Challenges in coronary heart disease prevention - experiences from a long-term follow-up study in Norway.

Objective. To determine longitudinal changes in lifestyle behaviour and lipid management in a chronic coronary heart disease (CHD) population. Design. A multi-centre cohort study consecutively included 1127 patients at baseline in 2014-2015, on average 16 months after a CHD event. Data were collected from hospital records, a questionnaire and clinical examination. Seven hundred and seven of 1021 eligible patients participated in a questionnaire-based follow-up in 2019. Data were analysed with univariate statistics. Results. After a mean follow-up of 4.7 years (SD 0.4) from baseline, the percentage of current smokers (15% versus 16%), obesity (23% versus 25%) and clinically significant symptoms of anxiety (21% versus 17%) and depression (13% versus 14%) remained unchanged, whereas the proportion with low physical activity increased from 53% to 58% (p < .001). The proportions with reduced physical activity level were similar in patients over and under 70 years of age. Most patients were still taking statins (94% versus 92%) and more patients used high-intensity statin (49% versus 54%, p < .001) and ezetimibe (5% versus 15%, p < .001) at follow-up. 73% reported ≥1 primary-care consultation(s) for CHD during the last year while 27% reported no such follow-up. There were more smokers among participants not attending primary-care consultations compared to those attending (19% versus 14%, p = .026). No differences were found for other risk factors. Conclusions. We found persistent suboptimal risk factor control in coronary outpatients during long-term follow-up. Closer follow-up and intensified risk management including lifestyle and psychological health are needed to improved secondary prevention and outcome of CHD. Trial registration: Registered at ClinicalTrials.gov: NCT02309255.Registered at 5 December 2014, registered retrospectively.

Preventable clinical and psychosocial factors predicted two out of three recurrent cardiovascular events in a coronary population.

BACKGROUND: The relative importance of lifestyle, medical and psychosocial factors on the risk of recurrent major cardiovascular (CV) events (MACE) in coronary patients' needs to be identified. The main objective of this study is to estimate the association between potentially preventable factors on MACE in an outpatient coronary population from routine clinical practice. METHODS: This prospective follow-up study of recurrent MACE, determine the predictive impact of risk factors and a wide range of relevant co-factors recorded at baseline. The baseline study included 1127 consecutive patients 2-36 months after myocardial infarction (MI) and/or revascularization procedure. The primary composite endpoint of recurrent MACE defined as CV death, hospitalization due to MI, revascularization, stroke/transitory ischemic attacks or heart failure was obtained from hospital records. Data were analysed using cox proportional hazard regression, stratified by prior coronary events before the index event. RESULTS: During a mean follow-up of 4.2 years from study inclusion (mean time from index event to end of study 5.7 years), 364 MACE occurred in 240 patients (21, 95% confidence interval: 19 to 24%), of which 39 were CV deaths. In multi-adjusted analyses, the strongest predictor of MACE was not taking statins (Relative risk [RR] 2.13), succeeded by physical inactivity (RR 1.73), peripheral artery disease (RR 1.73), chronic kidney failure (RR 1.52), former smoking (RR 1.46) and higher Hospital Anxiety and Depression Scale-Depression subscale score (RR 1.04 per unit increase). Preventable and potentially modifiable factors addressed accounted for 66% (95% confidence interval: 49 to 77%) of the risk for recurrent events. The major contributions were smoking, low physical activity, not taking statins, not participating in cardiac rehabilitation and diabetes. CONCLUSIONS: Coronary patients were at high risk of recurrent MACE. Potentially preventable clinical and psychosocial factors predicted two out of three MACE, which is why these factors should be targeted in coronary populations. TRIAL REGISTRATION: Registered at ClinicalTrials.gov: NCT02309255. Registered at December 5th, 2014, registered retrospectively.

Guía Europea de Prevención Cardiovascular en la Práctica Clínica (y II) / Spanish adaptation of the European Guidelines on Cardiovascular Prevention (and II)

No disponible

Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.

There is now clear scientific evidence linking regular aerobic physical activity to a significant cardiovascular risk reduction, and a sedentary lifestyle is currently considered one of the five major risk factors for cardiovascular disease. In the European Union, available data seem to indicate that less than 50% of the citizens are involved in regular aerobic leisure-time and/or occupational physical activity, and that the observed increasing prevalence of obesity is associated with a sedentary lifestyle. It seems reasonable therefore to provide institutions, health services, and individuals with information able to implement effective strategies for the adoption of a physically active lifestyle and for helping people to effectively incorporate physical activity into their daily life both in the primary and the secondary prevention settings. This paper summarizes the available scientific evidence dealing with the relationship between physical activity and cardiovascular health in primary and secondary prevention, and focuses on the preventive effects of aerobic physical activity, whose health benefits have been extensively documented.

Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.

The purpose of this statement is to provide specific recommendations in regard to evaluation and intervention in each of the core components of cardiac rehabilitation (CR) to assist CR staff in the design and development of their programmes; the statement should also assist health care providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of such programmes. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR.

Expression profile of 30,000 genes in rat hippocampus using SAGE.

Using the serial analysis of gene expression (SAGE) method, we generated a gene expression profile of the rat hippocampus. A total of 76,790 SAGE tags was analyzed, allowing identification of 28,748 different tag species, each representing a unique mRNA transcript. The tags were divided into different abundancy classes, ranging from tags that were detected over 500 times to tags encountered only once in the 76,790 tags analyzed. The mRNA species detected more than 50 times represented 0.3% of the total number of unique tags while accounting for 22% of the total hippocampal mRNA mass. The majority of tags were encountered 5 times or less. The genes expressed at the highest levels were of mitochondrial origin, consistent with a high requirement for energy in neuronal tissue. At a lower level of expression, several neuron-specific transcripts were encountered, encoding various neurotransmitter receptors, transporters, and enzymes involved in neurotransmitter synthesis and turnover, ion channels and pumps, and synaptic components. Comparison of relative expression levels demonstrated that glutamate receptors are the most frequent neurotransmitter receptors expressed in the hippocampus, consistent with the important role of glutamatergic neurotransmission in the hippocampus, while GABA receptors were present at approximately 10-fold lower levels. Several kinases were present including CaMKII, which was expressed at high levels, consistent with its being the most abundant protein in the spines of hippocampal pyramidal cells. This is the first extensive inventory of gene expression in the hippocampus and serves as a reference for future studies aimed at elucidating hippocampal transcriptional responses under various conditions.

Identification of corticosteroid-responsive genes in rat hippocampus using serial analysis of gene expression.

Adrenal corticosteroids (CORT) have a profound effect on the function of the hippocampus. This is mediated in a coordinated manner by mineralocorticoid (MR) and glucocorticoid receptors (GR) via activation or repression of target genes. The aim of this study was to identify, using serial analysis of gene expression (SAGE), CORT-responsive hippocampal genes regulated via MR and/or GR. SAGE profiles were compared under different conditions of CORT exposure, resulting in the identification of 203 CORT-responsive genes that are involved in many different cellular processes like, energy expenditure and cellular metabolism; protein synthesis and turnover; signal transduction and neuronal connectivity and neurotransmission. Besides some previously identified CORT-responsive genes, the majority of the genes identified in this study were novel. In situ hybridization revealed that six randomly chosen CORT-responsive genes had distinct expression patterns in neurons of the hippocampus. In addition, using in situ hybridization, we confirmed that these six genes were indeed regulated by CORT, underscoring the validity of the SAGE data. Comparison of MR- and GR-dependent expression profiles revealed that the majority of the CORT-responsive genes were regulated either by activated MR or by activated GR, while only a few genes were responsive to both activated MR and GR. This indicates that the molecular basis for the differential effects of activated MR and GR is activation or repression of distinct, yet partially overlapping sets of genes. The putative CORT-responsive genes identified here will provide insight into the molecular mechanisms underlying the differential and sometimes opposing effects of MR and GR on neuronal excitability, memory formation and behaviour as well as their role in neuronal protection and damage.

Cardiac rehabilitation after coronary artery bypass surgery: 10-year results on mortality, morbidity and readmissions to hospital.

AIM: To evaluate the long-term secondary preventive effect of a comprehensive rehabilitation programme after coronary artery bypass grafting (CABG). METHODS: The study group included 49 consecutive patients who underwent bypass surgery and were then offered a rehabilitation programme consisting of education in risk-factor control, a physical training programme and regular follow-up at a post-CABG clinic. The control group (n = 98), consisting of two well-matched CABG patients for each study patient, was offered the usual care with no access to a cardiac rehabilitation programme. The two groups were followed for 10 years and the results regarding cardiovascular mortality, morbidity, total cardiac events and readmissions to hospital were compared. RESULTS: The total mortality (study group 8.2%, control group 20.4%) and cardiovascular mortality (8.2 versus 15.3%) after 10 years did not differ significantly between the groups. In the study group, nine patients (18.4%) had 10 cardiac events (four cardiovascular deaths, five non-fatal myocardial infarctions and one CABG) compared to 34 patients (34.7%, P < 0.05) suffering 46 (P < 0.01) cardiac events (15 cardiovascular deaths, 18 non-fatal myocardial infarctions, eight CABG, five coronary angioplasties) in the control group. The number of readmissions to hospital (2.1 versus 3.5 per patient) and length of admissions (11 versus 26 days per patient) was significantly lower in the study group (P < 0.01). CONCLUSION: A comprehensive cardiac rehabilitation programme offered to patients after coronary artery bypass surgery will improve the long-term prognosis and reduce the need for hospital care.

Critical behavior of the two-dimensional Ising susceptibility.

We report computations of the short- and long-distance (scaling) contributions to the square-lattice Ising susceptibility. Both computations rely on summation of correlation functions, obtained using nonlinear partial difference equations. In terms of a temperature variable tau, linear in T/Tc-1, the short-distance terms have the form tau(p)(ln/tau/)q with p> or =q2. A high- and low-temperature series of N = 323 terms, generated using an algorithm of complexity O(N6), are analyzed to obtain the scaling part, which when divided by the leading /tau/(-7/4) singularity contains only integer powers of tau. Contributions of distinct irrelevant variables are identified and quantified at leading orders /tau/(9/4) and /tau/(17/4).

The imprinting box of the Prader-Willi/Angelman syndrome domain.

A subset of mammalian genes is monoallelically expressed in a parent-of-origin manner. These genes are subject to an imprinting process that epigenetically marks alleles according to their parental origin during gametogenesis. Imprinted genes can be organized in clusters as exemplified by the 2-Mb domain on human chromosome 15q11-q13 and its mouse orthologue on chromosome 7c (ref. 1). Loss of this 2-Mb domain on the paternal or maternal allele results in two neurogenetic disorders, Prader-Willi syndrome (PWS) or Angelman syndrome (AS), respectively. Microdeletions on the paternal allele share a 4.3-kb short region of overlap (SRO), which includes the SNRPN promoter/exon1, cause PWS and silence paternally expressed genes. Microdeletions on the maternal allele share a 0.88-kb SRO located 35 kb upstream to the SNRPN promoter, cause AS and alleviate repression of genes on the maternal allele. Individuals carrying both AS and PWS deletions on the paternal allele show a PWS phenotype and genotype. These observations suggest that cis elements within the AS-SRO and PWS-SRO constitute an imprinting box that regulates the entire domain on both chromosomes. Here we show that a minitransgene composed of a 200-bp Snrpn promoter/exon1 and a 1-kb sequence located approximately 35 kb upstream to the SNRPN promoter confer imprinting as judged by differential methylation, parent-of-origin-specific transcription and asynchronous replication.

Cardiac rehabilitation: applying exercise physiology in clinical practice.

In this paper new insights into the beneficial effects of physical training for patients with coronary artery disease are reviewed. Endurance training as part of a comprehensive cardiac rehabilitation programme in combination with strength training, smoking cessation and lipid management may slow down and in some cases reverse the progress of coronary atherosclerosis. Thus, exercise training remains an invaluable tool in the hands of the clinical cardiologist dealing with chronic coronary care.

The imprinting box of the mouse Igf2r gene.

Genomic imprinting is a phenomenon characterized by parent-of-origin-specific expression. The imprint is a mark established during germ-cell development to distinguish between the paternal and maternal copies of the imprinted genes. This imprint is maintained throughout embryo development and erased in the embryonic gonads to set the stage for a new imprint. DNA methylation is essential in this process as shown by the presence of differentially methylated regions (DMRs) in all imprinted genes and by the loss of imprinting in mice that are deficient in DNA methylation or upon deletion of DMRs. Here we show that a DMR in the imprinted Igf2r gene (which encodes the receptor for insulin-like growth factor type-2) that has been shown to be necessary for imprinting includes a 113-base-pair sequence that constitutes a methylation imprinting box. We identify two new cis-acting elements in this box that bind specific proteins: a de novo methylation signal and an allele-discrimination signal. We propose that this regulatory system, which we show to be involved in the establishment of differential methylation in the Igf2r DMR, represents a critical element in the imprinting process.

[Rehabilitation after myocardial infarction or coronary surgery: elderly patients may benefit as much as the younger ones]. / Rehabilitering efter hjärtinfarkt eller kranskärlskirurgi: äldre patienter har lika stor nytta av träning som yngre.

At most Swedish hospitals participation in cardiac rehabilitation programmes is restricted to patients of working age, although coronary patients predominately belong to the higher age groups. The article consists in a review of the benefits of cardiac rehabilitation to the elderly, such as enhanced quality of life and lower readmission rates, improvement in co-ordination, muscular strength and bone mineral constant, and a cardioprotective effect on risk factors. Cardiac rehabilitation programmes for the elderly, preferably organised in close so-operation between local hospitals, primary care facilities and patient organisations, might yield considerable individual and general health economic benefits.

Need cardiac rehabilitation be cost-effective?

In this article, the available health-economic literature in the field of comprehensive cardiac rehabilitation is reviewed. The effects of cardiac rehabilitation are well known, but cost-effectiveness studies are lacking in several important areas. The long-term effect on the number of life-years saved indicates that cardiac rehabilitation is a cost-effective use of health care resources, provided that cost-containing principles are applied in comprehensive programmes.

Cardiorespiratory adaptation of COPD patients to physical training on land and in water.

Physical training in water might be included in a comprehensive pulmonary rehabilitation programme, but data on the feasibility and safety of this technique in chronic obstructive pulmonary disease (COPD) patients are lacking. We studied cardiorespiratory parameters of 20 stable COPD patients (10 with forced expiratory volume in one second (FEV1) < 35% of predicted value, and 10 with FEV1 > or = 35% pred) on land and in a temperate-controlled pool (32 degrees C) both at rest and during a 15 min submaximal upper body muscle training programme. Compared to resting values on land, we found in water a decrease of systolic and diastolic blood pressure (14 and 6 mmHg, respectively), rate-pressure product (7%) and lung function (vital capacity (VC) 12%, FEV1 14%, peak expiratory flow (PEF) 18%). There were no differences in heart rate, breathing frequency or O2 saturation. The most strenuous exercise in water resulted in a slightly lower O2 saturation compared to work on land (95 and 93%, respectively), and an increase of Borg rating for dyspnoea from 4 to 5. In spite of the restriction of lung function in water, all patients (even those with FEV1 < 35% pred) performed the training in the pool well, without clinically relevant desaturation, arrhythmia or discomfort. No training session was discontinued due to dyspnoea. We conclude that a 15 min session of submaximal physical training in a pool with a water temperature of 32 degrees C is feasible and safe for nonhypoxaemic normotensive COPD patients without cardiac failure.

Long-term reduction of cardiac mortality after myocardial infarction: 10-year results of a comprehensive rehabilitation programme.

The long-term outcome of different methods of post-MI care has been studied in two non-selected groups of MI patients: an intervention group (n = 147), participating in a cardiac rehabilitation (CR) programme, was compared to a reference group receiving standard care (n = 158). The CR programme included a post-MI clinic, physical training, information on smoking and diet, and psychological support. After 5 years there was no difference in mortality (29.3 vs 31.6%), but the recurrence rate of non-fatal MI (17.3 vs 33.3%, P < 0.05) and of total cardiac events (39.5 vs 53.2%, P < 0.05) was lower in the intervention group, and more patients were still at work (51.8 vs 27.4% P < 0.01). After 10 years there was a reduction in total (42.2 vs 57.6% P < 0.01) and cardiac mortality (36.7 vs 48.1% P < 0.001). Fewer patients in the intervention group suffered from non-fatal reinfarction (28.6 vs 39.9%, P < 0.001). Among those patients who had not yet reached the age of retirement more patients had resumed employment (58.6 vs 22.0% P < 0.05). We conclude, that the secondary preventive effect of the programme has contributed to the higher rate of survival.