Residual risk of cardiovascular mortality in patients with coronary heart disease: the EUROASPIRE risk categories.

BACKGROUND: The EUROASPIRE I, II and III surveys revealed high prevalences of modifiable risk factors in the high priority group of coronary patients all over Europe. The potential to further reduce coronary heart disease (CHD) morbidity and mortality rates is still considerable. We report here on the relative risk of cardiovascular disease (CVD) death associated with common modifiable risk factor levels based on the mortality follow-up of patients participating in the first two EUROASPIRE surveys. We also present a novel simple risk classification system (ERC) that can be used in the management of patients with existing CHD. METHODS: The study cohort consisted of a consecutive sample of CHD patients aged ≤ 70 years from 12 European countries. Baseline data gathered in 1995-2000 through standardized methods, were linked to cardiovascular mortality in 5216 patients according to an accelerated failure time model. RESULTS: During 28,143 person-years of follow-up, 332 patients died from cardiovascular disease denoting a CVD mortality risk of 12.3 per 1000 person-years in men and 10.2 per 1000 person-years in women. In multivariate analysis, fasting glucose, total cholesterol and smoking emerged as the strongest independent modifiable predictors of cardiovascular mortality. CONCLUSIONS: The results of the mortality follow-up of the EUROASPIRE I and II CHD patients emphasize the continuing risk from elevated glucose and total cholesterol levels and underline the importance of smoking cessation in secondary prevention. The ERC risk tool that we developed may prove helpful to obtain these goals in the setting of secondary prevention.

[Data on secondary prevention of coronary artery disease in Hungary and some changes in the last ten years (EUROASPIRE 1995-2005)]. / Magyarországi adatok a koszorúér-betegség másodlagos megelozésének helyzetérol és a változás fobb jellemzoi (EUROASPIRE 1995-2005).

In year 1995 the European Society of Cardiology started an epidemiological study EUROASPIRE to evaluate the results of secondary prevention in some European countries. The first study period was in 1995, the second in 1999-2000 and the third in 2007. From Hungary the same study centers participated in EUROASPIRE I-II-III investigation. Authors present the Hungarian data and changes occurring the last ten years. During the three studies, 1627 coronary patients- younger than 70 years - were evaluated, using standardized methods. In the two Hungarian study centers, the proportion of women and patients older than 60 years increased. The hospital documentation of risk factors improved, at the time of EUROASPIRE III necessary data were found in 89%-99% of patient's records. Mean systolic and diastolic blood pressure continuously decreased between the first and second study period, but at the time of the third study 44% of the patients had elevated blood pressure (>140/90 mmHg). Prevalence of smoking decreased by 8% between second and third study period, however, at the time of the last study, 18% of coronary patients were smokers. The mean of total cholesterol was lower in the last study period comparing to the first investigation (5.6 vs. 5.2 mmol/l). HDL cholesterol level was unchanged and increasing triglyceride values were observed. During the study period the prevalence of obesity continuously increased from 23% to 49%. Prevalence of patients with total cholesterol level 5.5 mmol/l or higher has decreased from 60% to 24%, however 57% of patients did not reach the target level (4.5 mmol/l) although 80% of patients were treated with lipid lowering drugs: 76% of them received statins. Authors say that some part of secondary prevention improved during the last ten years, but many patients did not reach the target blood pressure and cholesterol level and it is embarrassing the prevalence of obesity and diabetes. The published data are not representative for whole Hungary; most probably the general situation is worse. Authors emphasize the importance of secondary prevention in the graduate and postgraduate education. For improving the secondary prevention, better cooperation is needed between hospital staff and patients and general practitioners as well.

Outcomes and optimal antithrombotic therapy in women undergoing fibrinolysis for ST-elevation myocardial infarction.

BACKGROUND: The manifestations, complications, and outcomes of cardiovascular disease differ between women and men. The safety and efficacy of pharmacological reperfusion therapy in women with ST-elevation myocardial infarction are of particular interest. METHODS AND RESULTS: We investigated outcomes in the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis in Myocardial Infarction (ExTRACT-TIMI) 25 study, which randomized ST-elevation myocardial infarction patients with planned fibrinolysis to enoxaparin or unfractionated heparin. Compared with men (n=15,696), women (n=4783) were older and more likely to have hypertension and diabetes (P<0.001). The unadjusted 30-day mortality rate for women was >2-fold higher than for men (13.2% versus 5.4%; odds ratio, 2.66; 95% CI, 2.40 to 2.96). After adjustment for age, fibrinolytic therapy, revascularization, region, and elements of the TIMI Risk Score, women had a 1.25-fold-higher 30-day risk of death (95% CI, 1.08 to 1.46) but similar risk of intracerebral hemorrhage (adjusted odds ratio, 0.81; 95% CI, 0.52 to 1.26). The 30-day rate of death or nonfatal MI in women was reduced by enoxaparin compared with unfractionated heparin in women (15.4% versus 18.3%; P=0.007). Major bleeding was more frequent in women receiving enoxaparin compared with those receiving unfractionated heparin (2.3% versus 1.4%; P=0.022) but similar among women and men receiving enoxaparin (2.3% versus 2.0%; P=0.39). The rates of death, nonfatal myocardial infarction, or nonfatal major bleeding (net clinical benefit) were lower with enoxaparin (absolute risk reduction, 2.6% in women [P=0.02] and 1.6% in men [P=0.001]). CONCLUSIONS: In ExTRACT-TIMI 25, women presented with a profile of higher baseline risk and increased short-term mortality. In this large, contemporary clinical trial, women had similar relative and greater absolute risk reductions than men when treated with enoxaparin compared with unfractionated heparin as adjunctive therapy with fibrinolysis.

Overweight and obesity in patients with established coronary heart disease: are we meeting the challenge?

AIMS: Several epidemiological studies have reported increasing obesity rates in the general population during last decades. We studied the prevalence of overweight and obesity in the high priority group of patients with established coronary heart disease (CHD) and the therapeutic control of manageable coronary risk factors in relation to body mass index. METHODS: Data from a representative sample of patients having experienced a recent cardiac event before the age of 71 years from 15 European centres participating in the EUROASPIRE II study, were gathered in the period 1999-2000 through standardized methods. In total, 5535 coronary patients with valid height and weight measurements were included. RESULTS: About one in three patients (31%) was diagnosed as obese with additionally half of the patient population being overweight (48%). Obesity was 10% more prevalent among women and significantly less smokers were observed among overweight and obese subjects, twice as many diabetics and more people with low education. Overweight and obese patients had more frequently raised blood pressure and elevated cholesterol after adjustment for age, gender, education, diabetes and centre. In patients using blood pressure lowering agents, 56% of obese and 51% of overweight patients were still having raised blood pressure compared to 42% in normal weight patients. A similar result was observed for the therapeutic control of total cholesterol. Since their hospital discharge, obese and overweight patients did not alter lifestyles regarding fat intake and physical activity. In the period between coronary event and interview, body weight had increased with at least five kilograms in a quarter of all patients. CONCLUSIONS: These results suggest that the growing population of overweight and obese coronary patients is at particularly high risk for further cardiovascular complications due to elevated risk factor levels on the one hand and their insufficient therapeuticcontrol on the other hand. Our results also confirm the considerable weight gain seen in a high proportion of patients following their cardiac event.

Predictive value of classical risk factors and their control in coronary patients: a follow-up of the EUROASPIRE I cohort.

BACKGROUND: Both EUROASPIRE studies revealed the suboptimal management of coronary patients regarding lifestyle changes and prophylactic use of cardiovascular drugs. We report here on the mortality follow-up of the EUROASPIRE I cohort over a median period of 4.4 years. DESIGN AND METHODS: The EUROASPIRE I cohort consisted of a consecutive sample of patients aged < or =70 years from nine European countries, hospitalized because of coronary artery bypass graft, percutaneous transluminal coronary angioplasty, acute myocardial infarction or myocardial ischaemia. Baseline data, gathered in 1995-96 through standardized methods, were linked to cause-specific mortality as registered up to 1 April 2000 in 3343 patients. RESULTS: After adjustment for age, gender and diagnostic category according to Cox modelling, smoking, previous coronary heart disease and diabetes proved significant predictors of total, cardiovascular (CVD) and coronary heart disease (CHD) mortality. Obesity, low education, raised blood pressure, elevated total cholesterol and low HDL cholesterol, however, were not significantly associated with higher mortality rates. In multivariate analysis, smoking and diabetes emerged as the strongest predictors of CVD [risk ratios (RR) 2.2 and 2.5 respectively] and CHD mortality (RR 2.4 and 2.4 respectively). CONCLUSIONS: The results of the mortality follow-up of the EUROASPIRE I patients underline the importance of smoking and diabetes in the secondary prevention of CHD. Failure to find statistically significant associations between other classical risk factors, such as blood pressure and plasma lipid levels, and mortality may be related to the extensive use of antihypertensive and lipid-lowering drugs in this cohort.

[Secondary prevention of coronary disease--at the turn of the millennium in light of the Hungarian data of the EUROASPIRE I-II. Studies]. / A koszorúér-betegség másodlagos prevenciója. Helyzetkép az ezredfordulón az EUROASPIRE I-II vizsgálat magyar adatainak tükrében.

UNLABELLED: Relevant national societies attribute special importance to the secondary prevention of coronary patients. This is well formulated in their recommendations (9, 11). Actual clinical practice was studied in 1995-1996 by the EUROASPIRE I study. Its Hungarian data were published in 1999 (8). The scope of EUROASPIRE II in 1999-2000 was to study changes occurred in these 5 years. In this paper the authors intend to answer the question whether the clinical practice of secondary prevention of coronary patients showed any changes at the turn of the millennium. Participating centres, the criteria of patient selection and the applied methods were identical in the two studies. Hospital data of 516 patients below the age of 70 were analysed. There was no difference between the two studies neither in the distribution according to gender and age, nor in the number of death. Documentation of the relevant data in the hospital records improved substantially: blood pressure was registered in every patient chart, lipid values in 91%. Information on smoking however is still missing in 1/3 of the patients, while on weight and height in half of them. The response rate at the follow up investigation on was 75%. The prevalence of obesity increased by 60%, that of smoking by 13% since the first investigation 5 years ago. This rate of increase is the largest among the 9 participating centres. The prevalence of hypertension decreased by 24.5% and the proportion of hypertensive patients receiving treatment increased by 7%. In spite of these blood pressure values over 140/90 mmHg were found in 37% of the patients. The mean triglyceride value increased by 53% and the prevalence of severe hypercholesterolaemia by 43%. Lipid lowering drugs are given to 51% of the patients in contrast to 22% 5 years earlier. In spite of this cholesterol values above 5.5 mmol/l were found in 42%. In respect of prophylactic drugs the proportion of patients receiving beta blockers increased from 58 to 84%. INTERPRETATION: The evaluation of complex risk of patients and their long-term care is still deficient. Drug treatment improved quantitatively but not qualitatively. This and the lack of lifestyle-improving medical efforts is reflected by the increase of the proportion of obese and smoking patients and the persistently high prevalence of hypercholesterolaemia and hypertension.