Kristina Orth-Gomér

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 …

European guidelines on cardiovascular disease prevention in clinical practice: full text. 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, Tony Fitzgerald, Marie Therese Cooney, Alexandra Dudina European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG): Alec Vahanian (Chairperson), John Camm, Raffaele De Caterina, Veronica Dean, Kenneth Dickstein, Christian Funck-Brentano, Gerasimos Filippatos, Irene Hellemans, Steen Dalby Kristensen, Keith McGregor, Udo Sechtem, Sigmund Silber, Michal Tendera, Petr Widimsky, Jose Luis Zamorano Document reviewers: Irene Hellemans (CPG Review Co-ordinator), Attila Altiner, Enzo Bonora, Paul N. Durrington, Robert Fagard, Simona Giampaoli, Harry Hemingway, Jan Hakansson, Sverre Erik Kjeldsen, Mogens Lytken Larsen, Giuseppe Mancia, Athanasios J. Manolis, Kristina Orth-Gomer, Terje Pedersen, Mike Rayner, Lars Ryden, Mario Sammut, Neil Schneiderman, Anton F. Stalenhoef, Lale Tokgözoglu, Olov Wiklund, Antonis Zampelas

European guidelines on cardiovascular disease prevention in clinical practice

Guidelines aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of guidelines have been issued in recent years by different organisations--European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC), and other related societies. By means of links to web sites of National Societies several hundred guidelines are available. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing guidelines. In spite of the fact that standards for issuing good quality guidelines are well defined, recent surveys of guidelines published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilisation of health resources. In addition, the legal implications of medical guidelines have been discussed and examined, resulting in position documents, which have been published by a specific task force. The ESC Committee for practice guidelines (CPG) supervises and coordinates the preparation of new guidelines and expert consensus documents produced by task forces, expert groups or consensus panels. The Committee is also responsible for the endorsement of these guidelines or statements.

European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice

Guidelines aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of guidelines have been issued in recent years by different organisations--European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC), and other related societies. By means of links to web sites of National Societies several hundred guidelines are available. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing guidelines. In spite of the fact that standards for issuing good quality guidelines are well defined, recent surveys of guidelines published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilisation of health resources. In addition, the legal implications of medical guidelines have been discussed and examined, resulting in position documents, which have been published by a specific task force. The ESC Committee for practice guidelines (CPG) supervises and coordinates the preparation of new guidelines and expert consensus documents produced by task forces, expert groups or consensus panels. The Committee is also responsible for the endorsement of these guidelines or statements.

INCREASED RISK OF ISCHAEMIC HEART DISEASE IN SHIFT WORKERS

504 papermill workers were followed up for 15 years and the incidence of ischaemic heart disease (IHD) in shift workers was compared with that in day workers. The relative risk (RR) of IHD rose with increasing duration of reported exposure to shift work. A significant risk of IHD was associated with an exposure of 11 - 15 years (RR = 2.2, p less than 0.04) and of 16 to 20 years (RR = 2.8, p less than 0.03. The association was independent of age and smoking history. The RR of IHD fell sharply after 20 years of shift work. This was ascribed to the pronounced positive selection that had taken place in this group.

Social network interaction and mortality. A six year follow-up study of a random sample of the Swedish population.

This study examined the relationship between social network interaction and total and cardiovascular mortality in 17,433 Swedish men and women between the ages of 29 and 74 during a 6 year follow-up period. The study group was interviewed concerning their social network interactions and a total score was formed which summarized the availability of social contact. A number of sociodemographic and health related background variables known to be associated with mortality risk were also considered. Mortality was examined by linking the interview material with the Swedish National Mortality Registry. In the 6-year follow-up period 841 deaths occurred. The crude relative risk of dying during this period was 3.7 (95% CL 3.2; 4.3) when the lower social network tertile was compared to the upper two tertiles. When controlling for potential confounding effects, only age had a major influence on the association between social network interaction and mortality (RR age-adjusted = 1.46, 95% CL 1.25; 1.72). Controlling for age and sex, age and educational level, age and employment status, age and immigrant status, age and smoking, age and exercise habits and age and chronic disease at interview left the relative risk virtually unchanged. Controlling simultaneously for age, smoking, exercise and chronic illness yielded a risk estimate of 1.36 (95% CL 1.06; 1.69). Similar results were obtained when separately analyzing for cardiovascular disease mortality in an identical manner.

Lack of social support and incidence of coronary heart disease in middle-aged Swedish men

&NA; Lack of social support has been found to predict all causes of mortality in population studies. It has often been assumed that the lack of social ties is associated with the general social conditions related to mortality and has little to do with specific disease etiology. So far, the association between lack of support and cardiovascular disease incidence has not been demonstrated. We have measured both emotional support from very close persons (“attachment”) and the support provided by the extended network (“social integration”). This measure was applied along with standard measures of traditional risk factors to a random sample of 50‐year‐old men born in Gothenborg in 1933. All men (n = 736) were followed for 6 years and the incidence of myocardial infarction and death from coronary heart disease (CHD) was determined. Both “attachment” and “social integration” were lower in men who contracted CHD, with a significant effect for social integration (p = 0.04) and an almost significant effect for attachment (p = 0.07). When controlling for other risk factors in multiple logistic regression analyses, both factors remained as significant predictors of new CHD events. Smoking and lack of social support were the two leading risk factors for CHD in these middle‐aged men.

Development of a social support instrument for use in population surveys

A wide variety of measures have been used to assess the effects of social support on physical and psychological well-being. Many instruments have incomplete information about reliability and validity. Other instruments appear to be reasonably valid, but involve a large number of questions and are therefore not suitable in population surveys. The main purpose of the study was to examine whether a psychometrically well documented, but time consuming instrument. The Interview Schedule for Social Interaction, could be abbreviated and simplified for the use in population surveys. By means of both item and content analyses the original instrument was shortened and both versions were tested in a study group of 83 middle-aged Swedish men. The distribution of scale scores were similar in the complete and in the abbreviated version and so was reliability, measured as internal consistency and split-half reliability. Validity was examined by comparing the two versions in relation to other measures of social integration, as well as personality and behaviour characteristics. Men with low social support were less socially and physically active, were more depressed and were less trustful than men with high support. Men who scored low on social support were also more often smokers, of lower social class, lower occupational level and lower education and had more complaints of ill health, mainly of cardiovascular nature. The discriminative capacity was as good for the complete as for the abbreviated version. Thus no obvious disadvantages in terms of reliability and validity could be demonstrated for the abbreviated version.

Physiological correlates of burnout among women

OBJECTIVES The purpose of this study was to investigate the immune, endocrine, and metabolic correlates of burnout among women. METHODS Forty-three participants with high and 20 participants with low scores for the Shirom-Melamed Burnout Questionnaire were compared in terms of subjective symptoms, job strain, social support, plasma levels of prolactin, tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta (TGF-beta), C-reactive protein (CRP), neopterin, serum levels of dehydroepiandrosterone sulphate (DHEAs), progesterone, estradiol, cortisol, and glycated hemoglobin (HbA1C) in whole blood. RESULTS Besides reporting more job strain, less social support at work, and higher levels of anxiety, depression, vital exhaustion (VE), and sleep impairments, participants with high burnout manifested higher levels of TNF-alpha and HbA1C, independent of confounders including depression. CONCLUSIONS Among women, burnout seems to involve enhanced inflammatory responses and oxidative stress.

Psychosocial factors and heart rate variability in healthy women.

OBJECTIVE This study was conducted to investigate associations between psychosocial risk factors, including social isolation, anger and depressive symptoms, and heart rate variability in healthy women. METHODS The study group consisted of 300 healthy women (median age 57.5 years) who were representative of women living in the greater Stockholm area. For the measurement of social isolation, a condensed version of the Interpersonal Support Evaluation List was used and household size assessed. Anger was measured by the anger scales previously used in the Framingham study and depressive symptoms by a questionnaire derived from Pearlin. Health behaviors were measured by means of standard questionnaires. From 24-hour ambulatory electrocardiographic monitoring, both time and frequency domain measures were obtained: SDNN index (mean of the SDs of all normal to normal intervals for all 5-minute segments of the entire recording), VLF power (very low frequency power), LF power (low frequency power), HF power (high frequency power), and the LF/HF ratio (low frequency by high frequency ratio) were computed. RESULTS Social isolation and inability to relieve anger by talking to others were associated with decreased heart rate variability. Depressive symptoms were related only to the LF/HF ratio. Adjusting for age, menopausal status, exercise and smoking habits, history of hypertension, and BMI did not substantially change the results. CONCLUSIONS These findings suggest heart rate variability to be a mediating mechanism that could explain at least part of the reported associations between social isolation, suppressed anger, and health outcomes.