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5th Belgian Congress on Acute cardiac care – Friday 3rd June – BIWAC
Programma [ pdf ]

[toggle title= »One-quarter of high risk patients denied anticoagulation after AF ablation »] One-quarter of high risk patients do not receive anticoagulants after ablation of atrial fibrillation (AF), according to the latest survey of European practice.The EORP Atrial Fibrillation Ablation Pilot Study, conducted by the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC), reveals that 65% of patients were taking anticoagulants one year after ablation of AF.1 But up to 25% of patients at high risk of stroke (defined as a CHA2DS2-VASc score >1) were not taking any anticoagulant drug. And around half of patients with a low stroke risk (CHA2DS2-VASc score of 0) were still anticoagulated one year after the procedure.Study author Professor Josep Brugada, Hospital Clinic, University of Barcelona, said:

Our pilot study was in medium to high volume AF ablation centres and we would expect them to be following anticoagulation protocols. But often the follow-up is performed by a GP or general cardiologist at another centre. Good collaboration between the two centres is absolutely mandatory to ensure that patients received recommended treatments.”

This was a prospective, observational registry of consecutive patients undergoing a first AF ablation procedure in 10 European countries. It included 1 410 patients from 72 cardiology centres with medium to high expertise (defined as performing >50 AF ablations per year). The current analysis of one-year follow-up data is published in European Heart Journal.2 It provides a contemporary picture of European AF ablation success and complication rates, and how centres assess success of the procedure.

The study found that catheter ablation of AF maintained sinus rhythm in 74% of patients overall. Success without antiarrhythmic drugs was achieved in 41% of patients. When post-ablation atrial flutter/tachycardia were excluded, complications occurred in 2.5% of patients and fewer than 1% were considered major. While 90% of patients had symptoms before the ablation, 55% had no symptoms afterwards.

Professor Brugada said:

In this survey of medium to high expertise centres the overall success rate of AF catheter ablation is relatively high and the overall complication rate is relatively low. The study protocol did not require discontinuation of antiarrhythmic therapy after the 3-month blanking period although it is considered good practice when there is no arrhythmia recurrence.”

He added: “We found that protocols for antiarrhythmic therapy were followed more strictly in Northern Europe. Physicians did not give the medication unless the patient had a documented arrhythmia recurrence. It could be that in Southern Europe there is a tendency to give antiarrhythmic drugs if patients have symptoms, without requiring specific documentation of an arrhythmia.”

Arrhythmia recurrences during the 3-month blanking period were the only predictor of failure 12 months after the procedure. Doctor Elena Arbelo, co author, also from the Hospital Clinic of Barcelona, said:

Patients who had an atrial arrhythmia during the first 3 months were more likely to have an arrhythmia after the blanking period. But an arrhythmia during the blanking period should not prompt an early re-ablation because 63% of these patients did not have a later arrhythmia. We should still wait for 3 months to assess the real result of the ablation.”

Success of the procedure was consistent across European regions. Both success and complication rates were not influenced by the number of AF ablations the centres performed each year. Professor Brugada said: “These results were not surprising because all centres in the study had medium to high expertise and 50 procedures per year is probably above the cut-off point for quality. We are currently conducting the long term registry which includes all centres and we may find different results in the low volume centres.”

The one year follow up was performed in-person for 58% of patients while 42% were followed up by telephone. In-person follow-up was more frequent in Southern and Eastern Europe. Dr Arbelo said:

The high level of telephone contact suggests that one centre performed the ablation and another conducted the follow up. It shows how different real life is from clinical studies which require intense follow up monitoring with devices to document arrhythmia recurrences and symptoms.

Professor Brugada concluded:

We found a consistently high success rate and few complications in medium to high volume centres across Europe. But inconsistent use of anticoagulants and antiarrhythmic drugs at one year shows that follow-up needs to be improved. Close cooperation between centres performing ablations and physicians doing the follow-up is essential to ensure that all patients in Europe receive appropriate treatment after the procedure.”
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[toggle title= »Study examines use of electrical energy for treating certain type of atrial fibrillation »] Among patients with untreated paroxysmal (intermittent) atrial fibrillation (AF), treatment with electrical energy (radiofrequency ablation) resulted in a lower rate of abnormal atrial rhythms and episodes of AF, according to a study in the February 19 issue of JAMA.Arial fibrillation affects approximately 5 million people worldwide and is associated with an increased risk of stroke. Drug treatment is recommended by practice guidelines as a first-line therapy in patients with paroxysmal AF. « Radiofrequency ablation is an accepted therapy in patients for whom antiarrhythmic drugs have failed; however, its role as a first-line therapy needs further investigation, » according to background information in the article.Carlos A. Morillo, M.D., F.R.C.P.C., of McMaster University, Hamilton, Canada, and colleagues compared ablation to drug treatment as first-line therapy in patients with paroxysmal AF who had not previously received treatment. The trial included 127 patients at 16 centers in Europe and North America; 61 patients received antiarrhythmic drug treatment and 66 radiofrequency ablation.

Recurrence of an atrial tachyarrhythmia lasting longer than 30 seconds (the primary measured outcome) occurred more often in the antiarrhythmic drug group than in the ablation group, 44 patients (72 percent) vs. 36 patients (55 percent). Asymptomatic AF was also observed more frequently with drug treatment, 11 patients (18 percent) compared with 6 patients (9 percent). Symptomatic recurrence of abnormal rhythm was more common with drug treatment, 36 patients (59 percent) in the antiarrhythmic drug group compared with 31 patients (47 percent) in the ablation group.

Quality of life was improved overall by both treatments but not significantly different between groups. No deaths or strokes were reported in either group; 4 cases of cardiac tamponade (the accumulation of a large amount of fluid [usually blood] near the heart that interferes with its performance) were reported in the ablation group.

The authors conclude that recurrence of an atrial tachyarrhythmia was frequent in both groups, and that when offering ablation as a therapeutic option to patients with paroxysmal AF who have not previously received antiarrhythmic drugs, the risks and benefits need to be discussed and treatment strategy individually recommended.
Link
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[toggle title= »Research in Clinical Cardiology – PRIZE 2014″] Leaflet [ pdf ]
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[toggle title= »Cold Weather and Cardiovascular Disease »] This winter season will bring cooler temperatures and ice and snow for some. It’s important to know how cold weather can affect your heart, especially if you have cardiovascular disease. People who are outdoors in cold weather should avoid sudden exertion, like lifting a heavy shovel full of snow. Even walking through heavy, wet snow or snow drifts can strain a person’s heart.How does cold weather affect the heart?
Many people aren’t conditioned to the physical stress of outdoor activities and don’t know the dangers of being outdoors in cold weather. Winter sports enthusiasts who don’t take certain precautions can suffer accidental hypothermia.Hypothermia means the body temperature has fallen below 95 degrees Fahrenheit. It occurs when your body can’t produce enough energy to keep the internal body temperature warm enough. It can kill you. Heart failure causes most deaths in hypothermia. Symptoms include lack of coordination, mental confusion, slowed reactions, shivering and sleepiness.Children, the elderly and those with heart disease are at special risk. As people age, their ability to maintain a normal internal body temperature often decreases. Because elderly people seem to be relatively insensitive to moderately cold conditions, they can suffer hypothermia without knowing they’re in danger.People with coronary heart disease often suffer angina pectoris (chest pain or discomfort) when they’re in cold weather. Some studies suggest that harsh winter weather may increase a person’s risk of heart attack due to overexertion.

Besides cold temperatures, high winds, snow and rain also can steal body heat. Wind is especially dangerous, because it removes the layer of heated air from around your body. At 30 degrees Fahrenheit in a 30-mile wind, the cooling effect is equal to 15 degrees Fahrenheit. Similarly, dampness causes the body to lose heat faster than it would at the same temperature in drier conditions.

To keep warm, wear layers of clothing. This traps air between layers, forming a protective insulation. Also, wear a hat or head scarf. Heat can be lost through your head. And ears are especially prone to frostbite. Keep your hands and feet warm, too, as they tend to lose heat rapidly.

Don’t drink alcoholic beverages before going outdoors or when outside. Alcohol gives an initial feeling of warmth, because blood vessels in the skin expand. Heat is then drawn away from the body’s vital organs.[/toggle]

[toggle title= »Preventie van hart- en vaatziekten in de klinische praktijk »] Leaflet – Aarzel niet een exemplaar te bestellen (info@liguecardioliga.be). Het is gratis [ pdf ]
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[toggle title= »Cardiovascular complications of type 2 diabetes associated with levels of physical activity »]

The risk of cardiovascular complications in people with type 2 diabetes is directly related to the frequency and duration of physical exercise, according to results of a large follow-up study reported today on World Diabetes Day.(1) Notably, those with low levels of physical activity had a 70% greater risk of cardiovascular death than those with higher levels.
Studies have shown indisputably that those diagnosed with type 2 diabetes are up to five times more likely to develop heart disease or stroke than healthy subjects in the general population. The risks for developing the disease have been clearly identified: age, family history and obesity, which is why the first-line treatments are a healthy diet, weight loss and regular exercise.
Studies have also consistently shown that physical activity is directly related to the risk of cardiovascular disease and mortality in all population groups. For example, a 2007 study from the National Institutes of Health in the USA found that recommendations for moderate activity (at least 30 minutes on most days of the week) or vigorous exercise (at least 20 minutes three times per week) was associated with a 27% and 32% overall decreased mortality risk, respectively.(2)
Now, on World Diabetes Day, a new follow-up study from a large Swedish cohort of subjects specifically with type 2 diabetes similarly shows that those who engage in low levels of physical activity are at a « considerably » greater risk of cardiovascular disease and death than those who exercise at higher levels.
The study is reported today in the European Journal of Preventive Cardiology.
Low level activity was defined in the study as never or once or twice a week exercise for 30 minutes, while high level activity was defined as three of more times a week. The cohort comprised a total of 15,462 subjects (6963 doing low level activity and 8499 high level) with a mean age of 60 years from the Swedish National Diabetes Register; they were followed for five years or until a first cardiovascular event or death.
Results showed that those in the low level activity group had a 25% greater risk of coronary and cardiovascular events than those in the higher activity group, and a 70% greater risk of a fatal cardiovascular event. The results were calculated as statistically significant, and were maintained when controlled for age, gender, diabetes duration, type of hypoglycaemic treatment and smoking.
Further sub-group analysis similarly found « statistically compelling » hazard estimates. For example, those with both baseline and final (five-year) low physical activity levels had considerably higher risk estimates (of 70–110%) for coronary and cardiovascular disease and mortality than all other study subjects (including those who raised their exercise levels from baseline). Thus, stepping up the duration and frequency of exercise following a diagnosis of type 2 diabetes will lower the risk of cardiovascular complications and death; remaining inactive will maximise the risk.
« Regular physical activity is an important part of the diabetes management plan and these findings underline the importance of implementing regular physical activity as part of lifestyle measures, » say the investigators.
Commenting on the results, the study’s first author Dr Björn Zethelius from the University of Uppsala in Sweden said: « The message from this study is clear. Avoid a sedentary lifestyle. Engage in physical activity. Alongside diet, these are the cornerstone of type 2 diabetes treatment. If you are presently on a low level of physical activity, do more. »
Dr Zethelius added that increased physical activity among those with type 2 diabetes has important public health implications, simply because of the increasing prevalence of the disease.
The results from the study, he said, have « high validity » because they were obtained from nationwide registers with wide coverage and real-life data from type 2 diabetes patients.

References
1. Zethelius1 B , Gudbjörnsdottir S, Eliasson B, et al. Level of physical activity associated with risk of cardiovascular diseases and mortality in patients with type-2 diabetes: report from the Swedish National Diabetes Register. Eur J Prevent Cardiol 2013; DOI: 10.1177/2047487313510893.
2. Leitzmann MF, Park Y, Blair A, et al. Physical activity recommendations and decreased risk of mortality. Arch Intern Med 2007; 167: 2453–2460.

* According to the World Diabetes Federation, the number of people with diabetes is increasing in every country. In Europe, prevalence is put at 6.7% of the total population, with more than one-third of the cases undiagnosed. In North America, prevalence has now gone beyond 10%.
*World Diabetes Day: http://www.idf.org/worlddiabetesday
* The European Journal of Cardiovascular Prevention and Rehabilitation is a journal of the European Society of Cardiology.
* More information on this press release and a PDF of the paper is available from the ESC’s press office
press@escardio.org
About the European Society of Cardiology
The European Society of Cardiology (ESC) represents 80,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.

Authors:
ESC Press Office
Email: press@escardio.org[/toggle]

[toggle title= »Young adults with congenital heart disease can benefit from physical activity »]

The diagnosis and treatments of congenital heart disease have improved so much that many babies now born with heart defects can still look forward to a long and fulfilling life. Just two generations ago, the majority of babies born with heart defects died before their first birthday, but today many of these conditions can be corrected.(1) Indeed, the population of patients with congenital heart disease who reach adulthood – and the number of adults – is now expected to grow at a rate of 5% per year. However, residual lesions may persist such that some patients may still need lifelong care.

Many in this newly emerging patient group have been heavily protected from birth and encouraged towards a sedentary non-disruptive lifestyle. In fact, one study found that only one in five children with congenital heart disease had ever been given formal advice on physical activity. Yet the truth is that exercise is as beneficial for this group as it is for any other; but which physical activities and with what frequency and intensity?

New recommendations published today by the Working Group of Grown Up Congenital Heart Disease and the Section of Sports Cardiology of the EACPR emphasise that the majority of those with congenital heart disease will achieve « significant improvement of their exercise capacity as well as their psychological state ».(2,3) The key, says the report’s first author Professor Werner Budts from the University Hospital Leuven, Belgium, is that the activity is appropriate for each individual.

« We hope that these recommendations will offer reassurance to patients and physicians alike, and encourage a physically active life style, so that patients with congenital heart disease can achieve the benefits of regular exercise at the lowest possible risk, » said Professor Budts.

The recommendations – the first ever specifically for adolescents and young adults with congenital heart disease – cover a wide range of physical exercise, from everyday activity to participation in leisure time sports, with the recommendation of individualised exercise prescription based on five hemodynamic parameters: ventricular function, pulmonary arterial pressure, aortic diameter, arrhythmia, and arterial saturation. These five parameters provide a basis for evaluation and for a tailored approach to each individual.Once these five parameters have been assessed, the programme of activity can be safely introduced with an intensity appropriate to each patient (« relative intensity »). It is for this reason, says Professor Budts, that a wide range of activities has been included in the recommendations, so that most patients with congenital heart disease can find a physically appropriate activity and can be positively encouraged. Some « high static » sports, for example, are included (such as water skiing and rowing) as are team games. Participation in team sports, in particular, are encouraged, where levels of similar physical fitness might be found.

But, warns Professor Budts, « patients should monitor their symptoms and heart rate to ensure they do not exceed the recommendations, at least for prolonged period of times, particularly for start-stop sports like football ». He adds that those who feel that their fitness is lower than that of their team-mates should be supported « to either find an alternative team or sport« .
« So the recommendations also offer physicians a decision platform to help keep patients within exercise limitations and ensure their sports are safe for them, » says Professor Budts.
« However, activity advice for those with normal hemodynamic and electrophysiological status will not differ from the general population. Only for those with residual lesions will recommendation be more restrictive. In these cases the severity of some lesions causes an additional pressure or volume load on the heart and great vessels which could become unacceptable at certain intensities. Being more (but not too) restrictive could avoid further damage.
« Yet, for the majority of young adults with congenital heart disease we believe that patient-tailored advice will improve health behavior, influence positively their cardiovascular risk profile, and ultimately benefit outcome. »

References
1. Congenital heart disease describes a range of heart defects present at birth. Such conditions include septal defects (« hole in the heart »), in- and outflow tract obstructions, great vessels stenosis, transposition of the great arteries, and univentricular hearts. Many of these defects can now be diagnosed during pregnancy with ultrasound scanning. In the majority of cases, no obvious cause is identified.
2. The Working Group of Grown Up Congenital Heart Disease and the Section of Sports Cardiology of the European Association for Cardiovascular Prevention & Rehabilitation are both communities of the European Society of Cardiology.
3. Budts W, Börjesson M, Chessa M, et al. Physical Activity in adolescents and adults with congenital heart defects; Individualized exercise prescription. Eur Heart J 2013; doi:10.1093/eurheartj/eht433

Authors:
ESC Press Office
Email: press@escardio.org[/toggle] [toggle title= »Obese children have precursors to atherosclerosis and diabetes »] Obese children have blood vessel damage and insulin resistance that are precursors to atherosclerosis and diabetes, reveals research by Dr Norman Mangner presented at ESC Congress 2013. The findings highlight the need to adopt a healthy lifestyle early in life to prevent cardiovascular disease (CVD) which is the theme of World Heart Day 2013, held today.

Professor Grethe Tell (Norway), ESC prevention spokesperson, said: “On World Heart Day 2013 the ESC is emphasising the importance of a healthy lifestyle from a young age. One in 10 school-aged children is overweight. Bad habits have an impact on young hearts and the effects carry on until adulthood. Regular exercise and a healthy diet need to be part of daily life from childhood and it’s essential that children do not take up smoking.”

A World Heart Federation survey last year found that half of adults believe they should wait until age 30 or older before taking action to prevent heart disease and stroke.
Professor Tell added: “It is alarming to see that popular belief has it that you should wait until age 30 before looking after your heart health. The reality is that only a lifetime of avoiding common risk factors can be expected to prevent heart disease in the long run. ESC guidelines recommend that prevention should start during pregnancy and last throughout life.”

Dr Mangner’s research(1) discovered that obese children had early stages of atherosclerosis, which is when arteries become clogged with fatty materials such as cholesterol. Atherosclerosis greatly increases the risk of developing CVD. Obese children also had insulin resistance as a pre-stage to diabetes and higher systolic blood pressure. The changes were still there after 2 years. He said: “It is worrying that young obese children already have early signs of atherosclerosis, which puts them at increased risk of developing heart disease in later life. On top of that they also show early signs of diabetes. It is crucial that children are active and eat healthily to avoid becoming obese and sentencing themselves to a life of ill-health.”

Other research(2) followed 2,552 subjects aged 25-39 years from the Framingham study for 30 years and found that obesity in young adults increases the risk of CVD or diabetes by 23%. Nearly the same increased risk was observed in normal weight adults with CVD risk factors (hypertension or dyslipidemia). Risk of CVD and diabetes was highest (45%) in obese young adults with risk factors, and lowest (13%) in those with normal weight and no risk factors.

First author Dr Tomasz Zdrojewski (Poland) said: “Adopting a healthy lifestyle in early life is clearly essential for avoiding disease later on. It’s not just being fat that is a risk. High blood pressure and high levels of fat in the blood are also dangerous. Eating healthy food and being active are a must for children.”

Professor Tell concluded: “There is increasing evidence that unhealthy lifestyles even in very young children can increase their risk of future heart disease. Children who eat nutritious food, exercise and do not smoke are not just learning behaviours that will be important as adults, they are increasing their chances of avoiding heart disease.”

World Heart Day sets the stage for the launch of two European initiatives in November. Cardiovascular Health Week will be held 4-8 November with the theme “Mind Your Heart”. Awareness raising activities at the European Parliament in Brussels will be held to inform EU policymakers of the reach of cardiovascular disease, which is the main cause of death and disability in Europe despite being largely preventable. The week is being hosted by the Member of European Parliament (MEP) Heart Group and organised by the group’s secretariat (the ESC and the European Heart Network).
Cardiopolicy is an ESC initiative that will be launched on 4 November with its first official meeting. It aims to strengthen the lobbying impact of National Cardiac Societies in EU Affairs and will start with seven pilot countries (Denmark, Lithuania, Netherlands, Poland, Portugal, Spain and the UK).

References
1. Reference for ESC CVD prevention guidelines – European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). European Heart Journal. 2012;33:1635–1701.
(1) Abstract 4361: Vascular alterations and risk factor profile in pre-pubertal obese children after two years of follow up
(2) Abstract 4362: Obesity confers similar 30-year risk of cardiovascular or diabetes as hypertension or hypercholesterolemia in young adults

Authors:
ESC Press Office
Email: press@escardio.org[/toggle] [toggle title= »Death rates from heart disease continue to decline in most of the EU, but some countries are ‘cause for concern’ »] Death rates from heart disease in the European Union have more than halved in many countries since the early 1980s, according to new research published online today (Wednesday) in the European Heart Journal [1]. In the majority of countries, there have been ongoing steady reductions in heart disease death rates in both sexes and most age groups, including among younger people, despite increases in obesity and diabetes during this time. However, heart disease remains a leading cause of death in Europe.

The authors of the study say their analysis shows little evidence for the hypothesis that the reduction in deaths from coronary heart disease (CHD) might be beginning to plateau among younger people in the EU as a whole as the gains from reduced smoking rates are increasingly cancelled out by recent upward trends in obesity, diabetes and other risk factors for heart disease.

However, there was significant variation between individual countries, and evidence of a levelling off and even increases in heart disease deaths among some age groups in some countries. The absolute numbers of deaths from CHD remain high, even in countries showing encouraging downward trends in mortality.

“It is clear that there are some countries in which trends are cause for concern, where overall rates of decrease in CHD mortality do appear to have slowed, and a small number of countries in which CHD mortality rates have begun to increase significantly in recent years or decades in younger subpopulations,” said Dr Melanie Nichols, a Research Associate from the British Heart Foundation Health Promotion Research Group at the University of Oxford (UK), who is now working as a research fellow at Deakin University, Australia. “In addition, we should emphasise that cardiovascular disease remains the leading cause of death in Europe, and it is important that we continue to focus efforts on primary prevention, including reducing smoking, improving diets and physical activity levels.” [2]

Dr Nichols and her colleagues in the Oxford research group looked at trends in deaths from coronary heart disease between 1980 and 2009 in both sexes and four age groups: under 45, 45-54, 55-64, and 65 years and over.

They found that almost all EU countries had a large and significant decrease in death rates from CHD over the last three decades in both men and women when all ages were considered together. Denmark, Malta, The Netherlands, Sweden and the UK had the largest decreases in mortality for both sexes during this time. The exceptions to these significant decreases were among men in Hungary, Latvia, Lithuania and Poland, where the decreases were small and not statistically significant, and in Romania where there was a small, statistically significant increase. Among women, non-significant decreases were found in Greece, Hungary, Lithuania, Poland, Romania and Slovakia.

There was some evidence that the downward trends were beginning to plateau in those aged under 45 among men and women in Italy, Latvia, Lithuania and the UK, among men in Poland and Slovakia, and among women in the Czech Republic and France. In the 45-54 year age group, there was evidence of a possible plateau in both sexes in Latvia and the UK, and also in Lithuania among women and Sweden, Austria, the Czech Republic and Slovakia among men. In Greece, women aged 45-54 showed a constant and significant increase in death rates.

Dr Nichols, said: “Overall, across the EU, rates of death from coronary heart disease have continued to fall in most age groups in most countries. There are some exceptions, however, and there remain wide disparities across Europe in both the absolute rates of death from heart disease and the rates of improvement.

“In a small number of countries, there is some evidence that the decreasing trends may be slowing, including among younger age groups, probably due to increases in risk factors such as obesity and diabetes. These countries are, however, clearly in the minority.”

In their paper, the authors say that the increase in risk factors for coronary heart disease, such as smoking, obesity and diabetes, could still have an impact on death rates in years to come. “This effect is, however, not yet clearly apparent across the EU, and there may still be time for public health policy and action to have an impact on these risk factors . . . ,” they write. “It is crucial that future research continues to monitor trends in CHD risk factors and mortality across the EU and to examine the relationships between preventable risk factors and CHD among younger adults. Any indications of potential plateauing of CHD mortality trends among younger age groups – which were evident in this study for some countries but not yet for the EU as a whole – would be an important advance warning of potentially very high future burden of CHD as the cohort ages.”

Dr Nichols points out that their results could be affected by differences in the way countries record and code data. In addition, the researchers were unable to look at any of the reasons for differences between countries, or to draw links between these results and the possible causes within countries.

References
1. “Trends in age-specific coronary heart disease mortality in the European Union over three decades: 1980-2009”, by Melanie Nichols, Nick Townsend, Peter Scarborough and Mike Rayner. European Heart Journal. doi:10.1093/eurheartj/eht159
2. Cardiovascular disease causes over four million deaths a year in Europe and over 1.9 million in the European Union. It causes 47% of all deaths in Europe and 40% in the EU. Ref: “European Cardiovascular Disease Statistics 2012”, by Nichols M, Townsend N, Scarborough P, Luengo-Fernandez R, Leal J, Gray A, Rayner M. European Heart Network: http://www.ehnheart.org/cvd-statistics.html
3. The British Heart Foundation funds the authors’ positions at the University of Oxford. The study arises from the European Heart Health Strategy II project (EuroHeart II), which has received co-funding from the European Union, in the framework of the Health Programme. The EuroHeart II project is coordinated by the European Heart Network and the European Society of Cardiology.

Authors
The European Heart Journal is the flagship journal of the European Society of Cardiology (http://www.escardio.org). It is published on behalf of the ESC by Oxford Journals, a division of Oxford University Press.[/toggle] [toggle title= »ESC guide on new oral anticoagulant drugs »]

Sophia Antipolis, 26 April 2013: A practical guide on the use of the new oral anticoagulants (NOACs) has been produced by the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC). A guide was needed to summarise existing information on different drugs, to answer clinical questions that fall outside what drug companies can legally answer, and to make distinctions between the different drugs.
ESC guidelines on atrial fibrillation recommend the NOACs as preferable to vitamin K antagonists for stroke prevention in patients with non-valvular atrial fibrillation.(1) Companies provide a Summary of Product Characteristics (SmPC) for their drug but the content is bound by legal restrictions and the information in SmPCs for different NOACs overlaps.Professor Hein Heidbuchel (Belgium), lead author of the EHRA guide, said: “Companies are bound by legal restrictions in their SmPCs and for physicians in the field the information is often not specific enough. EHRA goes further than the SmPCs and provides expert guidance, often admittedly based on incomplete data, on what to do in specific clinical situations.”

He added: “We have brought together information on all the NOACs in one document so it’s clear for physicians what the similarities and differences are. We worked closely with the drug companies to make sure that all of the information in the SmPCs is also in our document.”

The paper provides practical advice on how to handle 15 clinical scenarios. The full paper is published today in EHRA’s official journal, EP-Europace,(2) and the executive summary is published online in European Heart Journal.(3)

The clinical situations include how to initiate and monitor NOAC use, how to measure the anticoagulant effect if needed in specific situations, switching between anticoagulants, ensuring compliance, patients with chronic kidney disease and management of bleeding complications.

NOACs remove the regular monitoring of anticoagulation level that was required for the vitamin K antagonists. But Professor Heidbuchel said: “Compliance is very important for the novel anticoagulant drugs because they have a very short half-life. That means that if you don’t take them you will not be protected by anticoagulation and are at greater risk of thromboembolic events.”

The document provides tips on how to improve compliance. These include educating patients about the drug’s short half-life, and that small minor bleeding such as a nose bleed will stop by itself and patients should continue taking the drug. Compliance can also be improved with a pre-specified follow up scheme.

The guide does not cover the indications for switching from a vitamin K antagonist to a NOAC but it does advise how to switch safely. Professor Heidbuchel said: “We have learned from the big trials that these moments of transitioning from one anticoagulant to another can be dangerous in the sense that patients can be under-anticoagulated.”

He added: “The bleeding risk profile of the NOACs is definitely better than that of vitamin K antagonists. Nevertheless bleedings will occur and so our practical document has outlined what action should be taken.”

Professor Stefan Hohnloser (Germany), a reviewer of the EHRA guide and a member of the ESC atrial fibrillation guidelines task force, said: “The updated ESC guidelines on the treatment of atrial fibrillation recommend the NOACs to be used rather than the vitamin K antagonists. Like all new drugs these drugs have pitfalls – for example they are excreted via the kidneys and therefore physicians need to measure renal function regularly. Physicians who follow the practical advice in this guide will dramatically improve the safety of their patients.”

New information on the NOACs is rapidly becoming available and EHRA has developed a website with the latest information, www.NOACforAF.eu.

References
1. Camm AJ, Lip GYH, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal. 2012; 33:2719-2747.
2. Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013; 15:625-651, DOI: 10.1093/europace/eut083
3. Heidbuchel H, Verhamme P, Alings M, et Al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Advance Access published, European Heart Journal.213; DOI: 10.1093/eurheartj/eht134

Authors
ESC Press Office
press@escardio.org
33(0)4 92 94 77 56
European Society of Cardiology[/toggle][toggle title= »The adult generations of today are less healthy than their counterparts of previous generations »] Sophia Antipolis, 10 April 2013. Despite their greater life expectancy, the adults of today are less « metabolically » healthy than their counterparts of previous generations. That’s the conclusion of a large cohort study from the Netherlands which compared generational shifts in a range of well established metabolic risk factors for cardiovascular disease.

Assessing the trends, the investigators concluded that « the more recently born generations are doing worse », and warn « that the prevalence of metabolic risk factors and the lifelong exposure to them have increased and probably will continue to increase ».

The study, reported today in the European Journal of Preventive Cardiology, analysed data on more than 6,000 individuals in the Doetinchem Cohort Study, which began in 1987–1991 with follow-up examinations after six, 11, and 16 years.(1,2) The principal risk factors measured were body weight, blood pressure, total cholesterol levels (for hypercholesterolaemia) and levels of high-density lipoprotein (HDL) cholesterol, which is considered « protective ».

The subjects were stratified by sex and generation at baseline into ten-year age groups (20–29, 30–39, 40–49, and 50–59 years); the follow-up analyses aimed to determine whether one generation had a different risk profile from a generation born ten years earlier – what the investigators called a « generation shift ».

Results showed that the prevalence of overweight, obesity, and hypertension increased with age in all generations, but in general the more recently born generations had a higher prevalence of these risk factors than generations born ten years earlier. For example, 40% of the males who were in their 30s at baseline were classified as overweight; 11 years later the prevalence of overweight among the second generation of men in their 30s had increased to 52% (a statistically significant generational shift). In women these unfavourable changes in weight were only evident between the most recently born generations, in which the prevalence of obesity doubled in just 10 years.

Other findings from the study included:

  • Unfavourable (and statistically significant) generation shifts in hypertension in both sexes between every consecutive generation (except for the two most recently born generations of men).
  • Unfavourable generation shifts in diabetes between three of the four generations of men, but not of women.
  • No generation shifts for hypercholesterolaemia, although favourable shifts in HDL cholesterol were only observed between the oldest two generations.

As for the overall picture, and based on the evidence of a « clear » shift in the prevalence of overweight and hypertension, the investigators emphasise that « the more recently born adult generations are doing worse than their predecessors ». Evidence to explain the changes is not clear, they add, but note studies reporting an increase in physical inactivity.

What do the findings mean for public health? First author Gerben Hulsegge from the Dutch National Institute for Public Health and the Environment emphasises the impact of obesity at a younger age.

« For example, » he explains, « the prevalence of obesity in our youngest generation of men and women at the mean age of 40 is similar to that of our oldest generation at the mean age of 55. This means that this younger generation is ’15 years ahead’ of the older generation and will be exposed to their obesity for a longer time. So our study firstly highlights the need for a healthy body weight – by encouraging increased physical activity and balanced diet, particularly among the younger generations.

« The findings also mean that, because the prevalence of smoking in high-income countries is decreasing, we are likely to see a shift in non-communicable disease from smoking-related diseases such as lung cancer to obesity-related diseases such as diabetes. This decrease in smoking prevalence and improved quality of health care are now important driving forces behind the greater life expectancy of younger generations, and it’s likely that in the near future life expectancy will continue to rise – but it’s also possible that in the more distant future, as a result of our current trends in obesity, the rate of increase in life expectancy may well slow down, although it’s difficult to speculate about that. »

References
1. Hulsegge G, Susan H, Picavet J, et al. Today’s adult generations are less healthy than their predecessors: Generation shifts in metabolic risk factors: the Doetinchem Cohort Study. Eur J Prevent Cardiol 2013; DOI: 10.1177/2047487313485512
2. Doetinchem is a small town in the Netherlands from which at baseline (1987–1991) 20,155 people aged 20–59 were invited to participate in a cardiovascular risk factor monitoring project. From an initial participation of 12,405 (wave 1), a random sample of 7,768 was invited for a second examination in 1993–1997 (wave 2). The total random sample was invited again in 1998–2002 (wave 3) and in 2003–2007 (wave 4). In total, 21,786 examinations from 6,377 participants were included for the present study. The study was supported by the Ministry of Health, Welfare and Sport of the Netherlands and the National Institute for Public Health and the Environment.
[/toggle][toggle title= »Demanding physical work associated with an increased risk of cardiovascular disease »]Rome, 18 April 2013. Two studies presented at this year’s EuroPRevent 2013 congress suggest that demanding physical work has a detrimental effect on an individual’s risk of coronary heart disease.

The first was a case-control study described by Dr Demosthenes Panagiotakos, Associate Professor of Biostatistics-Epidemiology at Harokopio University, Athens, which evaluated occupation in 250 consecutive patients with a first stroke, 250 with a first acute coronary event and 500 equally matched controls.(1) Overall, when assessed on a 9-unit scale (1 = physically demanding work and 9 = sedentary/mental work) the analysis showed that those suffering the stroke and coronary events were more commonly engaged in physically demanding occupation than the controls.

After adjusting for various potential confounding factors such as age, sex, body mass index, smoking, hypertension, hypercholesterolemia, diabetes, family history of cardiovascular disease and adherence to the Mediterranean diet, results confirmed that those occupied in progressively less physically demanding jobs (that is, for each unit increase of the scale) were associated with a 20% lower likelihood of acute coronary events (a statistically significant odds ratio of 0.81%) or of ischaemic stroke (odds ratio 0.83%).

Commenting on the results, Dr Panagiotakos said that subjects with physically demanding manual jobs should be considered a primary target group for prevention of cardiovascular disease because of their higher risk.

Within the context of exercise recommendations, he noted that the somewhat paradoxical results could possibly be attributed to the stress experienced by people with physically demanding jobs. Stress, he added, may be one reason why hard physical work may not be comparable to the physical exercise recommended for health and well-being, which tend to be non-stressful behaviours. In addition, he explained, such work is often not well paid, which may restrict access to the healthcare system.

A second study reported here from investigators in Belgium and Denmark also supports the view that physically demanding work is a risk factor for coronary heart disease, even when leisure-time activity is taken into account.(2)

This was a cohort study of more than 14,000 middle-aged men who were free of coronary disease at the outset of the study in 1994-1998. Standardised questionnaires were used to assess socio-demographic factors, job strain and the level of physical activity at work and during leisure time. Classical coronary risk factors were also measured through clinical examinations and questionnaires.

The incidence of coronary events was monitored during a mean follow-up time of 3.15 years, with statistical modelling applied to assess the association between physical activity and coronary disease. Again, adjustments were made for age, education, occupational class, job strain, body mass index, smoking, alcohol consumption, diabetes, blood pressure, and cholesterol.

Results during follow-up showed an overall beneficial effect of leisure time physical activity, but an adverse effect of demanding physical work. However, Dr Els Clays, from the Department of Public Health at the University of Ghent, Belgium, added that an « interaction effect » was also evident in the results: while moderate-to-high physical activity during leisure time was associated with a 60% reduced risk of coronary events in men with low occupational physical activity (a statistically significant hazard rate of 0.40), this protective effect was not observed in those workers who were also exposed to high physical work demands (HR 1.67).

Dr Clays added that, after adjusting for socio-demographic and well established coronary risk factors, men with high physical job demands were more than four times likely to have coronary heart disease when they also engaged in physical activity during leisure time (HR 4.77).

Commenting on the results Dr Clays said: « From a public health perspective it is very important to know whether people with physically demanding jobs should be advised to engage in leisure time activity. The results of this study suggest that additional physical activity during leisure time in those who are already physically exhausted from their daily occupation does not induce a ‘training’ effect but rather an overloading effect on the cardiovascular system. However, only few studies until now have specifically addressed this interaction among both types of physical activity, and conflicting findings have been reported. More research using detailed and objective measures of activity is needed. »

References
1. Panagiotakos D, Georgousopoulou E, Kastorini CM, et al. Physically demanding occupation is associated with higher likelihood of a non-fatal acute coronary syndrome or ischemic stroke: a case/case-control study, Presented at EuroPRevent 2013 Final Programme Number P67.
2. Clays E, De Bacquer D, Janssens H, et al. Physical work demands and leisure time physical activity in relation to risk for coronary heart disease, Presented at EuroPRevent 2013 Final Programme Number P76.
[/toggle][toggle title= »Long-term exposure to fine particles of traffic pollution associated with increased risk of heart disease »] Rome, 18 April 2013. The association between road traffic and heart disease has been suggested in several studies. In 2012 a large prospective cohort study from Denmark showed that traffic noise was significantly associated with risk of heart attack – for every 10 decibel increase in noise exposure (either at the time of the attack or over the five years preceding it) there was a 12% increased risk.(1)

Now, a new study presented at the EuroPRevent 2013 congress in Rome shows that long-term exposure to fine particle matter (PM) air pollution in part derived from traffic pollution is also associated with atherosclerosis independent of traffic noise.(2)

Details of the study were described by Dr Hagen Kälsch from West-German Heart Center in Essen, Germany, who explained that the study was designed to establish where responsibility for the increased heart risks associated with traffic actually lay – with noise or particle pollution, or both.

The study was based on data from the German Heinz Nixdorf Recall Study, a population-based cohort of 4814 participants with a mean age of 60 years. Their proximity to roads with high traffic volume was calculated with official street maps, their long-term exposure to particle pollutants assessed with a chemistry transport model, and road traffic noise recorded by validated tests. The participants’ level of atherosclerosis was evaluated by measurement of vascular vessel calcification in the thoracic aorta, a common marker of subclinical atherosclerosis (known as TAC), by computed tomography imaging.

Results showed that in the 4238 subjects included in the study small particulate matter (designated as PM2.5) and proximity to major roads were both associated with an increasing level of aortic calcification – for every increase in particle volume up to 2.4 micrometers (PM2.5) the degree of calcification increased by 20.7% and for every 100 metre proximity to heavy traffic by 10%. The study also found a borderline increase in TAC for night time noise (of 3.2% per 5 decibels). The associations of PM2.5 and road traffic noise were not modified by each other.

Commenting on the results, Dr Kälsch confirms that long-term exposure to fine PM air pollution and to road traffic noise are both independently associated with TAC as a measure of subclinical atherosclerosis.

« These two major types of traffic emissions help explain the observed associations between living close to high traffic and subclinical atherosclerosis, » he says. « The considerable size of the associations underscores the importance of long-term exposure to air pollution and road traffic noise as risk factors for atherosclerosis. »

Fine PM and traffic noise are believed to act through similar biologic pathways, thereby increasing cardiovascular risk; they both cause an imbalance in the autonomic nervous system, which feeds into the complex mechanisms regulating blood pressure, blood lipids, glucose level, clotting and viscosity.

TAC, alongside coronary artery calcification (CAC), is a reliable marker of subclinical atherosclerosis. While sharing cardiovascular risk factors with coronary atherosclerosis, TAC like TAC has been shown to be independently related to the incidence of cardiovascular events.

A further study reported at this congress from French investigators found that all the main air pollutants (carbon monoxide (CO), nitrogen dioxide (NO2), sulphur dioxide (SO2), and particulate matter measured as PM10 or PM2.5, but with the exception of ozone (O3)) were significantly associated with an increased risk of myocardial infarction.(3)

References
1. Sørensen M, Andersen ZJ, Nordsborg RB et al. Road traffic noise and incident myocardial infarction: a prospective cohort study. PLOS One 2012; doi: 10.1371/journal.pone.0039283.
2. Kaelsch H, Hennig F, Moebus S, et al. Is urban particulate air pollution or road traffic noise responsible for the association of traffic proximity with subclinical atherosclerosis? Results from the Heinz Nixdorf Recall Study. Presented at EuroPRevent 2013 Poster presentation P307.
3. Mustafic H, Jabre P, Caussin C, et al. Main air pollutants and myocardial infarction: a systematic review and meta-analysis, Presented at EuroPRevent 2013 Poster presentation P89.
[/toggle][toggle title= »Mental vulnerability associated with increased risk of fatal and non-fatal cardiovascular disease independently of classical risk factors »]Rome, 18 April 2013. People deemed to be « mentally vulnerable » are at a significantly increased risk of both fatal and non-fatal cardiovascular disease, according to results of a large population study from Denmark. The details of the study were presented today at the EuroPRevent 2013 congress in Rome. (1)

The study’s first author, Dr Anders Borglykke from the Research Centre for Prevention and Health
 at Glostrup University Hospital, Denmark, explained that psychosocial factors and personality traits have been consistently associated with cardiovascular disease and all-cause mortality, but their role in the prediction of risk was still not clear. This study was to investigate whether mental vulnerability (defined as « a tendency to experience psychosomatic symptoms or inadequate interpersonal reactions ») increases the risk of cardiovascular disease and the precision of prediction models for cardiovascular disease.

The study incorporated data from three prospective Danish population cohorts from which almost 11,000 individuals free of any cardiovascular disease were followed-up for a mean period of 15.9 years (a total of 166,787 person-years). During this follow-up period all cardiovascular events (fatal and non-fatal) were recorded and, at the outset of the study, mental vulnerability measured on a validated 12-point scale originally constructed by the Military Psychology Services in Denmark. The results categorised subjects into three groups: « non-vulnerable, latent or mentally vulnerable ».

« The scale consists of questions on both mental and physical symptoms, » said Dr Borglykke, « and generally measures a level of stress or a personality which is more receptive to stress. The scale has previously been found associated with early mortality and ischaemic heart disease. »(2)

To assess the predictive ability of the scale, the results were added to a statistical model with classical risk factors for cardiovascular disease (age, sex, smoking, systolic blood pressure and total cholesterol).

During the follow-up period there were 3045 fatal and non-fatal cardiovascular events recorded in the study population of 10,943 subjects. When the statistical analysis was performed, results showed that mental vulnerability was significantly associated with fatal and non-fatal cardiovascular events independently of the classical risk factors; the risk of events in the mentally vulnerable was 36% higher than in the non-vulnerable (hazard ratio 1.366; 1.208 – 1.545).

Are the findings sufficiently robust to suggest that mental vulnerability is considered an independent marker of cardiovascular disease – and as such able to improve the precision of risk prediction? « Several studies have found risk factors for cardiovascular disease which are clearly independent but within a broader context contribute little if anything to actual risk prediction, » explains Dr Borglykke. « One of the reasons for this is that the impact of the well established risk factors – age, sex, smoking, blood pressure and total cholesterol – tend to dominate the risk stratification models. This means that a risk factor such as our scale of mental vulnerability clearly increases the risk significantly – by 36% – but still does not improve risk prediction in the general population. »

Statistical analysis in this study showed that adding mental vulnerability to a risk stratification model which included the principal risk factors resulted in only very small changes in discriminative ability.

« However, » added Dr Borglykke, « these results do not necessarily mean that we should ignore mental vulnerability in our assessment of individual risk. It is still possible that it might improve risk prediction – or even emerge as a new marker to explain or reclassify some cardiovascular cases which cannot be attributed to classical risk factors. »

« So mental vulnerability might describe a ‘new dimension’ when compared to the five classical risk factors, but to take this forward we need to identify sub-groups of the population where mental vulnerability does improve risk prediction beyond the classic risk factors. »

Commenting on how mental vulnerability might be associated with cardiovascular disease, Dr Borglykke suggested that the chronic psychological stress experienced by mentally vulnerable people might provide one explanation. This, he added, might also provide a clue for reducing the risk – by removing the triggers of chronic stress to which such individuals are exposed.

References
1. Borglykke A, Ebstrup J, Jørgensen T, et al. Mental vulnerability as a predictor of cardiovascular disease and death. Presented at EuroPRevent 2013 congress. Final Programme Number P52
2. Eplov LF, Jørgensen T, Birket-Smith M, et al. 
Mental vulnerability – a risk factor for ischemic heart disease. J Psychosom Res 
2006; 60: 169-76.
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