Jan Erik Otterstad

Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease

Background Lifestyle measures of coronary heart disease (CHD) prevention have been overshadowed by the efficacy of drug treatments. This is particularly the case in the setting of secondary prevention where the benefits of lipid lowering, anti-platelet and anti-hypertensive drugs have been emphasised in numerous trials. Lifestyle measures address several CHD risk factors at once and are generally free of serious side effects. Objectives The objective of the present study was to determine whether a comprehensive programme of lifestyle modification could favourably influence dietary and exercise habits in addition to smoking cessation over two years. In addition, an attempt was made to evaluate if this programme could favourably influence the five-year CHD-risk in the male population included in the study. Design A total of 197 patients with proven coronary heart disease were included and randomised to a lifestyle intervention programme or to usual care. Follow-up was after a period of two years. Methods Intervention comprised a low fat diet, regular exercise, smoking cessation, psychosocial support and education, delivered by nurses on the rationale for pharmacological and lifestyle measures. Usual care comprised follow-up in the routine outpatient clinic. Both groups were given the same comprehensive medication according to recent guidelines. Results Patients in the lifestyle intervention group reduced the intake of saturated fat, sugar and cholesterol (P<0.001), increased their exercise level (P<0.01) and stopped smoking (P<0.05) when compared with the usual care group. A subanalysis of the influence of five-year CHD calculated risk in males resulted in a relative risk reduction of 22% (95% confidence intervals 9-35). Although significant, this result must be interpreted with caution due to poor statistical power and reproducibility of the method. Conclusions In the presence of modern drug treatments for secondary cardiovascular disease prevention it remains possible through a favourable diet, exercise and smoking cessation to show an additional reduction in the five-year risk for CHD in males.

Normal reference ranges for left and right atrial volume indexes and ejection fractions obtained with real-time three-dimensional echocardiography

AIMS The aim of this study was to obtain normal reference ranges and intra-observer reproducibility for left (L) and right (R) atrial (A) volume indexes (VI, corrected for body surface area) and ejection fractions (EF) with real-time three-dimensional echocardiography. METHODS AND RESULTS One hundred and sixty-six participants, 79 males and 87 females, aged 29-79 years considered free from clinical and subclinical cardiovascular disease, were included. Normal ranges are defined as 95% reference values for atrial dimensions and reproducibility as coefficients of variations (CVs) for repeated measurements. Upper normal reference values were 41 mL/m(2) for maximum (max) LAVI and 19 mL/m(2) for minimum (min) LAVI. The lower normal reference value was 45% for LAEF. The respective values for RA were 47 mL/m(2), 20 mL/m(2), and 46%. The only relevant gender difference was a higher upper normal max RAVI among males vs. females. The CVs for repeated measurements were 9% for max LAVI, 8% for max RAVI, 13% for LAEF, and 14% for RAEF. CONCLUSION The present study provides normal ranges for atrial dimensions and contractility with a new, fast, and reproducible technique that can be used bedside without offline analysis.

Reference values for left ventricular volumes with real-time 3-dimensional echocardiography

Abstract Objectives. Obtain normal reference ranges for left ventricular (LV) volume indexes (VI) and ejection fraction (EF) with fast real-time 3-dimensional echocardiography (RT3DE) with online analysis. Design. After a screening visit 166 healthy participants, 79 males and 87 females aged 29–80 years were examined with RT3DE and Doppler. Results. Upper normal values (mean + 2 standard deviations [SD]) for LV end-diastolic volume index (LVEDVI) and LV end-systolic volume index (LVESVI) were 82 ml/m2 and 38 ml/m2, respectively. The lower limit (mean – 2 SD) for LVEF was 49%. LVVI were significantly larger among males (p < 0.001). LV stroke volume (SD) was 87 (22) ml with Doppler vs. 69 (14) ml with RT3DE (p < 0.001). In males there was a positive correlation between age and LVEF (r = 0.34, p = 0.003). In a reproducibility study of RT3DE and 2-dimensional echocardiography (2DE) the coefficients of variability for repeated recordings were 5.7% for LVEDV, 7.7% for LVESV and 6.7% for LVEF with RT3DE, and 8.6%, 8.6% and 6.4% with 2DE, respectively. Conclusions. These reference values presented from a large group of normal subjects over a wide age range with RT3DE may represent a valuable tool to evaluate if LV systolic dysfunction is present or not.

The anesthesia in abdominal aortic surgery (ABSENT) study: a prospective, randomized, controlled trial comparing troponin T release with fentanyl-sevoflurane and propofol-remifentanil anesthesia in major vascular surgery.

Background:On the basis of data indicating that volatile anesthetics induce cardioprotection in cardiac surgery, current guidelines recommend volatile anesthetics for maintenance of general anesthesia during noncardiac surgery in hemodynamic stable patients at risk for perioperative myocardial ischemia. The aim of the current study was to compare increased troponin T (TnT) values in patients receiving sevoflurane-based anesthesia or total intravenous anesthesia in elective abdominal aortic surgery. Methods:A prospective, randomized, open, parallel-group trial comparing sevoflurane-based anesthesia (group S) and total intravenous anesthesia (group T) with regard to cardioprotection in 193 patients scheduled for elective abdominal aortic surgery. Increased TnT level on the first postoperative day was the primary endpoint. Secondary endpoints were postoperative complications, nonfatal coronary events and mortality. Results:On the first postoperative day increased TnT values (>13 ng/l) were found in 43 (44%) patients in group S versus 41 (43%) in group T (P = 0.999), with no significant differences in TnT levels between the groups at any time point. Although underpowered, the authors found no differences in postoperative complications, nonfatal coronary events or mortality between the groups. Conclusions:In elective abdominal aortic surgery sevoflurane-based anesthesia did not reduce myocardial injury, evaluated by TnT release, compared with total intravenous anesthesia. These data indicate that potential cardioprotective effects of volatile anesthetics found in cardiac surgery are less obvious in major vascular surgery.

Optimal atrioventricular delay in physiological pacing determined by Doppler echocardiography.

Our study included eight patients with physiological pacemakers programmed to the VDD mode. The blood velocity in the aortic root was determined by Doppler echocardiography. Changes in the integral of maximum velocity reflect stroke volume changes. The Doppler probe was placed and held in the suprasternal position while programming the pacemakers from the VVI to all available AV delays in the VDD mode; the heart rates were nearly constant. Stroke volumes were highly dependent on changes of the AV delay; the optimum AV delay varied considerably from patient to patient. These changes were more pronounced in the patients with left ventricular strain due to aortic valve disease than in the patients with isolated conduction defects.

Physical performance is associated with markers of vascular inflammation in patients with coronary heart disease.

Background Coronary heart disease as well as major cardiovascular risk factors are associated with elevated levels of proinflammatory markers. There is, however, limited information about how changes in lifestyle improving the cardiovascular risk profile influence these levels. The aim of the study was to evaluate whether changes in lifestyle measures with special attention to physical activity, were associated with the levels of such markers. Design Coronary heart disease patients (n = 197) were randomized to either a comprehensive lifestyle intervention programme comprising regular physical activity, low fat diet and smoking cessation, or usual care with routine follow-up in the outpatient clinic for 6 months. An exercise test and fasting blood samples analysed for soluble cell adhesion molecules, C reactive protein and pro-inflammatory cytokines were evaluated before and at the end of the study. Results Improved diet, physical performance and reduction in smoking were obtained in the intervention programme when compared with usual care patients, but no significant group differences in levels of inflammatory markers were observed. In the total population, however, physical performance significantly and inversely predicted levels of soluble cell adhesion molecule 1, (P>0.001), C-reactive protein (P>0.001) and interleukin-6 (P=0.01) at 6 months. Smokers had elevated levels of soluble cell adhesion molecule 1 when compared with non-smokers (P=0.011). Conclusions We demonstrated that physical performance is inversely correlated with levels of pro-inflammatory markers in coronary heart disease patients, possibly retarding the process of atherosclerosis. No effect on inflammatory markers was obtained with a 6-month lifestyle intervention programme when compared with patients who received usual care follow-up. Eur J Cardiovasc Prev Rehabil 13:356-362

The effect of carvedilol in patients with impaired left ventricular systolic function following an acute myocardial infarction

In previous beta‐blocker trials, post‐myocardial infarction (MI) patients were essentially treated with a beta‐blocker or placebo. In the CAPRICORN trial, patients were selected on the basis of a left ventricular (LV) ejection fraction (EF) <40% following the index MI and randomised to carvedilol or placebo, in addition to modern secondary prophylaxis with ACE inhibitors, aspirin and statins. In 1959 patients with a mean LVEF of 33%, treatment with carvedilol over a mean follow‐up period of 15 months reduced total mortality from 15.3% with placebo to 11.9% with carvedilol [relative risk reduction (RRR) ‐23%, absolute risk reduction (ARR) ‐3.4%]. The incidence of recurrent MI was reduced from 5.8 to 2.3% (RRR 41%, ARR 2.3%). The number needed to treat (NNT) to prevent one death was 28 for the entire study period and 43 for 1 year of treatment. The results of the CAPRICORN trial are compared with three previous beta‐blocker post‐MI trials: the Gothenburg metoprolol trial (GMT), the Norwegian timolol trial (NTT) and the beta‐blocker heart attack trial (BHAT). The RRRs for total mortality were 36% in the GMT and NTT, and 27% in BHAT. The respective NNTs for total mortality were 32, 18 and 38. NNT for 1 year of treatment was 25 in NTT and 80 in BHAT. The RRR for recurrent MIs were 28% in NTT and 16% in BHAT. The reduction of mortality and recurrent MIs in CAPRICORN is within the range of previous post‐MI beta‐blocker studies. In post‐MI patients with LVEF<40%, add‐on treatment with a beta‐blocker should be given >48 h after initiation with an angiotensin‐converting enzyme inhibitor (ACEI) and then with a slow dose escalation as applied in CAPRICORN.

Atrial fibrillation and the risk for myocardial infarction, all-cause mortality and heart failure: A systematic review and meta-analysis

Background In contemporary atrial fibrillation trials most deaths are cardiac related, whereas stroke and bleeding represent only a small subset of deaths. We aimed to evaluate the long-term risk of cardiac events and all-cause mortality in individuals with atrial fibrillation compared to no atrial fibrillation. Design A systematic review and meta-analysis of studies published between 1 January 2006 and 21 October 2016. Methods Four databases were searched. Studies had follow-up of at least 500 stable patients for either cardiac endpoints or all-cause mortality for 12 months or longer. Publication bias was evaluated and random effects models were used to synthesise the results. Heterogeneity between studies was examined by subgroup and meta-regression analyses. Results A total of 15 cohort studies was included. Analyses indicated that atrial fibrillation was associated with an increased risk of myocardial infarction (relative risk (RR) 1.54, 95% confidence interval (CI) 1.26–1.85), all-cause mortality (RR 1.95, 95% CI 1.50–2.54) and heart failure (RR 4.62, 95% CI 3.13–6.83). Coronary heart disease at baseline was associated with a reduced risk of myocardial infarction and explained 57% of the heterogeneity. A prospective cohort design accounted for 25% of all-cause mortality heterogeneity. Due to there being fewer than 10 studies, sources of heterogeneity were inconclusive for heart failure. Conclusions Atrial fibrillation seems to be associated with an increased risk of subsequent myocardial infarction in patients without coronary heart disease and an increased risk of, all-cause mortality and heart failure in patients with and without coronary heart disease.

The role of medical and psychosocial factors for unfavourable coronary risk factor control

Abstract Objectives. This project aims to identify socio-demographic, medical and psychosocial factors (study factors) associated with coronary risk control and prognosis, and to test their impact in a representative sample of coronary heart disease (CHD) patients. Design. The first phase includes a cross-sectional study designed to explore the association between the study factors and coronary risk factor control in CHD patients. Data from hospital records, a questionnaire, clinical examination and blood samples were collected. The independent effects of study factors on subsequent coronary events will be explored prospectively by controlling for baseline coronary risk factors. In the second phase, we will test the effect of tailored interventions to modify the study factors associated with unfavourable risk profile in phase I. Results. In all 1366 patients (21% women), aged 18-80 years with a coronary event on average 17 (2-38) months prior to study participation were identified (83% participation rate). Of the 239 patients who refused participation, 229 patients consented to analysis of hospital record data (non- participants). Conclusions. If the study variables contribute to CHD risk factors and prognosis, the present project may be important for the development of prevention programs by tailoring these to the patients perceived needs and behaviour profiles. Trial registration: ClinicalTrials.gov identifier: NCT02309255.

The limited usefulness of real-time 3-dimensional echocardiography in obtaining normal reference ranges for right ventricular volumes

BackgroundTo obtain normal reference ranges and intraobserver variability for right ventricular (RV) volume indexes (VI) and ejection fraction (EF) from apical recordings with real-time 3-dimensional echocardiography (RT3DE), and similarly for RV area indexes (AI) and area fraction (AF) with 2-dimensional echocardiography (2DE).Methods166 participants; 79 males and 87 females aged between 29–79 years and considered free from clinical and subclinical cardiovascular disease. Normal ranges are defined as 95% reference values and reproducibility as coefficients of variation (CV) for repeated measurements.ResultsNone of the apical recordings with RT3DE and 2DE included the RV outflow tract. Upper reference values were 62 ml/m2 for RV end-diastolic (ED) VI and 24 ml/m2 for RV end-systolic (ES) VI. Lower normal reference value for RVEF was 41%. The respective reference ranges were 17 cm2/m2 for RVEDAI, 11 cm2/m2 for RVESAI and 27% for RVAF. Males had higher upper normal values for RVEDVI, RVESVI and RVEDAI, and a lower limit than females for RVEF and RVAF. Weak but significant negative correlations between age and RV dimensions were found with RT3DE, but not with 2DE. CVs for repeated measurements ranged between 10% and 14% with RT3DE and from 5% to 14% with 2DE.ConclusionAlthough the normal ranges for RVVIs and RVAIs presented in this study reflect RV inflow tract dimensions only, the data presented may still be regarded as a useful tool in clinical practice, especially for RVEF and RVAF.