Christoph Herrmann-Lingen

European guidelines on cardiovascular disease prevention in clinical practice: executive summary

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are not substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC web site (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in the tables below. The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report was entirely …

Depression as a risk factor for mortality in patients with coronary heart disease: A meta-analysis

Background: Prospective studies on physically healthy subjects have shown an association between depression and the subsequent development of coronary heart disease (CHD). The relative risk in meta-analytic aggregation is 1.64 (confidence interval [CI], 1.29–2.08) for any CHD event. However, the adverse impact of depression on CHD patients has not yet been the subject of a meta-analysis. Objective: To quantify the impact of depressive symptoms (eg, BDI, HADS) or depressive disorders (major depression) on cardiac or all-cause mortality. We analyzed the strength of the relationship, the time dependency, and the differences in studies using depressive symptoms or a clinical diagnosis as predictors of mortality. Method: English and German language databases (Medline, PsycInfo, PSYNDEX) from 1980 to 2003 were searched for prospective cohort studies. Sixty-two publications were identified. The inclusion criteria were met by 29 publications reporting on 20 studies. A random model was used to estimate the combined overall effect as crude odds ratios (OR) or adjusted hazard ratios (HR [adj]). Results: Depressive symptoms increase the risk of mortality in CHD patients. The risk of depressed patients dying in the 2 years after the initial assessment is two times higher than that of nondepressed patients (OR, 2.24; 1.37–3.60). This negative prognostic effect also remains in the long-term (OR, 1.78; 1.12–2.83) and after adjustment for other risk factors (HR [adj], 1.76; 1.27–2.43). The unfavorable impact of depressive disorders was reported for the most part in the form of crude odds ratios. Within the first 6 months, depressive disorders were found to have no significant effect on mortality (OR, 2.07; CI, 0.82–5.26). However, after 2 years, the risk is more than two times higher for CHD patients with clinical depression (OR, 2.61; 1.53–4.47). Only three studies reported adjusted hazard ratios for clinical depression and supported the results of the bivariate models. Conclusions: Depressive symptoms and clinical depression have an unfavorable impact on mortality in CHD patients. The results are limited by heterogeneity of the results in the primary studies. There is no clear evidence whether self-report or clinical interview is the more precise predictor. Nevertheless, depression has to be considered a relevant risk factor in patients with CHD. AMI = acute myocardial infarction; AP = angina pectoris; BDI = Beck Depression Inventory; CABG = coronary artery bypass graft; CHD = coronary heart disease; CI = confidence interval; DIS = Diagnostic Interview Schedule; DS = Zerssen Self-Rating Scale; DSM = Diagnostic and Statistical Manual of Mental Disorders; ECG = electrocardiogram; f/u = follow-up period; GMS = Global Mood Scale; HADS = Hospital Anxiety and Depression Scale; HDL = high-density lipoprotein; HPA = hypothalamic–pituitary–adrenocortical axis; HR (adj) = adjusted hazard ratio; IL = interleukin; LVEF = left ventricular ejection fraction; Medline = database of the U.S. National Library of Medicine; MI = myocardial infarction; MD = major depression; OR = odds ratio; PSE = Present State Examination; PsycInfo = database of the American Psychological Association; PSYNDEX = database of the Center for Psychological Information and Documentation at the University of Trier, Germany; PTCA = percutaneous transluminal coronary angioplasty; RR = relative risk; SBP = systolic blood pressure; SCID = Structured Clinical Interview for DSM; SDS = Zung Self-Rating Depression Scale; TNF = tumor necrosis factor.

Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Constituted by representatives of nine societies and by invited experts)

Other experts who contributed to parts of the guidelines: Edmond Walma, Schoonhoven (The Netherlands), Tony Fitzgerald, Dublin (Ireland), Marie Therese Cooney, Dublin (Ireland), Alexandra Dudina, Dublin (Ireland) European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG):, Alec Vahanian (Chairperson) (France), John Camm (UK), Raffaele De Caterina (Italy), Veronica Dean (France), Kenneth Dickstein (Norway), Christian Funck-Brentano (France), Gerasimos Filippatos (Greece), Irene Hellemans (The Netherlands), Steen Dalby Kristensen (Denmark), Keith McGregor (France), Udo Sechtem (Germany), Sigmund Silber (Germany), Michal Tendera (Poland), Petr Widimsky (Czech Republic), José Luis Zamorano (Spain) Document reviewers: Irene Hellemans (CPG Review Coordinator) (The Netherlands), Attila Altiner (Germany), Enzo Bonora (Italy), Paul N. Durrington (UK), Robert Fagard (Belgium), Simona Giampaoli(Italy), Harry Hemingway (UK), Jan Hakansson (Sweden), Sverre Erik Kjeldsen (Norway), Mogens Lytken Larsen (Denmark), Giuseppe Mancia (Italy), Athanasios J. Manolis (Greece), Kristina Orth-Gomer (Sweden), Terje Pedersen (Norway), Mike Rayner (UK), Lars Ryden (Sweden), Mario Sammut (Malta), Neil Schneiderman (USA), Anton F. Stalenhoef (The Netherlands), Lale Tokgözoglu (Turkey), Olov Wiklund (Sweden), Antonis Zampelas (Greece)

Screening for psychosocial risk factors in patients with coronary heart disease-recommendations for clinical practice

Psychosocial risk factors like low socio-economic status, chronic family or work stress, social isolation, negative emotions (e.g., chronic depression or acute anxiety), and negative personality patterns such as Type-D-pattern or hostility, may contribute significantly to the development and adverse outcome of coronary heart disease. Therefore, systematic screening for psychosocial risk factors in cardiological practice is recommended in order to initiate adequate intervention strategies, e.g., to involve additional psychosocial counselling or treatment. Reliable methods to assess psychosocial risk factors are: (1) standardized, structured interviews; (2) standardized questionnaires, and (3) ‘single-item’ questions to be included into the cardiologists clinical interviews. While structured interviews should be restricted to trained professionals, questionnaires are easily to administer, and have frequently been used in the field of cardiology. ‘Single item’ questions are sufficiently reliable and the most timesaving way to screen for psychosocial factors. For clinical practice, a two-step evaluation is recommended: firstly, cardiologists should include ‘single-item’ questions into their routine interview and/or use questionnaires in order to screen for a potential problem. Secondly, if problems are indicated, patients should be passed to qualified professionals for structured clinical interview. Instruments of all three methods are briefly presented, and implications for further treatment are discussed.

Titration to target dose of bisoprolol vs. carvedilol in elderly patients with heart failure: the CIBIS‐ELD trial

Various beta‐blockers with distinct pharmacological profiles are approved in heart failure, yet they remain underused and underdosed. Although potentially of major public health importance, whether one agent is superior in terms of tolerability and optimal dosing has not been investigated. The aim of this study was therefore to compare the tolerability and clinical effects of two proven beta‐blockers in elderly patients with heart failure.

EUROPEAN GUIDELINES ON CARDIOVASCULAR DISEASE PREVENTION IN CLINICAL PRACTICE FOURTH JOINT TASK FORCE OF THE EUROPEAN SOCIETY OF CARDIOLOGY AND OTHER SOCIETIES ON CARDIOVASCULAR DISEASE PREVENTION IN CLINICAL PRACTICE .

Authors/Task Force Members: Massimo F. Piepoli* (Chairperson) (Italy), Arno W. Hoes* (Co-Chairperson) (The Netherlands), Stefan Agewall (Norway)1, Christian Albus (Germany)9, Carlos Brotons (Spain)10, Alberico L. Catapano (Italy)3, Marie-Therese Cooney (Ireland)1, Ugo Corrà (Italy)1, Bernard Cosyns (Belgium)1, Christi Deaton (UK)1, Ian Graham (Ireland)1, Michael Stephen Hall (UK)7, F. D. Richard Hobbs (UK)10, Maja-Lisa Løchen (Norway)1, Herbert Löllgen (Germany)8, Pedro Marques-Vidal (Switzerland)1, Joep Perk (Sweden)1, Eva Prescott (Denmark)1, Josep Redon (Spain)5, Dimitrios J. Richter (Greece)1, Naveed Sattar (UK)2, Yvo Smulders (The Netherlands)1, Monica Tiberi (Italy)1, H. Bart van der Worp (The Netherlands)6, Ineke van Dis (The Netherlands)4, W. M. Monique Verschuren (The Netherlands)1

The novel biomarker growth differentiation factor 15 in heart failure with normal ejection fraction

Heart failure with normal ejection fraction (HFnEF) is an important clinical entity that remains incompletely understood. The novel biomarker growth differentiation factor 15 (GDF‐15) is elevated in systolic heart failure (HFrEF) and is predictive of an adverse outcome. We investigated the clinical relevance of GDF‐15 plasma levels in HFnEF.

Type D Personality and All-cause Mortality in Cardiac Patients-data From a German Cohort Study

Objective: Type D personality has been established as a predictor of adverse clinical events in patients with cardiovascular diseases. To date, all studies except one have been conducted by a single research group. Thus, the aim of our study was to provide an independent replication of the results regarding the prognostic validity of Type D personality in a German sample of cardiac patients. Methods: Cardiac patients (n = 1040) were recruited from cardiac rehabilitation centers (n = 484), an outpatient clinic (n = 249), and a university hospital (n = 307). Main analyses were based on the combined data from these three subsamples. Cardiac health status, medical risk factors, sociodemographic characteristics, psychological symptoms, and Type D personality were assessed at baseline. The primary end point was all-cause mortality. The Cox proportional hazards regression model was used to estimate the relative risk of death. Results: Vital status was known for 977 patients (22.5% women; mean [standard deviation] = 63.3 [10.7] years). Within the follow-up time (mean [standard deviation] = 71.5 [3.6] months), 172 patients died. Type D personality was found in 25.2% of survivors and in 22.2% of nonsurvivors (&khgr;2= 0.78, p =.38). Depressive symptoms (p =.13) and anxiety (p =.27) were also not predictive of mortality. In the multivariate analyses, neither Type D (p =.95) nor negative affectivity (p =.71) and social inhibition (p =.59), as well as their interaction (p =.88), were associated with all-cause mortality. Conclusions: In the present study, Type D personality and its constituents are not associated with increased mortality in patients with heart disease. The discrepancies with previous results deserve further investigation.BMI = body mass index; CAD = coronary artery disease; CHF = chronic heart failure; DS14 = Type D scale (14-item version); HADS = Hospital Anxiety and Depression Scale; HD = heart disease; HR = Cox proportional hazard ratio; NA = negative affectivity; SI = social inhibition

Galectin‐3 in patients with heart failure with preserved ejection fraction: results from the Aldo‐DHF trial

Galectin‐3 is a marker of myocardial fibrosis and mediates aldosterone‐induced cardiovascular inflammation and fibrosis. Characteristics of galectin‐3 and its response to spironolactone have not been evaluated in heart failure with preserved ejection fraction (HFpEF). The aim of this study was to determine the association between galectin‐3 levels and patient characteristics in HFpEF; to evaluate the interaction between spironolactone and galectin‐3 levels; and to assess the association between galectin‐3 and clinical outcomes.

Rationale and design of the 'aldosterone receptor blockade in diastolic heart failure' trial: a double-blind, randomized, placebo-controlled, parallel group study to determine the effects of spironolactone on exercise capacity and diastolic function in patients with symptomatic diastolic heart failure (Aldo-DHF).

Increasing evidence suggests that enhanced aldosterone signalling plays a key role in the onset and progression of diastolic heart failure (DHF). Aldo‐DHF will test the hypothesis that aldosterone receptor blockade by spironolactone will improve exercise capacity and diastolic function in patients with DHF.