Frailty in cardiology: definition, assessment and clinical implications for general cardiology. A consensus document of the Council for Cardiology Practice (CCP), Association for Acute Cardio Vascular Care (ACVC), Association of Cardiovascular Nursing and Allied Professions (ACNAP), European Association of Preventive Cardiology (EAPC), European Heart Rhythm Association (EHRA), Council on Valvular Heart Diseases (VHD), Council on Hypertension (CHT), Council of Cardio-Oncology (CCO), Working Group (WG) Aorta and Peripheral Vascular Diseases, WG e-Cardiology, WG Thrombosis, of the European Society of Cardiology, European Primary Care Cardiology Society (EPCCS).

Frailty is a health condition leading to many adverse clinical outcomes. The relationship between frailty and advanced age, multimorbidity and disability has a significant impact on healthcare systems. Frailty increases cardiovascular (CV) morbidity and mortality both in patients with or without known CV disease. Though the recognition of this additional risk factor has become increasingly clinically relevant in CV diseases, uncertainty remains about operative definitions, screening, assessment, and management of frailty. Since the burdens of frailty components and domains may vary in the various CV diseases and clinical settings, the relevance of specific frailty-related aspects may be different. Understanding these issues may allow general cardiologists a clearer focus on frailty in CV diseases and thereby make more tailored clinical decisions and therapeutic choices in outpatients. Guidance on identification and management of frailty are sparse and an international consensus document on frailty in general cardiology is lacking. Moreover, new options linked with eHealth are going to better define and manage frailty. This consensus document on definition, assessment, clinical implications, and management of frailty provides an input to integrate strategies pre- and post-acute CV events with a comprehensive view including out of hospital, office-based diagnostic and therapeutic choices, and based on a multidisciplinary team approach (general cardiologists, nurses, and general practitioners).

Survey on arterial hypertension management: a report from the ESC Council for Cardiology Practice and the ESC Council on Hypertension.

Aims: To explore the management of hypertensive patients by general cardiologists a few months after the European Society of Cardiology (ESC)-European Society of Hypertension (ESH) Guidelines publication. Methods and results: A survey based on a 26-point questionnaire was sent to ∼69 000 worldwide ESC members, a few months after the ESC-ESH Guidelines publication. A total of 1458 responses were collected via a web-based form. Among them, 68% were men, 48% were below 45 years old, and 60% were from Europe. Current guidelines have been read, at least partially, by 92.8%. Measurement of blood pressure (BP) is mostly done using the auscultatory method (58.8%) while unattended BP is rarely performed. Different bladder cuffs are not available for different arm circumferences for 27% of responders. Routine workup in hypertensive patients includes more often 12 leads ECG (97.7%) and echocardiography (79.6%). Only 30.9% of responders systematically assess the cardiovascular risk by the SCORE system and orthostatic hypotension is systematically researched by only 39.1%. Respondents consider that BP target of 140/90 mmHg is achievable in 60-80% of patients and 130/80 mmHg in 40-60%. Guidelines are considered too tight to be achievable by 15.6%, while 77.4% consider they are exactly right. Low patient's compliance, awareness of hypertension (HT) risk, and, at a lower degree, physician inertia, represent the main treatment challenges in reaching BP goals to most respondents, while treatment effectiveness is not in question. The present survey demonstrates specific gaps in HT management that need attention in clinical practice.

Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis.

OBJECTIVE: To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease. DESIGN: Bayesian network meta-analyses to combine direct within trial comparisons between treatments with indirect evidence from other trials while maintaining randomisation. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: A strategy of initial medical treatment compared with revascularisation by coronary artery bypass grafting or Food and Drug Administration approved techniques for percutaneous revascularization: balloon angioplasty, bare metal stent, early generation paclitaxel eluting stent, sirolimus eluting stent, and zotarolimus eluting (Endeavor) stent, and new generation everolimus eluting stent, and zotarolimus eluting (Resolute) stent among patients with stable coronary artery disease. DATA SOURCES: Medline and Embase from 1980 to 2013 for randomised trials comparing medical treatment with revascularisation. MAIN OUTCOME MEASURE: All cause mortality. RESULTS: 100 trials in 93,553 patients with 262,090 patient years of follow-up were included. Coronary artery bypass grafting was associated with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to 0.91) compared with medical treatment. New generation drug eluting stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42 to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal stents (0.92, 0.79 to 1.05), or early generation drug eluting stents (paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus (Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival compared with medical treatment. Coronary artery bypass grafting reduced the risk of myocardial infarction compared with medical treatment (0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The risk of subsequent revascularisation was noticeably reduced by coronary artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40; everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents (zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36; paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81) compared with medical treatment. CONCLUSION: Among patients with stable coronary artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment. All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree. Our results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment.

Smoking: a deadly pleasant habit--is there a way out?

It was not until 1958 that the first major epidemiologic study demonstrated a strong correlation between smoking and cardiovascular disease. Although not providing definitive evidence that tobacco smoke was responsible for the increased coronary risk, it prompted the first anti-smoking measures by the US Surgeon General in his 1964 report. Smoking is a highly addictive (biological and psychological) habit. The severity of withdrawal symptoms that patients find distressing can be reduced by nicotine replacement therapy. Bupropion SR was the first nonnicotine medication shown to be effective for smoking cessation. Its possible mechanisms of action include blockade of neuronal reuptake of dopamine and norepinephrine and blockade of nicotinic acetylcholinergic receptors. Varenicline, a nicotine receptor partial agonist, is the most recently developed nonnicotine preparation. The odds of smoking cessation after 12 weeks of 1 mg twice-daily varenicline treatment was approximately twice that achieved with 150 mg twice-daily bupropion and nearly 4-fold greater than with placebo.

Younger age potentiates post myocardial infarction survival disadvantage of women.

BACKGROUND: Female patients with acute myocardial infarction (MI) exhibit higher unadjusted in-hospital mortality rates compared to male patients. However, contradictory evidence exists on whether this survival disadvantage disappears after adjustment for age and other prognostic factors. This study, based on a countrywide survey of consecutive unselected patients with acute MI, examined whether female gender is an independent predictor of poor short-term outcome and less intensive in-hospital treatment. METHODS: Data on a total of 7433 patients were analyzed. RESULTS: The mean age was 64+/-13 years and the proportion of females in this population was 23%. Univariate and multivariate predictors of in-hospital mortality in female patients were estimated. Unadjusted in-hospital mortality rates of women were significantly higher compared to men (17.7 vs. 8.6, p<0.001). In multivariate analysis, female gender was an independent predictor of in-hospital mortality in the total population [relative risk (RR)=1.29, 95% confidence interval (CI)=1.02-1.64, p=0.036]. The RR of women for in-hospital death was exaggerated among younger patients, aged <55 years (RR=3.84, 95% CI=1.07-13.74, p=0.039). Female gender was also independently and inversely associated with administration of thrombolytic treatment (RR=0.724, 95% CI=0.630-0.831, p=<0.001). CONCLUSION: Although female gender is an independent predictor of higher post-MI in-hospital mortality with a pronounced effect among younger patients, women are less likely to receive thrombolysis than men. Based on the results from this countrywide study, we should consider women, especially of younger age, as patients at particular high risk, who contrary to common practice, deserve more intensive and aggressive in-hospital treatment.

Lack of association between common polymorphisms in genes of the renin-angiotensin system and mortality after myocardial infarction.

The insertion/deletion (I/D) polymorphism in the ACE gene and the A1166C polymorphism in the AT1R gene have been associated with left ventricular remodelling and prognosis after acute myocardial infarction (AMI). We investigated whether these genetic variants associate with impaired left ventricular ejection fraction (LVEF) and increased risk for in-hospital mortality after AMI. Consecutive AMI patients were recruited on admission and were genotyped for the above-mentioned polymorphisms. The frequency of the studied genotypes did not differ significantly between deceased patients and those who survived. The LVEF did not differ among patients with or without the DD genotype (45 +/- 10 vs. 45 +/- 10%, p = 0.892) or the CC genotype (45 +/- 10 vs. 46 +/- 10%, p = 0.859). These data question the role of the studied genotypes in the pathogenesis of AMI and do not support the previously supported hypothesis that these genotypes influence prognosis after AMI.

The paradoxical association of common polymorphisms of the renin-angiotensin system genes with risk of myocardial infarction.

BACKGROUND: The insertion/deletion polymorphism of the angiotensin-converting enzyme (ACE) and the A1166C polymorphism of the angiotensin-II AT1 receptor (AT1R) have been extensively investigated as possible risk factors for myocardial infarction (MI). DESIGN AND METHODS: Genetic association, case-control study, specifically designed to investigate the association of the above-mentioned polymorphisms with risk of MI in a homogeneous, low coronary risk, Caucasian population. The study population consisted of 1603 consecutive patients with acute MI who were recruited from nine clinics, located in three cities, and 699 unrelated adults who were randomly selected from the city catalogues. RESULTS: In univariate analysis, the DD genotype was found to be more prevalent among controls (40.8 vs. 35.2%, P=0.011). In multivariate analysis adjusted for age, gender, smoking status, diabetes mellitus, hypercholesterolaemia, hypertension and family history of coronary artery disease, the presence of the DD genotype was independently and negatively associated with risk of AMI (RR=0.743, 95% CI=0.595-0.927, P=0.008). The CC genotype was not found to be significantly associated with risk of MI, either in univariate (6.2 vs. 6.4%, P=0.856), or in multivariate analysis adjusted for the same confounders (RR=0.743, 95% CI=0.473-1.167, P=0.197). CONCLUSIONS: Contrary to previous reports, in this study the DD genotype of the ACE gene, but not the CC genotype of the AT1R gene, was associated with a lower risk of MI. Our results emphasize the complexity of genotype-phenotype interactions in the pathogenesis of ischaemic heart disease and question the previously hypothesized role of the DD genotype on risk of acute myocardial infarction.