The Impact of Educational Status on 10-Year (2004-2014) Cardiovascular Disease Prognosis and All-cause Mortality Among Acute Coronary Syndrome Patients in the Greek Acute Coronary Syndrome (GREECS) Longitudinal Study.

OBJECTIVES: The association between educational status and 10-year risk for acute coronary syndrome (ACS) and all-cause mortality was evaluated. METHODS: From October 2003 to September 2004, 2172 consecutive ACS patients from six Greek hospitals were enrolled. In 2013 to 2014, a 10-year follow-up (2004-2014) assessment was performed for 1918 participants (participation rate, 88%). Each patient's educational status was classified as low (<9 years of school), intermediate (9 to 14 years), or high (>14 years). RESULTS: Overall all-cause mortality was almost twofold higher in the low-education group than in the intermediate-education and high-education groups (40% vs. 22% and 19%, respectively, p<0.001). Additionally, 10-year recurrent ACS events (fatal and non-fatal) were more common in the low-education group than in the intermediate-education and high-education groups (42% vs. 30% and 35%, p<0.001), and no interactions between sex and education on the investigated outcomes were observed. Moreover, patients in the high-education group were more physically active, had a better financial status, and were less likely to have hypertension, diabetes, or ACS than the participants with the least education (p<0.001); however, when those characteristics and lifestyle habits were accounted for, no moderating effects regarding the relationship of educational status with all-cause mortality and ACS events were observed. CONCLUSIONS: A U-shaped association may be proposed for the relationship between ACS prognosis and educational status, with participants in the low-education and high-education groups being negatively affected by other factors (e.g., job stress, depression, or loneliness). Public health policies should be aimed at specific social groups to reduce the overall burden of cardiovascular disease morbidity.

Physical Activity Frequency on the 10-Year Acute Coronary Syndrome (ACS) Prognosis; The Interaction With Cardiovascular Disease History and Diabetes Mellitus: The GREECS Observational Study.

The association between physical activity, diabetes mellitus (DM), and long-term acute coronary syndrome (ACS) prognosis was evaluated. The GREECS study included 2,172 consecutive ACS patients from six Greek hospitals (2003-2004). In 2013-2014, a 10-year follow up was performed with 1,918 patients. Physical activity was categorized in never, rarely (monthly basis), 1-2 and ≥ 3 times/week. Multi-adjusted analysis revealed that 1-2 and ≥ 3 times/week vs. no physical activity had a protective effect on ACS incidence (OR = 0.63 95% CI 0.38, 1.05) and (OR = 0.63 95% CI 0.40, 0.99) respectively, only in patients without prior baseline CVD event. In a subgroup analysis, with DM as strata in these patients, engagement in physical activity (i.e., 1-2 times/week) had a significant protective effect among patients with diabetes (OR = 0.51, 95% CI 0.27, 0.96, p = .037). These findings revealed the beneficial role of exercise in secondary ACS prevention, even in DM patients. Public health-oriented policies should incorporate regular physical activity as a key protective factor in disease prognosis.

Depressive symptomatology in relation to 10-year (2004-2014) acute coronary syndrome incidence; the moderating role of diet and financial status.

BACKGROUND: The association between depression status and 10-year cardiovascular disease (CVD) incidence among acute coronary syndrome (ACS) patients, in relation to nutritional and financial status, was evaluated. METHODS: From October 2003 to September 2004, a sample of 2172 consecutive ACS patients from 6 Greek hospitals was enrolled. In 2013-14, the 10-year follow-up was performed. Depressive symptoms were evaluated using the validated CES-D score (range 0-60). Adherence to Mediterranean diet was assessed through MedDietScore (range 0-55) and financial status was determined by the annual income. RESULTS: Ranking from the 1st to 3rd CES-D tertile, recurrent fatal/non fatal ACS rates were 33%, 37% and 42%, respectively (p=0.006). Multiple logistic regression models revealed an adverse association of severe depression status (i.e. 3rd tertile) compared to no depression (i.e. 1st tertile) [odds ratio (OR)=1.31, 95% confidence interval (95% CI) 1.01, 1.69]. When controlling for financial status, the relationship between depression and ACS prognosis remained marginally significant; while subgroup analysis revealed that only patients with low/moderate income were negatively affected [OR=1.36, 95% CI 0.98, 1.88]. Further stratified analysis, by MedDietScore group, was applied; the above association remained significant only in patients with low compliance to this dietary pattern [OR=1.68, 95% CI 1.10, 2.18]. CONCLUSIONS: ACS coexisting with severe depression status seems to result in adverse disease outcomes while financial status and Mediterranean diet are proposed as potential moderators. Public health programs should focus on vulnerable groups and minimize depressive symptoms through appropriate medical treatment and lifestyle interventions, so as to ameliorate the disease prognosis in clinical and community levels.

Diabetes Mellitus, Hypertension and Hypercholesterolemia in Relation to the 10-Year ACS Prognosis; the GREECS Study.

Although hypertension, hypercholesterolemia and diabetes mellitus (DM) are recognized as major cardio-metabolic risk factors in primary Acute Coronary Syndrome (ACS) prevention, studies focusing on secondary ACS incidence are scarce. In the present study, the association between the aforementioned factors and 10-year ACS prognosis was evaluated. From October 2003 to September 2004 2,172 consecutive patients with ACS diagnosis, from 6 Greek hospitals, were enrolled. During 2013-14, the 10-year follow-up was performed in 1,918 participants. Baseline clinical factors were assessed through physical examination, medical records and pharmacological management. All-cause mortality and the development of fatal or non-fatal ACS events were recorded through medical records or hospital registries. Logistic regression models were applied to evaluate the impact of baseline clinical status on the ACS prognosis. The 10-year all cause and ACS mortality rate was 32.6 and 17.8%, respectively. Multi-adjusted analysis highlighted that, after taking into account various potential confounders, DM was the sole clinical factor associated with adverse effect on the 10-year ACS fatal incidence [Odds Ratio (OR)=1.35, 95% Confidence Interval (95% CI) 1.01, 1.80, p=0.04]. DM was the only clinical factor that aggravated ACS prognosis, whereas abnormal lipids profile and blood pressure did not seem to determine prognosis. Thus, glycaemic control may play a critical role in the secondary CVD prevention management of ACS patients.

Smoking determines the 10-year (2004-2014) prognosis in patients with Acute Coronary Syndrome: the GREECS observational study.

BACKGROUND: Smoking has long been positively associated with the development and progression of coronary heart disease. However, longitudinal cohort studies evaluating smoking habits among cardiac patients as well as the role of socio-demographic factors determining such behaviours are scarce and have been focused on primary care practice. Thus the aim of the present work was to examine the association of active smoking and behaviours and exposure to second-hand smoke, with the 10-year Acute Coronary Syndrome (ACS) prognosis, among cardiovascular patients. METHODS: From October 2003 to September 2004, a sample of six Greek hospitals was selected and almost allconsecutive 2172 ACS patients were enrolled. In 2013-14, the 10-year follow-up was performed in 1918 participants (11 % loss to follow-up). Smoking habits at the time of entry to the study, as well as during the follow-up period were studied using a standard questionnaire. RESULTS: Patients who had >60 pack-years of smoking had 57.8 % higher ACS mortality and 24.6 % higher risk for any ACS event. Nested model, adjusted only for age and sex, revealed that for every 30 pack-years of smoking increase, the associated ACS risk increased by 13 % (95 % CI 1.03, 1.30, p = 0.001). When further adjusted analysis, including several potential confounders, was applied the tested relationship was still significant (95 %CI 1.03, 1.30, p = 0.09). Accordingly, the risk for fatal ACS events increased by 8 % for every 30 pack-years of smoking increase (95 % CI 1.03, 1.63, p = 0.06). Moreover, 52 % of the patients reported being exposed to secondhand smoke and when further adjustments were made, it was revealed that they had 33 % (95 % CI 1.12, 1.60, p = 0.01) higher risk of having recurrent ACS events. CONCLUSIONS: Active smoking and second-hand smoke among cardiac patients still represent a substantial clinical burden. Thus, smoking cessation policies should be incorporated into the long-term therapeutic management.

The role of coffee consumption on the 10-year (2004-2014) Acute Coronary Syndrome (ACS) incidence among cardiac patients: the GREECS observational study.

The association between long-term coffee consumption and 10-year cardiovascular disease incidence among Acute Coronary Syndrome (ACS) patients was evaluated. From 2003 to 2004, 2172 ACS consecutive patients from six major Greek hospitals were enrolled. During 2013-2014, the 10-year follow-up was performed (88% participation rate) and recurrent fatal or non-fatal ACS was recorded. Baseline coffee consumption (cups/day) was assessed using a semi-quantitative Food Frequency Questionnaire. Multi adjusted analysis revealed that 1-2 cups of coffee/day versus no consumption had an adverse effect on the ACS incidence [odds ratio (OR) = 1.35, 95% confidence interval (CI) 1.01, 1.79]. In subgroup analysis, with hypertension as strata, only the normotensive reached significance. Odds ratios for 1-2 and ≥3 cups relative to no consumption were [OR = 1.66, 95% CI 1.07, 2.60] and [OR = 1.86, 95% CI 1.06, 3.27], respectively, after controlling for potential confounders. Thus, avoidance of coffee may be of high importance to ameliorate disease prognosis among cardiac patients.

Depression and marital status determine the 10-year (2004-2014) prognosis in patients with acute coronary syndrome: the GREECS study.

BACKGROUND: The aim of the present work was to examine the association of depression and marital status, with the long-term prognosis of acute coronary syndrome (ACS), among a Greek sample of cardiac patients. METHODS: From October 2003 to September 2004, a sample of 2172 consecutive ACS patients from 6 hospitals was enrolled. In 2013-2014, the 10-year follow-up was performed in 1918 participants. Depressive symptoms were evaluated using the validated CES-D score (range 0-60), while marital status was classified as: single, married/cohabitants, divorced and widowed at the time of entry to the study. RESULTS: Patients in the upper tertile of CES-D (>20 score) had 41% (95%CI 14%, 75%) higher risk of ACS incidence as compared with those in the lowest (<7 score). In contrary, married patients had 29% lower risk (95%CI 6%, 46%) of ACS mortality compared with single, widowed or divorced. Multi-adjusted analysis revealed that among the 'not married' patients, 1-point increase in the CES-D score was associated with 2% (p = .02) and 4% (p = .001) higher risk of having non-fatal and fatal cardiac events, respectively. CONCLUSIONS: The present study highlights the important role of depression in the context of marital relationships among ACS patients. Secondary public health care intervention programmes are needed to improve patient outcomes and minimise disease burden in clinical and community setting.

Lower Financial Status and Adherence to Medication Determines 10-Year (2004-2014) All-Cause Mortality and Risk for Acute Coronary Syndrome Incidence Among Cardiac Patients: the GREECS Study.

BACKGROUND: Financial status has been considered as an important health determinant and associated with compliance to healthier lifestyle habits, medical treatment and increased prevalence of mental disorders. The aim of this work was to evaluate the association between financial status, patient adherence to medication, 10-year allcause mortality and risk for Acute Coronary Syndrome (ACS), in a Greek sample of cardiac patients. METHODS: From October 2003-September 2004 a sample of 2,172 consecutive ACS patients from 6 hospitals was enrolled. In 2013-14, the 10-year follow-up was performed in 1,918 participants. Adherence to medical treatment was recorded through self-reports and financial status was classified as low (<9,000€), moderate (9-18,000€), good (19-48,000€) and very good (>48,000€). RESULTS: The "low"-to-"very" good financial status 10-year all-cause mortality rate was 1.7:1 (p<0.001). Unadjusted analysis revealed no association between financial status and ACS incidence (p=0.22); however, multi-adjusted analysis, after taking into account various clinical and lifestyle factors, revealed that "good/very good" financial status was associated with 23% (95%CI 2%, 40%, p=0.04) lower 10-year risk of ACS as compared with "low/moderate"; a finding that became insignificant when adherence to medication was taken into account. CONCLUSIONS: Low financial status seems to play a critical role in the long-term ACS prognosis. Health policies, to tackle non-compliance to medication, are needed to minimize the disease burden in clinical and community settings.

A comparative analysis of predictors for 1-year recurrent acute coronary syndromes events, by age group: the Greek observational study of ACS (GREECS).

OBJECTIVES: To evaluate the potential differences in risk factors' profile for in-hospital mortality and up to 1-year prognosis, between younger and older patients with first acute coronary syndromes (ACS). METHODS: From October 2003 to September 2004, 1323 patients with first ACS event from 6 urban and rural Greek hospitals were enrolled into the study, classified as those < 65 years and ≥ 65 years old. Multiple logistic regression analysis was used to evaluate the association between socio-demographic, lifestyle, clinical characteristics and the disease prognosis for one year after discharge. RESULTS: The men-to-women ratio was 8.5-to-1.5 for those < 65 years, whereas, it was 6.6-to-3.4 for those above 65 years (p < 0.001). In-hospital deaths and recurrent event within 30-days was higher among older patients (p < 0.001). After the period of 6-months, the event-rate was higher among the younger patients (p < 0.001). Current smoking was associated with increased risk of 1-month recurrent events, in patients < 65 years (p < 0.05). Myocardial infarction and history of diabetes were associated with increased risk in older patients (p < 0.1). CONCLUSION: Age-specific identification of the risk factors for recurrent events may have important clinical and public health implications and lead to the development of more effective risk reduction strategies.

Marital status, depressive episodes, and short-term prognosis of patients with acute coronary syndrome: Greek study of acute coronary syndrome (GREECS).

The association between marital status and short-term prognosis of patients hospitalized for acute coronary syndrome (ACS) was evaluated. From October 2003 to September 2004, a sample of 6 hospitals located in Greek regions was selected, and almost all survivors after an ACS were enrolled into the study (2172 patients were included in the study; 76% were men). The in-hospital mortality rate was 3.2% in male patients and 5.7% in female patients (p = 0.009). Never-married patients had 2.8-times higher risk of dying during hospitalization compared with married, after adjusting for various confounders (p < 0.01, attributable risk = 64%). Furthermore, never-married had 2.7-times higher risk of dying during the first 30-days following hospitalization compared with married (p < 0.01, attributable risk = 62%). Moderate depressive symptoms 3.26-fold (95% CI 1.40-7.11) the risk of recurrent events, while severe depressive symptoms were associated with 8.2-fold (95% CI 3.98-17.1) higher risk of events. No interaction was observed between marital status and depression on 30-day prognosis of ACS patients (p > 0.5). People who were not-married and depressed at the time of an acute cardiac episode were at higher risk of fatal events than people who were married, irrespective of depression status and other characteristics.

Physical activity status and acute coronary syndromes survival The GREECS (Greek Study of Acute Coronary Syndromes) study.

OBJECTIVES: We sought to evaluate the association between physical activity levels and the clinical outcome at presentation, as well as the 30-day prognosis of hospitalized patients with acute coronary syndromes (ACS). BACKGROUND: Regular physical activity has been associated with decreased risk of coronary heart disease. However, less is known about the effects of life-long physical activity on ACS prognosis. METHODS: From October 2003 to September 2004, a sample of 6 hospitals located in urban and rural Greek regions were selected, and almost all of their ACS patients were enrolled into the study (2,172 patients were included in the study; 76% men and 24% women). Logistic regression models were applied to evaluate the effect of physical activity status (as assessed using the International Physical Activity Questionnaire) on in-hospital mortality and the 30-day outcome of cardiovascular events (death or rehospitalization due to cardiovascular disease). RESULTS: An inverse association was observed between the level of physical activity and troponin I levels at presentation (p = 0.01). Moreover, after taking into account various potential confounders, physical activity was associated with a 0.56-fold (95% confidence interval [CI] 0.32 to 0.90) lower odds of in-hospital mortality and a 0.80-fold (95% CI 0.50 to 0.99) lower odds of cardiovascular events within the first month after discharge. CONCLUSION: In conclusion, physical activity is associated with a reduced severity of ACS, reduced in-hospital mortality rates, and improved short-term prognosis.

Systolic blood pressure on admission predicts in-hospital mortality among patients presenting with acute coronary syndromes: the Greek study of acute coronary syndromes.

The authors sought to evaluate whether the level of systolic blood pressure (SBP) on hospital admission is an independent prognostic factor for in-hospital mortality of patients hospitalized with acute coronary syndrome (ACS). From October 2003 to September 2004, 2172 consecutive patients with ACS were included in the study (76% men). The in-hospital mortality rate was 3.2% in male and 5.7% in female patients (overall, 82 deaths; P=.009). An inverse association was observed between in-hospital mortality rate and levels of SBP (<100 mm Hg, death rate 17.8%; 100-120 mm Hg, 3.7%; 120-140 mm Hg, 2.9%; >140 mm Hg, 2.6%; P<.001). Women, hypertensives, diabetics, dyslipidemics, and older patients had higher levels of SBP compared with other groups. The SBP of patients who received thrombolytic agents was lower than that of those who did not receive this therapy. Multi-adjusted analysis revealed that a 10-mm Hg increment in SBP was associated with a 27% lower likelihood of death during hospitalization (odds ratio, 0.73; 95% confidence interval, 0.66-0.90).

Sex-related characteristics in hospitalized patients with acute coronary syndromes--the Greek Study of Acute Coronary Syndromes (GREECS).

We studied the sex-specific distribution of various factors in hospitalized patients who presented with acute coronary syndromes (ACS), as well as the annual incidence and the in-hospital and short-term outcomes in males and females. A sample of six hospitals located in Greek urban and rural regions was selected. In these hospitals we recorded almost all nonfatal admissions with a first event of ACS, from October 2003 to September 2004. Sociodemographic, clinical, dietary, and other lifestyle characteristics were recorded. A total of 2,172 patients were included in the study (1,649, 76% male and 523, 24% female). The annual incidence rate was almost three times higher in males than in females (34 per 10,000 males and 10.9 per 10,000 females). The highest frequency of events was observed in winter, in both sexes. Females had higher in-hospital mortality rate as compared to males (5.7% vs 3.2%, P = 0.007), while the 30-day mortality and rehospitalization rate was 17% in male and 16% in female patients. The most common discharged diagnosis for males was Q-wave myocardial infraction (35%), while females were more likely to suffer from unstable angina (42%). Females were older than males, waited longer between seeking and receiving medical advice, and were more likely to have a history of hypertension, obesity, and diabetes mellitus as compared to males. On the other hand, males were more likely to be smokers, to follow a more typical Mediterranean diet, and to be more physically active (P < 0.05). We revealed a sex-related difference in the profile of clinical characteristics and other cardiovascular risk factors in hospitalized patients for ACS.

Association of creatinine clearance and in-hospital mortality in patients with acute coronary syndromes: the GREECS study.

BACKGROUND: The relationship between renal dysfunction and mortality in patients with myocardial infarction (MI) has been extensively investigated, but there are limited data about this relationship in patients presenting with non-ST-segment-elevation MI and unstable angina. Therefore, the aim of the present study was to investigate whether renal insufficiency is an independent predictor for in-hospital mortality among such patients. METHODS AND RESULTS: Two thousand a hundred and seventy-two patients presenting with acute coronary syndrome (ACS) in 6 Greek hospitals were enrolled. Creatinine clearance rates were estimated by the Cockcroft-Gault formula. Five percentage of patients presented with severe renal dysfunction, 27% with moderate dysfunction and the other 68% were normal. Patients with moderate or severe renal dysfunction were older, more likely to be women and more likely to have history of hypertension and diabetes mellitus compared with those with normal renal function. In comparison with patients with normal renal function, those with moderate and severe renal dysfunction were respectively 3- and 12-fold more likely to die. Moreover, moderate and severe renal insufficiency continued to be a prognostic factor for mortality, even after controlling for potential confounders. CONCLUSIONS: Creatinine clearance rate is an important independent predictor of in-hospital mortality, so patients with ACS complicated by renal dysfunction should receive more aggressive medical care.

The relationship between adherence to the Mediterranean diet and the severity and short-term prognosis of acute coronary syndromes (ACS): The Greek Study of ACS (The GREECS).

BACKGROUND: Although adherence to the Mediterranean diet has long been associated with lower incidence of various chronic diseases among apparently healthy individuals, its relationship with the severity and short prognosis (30 d) of patients with cardiovascular disease has rarely been investigated. OBJECTIVE: We sought to evaluate the association between adherence to the Mediterranean diet and the severity and prognosis of acute coronary syndromes. METHODS: From October 2003 to September 2004, a sample of 6 hospitals located in several urban and rural Greek regions was selected, and almost all survivors after an acute coronary syndrome were enrolled into the study (2172 patients were included in the study; 76% were men and 24% women). Adherence to the Mediterranean diet was assessed by a diet score that incorporated the inherent characteristics of this diet. Higher values of the score (range 0-55) were closer to the Mediterranean diet. Biochemical indices of myocardial damage were also considered. RESULTS: Diet score was inversely correlated with entry values of cardiac troponin I (rho = -0.19, P < 0.001), creatine phosphokinase (rho = -0.09, P < 0.001), and creatine phosphokinase-MB (rho = -0.09, P < 0.001). An increment in the diet score was associated with significant decrease in troponin I and creatine phosphokinase-MB levels (P < 0.01) after adjusting for various potential confounders. Moreover, diet score was associated with lower risk of recurrent events (odds ratio = 0.81, 95% confidence interval 0.61-0.98). However, this association became insignificant when the discharge diagnosis of the patients was taken into account. CONCLUSION: Background dietary habits close to the Mediterranean diet seem to be associated with lower severity of coronary heart disease.

Association between TNF-alpha -308G>A polymorphism and the development of acute coronary syndromes in Greek subjects: the CARDIO2000-GENE Study.

PURPOSE: We investigated the association of a polymorphism within the promoter of TauNuF-alpha locus at the position -308 on the likelihood of having acute coronary syndromes (ACS) in Greek adults. METHODS: We studied demographic, lifestyle, and clinical information in 237 hospitalized patients (185 males) with a first event of an ACS and 237 matched by age and sex (controls) without any clinical evidence of coronary heart disease. Genotyping was performed by PCR-RFLP analysis. RESULTS: The genotype frequencies were in patients, 87% (n = 206), 12% (n = 29), and 1% (n = 2) for G/G, G/A, and A/A, and in controls, 96% (n = 227), 4% (n = 10), and 0% (n = 0) for G/G, G/A, and A/A, respectively (P = 0.04). After adjusting for age and sex, as well as various potential confounders, we observed that G/A or A/A genotypes were associated with 1.94-fold higher odds (95% CI 1.06 to 3.68) of ACS compared to G/G homozygotes. No gene to-gender or to-clinical syndrome interactions were observed. Further subgroup analysis showed that the distribution of TNF-alpha -308G>A polymorphism was associated with the presence of family history of CHD in patients, but not in controls. In particular, in G/A and A/A patients 17.2% reported family history of CHD, whereas in G/G patients, 34.5% reported family history (P = 0.036). CONCLUSIONS: Our findings may state a hypothesis of an association between the -308G>A TNF-alpha polymorphism the development of ACS and the presence of family history of CHD, in Greece.

Epidemiology of acute coronary syndromes in a Mediterranean country; aims, design and baseline characteristics of the Greek study of acute coronary syndromes (GREECS).

BACKGROUND: The present study GREECS was conducted in order to evaluate the annual incidence of acute coronary syndromes (ACS) and to delineate the role of clinical, biochemical, lifestyle and behavioral characteristics on the severity of disease. In this work we present the design, methodology of the study and various baseline characteristics of people with ACS. METHODS/DESIGN: A sample of 6 hospitals located in Greek urban and rural regions was selected. In these hospitals we recorded almost all admissions due to ACS, from October 2003 to September 2004. Socio-demographic, clinical, dietary, psychological and other lifestyle characteristics were recorded. 2172 patients were included in the study (76% were men and 24% women). The crude annual incidence rate was 22.6 per 10,000 people and the highest frequency of events was observed in winter. The in-hospital mortality rate was 4.3%. The most common discharged diagnosis for men was Q-wave MI, while for women it was unstable angina. DISCUSSION: This study aims to demonstrate current information about the epidemiology of patients who suffer from ACS, in Greece.