) in the 40 to 69 year old general population in Germany stratified by sex and to analyze differences between socio-economic status (SES), region and community size in individuals without CVD. The analysis is based on the newly recalibrated SCORE Deutschland risk charts and considered other comorbidities for the classification of the high CVD risk group according to the guidelines of the European Society of Cardiology. METHODS AND RESULTS: In 3,498 participants (40-69 years) from the German Health Examination Survey for Adults 2008-2011 (DEGS1) without a history of CVD (myocardial infarction, coronary heart disease, heart failure, stroke) we estimated the proportion with a low (SCORE <1%), moderate (SCORE 1-<5%) and high 10-year CVD mortality risk (SCORE ≥5% or diabetes, renal insufficiency, SBP/DPB ≥180/110 mmHg or cholesterol >8 mmol/l). The prevalence of low, moderate and high risk was 42.8%, 38.5% and 18.8% in men and 73.7%, 18.1% and 8.2% in women. The prevalence of high risk was significantly lower in women with a high compared to a low SES (3.3% vs. 11.2%) and in communities with ≥100.000 inhabitants compared to <20.000 inhabitants (5.4% vs.10.9%). There were no significant associations between predicted CVD mortality risk and SES or community size in men and regions in men and women. Among the high risk group, 58.2% of men and 9.8% of women had SCORE ≥5%, leaving the majority of women (60.1%) classified as high risks due to diabetes and SCORE <5%. CONCLUSION: Our results suggest the persistence of socioeconomic disparities in predicted cardiovascular mortality in women and support the need of large-scale prevention efforts beyond individual lifestyle modification or treatment. Furthermore, the importance of additional comorbidities for the high risk group classification is highlighted.

Cardiovascular health among adults in Syria: a model from developing countries.

PURPOSE: Despite the considerable mortality and morbidity associated with cardiovascular disease (CVD), many developing countries lack reliable surveillance of these ailments and their risk factors to guide intervention. This study aims to provide the first population-based estimates of CVD morbidity and mortality among adults in Aleppo, Syria and the distribution of their risk factors. METHODS: A cross-sectional survey of adults 18 to 65 years old residing in Aleppo, Syria was carried out in 2004, involving 2038 household representatives (45.2% men; mean age, 35.3 years; response rate, 86%). Main outcomes of interest were physician-diagnosed CVD (infarction, angina, failure, stroke) among survey participants, and past 5-year mortality due to CVD among their household members older than 20 years of age (N = 6252, 49.5% men). Measurement of blood pressure (BP), height and weight, and smoking history were obtained as well. RESULTS: Prevalence of CVD was 4.8% for heart disease and 1.0% for stroke. CVD was responsible for 45.0% of overall mortality reported in the past 5 years, whereby 49% of CVD deaths occurred before the age of 65 years. Mean age of death was 62.6 years (63.6 years for heart disease and 61.4 years for stroke). Annual crude death rate due to CVD was 314 per 100,000 (95% confidence interval [95% CI]: 215-414); of these, 179 were due to heart disease, and 135 due to stroke. More men than women died from heart disease, whereas the opposite was true for stroke. Hypertension was detected in 40.6% (47.7% men, 34.9%women), obesity in 38.2% (28.8% men, 46.4% women), and smoking (cigarettes or waterpipe) in 38.7% (63.6% men, 19.2% women) of participants. Of those surveyed, 39.3% had one CVD risk factor, 27.4% had two risk factors, and 8.3% had 3 risk factors. Main predictors of clustering of risk factors were older age, male gender, and low education. CONCLUSIONS: Syria is currently undergoing a stage in which morbidity and mortality from CVD are high but likely to increase based on the population's risk profile. CVD risk distribution in Syrian society highlights the non-generalizability of CVD models from developed societies, and calls for local studies to inform effective interventions and policies.

Assessing bronchial responsiveness to hypertonic saline using the stepwise protocol of Phase Two of the International Study of Asthma and Allergies in Childhood (ISAAC II).

Measurement of bronchial responsiveness to hypertonic saline was applied in 22 study centers worldwide as part of Phase Two of the International Study of Asthma and Allergies in Childhood (ISAAC Phase Two). Because the amount of inhaled saline was difficult to standardize during the stepwise protocol with inhalation periods of increasing duration, we evaluated different statistical procedures based on inhalation time in relation to wheeze and current asthma. Data on random samples on 9 to 11-year-old children (n = 1,418) from two German centers were analyzed. The following statistical approaches were evaluated: (1) bronchial hyperreactivity (BHR) defined dichotomously as a fall in FEV1 (forced expiratory volume in 1 s) >or=15%; (2) PT15: the provocation time causing BHR using survival-analyses methods; (3) time-response-slope (continuous) of the individual FEV1-courses calculated by a linear model after comparing different mathematical models. The sensitivity and specificity of BHR versus current asthma were 47% and 87%, respectively. Analyses of the provocation time indicated an increased risk (adjusted hazard-ratio: 4.3; 95% CI: 2.8-6.5) for a fall in FEV1 >or= 15% among children with current asthma in comparison to those without. The time-response-slope differed markedly between children with and without wheeze and current asthma (P < 0.0001). BHR is meaningful and relatively easy to use, but has low sensitivity. Time-response-slopes utilize the available information from the stepwise protocol better than BHR and survival-analysis based on PT15. Response parameters based on inhalation time discriminate well between children with and without asthma and will be compared in the analyses of ISAAC Phase Two data.

Contribution of industry funded post-marketing studies to drug safety: survey of notifications submitted to regulatory agencies.

OBJECTIVES:  To investigate the practice of post-marketing studies in Germany during a three year period and to evaluate whether these trials meet the aims specified in the German Medicinal Products Act. DESIGN:  Survey of notifications submitted to German regulatory agencies before post-marketing studies were carried out, 2008-10. SETTING:  Notifications obtained through freedom of information requests to the three authorities responsible for registering post-marketing studies in Germany. MAIN OUTCOME MEASURES:  Descriptive statistics of post-marketing studies, including the products under study, intended number of patients, intended number of participating physicians, proposed remunerations, study plan and protocol, and availability of associated scientific publications and reports on adverse drug reactions. RESULTS:  Information was obtained from 558 studies, with a median of 600 (mean 2331, range 2-75 000) patients and 63 (270, 0-7000) participating physicians per study. The median remuneration to physicians per patient was €200 (€441, €0-€7280) (£170, £0-£6200; $215, $0-$7820), with a total remuneration cost of more than €217m for 558 studies registered over the three year period. The median remuneration per participating physician per study was €2000 (mean €19 424), ranging from €0 to €2 080 000. There was a broad range of drugs and non-drug products, of which only a third represented recently approved drugs. In many notifications, data, information, and results were, by contract, strictly confidential and the sole property of the respective sponsor. No single adverse drug reaction report could be identified from any of the 558 post-marketing studies. Less than 1% of studies could be verified as published in scientific journals. CONCLUSIONS:  Post-marketing studies are not improving drug safety surveillance. Sample sizes are generally too small to allow the detection of rare adverse drug reactions, and many participating physicians are strictly obliged to maintain confidentiality towards the sponsor. High remuneration and strict confidentiality clauses in these studies could influence the physicians' reporting behaviours of adverse drug reactions.

Regular exercise behaviour and intention and symptoms of anxiety and depression in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey.

BACKGROUND: Regular exercise lowers the risk of cardiovascular death in coronary heart disease (CHD) patients. We aimed to investigate regular exercise behaviour and intention in relation to symptoms of anxiety and depression in CHD patients across Europe. DESIGN: This study was based on a multicentre cross-sectional survey. METHODS: In the EUROpean Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE) III survey, 8966 CHD patients <80 years of age from 22 European countries were interviewed on average 15 months after hospitalisation. Whether patients exercised or intended to exercise regularly was assessed using the Stages of Change questionnaire in 8330 patients. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Total physical activity was measured by the International Physical Activity Questionnaire in patients from a subset of 14 countries. RESULTS: Overall, 50.3% of patients were not intending to exercise regularly, 15.9% were intending to exercise regularly, and 33.8% were exercising regularly. Patients with severe symptoms of depression less frequently exercised regularly than patients with symptoms in the normal range (20.2%, 95% confidence interval (CI) 14.8-26.8 vs 36.7%, 95% CI 29.8-44.2). Among patients not exercising regularly, patients with severe symptoms of depression were less likely to have an intention to exercise regularly (odds ratio 0.62, 95% CI 0.46-0.85). Symptoms of anxiety did not affect regular exercise intention. In sensitivity analysis, results were consistent when adjusting for total physical activity. CONCLUSIONS: Lower frequency of regular exercise and decreased likelihood of exercise intention were observed in CHD patients with severe depressive symptoms. Severe symptoms of depression may preclude CHD patients from performing regular exercise.