10-year risk for atherosclerotic cardiovascular disease and coronary heart disease among Korean adults: Findings from the Korean National Health and Nutrition Examination Survey 2009–2010

Background

This study examined the distribution of the 10-year risk for development of atherosclerotic cardiovascular disease (ASCVD) and coronary heart disease (CHD), and the proportion of participants eligible for lipid management, in the Korean population.

Methods

The risk was estimated using the Pooled Cohort Equations for non-Hispanic Whites and the Adult Treatment Panel (ATP) III equations. Eligibility for lipid-lowering treatment was assessed using the American College of Cardiology/American Heart Association Blood Cholesterol Guideline and the ATP III recommendation. Complex sampling design and area under the receiver operator characteristic curve (AUC) were used.

Results

Among 7594 ASCVD-free Korean adults, aged 40–79 years, 31.3% (men, 44.1%; women, 19%) had a 10-year risk for an ASCVD event of ≥ 7.5%, and 27.1% (men, 39.4%; women, 15.2%) had a 10-year risk for a CHD event of ≥ 10%. These proportions differed according to age groups, ranging from 6.1 to 91.9% and 8.7 to 58.7% for patients in their 40s–70s, using the ASCVD and CHD risk estimations, respectively. Overall, 78.7% of individuals remain in the same risk stratum. Those eligible for lipid management included 32.8% of the participants using the ACC/AHA Guideline and 11.9% of those using the ATP III recommendation. In discriminating ASCVD, AUCs for the ASCVD risk assessment method and the CHD risk assessment method were 0.70 and 0.64, respectively (P < 0.001).

Conclusions

The distribution of 10-year ASCVD and CHD risk was different according to the risk assessment methods.     

Walnut-enriched diet reduces fasting non-HDL-cholesterol and apolipoprotein B in healthy Caucasian subjects: A randomized controlled cross-over clinical trial

Background

Walnut consumption is associated with reduced risk of coronary heart disease (CHD).

Objective

We assessed the effect of walnuts on lipid and glucose metabolism, adipokines, inflammation and endothelial function in healthy Caucasian men and postmenopausal women ≥ 50 years old.

Design

Forty subjects (mean ± SEM: age 60 ± 1 years, BMI 24.9 ± 0.6 kg/m²; 30 females) were included in a controlled, cross-over study and randomized to receive first a walnut-enriched (43 g/d) and then a Western-type (control) diet or vice-versa, with each lasting 8 weeks and separated by a 2-week wash-out. At the beginning and end of each diet phase, measurements of fasting values, a mixed meal test and an assessment of postprandial endothelial function (determination of microcirculation by peripheral artery tonometry) were conducted. Area under the curve (AUC), incremental AUC (iAUC) and treatment × time interaction (shape of the curve) were evaluated for postprandial triglycerides, VLDL-triglycerides, chylomicron-triglycerides, glucose and insulin.

Results

Compared with the control diet, the walnut diet significantly reduced non-HDL-cholesterol (walnut vs. control: − 10 ± 3 vs. − 3 ± 2 mg/dL; p = 0.025) and apolipoprotein-B (− 5.0 ± 1.3 vs. − 0.2 ± 1.1 mg/dL; p = 0.009) after adjusting for age, gender, BMI and diet sequence. Total cholesterol showed a trend toward reduction (p = 0.073). Fasting VLDL-cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides and glucose, insulin, HOMA-IR, and HbA1c did not change significantly. Similarly, fasting adipokines, C-reactive protein, biomarkers of endothelial dysfunction, postprandial lipid and glucose metabolism and endothelial function were unaffected.

Conclusion

Daily consumption of 43 g of walnuts for 8 weeks significantly reduced non-HDL-cholesterol and apolipoprotein-B, which may explain in part the epidemiological observation that regular walnut consumption decreases CHD risk.     

Typical and atypical coronary heart disease deaths and their different relationships with risk factors. The Gubbio residential cohort Study

Objectives

The Seven Countries Study showed that fatal coronary heart disease (CHD) with only chronic heart failure, arrhythmia or blocks (atypical CHD, A-CHD) may represent a distinct disease as compared to fatal CHD cases with angina pectoris, acute myocardial infarction (AMI) or sudden death (typical CHD, T-CHD). We aimed at validating this, using identical diagnostic criteria, in a separate residential cohort first examined in 1983–85 in Gubbio, central Italy.

Material and methods

Forced Cox's models were run to assess 9 classic risk factors and their 20-year predictivity of A-CHD versus T-CHD, in the entire cohort or separately for men and women.

Results

There were 3229 subjects aged 30–79 years. Entry mean age was slightly higher in women than men although age at death was lower in men than in women for both T-CHD (71.99 ± 11.38 versus 81.20 ± 9.35 years, p < 0.0001) and A-CHD (80.22 ± 9.44 versus 84.98 ± 8.13 years, p < 0.0001). T-CHDs were predicted by male gender, age, continued smoke, systolic blood pressure (SBP), blood glucose, total and HDL-cholesterol (protective). A-CHDs were predicted by age, continued smoke, SBP, body mass index and blood glucose but neither total nor HDL-cholesterol or gender was significant. In the entire cohort and in men there were predictive differences of T-CHD versus A-CHD fatalities only in relation to age (p < 0.01), SBP (p < 0.05) and total cholesterol (p < 0.01).

Conclusion

As age, SBP and total cholesterol had a different predictive role of T-CHD versus A-CHD fatalities also in the Gubbio cohort, the possibility is reinforced that a different etiology exists between these entities.     

Decreased cardiotrophin-1 levels are associated with a lower risk of developing the metabolic syndrome in overweight/obese children after a weight loss program

Objective

Cardiotrophin-1 (CT-1) shares some similarities with other cytokines, and participates in the control of energy metabolism. Higher circulating levels are observed in obese humans, but little information is gathered in weight loss (WL) programs. Therefore, we aimed to investigate the association of serum CT-1 levels with metabolic variables and the risk of developing metabolic syndrome (MetS) after a WL program in overweight/obese children.

Subjects and Methods

Forty-four overweight/obese children (mean age 11.5 y; 50% males) undergoing a 10-week WL program were enrolled. Subjects were dichotomized at the median of Body Mass Index-Standard Deviation Score (BMI-SDS) change, as high and low responders after intervention.

Results

CT-1 levels were significantly reduced (− 48 fmol/mL, p = 0.043) in the high responder group after the WL program. They had significantly lower body weight (− 3.7 kg, p < 0.001), body fat mass (− 8%, p < 0.001), BMI-SDS (− 0.78, p < 0.001) and waist circumference (− 5.4 cm, p < 0.001), and a significant improvement in lipid and glucose profiles (p < 0.05). Interestingly, decreased CT-1 levels significantly predicted changes in total cholesterol (41%) and LDL-cholesterol (28%). Moreover, in our participants the lower the CT-1 levels, the higher the reduction in MetS risk components, after the 10-week intervention, (p-ANCOVA = 0.040, p-trend = 0.024).

Conclusion

We showed, for the first time, a reduction in serum CT-1 levels after a WL program and this decrease in CT-1 was strongly associated with a reduction in cholesterol levels and in MetS risk factors in overweight/obese children. Our findings may suggest that CT-1 could be an indirect marker for the diagnosis of MetS in this population.     

Bariatric surgery in severely obese adolescents improves major comorbidities including hyperuricemia

Objective

Serum uric acid (sUA) is believed to contribute to the pathogenesis of metabolic comorbidities like hypertension, insulin-resistance (IR) and endothelial dysfunction (EDF) in obese children. The present pilot study investigated the association between sUA concentrations and loss of body weight following laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y-gastric bypass (RYGB) in severely obese adolescents.

Materials/Methods

10 severely obese adolescents underwent either LSG (n = 5) or RYGB (n = 5). 17 normal weight, healthy, age- and gender-matched adolescents served as a normal weight peer group (NWPG). Pre- and 12 months postoperatively, sUA and relevant metabolic parameters (glucose homeostasis, transaminases, lipids) were compared.

Results

Preoperatively, sUA was significantly elevated in patients with severe obesity compared to NWPG. Twelve months after LSG and RYGB, a significant decrease in sUA, BMI, CVD risk factors, hepatic transaminases, and HOMA-IR was observed. Reduction in SDS-BMI significantly correlated with changes in sUA.

Conclusions

sUA levels and metabolic comorbidities improved following bariatric surgery in severely obese adolescents. The impact of changes in sUA on long-term clinical complications of childhood obesity deserves further study.     

Red blood cell fatty acid levels improve GRACE score prediction of 2-yr mortality in patients with myocardial infarction

Background

Blood omega-3 and omega-6 fatty acid levels have been associated with reduced risk for total mortality in patients with stable coronary heart disease (CHD), but their relationships with mortality in the setting of myocardial infarction (MI) are unknown.

Objective

To determine the association between red blood cell (RBC) fatty acid levels measured at admission and 2-year mortality in MI patients, independent of the GRACE risk score, a traditional mode of risk stratification.

Design

Admission RBC fatty acid levels were measured in patients enrolled in a prospective, 24-center MI registry (TRIUMPH). Two-year mortality was modeled with Cox proportional hazards regression to assess the extent to which the inclusion of fatty acid levels would improve, over and above the GRACE score, risk stratification for 2-year mortality.

Results

RBC fatty acid data were available from 1144 patients who did not report taking fish oil supplements after discharge. Two RBC fatty acids [eicosapentaenoic acid (EPA) and docosapentaenoic n − 6 (DPA)] were univariate predictors of total mortality. The combined fatty acid c-statistic (0.60, p < 0.001) improved the c-statistic of the GRACE score alone from 0.747 (p < 0.001) to 0.768 (p < 0.05 vs. GRACE alone). The net reclassification index improved by 31% (95% CI, 15% to 48%) and the relative incremental discrimination index improved by 19.8% (7.5% to 35.7%).

Conclusion

RBC EPA and DPA n − 6 levels improved the prediction of 2-yr mortality over and above the GRACE score in MI patients.     

The obesity paradox in men with coronary heart disease and heart failure: The role of muscle mass and leptin

Aims

We have investigated the role of muscle mass, natriuretic peptides and adipokines in explaining the obesity paradox.

Background

The obesity paradox relates to the association between obesity and increased survival in patients with coronary heart disease (CHD) or heart failure (HF).

Methods

Prospective study of 4046 men aged 60–79 years followed up for a mean period of 11 years, during which 1340 deaths occurred. The men were divided according to the presence of doctor diagnosed CHD and HF: (i) no CHD or HF ii), with CHD (no HF) and (iii) with HF.

Results

Overweight (BMI 25–9.9 kg/m²) and obesity (BMI ≥ 30 kg/m²) were associated with lower mortality risk compared to men with normal weight (BMI 18.5–24.9 kg/m²) in those with CHD [hazards ratio (HR) 0.71 (0.56,0.91) and 0.77 (0.57,1.04); p = 0.04 for trend] and in those with HF [HR 0.57 (0.28,1.16) and 0.41 (0.16,1.09; p = 0.04 for trend). Adjustment for muscle mass and NT-proBNP attenuated the inverse association in those with CHD (no HF) [HR 0.78 (0.61,1.01) and 0.96 (0.68,1.36) p = 0.60 for trend) but made minor differences to those with HF [p = 0.05]. Leptin related positively to mortality in men without HF but inversely to mortality in those with HF; adjustment for leptin abolished the BMI mortality association in men with HF [HR 0.82 (0.31,2.20) and 0.99 (0.27,3.71); p = 0.98 for trend].

Conclusion

The lower mortality risk associated with excess weight in men with CHD without HF may be due to higher muscle mass. In men with HF, leptin (possibly reflecting cachexia) explain the inverse association.     

The prevalence and risk factors for cholelithiasis and asymptomatic gallstones in adults with congenital heart disease

Purpose

Cyanosis is considered to be a risk factor for cholelithiasis which is an important complication of cyanotic congenital heart disease (CCHD) in adults. In this study, the prevalence of cholelithiasis and asymptomatic calcium bilirubinate gallstones was evaluated in adults with congenital heart disease (CHD). Furthermore, risk factors for this potentially high risk complication were assessed.

Materials and methods

Subjects were derived from 114 consecutive congenital patients who visited our center from May 2008 to January 2009. For analyses of risk factors, we divided them into 4 groups: group A, 15 CCHD patients without reparative surgery (7 men, 31.8 ± 7.0 years old); group B, 41 CCHD patients rendered acyanotic by reparative surgery (21 men, 32.5 ± 11.8 years old); group C, 23 unoperated acyanotic CHD patients (11 men, 42.4 ± 16.4 years old); and group D, 35 patients who were acyanotic before and after operation (18 men, 36.3 ± 14.8 years old). Gallstones were identified by abdominal ultrasound and risk factors were analyzed by a multivariate logistic regression model.

Results

Cholecystectomy was performed in 5/114 (4.3%), asymptomatic gallstones were seen in 16/114 (14%), and symptomatic gallstones except for patients after cholecystectomy were seen in 7/114 (6.1%). In group A, 4 (27%) with gallstones underwent cholecystectomy (p < 0.01). Non-cholesterol gallstones were observed in 5 patients (33%) in group A, 12 patients (29%) in group B, nobody in group C, and 3 patients (8.6%) in group D. By a multivariate logistic regression model, CCHD by nature regardless of repair, prolonged cyanosis periods, higher frequency of cardiopulmonary bypass (CPB), and lower platelet counts were significant factors predicting gallstones (odds ratio 4.48, 1.08, 3.96, and 0.87, 95% CI, 1.14-17.5, 1.00-1.18, 1.65-9.54, and 0.75-0.99, respectively).

Conclusions

The prevalence of cholelithiasis and asymptomatic gallstones is significantly high in CCHD patients regardless of cardiac repairs. CCHD by nature, prolonged cyanosis durations, high frequency of CPB and low platelet counts have influences on gallstone formation in adults with CHD.     

Differential responses of adiposity,inflammation and autonomic function to aerobic versus resistance training in older adults

Background

Increased body fat, autonomic dysfunction and low-grade chronic inflammation are interrelated risk factors implicated in the etiology of several chronic conditions normally presented by older adults.

Objective

This study aims to assess the effectiveness of different training protocols on reducing body fat, improving autonomic function, and decreasing low-grade systemic inflammation in community-dwelling elderly adults.

Methods

Fifty participants (11 men, 68 ± 5.5 years) were randomly allocated into resistance or aerobic training or control groups. Evaluations were done at baseline and following the 8-month intervention period on their body composition (assessed by DXA), inflammatory biomarkers (high-sensitivity C-reactive protein [hs-CRP], tumor necrosis-alpha [TNF-α], interferon-gamma [IFN-γ], interleukins-6 and -10 [IL-6, IL-10]), lipoproteic profile, fasting glycemia, blood pressure, heart rate variability (HRV; frequency and time domains) and aerobic fitness (assessed by six-minute walk distance [6MWD]). A paired t-test was used to detect changes (%Δ = [(post‐test score − pretest score) / pre‐test score] × 100) within groups, while between-group differences were analyzed using the one-way ANOVA or General Linear Models.

Results

A significant change (Δ%) both in total (− 5.4 ± 6.3% and − 3.3 ± 2.9%, respectively) and central body fat (8.9 ± 11.3% and − 4.8 ± 4.5%) was observed in resistance and aerobic training groups, respectively; along with a change in resting systolic and diastolic blood pressures (− 9.2 ± 9.8% and − 8.5 ± 9.6%), heart rate (− 4.6 ± 6.5%), hs-CRP (− 18.6 ± 60.6%), and 6MWD (9.5 ± 6.9%) in response to aerobic training.

Conclusions

The present findings provide further evidence for the benefits of aerobic and resistance training on reducing body fat. Aerobic training was demonstrated to reduce hs-CRP and blood pressure in community-dwelling elderly participants with no serious medical conditions.     

Impact of Bariatric Surgery on N-Terminal Fragment of the Prohormone Brain Natriuretic Peptide and Left Ventricular Diastolic Function

Background

Obesity is often associated with left ventricular (LV) diastolic dysfunction (DD). Elevated N-terminal fragment of the prohormone brain natriuretic peptide (NT-proBNP) is considered a biomarker of LV dysfunction. Weight loss induced by bariatric surgery may improve LV DD, but conflicting results regarding NT-proBNP levels have been reported. Our objective was to determine the impact of bariatric surgery–induced weight loss on NT-proBNP levels and LV DD.

Methods

Seventy (70) patients were evaluated before and 6 and 12 months following a biliopancreatic diversion with duodenal switch (BPD-DS), and 33 subjects were followed as controls at baseline and 6 and 12 months later. Blood was collected for NT-proBNP measurement, and LV diastolic function was assessed with echocardiography.

Results

Among the 103 severely obese patients, 82% presented some degree of LV DD. Systolic function was preserved in all subjects. Along with significant weight loss, LV DD significantly improved (P < 0.001) in the BPD-DS group, whereas there was no change in the control group. NT-proBNP levels decreased over time in the control group (P = 0.016) and increased in subjects following BPD-DS (baseline vs 6-month vs 12-month follow-up: 51.8 ± 62.8 vs 132.0 ± 112.9 vs 143.3 ± 120.4 pg/mL; P < 0.001). The most significant associations with changes in NT-proBNP levels were improvements in the metabolic profile.

Conclusions

In severely obese patients, NT-proBNP levels decrease with sustained obesity for 1 year. Despite significant improvements in LV DD following bariatric surgery, NT-proBNP levels increase. These results suggest that monitoring NT-proBNP levels following bariatric surgery may be misleading regarding LV DD and symptoms of dyspnea.     

Postoperative arrhythmias in adults with congenital heart disease: Incidence and risk factors

Background

Little is known about the clinical impact of arrhythmias after surgery for congenital heart disease (CHD) in adults. Therefore, we investigated the prevalence of in-hospital arrhythmias after CHD surgery and their impact on clinical outcome.

Methods

This was a multicenter retrospective study and included adults who underwent congenital cardiac surgery between January 2009 and December 2011. Clinical events were defined as all cause mortality, heart failure (HF) requiring medical treatment, thrombo-embolic event, major infections and permanent pacemaker (PM) implantation.

Results

Overall, 419 patients were included (mean age 38 ± 14 years, 55% male). Arrhythmias occurred in 134 patients (32%) and included supraventricular tachycardia (SVT, n = 100), bradycardias (n = 47) and ventricular tachycardia (VT, n = 19). In multivariate analysis age ≥ 40 years at surgery (OR 2.48, 95% Cl 1.40–4.60, P = 0.003), NYHA class ≥ II (OR 2.42, 95% Cl 1.18–4.67, P = 0.009), significant subpulmonary AV-valve regurgitation (OR 2.84, 95% Cl 1.19–6.72, P = 0.018), coronary bypass time (OR 1.35/60 minute increase, 95% Cl 1.06–1.82, P = 0.019) and CK-MB (OR 1.05 per 10 U/L increase, 95% Cl 1.01–1.09, P = 0.021) were associated with in-hospital arrhythmias. Overall, 58 clinical events occurred in 55 patients (13%) and included in the majority of the cases permanent PM implantation (5%), HF (4%) and death (2%). In-hospital arrhythmias were independently associated with clinical events (OR 7.80, 95% CI 2.41–25.54, P = 0.001).

Conclusion

Arrhythmias are highly prevalent after congenital heart surgery in adults and are associated with worse clinical outcome. Older and symptomatic patients with significant valvular heart disease at baseline are at risk of in-hospital arrhythmias.     

Performance of Framingham cardiovascular disease (CVD) predictions in the Rotterdam Study taking into account competing risks and disentangling CVD into coronary heart disease (CHD) and stroke

Background

To evaluate the performance of Framingham predictions of cardiovascular disease (CVD) risk corrected for the competing risk of non-CVD death, in an independent European cohort of older individuals and subsequently extend the predictions by disentangling CVD into coronary heart disease (CHD) and stroke separately.

Methods

We used the Rotterdam Study data, a prospective cohort study of individuals aged 55 years and older (N = 6004), to validate the Framingham predictions of CVD, defined as first occurrence of myocardial infarction, coronary death or stroke during 15 years of follow-up, corrected for the competing risk of non-CVD death. We subsequently estimated the risks of CHD and stroke separately, and used the sum as a predictor for the total CVD risk. Calibration plots and c-statistics were used to evaluate the performance of the models.

Results

Performance of the Framingham predictions was good in the low- to intermediate risk (≤ 30%, 15-year CVD risk) (17.5% observed vs. 16.6% expected) but poorer in the higher risk (> 30%) categories (36.3% observed vs. 44.1% expected). The c-statistic increased from 0.66 to 0.69 after refitting. Separately estimating CHD and stroke revealed considerable heterogeneity with regard to the contribution of CHD and stroke to total CVD risk.

Conclusions

Framingham CVD risk predictions perform well in the low- to intermediate risk categories in the Rotterdam Study. Disentangling CVD into CHD and stroke separately provides additional information about the individual contribution of CHD and stroke to total individual CVD risk.     

Income and heart disease mortality trends in Sao Paulo,Brazil, 1996 to 2010

Background

Reductions in heart disease mortality rates are variable according to socioeconomic status.

Methods

We performed a time trend analysis of all heart diseases (all circulatory diseases, except rheumatic, cerebrovascular, and aortic diseases) comparing three different household income levels (high, middle, and low) in the city of Sao Paulo from 1996 to 2010.

Results

A total of 197,770 deaths were attributed to heart diseases; 62% of them were due to coronary diseases. The rate of death due to heart diseases declined for the city as a whole. The annual percent change (APC) and 95% confidence intervals for men living in the high, middle and low income areas were − 4.1 (− 4.5 to − 3.8), − 3.0 (− 3.5 to − 2.6), and − 2.5 (− 2.8 to − 2.1), respectively. The decline in death rate was greatest among men in the wealthiest area. The trend rates of women living in the high-income area had one joinpoint; APC was − 4.4 (− 4.8 to − 3.9) from 1996–2005 and − 2.6 (− 3.8 to − 1.4) from 2005–2010. Middle and low income areas had an APC of − 3.6 (− 4.1 to − 3.1) and − 3.0 (− 3.2 to − 2.7) from 1996–2010, respectively. During the last 5 years of observation, there was a gradient of the decline of the risk of death, faster for people living in the wealthiest area and slower for people living in the more deprived neighborhoods.

Conclusion

Reduction in deaths due to heart diseases is greatest for men and women living in the wealthiest neighborhoods.     

Contemporary prevalence of pulmonary arterial hypertension in adult congenital heart disease following the updated clinical classification

Background

The aging congenital heart disease (CHD) population is prone to develop a variety of sequelae, including pulmonary arterial hypertension (PAH). Previous prevalence estimates are limited in applicability due to the use of tertiary centers, or database encoding only. We aimed to investigate the contemporary prevalence of PAH in adult CHD patients, using a nationwide population.

Methods

A cross-sectional study was performed, using the population-based Dutch CONgenital CORvitia (CONCOR) registry. All patients born with a systemic-to-pulmonary shunt, thereby at risk of developing PAH, were identified. From this cohort, a random sample was obtained and carefully reviewed.

Results

Of 12,624 registered adults with CHD alive in 2011, 5,487 (44%) were at risk of PAH. The random sample consisted of 1,814 patients (mean age 40 ± 15 years) and 135 PAH cases were observed. PAH prevalence in patients born with a systemic-to-pulmonary shunt was 7.4%. The prevalence of PAH after corrective cardiac surgery was remarkably high (5.7%). Furthermore, PAH prevalence increased with age, from 2.5% under 30 years until 35% in the eldest. PAH prevalence in the entire CHD population was 3.2%. Based on 3000 per million adult CHD patients in the general population, we can assume that PAH-CHD is present in 100 per million.

Conclusions

This new approach using a nationwide CHD population reports a PAH prevalence of 3.2% in CHD patients, and 100 per million in the general adult population. Especially in patients after shunt closure and the elderly, physicians should be aware of PAH-CHD, to provide optimal therapeutic and clinical care.     

Irisin in patients with nonalcoholic fatty liver disease

Objective

Irisin is a recently discovered myokine proposed to increase thermogenesis-related energy expenditure and improve metabolism. We aimed to comparatively evaluate serum irisin levels in patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD) vs. controls and study their association with disease severity.

Methods

Fifteen and 16 consecutively enrolled patients with biopsy-proven nonalcoholic simple steatosis (NAFL) and steatohepatitis (NASH), respectively, and 24 lean and 28 obese controls without NAFLD were recruited. Irisin, established adipokines and biochemical tests were measured.

Results

Serum irisin levels were statistically different in obese controls (33.7 ± 2.7 ng/mL; p < 0.001) and patients with NAFL (30.5 ± 1.5 ng/mL; p < 0.001) and NASH (35.8 ± 1.9 ng/mL; p = 0.001) compared with lean controls (47.7 ± 2.0 ng/mL), but were similar among patients with NAFL, NASH and obese controls. This difference remained significant after adjustment for body mass index (or waist circumference), gender, age, insulin resistance (assessed by HOMA-IR or QUICKI), exercise and time since blood collection. Serum leptin and adiponectin, but not irisin, levels were independently from BMI correlated with insulin resistance and cardiometabolic factors. Serum irisin tended to be higher in patients with (36.7 ± 2.4 ng/mL) than without (30.8 ± 1.2 ng/mL; p = 0.02) portal inflammation and independently associated with the latter; these data need to be confirmed by future studies.

Conclusions

Serum irisin levels differ between lean controls and obese controls or NAFLD patients. Despite similar circulating irisin levels between NAFL and NASH groups, irisin may be independently and positively associated with the presence of portal inflammation. Future clinical and mechanistic studies are needed to confirm and extend these data.     

Reduced health-related quality of life in older patients with congenital heart disease: A cross sectional study in 2360 patients

Objective

Health-related quality of life questionnaires are frequently used to involve patients' impressions and feelings in the outcome evaluation. In patients with congenital heart disease (CHD) methodological heterogeneities, assessment in different age and diagnostic groups led to controversial findings. This study aims to give a comprehensive answer to the health-related quality of life in patients with CHD.

Patients and methods

From July 2001 to June 2013, 2360 patients (1058 female, 28.6 ± 11.2 years, range 14–75 years) with various kinds of CHD underwent a quality of life assessment with the SF-36 questionnaire and underwent a cardiopulmonary exercise test as part of their routine follow-up.

Results

Physical component summary score (PCS) develops from 96.1 %predicted in patients younger than 20 years, to 96.2 %predicted in patients aged 20 to 30 years, 92.3 %predicted in patients aged 30 to 40 years, and 92.6 %predicted in patients 40 years or older (r = − .114; p < .001). The decline was more prominent in the mental component summary score (MCS) declining from 104.1 %predicted in patients younger than 20 years, to 103.4 %predicted, 99.9 %predicted, and 97.5 %predicted (r = − .132; p < .001). Exercise capacity was impaired with 80.1 ± 23.0 %predicted and also declined slowly with age (r = − .084; p < .001).

Conclusions

Health-related quality of life in patients with CHD is progressively reduced in older age-groups. The decline is small, but more prominent in the mental components. This should be considered in the interpretation of studies, and strategies have to be developed to reduce this effect in future.     

A combination of increased Rho kinase activity and N-terminal pro-B-type natriuretic peptide predicts worse cardiovascular outcome in patients with acute coronary syndrome

Background

Recent experimental evidence suggests that the Rho/Rho-kinase (ROCK) system may play an important role in the pathogenesis of acute coronary syndrome (ACS) but there are little clinical data. This study examined if ROCK activity is increased in patients with acute coronary syndrome and if ROCK activity predicts long‐term cardiovascular event.

Method

Blood samples were collected from 188 patients within 12 h after admission for ACS (53% men; aged 70 ± 13) and from 61 control subject. The main outcome measures were all cause mortality, readmission with ACS or congestive heart failure (CHF) from presentation within around 2 years (mean:14.4 ± 7.2 months; range: 0.5 to 26 months).

Results

ROCK activity increased in ST elevation myocardial infarction (STEMI, n = 90) (3.33 ± 0.93), non-STEMI (NSTEMI, n = 68) (3.37 ± 1.04) and unstable angina (UA, n = 30) (2.53 ± 0.59) groups when compared with disease controls (n = 31) (2.06 ± 0.38, all p < 0.001) and healthy controls (n = 30) (1.54 ± 0.43, all p < 0.001). There were 24 deaths, 34 readmissions with ACS and 15 admissions with CHF within 2 years. Patients with a high N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high ROCK activity on admission had a five-fold risk of a cardiovascular event (RR: 5.156; 95% CI: 2.180–12.191) when compared to those with low NT-proBNP and low ROCK activity.

Conclusion

ROCK activity was increased in patients with ACS, particularly in those with myocardial infarction. The combined usage of both ROCK activity and NT-proBNP might identify a subset of ACS patients at particularly high risk.     

Perceived hardships at midlife: Prediction of long-term stroke mortality

Objectives

The objective of this study is to examine the association between perceived hardships and long-term stroke mortality among a large cohort of middle-aged men.

Background

Unlike cardiovascular morbidity and mortality, much less is known about the relationship between psychosocial factors and risk of stroke.

Methods

A cohort of 10,059 men aged ≥ 40 years at study inclusion that were tenured civil servants or municipal employees were followed for mortality over a median of 28.1 years (IQR 18.9–34.3). During follow-up 6528 (64.9%) men died, 665 of stroke and 1769 of coronary heart disease (CHD). A composite score of perceived hardships was calculated based on a structured psychosocial questionnaire filled at baseline, assessing domains of work, family, and finance. Cox proportional hazard models were used adjusting for traditional risk factors and socio-economic status.

Results

At baseline, subjects with higher hardship scores were slightly older, smoked more cigarettes, had higher prevalence of CHD, lower systolic blood pressure, higher anxiety levels and lower socio-economic status. Compared with the bottom tertile, the middle (HR 1.26, 95% CI 1.04–1.53) and top tertiles of the hardship score (HR 1.33, 95% CI 1.07–1.64) exhibited higher risk of stroke mortality (P for trend = 0.008), while no significant association was found with long-term mortality from CHD. The magnitude of the association was comparable to that of diabetes (HR 1.30, 95% CI 1.02–1.66).

Conclusion

Perceived hardships measured at midlife in a large cohort of apparently healthy men independently predict stroke mortality over long-term follow-up.     

Adherence to dietary guidelines and cardiovascular disease risk in the EPIC-NL cohort

Background

Global and national dietary guidelines have been created to lower chronic disease risk. The aim of this study was to assess whether greater adherence to the WHO guidelines (Healthy Diet Indicator (HDI)); the Dutch guidelines for a healthy diet (Dutch Healthy Diet-index (DHD-index)); and the Dietary Approaches to Stop Hypertension (DASH) diet was associated with a lower risk of cardiovascular disease (CVD), coronary heart disease (CHD) or stroke.

Methods

A prospective cohort study was conducted among 33,671 healthy Dutch men and women aged 20–70 years recruited into the EPIC-NL study during 1993–1997. We used Cox regression adjusted for relevant confounders to estimate the hazard ratios per standard deviation increase in score and 95% confidence intervals (CI) of the associations between the dietary guidelines and CVD, CHD and stroke risk.

Results

After an average follow-up of 12.2 years, 2752 CVD cases were documented, including 1630 CHD cases and 527 stroke cases. We found no association between the HDI (0.98, 95% CI 0.94; 1.02) or DHD-index (0.96, 95% CI 0.92; 1.00) and CVD incidence. Similar results were found for these guidelines and CHD or stroke incidence. Higher adherence to the DASH diet was significantly associated with a lower CVD (0.92, 95% CI 0.89; 0.96), CHD (0.91, 95% CI 0.86; 0.95), and stroke (0.90, 95% CI 0.82; 0.99) risk.

Conclusion

The HDI and the DHD-index were not associated with CVD risk, while the DASH diet was significantly associated with a lower risk of developing CVD, CHD and stroke.     

Infiltrated atrial fat characterizes underlying atrial fibrillation substrate in patients at risk as defined by the ARIC atrial fibrillation risk score

Background

It is known that expanded epicardial fat is associated with atrial fibrillation (AF). However, infiltrated intraatrial fat has not been previously quantified in individuals at risk as determined by the ARIC AF risk score.

Methods

Patients in sinus rhythm (N = 90, age 57 ± 10 years; 55 men [63.2%]), in 3 groups at risk of AF as determined by the ARIC AF risk score [low (≤ 11 points; n = 15), moderate (12–18 points; n = 40), high (≥ 19 points; n = 23) risk of AF], and paroxysmal AF (n = 12) underwent cardiac magnetic resonance study. Intraatrial and epicardial fat was analyzed with a Dark-blood DIR-prepared Fat-Water-separated sequence in the horizontal longitudinal axis. OsiriX DICOM viewer (Geneva, Switzerland) was used to quantify the intraatrial fat area. Width of the cephalad portion of the interatrial septum was measured at the level of the fossa ovalis.

Results

Intraatrial fat monotonically increased with growing AF risk in study groups (low AF risk 16 ± 4 vs. moderate AF risk 32 ± 18 vs. high AF risk 81 ± 83 mm²; ANOVA P = 0.012). Log-transformed intraatrial fat predicted ARIC AF risk score in multivariate ordered probit regression after adjustment for sex, race, left and right atrial area indices, and body mass index (β-coefficient 0.50 [95% CI 0.03–0.97]; P = 0.037), whereas epicardial fat did not. Interatrial septum width showed similar association (3.0 ± 1.4 vs. 5.0 ± 1.8 vs. 7.1 ± 2.7 mm; ANOVA P < 0.001; adjusted β-coefficient 2.80 [95% CI 1.19–4.41]; P = 0.001).

Conclusions

Infiltrated intraatrial fat characterizes evolving substrate in individuals at risk of AF.